Even in ancient societies, it was noticed that physical exercises affect the state of human health. And properly selected training complexes help in the treatment and prevention of many diseases.

In China, breathing exercises were developed and are still being successfully used, in India - yoga. Known methods of application of physiotherapy exercises by Avicenna and Hippocrates.

In subsequent years, the use of exercise therapy has evolved and improved, and in modern society has become a necessary part of almost any treatment.

Physiotherapy used in the form of training in order to obtain a therapeutic effect. It must be carried out in compliance with the general rules:

• regularity of classes;
• reasonable duration;
• alternation of classes and rest;
• gradual increase in physical activity during treatment;
• combination exercise and proper breathing
• hygiene;
• individual approach to each patient.

Forms of physical education classes depend on the purpose of the therapeutic effect - restorative, trophic, in the formation of compensation or normalization of body functions.

1. Hygienic gymnastics or morning work-out. Performed for a general strengthening and tonic effect. It can be used for all patients, except for those in a coma. Short exercises (no more than 15 minutes) in a ventilated room or in the open air can be accompanied by music.
2. Physiotherapy. A set of exercises, formed taking into account a specific disease. May contain various activities - in bed, on the street, in the water.
3. Walking, dosed for each patient. Used for patients with diseases respiratory organs, heart and blood vessels in order to gradually adapt to the loads. The dosage is made by the speed of walking, the distance covered, the local terrain (plains, ascents, descents).
4. Swimming, sports games, limited distance tourism, etc.

Physiotherapy

This is the main form physical training used in almost all diseases. Exercises are developed individually, for small and large groups.

By individual plan classes are performed by seriously ill patients. If the patient's condition improves, he can be introduced into the group.

Small groups (up to 5 people) are selected based on the same type of disease.

Large groups (up to 15 people) are made up of patients who are at the same stage of treatment, with similar goals. Classes are scheduled in the office for exercise therapy or in an open area.

Important! The group method brings the greatest effect due to the simultaneous impact on a large number of patients.

To conduct classes, a plan must be drawn up, according to which the training is divided into introductory exercises, basic, final.

The introductory part has a warm-up character and prepares patients for the main complex of special exercises. Here the body is tuned to physical activity, the interaction between the nervous system and muscles is optimized. This is approximately 10-15% of the total length of the lesson.

The main part is aimed directly at solving medical problems. Exercises affect problematic organs and parts of the body and generally strengthen the body. The duration of the main section is 75-80%.

The final part consists of exercises designed to smoothly reduce physical activity. Takes up the rest of the class.

The ratio of exercise time to total duration training should be:

• patients in a hospital - 50% (at the beginning of classes - 25%);
• patients in the sanatorium - 80%.

In addition to classes in a group, patients can supplement the treatment course with individual classes to increase the effectiveness of exercise therapy.

Efficiency mark

Patients should be monitored during training. Responses are measured and studied during the exercise. At the same time, based on indicators such as pulse, blood pressure and the respiratory rate is plotted - a physiological curve.

It shows the impact of sports load on the state of the body. The graph has the form of peaks and declines, where the peaks correspond to the most frequent contractions of the heart, and the declines correspond to a slowing of the pulse during breathing exercises, rest, relaxation of the muscles of the body.

Important! Evaluation of the effectiveness of classes is also needed in order to regulate, as necessary, physical activity. The optimal dosage of exercise is necessary for the correct effect on the body. An overdose can worsen the patient's condition, a lack of exercise weakens the effect produced.

Ways to track the effect of exercise therapy depend on the type of disease, the form of exercise therapy. They come down to assessing the patient's condition - changes in the pulse rate, activity of the heart and blood vessels, work respiratory system, fatigue or shortness of breath.

Functional diagnostic methods include taking samples and analyzes based on the type of disease, for example:

• in traumatology - measurement of the circumference of the legs and arms, dynamometry, myotonometry;
• diseases vascular system and heart - pulsometry, electrocardiography;
• pathology of the respiratory system - pneumotachometry, spirography.

All the results obtained are compared with respect to the time of measurements (at the beginning of classes, their development and end).

Types of efficiency control

1. Step control. It is carried out before the start of training and at the end. It consists of a deep examination of the patient using functional diagnostic methods to assess the activity of the heart, blood vessels, nervous system, respiratory organs, musculoskeletal system. Diagnostic methods depend on the nature of the disease.
2. current control. Conducting observations during treatment once a week using the simplest diagnostic methods - pulse control, blood pressure, ECG, etc.
3. Express control. Measurement of the body's response to a specific physical activity. It can be carried out using advanced methods of research or according to an abbreviated program. Must be evaluated external manifestations- fatigue, well-being, pulse control is carried out.

Contraindications to exercise therapy

1. The disease is in an acute form.
2. Fever, fever.
3. The presence of severe pain.
4. Possibility of bleeding.
5. Conservative therapy of malignant neoplasms.
6. body intoxication.
7. Mental pathology, severe oligophrenia.
8. The existence of foreign objects in dangerous proximity to blood vessels or nerve trunks.

The value of physical education in complex treatment

Physiotherapy exercises, as an important part of therapy, are used without age restrictions, for any diseases and traumatic injuries. It is based on the activation of regulatory mechanisms to activate the adaptive, protective, compensatory functions of the body in order to participate in overcoming the disease. The dominant role of the movement contributes to the overall recovery and support of health.

The tonic effect of physical training is the most versatile. In any disease, they are used to activate excitation in the nervous system, normalize and improve the functioning of the vascular system, heart, respiratory organs, accelerate metabolism and immunobiological reactions. As a result of the choice of exercises, certain muscle groups are involved, work improves internal organs.

The trophic effect of exercise therapy is to stimulate regeneration processes. If real organ regeneration is not possible, training accelerates the formation of scar tissue. Compensatory hypertrophy occurs faster.

In connection with the improvement of blood supply under the influence of physical education, the resorption of non-viable tissue elements is activated. At various pathologies oxidative processes are slowed down. Muscle activity, stimulating all forms of metabolism, also accelerates oxidative reactions.

The normalizing effect of physical therapy is expressed in the inhibition of the resulting conditioned reflex interactions that have pathological character and return to normal functioning of the body.

A compensatory effect is observed in pathologies of a certain function. Special exercises promote the use of healthy systems to compensate for the activities of the affected. Exercise therapy stimulates these processes, accelerating and improving them.

Conclusion

Competently designed and systematically performed physical therapy exercises will help speedy rehabilitation in case of serious illnesses. They will serve as an excellent prevention to strengthen the body, increase immunity, endurance.

1. Juvenile rheumatoid arthritis

Juvenile rheumatoid arthritis (JRA) is an immunopathological process with systemic joint damage.

Early rehabilitation is carried out in a hospital. Biogenic stimulants are prescribed - apilac, anabolic hormones. Against the background of treatment, physical factors are used: UV rays on the area of ​​​​damage to the joints (the affected joints are irradiated daily in turn, but not more than two large or a group of small joints) after 2-3 days. In case of trophic disorders, the skin of the collar or lumbosacral zone is irradiated. Effective UHF electric field on the joints. Apply massage, exercise therapy, novocaine electrophoresis on the joints.

Late rehabilitation is carried out in a local sanatorium or clinic. Microwave therapy, ultrasound on the joints, diadynamic currents on the joints and reflex zones. Other factors of sanatorium treatment are also applied. Special attention given to exercise therapy, massage.

In rehabilitation treatment, resort factors treatments, among which thermal procedures (paraffin, ozocerite, hot sand, mud) and other factors (close tourism, outdoor games, dances) predominate. With restriction of movements in the joints, mechanotherapy, exercise therapy, massage, balneotherapy in the form of chloride, radon baths are indicated.

Orthopedic care started at the stage of early rehabilitation, movement treatment continues at the stage of rehabilitation treatment.

At all stages of rehabilitation, it is necessary to carry out sanitation of foci of infection, timely treatment of intercurrent diseases.

Dynamic observation is carried out within 5 years after the exacerbation of the disease by the local doctor and orthopedist (if necessary). The frequency of observation is once a quarter. A complete examination and clarification of the diagnosis are carried out in stationary conditions 2 times per year.

Systemic lupus erythematosus (SLE) is an immunopathological disease connective tissue, characterized by a predominant lesion of the nuclei of cellular structures by universal capillaritis.

Early rehabilitation begins from the moment the diagnosis is established; its purpose is to reduce activity pathological process, which is achieved by the appointment of glucocorticoids and cytostatics, good nutrition with the addition of dietary supplements.

Late rehabilitation is a sanatorium stage. Maintenance therapy with glucocorticoids prescribed in the hospital is carried out, and all individually selected factors of sanatorium rehabilitation are used. Sanitize foci chronic infection. Set the daily routine corresponding to the age of the child, with an increase in the number of hours of sleep. Necessary good nutrition. Medical pedagogy is of great importance. It is necessary to take into account the presence of lesions of internal organs.

In restorative treatment, constant hardening is carried out, factors are carefully used spa treatment, but only in the same climate zone (it is necessary to avoid sun rays, hypothermia, overheating). Recommended physical exercise without fatigue; dosed health path and outdoor games.

Dynamic observation is carried out continuously until the transfer of the child to the polyclinic for adults. The local doctor observes the patient once a quarter. Twice a year, the child is hospitalized for a complete examination and diagnosis in the dynamics of rehabilitation.

Systemic sclerosis (scleroderma) is a connective tissue disease with a predominant lesion of collagen, characterized by fibro-sclerotic processes in the affected organs and tissues.

Early rehabilitation begins after diagnosis and is consistent with treatment. Means that improve microcirculation, anti-inflammatory drugs and glucocorticoids are prescribed. With insufficient effect, cytostatics are prescribed (leukeran 0.1–0.2 mg/kg per day), D-penicillamine 1.2–2 g/day, unithiol 0.05–0.1 2 times a day , angiotrophin 1 ml. Electrophoresis with hyaluronidase, lidase is used. Showing complamin 0.1 g 2 times a day, aloe extract, ATP; vasodilators.

Late rehabilitation - after discharge from the hospital, the treatment prescribed in the hospital continues in maintenance doses. It is better to carry it out in a local sanatorium, using all the factors of sanatorium treatment with their individual selection.

Of great importance are massage, exercise therapy, nutrition with the mandatory appointment of dietary supplements. The mode provides for an increase in hours of sleep. It is important to carry out timely rehabilitation of foci of infection and the prevention of other diseases.

With restorative treatment (secondary prevention), predisposing factors are eliminated, children are hardened. When stabilizing the process, the factors of resort treatment (balneo-mud therapy) are widely used.

Dynamic monitoring is carried out constantly. Examinations by the local doctor and, if necessary, by other specialists (depending on the affected organs) are carried out once a quarter. Twice a year, the child can be hospitalized for a complete clinical examination, diagnosis and rehabilitation.

Dermatomyositis is a systemic connective tissue disease with a primary lesion of muscles and skin.

Early rehabilitation is carried out after the diagnosis of the disease is established and is consistent with the treatment. Corticosteroids, non-steroidal anti-inflammatory drugs, ATP, vitamins are prescribed. As a result of treatment, the function of the affected organs improves. Physiotherapy in the acute period is contraindicated (except for electrophoresis of drugs). Exercise therapy and massage should be prescribed immediately after the pain syndrome has decreased.

Late rehabilitation is carried out after discharge from the hospital using all the factors of sanatorium rehabilitation and simultaneous treatment (prevention) of calcifications, contractures. Supportive drug therapy prescribed in the hospital. Nutrition is of great importance (complete proteins of animal origin, dietary supplements are recommended).

Rehabilitation is being carried out actively. Rehabilitation of calcifications, contractures, supporting anti-relapse treatment, and hardening continue. The factors of resort treatment or the stay of children in resorts with the use of balneotherapy, exercise therapy, massage, mechanotherapy are used. Medical pedagogy and psychotherapy are important.

Dispensary supervision is carried out constantly. It is necessary to exclude insolation, hypothermia, physical and mental overwork. Children should constantly engage in exercise therapy, have extra days of rest (not attend school), good nutrition, extra hours of sleep. Supervision of the local doctor is carried out constantly.

Patients are examined according to the presence residual effects once a month or quarter, 2 times a year are hospitalized for clinical examination, diagnosis clarification and the need for anti-relapse treatment.

Disability for a period of 6 months to 2 years is established in pathological conditions caused by diffuse lesions of the connective tissue with a high degree process activity for more than 3 months and annual exacerbations.

Article publication date: 03/18/2014

Article last updated: 06/04/2019

Rheumatoid arthritis is characterized by deformity of the joints, limitation of their mobility and development of contractures (immobility). To reduce symptoms in the treatment, exercise therapy, massage, swimming and physiotherapy are used. Therapeutic exercise for rheumatoid arthritis is aimed at strengthening the ligaments and muscles, increasing the range of motion in the 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 treatment with a position (more details -).

The main contraindications for the appointment of 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).

Basic methods and stages of classes

All approaches to physiotherapy exercises for rheumatoid arthritis can be divided into three groups:

Individual classes are ideal for patients with the most severe stage of the disease, as well as for rehabilitation after surgical treatment.

Group classes are the most accessible and rational approach. Patients are combined into groups according to the degree of limitation of mobility.

At consultations, patients are taught techniques and exercises that they can apply at home.

The main condition for exercise therapy with is the regularity of classes and a systematic increase in load. You should not perform exercises with effort: after the correct 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:

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.

During the main period, a basic set of exercises is performed. Classes are held daily for two weeks, each lasting about half an hour.

The final stage is carried out just before discharge: the doctor teaches the patient exercises that he can do at home.

Position treatment

The method of treating rheumatoid arthritis by "position" is also referred to 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 should be flat 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. At least once an hour you need to change the position of the body, if necessary with the help of another person.

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

Brush exercises

In rheumatoid arthritis, the joints of the fingers are most commonly affected. Usually, the hand takes on the characteristic shape of a flipper, which leads to its limitation. functionality and disability.

To reduce the strain rate, it is desirable:

• do not move your fingers towards the little finger;
• reduce the load on the fingertips;
• at rest, ensure the correct position of the hand;
• write only with cone-shaped thickened pens;
• correctly perform household activities: 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 of the sets of exercise therapy exercises for hand damage:

Starting position: hands in front of you, next to each other. Alternately turn your palms up and down.

Put the brushes on the table and raise and lower them first, and then only the fingers.

Hands clenched into fists, stretch forward. Rotate the brushes clockwise and counterclockwise.

Put your elbows on the table, squeeze your palms, spread and bring your elbows together without lifting them from the surface.

Move up and down, left and right and circular motions with each finger in turn.

Touch each of the fingers to the big one, as if clasping something round.

Squeeze and decompress the soft ball in your hand, roll it over the surface.

Rotate the hands in the wrist joint, while trying to relax the palm.

Move your fingers along the stick from the bottom up.

Rub your palms together.

Each exercise should be performed 5-7 times, depending on the condition of the patient. There should be no pain during exercise.

Click on the picture to enlarge

Exercises for the defeat of the shoulder girdle

Raise and lower your shoulders, make circular movements back and forth.

Put your palms on your shoulders, alternately bring your elbows forward.

Clasping your elbows with your palms, raise them and lower them.

Lying on your back, bend, raise and lower straightened arms.

Put your hands on your belt and alternately wind them behind your head.

Hug yourself.

During exercise, it is very important to observe the correct rhythm of breathing.

The above exercises are called dynamic, that is, associated with 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 the work of the muscles is not accompanied by the movement of the limb, since it is fixed: isometric. Isometric exercise helps to strengthen muscle fibers, even with severe mobility restrictions. An example of such an exercise: lying on your back, press with straightened arms on the surface.

Leg exercises

Lying on your back bend your leg knee joint without lifting the soles from the surface (gliding steps).

Exercise bike.

Legs bent at the knees spread apart and bring back.

Mahi with a straightened leg lying and standing, holding on to a support.

Circular movements in the hip joint with the leg bent at the knee.

Breeding straight legs to the sides in a prone position.

Circular movements with a straight leg.

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

Ankle exercises

With rheumatoid, it is not often affected, but its deformation rather quickly leads to limitation of movement and disability. To prevent contracture, it is recommended to perform the following complex:

Sitting bend and unbend the feet and toes.

Roll from heel to toe and back.

Get up on your toes at the support.

Try to pick up objects from the floor with your toes.

Roll a stick or ball with your feet.

Walk across the stick, stepping on it with the middle part of the sole.

Make circular movements with the foot.

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

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

water exercises

Of all the sports for the treatment of rheumatoid arthritis, swimming is most suitable, since in the water there is no load 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 those 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. The higher density of water requires more effort to overcome the resistance.

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

Contraindications for water activities:

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

In the pool, you can perform the following complex:

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.

Swing your legs back and forth, to the side, circular movements.

Squats with legs wide apart (it is important to keep your back straight).

Having plunged into the water up to the neck, spread straight arms to the sides and perform circular movements in the shoulder, elbow and wrist joints.

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

Functional motor test

Before the start of the rehabilitation period, the exercise therapy doctor assesses the degree of damage to the patient's motor system. Various tests can be used for this, 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 results of the test allow you to objectively assess the violation of functions:

• There are no functional restrictions.
• Preservation of professional ability to work.
• The ability to work is completely lost.
• Cannot take care of himself.

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

If you have rheumatoid arthritis - do not give up on yourself. Start doing special exercises. Daily physical therapy exercises will help to tone the muscles, improve well-being and increase mobility. Before starting gymnastics, you should consult with your doctor.

Juvenile rheumatoid arthritis (JRA) is a chronic acquired disease of the joints of an immunological (autoimmune) nature that begins in a child under 18 years of age, belongs to the group of collagenoses and is characterized by a systemic lesion, recurrent nature and progression of the articular syndrome with destruction and dysfunction of the joints.

Epidemiology: The primary incidence of JRA is 6-19 per 100,000 children.

Pathogenesis of juvenile rheumatoid arthritis (JRA). JRA pathogenesis is based on the activation of immunocompetent cells, autoimmune reactions and the formation of immune complexes.

Classification: According to clinical and anatomical characteristics:
1) RA, predominantly articular form with or without eye damage - polyarthritis, oligoarthritis (2-3 joints), monoarthritis;
2) RA, articular-visceral form (with limited vnsceritis, Still's syndrome, allergic septic syndrome);
3) RA in combination with rheumatism and other DBST.

According to clinical and immunological characteristics:
1) test for rheumatoid factor is positive;
2) test for rheumatoid factor is negative.

According to the course of the disease:
1) rapid progression;
2) slow progression;

3) without noticeable progression. By the degree of activity of the process:
1) high (III degree);
2) medium (II degree);
3) low (I degree).

According to the radiological stage of arthritis:
1) periarticular osteoporosis, signs of effusion into the joint cavity, compaction of periarticular tissues, accelerated growth of the epiphyses of the affected joint;
2) the same changes and narrowing of the joint space, single bone usura;
3) widespread osteoporosis, pronounced bone and cartilage destruction, dislocations, subluxations, systemic bone dysplasia;
4) the same changes and ankylosis.

According to the functional ability of the patient:
1) saved;
2) impaired due to the state of the musculoskeletal system:
- the ability to self-service is preserved;
- the ability to self-service is partially lost;
- the ability to self-service is completely lost;
3) is disturbed by the condition of the eyes or internal organs.

clinical picture. Joint damage has a number clinical features: persistence of arthritis, pain appears only when moving, palpation of the joint is painless, except for rare cases with pronounced exudative phenomena in the periarticular tissues, morning stiffness of varying severity and duration is characteristic with a simultaneous morning circadian rhythm of arthralgia. Affected joints are hot to the touch, but flushing of the skin is rare.

The most common mono-oligoarthritic (up to 4 joints) variant, starting at the age of 2-4 years. The onset of the disease is subacute: morning stiffness in the area of ​​the affected joint (knee, more often the right, ankle, other joints - rarely), changes in configuration and volume, increased local temperature, pain contractures, course (without damage to the organ of vision) is favorable, benign, responds well to treatment .

The polyarthritic variant can proceed in different ways: either with the defeat of several large vessels, or with the involvement of small joints of the hands and feet in the process.

When defeated large joints the disease develops acutely: fever, intoxication, severe pain syndrome with a change in the configuration of the joint and a violation of its function. In the future, the persistence of the pain syndrome, its poor curability, involvement of internal organs in the process, rapid progression with bone destruction are noted.

When the small joints of the hands and feet are affected, the process develops imperceptibly: morning stiffness, awkwardness, changes in the configuration of the joints with the rapid progression of changes in the bones and dysfunction. There is a symmetrical lesion of the small joints of the hands and feet with a predominance of proliferative changes with minimal activity according to laboratory parameters. In a third of patients, damage to the intervertebral joints of the cervical spine is observed, arthritis in the temporomandibular joints is often found. Destruction of the articular cartilage and subchondral bones, deformity of the joints is formed in children much more slowly than in adults with RA. Characteristic signs of a chronic course are the child's lag in physical development, impaired growth of individual segments of the skeleton.

Extra-articular manifestations also have peculiarities, one of the most significant is eye damage - chronic uveitis, which practically does not occur in adults with RA.

Chronic uveitis occurs most often in young children with mono- and oligoarthritis and often precedes articular syndrome. It is characterized by a triad: iridocyclitis, cataract, ribbon-like dystrophy of the cornea. Eye damage in 65-70% of cases is bilateral, occurs with few symptoms, does not have parallelism with the degree of articular manifestations. Gradually, the child complains of decreased vision, a feeling of "sand in the eyes." The disease can be detected by examination with a slit lamp.

Systemic variants of juvenile RA are more common than in adults (10-20%) and include 5 diagnostic signs: fever, rash, lymphadenopathy, hepatolienal syndrome, arthralgia (arthritis).

The fever has an intermittent character, up to 39.9 ... 40 ° C, accompanied by excruciating chills, does not decrease with antibiotic treatment, but decreases with large doses of aspirin and prednisolone, an increase in body temperature is possible either in the evening or in the morning.

The rheumatoid rash has features: a rash of a macular nature, pinkish, polymorphic, unstable, blooming with a rise in fever and disappearing when the body temperature returns to normal.

Lymphadenopathy is characterized by an increase in predominantly axillary, inguinal and cervical lymph nodes.

Other extra-articular manifestations include exudative pericarditis, myocarditis, endocarditis, pleurisy, pneumonitis, glomerulitis with the development of renal amyloidosis.

Still's disease is a variant of the systemic course of juvenile RA, which is characterized by the first four diagnostic signs and clinically pronounced arthritis and is manifested by high hectic fever, generalized enlargement of the lymph nodes, liver, spleen, damage to internal organs - kidneys (glomerulonephritis), lungs (interstitial pneumonia), heart (myocarditis), etc. The articular syndrome can either be ahead of the damage to the internal organs, or be somewhat late, but in any case, the damage to the joints is of a bright inflammatory nature, characterized by persistence, poor curability, and rapid destruction of bone tissue; damage to internal organs is complicated by amyloidosis.

Wiesler-Fanconi subsepsis (pseudosepsis, allergosepsis) is the second variant of the systemic course of juvenile RA, in which the first four diagnostic features systemic lesion combined with arthralgia, it also manifests itself acutely: high fever of the wrong type (more often in the morning) with good health of patients, polymorphic maculopapular or urticarial rash on the limbs and trunk, polyarthralgia, heart damage, hematuria, proteinuria, less often - damage to other organs. In peripheral blood, leukocytosis up to (30...50)x10*9/l is characteristic due to neutrophilia, with a shift in leukocyte formula to the left (up to the leukemoid reaction). ESR increased to 60-70 mm/h. anemia, increased platelet count are detected. It was the combination of fever with high leukocytosis and a pronounced stab shift that caused the introduction of the term "subsepsis". Process activity indicators (proteinogram, fibrinogen, sialic acid titers, CRP, immunoglobulins) also changed significantly. Approximately half of the patients have transient hematuria, proteinuria. Subsepsis is characterized by an undulating course and ends, as a rule, after one or two relapses, with recovery in 70% of patients, the rest develops long course polyarthritic variant of arthritis.

Complications: amyloidosis; deformity and dysfunction of the joints; damage to the kidneys and heart with the development of chronic renal failure. chronic cardiovascular insufficiency; vision loss.

Laboratory and instrumental methods confirming the diagnosis:
1) clinical analysis blood (leukocytosis, neutrophilia with a shift in the formula to the left, an increase in ESR, anemia, an increase in platelet count);
2) biochemical blood tests (proteinogram and acute-phase proteins of inflammation indicate an acute inflammatory process);
3) detection of autoAT against immunoglobulins, antinuclear and rheumatoid factors; determination of the content of immunoglobulins, especially IgA. the concentration of which increases as the activity of the process increases;
4) x-ray examination of the affected joints (reflects the stage of the articular process);
5) consultation with an ophthalmologist;
6) study of synovial fluid.

Clinical and laboratory diagnostic criteria:
1) the onset of the disease before the age of 18;
2) involvement of one or more joints, characterized by swelling or effusion, or having at least two of the following signs: limitation of joint function, joint contracture, pain on palpation, increased local temperature, muscle atrophy;
3) symmetrical damage to small joints;
4) damage to the cervical spine:
5) the duration of changes in the joints is at least 6 weeks;
6) morning stiffness;
7) uveitis;
8) rheumatoid nodules;
9) ESR more than 35 mm/h;
10) detection of rheumatoid factor;
11) characteristic data of a biopsy of the synovial membrane.

Radiological signs:
1) osteoporosis;
2) narrowing of the joint spaces;
3) violation of bone growth.

In the presence of 3 signs, the diagnosis is considered probable, in the presence of 4 - definite. in the presence of 7 - classic.

Treatment: "basic" therapy - the appointment of NSAIDs with long courses: acetylsalicylic acid in daily dose 75-100 mg/kg for 2-4 weeks. then voltaren (2-3 mg/kg per day), indomethacin (1-3 mg/kg per day), naproxen (10-20 mg/kg per day), ibuprofen (20-30 mg/kg per day); with the ineffectiveness of NSAID treatment after 4-6 months, especially with polyarthritis, the appointment of long-acting and slow-acting antirheumatic drugs is indicated: gold salts (krizanol and tauredon) for a period of at least 20 weeks, as well as D-penicillamine.

Indications for the appointment of glucocorticoids (prednisolone at a dose of up to 3-4 mg / kg per day, but not more than 75 mg / day) are a systemic variant of juvenile RA with high fever or carditis (picture of subsepsis); the presence of uveitis that does not stop with topical application of glucocorticoids; pronounced exacerbation of the articular syndrome in the polyarthritic variant of juvenile RA. When systemic phenomena subside after 2-3 weeks, the dose of prednisolone is gradually reduced to maintenance, switched to intermittent administration, and then the drug is canceled. The general principle of glucocorticoid withdrawal is: the lower the dose, the slower it should be reduced. The method of intra-articular administration of hydrocortisone (hydrocortisone 25-50 mg or kenalog 5-20 mg) is effective. With an aggressively current systemic variant of the disease, relapses of subsepsis, uveitis, the use of immunosuppressants is indicated (cyclosporine at a daily dose of 4-6 mg / kg for 6-8 months, methotrexate at a dose of 2.5-7.5 mg once a week, cyclophosphamide according to 4-5 mg/kg daily). The effect of maximum immunosuppression should be achieved at the most early stages diseases to induce remission, since progression, even if slow, leads to irreversible processes in the body

In recent years, intravenous immunoglobulin preparations have been successfully used in the treatment of systemic forms of juvenile RA.

Treatment of juvenile RA is carried out only in specialized clinics. Outpatient conduct permanent long-term treatment according to selected schemes. In addition, exercise therapy, massage, FTL, prevention of limb deformities and contractures, and rheumatic orthopedic methods of treatment are of importance.

The prognosis is determined both by the nature of the process itself, and by timely and adequate treatment. Even with systemic variants of juvenile RA, it is rarely life-threatening for the child and the prognosis is generally more favorable than with RA in adults. Long-term remissions are observed in 75% of patients, but contractures and ankylosis gradually develop in 1/3-1/4 patients, especially in seropositive polyarthritis. The most common causes of disability are damage to the hip joint, uveitis and amyloidosis of the kidneys.

Disability Criteria: Still's disease, polyarthritic variant of the disease, iridocyclitis, persistent grade 2 and 3. disease activity.

Rehabilitation: medical rehabilitation during periods of exacerbations and during the period of relative remission of the disease, psychological, pedagogical and professional - during the period of remission of the disease; Exercise therapy, massage.

Juvenile idiopathic arthritis (JIA, juvenile rheumatoid arthritis, juvenile chronic arthritis) is a heterogeneous group of diseases united by a tendency towards a chronic progressive course. The term was proposed by the WHO Standing Committee on Pediatric Rheumatology (1994) to replace the previously used terms juvenile chronic and juvenile rheumatoid arthritis.

Statistical data. Incidence: 2–19 per 10,000 child population per year. Boys and girls get sick equally often. The etiology is unknown. Pathogenesis - see Rheumatoid arthritis.

Etiology and pathogenesis of juvenile rheumatoid arthritis

Currently, a disease such as juvenile rheumatoid arthritis (ICD code 10 - M33.0) is not well understood.

The causes of this pathological condition in children have not yet been fully established. It is believed that a predisposing factor to the appearance of such a disease in children under the age of 16 years is genetic predisposition.

At the same time, even if a child has defective genes that contribute to the appearance of a malfunction of the immune system, the disease may not develop in all cases. Causes of juvenile rheumatoid arthritis include:

• viral and bacterial infections;
• trauma;
• severe stress;
• the use of protein preparations;
• additional insolation;
• hypothermia.

Due to the influence of various factors external environment immune agents that are hypersensitive give the wrong immune response. Thus, white blood cells, which are a kind of soldier cells of the immune system, go astray and begin to attack healthy cells of the synovium of the joints.

In addition, connective tissues located in other organs may also suffer.

The pathogenesis of juvenile rheumatoid arthritis is quite complex. The problem begins when the immune system attacks the special cells that line the synovial membrane.

In response to such actions, tissues begin to produce special proteins and enzymes that significantly aggravate the situation. This leads to the development of persistent inflammation, and the joint begins to deform and fluid accumulates in it.

Further, the enzyme system is activated, which leads to an extremely rapid destruction of cartilaginous surfaces and disruption of the entire articulation. After that, there is an activation of the growth of new blood vessels and the destruction of existing articular surfaces.

In the aggressive course of juvenile rheumatoid arthritis in the tissues of the joint, under the influence of a constantly ongoing inflammatory process, cell division is accelerated, which leads to the formation of the so-called pannus, that is, a special coating that in some way reduces the intensity of symptomatic manifestations.

At the same time, pannus interferes with the normal course of all metabolic processes in the elements of the joint, which leads to their faster destruction.

What causes joint damage?

Genetic aspects. A high prevalence of HLA - DRB1 * 0801 and * 1401 in patients with polyarthritis, HLA - DRB1 * 0101 and 0801 in patients with oligoarthritis was established. The connection of HLA-B27 Ag with the development of arthritis with enthesopathy, as well as HLA-DRB1*0401 with RF-positive polyarthritis, has also been proven.

CLASSIFICATION (Durban, 1997)

Systemic variant - arthritis with / or previous fever for at least 2 weeks in combination with two or more signs: a fleeting, non-fixed erythematous rash; generalized enlargement of the lymph nodes; hepato- or splenomegaly; serositis.

Description Age of disease onset Characteristics of arthritis during the first 6 months of disease oligoarthritis polyarthritis presence of arthritis only after 6 months of systemic disease Characteristics of arthritis after 6 months of disease oligoarthritis polyarthritis no arthritis after 6 months of systemic disease Features of systemic disease after 6 months Presence of RF CRP level.

The exact cause has not yet been established. Therefore, the name "juvenile idiopathic arthritis" (unknown) is quite right. The association of primary joint damage with:

• transmitted viral or bacterial infection;
• general hypothermia of the child's body;
• joint trauma;
• an overdose of sunburn;
• allergic manifestations to protein foods, drugs.

A genetic predisposition has been found in individual families with a characteristic set of chromosomes.

Scientists agree that the main mechanism of pathology is an excessive protective reaction of the body (or too high sensitivity) to the impact external factors. It develops to the level of a pathological effect on its own tissues.

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And the place of the destructive effect is the articular surfaces, cartilage, synovial fluid. All treatment options are aimed at normalizing the response.

The exact causes of the development of the disease have not been established to date. However, based on research, doctors tend to believe that genetics and heredity are directly related to the appearance this disease.

ON A NOTE! Children's juvenile arthritis is 2 times more common in girls.

Factors that can provoke changes in the processes of the body, and further lead to a pathological condition:

• contact with a viral, bacterial infection;
• drop in body temperature to critical levels (hypothermia);
• articular injuries in the past;
• prolonged exposure to the sun;
• untimely vaccination as a preventive measure.

After a collision with one of the environmental factors the immune system changes so that its cells are identified as foreign. Simply put, an autoimmune reaction is formed, which is the basis of juvenile rheumatoid arthritis (JRA).

International interpretation and classification

The name of the disease differs depending on the terminology of organizations and specialists who are trying to more fully reflect the features in it:

• according to the terminology of the League of Rheumatological Associations ILAR, it is called juvenile idiopathic arthritis;
• according to the antirheumatic European organization EULAR, juvenile chronic arthritis;
• according to the American College of Rheumatology ACR, juvenile rheumatoid arthritis.

AT International classification(ICD-10) juvenile (juvenile) diseases of the joints include only inflammatory processes of various localization, lasting more than three months. In fact, we are talking about prolonged acute or chronic forms polyarthritis with an unexplained cause.

The disease was taken into account in class No. 13 "Diseases of the bone and muscular systems, connective tissue", in the group "Arthropathy". Based on rheumatic diseases joints, confirmed or not by blood tests for the presence of rheumatoid factor.

• M08.0 Juvenile (juvenile) rheumatoid arthritis with or without rheumatoid factor
• M08.1- ankylosing spondylitis in childhood;
• M08.2 - Arthritis in children with systemic onset (Still's disease);
• M08.3- seronegative polyarthritis, chronic juvenile polyarthritis;
• M08.4 - Arthritis pauciarticular (up to four joints are affected at once);
• M08.8 - Other inflammation of the joints in adolescence;
• M08.9 - unspecified.

Separately, a group of juvenile arthritis associated with other diseases was derived:

• M09.0- psoriatic arthritis(L40.5);
• M09.1 - joint damage in Crohn's disease and enteritis (K50);
• M09.2 - background arthritis ulcerative colitis(K51);
• M09.8 - Inflammation of the joints in other diseases

In parentheses are the codes for the underlying disease that caused the arthritis.

Characteristic signs of an acute form of childhood rheumatoid arthritis

Incidence rheumatoid arthritis found in different countries 6 to 19 cases for every 100,000 children. Such a scatter of numbers is explained by different approaches to diagnostics and health care capabilities. According to international standards, a true rheumatic process, systemic collagenoses involving the joints, and a complicated course of sepsis should be excluded.

Main features of juvenile rheumatoid arthritis

The clinical picture is described in the classification characteristics of each of the forms.

Juvenile rheumatoid arthritis (ICD code 10 - M33.0) is often manifested by extra-articular symptoms.

Many girls suffering from this condition have eye involvement, often accompanied by uveitis and iridocyclitis. Because of these pathological conditions caused by a disease such as juvenile rheumatoid arthritis, visual acuity can drop significantly.

In addition, glomerulonephritis, an inflammatory disease of the kidneys, is not excluded. In severe cases of juvenile rheumatoid arthritis, there is a possibility of damage to the heart muscles.

The most common condition in children with juvenile arthritis is inflammation of the heart muscle and pericarditis. Additional signs of rheumatic disorders from other organs and systems are also possible.

Symptoms of juvenile rheumatoid arthritis

The disease under consideration, depending on the form, manifests itself in different ways. The general clinical picture, characteristic of all types of arthritis, is as follows:

• pain syndrome along the circumference of the joint, stiffness at the time of movement (mainly in the morning);
• redness of the skin in the affected area;
• swelling in the joint area;
• feeling of warmth in the affected area;
• strong pain in motion, as well as in an immobilized state;
• the limbs are poorly bent, the appearance of subluxations in the joints;
• stains form around the nail plates Brown;
• a pronounced feeling of weakness in the body;
• anemia, pallor of the epidermis.

Since arthritis in children is classified into several types (reactive, subacute, oligoarticular), in addition to common features, each of them is characterized by additional features. Let's consider each separately.

Signs in reactive juvenile arthritis:

• increase in body temperature;
• peculiar allergic rashes;
• an increase in the size of the liver, spleen, peripheral lymph nodes;

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Subacute type of childhood arthritis is manifested as follows:

• pain of low intensity;
• swelling around the joint, impaired performance;
• traffic tension in the morning;
• a slight increase in temperature (very rarely observed);
• slight enlargement of the lymph nodes, liver and spleen in a normal state.

Symptoms of oligoarticular juvenile arthritis:

• unilateral inflammatory process;
• stunting;
• cataract (clouding of the lens);
• asymmetrical position of the limbs of the body;
• inflammation inner shells eye.

Diagnostics

Laboratory data Normochromic normocytic anemia Leukocytosis An increase in ESR and an increase in the concentration of CRP correlate with activity. IgM concentration correlates with RF titers, IgA - with the formation of erosions and RF activity.

Instrumental data X-ray examination No changes in the early stages Late stages: osteoporosis, periosteal growths, premature fusion of the epiphyses, erosion, narrowing of the joint spaces, ankylosis.

diagnostic tactics. The diagnosis of JIA, according to the WHO proposal, is established in the presence of arthritis of unknown etiology, present for 6 weeks in a child under 16 years of age, with the exclusion of other diseases ( congenital pathology joints, etc.).

Considering that young children often suffer from juvenile rheumatoid arthritis, the first symptoms of the disease can be mistakenly assessed by doctors and parents as manifestations of the flu or SARS. In the future, the baby may complain that he does not want to go to school, or that he does not want to run or walk at all.

Many modern parents attribute these symptoms to the usual whims of the child and do not pay attention to them, but this is a very important point. As a rule, children get to see a rheumatologist after the joints affected by a disease such as juvenile rheumatoid arthritis begin to swell.

Collecting an anamnesis and examining a child is usually not enough to confirm the diagnosis. Diagnosis of the disease involves the following activities:

• radiography;
• determination of rheumatoid factor;
• analysis for the determination of C-reactive protein;
• general analysis blood;
• general urine analysis.

Treatment of juvenile rheumatoid arthritis in children primarily involves taking basic drugs that help suppress the development of this disease. Medicines used as basic therapy for the treatment of a disease such as juvenile rheumatoid arthritis include:

1. Sulfasalazine.
2. Methotrexate.
3. Hydroxychloroquine.
4. Azathioprine
5. Infliximab, etc.

Juvenile polyarthritis occurs with quite severe symptoms, therefore, in the vast majority of cases, patients are also shown taking non-steroidal anti-inflammatory drugs, as well as glucocorticosteroids. These groups of drugs include:

• ibuprofen;
• Indomethacin;
• Diclofenac;
• Methylprednisolone;
• Diprospan;
• Hydrocortisone.

In addition, short courses of corticosteroids and selective inhibitors may be given. Some drugs, including glucocorticosteroids and corticosteroids, are prescribed with extreme caution, as they can lead to impaired growth of the child.

Juvenile rheumatoid arthritis in children (ICD code 10 - M33.0) requires a special diet, which should contain a minimum of salt.

In addition, a long course of exercise therapy is required, as well as various means of physiotherapy. Juvenile rheumatoid arthritis, with proper and timely treatment, usually has a favorable prognosis.

Treatment

The general tactics depend on the form of the disease. In the systemic variant: NSAIDs, with ineffectiveness - prednisolone 2 mg / kg / day or pulse - methylprednisolone therapy 10-30 mg / kg / day for 1-3 days (especially with myocardial damage).

In the absence of effect - methotrexate 0.3-0.5 mg / kg / week. In the case of the development of macrophage activation syndrome - cyclosporine and pulse - methylprednisolone therapy.

The use of salts of gold and penicillamine is contraindicated. In the polyarticular form, first NSAIDs, and when the diagnosis is confirmed, sulfasalazine 30-40 mg / kg (especially with enthesitis) or methotrexate 0.3 mg / kg / week.

If ineffective - methotrexate 1 mg / kg IV, or combination therapy (methotrexate, sulfasalazine and / or hydroxychloroquine). In special severe cases, it is possible to prescribe cyclosporine For oligoarthritis - NSAIDs, with inefficiency - GC intra-articular, in case of no effect within 2-3 months - sulfasalazine 30-40 mg / kg / day, or hydroxychloroquine 5 mg / kg / day, or methotrexate 0.3 mg / kg / week with a gradual increase in dose to 0.5 mg / kg / week.

Mode. Patients should form a stereotype of movements that counteracts the development of deformities (for example, to prevent ulnar deviation, one should open a tap, dial a telephone number and other manipulations not with the right, but with the left hand).