Juvenile (PT)

Juvenile idiopathic Arthritis
Definition:
Juvenile idiopathic arthritis ( JIA ) is the most common of the rheumatic diseases
of childhood . It is characterized by joint inflammation , but can impact multiple
body systems , causing limitations , impairments , activity And participation
restrictions.
Other names : Juvenile Rheumatoid Arthritis . Juvenile Chronic Arthritis
■ An inflammatory disease of connective tissue mostly joints ( knees , elbows ,

and ankles ) . It may also involve adjacent muscles , cartilage and membranes
lining the joints .
■ More common in girls .
■ Incidence from 10 to 20 in 100,000 children per year .
Criteria for diagnosis:

-Onset before the age of 16 years.
Persistent Arthritis for at least 6 weeks involving one or more joints with presence
of at least two of the following findings :
-Limitation in range of motion .
-Tenderness or pain with joint movement.
- Increased fever.
-Painful swelling and stiffness in the joints.
Etiology:
The exact causes of JIA are unknown yet , JIA involves abnormalities of the
immune system , which defends our bodies against infections and diseases caused
by bacteria and viruses.
JIA is an autoimmune disorder. The immune system , begins to attack healthy cells
and tissues. The child's own immune system fights against connective tissue .The
result is inflammation- marked by redness , hotness , pain and swelling.
Types of Juvenile idiopathic Arthritis:

a ) Oligoarthritis ( Pauciarticular ) : in fewer than 5 joints ; 60 %
b ) Polyarthritis : inflammation in 5 or more joints ; 10 %
c ) Systemic : characteristic arthritis develops with fever ; 15 %
Pathology:
Manifestations of JIA:
➤Swollen , red or hot joints.
➤Joint stiffness especially in the morning including toes , knees , ankles , elbows ,
shoulders or neck joints .
➤The pain may begin suddenly or gradually , and may involve only one or many
joints .
➤ Movements of joints become more difficult .
➤ The child may refuse to walk .
➤ Irritability ; restlessness . In systemic cases rashes and fever or swollen lymph
glands .
➤Eye pain and redness.
➤Poor appetite ; weight loss and anemia.
➤Chest pain.
Diagnosis:
➤Blood tests that may include :
Rheumatoid factor ( RF ) .
Erythrocyte sedimentation rate ( ESR ).
Complete blood count ( CBC ) .
Low levels of RBCs ( anemia ) is common in JIA.
Increased levels of white blood cells may indicate an infection .
➤Arthrocentesis : A sample of synovial fluid in the joint for examination
➤Urine analysis: for protein , casts to indicate kidney disease associated with
several rheumatic diseases .
➤X - ray , MRI , CT of joint , Bone , muscles .
Physical therapy assessment:
History
• Morning stiffness and arthralgia during the day .
• A school history of absences , and their abilities to participate in physical
education classes severity of the disease . may reflect
• Typically , large weight bearing joints ; knees and ankles are affected .
• Both large and small joints can be involved in symmetric bilateral distribution .
• Muscle atrophy of extensor muscle is found and flexion contractures in the knees .
• Pain and sever limitations in ROM are usually accompanied by weakness and
decreased physical function .
2- Observation
3- Palpation
Measurement:
➤Long measurement for leg length discrepancy .

➤Leg length should be examined in supine , measuring from the anterior superior
iliac spine ( ASIS ) to the medial malleolus . The length of the femur and tibia
should be measured separately if the child has a hip or knee flexion contracture.
➤Round measurement for swelling ( knee effusion ).
5- Pain assessment:
Pain assessment should focus on the :

➤Type and quality of pain .
➤Source , intensity , location .
➤Duration , pain effects on personal lifestyle .
Symptoms were significantly associated with decreased participation in school and
social activities.
The child can also indicate pain distribution or location and intensity on a body
map using different colors to represent levels of pain intensity either red , yellow ,
green , blue . Children at least 5 years old can report pain intensity on a numeric
scale ( VAS ).
6- Manual muscle strength:
➤ Manual muscle testing .

➤ Functional muscle testing.
➤ Isokinetic testing.
➤Active ROM ➤Passive ROM
7- Posture:
8- Gait and functional assessment

Special problems:
Growth Disturbances: Since children are still growing when the arthritis affects
them , it can lead to growth disturbances . Short stature , jaw alignment and dental
problems and asymmetric growth disturbances can occur .
2 - Osteoporosis: Since these disorders affect growing skeleton it can lead to weak
bones.
3 - Emotional problems: Since a growing child goes through various stages of
normal development , these can be affected when JIA affects them .
4 - Schooling and education: These can be affected depending on the severity of
the disease . The school authorities may need to be informed about the chronic
nature of the condition and its tendency for episodes.
Goals for management:
➤Control the clinical manifestations of the disease.

➤Preserve joint integrity , mobility and function.
➤Prevent deformity.
➤Maximize function and minimize the disability.
➤Promote independence .
➤Provide education & support for the child and family.
➤Help a child have a normalifestyle . Preserve a high level of physical & social
functioning and maintain a good quality of life.
Aims of physiotherapy intervention:
➤Controlling pain .
➤Reduce swelling .
➤Improve range of motion .
➤Reduce joint stiffness .
➤Improve muscle strength and length .
➤Improve function and independence .
➤Improve mobility .
➤Ensuring normal growth & development .
During a disease flare:

•Limit activities depending on the joints involved.
•Sleep at least 10-12 hours each night & avoid overtired.
•Gentle passive ROM ( maintain the normal ROM of a joint ).
•Mild isometric exercises ( to maintain muscle strength ).
•Wearing a resting splint at night to support and protect an inflamed joint .
Once the flare is over :

➤Start regular activities again with rest periods.
➤Most children with JIA can take part in physical activities when their symptoms
are under control.
➤Isotonic exercises can improve muscle strength.
Pain management
Inflammation and muscle spasms around joints can cause significant pain and
movement problems .
1- TENS
2- Heat and cold
3- Ultrasound
4- Hydrotherapy
5- Relaxation techniques
Cold and heat therapy
•Analgesic effect in inflamed joints during acute flare .

•Ice or cold packs can be applied following heat therapy or can be used alone .
•Rest , ice , compression , and elevation ( RICE ) applied immediately to reduce
inflammation , swelling , and pain .
•Placing a dry towel between the cold source and skin allows the cold to penetrate
slowly without stinging .
•Taking a hot shower may relief morning stiffness .

•Taking a bath before going to bed may control night pain .
•Ultrasound as a source of deep heat .
•Infrared leads to an increase release of endorphins , which could affect the pain
gate mechanism .
•Superficial or deep heat applied directly over inflamed joints is contraindicated .
•Joints that are not swollen may benefit from heat in the form of hot packs , warm
whirlpools , paraffin or infrared .
Relaxation therapy:
Relaxation therapy in the form of massage can release muscle tension which helps
relieve pain and prevent adhesions in the subcutaneous tissues . It is applied with
heat treatment generally before stretching exercises .
Exercises
➤Range of motion exercises .

➤Stretching exercises .
➤Strengthening and endurance exercises
Intensity , duration and frequency adjusted
1-Range of motion
Active and passive ROM exercise can help to:

• Preserve and recover joint ROM .
• Preserve joint integrity , mobility and function .
• Passive ROM helps to maintain the joint ROM , this type of exercise have to be
done even when a child has acute inflammation and pain .
2-Streching exercise:
• After the active phase subsides , stretching exercises are the main exercises
performed to improve ROM & lengthening shortened tissues .
• Before_stretching , warm up exercises through light exercise , passive ROM &
heat modalities.
• The stretching exercises must be performed from 5 to 10 times in each session
twice a day ( 10- second hold , 20 - second relax ) .
• The joints could be stretched through active motion , e.g. kick a soft foam ball to
get active knee extension .
3-Strengthing exercise:
During an acute flare of arthritis

• Mild isometric exercises are helpful to maintain muscle strength .
When arthritis is less active
• Isotonic exercises can be done with or without weights to regain or improve
muscle strength .
4-Endurance exercises:
•With less active disease , aerobic or conditioning exercises could be applied

through:
➤Swimming
➤Bicycling
➤Walking .
•Physical therapist determine the level of intensity & duration of aerobic exercises
to increase endurance and provide cardiovascular fitness .
Splints
➤Children with JIA should avoid keeping their joints bent for long periods of time
to prevent joints stiffness and contractures.
Wearing a resting splint at night help to :

• keep the joints straight .
• Keep joints growing evenly .
• Prevent pain at night .
• Decrease morning stiffness .
• Help prevent contractures .
➤Commonly used splints include knee , wrist extension splints and ring splints for
the fingers .
➤Regular ROM exercises are very important when splints are used to prevent loss
of movement & improve flexibility .
Shoe lifts or inserts:
In unequal leg lengths by using shoe lifts or inserts help to :

➤Equalize leg lengths .
➤Improves the ability to walk normally .
➤Decreases the tendency to develop contractures
➤Redistribute weight into the heel taking weight off the middle or front of the
foot .
Assistive devises:
Adaptive equipments are appropriate for children whose daily activities are
limited.
➤Comb handles are extended.

➤Thicker spoon are used ,
➤Shoehorn to put on shoes ,
➤Angled glasses ( cervical stiffness ) ,
➤Clothes with easy opening or velcro ,
➤Lightweight wheel chair ( only a few children need wheelchair ) .
Prognosis:
•Outcome on all levels depends highly on the disease type and course.
•The largest percentage of children ( with the oligoarticular JIA ) recover
completely within 1 to 2 years.
•Only about 15 % of all children with the JIA will have permanent disabilities.
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Juvenile idiopathic Arthritis

■ An inflammatory disease of connective tissue mostly joints ( knees , elbows ,

Criteria for diagnosis:

Types of Juvenile idiopathic Arthritis:

➤Long measurement for leg length discrepancy .

Pain assessment should focus on the :

6- Manual muscle strength:

➤ Manual muscle testing .

8- Gait and functional assessment

Goals for management:

➤Control the clinical manifestations of the disease.

Aims of physiotherapy intervention:

During a disease flare:

Once the flare is over :

Cold and heat therapy

•Analgesic effect in inflamed joints during acute flare .

•Taking a hot shower may relief morning stiffness .

➤Range of motion exercises .

Active and passive ROM exercise can help to:

During an acute flare of arthritis

•With less active disease , aerobic or conditioning exercises could be applied

Wearing a resting splint at night help to :

Shoe lifts or inserts:

In unequal leg lengths by using shoe lifts or inserts help to :

➤Comb handles are extended.

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