The fewer joint affected type of arthritis (oligoarticular) is characterised by having four or fewer joints affected, with the larger joints more typically affected such as the knees and ankles. These children usually appear well even though they may limp on walking. If only one hip seems affected this is very unusual for this type of arthritis and a different condition such as Perthes disease should be suspected. If the joints, such as the knees, are affected over a long period then the large extensor muscles of the thighs can weaken and waste, with tight hamstrings leading the flexion contractures of the knees. If the legs are affected asymmetrically then the length of the legs can develop a discrepancy.

With a larger number of joints affected, a minimum of five or more, the child has the many joint or polyarticular form of arthritis, with typically joints affected on both sides, a so called symmetrical involvement. A mild fever may be present and there can be significant muscle weakness and limitation of normal functioning if the joints have a severe limitation in their ranges of motion. A complete physical examination of the patient is vital to ensure that the diagnosis is juvenile arthritis, in what areas the physical limitations exist and which type of arthritis the patient is suffering from.

Settling on the diagnosis of juvenile arthritis depends on a joint showing an effusion which is the presence of inflammatory fluid within the joint, along with other symptoms and signs such as warmth, redness, limited range of motion and pain. Some joints may have an effusion which is not apparent such as the hip, but they can still show limited movement of the joint and pain. It may not be possible to establish the diagnosis of juvenile arthritis as the fever and rashes may come on initially without the arthritis at the time, with the arthritis appearing later by several months. Enlargement of lymph nodes and the liver and tenderness of muscles may be evident.

In the many jointed polyarticular form of juvenile arthritis the weight bearing joints are typically affected in a symmetrical pattern, as are the small joints of the hand. There may be loss of the articular cartilage with areas of cartilage erosion and in some cases a fusion across the joint, with thickening of the synovial membranes and effusions within the joints. Long term changes in a joint which is arthritic can include partial dislocation, joint stiffness and contractures, bony enlargement and deformities, especially of the fingers. Other findings can be loss of bone stock around the joints and narrowing of the joint spaces due to cartilage loss.

A reduction of extension in the neck may not produce any symptoms but it is important to identify this as it can indicate arthritic changes in the cervical spine which can lead to partial dislocation (subluxation) of the upper neck bones, a potentially dangerous situation. The neck bones can also fuse together along the posterior structures. The jaw joints, the tempero-mandibular joints, may also be affected and lead to reduced amount of growth in the lower jaw with inability to open the mouth as wide as normal. There may also be involvement of the eyes in the inflammatory process.

Juvenile arthritis and other complex conditions are best managed by a specialised multidisciplinary team due to the numerous problems which patients have to do with family and patient education and schooling, drug treatments, physiotherapy and occupational therapy. It is rarely if ever successful to give isolated treatments to this patient group. Reviewing patients at regular intervals allows the drug treatments to be fine tuned towards a reduction in the morning stiffness and towards fewer affected joints until no symptomatic joints remain. A typical team to manage these conditions may include a physiotherapist, occupational therapist, social workers, a paediatric rheumatologist and nurse.

These patients do not routinely require surgical care although steroid injections into some joints can be useful. Knee and hip arthritis in polyarticular arthritic patients may be managed by joint replacement once bone growth has ceased at skeletal maturity. Resting for long periods is unhelpful and patients should be encouraged to keep active for a better end result.

Jonathan Blood Smyth, editor of the Physiotherapy Site, writes articles about Physiotherapy, back pain, orthopaedic conditions, neck pain, injury management and Local Croydon Physiotherapists. Jonathan is a superintendant physiotherapist at an NHS hospital in the South-West of the UK.

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Juvenile Rheumatoid Arthritis is the commonest rheumatological disease which occurs in children and one of the commonest child chronic diseases. It covers a number of individual disorders which all have chronic joint inflammation in common. The causes of these conditions are not apparent and the underlying genetic reasons are complicated in that different types of arthritis cannot easily be distinguished. Juvenile idiopathic arthritis is gradually becoming more widely used, indicating the unknown reasons for this condition.

Three main divisions of juvenile rheumatoid arthritis can be described, that affecting many joints which is called polyarticular, that involving few joints and termed pauciarticular and a more body wide disease onset known as systemic arthritis. The arthritis is a chronic disease which flares up at times and then goes into remissions, with targeting of the medical treatment towards the induction and maintenance of a remission. Recent advances in the development of drugs have produced the biological agents which are much more effective for arthritic diseases.

The triggering factors for juvenile rheumatoid arthritis have not been clearly identified, with a possible trigger of trauma or infection developing an autoimmune attack against joint tissues. The synovial lining of the joint increases in bulk and develops chronic inflammation, with perhaps some genetic vulnerability contributing to this process. A group of genes are understood to be involved in the pattern of disease presentation and the nature of its onset. There are many factors which influence the incidence of these types of arthritic diseases, such as how susceptible individuals are and the population types involved.

The oligoarticular type of juvenile chronic arthritis, in which a small number of joints are inflamed, is the commonest disease type, consisting of about half of all patients. Thirty percent have a large number of joint affected, the polyarticular type, and the rest have the systemic form. Sufferers from chronic juvenile arthritis may at some type suffer also from another autoimmune disorders. The severe pain and disability due to the arthritis causes significant psychological distress, behavioural problems, anxiety and depression. The polyarticular and oligoarticular forms occur more often in girls than boys with a frequency of three to four and a half to one. The systemic form occurs equally.

In terms of age, the few joint (oligoarticular) type occurs most commonly in children of two to four years in age, while the many joint (polyarticular) peaks at one to four years and also at six to twelve years. The systemic type can occur right through the childhood years. The division of juvenile chronic arthritis that a child belongs in is determined by the pattern of onset of the disease over the first six months. If four joints or fewer are involved then the child is classified into the oligoarticular chronic arthritis group. If a child has more than five joints affected in the six month period then they are recognised as being in the polyarticular type. The type which presents with a systemic onset comes on with the arthritis, fever and rashes.

If a diagnosis of juvenile arthritis of some form is to be made then the patient should have arthritis of some of their joints for at least six weeks. Stiffness in the morning or after periods when the joint has been kept still is a typical complaint. The start of the disease can be very sudden and dramatic or may come on slowly over some time, with common symptoms including stiffness of the joints as mentioned, joint pain in the day, periods of absence from school and a limping gait. Some patients also suffer from inflammatory disease of the bowel. A child may not always report actual pain in a joint but instead they may just allow the joint to go unused and develop atrophy or a joint contracture.

In the systemic form of juvenile arthritis the child suffers from fevers which spike once or twice a day at around the same time, the temperature typically returning back to normal each time. This pattern is different from infections so helps to distinguish what the patient is suffering from. These patients usually show a short lasting rash over the trunk and limbs, joint pain often in the bigger joints and appear to be unwell.

Jonathan Blood Smyth, editor of the Physiotherapy Site, writes articles about Physiotherapy, back pain, orthopaedic conditions, neck pain, injury management and Local London Physiotherapists. Jonathan is a superintendant physiotherapist at an NHS hospital in the South-West of the UK.

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Hampstead Heath this morning was beautiful but treacherous and all of a sudden, as is usual with such things, I fell over on the ice. One minute I was walking along chatting and the next minute I was on my bottom as my wrist, forearm, shoulder and buttock took a bash. I slid sideways fast in the fall, thereby distributing the blow to several parts of my body and reducing its impact, entirely by luck. So I escaped joining the legions of people who, over the UK Christmas festivities, suffered a fall as the weather managed to concoct a particularly tricky combination of sub-zero temperatures and sharp showers.

The increasing and continual ageing of the populations of many countries throws up many challenges around falls which are important and independent of the weather. We learn very early to keep our balance when walking or running and take it for granted ever since, forgetting that this skill relies on functional abilities which typically reduce as we age. Within elderly populations the issue of falls is increasing in importance as falls take up many medical and surgical resources and are risky in terms of individual independence. The clinical work and costs which result from large numbers of falls is an issue in many medical systems in the world.

We need a variety of both physical and mental skills to manage to maintain our physical state of equilibrium when conditions become challenging. As we age our limb muscles gradually lose their strength and we use less and less of our potential joint movements as we walk. Older people gradually adopt a more restricted gait as they increase the number of shorter steps and decrease the amount of joint movement they employ in each gait cycle. If keeping balance suddenly needs a much bigger joint movement this may not be possible any longer or they may not be able to perform the movement in time to complete the required task.

One of our vital abilities is that which tells our brains continually where the segments of our limbs and trunk are located and whether they are moving in a certain direction. This is joint position sense or proprioception and is essential for normal movement and posture. Losing this sense or more widespread sensation loss from part of or a whole leg stops critical information getting to the brain, meaning it is unable to plan the next movement as it is unsure where the limb is to start with. Function can be more severely affected by loss of position sense than by weakness as people cope with weakness if they have good position sense.

Central nervous system abilities which contribute strongly to the ability to maintain balance whilst moving about include vision, balance pathways, coordination systems and cognitive systems such as understanding and logical thought. Good vision is very important as it alerts us to the changing nature of the terrain we are facing and enables us to judge which movements we need to make and whether these movements are being effective in reducing the risk of falling. Closing our eyes makes our balance significantly worse and loss of some vision combined with poor joint position awareness can lead to a very vulnerable state.

To achieve the correct reactions to balance challenges demands various brain systems to be working effectively as the balance organs and the eyes provide the required input. Loss of accurate input from the balance organs of the ears can cause problems or make a person dizzy on movement of the head and so make falling more likely from loss of balance. As we age our neural abilities reduce in efficiency and the cerebellar part of the brain which deals with coordination can also suffer from this process.

Awareness of what is around us in our environment is vital in permitting us to make the quick and correct decisions to keep our balance. Being alert to what is going on means we can make early plans for managing the presenting circumstances such as other people’s actions, sudden obstacles and wet or slippery surfaces. Maintaining our minds in a mentally active and alert state allows integration of complex information and the formulation of plans to keep our balance.

Jonathan Blood Smyth, editor of the Physiotherapy Site, writes articles about Physiotherapist, back pain, orthopaedic conditions, neck pain, injury management and Physiotherapists in Leeds. Jonathan is a superintendant physiotherapist at an NHS hospital in the South-West of the UK.

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The foot’s design is complex and specialised to manage the forces generated by bearing the weight of the body and by the need to propel the body in gait. The talus is at the apex of the main longitudinal foot arch and is held firmly by the ankle mortise. The largest arch is the lengthways or medial arch of the foot which manages the forces involved in moving the body and standing, the spring ligament contributing to this by storing and releasing the energies involved. The outside or lateral arch is less obvious as is the transverse arch at the front of the foot.

The foot would be unable to fulfil its job of dynamically propelling and supporting the body without the arches it is designed to have. The arches absorb and hold the energies as the weight of the body interacts with the surface, releasing the energies as the step is completed. Watching someone walking who has flat and painful feet it is clear that their feet are just platforms, exhibiting a complete lack of dynamism and flexibility. It is important to maintain the health of the arches to keep our mobility at its highest level as the years go by.

The foot is designed to fulfil two main actions: to accept the forces generated in locomotion and generate propulsive forces to effect gait and to manage the forces involved in movement of the body weight which are often greatly increased by motion. Some of the calf muscles, as mentioned in an ankle article recently, function to keep the arches of the feet working but the long flexor muscles of the toes do this also. Originating from the calf and running underneath the foot to insert into the toes, these muscles bend the toes and work by gripping the ground for stability and movement. The shorter intrinsic muscles, originating in the feet and inserting in the toes, bend the toes whilst keeping them straight.

When a person with a normally functioning foot takes a step the first contact with the ground is with the heel somewhat on the outside. As the step continues the lower leg rolls over the talus inside the ankle joint and the foot arches, the joints and ligaments, absorb the energies of weight bearing and movement. Moving forwards and inwards, the weight is borne finally by the metatarsal heads of the second and first toes, with the final push from the toe muscles.

Each moving joint in our body has a degree of accessory movements in it, which are limited and subtle internal movements between joint surfaces which cannot be exhibited in isolation. A normal joint depends to some degree on the accessory movements present within the joint and if these are lost or reduced the joint’s function is compromised. A high number of intricately designed foot bones are packed into a small area, creating the arches, and all these bones have highly functional accessory movements between them.

The foot arches begin to flatten as the weight of the body is passed through the foot and the tension and elasticity of the foot ligaments counteracts this with the strength of the calf and foot muscles. In moving towards push off the foot is aided by the calf muscles contracting as a sling to maintain the arch, the gripping of the ground by the toe muscles and by the energy recoil of the ligaments. The arch varies in height as the walking cycle continues and this means accessory movements between the many arch bones are constantly occurring so that the bones can slide and glide into the required positions.

The independence of movement between all the many foot bones is vital as the weight causes a spreading of the under surface of the joints and a closing in of the upper joint lines. The foot can accommodate to the circumstances which present themselves in a dynamic fashion at least partly to the individual inter-joint movements. The foot will lose some of its flexibility in responding dynamically to circumstances if accessory movement is lost and the foot changes function from an active system to a passive platform.

Jonathan Blood Smyth is the Superintendent of Physiotherapy at an NHS hospital in the South-West of the UK. He writes articles about back pain, neck pain, and injury management. If you are looking for physiotherapists in Bolton visit his website.

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The management of dislocated shoulders is a matter of controversy in the orthopaedic field, with the usual management being confined to a sling for between one and six weeks, with or without a strap around the waist to prevent external rotation. The arm is maintained close to the body with the forearm across the belly, a position known as medial rotation and adduction. This avoids the stresses which would be applied to the joint if it were moved to the side or outwards, known as lateral rotation and abduction.

Recent studies of dislocation in the scientific literature have shown some clues as to how these injuries should be managed. One study involved MRI scanning to show that the relationship between the rim of the socket and the socket itself is best maintained by placing the arm by the side and rotating it laterally 35 degrees. A cadaveric study of shoulders showed that keeping the arm in slight adduction close to the body allowed a reasonable range of motion without disrupting the close approximation of the structures. Lifting the arm up forwards or out to the side (flexion and abduction) disturbed this relationship.

The time of immobilisation is not one of general agreement with three or four weeks in a sling typically prescribed for younger people and shorter periods for older people. A longer period of immobilisation was shown in one study to significantly lower the rates of recurrent dislocation. Another study followed patient with shoulder dislocation for ten years and found no influence of the period of immobilisation on the rate of recurrent dislocation. After the patient is reviewed at the three week period they start their rehabilitation with the physiotherapists.

Initial exercises will include pendular exercises, chosen for their reduced joint stresses due to the patient being bent over and the arm hanging in a relaxed position. This keeps the shoulder joint moving without fear of overstressing the joint capsule. Scapular movements are also performed early so that the shoulder girdle remains mobile and functional. Active assisted movements are the next progression taught by the physiotherapist, allowing the range of movement to be increased whilst reducing joint stresses as the other shoulder contributes much of the force needed.

The risk of dislocating again means that lateral rotation of the joint will be restricted and the range gradually progresses as healing occurs, without ever being strongly stressed as a loss of the end range of this movement may help this joint prevent further dislocations. Restricting the joint from attaining the risk position may reduce the likelihood of it dislocating again. Six weeks is typical soft tissue healing time and patients are then progressed onto performing full active range of motion exercises and also muscle strengthening.

Some patients demand high performance from their joint and need ongoing advanced rehabilitation but should be prevented from pursuing overhead sports for about four months. If the patient has a greater tuberosity fracture (a small bony upper arm area with tendinous insertions) or is an older person then their outcome is somewhat better. Patients may be required to modify their typical activities by limiting overhead actions, avoiding sports which demonstrate high risks and change to lighter physical work.

Overall the incidence of re-dislocation of the shoulder is around 30 percent in non-sporting people but rises to eighty-two percent in those in athletic sports. The age of the patient is however very important in determining the recurrence rate. There is a one hundred percent chance of dislocation recurrence in patients under 10 years old and only zero to 24 percent likelihood in patients who are in their forties. Surgical management may be required should a patient suffer from recurrent dislocation of the shoulder.

The timing of surgical management is not clear although early surgery after the initial dislocation may be advantageous. Studies vary but one showed that after stabilisation surgery via the arthroscope there was a four percent dislocation rate but a 94 percent repeat dislocation rate after conservative treatment. Overall it looks like the recurrence rate is higher for those patients managed by non-operative immobilisation. The level of stability given in operation was better with open surgery but arthroscopic techniques have advanced considerably and this distinction has disappeared.

Jonathan Blood Smyth, editor of the Physiotherapy Site, writes articles about Physiotherapist, back pain, orthopaedic conditions, neck pain, injury management and physiotherapist in hartlepool. Jonathan is a superintendant physiotherapist at an NHS hospital in the South-West of the UK.

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