PhysiotherapyforJuvenileIdiopathicArthritis.ppt

physiotherapy for juvenile idiopathic arthritis,sue maillard msc specialist physiotherapist paediatric rheumatology great ormond street hospital, london,j.i.a. r.a.,a disease effecting a growing developing skeleton.,a disease effecting a developed skeleton.,the treatment needs to be different.,in children there is the capacity for regeneration, re-modelling and repair. this needs to be used to a maximum.,subjective assessment,symptoms / pain / stiffness when, where, what the impact jia has on the childs life. home, school, hobbies the impact jia has on family life. home, hobbies the impact life has on the jia! accommodation / support available (home, religion and school),medication benefits other treatments / support agencies understanding of the disease,objective assessment,joint range of movement,range active passive pain feel stiffness end-feel palpation,look soft-tissue swelling effusion muscle atrophy hypermobility stability leg length,muscle strength,static dynamic manual muscle strength mrc / oxford scale myometry,stamina / endurance,specific muscle specific no. of reps. muscle fatiguing general 6 minute walk test subjective walking distance,balance / proprioception,standing on 1 leg eyes open eyes closed,posture / gait,head shoulders arms trunk hips knees feet,goals of treatment 1,no pain full joint range of movement. no contractures full muscle strength stable joints excellent stamina specific general,goals of treatment 2,good balance age appropriate neuro-muscular co-ordination maximal independent function educated family and child,pain relief,ice / heat packs / wax hydrotherapy stretches exercises tens splinting massage relaxation techniques,stretches,reduce pain reduce stiffness increase joint movement increase muscle length,loss of elasticity effusions,important rules of stretching,one joint at a time apply a slight traction force firmly , but gently slightly into the pain usually into extension - except: fingers, elbows & feet. even when joints are inflamed,hydrotherapy,reduce pain & muscle spasm increase joint range of movement reduce joint stiffness increase muscle strength increase aerobic capacity increase fun element to programme bouyancy,joints can only be actively protected by muscles.,exercises,reduce pain and stiffness maintain joint range of movement increase muscle strength increase stamina increase function increase independence as important as the medication,goals of exercise programme,specific muscle exercised at least 20 - 30 repetitions progress with weights up to 5lb (!10lb / 5kg) rehab. 5x weekly maintain 2-3x weekly other activities are a bonus swimming / yoga / pilates etc,muscle repair and growth,requirements exercise repetitions resistance concentric eccentric isometric isokenetic closed and open chain satellite cells can replace and increase numbers of muscle fibres. satellite cells are stimulated by exercise.,american academy of pediatrics recommendations,low resistance until 15 reps. strength and fitness increase with reps and resistance. need to train 20 30 minutes each session min. 2 3 times a week no increase in benefit of exercising 4/7 strength gains lost after 6 weeks of deconditioning.,pediatrics vol.107 no.6 june 2001,muscle strengthening and stamina,high repetitions low weights resistance work concentric and eccentric work open and closed chain postural / static work aerobic work,specific muscles not global,children do best with high repetitions and low weights,philosophy,the child and family should learn to self-manage the home exercise programme.,physiotherapy is there to provide the tools.,cytokines, muscles and exercise,why do children with rheumatlological disease get so weak?,“flu”,how do your muscles feel ?,this feeling is caused by:,cytokines,paediatric rheumatology,children have weaker muscles pain swelling stiffness loss of movement loss of activity and mobility unbalanced muscles disease activity cytokines,cytokines,pro-inflammatory il-1 il-6 il-8 il-15 tnf,anti-inflammatory il-4 il-10 il-13,not that simple!,action of each cytokine depends upon how it reacts with all the others and how much of it there is!,il-10,level too low = inflammatory changes muscle changes level too high = inhibition of: tnf il-1 il-6,=reducing inflammation,inflammatory disease cytokines reactive oxygen species (ros) proteolytic enzyme production depresses myofilament function insulin resistance loss of muscle protein muscle weakness adverse patient outcomes,winkelmann c; tnf aacn clinical issues, 2004,the cytokines that initiate and regulate inflammation also affect muscles.,when considering muscle function,inflammation vs normal response,il-15,reduces level of soluble tnf reduces muscle breakdown and atrophy important in the management of muscle atrophy in cancer patients,figueras m et al; febs lett. 2004,il-1 & toxic to muscles and induces fever,il-1 inhibits insulin-growth factor causing derangement of myocyte metabolism inhibits protein synthesis promotes muscle proteolysis,il-1 production of prostaglandins peripheral inflammation sensitivity to pain promotes apoptosis,winkelmann c; aacn clinical issues, 2004,il-6,tnf,inhibits,promotes,tnf,yi-ping li and michael b reid; current opinion in rheumatology 2001 respiratory research 2001,inhibits contractile function of skeletal muscles.,in the 1st few hours of increased levels: increases no production = reduction in contractile force. blunts the response of muscle cells to calcium activation,causes muscle atrophy,promotes protein loss via the central pathway that influences the inflammation genes (nf b),directly opposes insulin affects on muscles blocks glycogen uptake in muscles,chronic increase in tnf,inhibits protein synthesis in skeletal muscle causes skeletal cell myopathy and endothelial dysfunction.,tnf is important in muscle development and regeneration,increase in tnf occurs in 1st hours of cell differentiation and is required for normal cell differentiation. blocking tnf causes impaired expression of adult-type fast myosin heavy chain,tnf and mature myotubules,tnf reduces fast-type myosin heavy chain,tnf has a bi-phasic response,tnf increase in mm cells apoptosis of mature cells mature mm cells,tnf,il-6,winkelmann c; aacn clinical issues, 2004,multiple effects,increases il-1 increases production of b cells increases production of prostaglandins affects tnf production and regulation,il-6,pro-inflammatory cytokine produced by working muscles eccentric concentric endurance resistance dependent on effort and time normal response metabolism control,homeostasis,muscle function glycogen,il-6,il-6,il- 6,controlled by: type of exercise degree of exercise duration of exercise glycogen availability controls: glucose homeostasis lipolysis,cytokines and exercise,excessive eccentric, endurance and strenuous exercise causes an increase in cytokine production: local muscle inflammation local muscle damage glycogen supplies,muscle repair,moderate progressive resisted exercise programmes:,reduce production of: il-6 tnf improves the bodies homeostasis abilities efficient use of glycogen and lipolysis and therefore are,greiwe js; faseb j 2001,anti-inflammatory,castaneda c; am j kidney dis. 2004. gielen s; j am coll cardiol. 2003 perdersen bk; pflugers arch. 2003. starkie r; faseb j 2003,in healthy individuals a progressive resisted exercise regime has an anti-inflammatory effect. ? can we extrapolate to children with inflammatory disease?,conclusion,children with rheumatological conditions have many reasons to lose muscle strength and function. cytokines that control the disease also affect the muscle function.,children require progressive resisted exercise programmes in order to improve the biomechanical problems.,we propose that such exercises also contribute to muscle repair through cytokines,physiotherapy,should provide the tools to enable a full and actively independent life. but it will require participation in a regular specific treatment programme as well as participation in sporting activities.,but,swimming,pilates,walking,cycling,yoga,are not physiotherapy treatments,ethos of treatment programme,start exercise programme from beginning of diagnosis teach the children the exercises first specific exercises for specific joints explain the benefits of the exercises,associate the exercises with other activities i.e. sports training stamina training as well as muscle strength involve the parents,lifetime therapy programme 1:,inform & always be honest about goals select activities they enjoy that can be performed with minimal discomfort / inconvenience combine different activities include a recreational game that minimises skill & competition & maximises participant success use progress charts to recognise individual