Download Physiotherapy for Juvenile Idiopathic Arthritis

Physiotherapy for
Juvenile Idiopathic
Arthritis
Sue Maillard MSc
Specialist Physiotherapist
Paediatric Rheumatology
Great Ormond Street Hospital, London
J.I.A.
►a
disease effecting a
growing developing
skeleton.
R.A.
►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.
Goal setting
Assessment
Interventions
Subjective Assessment
► Symptoms
/ Pain / Stiffness
 When, where, what
► The
impact JIA has on the child's’ 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
► Look
► Soft-tissue
► Active
► Effusion
► Passive
► Pain
► Feel
► Stiffness
► Muscle
atrophy
► Hypermobility
► Stability
► End-feel
► Palpation
swelling
► 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
Assessment
Interventions
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
Goals
Assessment
Interventions
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
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
Children do best with high
repetitions and low weights
► Low weights
► Resistance work
► Concentric and eccentric work
► Open and Closed chain
► Postural / static work
► Aerobic work
Philosophy
The child and family should learn to
self-manage the home exercise programme.
Cytokines, Muscles and
Exercise
“FLU”
This feeling is caused by:
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
Anti-inflammatory
IL-1
IL-6
IL-8
IL-15
TNFα
IL-4
IL-10
IL-13
IL-10
► Level
too low =
► Level
too high = inhibition of:
 TNFα
 IL-1
 IL-6
inflammatory changes
muscle changes
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; TNFα AACN Clinical Issues,
2004
When considering Muscle
Function…..
IL-15
► Reduces
level of soluble TNFα
► Reduces muscle breakdown and atrophy
► Important in the management of muscle
atrophy in Cancer patients
Figueras M et al; FEBS Lett. 2004
IL-1α & β
Toxic to Muscles and induces fever
►
►
►
IL-1 α
Inhibits insulin-growth
factor
 Causing derangement of
myocyte metabolism
Inhibits protein synthesis
Promotes muscle
proteolysis
IL-1β
►
►
►
►
Production of
prostaglandins
Peripheral
inflammation
Sensitivity to pain
Promotes apoptosis
Winkelmann C; AACN Clinical Issues, 2004
INHIBITS
PROMOTES
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 – κB)
Directly opposes Insulin affects on muscles
Blocks glycogen uptake in muscles
Chronic Increase in TNFα
Inhibits protein synthesis in skeletal muscle
Causes Skeletal cell myopathy and endothelial
dysfunction.
TNFα is important in
Muscle development and
regeneration
► Increase
in TNFα occurs in 1st hours of cell
differentiation and is required for normal cell
differentiation.
► Blocking
TNFα causes impaired expression
of adult-type fast myosin heavy chain
TNFα and Mature Myotubules
TNFα reduces fast-type myosin heavy chain
TNFα has a bi-phasic response
TNFα
Increase in MM cells
Apoptosis of mature cells
Mature MM cells
TNFα
Winkelmann C; AACN Clinical Issues, 2004
Multiple effects
► Increases
IL-1
► Increases production of B cells
► Increases production of prostaglandins
► Affects TNFα 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
IL-6
Muscle function
GLYCOGEN
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
Moderate progressive resisted
exercise programmes:
► Reduce
production of:
 IL-6
 TNFα
► Improves
the bodies homeostasis abilities
 Efficient use of glycogen and Lipolysis
AND THEREFORE ARE
Greiwe JS; FASEB J 2001
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.
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
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
achievements / set goals & contracts
► Periodic 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 them with others
► Exercise in different places & facilities
► Progress at a rate unlikely to promote injury,
but that provides a challenge
► Variation
► Choice
Lifetime Therapy Programme 3
► Specific
exercise programme to ensure
muscles are strong enough and fit enough
to protect joints.
► Home exercise programme will alter
depending upon disease activity
 Rehab / maintenance
► Paced
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 quick
►Lack
of activity
►Pain
►Loss
of range of movement
► Strength
only regained with exercise
New Philosophy