The Childrens Chronic Arthritis Association

An occupational therapist can help your child manage the daily activities of living and playing

As occupational therapists our main role is to assess and make some kind of intervention in the following areas:- Activities of Daily Living (ADL), Education, Leisure, Environment and Hand Function (including Splinting). We look at how the child’s JIA affects their ability to ‘get on’ as independently as possible in these areas at a level that is appropriate to their age and development. The first four areas will be briefly discussed, followed by a slightly more in-depth look at hand function and splinting. Lastly some information will be given about how to access the various occupational therapy services in your area.

ADL covers things like washing, dressing, going to the toilet, bathing, cooking, etc. The majority of children with-out JIA or any other illness are able to become independent in personal care between the ages of 5 and 7.
It is important to encourage children with JIA to become as independent as possible without setting them up for failure. Many children with JIA will become independent in line with their normal development, but if there has been a long history of JIA, especially systemic, and there is still ongoing active disease then the general rule of thumb would be to aim for full independence by the age of 10 years so that they are independent before puberty.
Children with JIA can often struggle because their joints lack the range of movement needed to do a task, or they are below the average height for their age. Most difficulties are overcome by the child themselves but they may benefit from some simple problem solving.
If a child has not been able to reach independence by this time then they may benefit from a fuller assessment of their difficulties and may need to use dressing aids (small tools and reachers that can help pull on/off and fasten clothes) or have their homes adapted to enable them to bath, go up and down stairs, use the toilet, use the kitchen independently.
Many children and young people will experience temporary difficulties in their independence during a flare but will return to independence after medical treatment and
physiotherapy. During this time it is important to encourage them to do as much as possible for themselves as is realistically possible. When a child has gained a skill (e.g.
pulling on socks) it is imperative that they keep up using it. If very unwell they may be given help but must return to doing as much for themselves as soon as possible, as a child can quickly forget the skill if not constantly using it.
Within day to day family life it is not always realistic to do dressing practice in the morning before school when there are a thousand other jobs to be done in half an hour. It is often therefore better to spend some more time practicing at the weekends.
Your occupational therapist may also use a more formal assessment or questionnaire in order to keep a record and measure of the current level of independence.

Education
This area addresses how a child’s difficulties can compromise their ability to perform and learn to their maximum potential.
JIA can interrupt a child’s ability to fully embrace their education. This may simply be through absence and hospital admission or physio / hydro appointments. It may be that their hand function is affected and that writing is painful and tiring. Getting around a busy school can be tiring and scary for a child who is having difficulties in walking. A child may also need their seating, desk height and position in the classroom looked at and they may need an adjustable-height chair and a table that tilts to keep the back and neck from being too hunched, if appropriate.
If they have eye involvement this could obviously significantly impact education, especially if undetected. An occupational therapist is able to make an assessment in these areas and give appropriate advice, input or make a referral to an appropriate agency. (See Further Information page).

Play
This involves assessing how a child’s JIA restricts their ability to play, interact with the environment, acquire new skills and learn.
Play and leisure activities are key issues that can be marginalised in JCA. An occupational therapist is interested in helping that child to access his or her interests as much as possible. This is a vital area, as much of a child’s development and skill acquisition happens informally in this arena. Whether through using different toys, or giving extra help or joining clubs (Cubs, Brownies, swimming clubs, horse riding etc.). A useful contact, especially for those under 11 is PLANET who have a wide experience of getting the right sort of toys for a child’s needs. (See Further Information page.)

Environment
In this area we assess the child’s ability to negotiate the environment, open doors, get up stairs, get out of bed, go up a ramp, and the subsequent needs for these to be adapted.

In all the above areas the physical environment has a key influence. The environment is made and designed by and for non-disabled people and is unfortunately only slowly changing. But in the home or at school assessments can be made to adapt the environment to a greater or lesser extent to facilitate a child’s independence.

A motor/sensory assessment is made of the child’s upper limb which may involve the following:

	Range of movement in all joints from the shoulder and below (using a goniometer to take an accurate record).
	Grip strength (using a vigorometer to take an accurate record).
	Muscle power.
	Deformity (ulnar and radial deviation of wrist and fingers, as well as subluxation and contractures).
	Appearance (looking out for swelling, changes in colour and temperature, muscle wasting and tenderness).
	Functional ability (including writing and dressing skills) appropriate to the child’s developmental milestones and chronologicarage.
	Sensation (including the ability to feel and recognise objects and control the hand when it’s out of sight, as well as recognise temperature and pressure. This is not normally a problem in JIA but occasionally a child’s problems may not purely be caused by JIA alone).

Splinting in JIA is split into four basic categories:

1. Night / resting splints.

	To maintain a correct position and alignment of joints
	To relieve pain (although splints can be uncomfortable when first worn)
	To protect a joint
	To reduce swelling through rest
	To promote healing
	To prevent deformity
	To rest and support weakened joints.

To normally wear for at least 6 hours at night but follow instructions given for your particular child. If a child has a number of splints then they often rotate them on different nights so they don’t have to wear 3 or 4 at a time which is normally unrealistic.

Examples:
Paddle splints keep the wrist and hand in the best possible position at night. (Wrist extended with the finger joints slightly flexed.)
Knee extension splints to keep the knee aligned and the leg as straight as possible. Knee and ankle splints to keep the knee extended (as before) and the foot dorsiflexed at a right angle to the leg.

2. Day / working splints.

	To improve hand function
	Stabilise and support weakened joint
	Reduce pain
	Correct / prevent deformity
	Maintain good positioning and alignment
	To minimise fatigue.

Cock Up (or Wrist Extension) splints keep the wrist in an extended position, but leaves the thumb and fingers completely free to move. They are either worn during the day for writing, activity and school work etc. or they are worn as resting splints for night use when there is no finger involvement.

3. Corrective splints.
To correct a damaging position created by contractures, muscle imbalance or inflammation. These can be variations on the resting splints mentioned above but are strapped differently to achieve correct joint alignment, especially during times of growth. They may apply a dynamic force to increase range of movement as well as being part of an exercise programme.

4. Serial splinting.
This is mainly done with the knee joint where it is cast in the maximum amount of knee extension if it has a stubborn fixed flexion deformity. The cylindrical cast is often left on for approximately three days and then is cut in half, length ways, and is then held on with bandages. It can be walked on and is only taken off for physiotherapy. The knee can be recast a number of times until the maximum amount of extension has been reached (hopefully full). A normal knee backalab is then made to maintain these gains and is worn at night. The knee is fully assessed and X-rays looked at before serial splinting, as some knees may have other problems that would make it inappropriate.

Occupational therapists work in many different settings with different areas of focus, such as:-

	Hospitals - Mainly assessing and treating patients, ensuring safe discharge home.
	Social Services / GP Practices - Helping people to live independently and safely at home, supplying equipment and adapting the home to this end.
	Schools / Child Development Centres - Assessing and treating children’s functional needs, supplying and adapting equipment.

Getting to see an occupational therapist will vary in different areas. You may be able to refer yourself, or via a GP, Consultant, other professional, teacher or school nurse. Occupational therapists will be based at many different places including Town Halls, Hospitals, Child Development Centres, Special Schools, Wheelchair Services and GP practices. If you explain your need you will be pointed in the right direction.