With the growing array of powerhouse medications available to treat juvenile idiopathic arthritis (JIA), it may be easy to overlook the vital part that low-tech exercise, physical therapy (PT) and occupational therapy (OT) can play in your child’s treatment plan.
Used together, the different approaches complement each other. “I think establishing and maintaining a good therapeutic exercise program will definitely add to any benefits that medicine can provide,” says Greg Shahum, OTR/L, director of Rehabilitation at Regency Heights of Stamford in Connecticut. Take the example of a child who comes to their rheumatologist with a swollen knee that has lost range of motion. The physician may decide to inject the joint with a corticosteroid that would decrease the pain and swelling, allowing the child to regain much of the range of motion but possibly not all.
“That’s where a physical therapist can help by providing exercises to regain the range of motion, muscle strength and bulk,” says Susan Klepper, PT, assistant professor of Clinical Physical Therapy at Columbia University in New York City.
Klepper also points to a study that showed that kids with active disease lost some muscle bulk and strength each time they had a flare. When the flare subsided they regained only some of the bulk and strength. So although medications can quiet the inflammation, the only way to completely restore muscle function is by exercise.
Kids typically love to run, play, get involved in sports and other types of exercise. JIA can interfere with those pursuits and in fact research shows that children with JIA are less physically active and less fit than kids without the disease. Dutch researchers found that children with rheumatoid factor positive polyarticular-onset JIA had the greatest deficits in exercise capacity while those with persistent oligoarticular-onset JIA were the least affected. Overall, girls had worse aerobic and anaerobic capacity than boys.
There’s a flip side too. “Looking at the whole group of exercise studies done on children with JIA shows there’s no harm from exercise, kids generally report fewer symptoms such as decreased pain and stiffness after exercise programs, and they can improve their physical fitness,” says Klepper.
PT and OT
Both PT and OT can help facilitate fitness goals and improve a child’s quality of life by enabling them to perform routine daily tasks with greater ease.
After recommendation by a physician for OT and/or PT, the therapist evaluates the child. OT concentrates more on hand function (reach, grasp and manipulation of objects) with an emphasis on activities of daily living such as dressing, bathing and eating. OTs try to determine if children can move through their day the way kids their age without JIA do.
A PT evaluation measures and establishes a baseline for joint range of motion, muscle strength, muscle bulk, physical activity and fitness, coordination, and neuromuscular function. PTs look at activities children do or want to do, identify any physical limitations and try to address those deficits.
Adaptive equipment may be used both in PT and OT including splints which can help keep joints in correct position, relieve pain and help stretch muscles and other soft tissues that have been shortened due to the disease. Assistive devices can help a child with daily activities like eating, dressing, bathing or writing. Custom molded in-shoe orthotics may help to relieve a child’s foot and leg pain while walking.
There are always at home exercises to do with OT and PT and, depending on the child’s condition, regular or periodic direct therapy sessions. For instance Klepper’s home program for a child with moderately active disease and stiffness but good range of motion might include daily range of motion exercises at night during or after a bath and in the morning in bed to offset stiffness. She’d give two or three strengthening activities to do during the day. She’d give older kids straight strengthening exercises while for young kids she’d devise play activities to get the job done.
Range-of-motion exercises keep joints flexible. Strengthening exercises build muscle, strength and endurance plus can help support weak joints. Kids with JIA should also strive to meet health guidelines that recommend an hour of daily moderate physical activity.
Best of Both
The optimum situation occurs when medication and exercise therapy work together to provide the best outcome for the child. “Just as kids with JIA need very specific pharmacologic management, they need specific instruction in exercise to try to get them to a good level of function with the emphasis on leading as normal, healthy, and active a life as possible,” concludes Klepper.
10 Tips for Sticking With the Program
Though it’s clear that PT, OT and exercise are beneficial, getting kids to adhere to a program can be difficult. Klepper and Shahum offer some strategies:
- Go to therapy appointments with your child so you know exactly what she's being asked to do. Request take home illustrations.
- Consider setting up a reward system to build motivation. Perhaps make a sticker board where you give a prize once your child earns a certain number of stickers.
- Have your child set a goal that is important to her with the therapist.
- Make sure the entire family knows of the child’s exercise plan. Family should be the strongest support system.
- Set aside time in your child’s schedule for exercise each day. This way it’s less likely to be pushed aside.
- Have your child keep an exercise log or journal.
- Encourage your child to have a training buddy, whether it’s a sibling, friend or you.
- Change up exercise options to keep things fresh. Take a nature hike, play the Wii or similar game, swim, or walk the mall when it rains.
- Even when your child is sore or achy, stretching is beneficial. Try not to let her completely skip a day.
- If your child likes watching DVDs, ask your therapist to videotape your child doing her exercises. Most kids like watching themselves.