THE PHYSIOTHERAPIST and JUVENILE RHEUMATOID ARTHRITIS

findings.Rheumatoid arthritis is a systemic disease which is defined by Jones as affecting four or more joints and lasting longer three months. Initially the disease attacks joint synovial membranes progressively destroying cartilage and bone and producing disruption of the joint. The disease may encroach on surrounding muscles, nerves, tendons, bursae and may directly attack supplying blood vessels. rheumatoid

The Juvenile Rheumatoid Arthritis U nit a t The Hospital for Sick Children, Toronto, recently did physical assess ments on 33 children suffering from rheum atoid arthritis. Many treatment programmes were revised in view o f the findings.
Rheumatoid arthritis is a systemic disease which is defined by Jones as affecting four or m ore joints and lasting longer than three months. Initially the disease attacks joint synovial membranes progressively destroying cartilage and bone and producing disruption of the joint. The disease may encroach on surrounding muscles, nerves, tendons, bursae and may directly attack supplying blood vessels.
Juvenile rheum atoid arthritis, often called Still's disease, djffers from the adult form in that it often presents with high spiking fevers and rashes, and also differs in the type of deformity (see list of common deformities). The onset in the adult is insidious and less dramatic. Several groups consider it may even be a different disease. Unlike adults, immobilized for lengthy periods, children tend to be mobile once the initial fever (lasting one to two weeks) has been controlled and in spite of acute joint involvement. Because o f these differences the management o f the disease has to be modified.
The peak onset ages were found to be between one to three and seven to ten years of age, closely conforming to the studies done by Laaksonen and Laine, and Ansell and Bywaters. The older the child at the onset o f the disease, the more severely his joints were affected and the slighter his chance that the disease would become inactive. In 70 per cent of childhood cases, however, the disease is thought to become inactive after a duration o f one to eight years.
Influenced by such findings, a programme was designed to help the child develop as normally as possible during the active phase o f the disease.
A functional grading was also devised for both the upper and lower limbs. This took into account (a) the number of joints affected; (6) the number of fixed deformities; (c) the age of onset; and (rf)the duration o f the disease. The results o f these assessments indicated that, due to the greater number o f joints affected, the lower limb usually suffered greater functional impairment than the upper limb.
In order of frequency, the most common deformities seen in 33 cases were: (a) wrist fixed in a flexed position in the early stages, may require m ore rest and sleep than norm al children.
Our aims are: 1. To relieve pain. 2. To prevent deformities by stretching, strengthening and splinting. 3. To record the process o f the disease (Fig. 1). 4. To help prevent emotional disturbances by ensuring th at the child participates in normal, daily activities. 5. To provide pre-and post-surgical treatm ent for children when necessary. These programmes vary with each patient and doctor. The post-surgical treat ment is intensive and specific for each individual.

II. M E T H O D S AND RATIONALE O F TREATING
ARTHRITIC CHILDREN It should be emphasized that only a small percentage of children seen in the Rheumatoid Clinic need physiotherapy treatm ent. The children are assessed by a rheumatologist, physiotherapist and social worker before a treatment regimen is established.
Education arid household routines are disrupted as little as possible, treatm ents being done after school and in the patient's home whenever possible.
M uch has been written on the parents' role in enforcing one hour o f exercise daily. F o r the large family this may be an unnecessary demand and may create feelings of guilt in the busy mother who has difficulty finding the time. Specific exercises, such as quadriceps drill, are, however, taught to the parents when possible. These are simple and should be kept to the minimum. Regular daily activities and, in some cases, periodic supervision by a physiotherapist should be adequate to ensure that muscle strength and joint mobility are maintained.

A. Pool Therapy
In a heated pool, G roup programmes that stress strength ening and stretching are popular with patients. The buoyancy o f the water facilitates mobility; the setting promotes social mixing. M ore joints can be exercised simultaneously and more patients can be treated at one time.

B. Exercise Therapy
Exercises using proprioceptive neuromuscular facilitation (PN F) technique and/or isometric routines incorporate mass movement patterns and prove an-efficient, time-saving way o f exercising when several joints and muscle groups are affected. The adaptations for various age groups are dis cussed in the section "Treatment for Different Age G roups" .

C. Using Daily Activities
Each age group has certain abilities, skills and activities which should be used as exercise. D. Special Techniques 1.
Stretching techniques can be used in specific cases where ligamentous and capsular tightening restrict accessory movements. Techniques using traction with minimal passive movements break the small fibrinous adhesions. Restoring these movements will in turn stimulate the synovial mem brane and secretion of synovial fluid thus lubricating the joint. They are most effectively performed on affected finger joints but do not w ork in every case and should only be done by trained personnel.
Splinting is used either to prevent or correct deformities. Once a deformity has developed, an individual splint has to be devised to correct or minimize it.
In the past, splinting for children's joints has been the same as that for adults. Deformities in children, however, Qmer from those in adults (see earlier list of common uetormities) and consequently the physiotherapist, Occu-PA l?na! Therapy D epartm ent and Orthopaedic W orkshop m tK °iIC J-,ePartm ent) are experimenting with new splinting tnK u S and raaterials. The children's splints have tended anH i, ' included unaffected joints, increased deformities no have not been durable. We are experimenting with nlact^r' coate^ Poster, fiberglass impregnated bandages and c materials such as sansplint and polycast. M ost of these splints are made in the patient's home, an im portant factor when selecting splinting material. The wrist splint is applied after three m onths if the wrist remains swollen and limited in m otion (especially extension) or if there is a wrist flexion contracture. A plastic backslab (sansplint®) is the most comfortable type o f wrist splint because it " pulls" rather than " pushes" the wrist into slight extension. The backslab extends from mid-forearm to onehalf inch proximal to the m etacarpal heads; an anterior bar extends across the palm. Fingers are not included in the splint since finger m otion should be encouraged especially at the metacarpo-phalangeal joint, which frequently lacks flexion. Furtherm ore, ulnar drifting o f the fingers is un common in children. The splint is worn most o f the day MARCH, 1972 and night, the time being decreased as pain subsides and movement returns.
The knee splint is applied to a swollen knee joint that has developed a flexion contracture. A bivalved stovepipe type o f cast is used fo r this purpose and the patient is encouraged to walk as much as possible. The cast is removed for exer cises. W hen walking with the knee extended, n o t only are the quadriceps muscles being worked statically against the resistance supplied by the body weight, but also the collateral ligaments and capsule are taught, thus stretching these tightened structures. The patient wears the cast day and night until the contracture has been corrected and the quadriceps are strong enough to m aintain the knee in extension when walking. This may require three to four months. As this m ethod o f splinting differs so radically from the conventional resting splints, we are documenting all cases and studying the problems o f managing knee flexion contractures in children.
F o r the children requiring a resting knee splint for pain, swelling and severe morning stiffness, a bivalved stovepipe cast seems most satisfactory. The foot is rarely enclosed in the cast since usually the knee can be fully extended without it. Since children are seldom immobilized in bed, there is no tendency to foot drop, even when the ankle is affected. Crutches are seldom used as the majority o f children are able to bear weight and move well once the initial morning stiffness is overcome.

ID . TREATM ENT FO R D IFFEREN T AGE GROUPS A. One to Three Years
Tickling the bottom s of the feet results in hip and knee flexion. Placing a bracelet over the foot results in hip and knee flexion when the child tries to pull it off. Certain toys can be used to correct problems. A tricycle stresses hip and knee flexion as well as knee extension, ankle plantar, and dorsiflexion. D rum s o r xylophone encourage finger flexion and static wrist extension. Blocks and building toys require finger movements. The child should be encouraged to walk and feed himself.
Binding techniques, whereby the therapist grasps the child firmly and then encourages him to break free, results in the child unwittingly exercising isometrically against the manual resistance. F o r example when the therapist stretches the child's arms above his head he tries to bring his arms down producing isometric contractions o f shoulder extensors, elbow, wrist and finger flexors.
W hen a child's legs are painful, he will prefer to sit, and his parents may have to lure him into walking by placing a favourite toy beyond reach. The mother is shown what play techniques will help her child exercise in his morning bath. The warm bath also relieves early morning stiffness. B. Four to Six Years Children in this age group enjoy hitting a balloon thus exercising shoulder elevators, elbow, wrist and finger extensors. Toys such as a bicycle o r skipping rope provide additional exercise. Should there be increased'-swelling or pain after an activity such as skipping, the activity is de creased and eliminated if necessary. Pool therapy in warm water can be started in this age group. Isometric exercises using binding techniques (see under One to Three Years) are helpful.
The m other should teach her child to dress and undress. She should also encourage and praise him, and report to the physiotherapist any problems such as increase of pain and swelling after certain activities, inability to perform any daily activity, any new jo in t involvement, behavioural problems o r problems with medication. C. Seven to Ten Years Play techniques such as ball throwing will prom ote mobility of the joints. A lthough body contact sports such as football are discouraged, activities such as ice skating, bicycling and swimming are encouraged.
Organized resisted exercises using isometric and PN F techniques can be fun especially if the routine is changed frequently. Participation in either Brownies or Cubs is socially beneficial for the child. Domestic activities are also encouraged. Pool therapy is popular. The parent should support and encourage the child and report any problems to the therapist.

D. Eleven Years and Over
Organized resisted exercises using P N F with isometric exercises, o r isometric exercises alone, are helpful. Dancing and swimming are popular and foster camaraderie. Pool therapy is excellent. Cooking and babysitting for girls and repair jobs for boys prom ote natural exercise. Taking medication and exercising are now the responsibilities o f the child who can be taught exercises for specific problems. He should be encouraged to report any problems to the physio therapist.

IV. GENERAL TREATM ENT D ISCUSSIO N
The majority of. children with joint mobility loss and/or muscle weakness require only a weekly visit from the thera pist. We found in comparing results of the "once weekly group pool therapy programme" to those o f the "once weekly home exercise programme" that hip and knee mobility as well as quadriceps strength was maintained but not increased in 90 per cent o f the patients in both groups. Twelve children (six per group) took part in these pro grammes and it was felt that, physically, the programmes were of equal benefit. Should specific muscle strengthening and joint mobilization be required, a m inim um o f three treatm ents per week is necessary and should be done in the child's home by either the parent or physiotherapist. When the child's arthritis becomes inactive, regular check-ups are still essential to prevent deformities resulting from weaknesses and to modify treatments. Such check-ups should continue until the child stops growing.
I f the parents are unco-operative o r unable to assist, the physiotherapist may have to assume the responsibility for the. child's weekly treatm ent. The child o f unco-operative parents may have difficulty coping with arthritis in later life.
In addition, a specialized treatm ent centre provides vocational guidance, aptitude testing and physical tolerance assessments, orthopaedic research brace shops, research units, and community physiotherapy. The physiotherapist is part of a team consisting o f paediatric rheumatologists; paediatric orthopaedic surgeons; paediatric opthalmologists; social workers; occupational therapists; public health nurses. Such a team is dedicated to caring for children suffering from juvenile rheum atoid arthritis.