INTERNATIONAL JOURNAL OF RESEARCH AND SCIENTIFIC INNOVATION (IJRSI)  
ISSN No. 2321-2705 | DOI: 10.51244/IJRSI |Volume XII Issue XI November 2025  
Comprehensive Rehabilitation Approach in a Paediatric Case of  
Juvenile Rheumatoid Arthritis  
Dr.Pranali Thakkar  
MPT Pediatrics,PhD, Assistant Professor, SPB Physiotherapy college, surat, India  
DOI: https://doi.org/10.51244/IJRSI.2025.12110030  
Received: 19 November 2025; Accepted: 26 November 2025; Published: 04 December 2025  
ABSTRACT  
Background: Juvenile Rheumatoid Arthritis (JRA), also known as Juvenile Idiopathic Arthritis, is a chronic  
autoimmune inflammatory disorder affecting children under 16 years of age. It primarily involves synovial  
joints, leading to pain, stiffness, swelling, and functional limitations. Early diagnosis and multidisciplinary  
management, including physiotherapy, are vital for preventing deformities and improving functional outcomes.  
Case Presentation: A 10-year-old female child diagnosed with polyarticular JRA presented with pain and  
stiffness in bilateral knees, wrists, and ankles, along with morning stiffness and difficulty in performing daily  
activities. Assessment revealed restricted joint range of motion, muscle weakness, and functional dependency.  
A six-week physiotherapy intervention program was designed, incorporating pain management modalities,  
range of motion and strengthening exercises, hydrotherapy, gait training, and caregiver education.  
Results: After six weeks of structured physiotherapy, the patient demonstrated significant improvement in pain  
(VAS reduced from 6/10 to 2/10), knee flexion (increased from 90° to 120°), muscle strength (quadriceps  
improved from grade 3/5 to 4+/5), and walking tolerance (increased to 500 meters). Functional outcomes  
measured by the Childhood Health Assessment Questionnaire (CHAQ) improved from 1.8 to 0.8, indicating  
enhanced quality of life.  
Conclusion: Early and individualized physiotherapy intervention plays a crucial role in managing Juvenile  
Rheumatoid Arthritis by reducing pain, maintaining joint function, improving mobility, and enhancing overall  
quality of life. Continuous follow-up and parent education are essential to ensure long-term functional  
independence and prevent disability progression.  
Keywords: Juvenile Rheumatoid Arthritis, Physiotherapy, Pediatric Rehabilitation, Functional Outcomes, Pain  
Management  
INTRODUCTION  
Juvenile Rheumatoid Arthritis (JRA), also known as Juvenile Idiopathic Arthritis (JIA), represents a  
heterogeneous group of autoimmune disorders characterized by chronic synovial inflammation that persists for  
more than six weeks in children below 16 years of age¹,². The condition involves the immune system  
mistakenly attacking synovial tissues, resulting in joint effusion, synovial hypertrophy, pain, stiffness, and  
gradual erosion of cartilage and bone¹. If left untreated, these inflammatory changes can cause growth  
disturbances, joint deformities, muscle atrophy, and long-term functional disability²,³.  
JRA is broadly classified into three major subtypes:  
1. Oligoarticular, Polyarticular, and Systemic Onset Arthritis¹,⁴. Oligoarticular JRA affects four or fewer  
joints, typically large joints such as the knees or ankles, and may be associated with uveitis⁴.  
2. Polyarticular JRA involves five or more joints and often includes small joints of the hands and wrists,  
mimicking adult rheumatoid arthritis⁴.  
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INTERNATIONAL JOURNAL OF RESEARCH AND SCIENTIFIC INNOVATION (IJRSI)  
ISSN No. 2321-2705 | DOI: 10.51244/IJRSI |Volume XII Issue XI November 2025  
3. Systemic Onset JRA, also known as Still’s disease, is characterized by systemic features such as fever,  
rash, hepatosplenomegaly, and serositis along with arthritis⁵.  
The etiology of JRA is multifactorial, involving a complex interplay between genetic susceptibility,  
environmental triggers, and immune dysregulation²,⁶. Studies have identified associations with HLA gene  
variants (particularly HLA-DRB1 and HLA-A2) and cytokine imbalances, including elevated levels of  
interleukin (IL)-1, IL-6, and tumor necrosis factor-alpha (TNF-α), which contribute to synovial inflammation  
and joint destruction²,⁶. Environmental factors such as viral infections, gut microbiome alterations, and early-  
life stress may act as precipitating agents in genetically predisposed children².  
Epidemiologically, JRA is the most common chronic rheumatic disease in children, with a global incidence  
ranging from 2 to 20 per 100,000 children and a prevalence of 16 to 150 per 100,000³. The condition shows a  
female predominance, especially in oligoarticular and polyarticular forms, with onset typically between 1 and  
12 years of age³.  
The pathophysiology involves persistent activation of immune cells such as T-helper (Th1/Th17) lymphocytes  
and macrophages, leading to production of pro-inflammatory cytokines and formation of pannus tissue, which  
progressively erodes cartilage and bone⁷. Chronic inflammation within the growth plates can result in growth  
retardation and limb length discrepancies⁷.  
Physiotherapy plays a central role in the multidisciplinary management of JRA, alongside pharmacological  
therapy (including disease-modifying antirheumatic drugs and biologics)¹,⁸. The primary physiotherapy goals  
are to control pain and inflammation, maintain joint mobility, strengthen periarticular muscles, and improve  
endurance, posture, and functional participation⁸. Early and continuous physiotherapy helps prevent secondary  
musculoskeletal complications such as contractures, muscle wasting, and postural deviations⁹. Evidence  
supports that structured exercise programs, hydrotherapy, and joint protection strategies significantly enhance  
quality of life and promote independence in children with JRA⁹.  
Understanding the pathophysiological mechanisms, functional implications, and the role of physiotherapy is  
essential for optimizing the management and long-term outcomes in children affected by Juvenile Rheumatoid  
Arthritis.  
Case Presentation  
Patient Profile  
•
•
•
•
•
Name: [Confidential]  
Age/Sex: 10-year-old female  
Diagnosis: Polyarticular Juvenile Rheumatoid Arthritis  
Duration of Symptoms: 8 months  
Referral: Department of Physiotherapy, Pediatric Rehabilitation Unit  
Chief Complaints  
•
Pain and stiffness in multiple joints (both knees, wrists, and ankles)  
Morning stiffness lasting approximately 45–60 minutes  
Difficulty in walking and performing school activities  
Fatigue and generalized weakness  
•
•
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INTERNATIONAL JOURNAL OF RESEARCH AND SCIENTIFIC INNOVATION (IJRSI)  
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History  
•
Medical History: Diagnosed with JRA 8 months ago by a pediatric rheumatologist. On methotrexate  
and NSAIDs.  
•
•
Family History: Negative for autoimmune disorders.  
Birth and Developmental History: Full-term normal delivery; developmental milestones achieved  
normally.  
•
Personal History: Attends school with occasional absenteeism due to pain.  
Clinical Assessment  
Observation  
•
•
•
Mild swelling over bilateral knees and wrists  
Antalgic gait with reduced step length  
No obvious deformity noted  
Palpation  
•
•
Tenderness Grade II (knee and wrist joints)  
Mild warmth and effusion present  
Range of Motion (ROM)  
Joint Active ROM  
Passive ROM  
0–100°  
Limitation  
Knee Flexion 0–90°  
Wrist Flexion 0–45°  
Ankle Dorsiflexion 0–10°  
Pain-limited  
Pain-limited  
Mild stiffness  
0–60°  
0–15°  
Muscle Strength (Manual Muscle Testing)  
•
•
•
Quadriceps: Grade 3/5  
Hamstrings: Grade 3+/5  
Wrist extensors: Grade 3/5  
Functional Assessment  
•
•
Walking tolerance: 100 meters with pain  
Activities of Daily Living (ADL): Difficulty in dressing and writing  
Pain scale: 6/10 (VAS – Visual Analogue Scale)  
Outcome Measures  
•
Childhood Health Assessment Questionnaire (CHAQ): 1.8  
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INTERNATIONAL JOURNAL OF RESEARCH AND SCIENTIFIC INNOVATION (IJRSI)  
ISSN No. 2321-2705 | DOI: 10.51244/IJRSI |Volume XII Issue XI November 2025  
•
Pediatric Quality of Life Inventory (PedsQL): 60%  
Physiotherapy Goals of Treatment  
The primary objectives of physiotherapy in Juvenile Rheumatoid Arthritis (JRA) are to:  
1. Reduce pain and inflammation – minimizing discomfort to allow participation in daily activities and  
therapeutic exercises¹⁰.  
2. Maintain and improve joint mobility – preserving functional range of motion and preventing stiffness  
or contractures¹¹.  
3. Strengthen surrounding muscles – improving muscle support around affected joints to reduce load and  
prevent secondary deformities¹².  
4. Prevent deformities and contractures – protecting joint integrity through stretching, posture correction,  
and proper alignment¹³.  
5. Improve functional independence – enabling safe participation in activities of daily living (ADLs),  
school tasks, and recreational activities¹⁴.  
Treatment Plan  
1. Pain and Inflammation Control  
Pain management is the first step in enabling active participation in physiotherapy:  
1. Moist heat application prior to exercises to reduce stiffness and improve tissue elasticity.  
2. Cryotherapy during acute inflammatory episodes to decrease joint swelling and pain.  
3. Transcutaneous Electrical Nerve Stimulation (TENS) in conventional mode for 15 minutes, providing  
analgesic effect through modulation of pain pathways¹⁰.  
2. Range of Motion (ROM) Exercises  
Maintaining joint mobility prevents stiffness and functional limitations:  
1. Gentle active and active-assisted ROM exercises for affected joints within pain-free limits, performed  
daily.  
2. Stretching exercises targeting tight muscles such as hamstrings, calf muscles, and wrist flexors to  
prevent contractures.  
3. Hydrotherapy sessions twice weekly, providing a low-impact environment that reduces joint loading  
and allows smooth movement¹¹,¹².  
3. Strengthening Program  
Muscle strengthening is critical for joint stability and functional performance:  
Isometric exercises for quadriceps and gluteal muscles during acute stages to minimize joint stress.  
1. Progressive resistive exercises using therabands as inflammation reduces, gradually increasing  
resistance to enhance muscle strength.  
2. Functional strengthening activities, including sit-to-stand, wall slides, and step-ups, simulate daily tasks  
and promote independence¹²,¹³.  
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INTERNATIONAL JOURNAL OF RESEARCH AND SCIENTIFIC INNOVATION (IJRSI)  
ISSN No. 2321-2705 | DOI: 10.51244/IJRSI |Volume XII Issue XI November 2025  
4. Posture and Gait Training  
Proper posture and gait reduce joint stress and prevent secondary complications:  
1. Gait re-education emphasizing equal weight-bearing and correct alignment during walking.  
2. Orthotic advice, including soft knee and wrist supports during activities, to prevent deformity and  
provide joint stability¹³.  
5. Aerobic Conditioning  
Aerobic exercises improve endurance, reduce fatigue, and enhance overall physical conditioning:  
•
•
Low-impact activities such as cycling or swimming three times per week.  
Breathing and relaxation exercises to enhance oxygenation, reduce fatigue, and manage stress¹⁴.  
6.Education and Home Program  
Parental involvement and home exercises are critical for long-term success:  
1. Educated parents on joint protection, energy conservation techniques, and the importance of regular  
exercises.  
2. Provided a structured home exercise program, including gentle stretching, strengthening exercises, and  
functional tasks to be performed daily.  
Progress and Outcome  
After six weeks of consistent physiotherapy intervention, the patient demonstrated significant functional  
improvements:  
1. Pain reduction: VAS decreased from 6/10 to 2/10.  
2. Range of motion: Knee flexion improved from 90° to 120°.  
3. Muscle strength: Quadriceps strength improved from 3/5 to 4+/5.  
4. Endurance: Walking tolerance increased from 100 meters to 500 meters without rest.  
5. Functional outcomes: Childhood Health Assessment Questionnaire (CHAQ) improved from 1.8 to 0.8,  
and Pediatric Quality of Life Inventory (PedsQL) increased from 60% to 85%.  
DISCUSSION  
Juvenile Rheumatoid Arthritis significantly impacts a child’s physical, psychological, and social  
development¹⁰,¹¹. Chronic pain, joint stiffness, and reduced mobility often interfere with school participation,  
play, and self-care activities, leading to decreased quality of life¹⁰,¹². Moreover, prolonged inflammation can  
result in muscle weakness, joint contractures, and growth disturbances, further limiting functional  
independence¹¹,¹³.  
Physiotherapy plays a pivotal role in the management of JRA, complementing pharmacological  
interventions¹²,¹⁴. Its primary objectives include pain relief, maintenance of joint range of motion, muscle  
strengthening, and functional rehabilitation¹³,¹⁵. Early initiation of physiotherapy, including active and active  
assisted exercises, hydrotherapy, and posture correction, has been shown to prevent secondary musculoskeletal  
deformities and improve overall functional outcomes¹²,¹⁶.  
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INTERNATIONAL JOURNAL OF RESEARCH AND SCIENTIFIC INNOVATION (IJRSI)  
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Hydrotherapy provides a low-impact environment that facilitates pain-free movement, increases endurance,  
and promotes joint mobility, particularly in children with polyarticular involvement¹⁶,¹⁷. Similarly,  
individualized exercise programs targeting strength, flexibility, and aerobic capacity have been associated with  
enhanced participation in daily activities, improved muscle tone, and better long-term physical function¹⁴,¹⁷.  
Family and caregiver education is crucial to ensure adherence to home exercise programs and implementation  
of joint protection techniques, energy conservation strategies, and safe physical activity participation¹⁵,¹⁸.  
Active engagement of parents not only improves functional outcomes but also reduces the psychosocial burden  
of chronic disease in children¹⁵.  
A multidisciplinary approach, involving rheumatologists, occupational therapists, physiotherapists, and  
psychologists, is essential for holistic care¹⁰,¹². Regular follow-up ensures monitoring of disease activity,  
adaptation of physiotherapy protocols, and prevention of complications, thereby promoting long-term  
independence and quality of life¹³,¹⁸.  
Overall, this case supports existing evidence that early and structured physiotherapy intervention is  
fundamental to optimize functional recovery in children with JRA, emphasizing the integration of clinical,  
rehabilitative, and psychosocial strategies¹⁴,¹⁶.  
Table 1: Comprehensive Physiotherapy Management Plan for JRA  
Treatment  
Component  
Intervention  
Frequency /  
Duration  
Purpose / Outcome  
Moist heat before exercises  
Daily, 10–15 Reduces stiffness, prepares  
Pain  
&
min  
joints for exercise  
Inflammation  
Control  
Cryotherapy during acute flare As  
needed, Decreases swelling and pain  
10– 15 min  
Daily, 15 min  
Daily  
TENS (conventional mode)  
Active / active-assisted ROM  
Pain modulation  
Maintains  
joint  
mobility,  
Range of Motion  
(ROM) Exercises  
prevents stiffness  
Stretching (hamstrings, calf, Daily  
wrist flexors)  
Prevents contractures, improves  
flexibility  
Hydrotherapy  
Twice weekly  
Low-impact mobility, reduces  
joint stress  
Isometric  
(quadriceps, gluteals)  
exercises Daily  
Maintains muscle strength  
during acute inflammation  
Strengthening  
Program  
Progressive resistive exercises 3–4  
Increases muscle strength as  
inflammation reduces  
(therabands)  
times/week  
Treatment  
Component  
Intervention  
Frequency /  
Duration  
Purpose / Outcome  
Functional strengthening (sit- 3–4  
Improves ADL performance  
tostand, wall slides, step-ups)  
Gait re-education  
Gait  
times/week  
3–4  
Corrects abnormal patterns,  
Posture  
&
times/week  
promotes  
even  
weight  
Training  
distribution  
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INTERNATIONAL JOURNAL OF RESEARCH AND SCIENTIFIC INNOVATION (IJRSI)  
ISSN No. 2321-2705 | DOI: 10.51244/IJRSI |Volume XII Issue XI November 2025  
Orthotic  
knee/wrist supports)  
advice  
(soft During  
activities  
Prevents deformities, provides  
stability  
Low-impact activities (cycling, 3 times/week  
swimming)  
Improves  
reduces fatigue  
endurance  
and  
Aerobic  
Conditioning  
Breathing  
exercises  
&
relaxation Daily  
Reduces stress and promotes  
overall well-being  
Parental education on joint Once,  
Ensures adherence and safety  
Education & Home  
Program  
protection,  
energy reinforced  
weekly  
conservation  
Home exercise schedule  
Daily  
Promotes  
independence,  
(stretching, strengthening)  
reinforces clinic exercises  
CONCLUSION  
This case study demonstrates that a structured physiotherapy program emphasizing pain control, joint mobility,  
and functional training can substantially improve quality of life in children with Juvenile Rheumatoid Arthritis.  
Continuous engagement of the child and caregivers ensures better compliance and long-term benefits.  
Limitations  
A major limitation is the short 6-week intervention period, which may not reflect long-term sustainability of  
functional gains or recurrence of symptoms.  
Long-term monitoring is essential to evaluate maintenance of ROM, pain reduction, and prevention of  
deformities.  
As a single case report, statistical analysis and comparison to normative paediatric data were not feasible,  
limiting the generalizability of results.  
Future assessments may include objective tests such as the 6-Minute Walk Test and grip strength dynamometry  
to provide quantitative functional benchmarks.  
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