Haley Thomas, SPT Vanessa DeLaRosa, SPT

1. Haley Thomas, SPT Vanessa DeLaRosa, SPT

2. 7 y/o Female- Taylor • Seen monthly by PT for HEP modifications

3. B knee and ankle inflammation • Mild limb involvement LLE>RLE • B LE weakness and stiffness • Bruising on inner thighs & wrists • Mother states the child fell while playing. • The child is more reserved than usual

4. Neuro screen WNL • ROM decreased in L>R 2°inflammation • MMT WNL: L>R • Photographs taken to document inflammation and bruising

5. VAS • JASI • JAFAR • QOL • 6-Minute Walk Test: • Patients walked around a track and at the end of the 6 minutes, the distance they walked was measured. • Heart Monitor & Mobile Gas Analysis System • The 6-mwt can be regarded as a good test for measuring functional exercise; it’s necessary to establish normative values and baselines to set goals for interventions.

7. Incidence: • 7 to 400 per 100,000 children • Prevalence: • 16-150 per 100,000 a year in developed countries

8. Unknown- Idiopathic • A viral or bacterial infection often precedes disease onset

9. An autoimmune inflammatory disorder, activated by an external trigger, in a genetically predisposed host. • RA is defined as persistent arthritis in 1 or more joints for at least 6 weeks if certain exclusionary conditions have been eliminated; disease onset subtype is defined by clinical symptoms in the first 6 months of disease. The course of JRA is defined by what happens after the first 6 months. - http://www.youtube.com/watch?v=ae4ZdRfZR3I&feature=related

10. Joint Swelling • Limited joint motion • Soft tissue contractures • Morning stiffness • Muscle atrophy and weakness • Poor muscle endurance • Fatigue • Common complication: Uveitis • Decrease aerobic capacity • Both aerobic and anaerobic exercise capacity were significantly decreased • Reduced exercise tolerance • Gait deviations • Difficulties with ADLs • Acute or chronic uveitis • Osteopenia or Osteoporosis • Activity restrictions

11. Polyarthritis • Oligoarthritis (Pauciarticular Diease) • Systemic Disease

12. Most common (50%) • ≤ 4 joints involved • Onset: Early childhood • Peaks at 1-2 years • 5 F : 1 M • 20% chance of chronic uveitis • No systemic involvement

13. Approx. 40% of cases • ≥ 5 joints involved • Onset: Throughout childhood • Peaks at 1-3 years • 3 F: 1 M • 5% chance of chronic uveitis • Moderate systemic involvement

14. Number of joints involved is variable • Onset: Throughout childhood • No peak age • 1 F : 1M • Major systemic involvement • Rare chance of chronic uveitis

15. Once again, our patient suffers from Juvenile Rheumatoid Arthritis, specifically oligoarthritis. • Review of oligoarthritis: • ≤ 4 joints involved • Onset: Early childhood • Peaks at 1-2 years • 5 F : 1 M • 20% chance of chronic uveitis • No systemic involvement • Assessed using the Juvenile Arthritis Functional Assessment Index (JASI) & Juvenile Arthritis Functional Assessment Report (JAFAR) http://www.youtube.com/watch?v=NqyB-cTxvs8

16. NCMRR Pathophysiology Disability Societal Limitation Impairments Functional Limitations Juvenile RA Joint Stiffness Weakness Inflammation B LE ↓Aerobic/Anaerobic Capacity Endurance Activities High Intensity Activities Unable to play with friends @ school Unable to fully Participate in dance class Decreased social Interaction w/ peers Decreased Self-esteem

17. Musculoskeletal 4D: Impaired Joint Mobility, Motor Function, Muscle Performance, & Range of Motion Associated With Connective Tissue Dysfunction. • Cardiovascular/Pulmonary6B: Impaired Aerobic Capacity / Endurance Associated With Deconditioning.

18. Goals: • Control the arthritis • Prevent joint erosions • Manage articular manifestations • Common: • NSAIDS • Steroid Injections • DMARDs (Disease-Modifying Antirheumatic drugs)

19. General Goals: • Controlling pain • Control Inflammation • Maintaining ROM, STR, & endurance activities • Ensure typical growth & development

20. Control Pain, decrease inflammation, improve joint stiffness • Modalities • Heat: • Hot showers • Paraffin or warm hot towels • Increase blood flow before exercise & reduce mm spasm • Cold: ice to decrease swelling & inflammation • Massage: can relieve pain & reduce anxiety

21. ROM • Stretching exercises for a 10 second period using a contract-relax technique STR- MM Function • Low-load resistance • Isometrics  during acute inflammation • Dynamic  inflammation subsides • Progress from resistance  thera-band  dumbbells  free weights

22. Aerobic Capacity • Aquatic Therapy • Reduces weight bearing, while encouraging the use of aerobic capacity • There was no significant difference within groups, but there was a clear improved joint status during the training. A review of studies concluded that children who perform aerobic exercise for at least 30 minutes 2/wk x 6/wks actually experience a decrease in clinical sxs, including joint swelling, pain, and limited motions.

23. LTG 2: Pt to play tag with friends at school for 15 minutes during break in 4 wks. • STG1: Pt to play tag with friends at school during short recess for 5 minutes in 1 wk. • STG2: Pt to play tag with friends at school during recess for 10 minutes in 3 wks. LTG 1: Pt to complete a hip hop performance at Spring Recital in 4 wks. • STG 1: Pt to participate in 30 minute hip hop class with two 5 minute breaks in 1 wk. • STG 2: Pt to participate in 30 min hip hop class with one 5 minute break in 3 wks. http://www.youtube.com/watch?v=g7kqi3xKqUY

24. Oligoarthritis (Pauciarticular Diease): • Excellent except for eyesight • Be cautious of possible future issues: • Eyesight – ophthalmologist • Growth & development – puberty • School issues: time out of class, extra help/materials • Behavior issues/Counseling  considering current embedded issue

25. Despite short term results of intervention studies, the long term affect of exercise therapy remain unclear and warrants further research. • No studies showed evidence that exercise exacerbated the arthritis. • Given the prevalence of arthritis in children and the significant and long-term impact of the disease, increased efforts to stimulate research would be prudent.

26. Remember those mysterious bruises • After examining the patient and understanding her condition, we determined the bruises were not any type of sign or symptom of JRA. • Possible Child Abuse

28. An estimated 896,000 children were determined to be victims of child abuse or neglect in 2002, representing a rate of victimization of 12.3 per 1,000 children.    • Each year ~ 1500 children die as a result of maltreatment. • More than 60% of child victims were neglected by their parents or other caregivers. Almost 20% were physically abused; 10% were sexually abused; and 7% were emotionally maltreated.    • Children ages birth to 3 years had the highest rates of victimization at 16.0 per 1,000 children. Girls were slightly more likely to be victims than boys.    • Reports alleging child abuse came most frequently from educational personnel (16.1%); legal, law enforcement, or criminal justice personnel (15.7%); social services personnel (12.6%); anonymous sources (9.6%); relatives (8.0%); and medical personnel (7.8%) (APTA)

29. More: • Welts • Internal injuries • Contusions • Emotional changes • Red Flags: • Bony Fractures • Soft tissue injuries • Burns • Hematomas

30. “ The law dictates that certain persons, including hospital or medical personnel, report all suspected cases of abuse and neglect to the appropriate state agency. Failure to report a suspected case of abuse or neglect results in a misdemeanor charge.”

31. Generally, if a physical therapist suspects abuse (as is the case in Pennsylvania, where Potter practices), the therapist has an obligation to file a report. "If you suspect, you have to report," states Potter. "You do not have to be sure, you just need to have a reasonable suspicion.

32. Ethical Principles: - Principle 2: A physical therapist shall act in a trustworthy manner towards patients/clients, and in all other aspects of physical therapy practice. - Principle 3: A physical therapist shall comply with laws and regulations governing physical therapy and shall strive to effect changes that benefit patients/clients. - Principle 4: A physical therapist shall exercise sound professional judgment. - Principle 9: A physical therapist shall protect the public and the profession from unethical, incompetent, and illegal acts. • http://www.youtube.com/watch?v=ZQbYCp8FRmY • http://www.youtube.com/watch?v=ZQbYCp8FRmY

33. 1.Paap E, Van Der Net J, Helders JM, Takken T. Physiologic Response of the Six-Minute Walk Test in Children With Juevnile Idiopathic Arthritis. Arthritis & Rheumatism. 2005;53(3):351-356. 2. Rouster-Stevens K, Nageswaran S, Arcury T, Kemper K. How Do Parents of Children With Juvenile idiopathic arthritis (JIA) Perceive Their Therapies? BMC Complimentary & Alternative Medicine. 2008; 8:25-33. 3. Takken T, Van Brussel M, Engelbert R, Van Der Net J, Kuis W, Helders P. Exercise Therapy in Juvenile Idiopathic Arthritis: a Cochrane Review. European Journal of Physical and Rehabilitation Medicine. 2008;44 (3): 287-297. 4. Campbell K, Vander Linden D, Palisano R. Physical Therapy for Children. 5. Ilowite C. Current Treatment of Juvenile Rheumatoid Arthritis. Pediatrics. 2002;109:109-115. 6. Van Brussel M, Lelieveld O, Van Der Net J, Engelbert R, Helders P, Takken T. Aerobic and Anaerobic Exercise Capacity in Children With Juvenile Idiopathic Arthritis. Arthritis & Rheumatism. 2007;57(6): 891-897. 7. American Physical Therapy Association. Guide to Physical Therapist Practice. 2 ed., 2003. 8. Cakmak A, Bolukbas N. Juvenile Rheumatoid Arthritis: Physical Therapy and Rehabilitation. Southern Medical Journal. 2005;98(2): 213-216. 9. Klepper SE. Effects of an eight-week Physical Conditioning Program on Disease Signs and Symptoms In Children With Chronic Arthritis. Arthritis Care Research. 1999;12:52-60. 3. Campbell K, Vander Linden D, Palisano R. Physical Therapy for Children. 4. APTA Practice Patterns 5. APTA Practice Act 6. Cakmak

34. 10. Takken T, Van Der Net J, Kuis W, Helders P. Aquatic Fitness Training for Children With Juvenile Idiopathic Arthritis. Rheumatology. 2003;42:1408-1414. 11. Klepper SE. Making the Case for Exercise in Children With Juvenile Idiopathic Arthritis: What We Know and Where We Go From Here. Arthritis & Rheumatism. 2007;57(6): 887-890. 12. Klepper SE. Exercise and Fitness in Children With Arthritis: Evidence of Benefits for Exercise and Physical Activity. Arthritis & Rheumatism. 2003;49(3): 435-443. 13. Flaherty E, Sege R, Hurely T. Translating Child Abuse Research Into Action. Pediatrics. 2008;122:S1-S5. 14.Child Abuse Statistics. Resources page. Available at http://www.apta.org/AM/Template.cfm?Section=Home&TEMPLATE=/CM/HTMLDisplay.cfm&CONTENTID=8446. Accessed April 10, 2009. 15. Dalton A. Recognizing the Signs, Offering Help Physical therapists are ideally situated to screen for and respond to family violence in all its forms-intimate, partner, child, and elder abuse. PT Magazine. January 2005;13(1). 16. Ethics and Judicial Committee of American Physical Therapy Association. Code of Ethics. APTA. 2000.