Juvenile rheumatoid arthritis Juvenile rheumatoid arthritis (JRA), also referred to as juvenile idiopathic arthritis, is the most common form of arthritis diagnosed in children under the age of 16. The disease causes pain, stiffness, and swelling in the joints (Mayo Clinic, 2017). Once diagnosed with JRA, the child or adolescent is often medically managed with aspirin or NSAIDs to relieve symptoms. Corticosteroid injections may be administered for temporary relief of synovitis, and disease-modifying antirheumatic drugs (DMARDs) may be used to reduce or prevent joint damage from JRA, prevent loss of function, and alleviate pain. These pharmaceuticals including methotrexate, sulfasalazine, hydroxychloroquine, and leflunomide are considered standard of medical care for JRA (Mayo Clinic, 2017). Physical therapy treatment is often prescribed to address pain, range of motion restrictions, and to educate the child and family in joint protection. Splints and braces may be used for joint protection as well.
Thus, differential diagnosis is important in these cases. Patients may have been improperly diagnosed with a groin strain, or with mechanical knee pain, and sent to physical therapy. If knee pain becomes progressively worse in the absence of continued trauma, a reasonable suspicion of SCFE should be elicited and discussed with the child’s physician (OrthoInfo, n.d.c). Initial treatment begins with surgery, usually within 24 to 48 hours of diagnosis, and varies depending on the degree of slippage. Most procedures involve placing a screw through the femoral epiphysis, with highly displaced slips requiring additional screws (OrthoInfo, n.d.c). Physical therapy treatment may be prescribed following surgery and should consist of hip strengthening, aerobic conditioning, and gait and balance training.
OUTCOME MEASURES FOR THE KNEE
As with the hip, there are several outcome measures for the knee that are used to establish baseline scores and track changes over time. Some of these tools are self-report and some are administered by a physical therapist or other qualified examiner. The following are some of the most widely used and validated tools: ● Knee injury and osteoarthritis outcome score (KOOS ): This is a scale measuring pain, functional ability, quality of life, and sport and recreation participation. A higher score indicates fewer problems. ● Rheumatoid and Arthritis Outcome score for the lower extremity (RAOS ): The RAOS, an adaptation to the
KOOS, evaluates functional limitations of individuals with inflammatory joint diseases and impairments to the lower extremities. Additionally, it takes into consideration pain, symptoms, sports and recreation, and quality of life. ● Lower-extremity functional score (LEFS) : This outcome measure is applicable to all lower-extremity impairments and has a minimum clinically significant difference of 9 points. ● Lysholm knee scale : This is a 10-point questionnaire covering pain and symptoms including swelling, locking, ambulatory device, stair climbing, and squatting. It is quick to score, but it is very specific regarding symptomology and does not include many functional measures.
KNEE PATHOLOGIES AND EVIDENCE FOR INTERVENTIONS
Knee pain and impairments require thorough and complete assessment in order to develop a plan of care. Mobility and Knee osteoarthritis The diagnosis of knee osteoarthritis is used to describe a prevalent form of DJD and is a complex disease involving varied structural processes occurring at the knee joint. As the population of Americans ages, the incidence rate is expected to increase significantly, with current statistics revealing that 30% of adults over age 60 demonstrate functional difficulties with tasks such as rising from a chair and ambulating on stairs due to knee OA (Currier et al., 2007). Even though the incidence rate increases with age, OA is not thought to be simply a normal part of aging (Swagerty & Hellinger, 2001). Obesity and a history of traumatic knee injury (e.g., anterior cruciate ligament rupture and/or meniscal tear) are key risk factors for the accelerated development of knee OA. Hallmark signs include patient-reported pain and radiographic evidence of osteophyte formation on the joint surface. There has been significant discussion and research aimed at determining the link between the patient’s report of pain and classical radiographic findings of OA of the knee, including articular cartilage degradation, joint-space narrowing, and osteophyte formation. Radiographic findings are considered the gold standard in diagnosing knee OA; however, the causal relationship between radiographic OA and its primary clinical signature (patient report of pain) remain poorly understood. This is mostly because in several large-scale studies of adults with knee pain, only about half demonstrated evidence of OA on radiographic films. On the other hand, of all subjects demonstrating radiographic evidence of OA, only half reported pain (Swagerty & Hellinger, 2001). It is thought that there is a relationship between severity of knee OA and pain, as research subjects with severe OA were more likely to report pain than subjects with less severe OA. Similarly, MRI studies have identified relationships between pain and findings of synovial thickening, effusion, bone marrow lesions, and meniscal tears; however, converse studies demonstrated
motor control of the knee should be evaluated in conjunction with the hip and the foot due to their roles in ambulation.
similar findings on MRI, yet no patient-reported pain or radiographic evidence of degeneration (Kittleson et al., 2014). There has been a movement recently toward phenotyping pain in patients with knee OA, promoting the idea that tailoring pain care to each person’s experience will result in better targeted pain therapy. Different phenotypes currently being analyzed for sub-categorization include pain, stiffness, knee instability, and functional deficits. A new conceptual model for knee OA pain emphasizes the importance of contributing factors from three domains: (1) knee OA pathology, (2) psychological distress, and (3) neurophysiological changes in pain processing (Kittleson, 2014). Knee pathology includes structural abnormalities, joint loading and alignment, quadriceps dysfunctions, and joint inflammation. Quadriceps muscle weakness appears to be strongly related to presence of pain, which suggests that the inability to attenuate forces surrounding the knee joint could play a crucial role in the patient’s experience of pain. Psychological distress includes fear and avoidance beliefs, pain catastrophizing, self-efficacy issues, and depression. There is evidence that high levels of self-efficacy and successful self-management strategies are associated with improved pain levels and better functional outcomes. Pain neurophysiology includes reduced pain thresholds, temporal summation, spreading sensitization, and impaired descending modulation. Descending modulation of nociception has been shown to be disrupted in people with OA (Kittleson et al., 2014). Management of patients with knee OA should include a comprehensive program of manual therapy and supervised clinical exercise. Deyle et al. (2005) demonstrated that patients receiving manual therapy and clinical exercise vs. exercise alone showed two times greater improvement on the WOMAC outcome measure. Manual therapy should be tailored to the
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