Proper physical therapy for rheumatoid arthritis

Author of the article: Alexandra Burguta, obstetrician-gynecologist, higher medical education in the specialty “General Medicine”.

Article publication date: 03/18/2014

Article updated date: 07/14/2020

Rheumatoid arthritis is characterized by joint deformation, limited mobility and the development of contractures (immobility). To reduce symptoms, treatment includes exercise therapy, massage, swimming and physiotherapy. Therapeutic exercise for rheumatoid arthritis is aimed at strengthening ligaments and muscles, increasing range of motion in joints and slowing down pathological reactions.

Indications and contraindications for physical education

Exercise therapy is indicated for almost all patients. With significant restrictions, it is possible to perform breathing exercises or positional treatment (more details later in the article).

The main contraindications for prescribing physical education:

• exacerbation of rheumatoid arthritis, accompanied by severe pain and inflammation;
• systemic manifestations of the disease with serious damage to internal organs (vessels, kidneys, heart, lungs);
• some concomitant chronic pathologies (infections, cardiovascular and respiratory failure).

The recommendations are extremely wrong.

• Strengthen the joint.
• “Knock out a wedge with a wedge.”
• “Disperse the salts.”
• “Overcoming the pain” - this often increases the pain syndrome, provokes inflammation and destruction of the joint.

Don't crawl on your knees at home - it destroys the joint!
Remember - regular exercise and relaxation will help more than medications or massage, rest and moderate exercise should be balanced, never put stress on the damaged area. Whether sitting or standing, be aware of your posture. Medical rehabilitation has accumulated extensive experience in the rehabilitation of patients with pathologies of the musculoskeletal system using physical therapy methods. Classes are conducted according to an individual program, under the supervision of a physical therapy doctor and experienced instructors. Author: V.I. Dikul

Basic methods and stages of classes

All approaches to physical therapy for rheumatoid arthritis can be divided into three groups:

1. Individual classes are ideal for patients with the most severe stage of the disease, as well as for rehabilitation after surgical treatment.
2. Group classes are the most accessible and rational approach. Patients are grouped according to the degree of mobility limitation.
3. During consultations, patients are taught techniques and exercises that they can use at home.

The main condition for exercise therapy in the treatment of rheumatoid arthritis is regularity of exercise and systematic increase in load. Exercises should not be performed with force: after proper physical activity, the patient should experience an increase in strength and a decrease in stiffness.

During inpatient treatment, three periods of rehabilitation can be distinguished:

1. Preparatory, when the doctor teaches the patient relaxation and breathing techniques. The duration of these exercises is about 10 minutes, the duration of training is 1–2 days.
2. During the main period, a basic set of exercises is performed. Classes take place daily for two weeks, each lasting about half an hour.
3. The final stage is carried out before discharge: the doctor teaches the patient exercises that he can do at home.

Prevention of joint diseases

Arthrosis occupies a leading position in joint diseases. The cause of the disease lies in poor blood circulation and lack of tissue nutrition. The best prevention is walking barefoot on uneven natural surfaces: stones, sand, grass.

Other preventative measures include:

• massage mats - used when it is not possible to walk barefoot on grass or sand;
• a balanced diet rich in substances necessary for joints;
• walks in the open air;
• daily gymnastics.

These activities will help maintain healthy legs and the whole body.

Arthrosis of the feet causes a lot of inconvenience and requires mandatory treatment. It is not possible to completely get rid of the disease. Therapeutic exercises and massage will help reduce pain and slow down the process of destruction of cartilage tissue. It is important to follow your doctor’s recommendations and perform a set of exercises regularly.

We also recommend reading:

Osteoarthritis of the foot is a very common disease. It is impossible to fully assess the extent of the disease. Patients turn to doctors when the pain becomes severe. The disease progresses slowly, but leads to irreversible changes in cartilage tissue. Therapeutic gymnastics in the subacute period and in remission improves recovery processes, reduces the need for painkillers and speeds up the patient’s rehabilitation.

Treatment by position

The “position” method of treating rheumatoid arthritis is also classified as exercise therapy and is used for severe lesions, when the patient is practically unable to move and is mainly in bed. It should also be carried out during periods of exacerbation of the disease.

What is its essence? The mattress on which the patient lies must be smooth and hard; it is advisable to use a special orthopedic one. The feet should have support; for this you can use either a moving headboard or a stand. You need to change your body position at least once an hour, if necessary with the help of another person.

If contractures begin to form, special splints (hard strips of plaster-impregnated bandages) are applied. If this is difficult to do, you can use rollers, weights and other devices. For example, if the hip joint is affected, a two-level mattress is made, allowing the leg to be extended in a relaxed position.

Gymnastics - a means to prevent arthritis

For arthritis of the finger joints, special exercises should be performed repeatedly. This does not require special conditions, you can perform them even outside the home, the required number of repetitions is up to 9 times daily, which is quite doable for any person. Thanks to active gymnastic exercises, blood circulation improves and inflammatory activity decreases. The fluid accumulated in the periarticular tissues and cavities begins to dissolve, swelling and redness subsides. Gymnastics for arthritis of the hands helps to increase muscle tone . Motor ability in the joints improves, and hand motor skills are gradually restored. If all recommendations are followed, the patient’s general condition improves significantly. Basic rules of health-improving exercises for arthritis:

• systematic and regular implementation of classes;
• perform exercises during an exacerbation of the disease;
• train both hands at the same time;
• monitor free breathing and pace.

Special gymnastics for arthritis consists of simple movements that must be performed in such a way as not to experience discomfort. Many people often develop the disease on one finger of one hand. This may be the beginning of the development of disease in all joints of the hand. In any case, exercises should be performed on both hands. Before starting the exercises, you should consult with your doctor, he will recommend the set of exercises that you need. As a rule, gymnastics for the hands is easy to perform; each exercise should be done an average of 8 times, it all depends on the severity of the disease and general well-being. At first it will be a little difficult to perform individual movements, but gradually the joints will become stronger, the time of exercises and their quality will increase.

Hand exercises

In rheumatoid arthritis, the joints of the fingers are most often affected. Usually the hand takes on the characteristic appearance of a flipper, which leads to limited functionality and disability.

To reduce the strain rate it is advisable to:

• do not move your fingers towards the little finger;
• reduce the load on the fingertips;
• when at rest, ensure the correct position of the hand;
• write only with cone-shaped thickened pens;
• perform everyday activities correctly: trying to ensure that the axis of movement in the joints does not deviate to the side;
• at night, use orthoses - devices that limit mobility.

Here is one set of exercise therapy exercises for hand injuries:

1. Starting position: hands in front of you, next to each other. Alternately turn your palms up and down.
2. Place your hands on the table and raise and lower them first, and then only your fingers.
3. Stretch your hands clenched into fists forward. Rotate the brushes clockwise and counterclockwise.
4. Place your elbows on the table, clasp your palms, spread and bring your elbows together without lifting them from the surface.
5. Make up-down, left-right and circular movements with each finger in turn.
6. Touch each finger to the thumb, as if grasping something round.
7. Squeeze and unclench the soft ball in your hand, roll it over the surface.
8. Rotate your hands at the wrist joint, while trying to relax your palm.
9. Move your fingers along the stick from bottom to top.
10. Rub your palms together.

Each exercise should be performed 5–7 times, depending on the patient’s condition. There should be no pain during exercise.

Click on the picture to enlarge

What does exercise therapy give?

Thanks to therapeutic exercises for rheumatoid arthritis, joint mobility is maintained.
With a decrease in activity, muscle tissue atrophies, blood circulation slows down, and swelling develops. At the same time, body weight increases. This is important because excess weight interferes with movement and causes increased stress on the joints. Thanks to exercises, muscle and connective tissues and tendons are strengthened. As a result, the risk of injury is reduced. At the same time, during exercise, muscles relax, and in case of rheumatoid arthritis, this helps prevent pain and accelerates regeneration processes.

Exercises have a positive effect on metabolic processes and oxygen absorption, and weight loss. But exercise therapy for rheumatism is contraindicated if the disease is in an advanced stage, and also when:

• inflammation was detected in internal organs and the cardiovascular system;
• the acute stage of a chronic disease has arrived;
• infection has occurred;
• there is intoxication of the body;
• infection develops;
• have heart or lung failure;
• suffers from fever;
• the temperature has risen;
• a hernia appeared;
• cancer was diagnosed.

Physical activity for rheumatoid arthritis should be regular and feasible. It is necessary to perform the exercises three times a day: in the morning, at lunch and before bed. In this case, you need to try to evenly distribute the load, working equally with both right and left limbs. You should breathe regularly, deeply, and increase the load gradually, taking into account how you feel.

Exercises for lesions of the shoulder girdle

1. Raise and lower your shoulders, make circular movements forward and backward.
2. Place your palms on your shoulders, alternately bringing your elbows forward.
3. Clasping your elbows with your palms, raise them and lower them.
4. Lying on your back, bend, raise and lower your straightened arms.
5. Place your hands on your belt and alternately place them behind your head.
6. Hug yourself.

During exercises, it is very important to maintain the correct breathing rhythm.

The above exercises are called dynamic, that is, related to the movement of the body in space. They are mainly aimed at restoring mobility and preventing contractures.

There is another type of load in which muscle work is not accompanied by movement of the limb, since it is fixed: isometric. Isometric exercise helps strengthen muscle fibers, even with severe mobility limitations. An example of such an exercise: lying on your back, press with straightened arms on the surface.

Daily morning exercises for rheumatoid arthritis

Every morning after waking up, before getting out of bed, you must do exercises. Having done these two exercises, you can slowly and smoothly get out of bed.

• Morning workout for healthy feet

We stretch our entire body, transfer all the tension to our feet, and pull our toes forward. In this position, you need to freeze for 15 seconds, then pull your toes towards you.

• Morning workout for healthy hands

We inhale air, raise our arms above our heads, arch our back and, as we exhale, return to the starting position.

Leg exercises

1. Lying on your back, bend your leg at the knee joint without lifting the soles from the surface (sliding steps).
2. Exercise bike.
3. Move your legs bent at the knees to the sides and bring them back.
4. Swing with a straight leg while lying and standing, holding onto a support.
5. Circular movements in the hip joint with the leg bent at the knee.
6. Raising straight legs to the sides in a lying position.
7. Circular movements with a straight leg.

Isometric exercises are performed with the help of an assistant, who provides resistance and prevents the limb from moving.

Physical therapy for a child

In children, foot deformities include flat feet and hallux valgus (X-shaped feet). Gymnastics for these pathologies will not only help strengthen the muscles and ligaments of the legs, but will also prevent the development of arthrosis of the feet in the future. It is convenient to conduct classes in a playful way.

For flat feet, it is good to combine training lying on the floor and sitting on a chair with walking alternately on your toes and heels, as well as on an uneven surface (pebbles, sand, ribbed rug).

Below are exercises for hallux valgus in a child (1.5-2 minutes for each set).

Standing

1. We rise onto our toes several times and lower ourselves back onto the entire sole.
2. We squat with our feet pressed tightly to the floor.

Sitting on a chair

For classes, you need a chair that matches the child’s height and a gymnastic ball with a medium-sized ribbed surface, and you can also use various small objects, rags, and handkerchiefs.

1. We put our feet on the ball. Pressing on the ball, we roll it with both feet.
2. We squeeze the ball with our feet one by one.
3. We stretch our legs forward and use our toes to collect and move small objects. We practice for about 10 minutes.

It is good to supplement the exercises listed above with walking: alternately on your heels and on your toes, on the outer edge of the foot, on sand or small grains, along a straight line (drawn or imaginary), in a bathroom, at the bottom of which a bubble mat filled with warm water is laid (temperature 35 degrees Celsius).

Add vegetables and fruits and foods high in calcium to your diet. Don't forget about good emotions and smile. Do exercises every day and leg pain will not bother you.

7321

Arthrosis of the feet is a dangerous disease that manifests itself in the form of destruction of cartilage tissue in the joints. Without timely treatment, degenerative-dystrophic changes will become irreversible, as a result of which the joint will completely lose mobility. Exercises for the feet with arthrosis are part of a comprehensive treatment. Such gymnastics can also be performed to prevent the development of pathology.

Ankle exercises

With rheumatoid arthritis, the ankle joint is not often affected, but its deformation quite quickly leads to limited movement and disability. To prevent contracture, it is recommended to perform the following complex:

1. While sitting, bend and straighten your feet and toes.
2. Roll from heel to toe and back.
3. Stand on your toes against a support.
4. Try to lift various objects from the floor with your toes.
5. Roll a stick or ball with your feet.
6. Walk across the stick, stepping on it with the middle part of the sole.
7. Make circular movements with your feet.

When performing any complex of therapeutic exercises, it is advisable to alternate isometric and dynamic exercises, breathe correctly, and at the end of the session, conduct a muscle relaxation session.

To increase the load, you can gradually increase the range of motion in the affected joints and the number of repetitions.

Features of Bubnovsky's technique

The main goal of classes using the method of Sergei Bubnovsky is to maximize joint unloading by strengthening skeletal muscles and ligaments. In this case, the muscles will take on part of the load, movements in the joints will become easier and painless, and rheumatoid arthritis will slow down its progression.

1. We “walk” on the floor on our knees.
2. We get on our knees, lower our buttocks onto our heels and lift them back up.
3. We lie down on the floor and pull our bent legs to our chest.
4. In the same position, place your hands behind your head, at the same time pull your legs to your chest and raise your shoulder girdle.
5. We turn over on our side. We swing the leg lying on top up, forward and backward.
6. We sit on a stool. We roll a tennis ball on the floor with our bare feet.

Whatever set of exercises you prefer, they all require regular, systematic exercise and perseverance. Loads should be moderate, but daily. Then, with the parallel use of prescribed medications, you will have the opportunity to alleviate the course of the disease and slow down its development.

Exercises in water

Of all the sports, swimming is most suitable for the treatment of rheumatoid arthritis, since in water there is no stress on the joints due to the weight of the body. With a weight of 60 kg, completely immersed in water, a person feels only 7 kg. Therefore, exercises in the pool can be performed even by patients who practically do not move.

The intensity of the load is determined by the degree of immersion, which allows you to gradually restore motor activity. Higher water density requires greater effort to overcome resistance.

The temperature in the pool also has a positive effect: with thermal exposure, the pain syndrome is significantly reduced.

Contraindications to water activities:

• open damage to the skin;
• allergy to chlorine;
• eye diseases (conjunctivitis);
• lesions of the ear, nose and throat;
• venereal diseases;
• some chronic pathologies of other organs and systems.

In the pool you can perform the following complex:

1. Walking with straight and bent legs. It is advisable to spread your arms to the sides so as not to lose balance; if necessary, you can hold on to the support. The water level is adjusted depending on the required load.
2. Swing your legs back and forth, to the side, in circular movements.
3. Squats with legs wide apart (it is important to keep your back straight).
4. Having immersed yourself in water up to your neck, spread your straight arms to the sides and perform circular movements in the shoulder, elbow and wrist joints.

The swimming itself can be free or facilitated (using fins, special foam boards or inflatable objects). Depending on the goals pursued, you can increase the load on your legs or arms.

Massage as an additional method of improving condition

Massage is an especially necessary and important procedure for poor blood circulation in the tissues. It helps activate metabolic processes, improves overall muscle tone and, as a result, alleviates the condition of arthrosis. Spend 5-10 minutes on your feet before going to bed. First apply a light massage cream to clean skin and follow these steps:

• stroking and rubbing, starting from the fingertips, moving to the ankle joint;
• finger rotation;
• flexion and extension of toes;
• stroking with light pressure on the sole of the foot, then the top and sides;
• light pats on the heel area.

Functional motor test

Before the start of the rehabilitation period, the physical therapy doctor assesses the degree of damage to the patient’s motor system. To do this, you can use various tests, but the most popular is the functional motor study, which lasts only 5–6 minutes. The doctor asks the patient to perform various actions, for each of which a certain number of points is assigned. The test results allow you to objectively assess the dysfunction:

• No functional limitations.
• Maintaining professional ability to work.
• The ability to work is completely lost.
• Cannot take care of himself.

Based on the results obtained, patients are divided into groups and the optimal complex of exercise therapy is selected.

If you have rheumatoid arthritis, don’t give up on yourself. Start doing special exercises. Daily physical therapy exercises will tone your muscles, improve your well-being and increase your mobility. Before starting gymnastics, you should consult your doctor.

The main causes of the disease

Adequate support for the foot is provided by walking on rough surfaces (earth, grass, sand, pebbles, etc.). When walking on a hard and level surface, the spring properties of the arches are lost: the foot flattens, the heel and toes take the wrong position. Violation of the biomechanics of foot movements entails destructive and degenerative changes in all joints of the spine and lower extremities, leading to stagnation of venous blood. Cartilage destruction and joint dysfunction are caused by many factors:

1. Congenital or acquired deformities of the joints and bones of the lower extremities.
2. Longitudinal and transverse flatfoot.
3. Injuries to the lower extremities, such as fractures, bruises, sprains.
4. Chronic metabolic diseases: diabetes, gout and others.
5. Chronic autoimmune diseases.

Predisposing factors for the development of arthrosis will be:

1. Using the wrong shoes. Wearing shoes with high heels or, on the contrary, with too flat soles, poor fixation in the ankles, uncomfortable lasts, non-breathable materials, shoes that are too narrow or, on the contrary, too wide - this is an incomplete list of factors that contribute to cartilage damage.
2. Heavy weight. The joints of the lower limb are supporting. Increasing the load on them can lead not only to fatigue, but also to arthrosis.
3. Pregnancy. A pregnant woman's weight increases. Due to the fact that the body is weakened, the ligaments lose their elasticity.
4. Professions, especially those associated with vibration, hypothermia, may result in occupational injuries.
5. Genetic predisposition.
6. Excessive sports activities.
7. Poor nutrition.

In patients with arthrosis, the disease begins gradually. They may note that there was a period of discomfort in their legs, and then nothing bothered them for a long time. Then there are complaints about the appearance of “foot bunions”, “corns”, Heberden’s nodes (thickenings on the joints), and joint deformation. Poor circulation, trauma and compression of periarticular tissues, muscle spasms cause pain. In advanced cases, the pain becomes constant and bothers you at night due to poor outflow of venous blood.

Treatment of osteoarthritis is complex. Medications (anti-inflammatory, painkillers, chondroprotective) are combined with treatment methods such as a balanced diet, physiotherapy, massage and physical therapy. In cases where joint deformation causes the development of persistent contractures, surgical intervention may be indicated.

The place of physical rehabilitation in the treatment of juvenile arthritis

Rheumatology is one of the fastest growing specialties, and successes in treating patients, including those with such a serious disease as juvenile idiopathic arthritis (JIA), are undeniable. Timely prescribed adequate basic therapy, including genetic engineering therapy, significantly reduces the activity of rheumatic disease, as a result the patient’s condition improves, the range of motion in the joints expands, which allows the child to lead an age-appropriate active lifestyle [1–3]. Nevertheless, rehabilitation measures aimed at both improving the function of the affected joints and strengthening the child’s body as a whole and increasing his endurance are important for juvenile idiopathic arthritis. Therapeutic physical education (physical therapy) and other rehabilitation activities accustom the child to the need for constant exercise and help develop the correct stereotype of motor activity for life. However, at present there is not enough methodological literature devoted to the rehabilitation of children with rheumatic diseases; the available literature concerns mainly adult patients, so discussion of the problem is relevant and timely.

JIA is one of the most common and disabling rheumatic diseases in children. The incidence ranges from 2 to 16 per 100,000 children, and is more common in girls than boys. In the Russian Federation, the prevalence of JIA in children under 18 years of age reaches 62.3 [4, 5]. The classification and nomenclature of JIA includes the identification of seven variants of the course of the disease (according to the classification of the International League of Associations for Rheumatology (ILAR)):

1) systemic arthritis; 2) polyarthritis: negative for rheumatoid factor (RF); 3) polyarthritis: positive for the Russian Federation; 4) oligoarthritis: a) persistent and b) spreading; 5) enthesitic arthritis; 6) psoriatic arthritis; 7) other arthritis that: a) does not meet any of the categories or b) meets the criteria of more than one category.

To date, the etiology of juvenile idiopathic arthritis remains unknown. The mechanism of development of the disease is based on the activation of cellular and humoral immunity, probably in response to the appearance of a foreign or altered self-antigen. As a result of complex interactions, activated T-lymphocytes, macrophages, fibroblasts, synoviocytes produce pro-inflammatory cytokines, causing a cascade of pathological changes with the development of progressive inflammation in the joint cavity. Uncontrolled reactions of the immune system lead to the development of acute immune inflammation with its transformation into chronic inflammation with the development of pannus and irreversible destruction of articular structures [4, 5].

Articular syndrome is the leading symptom complex of all forms of idiopathic arthritis, and, from the point of view of rehabilitation, it should be assessed as a manifestation of maladaptation of the musculoskeletal system, in which the following typical pathomorphological processes are observed: inflammation, circulatory disorders, dystrophy and degeneration. As a result of these processes, pain, distortion, and deformation occur, leading to dysfunction of the joint. This pathological chain inevitably leads to a deterioration in the quality of life and disability of the child.

Rehabilitation, or restorative treatment of children, is a process that includes a set of measures. Rehabilitation measures are aimed at preserving the functionality of the affected joints and stabilizing the pathological process. In the rehabilitation of children, compliance with dietary recommendations is important; daily routine, physiotherapeutic methods of treatment; reflexology; Spa treatment.

Our publication focuses on kinesiotherapy methods, which occupy a central place in the physical rehabilitation of children with juvenile arthritis. By the term “kinesitherapy” we mean positional treatment (including orthotics), exercise therapy, massage, manual techniques, mechanical and occupational therapy.

Among the general recommendations, it should be noted that the child should sleep on a comfortable bed; an orthopedic mattress is preferable, not too soft, but not too hard. If the joints of the lower extremities and spine are affected, orthopedic shoes can be used, but, in any case, shoes with a hard back. Disability of our patients is often caused by damage to the joints of the hand. Therefore, it is necessary, with the help of doctors, exercise therapy methodologists, and parents, to form the correct stereotype of movements in the wrist joint to correct possible or existing ulnar deviation in it. So, you need to maintain a straight axis when performing all movements, including when performing physical therapy exercises (position on the edge of the palm), avoid positioning the hand towards the little finger. To prevent the formation of “swan neck” type deformities, it is recommended to reduce the load on the terminal phalanges - that is, a “cushion grip” is developed, thickened cone-shaped handles and pencils are used.

One of the key places in the rehabilitation of children with lesions of the musculoskeletal system is occupied by physical therapy. As a result of inflammation and painful sensations in the joints, a forced compensatory limitation of limb mobility occurs and, as a result, hypoxic and subsequently hypotrophic processes in the muscles [6, 7]. Exercises allow you to maintain and restore range of motion in affected joints, prevent the development of muscle wasting, and maintain muscle strength and endurance. Physical activity is a proven method of preventing osteoporosis, the risk of which is increased in patients with JIA [8]. Also, exercise therapy in childhood stimulates psychomotor development, is an excellent means of distraction from illness, and is an element of psychotherapy.

When carrying out exercise therapy, the level of load is dosed individually depending on the functional and age capabilities of the child. It is advisable to carry out a set of exercises 2-3 times a day (by a methodologist and trained parents). The complex necessarily includes breathing exercises, as well as exercises for developing correct posture, strengthening the muscle corset, and activating large and small muscles of the limbs.

Exercise therapy has virtually no contraindications, with the exception of the period of high activity of JIA, accompanied by fever, other systemic manifestations of the process, severe pain, and pronounced humoral changes. In this situation, for the purpose of early prevention of the formation of contractures, the so-called. passive gymnastics, when work with joints is carried out by a physical therapy instructor or a trained parent; the range of motion in the joints is determined within the pain-free corridor [6]. Passive gymnastics may also be necessary for young children if the child himself is not yet able to follow the instructions of the methodologist. The use of this method may be indicated in the case of active complicated uveitis in patients with JIA if joint development is necessary. According to individual indications, after performing a complex of passive gymnastics, treatment with a weighted position can be used.

Treatment with positioning using weights is also used in the presence of formed joint contractures. According to the method, the joint is brought to the “extreme” position in the direction of limited movement and a weight is fixed on it, the gravity vector of which coincides with the vector along which movement is limited. Depending on the age and condition of the patient, the lesson time ranges from 10 to 30 minutes 3–5 times a day. When performing this manipulation, a gradual slow passive stretching of the periarticular muscle-tendon apparatus occurs, which leads to an improvement in the motor function of the joint. However, according to the children’s department of the Research Institute of Rheumatology, the use of weights (including “cuff traction”) has worked well for damage to the knee joint, but in the acute period it only worsens the condition of the elbow joint [8].

Orthosis is an important method of rehabilitation treatment for patients with JIA, the main goal of which is the correction of pathological deviations of the joints and the formation of their correct functional alignment. The use of orthoses during physical therapy exercises is especially effective for maintaining and consolidating the achieved results during the development of joints.

The orthosis mode and its use are selected individually in each case. Practice shows that the most “in demand” are orthoses for the wrist, knee, and ankle joints. If necessary, some orthoses can be worn at night [4, 6].

It is recommended to wear a “Schanz collar” if the cervical spine is affected. The height of the treatment collar should be equal to the distance from the bottom to the top of the neck, that is, to the jaw in front and to the base of the skull at the back. It is recommended to wear the collar for a total of 1.5 to 3 hours a day, depending on the age and individual characteristics of the child [6].

The myofascial component has a certain significance in the formation of chronic pain syndrome and the development of pain contractures. Myofascial pain syndrome (MPS) is a myalgia manifested by local and/or referred pain, the source of which is the myofascial trigger point (MTP). MTT is a group of compacted, as if frozen muscle fibers, in which there is an area of ​​intense pain [9]. MTT is characterized by the presence of a constantly or not always palpable compaction (“cord” or “nodule”) within the muscle, as well as a sensory disorder, which most often manifests itself as pain. The mechanism for the appearance of MTT is believed to be irritation of sensitive nerve endings in joints, muscles and ligaments, which leads to chronic excitation of mechanoreceptors involved in the formation of pain, and physical and metabolic muscle tension occurs. The structure of muscle contraction changes, satellite trigger points are formed in the muscles that perform a compensatory function. An important part of stress is hypoxic (ischemic) damage. Trigger points can contribute to the formation of tendinosis due to disruption of the dynamics of muscle contraction, local overload of the tendon and the occurrence of relative hypoxia in these areas [9, 10]. This mechanism is also implemented in patients with JIA: when local pain occurs, the “muscle protection” mechanism is activated, and the resulting spasm leads to a decrease in motor activity. In a state of physical inactivity, conditions are created for ischemia of the muscular system, which is one of the prerequisites for the development of MBS [9]. The pain syndrome can be “reflected” from spasmodic periarticular muscles and tendons: thus, according to our observations, when they are relaxed using manual techniques, pain in the joint area has a clear tendency to decrease. Manual influence on the area of ​​the myofascial pain point in our patients leads to a pronounced softening of the dense cord and an increase in the pain threshold. It was also noted that with myofascial relaxation, in a large proportion of cases the severity of enthesopathies decreases. In order to correct the myofascial component of the pain syndrome, our patients use the post-isometric relaxation (PIR) method, as well as soft manual (osteopathic) techniques.

PIR is used in the presence of myalgic syndrome. By relaxing spasmed muscles, the ischemic component of the formation of MBS is eliminated, their blood supply is restored, and pain is reduced. In addition, PIR has proven itself well when working with joints in which restriction of movement has developed due to both severe pain and painless spasms of the periarticular muscles and tendons, as well as due to a decrease in the size of the joint space. The exercises are performed as follows: the patient moves towards the restriction to the “barrier”, then fixes the joint in this position for 1–2 minutes and relaxes the tension. The training regimen is selected individually and performed by a trained specialist.

In the case of multiple trigger points and the patient’s increased sensitivity to pain, it is possible to use osteopathic correction of myofascial tension. The actions are carried out with the lightest touches at the level of the muscle fascia, which makes it possible to achieve relaxation of the muscle-tendon system without causing pain. Typically, this technique is used 1–2 times, after which the patient is transferred to a combination of PIR + exercise therapy to establish positive feedback between one’s own work and the achieved result [6].

Osteopathic correction and PIR techniques are used both in the stage of remission and in the stage of clinical and laboratory exacerbation of the disease and can accelerate the reduction of pain, improve the well-being and motor function of the joints, and help prevent the formation of joint contractures. Unfortunately, these techniques are not always applicable to small joints of the hands and feet; they have proven themselves much better on large and medium-sized joints [6].

Manual massage is also included in the complex of rehabilitation measures for JIA. It prevents the increase in muscle hypotonia and malnutrition and is aimed at eliminating muscle imbalance in the periarticular muscles. Massage can be indicated at the stage of proliferative changes in the joints without exacerbation of the disease. Methods generally accepted in childhood are used. The joint area is not massaged. Massage is contraindicated for acute synovitis, febrile syndrome, serositis and visceritis, humoral activity above grade 1, and the presence of general contraindications (acute respiratory viral infections, skin diseases, etc.) is also taken into account.

Mechanotherapy is one of the methods of medical rehabilitation. It is based on the use of dosed movements performed by patients using special devices. The method is more suitable for older children. Contraindications for mechanotherapy are the presence of bone ankylosis, severe pain in the joints, severe muscle weakness, and impaired congruence of the articulating surfaces of bones [11].

Rehabilitation and treatment of our young patients is ultimately aimed at ensuring a high quality of their future life, adaptation to living conditions and future work. Occupational therapy, or “occupation therapy,” promotes integration into public life and socialization of children with juvenile arthritis. Occupational therapy is of great importance in cases of damage to the small joints of the fingers, allowing to slow down the progression of impairment of their motor functions. Modeling, beading, knitting, playing the piano, etc. are recommended. This method is also useful as a means of increasing general and mental tone, and allows the use of play techniques in younger children. Receiving the product of labor serves as an incentive for better performance of work and includes elements of competition and creativity. The correct stereotype of hand function developed in the process of occupational therapy is reinforced when performing everyday manipulations.

In conclusion, I would like to note that, despite all the successes of modern drug treatment of juvenile arthritis, physical methods of rehabilitation occupy an important place in the complex of patient management. The rehabilitation plan is drawn up individually, based on the problems of a particular patient, and not just on his diagnosis. Rehabilitation should be an activity not only for doctors and methodologists, but also for the patients themselves and their parents. The tactics of rehabilitation measures and the program should be drawn up together with them; with this approach, the patient becomes the central figure of rehabilitation treatment and an active participant in this process.

Literature

1. Konopelko O. Yu., Zholobova E. S., Rozvadovskaya O. S., Elyashevich V. Ya., Nikolaeva M. N. Etanercept in real clinical practice in the treatment of patients with active juvenile idiopathic arthritis) // Scientific and Practical Rheumatology. 2013, 51(1): 44–47.
2. Neroev V.V., Katargina L.A., Denisova E.V., Starikova A.V., Lyubimova N.V. Efficacy of genetically engineered biological drugs in the treatment of uveitis associated with rheumatic diseases in children // Scientific and Practical rheumatology. 2012, 53(4): 91–95.
3. Michels H., Nikishina I.P., Fedorov E.S., Salugina S.O. Genetic engineering biological therapy of juvenile arthritis // Scientific and practical rheumatology. 2011, no. 1, 78–93.
4. Zholobova E. S., Shakhbazyan I. E., Ulybina O. V. et al. Juvenile rheumatoid arthritis. Guide to pediatric rheumatology / Ed. N. A. Geppe, N. S. Podchernyaeva, G. A. Lyskina. M.: GEOTAR, 2011. pp. 162–245.
5. Pediatric rheumatology: clinical recommendations for pediatricians / Ed. A. A. Baranova, E. I. Alekseeva. M.: Union of Pediatricians of Russia, 2011. 236 p.: ill.
6. Geppe N. A., Meleshkina A. V., Makarova M. R., et al. Physical rehabilitation of children with juvenile arthritis: a textbook for students of medical universities: local electronic publication. M.: Publishing house GBOU VPO First Moscow State Medical University named after. I. M. Sechenova, 2014.
7. Milyukova I. V., Evdokimova T. A. Therapeutic physical education: The latest reference book / Ed. ed. prof. T. A. Evdokimova. St. Petersburg: Sova; M.: Eksmo Publishing House, 2003. 862 p.
8. Shelepina T. A. Therapeutic gymnastics in complex therapy in patients with juvenile chronic arthritis // Modern rheumatology. 2013, (3): 64–6.
9. Ferguson LW, Gerwin R. Clinical Mastery in the Treatment of Myofascial Pain. Lippincott Williams & Wilkins, 2005.
10. Naomi Lynn Gerber, Siddhartha Sikdar, Jen Hammond, Jay Shah. Brief Overview and Update of Myofascial Pain. Syndrome and Myofascial Trigger Points // Journal of The Spinal Research Foundation. Spring. 2011, vol. 6, no. 1.
11. Physical rehabilitation. Textbook for students of higher educational institutions / Under the general editorship. prof. S. N. Popova. Ed. 3rd. Rostov-on-Don: Phoenix, 2005. 608 p.

A. V. Meleshkina1, Candidate of Medical Sciences A. V. Bunin N. A. Geppe, Doctor of Medical Sciences, Professor S. N. Chebysheva, Candidate of Medical Sciences

GBOU VPO First Moscow State Medical University named after. I. M. Sechenova Ministry of Health of the Russian Federation, Moscow

1 Contact information