REHABILITATION OF THE CHILD WITH JIA

Goals of treatment include controlling symptoms, preventing joint damage, achieving normal growth and development, and maintaining function and normal activity levels.

Treatment goals may vary during maintenance and acute flare-ups of the disease.

Resting a joint may be necessary during an acute flare-up to prevent aggravation of the disease process; activities that affect or excessively stress joints should be discouraged during acute flare-ups. Resting a joint may also be useful during the maintenance phase for joint protection. Rest periods may be necessary to reduce fatigue; resting in the prone position will help reduce hip and knee flexion contractures.

Splinting is used during a flare-up to provide alignment during a rest period. Functional splints may be used during flare-ups and maintenance phases if they provide joint relief and allow functional activities without stressing inflamed joints. Splinting can be used during the maintenance phase to promote local joint rest, support weakened structures, and assist function. To prevent flexion contractures, the upper extremity is splinted in a functional position as follows: wrist 15 to 20 degrees of extension, some finger flexion, 25 degrees at the metacarpophalangeal (MCP) joint, and 5 to 10 degrees at the PIP joint, with the thumb in opposition. Ring splints can be used for finger deformities. Knee immobilizers may be used to maintain knee extension at night; rotate on alternate legs for better compliance. Dynamic splints or serial casts can increase ROM. Foot orthoses can promote arch support and reduce pain in weight-bearing.

Gentle ROM with passive extension greater than flexion two to three times a day is used to preserve joint ROM. Incorporating pain medication, progressive muscle relaxation, breathing exercises, biofeedback, massage, or doing the exercises in a nice, warm tub can greatly facilitate ROM exercises. Gentle ROM exercises should be done as tolerated during acute flare-ups to prevent flexion contractures.

Heat is an excellent modality in the maintenance phase to decrease stiffness, increase tissue elasticity, and decrease pain and muscle spasm. Hydrotherapy with temperatures 90 to 100 degrees Fahrenheit, fluidotherapy, paraffin, or moist heat can be used. Most children prefer heat to cold. Taking a hot bath or shower, sleeping in a sleeping bag, or using a hot pack (along with ROM exercises) may help relieve morning stiffness. Caution must be exercised in insensate areas to avoid burns. Ultrasound is contraindicated in children with open growth plates. Heat should not be used during an acute flare-up, as it increases the inflammatory response and causes further joint destruction.

Cold can be used during an acute flare-up for pain relief and to decrease swelling. It may also be beneficial during the maintenance phase for the same reasons. Cold should not be used over insensate areas or in those with Raynaud's phenomenon.

Adaptive strengthening exercises can be incorporated into play and recreational activities. Some examples include throwing a ball (strengthens elbow and shoulder), riding a bike (promotes knee and hip extension), and swimming (decreases weight-bearing on painful joints). Incorporating general aerobic conditioning is also important and may include activities such as swimming, dancing, noncontact karate, and tai chi. Isometric strengthening exercises are fine during an acute flare-up, but vigorous exercise should be avoided until the acute process is over. Hydrotherapy can be combined with land-based physiotherapy in treating JIA (114).

Adaptive equipment can be used for joint protection, rest, and to minimize further joint destruction during both phases. Examples include adaptive utensils, adaptive pens and computer access, table and desk modifications (to prevent excessive trunk and neck flexion), zipper pulls, dressing sticks, long-handled brushes, elastic waistbands, Velcro closures, and larger buttons. Children should actively participate in functional activities of daily living (ADLs) training in order to choose acceptable devices and improve their use.

Activity and ambulation should be encouraged as much as possible. A posterior walker for upright posture (with decreased flexion) and a standing program may be useful for functional mobility training if wheelchair use cannot be avoided. In children with JIA, custom-made semirigid foot orthotics with shock-absorbing posts have been found to significantly improve pain, ambulation speed, self-rated activity, and functional ability levels compared to prefabricated off-the-shelf shoe inserts or supportive athletic shoes alone (115).

A presurgical joint rehabilitation program aims to strengthen the muscles needed for mobility in the postoperative period, train for future ambulation aids, and identify other joint involvement that may affect the rehabilitation process. Postsurgical rehabilitation fulfills those goals set in the presurgical rehabilitation program. Ambulation aids such as the platform walker may be used to better distribute weight-bearing pressure on affected upper extremity joints after knee or hip surgery. In children, post hip prosthesis, the acetabular component should be checked for loosening (as opposed to the femoral component in adults), especially if children are active.

Growth retardation can occur during periods of active disease; it may also be compounded by corticosteroid use. Maximize growth by promoting optimal nutrition. Children with JIA should eat a balanced diet with supplemental multivitamins, calcium, vitamin D, and sunshine secondary to the high risk of osteopenia. Plenty of (nonimpact) activity again should be encouraged.

Counseling for both the child with JIA and his or her family should be provided to maximize psychosocial and emotional well-being. Treatment goals also include addressing family, school, and vocation. Assisting in the preparation of a 504 plan for school accommodations enables a child with joint disease opportunity for more complete participation in his or her school life and academic career. Summer camps are a practical way of addressing peer support within adolescent rheumatology services; positive effects include increased control, self-esteem, physical fitness, independence from parents, self-management of health care, and an opportunity to meet others with a similar condition (116).

 
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