Physiotherapy plays a very important part in the management of arthritis and your child should see a physiotherapist who has experience with juvenile arthritis.
Your Consultant or GP will be able to refer your child to a suitable physiotherapist. Your physiotherapist will be trained to assess your child’s needs and provide invaluable advice.
There will, of course, be differences in styles of treatment between physiotherapists. If you are seen at a centre for juvenile arthritis your physiotherapist will communicate with your local physiotherapist, if involved, to ensure continuity of treatment.
There may be a physiotherapist present in the rheumatology clinic or you may have to take your child to a hospital department or health centre.
At the initial consultation your physiotherapist will spend time talking with you and your child to assess their needs, review their history and any particular difficulties or pain they may have.
A full assessment will be made of your child’s posture, walking style, freedom of joint movement and muscle strength. From this assessment they will give you a personalised exercise programme to follow at home. It is essential that you and your child find time to carry this out as advised. The physiotherapist will also give you further appointments to monitor how your child is progressing and fine-tune their programme specifically for them.
Initially frequent and regular appointments may be necessary; this should decrease as you, your child and your physiotherapist become confident that the programme is having the desired effect.
It is important that you have contact details of your physiotherapist readily available so that you can seek their advice quickly should your child develop new symptoms.
The exercise plan may involve the following;
• Muscle strengthening exercises
• Balance and co-ordination exercises
• Fitness training
• Stretches to muscles and joints
• Advice on icing, hot packs and other pain relieving methods
Exercise is beneficial to us all but it is a vital part of the treatment of juvenile arthritis.
It is very important to exercise even when your joints are very sore, increased mobility will result in freer movement and increased muscle strength. Your child may also be reluctant to move, as they may be frightened of the pain. However, by exercising and stretching joints and muscles you will help to ease the stiffness and reduce the pain.
It is important that your child is given the correct exercises to carry out and if their joints are particularly sore, adequate pain relief should be made available when performing these exercises.
This will be decided on an individual basis depending on the joints that are affected.
Muscle weakness happens quite quickly in children with arthritis, as muscles are not being used and exercised in the normal way, inflammation also contributes further to this weakness.
It is important that each exercise is repeated (usually 15 times) and increased (usually to 30 times), as your child gets stronger. The physiotherapist may then advise you to add weights during these exercises to increase the muscle strength further. It is important that these exercises are carried out at least four times a week.
Balance and co-ordination exercises are also useful to help your child carry out functional activities more easily.
As your child becomes stronger and fitter the programme can again be modified and performed at a level that maintains this fitness, usually 2-3 times a week.
As well as exercising it should be remembered that your child may be easily tired and rest periods can therefore be important during the day.
Maintaining and improving cardiovascular fitness helps maintain healthy organs, muscles and joints, can assist weight control and promote self-esteem.
Swimming, cycling and lower impact sports are advisable initially and when your child is ready they can participate in higher impact or contact sports.
Although your child may not be able to take part in their usual sports your physiotherapist will advise you on which sports will be beneficial. Sports do not take the place of the home exercise programme but are an important addition.
Stretches need to be taught by your physiotherapist, as it is very important to stretch muscles and joints in the correct way. It is a good idea to try and do them in the morning to help relieve the morning stiffness and pain but doing them in a warm bath is also beneficial.
Hydrotherapy (exercising in water) is offered in many hospitals. It is an ideal form of treatment as the warm water will ease pain and support the body to make exercising easier.
It is also very enjoyable and you can learn the exercises you are shown and perform them at your local pool. Some pools have specific sessions designed for those who have mobility problems. These sessions are quieter and the water may be at a higher temperature. It is worth asking at your local pool about these sessions, if they are not offered then exercising at your local pool is still advisable, however, keep the sessions shorter to avoid your child getting cold.
The use of splints is less common but there may be a reason to provide your child with a splint. If it is to address loss of movement because of tissue shortening, the use of a splint will be accompanied by an intensive stretching and exercise regime.
Pain can be very difficult to cope with and is unfortunately a feature of juvenile arthritis. Medication is important to alleviate pain but your physiotherapist may advise other methods, in addition to the home exercise programme, to work alongside drug treatment to help with pain relief. The following can be useful:
• Ice and hotpacks
• TENS (Transcutaneous Electrical Nerve Stimulation)
Ask your physiotherapist for more information on these methods.
As long as you have given permission your physiotherapist will be able to contact your child’s nursery or school and speak to their teacher and/or SENCO (Special Educational Needs Co-ordinator). Each school has an appointed SENCO whose role it is to support any child with a special need.
Ideally your physiotherapist would be able to visit the school to assess the environment and give practical advice. Schools are usually delighted to arrange a visit and very welcoming of any help and advice that your physiotherapist may offer.
There may be specific issues to discuss with the school, for example:
• Problems with accessing the school environment – The school may have a lift that your child could use or they could be allowed extra time to travel between classrooms. It is useful to check that the chair and desk allows good posture to be maintained, that your son or daughter is sitting in a position where they can comfortably see the board and that they can get up and move around the classroom easily if they need to. If they find sitting cross-legged difficult they should be allowed to sit on a chair.
• Carrying of heavy bags – The school may be able to appoint a ‘buddy’, one of your child’s friends who can carry heavy books for them. The school may also be able to allow your child two sets of books, one for school and one to keep at home avoiding unnecessary carrying. It is useful if the school can provide an accessible locker for your child
• Extra time in exams – Particularly if your child’s hands or wrists are affected it is important that they are allowed rest breaks and extra time in exams. They also may be entitled to a ‘scribe’, someone to write in the exam for them.
• Participating in PE – Your physiotherapist can advise the school on the best exercise for your child to participate in. This may change as your child’s condition changes.
• It is important that your child has the opportunity to join in with their classmates but he or she must be allowed to stop or ease up on an activity if they are starting to struggle. With younger children, schools are often happy to incorporate your son or daughter’s exercises into the PE session.
• Adequate rest periods – If your child gets tired easily it may be useful to have somewhere quiet within the school that they can go to either alone or with a friend during break or lunch times.
There can be times when your child does not want to do their exercises. This is perfectly understandable and it can be hard to motivate them but it is so important to encourage them, as it will help to reduce their pain and increase their muscle strength. These positive effects will help with their functional independence.
Having a set time to do the exercises and being present in the room with them, even if you are not actively involved, may help. Doing the exercises to their favourite music or DVD may help. A sticker chart or appropriate reward system may work with your child depending on their age.
It is useful to discuss these problems with your physiotherapist, as they may be able to assist by altering the exercises if they have become boring and review your child more frequently.
By explaining, in ways your child is able to understand, what happens within their joints with arthritis and why the treatment is so important you will be working together with the professionals involved to improve the quality of life for your son or daughter.
Glenda Dalton, Senior Paediatric Physiotherapist, at Milton Keynes General NHS Foundation Trust