Juvenile Arthritis and Sports Participation: Is it Safe?

Posted on May 22, 2013 by

By: Sara Rau, DPT

In honor of National Arthritis Awareness Month, this week’s topic is on juvenile arthritis.

What is Juvenile Arthritis?

Juvenile Idiopathic Arthritis (JIA), formerly referred to as Juvenile Rheumatoid Arthritis (JRA), affects over 200,000 children in the United States.  JIA encompasses various typesJIA 1 of arthritis in children involving chronic inflammation of the joints causing pain, stiffness, swelling, and loss of motion.   Children with JIA have at least a 45% chance of recovering from JIA with no recurrence of symptoms into adulthood.  Studies are showing that exercise and sports participation can actually help improve symptoms of JIA.

What can exercise do for JIA?

There are many benefits of exercise in the management of arthritis.  They include:

  • JIA 2Improve and maintain joint range of motion
  • Improve strength and flexibility
  • Optimize bone density
  • Reduce cartilage damage
  • Decrease risk of obesity
  • Decrease pain
  • Decrease risk for cardiovascular disease
  • Improve energy levels
  • Improve sleep patterns
  • Improve mood and self-esteem

Is sports participation safe for kids with JIA?

Yes, in most cases sports participation is safe.  It was once believed that kids with JIA should avoid any contact or high-impact sports.  Studies have shown that kids with well controlled arthritis are able to participate in impact sports safely.  Not only does this mean that they are able to stay more physically fit, but they reap the psychosocial benefits of group sports participation.  

When should sports participation be avoided?

It is not recommended that kids with severe joint damage participate in high-impact or contact sports.  For kids with moderate to severe arthritis or those who have actively inflamed joints, exercise needs to be reduced to within pain limits.  In other words, exercise should not increase pain.  Once the flare-up has subsided, these kids can gradually return to their previous activity level.  If they return to full activity too quickly, they risk an exacerbation of symptoms and possible joint damage. 

What are other possible risks to consider with this population?

Kids with JIA may have some gross motor delays that can affect their readiness to safely participate.  Those who have had arthritis for a longer duration may have difficulty with endurance sports.  Those with arthritis in the neck are at greater risk for a spinal cord injury while those with arthritis in the jaw have a greater risk for dental injury.  Some recent studies have suggested that imbalances in muscle strength and muscular control with high impact activities, like jumping, can affect their technique.  Taxter et al. “suggests that the child transition into a sport preparatory-conditioning program to address any underlying deficits.  A pediatric exercise specialist who is sensitive to the needs of this population can work with a physical therapist to then appropriately integrate the child safely into sport.”   CHKD has pediatric exercise specialists at all 3 of the Southside Sports Medicine Physical Therapy clinic locations.  At this time, an exercise specialist is not available at our Oyster Point location in Newport News.  For more information, please call (757)668-PLAY.   And as always, it is important to talk with your doctor prior to starting any physical activity.

 References:

Ford KR, Myer GD, Melson PG, Darnell SC, Brunner HI, Hewett TE.  Land-jump performance in patients with juvenile idiopathic arthritis (JIA): a comparison to matched controls. Int J Rheumatol 2009;2009:478526

Norgaard M, Herlin T.  Sport and exercise habits in children with juvenile idiopathic arthritis (JIA).  Pediatric Rheumatology 2011;9(Suppl 1):126.

Philpott J, Houghton K, Luke A.  Physical activity recommendations for children with specific chronic health conditions: Juvenile idiopathic arthritis, hemophilia, asthma and cystic fibrosis. Paediatr Child Health 2010;15(4):213-218.

Taxter A, Foss KB, Melson P, Ford KR, Shaffer M, Myer GD.  Juvenile idiopathic arthritis and athletic participation: are we adequately preparing for sports integration?  Phys Sportsmed 2012;40(3):49-54.

http://www.rheumatoid-arthritisdiet.com/juvenile-rheumatoid-arthritis-symptoms.html.

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Shin Splints: What Are They? How Do I Treat Them?

Posted on May 15, 2013 by

By: Adam S. Mistr, MSEd, ATC, VAT/L

Shin splints are one of the most common injuries experienced by athletes.  It is also a very misunderstood injury.  Shin splints have become a very broad term used to describe anterior and medial shin pain experienced during participation in athletics.  Most common in runners, this ailment can befall any athlete whose sport requires repetitive running, jumping, bounding, etc. 

Shin splints are responsible for 12-18% of injuries in runners.  They are also experienced by roughly 4% of military recruits during basic training.  More commonly experienced by women than men, the shin pain is usually felt in the lower 1/3 of the medial aspect of the tibia.   Shin splints are an overuse injury and in a majority of cases, the athlete will only report pain during activity.  Some more severe cases can have pain while at rest as well.

Shin splints can pose a risk for greater injury if they go untreated.  If an athlete tries to ignore or “tough out” the pain; the injury can worsen to a stress reaction, stress fracture, or even a complete fracture of the tibia.  Early evaluation and diagnosis is very important in the management of shin splints and the prevention of a worse injury. 

Some common causes of shin splints are running on hard surfaces, i.e. road running vs. running on a rubberized track or on grass.  Shoe choice is another major factor in the occurrence of shin splints.  Proper fitting running shoes with a good arch support are important in providing the best support for the feet, legs, and body while running.  Appropriate stretching is critical with any athletic activity, but lower leg flexibility is an important method of preventing shin splints.

There are several methods of treatment for shin splints available; with the most notable being rest.  Allowing the body to rest and recover from the repetitive activities that cause pain is very important.  Ice or ice massage can be applied to the affected area to help with pain reduction.  NSAIDs (non-steroidal anti-inflammatory drugs) may be taken over the counter or prescribed at a stronger dose by the attending physician.  There are some taping methods that have been shown to help reduce shin pain during activity as well.  Supporting the arch of the affected leg with tape or orthotics can help place the athlete’s foot in a more neutral position and therefore, alleviate pain. 

Stretching and therapeutic exercises are good ways to help eliminate shin pain.  Stretching of the calf, both the gastrocnemius and soleus, is very important.  In order to stretch both muscles, calf stretches must be performed with the knee fully extended as well as with the knee slightly bent to about 15-20 degrees.  Also, stretching the anterior muscles of the shin can prove beneficial in the reduction of shin pain.  This can be done from a seated position and pulling the toes of the affected leg into plantar flexion.  It is also recommended to maintain flexibility in the hamstrings, quadriceps, hip flexors, and groin. 

 Exercises for ankle and knee strengthening are also important for the treatment of shin splints.  Open chain exercises such as resisted Thera-Band® exercises, knee extensions and standing or prone hamstring curls are some basic exercises for the ankle and knee.  As well as closed chain exercises such as lunges, squats, heel raises and toe raises. 

Depending on the severity of the injury, therapeutic modalities such as electric stimulation and ultrasound can be used for pain management.  Hydrotherapy can also be used in the form of a warm or cold whirlpool to assist with pain reduction, provide a massaging effect, and increase blood flow to the affected area.

As stated before, appropriate shoes are very important for any athletic activity, especially running.  Old, worn out shoes are a very common cause of shin pain and replacing them with a new, proper fitting pair has shown to be very beneficial in the prevention and severity of shin splints.  Cross-training can be very helpful to athletes suffering from shin splints.  This changes the surface on which the athlete trains and does not place the same demands on the athlete’s body as he/she experiences on a daily basis with their regular training regimen.  Some more commonly used cross-training activities include: biking, elliptical training, and swimming.

In summary, shin splints are not something that the athlete should take lightly.  A period of rest is recommended and a consultation with a trained medical professional (i.e. Physician, Physical Therapist, Athletic Trainer, etc.) is often required.  If you are experiencing symptoms similar to these and would like to schedule a consultation with one of our Sports Medicine physicians please call (757) 668-PLAY (7529).

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“Increase” is Not Always Positive

Posted on May 8, 2013 by

By: Oscar Mallory, ATC

     We are all familiar with certain increases in our world; some are good and some bad, such as an increase in our salaries (Good), or an increase in the average temperature change globally (Bad).  There is also the increase in young children entering athletics (Good), and in the number of children growing up suffering from obesity (Bad).  However would you be surprised to know that there has been an increase of overuse injuries within the middle school and beginning high school athletes?  Well yes, it is a fact that there has been a larger amount of young athletes coming into clinics, training rooms, and emergency rooms, reporting injuries that fall into this category. 

     Overuse injuries are those that happen over a period of time, instead of happening suddenly, and can go largely unnoticed or at least unspoken of.  They include, but are not limited to, stress reactions, stress fractures, tendonitis, falling arches, shin splints, knee problems, and general muscle soreness.  The focus of this discussion will be on the lower extremities of athletes that tend to do more running than most.

     Typically people ask, “Why does this happen?”, “What can or could be done to prevent this from happening?”, and “When can I start playing or practicing?”  The answers are not so simple, because athletes respond differently to stresses and strains.  The answer involves a mixture of proper frequency, duration, intensity and strength training.  Preventing injuries in middle school children is achievable through open lines of communication between coaches, athletic trainers, and parents.  Pain or injury of the youth should be reported to coaches and athletic trainers immediately in order for overuse to be caught early and therapeutic exercise should begin along with time off. 

      Coach and parent education on the developmental differences between middle and high school children is very important, especially if, for instance, 8th graders are competing with the high school team.  Some of the overuse injuries occur because there are coaches and parents that run younger athletes for the same amount of miles, time or intensity as older athletes.  The younger athletes are still developing and their musculoskeletal system is at a crucial stage of growth.  Too much pressure or trauma (micro trauma) can cause break down of muscle and bone, (ex. shin splints or stress fractures).  Continued micro trauma can lead to growth plate injuries, which can hinder normal growth.

     The more common injuries that I have noticed are shin splints, stress reactions and knee issues.  To prevent these injuries, coaches may want to develop a training regimen for each of the age groups.  For instance, have the younger runners only practice for three days a week at half the mileage of the upperclassmen, but with increased intensity (faster times). This could save the athletes from suffering unnecessary injuries, allow recovery time, and provide the coach with backup runners for future meets.  Parents should be careful about having their children in multiple sports at the same time, which could slow down recovery time for the child.  Just like in weight lifting 101, you don’t lift heavy every day and you don’t work the same part of the body every day, because the body needs its recovery time.

     Some knee issues can be prevented by proper strength training, such as weight lifting, low impact aerobics, and swimming when geared towards the specific muscles being used in that sport.  Poor muscular strength and tired, overworked muscles can lead to an increased possibility for injury and pain.  For example, young women and girls are prone to knee issues because of muscular strength imbalances and the angle of the hips to knees and ankles.  Strengthening the quadriceps and hamstring muscles can add stability to the knee joint and decrease pain.  Lower leg strengthening prior to the start of the season can help an athlete deal with the weekly stresses placed on them.  Some of the exercises that can be used for lower extremity strengthening are heel and toe walking, heel raises, toe raises, lunges (with or without weights), and step ups and step downs (with heel touch).  A very important thing to remember is to make sure these exercises are performed in the presence of someone trained in their application.

     There’s no magic elixir for any of the issues that affect our middle and high school children, but let safety be your guide.  We should also make sure our motivations for having these kids in athletics are pure and not driven by any personal gains.  This experience should be fun and not feel like a job, so they grow to love their sport.  Remember, there are many people and resources available to us to learn safe practices for introducing our children into the sports world.

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Sideline Concussion Assessment Tool: A Children’s Version

Posted on April 23, 2013 by

By: Laura Mushik, MEd, ATC

With the number of reported and diagnosed concussions in youth sport increasing each year, it only makes sense that the assessment tools used to help determine one be updated.  According to the Consensus Statement issued after the 4th International Conference on Concussion in Sport held in Zurich in November 2012, as of March 2013 the previous Sideline Concussion Assessment Tool (SCAT2) was replaced by the SCAT3 for athletes 13 years and older.  With this updated assessment tool, a modified version, the Child SCAT3 was issued to be used in children aged from 5 to 12 years.  There has never been a specified SCAT for children under the age of 12, and some healthcare providers believe that the SCAT is too difficult for younger athletes regardless if they have sustained a head injury or not.

Licensed healthcare providers utilize the SCAT3 as a standardized tool for evaluating injured athletes for a concussion.   It is a test that determines cognitive function, physical evaluations, delayed recall, balance, and the Glasgow Coma Scale (GCS).  The Glasgow Coma Scale evaluates eye opening, verbal and motor responses, and brainstem reflex function.  The test is broken up into sections which include GCS, Maddocks score, symptom evaluation, cognitive assessment, neck examination, balance, coordination, and delayed recall.  It also includes information for the athlete and parent such as signs to watch for, return to play criteria, and concussion injury advice.

The Child SCAT3 does follow the same format as the SCAT3, however, there are a few notable differences in the testing.  These differences can help the healthcare provider, athlete, and parent better understand the injury and severity.  The symptom evaluation is ranked on a scale of 0-3, compared to 0-6, and has a child report AND parent report section.  This will help with miscommunication from either party as to what the athlete is experiencing and will hopefully decrease the downplaying of a symptom to return to school and sport early.  The SCAT3 uses orientation, immediate memory, and concentration to assess cognitive function.  For the concentration portion of the Child SCAT3, they are asked to give the days of the week in reverse order instead of the months in reverse order.  This is a great example of how this test is more appropriate for its intended audience.  Another difference is for children aged from 5-12 years, is a modified balance test.  What typically is a three part sequence including double leg, single leg, and tandem stance is tailored for children by eliminating the single leg stance. 

It is hopeful that this test becomes more reliable and valid in evaluating the younger population for a concussion and increases awareness of head injuries in youth sports.  For more information regarding the new SCAT3 and Child SCAT3 please refer to the Consensus Statement on Concussion in Sport found in the British Journal of Sports Medicine.

Click HERE for more information on CHKD’s Sports Concussion Program or call 757-668-PLAY to schedule an appointment.

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The Use of Ice to Treat Acute Soft Tissue Injury

By: Ashley Perry, DPT

Water 1 “Should I use ice on my knee?”  Patients and parents routinely ask if ice should be used following injury to prevent swelling and decrease pain.  The use of ice to treat acute soft tissue injury has been used for many years; however, very little research has shown the exact benefits of cryotherapy.   Cryotherapy is the local or general use of low temperature, i.e. ice, to treat therapeutically.  In the article reviewed, a few studies from the 1950s and 1960s indicated that cold therapy was successful in decreasing hemorrhage, decreasing edema in acute injuries, and providing an analgesic effect for acute muscle spasm.   As a result of so little evidence, more recent research has been successful at identifying additional mechanisms responsible for proving that ice therapy is beneficial to patients with effusion and edema.  Water 2Through the use of the article, which was found using the contemporary search engine Medline and the key words “use of cryotherapy for orthopedic patients”, the author discussed valuable research studies with human and animal subjects through a systematic review of randomized control trials as well as non-random trials and trials using a small population.

The author determined the following statistics: 73% of consultants most often advocate the use of ice and 23% of those consultants had read literature supporting the use of cryotherapy.  This information helped to show that a majority of physicians are using ice therapy, but very little evidence has been presented showing the benefits the therapy may have for the patient.  Thus I performed a literature search in order to find research articles on the topic including human trials, animal trials and systematic reviews.  The outcomes measured to determine the effects on acute soft tissue injuries included reduction in pain, a reduction in swelling, an improvement in function, and a quicker recovery and return to previous level of functioning.

Human trials, which focused more on function and less on pain and edema, were found to have many flaws including non-randomization and no blinding.  As a result the data was variable and suspect.  One study by Airaksinen et al. (2003) revealed that pain at rest, pain on movement, and functional disability were all reduced in patients receiving cold gel for treatment of sports-related soft tissue injuries.  A study by Cote et al. (1988) showed that cold treatment, hot treatment and contrast bath all increased ankle edema, but cold treatment increased ankle edema to a lesser degree.  Although most of the human studies lacked statistical evidence for support of ice in the reduction of pain and swelling, most studies revealed faster healing times.  A study by Laba (1989) concluded that patients with a grade 4 ankle sprain recovered in 7.3 days with ice vs. 10.2 days without ice.  Basur et al. (1976) reached a similar conclusion:  patients with ankle sprains recovered in 9.7 days with cryogel and crepe bandage vs. 14.8 days in patients with bandage alone. The animal studies were successful in proving a reduction of edema with cold therapy; however, little evidence about the faster clinical recovery time can be drawn from these studies.

Water 3

Of the two systematic reviews included in the article, one from 2004 lacked statistical support for ice and concluded that further studies were needed to ensure adequate evidence-based practice.  The second systematic review (2004) concluded that cryotherapy instituted soon after injury may be effective in returning the patient back to activities in less time than other treatments.  The author believed that cryotherapy was an acceptable practice due to the low price, relative safety, ease of use and the ability of the patient to tolerate the therapy.  In conclusion, the article presented the benefit of cryotherapy in the treatment of acute soft tissue injury only if given soon after the injury and only when the cold therapy is within necessary treatment times and temperatures.

Ice ChartWater 4

 

References:

 Collins NC.  Is ice right?  Does cryotherapy improve outcome for acute soft tissue injury?  Emergency Medicine Journal.  2008; 25: 65-68.

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