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1、Physiotherapy forJuvenile Idiopathic Arthritis,Sue Maillard MScSpecialist PhysiotherapistPaediatric RheumatologyGreat 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
2、 there is the capacity for regeneration,re-modelling and repair.This needs to be used to a maximum.,Subjective Assessment,Symptoms/Pain/StiffnessWhen,where,whatThe impact JIA has on the childs life.Home,school,hobbiesThe impact JIA has on family life.Home,hobbiesThe impact life has on the JIA!Accomm
3、odation/support available(home,religion and school),MedicationBenefitsOther treatments/support agenciesUnderstanding of the disease,Objective Assessment,Joint Range of Movement,Range ActivePassivePain FeelStiffnessEnd-feelPalpation,LookSoft-tissue swellingEffusionMuscle atrophyHypermobilityStability
4、Leg length,Muscle Strength,Static DynamicManual Muscle Strength MRC/Oxford scale Myometry,Stamina/Endurance,SpecificMuscle specificNo.of reps.Muscle fatiguingGeneral6 minute walk testSubjective walking distance,Balance/Proprioception,Standing on 1 legEyes openEyes closed,Posture/Gait,HeadShouldersAr
5、msTrunkHipsKneesFeet,Goals of Treatment 1,No painFull joint range of movement.No contracturesFull muscle strength Stable jointsExcellent Staminaspecificgeneral,Goals of Treatment 2,Good balanceAge appropriate neuro-muscular co-ordinationMaximal independent functionEducated family and child,Pain Reli
6、ef,Ice/Heat Packs/WaxHydrotherapyStretchesExercisesTENSSplintingMassageRelaxation techniques,STRETCHES,Reduce PainReduce StiffnessIncrease Joint movement Increase muscle length,Loss of ElasticityEffusions,Important Rules of Stretching,ONE Joint at a timeApply a slight traction forceFirmly,but GENTLY
7、Slightly into the PainUsually into Extension-Except:Fingers,Elbows&Feet.Even when Joints are inflamed,HYDROTHERAPY,Reduce Pain&Muscle SpasmIncrease Joint Range of MovementReduce Joint StiffnessIncrease Muscle StrengthIncrease Aerobic CapacityIncrease Fun Element to ProgrammeBOUYANCY,Joints can only
8、be actively protected by MUSCLES.,Exercises,Reduce pain and stiffnessMaintain joint range of movementIncrease muscle strengthIncrease staminaIncrease functionIncrease independenceAs important as the medication,Goals of exercise programme,Specific muscle exercisedAt least 20-30 repetitionsProgress wi
9、th weights up to 5lb(!10lb/5kg)Rehab.5x weeklyMaintain 2-3x weeklyOther activities are a bonusSwimming/yoga/pilates etc,Muscle Repair and Growth,RequirementsExerciseRepetitionsResistanceConcentricEccentricIsometricIsokeneticClosed and Open chainSatellite cells can replace and increase numbers of mus
10、cle fibres.Satellite cells are stimulated by exercise.,American Academy of PediatricsRecommendations,Low resistance until 15 reps.Strength and fitness increase with reps and resistance.Need to train 20 30 minutes each sessionMin.2 3 times a week No increase in benefit of exercising 4/7 Strength gain
11、s lost after 6 weeks of deconditioning.,Pediatrics Vol.107 No.6 June 2001,Muscle Strengthening andStamina,High repetitionsLow weightsResistance workConcentric and eccentric workOpen and Closed chainPostural/static workAerobic work,Specific muscles not global,Children do best with high repetitions an
12、d 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 doChildrenwith Rheumatlological Diseaseget soWEAK?,“FLU”,HOW do YOUR MUSCLESFEEL?,This feeling is caused by:,CYTOKINE
13、S,Paediatric Rheumatology,Children have weaker musclesPainSwellingStiffnessLoss of movementLoss of activity and mobilityUnbalanced musclesDisease activityCytokines,Cytokines,Pro-InflammatoryIL-1IL-6IL-8IL-15TNF,Anti-inflammatoryIL-4IL-10IL-13,NOT THAT SIMPLE!,Action of eachCYTOKINEdepends upon how i
14、t reacts with all the othersand how much of itthere is!,IL-10,Level too low=inflammatory changes muscle changes Level too high=inhibition of:TNFIL-1IL-6,=Reducing inflammation,Inflammatory disease Cytokines Reactive Oxygen Species(ROS)Proteolytic enzyme productionDepresses myofilament function Insul
15、in resistance Loss of muscle proteinMuscle weaknessAdverse patient outcomes,Winkelmann C;TNF AACN Clinical Issues,2004,The cytokines that initiate and regulate inflammationalsoaffectmuscles.,When considering Muscle Function.,INFLAMMATIONVSNORMAL RESPONSE,IL-15,Reduces level of soluble TNFReduces mus
16、cle breakdown and atrophyImportant 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 factorCausing derangement of myocyte metabolismInhibits protein synthesisPromotes muscle proteolysis,IL-1Prod
17、uction of prostaglandinsPeripheral inflammationSensitivity to painPromotes apoptosis,Winkelmann C;AACN Clinical Issues,2004,IL-6,TNF,INHIBITS,PROMOTES,TNF,Yi-Ping Li and Michael B Reid;Current Opinion in Rheumatology 2001Respiratory Research 2001,Inhibits contractile function of skeletal muscles.,In
18、 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
19、 musclesBlocks glycogen uptake in muscles,Chronic Increase in TNF,Inhibits protein synthesis in skeletal muscleCauses Skeletal cell myopathy and endothelial dysfunction.,TNF is important inMuscle development and regeneration,Increase in TNF occurs in 1st hours of cell differentiation and is required
20、 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,TNFIncrease in MM cellsApoptosis of mature cellsMature MM cells,TNF,IL-6,Winkelmann C;AACN Cl
21、inical Issues,2004,Multiple effects,Increases IL-1Increases production of B cellsIncreases production of prostaglandinsAffects TNF production and regulation,IL-6,Pro-inflammatory cytokineProduced by working musclesEccentric ConcentricEndurance resistanceDependent on effort and timeNormal responseMet
22、abolism control,HOMEOSTASIS,Muscle functionGLYCOGEN,IL-6,IL-6,IL-6,Controlled by:Type of exerciseDegree of exerciseDuration of exerciseGlycogen availabilityControls:Glucose homeostasisLipolysis,CYTOKINES and EXERCISE,Excessive eccentric,endurance and strenuous exercise causes an increase in cytokine
23、 production:Local muscle inflammationLocal muscle damageGlycogen supplies,Muscle repair,Moderate progressive resisted exercise programmes:,Reduce production of:IL-6TNFImproves the bodies homeostasis abilitiesEfficient use of glycogen and Lipolysis AND THEREFORE ARE,Greiwe JS;FASEB J 2001,ANTI-INFLAM
24、MATORY,Castaneda C;Am J Kidney Dis.2004.Gielen S;J Am Coll Cardiol.2003Perdersen 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 w
25、ith rheumatological conditions have many reasons to lose muscle strength and function.CYTOKINES that control the disease also affect the muscle function.,Children requireprogressive resisted exercise programmesin order to improve thebiomechanical problems.,We propose that suchexercisesalso contribut
26、e tomuscle repairthroughcytokines,PHYSIOTHERAPY,Should provide the tools to enable a full and actively independent life.But it will require participation in a regular specific treatment programmeas well asparticipation in sporting activities.,But,Swimming,Pilates,Walking,Cycling,Yoga,Are not physiot
27、herapy treatments,Ethos of treatment programme,Start exercise programme from beginning of diagnosisTeach the children the exercises firstSpecific exercises for specific jointsExplain the benefits of the exercises,Associate the exercises with other activities i.e.sports trainingStamina training as we
28、ll as muscle strengthInvolve the parents,Lifetime Therapy Programme 1:,Inform&always be honest about goalsSelect activities they enjoy that can be performed with minimal discomfort/inconvenienceCombine different activities Include a recreational game that minimises skill&competition&maximises partic
29、ipant successUse progress charts to recognise individual achievements/set goals&contractsPeriodic assessments(positive reinforcement),Lifetime Therapy Programme 2,Set aside a regular time for exercise Use the proper clothing&equipment for exercise Find a friend(s)to exercise with Set goals&share the
30、m with others Exercise in different places&facilities Progress at a rate unlikely to promote injury,but that provides a challengeVariationChoice,Lifetime Therapy Programme 3,Specific exercise programme to ensure muscles are strong enough and fit enough to protect joints.Home exercise programme will
31、alter depending upon disease activityRehab/maintenancePaced activities,Important Considerations,Often an underestimation of normal muscle strength in children.Often starting with children who have less muscle strength than normal.Loss of strength is very quickLack of activityPainLoss of range of movementStrength only regained with exercise,New Philosophy,FIT for LIFE,Independent and Healthy Children,
