Normal knee anatomySymptoms and pathology of juvenile rheumatoid arthritis

Pain managementStages of development and psychosocial issues

Multidisciplinary approach

Anatomy of the knee

Synovial joint components

What is juvenile rheumatoid arthritis? Joint contracture

Joint inflammation

Joint damageAlteration or change in growth

Juvenile idiopathic arthritisPolyarticular JRA - typically affects 5 or more joints

Systemic onset JRA - high spiking fevers and rash

Oligoarticular JRA - typically affects 4 or fewer joints

Pauciarticular JRA - may cause eye inflammation

DiagnosisJoint swellingJoint tendernessLoss of movementJoint malalignmentRash

Pain managementMedicationTENS Ice

Jean Piaget (1896-1980)Piaget developed four stages to his theory of cognitive development:

Sensori-Motor StagePre-Operational StageConcrete Operational StageFormal Operational Stage

Pre-operational stageThe child’s thoughts become more

symbolic and they represent their world through images and words

However they do not have the skill of ‘reversibility’

They do not understand quantity, volume and number have not changed despite a change in its appearance

Concrete Operational StageChildren acquire internally

consistent (adult) logic but only in concrete situations such as problem solving

Children in this stage are able to conserve and decentrate, they may also be able to use reversibility

• Piaget’s theory has had an enormous impact on our understanding of cognitive development

CBT further developed in the 1970’s by Beck

Cognitive - Thinking and beliefs

Behavioural – Behaviours and actions

• (CBT) is tuning into emotions, challenging, negative automatic thoughts, and unlearning unhelpful habits of thinking that can leave us at the mercy of unwanted emotions

How does this relate to Tilly or her close family members?When therapists elicit and gracefully deal with

deeply felt emotional issues, treatment takes offEffective CBT reveals and deals with the tragedies

of young patients lives (Leahy 2007)Since CBT is so flexible it may be applied in a

variety of formats including individual, family and groups

The International Association of Study of Pain describe pain as “An unpleasant sensory and emotional experience which is due to actual or potential tissue damage, or which is expressed in terms of such damage”

Lev Vygotsky (1896-1934)Vygotsky felt the acquisition of

knowledge was active and socially constructed rather than a passive conditioning

He believed that social interaction played a vital role in cognitive development firstly on a social level (between child and the world) and then on a individual level (internally)

Culture teaches children both what and how to think, through the acquisition of knowledge via intellectual tools

Since much of what children learn is through interaction, Vygotsky believed isolation was inappropriate...guidance by a another is usually most beneficial

Woods et al described this process as scaffolding i.e. The support given by a significant other, e.g. teacher, parent or even peer

The stages of scaffoldingRECRUITMENT - gaining the child’s interestREDUCTION OF DEGREES OF FREEDOM –

breaking the task down into manageable stepsDIRECTION MAINTENANCE – encouraging and

motivating the child until they have become self-motivating

MARKING CRITICAL FEATURES – drawing attention to aspects of the problem that will help further progress

DEMONSTRATION - the tutor (parent) finishes the task off so that the learner can imitate this back in a better form

Applying the theoryLearning as collaboration- Learning together

rather than individuals...promotes critical thinking & interest

Zone of proximal Development (ZPD)- MKO (more knowledgeable other) i.e. teacher or friend. ZPD encompasses the tasks that learners cannot perform on their own but can with help from the MKO

Scaffolding- Begin with full support, gradually remove support as abilities and confidence increase

Physical management programme

OrthosesReferral to other health professionals

Family members

Multidisciplinary team GPConsultant paediatric rheumatologistPaediatric rheumatology nursePaediatric physiotherapistOccupational therapistPlay therapistPodiatristPharmacistPaediatric pain service

The children's chronic arthritis associationRegular newsletterActive support

network

Annual family weekend

Outings for the children