The Childrens Chronic Arthritis Association

This involves exercise and the use of applications to counteract the effects of JIA

	The Aims of Physiotherapy:-
	Main Problems Associated with JIA	Aims, and Some Methods of Treatment
	Pain	Reduce Pain by Ice/heat packs /TENS/ stretches/ exercises & Splints
	Inflammation of the joints	Reduce Inflammation by Ice/heat packs may assist drug therapy
	Joint stiffness	Reduce Joint Stiffness by Stretches and splints
	Sort tissue shortening (contractures)	Maintain / Improve Joint Range of Movement by Stretches/splints/exercises
	Muscle weakness	Improve Muscle Strength by Exercises
	Loss of function ie inability to walk, etc.	Improve Function by Specific exercise programme ie Gait re-education/balance work

Ice-Packs
Use a bag of frozen peas wrapped in a wet tea-towel, place around the affected joint for 15-20 minutes. For hands/fingers use a bowl of cold water with ice-cubes in it for 10-15 minutes. Be careful to avoid ice-burns.

Heat-Packs
Use a hot-water bottle or a heat pack from a chemist, wrapped in a dry towel, place around the affected joint for 20-30 minutes. A hot bath will also have a similar response and may be better if many joints are affected.

TENS
A non-invasive method of pain control which uses electrical impulses to ‘block’ the ‘pain pathways’ to the brain, therefore reducing the level of pain experienced. It is more effective if used for one specific joint at a time.

Stretches
Stretches are aimed at loosening stiff joints first thing in the morning and increasing the range of movement the joints have. Here are some guidelines to consider with stretches, however it is strongly recommended that you are shown the stretches by your physiotherapist before you try them at home.

1. Stretches need to be done to every joint affected.
2. Only stretch one joint at a time.
3. Support above the joint and stretch from below the joint, always using a slight and steady pulling force.
4. Get your child to try to move the joint in the direction you are stretching, this will help to make it less uncomfortable for them.
5. Take the stretch to the end of their pain-free range (and hopefully active range) and then hold in position to allow a little relaxation, then stretch a little further into the discomfort. This needs to be done slowly and smoothly.
6. Hold the stretch for a slow count of 10.
7. Relax the stretch slightly, back into the pain-free range for a slow count of 10.
8. Repeat the above 3 times.
9. Get your physiotherapist to show you how to stretch each joint. This is necessary as incorrect technique can cause more harm than good.
10. Repeat the stretches 3-4 times daily. It is often easier and less uncomfortable if the joints are stretched first thing in the morning, in the bath. This will also be the most effective way to reduce morning stiffness.
11. Stretches still need to be done even if the joint is inflamed to prevent contractures occurring.
NB: This is specific to the treatment of children with arthritis.

1. Aims to build each muscle group to an adequate strength so that the muscle can:
i) Support the joint more effectively and therefore reduce pain and stiffness,
ii) Reduce the stresses placed on the joints during weight bearing.
iii) Work in correct balance with the other muscles in all activities.

These exercises need to be done 1-2 times daily, each exercise should be repeated 30 times on each leg to ensure balanced muscles; the exercises should be progressed using the addition of ankle weights starting with 1Ib and gradually building up to 3-5 lb depending on the size of your child. This progression should be advised your physiotherapist. There will be no risk of damage to your child’s joints with the inclusion of these grades of weight, and their use is vital to ensure full muscle strength is achieved, as this requires some resistance against the exercises.
A specific programme for each child may also need to be included into the regime. This should also work on their specific areas of difficulty, e.g. stairs, sitting to standing, balance, etc. Your physiotherapist will advice you on this. However this programme should be used with the general exercise programme.

Hydrotherapy is exercise/treatment in warm water. It is exceptionally useful for children with arthritis for the following reasons:

1. The water can be used to:
   i) Support the body/limb - useful for mobilising
   ii) Assist movement - joints
   iii) Resist movement - useful for strengthening muscles.
2. The warmth of the water is also very useful to help reduce muscle spasm and pain.
3. It is good to encourage your child to go swimming as this is something they can do with their friends.

Hydrotherapy may be provided by your local hospital/ community out-patient physiotherapy service and will provide your therapist with another way to treat your child in conjunction with the dry-land treatments. During the sessions, stretches and exercises may be given as well as time to swim.

If there is no hydrotherapy available to you locally, then it is very beneficial for you to take your child swimming. It is advisable to find the warmest pool near to you, but this is not absolutely essential as there are many other benefits apart from the warmth. If it is not a warm pool, please ensure that your child does not stay in the pool until they are cold.

If you are taking your child swimming regularly then it is advisable to start by moving each joint to full range, as shown by your therapist and then encouraging as much fun and enjoyment as possible as your child will be working very hard without realising it.

It is hoped that this information will give you an insight as to the physiotherapy treatment for your child and the some of reasons behind it. It is also hoped that it will show you that there is a great deal you can do to help your child and to improve the quality of their life.

There are also many activities your child can do which will compliment the physiotherapy programme and help maintain joint range of movement and improve muscle strength, these include bike riding (exercise-bike and ordinary bicycle), walking, swimming and non-contact sports, badminton, tennis etc.

It is also recognised that it may be very difficult to do the exercise and stretching programme daily due to the:
i) Time constraints of every family;
ii) Difficulty of making your child do something that is uncomfortable and not the same as everyone else.

The best advice to counteract this is to always remember the importance of the programme to your child’s mobility and that doing the exercises should make them more pain free for the rest of the day. Also with good muscle strength your child will be far more independent.

It is also important to find a time in the day when you can do the exercises and stick to it so your child will know this is always exercise time. It is quite useful to do this before a favourite TV programme so they know the longer they take the more chance they have of missing it, this should help reduce the arguments. However if you are finding the exercise programme really difficult, do not hesitate to talk to your physiotherapist or to contact Arthritis Care, the CCAA or the Lady Hoare Trust.
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Physiotherapy written by Susan Maillard SRP, MCSP, Senior Physiotherapist Paediatric Rheumatology, Great Ormond Street Hospital, London. In conjunction with Ann Parkin SRP, MCSP Senior Physiotherapist Paediatric Rheumatology Birmingham Children's Hospital.