Page 2 P H Y S I O T H E R A P Y MARCH, 1972 THE PHYSIOTHERAPIST and JUVENILE RHEUMATOID ARTHRITIS JO A N B A L D W IN , B.Sc. Phys. (R and) Reprinted by kin d permission fro m Journal o f the Canadian Physiotherapy Association, Vol. 23, N o. 3, June, 1971 The Juvenile R heum atoid A rthritis U n it a t T he H ospital for Sick Children, T o ro n to , recently did physical assess­ ments on 33 children suffering from rheum atoid arthritis. Many treatm ent program m es were revised in view o f the findings. R heum atoid arthritis is a systemic disease which is defined by Jones as affecting four o r m ore joints an d lasting longer than three m onths. Initially the disease attacks joint synovial membranes progressively destroying cartilage an d bone and producing disruption o f the joint. T he disease may encroach on surrounding muscles, nerves, tendons, bursae an d m ay directly attack supplying blood vessels. Juvenile rheum atoid arthritis, often called Still’s disease, djffers from the adult form in th a t it often presents with high spiking fevers and rashes, and also differs in the type o f deformity (see list o f com m on deformities). The onset in the adult is insidious and less dram atic. Several groups consider it m ay even be a different disease. U nlike adults, immobilized for lengthy periods, children tend to be mobile once the initial fever (lasting one to tw o weeks) has been controlled and in spite o f acute jo in t involvement. Because o f these differences the m anagem ent o f the disease has to be modified. T he peak onset ages were found to be between one to three and seven to ten years o f age, closely conform ing to the studies done by L aaksonen an d Laine, an d Ansell and Bywaters. T he older th e child a t the onset o f the disease, the more severely his joints were affected and the slighter his chance th a t the disease would become inactive. In 70 per cent o f childhood cases, however, th e disease is thought to become inactive after a d uration o f one to eight years. Influenced by such findings, a program m e was designed to help the child develop as norm ally as possible during the active phase o f the disease. A functional grading was also devised fo r b o th the upper and lower limbs. This to o k into account (a) the num ber of joints affected; (6) the num ber o f fixed deform ities; (c) the age o f onset; and (rf)the d uration o f the disease. The results o f these assessments indicated that, due to the greater num ber o f joints affected, th e lower limb usually suffered greater functional im pairm ent th a n the upper limb. In order o f frequency, th e m ost com m on deformities seen in 33 cases were: (a) wrist fixed in a flexed position (b) hip flexion contracture (c) knee flexion contracture (d) loss o f p ro n atio n and supination (e) lim itation o f neck extension ( / ) lack o f flexion at the m etacarpophalangeal joint and lack o f extension a n d /o r flexion at the proxim al inter- phalangeal joints. I. T H E A IM S O F P H Y SIO T H E R A P Y In our program m es, m inim al bed rest an d maximal mobility are encouraged. M any children, however, especially M rs. Baldwin graduated fro m the University o f ,the Witwatersrand, Johannesburg, South Africa, in 1960. She worked in South Africa, England and Norway before coming to Canada where she worked in two other hospitals before joining the H ospital fo r S ick Children. She is now Research Therapist, Juvenile Rheumatoid Arthritis Unit. in th e early stages, may require m ore rest an d sleep than norm al children. O ur aims are: 1. T o relieve pain. 2. T o prevent deformities by stretching, strengthening a n d splinting. 3. T o record the process o f the disease (Fig. 1). 4. T o help prevent em otional disturbances by ensuring th a t th e child participates in norm al, daily activities. 5. T o provide pre- and post-surgical treatm ent for children when necessary. These program m es vary w ith each patient and doctor. T he post-surgical treat­ m ent is intensive and specific for each individual. II. M E T H O D S AND R A T IO N A L E O F TREATING A R T H R IT IC C H ILD R EN I t should be emphasized th a t only a small percentage of children seen in the R heum atoid Clinic need physiotherapy treatm ent. The children are assessed by a rheum atologist, physiotherapist an d social w orker before a treatm ent regimen is established. E ducation arid household routines are disrupted as little as possible, treatm ents being done after school and in the p atient’s hom e whenever possible. M uch has been w ritten o n the parents’ role in enforcing one h o u r o f exercise daily. F o r the large family this m ay be an unnecessary dem and and may create feelings o f guilt in the busy m other who has difficulty finding the time. Specific exercises, such as quadriceps drill, are, however, taught to th e parents when possible. These are simple and should be kept to the minim um . R egular daily activities and, in some cases, periodic supervision by a physiotherapist should be adequate to ensure th a t muscle strength and jo in t mobility are m aintained. A. P ool Therapy In a heated pool, G ro u p program m es th at stress strength­ ening an d stretching are popular with patients. The buoyancy o f the water facilitates m obility; the setting prom otes social mixing. M ore joints can be exercised simultaneously and m ore patients can be treated a t one time. B. Exercise Therapy Exercises using proprioceptive neurom uscular facilitation (P N F ) technique a n d /o r isometric routines incorporate mass movem ent patterns and prove an-efficient, time-saving way o f exercising when several joints and muscle groups are affected. The adaptations fo r various age groups are dis­ cussed in th e section “ T reatm ent for D ifferent Age G roups” . C . Using Daily Activities E ach age group has certain abilities, skills and activities which should be used as exercise. D . Special Techniques 1. Stretching techniques can be used in specific cases where ligamentous and capsular tightening restrict accessory movem ents. Techniques using tractio n w ith minim al passive movem ents break th e small fibrinous adhesions. Restoring these movem ents will in tu rn stim ulate the synovial mem­ brane an d secretion o f synovial fluid thus lubricating the jo in t. They are m ost effectively perform ed on affected finger joints but do not w ork in every case and should only be done by trained personnel. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) MARCH, 1972 P H Y S I O T H E R A P Y Page 3 KEY CKffltBAT. ASSESSMENT CHART ( JUVENILE RHEUMATOID PROJECT - HOSPITAL FOR SICK JOINT INVOLVEMENT (Mark in Red) Affected Joint ^ Fixed Deformity Deformity Can j— i Be Passively U Corrected MOBILITY PLANES OF MOTION RANGE OF MOTION I , Flexion & Extension I I . Abduction & Adduction I I I . Rotation (in t . & ext. or- pron. & sup in) a."Normal Range b.-Stretched Range c.sShortened Range d.°M id Ranee max max shortened ^ Ik stretched * >— < GENERAL Acute Tenderness on Palpation Tenderness on motion Crepitus Tenderness on Extreme Motion ' “5 ? # • V / f 1 \ \ V REMARKS HANDS FEET 2 . Splinting is used either to prevent or correct deformities. Once a deformity has developed, an individual splint has to be devised to correct o r minimize it. In the past, splinting for children’s joints has been the same as that fo r adults. Deform ities in children, however, Qmer from those in adults (see earlier list o f com m on uetormities) and consequently the physiotherapist, Occu- PA l?na! T herapy D epartm ent and O rthopaedic W orkshop m tK ° i IC J-,ePartm ent) are experim enting w ith new splinting tnK u S and raaterials. T he children’s splints have tended anH i, ’ included unaffected joints, increased deformities no have not been durable. We are experimenting with nlact^r’ coate^ P o ster, fiberglass im pregnated bandages and c materials such as sansplint and polycast. M ost o f these splints are m ade in the p atient’s home, an im portant factor when selecting splinting material. The wrist splint is applied after three m onths if the wrist remains swollen an d limited in m otion (especially extension) o r if there is a wrist flexion contracture. A plastic backslab (sansplint® ) is th e m ost com fortable type o f wrist splint because it “ pulls” rath er th an “ pushes” the wrist into slight extension. T he backslab extends from m id-forearm to one- h a lf inch proxim al to the m etacarpal heads; an anterior b a r extends across the palm . Fingers are not included in the splint since finger m otion should be encouraged especially a t the m etacarpo-phalangeal joint, which frequently lacks flexion. F urtherm ore, u lnar drifting o f the fingers is un­ com m on in children. T he splint is w orn m ost o f the day R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Page 4 P H Y S I O T H E R A P Y MARCH, 1972 and night, the tim e being decreased as pain subsides and m ovem ent returns. The knee splint is applied to a swollen knee jo in t th a t has developed a flexion contracture. A bivalved stovepipe type o f cast is used fo r this purpose and the patient is encouraged to walk as m uch as possible. T he cast is rem oved for exer­ cises. W hen w alking w ith the knee extended, n o t only are th e quadriceps muscles being w orked statically against the resistance supplied by the body weight, b u t also th e collateral ligaments and capsule are taught, thus stretching these tightened structures. The p atient wears the cast day and night until the contracture has been corrected an d the quadriceps are strong enough to m aintain the knee in extension when walking. This may require three to four m onths. As this m ethod o f splinting differs so radically from th e conventional resting splints, we are docum enting all cases and studying the problem s o f m anaging knee flexion contractures in children. F o r th e children requiring a resting knee splint fo r pain, swelling and severe m orning stiffness, a bivalved stovepipe cast seems m ost satisfactory. T he foot is rarely enclosed in th e cast since usually th e knee can be fully extended w ithout it. Since children are seldom immobilized in bed, there is no tendency to foot drop, even when the ankle is affected. C rutches are seldom used as th e m ajority o f children are able to bear weight and move well once th e initial morning stiffness is overcome. ID . T R E A T M E N T F O R D IFFE R E N T A G E G R O U PS A. One to Three Years Tickling th e bottom s o f th e feet results in hip and knee flexion. Placing a bracelet over the fo o t results in hip and knee flexion when th e child tries to pull it off. Certain toys can be used to correct problem s. A tricycle stresses hip an d knee flexion as well as knee extension, ankle plantar, and dorsiflexion. D rum s o r xylophone encourage finger flexion and static w rist extension. Blocks and building toys require finger movements. T he child should be encouraged to walk an d feed himself. Binding techniques, whereby th e therapist grasps the child firmly and then encourages him to break free, results in the child unw ittingly exercising isometrically against the m anual resistance. F o r example when the therapist stretches th e child’s arm s above his head he tries to bring his arm s dow n producing isometric contractions o f shoulder extensors, elbow, wrist an d finger flexors. W hen a child’s legs are painful, he will prefer to sit, and his parents m ay have to lure h im in to w alking by placing a favourite toy beyond reach. The m other is show n w hat play techniques will help her child exercise in his m orning bath. T he w arm b ath also relieves early m orning stiffness. B. Four to Six Years C hildren in this age group enjoy hitting a balloon thus exercising shoulder elevators, elbow, wrist and finger extensors. Toys such as a bicycle o r skipping rope provide ad ditional exercise. Should there be increased'- swelling o r pain after an activity such as skipping, the activity is de­ creased and elim inated if necessary. Pool therapy in w arm w ater can be started in this age group. Isom etric exercises using binding techniques (see under O ne to Three Years) are helpful. T he m other should teach h e r child to dress an d undress. She should also encourage an d praise him , and report to th e physiotherapist any problem s such as increase o f pain and swelling after certain activities, inability to perform any daily activity, any new jo in t involvement, behavioural problem s o r problems with medication. C. Seven to Ten Years Play techniques such as ball throw ing will prom ote m obility o f th e joints. A lthough body contact sports such as football are discouraged, activities such as ice skating, bicycling and swimming are encouraged. O rganized resisted exercises using isometric and P N F techniques can be fun especially if the routine is changed frequently. Participation in either Brownies o r Cubs is socially beneficial fo r the child. D om estic activities are also encouraged. Pool therapy is popular. The parent should support an d encourage th e child an d report any problems to th e therapist. D . Eleven Years and Over O rganized resisted exercises using P N F w ith isometric exercises, o r isometric exercises alone, are helpful. Dancing and swimming are popular and foster cam araderie. Pool therapy is excellent. C ooking and babysitting for girls and repair jo b s fo r boys prom ote n atu ral exercise. Taking m edication and exercising are now th e responsibilities o f the child w ho can be taught exercises fo r specific problems. H e should be encouraged to rep o rt any problem s to the physio­ therapist. IV . G EN ERA L TRE A TM EN T D ISC U SSIO N T he majority of. children w ith jo in t m obility loss and/or muscle weakness require only a weekly visit from th e thera­ pist. We found in com paring results o f the “ once weekly group pool therapy program m e” to those o f th e “once weekly hom e exercise program m e” th at hip and knee m obility as well as quadriceps strength was m aintained but n o t increased in 90 per cent o f th e patients in both groups. Twelve children (six per group) to o k p art in these pro­ gram mes and it was felt th at, physically, the programmes were o f equal benefit. Should specific muscle strengthening an d jo in t m obilization be required, a m inim um o f three treatm ents per week is necessary and should be done in the child’s hom e by either the parent or physiotherapist. When the child’s arthritis becomes inactive, regular check-ups are still essential to prevent deformities resulting from weaknesses and to modify treatm ents. Such check-ups should continue until the child stops growing. I f the parents are unco-operative o r unable to assist, the physiotherapist may have to assum e the responsibility for the. child’s weekly treatm ent. The child o f unco-operative parents may have difficulty coping w ith arthritis in later life. I n addition, a specialized treatm ent centre provides vocational guidance, aptitude testing and physical tolerance assessments, orthopaedic research brace shops, research units, and com m unity physiotherapy. The physiotherapist is p a rt o f a team consisting o f paediatric rheum atologists; paediatric orthopaedic surgeons; paediatric opthalm ologists; social w orkers; occupational therapists; public health nurses. Such a team is dedicated to caring fo r children suffering from juvenile rheum atoid arthritis. BIB LIO G R A PH Y Ansell, B arbara, and Bywaters, E. G . : “D iagnosis o f 1 ‘P robable’ Still’s Disease and Its O utcom e.” 1962, Ann. Rheum. Dis., 21: 253. H ollander, J. L .: “ A rthritis an d Allied C onditions,” 6 th E dition, 1960, Lea and Febiger, Philadelphia. L aaksonen, A. L ., an d Laine, U . A .: ‘‘C om parative Study o f Jo in t Pain in A dult an d Juvenile Rheumatoid A rthritis.” 1961, Ann. Rheum. Dis., 20: 386. C O R R E C T IO N D EC E M B ER , 1971 M odular Lower Extrem ity Prosthetics by J. FO O R T , form erly Technical Director, Manitoba Rehabilitation Hospital, Winnipeg, Canada. South African Jo u rn al o f Physiotherapy, 1971, 27(4): 2-5. The p hotograph labelled “ A M odular H ip D isarticulation Prosthesis o f the W innipeg type,” on page 2, should be preceded by Fig. 3. I t is an integral p a rt o f the article, “ M odular Lower Extrem ity Prosthetics,” by J. F oort, pages 3-5. T he last line o f colum n 1, page 4, should read : “ . . - the socket bolted on to the hip jo in t (Fig. 3)” . R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )