Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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