Juvenile Idiopathic Arthritis(JIA)

Definition:
Arthritis is an inflammation of the joints, with pain or stiffness. It may be acute or chronic. Acute arthritis is also called septic arthritis and may affect one or more joints.

Juvenile Idiopathic Arthritis (JIA) (once called Juvenile Rheumatoid Arthritis or JRA) is a type of arthritis that affects children who are under 16 years of age. This is an autoimmune disease that causes joints to swell and become stiff, sometimes hindering a child’s mobility. It can affect any joint, and in some cases it can affect internal organs and eyes as well. Symptoms can come and go, flare-up on occassion, while others have symptoms that never go away.

There are three types of JIA, which are diagnosed according to symptoms and blood tests:-
•Oligoarticular JIA – the most common kind of childhood arthritis, which often starts at the age of two or three. The problem is limited to four joints or fewer, which become swollen and painful. Sometimes the eyes are affected, too. It is also known as pauciarticular arthritis.

•Polyarticular JIA – affects five or more joints. It can start at any age, from a few months onwards, and usually spreads quite quickly from one joint to another. Children often feel generally unwell, sometimes with a fever.

•Systemic onset JIA – affects the whole body, and causes fever and rashes as well as inflamed and painful joints. It usually starts in children under five but can affect children of any age. It used to be called Still’s disease.

About one in 1,000 children has arthritis. In many cases, the inflammation stops in late childhood, but about one-third of children affected have problems that last into their adult life.

Juvenile idiopathic arthritis affects somewhere between 8 and 150 of every 100,000 children, depending on the analysis. Of these children, 50 percent have pauciarticular JIA, 40 percent have polyarticular JIA and 10 percent have systemic JIA.

Symptoms:
Symptoms depend on the type of arthritis and joints affected . They could include:
*Pain
*Fever
*Joint Pain
*Knee Pain
*Joint Swelling
*Ankle Pain
*Hip Pain
*Swollen Lymph Nodes
*Elbow Pain
*Wrist Pain
*Limited Range of Motion
*Morning Stiffness
*Migratory Joint Pain
*Hip Stiff
*Back Pain
*Rash
*Chronic pain
*Shoulder Pain
*Foot Pain
*Dry Mouth
*Joint Stiffness
*Eye Pain
*Arm Pain
*Inflamed Joint
*Double-Vision
*Visual Disturbance
*Joint Tenderness
*Enlarged Spleen
*Eye Redness
*Visual Impairment
*Joint Erythema
*Joints Warm
*Blurred vision
*Knee Stiff
*Feels Hot to Touch
*Light Hurts Eyes
*Uneven Limb Lengths

Causes:
So far the actual cause of JIA remains a mystery. However, the disorder is autoimmune   – meaning that the body’s own immune system starts to attack and destroy cells and tissues (particularly in the joints) for no apparent reason. It is believed that the immune system gets provoked by changes in the environment or perhaps there is an error in the gene. Experimental studies have shown that certain viruses that have mutated may be able to trigger JIA. JIA appears to be more common in young girls and the disease is most common in Caucasians.   Associated factors that may worsen or have been linked to rheumatoid arthritis include the following:

*genetic predisposition; it appears that when one family member has been diagnosed with rheumatoid arthritis, the chances are higher that other family members or
*siblings may also develop arthritis

*females are more likely to develop rheumatoid arthritis than males at all ages

*there is a strong belief that psychological stress may worsen the symptoms of rheumatoid arthritis. However, when the emotional stress is under control the arthritis symptoms do not always disappear suggesting that the association is not straightforward

*even though no distinct immune factor has been isolated as a cause of arthritis, there are some experts who believe that the triggering factor may be something like a virus which then disappears from the body after permanent damage is done

*because rheumatoid arthritis is more common in women, there is a belief that perhaps sex hormones may be playing a role in causing or modulating arthritis.

Unfortunately, neither sex hormone deficiency nor replacement has been shown to improve or worsen arthritis.
The cause of JIA, as the word idiopathic suggests, is unknown and currently an area of active research. Current understanding of JIA suggests that it arises in a genetically susceptible individual due to environmental factors.

Diagnosis:
Diagnosis of JIA is difficult because joint pain in children can be from many other causes. There is no single test that can confirm the diagnosis and most physicians use a combination of blood tests, x rays and the clinical presentation to make an initial diagnosis of JIA. The blood tests measure antibodies and the rheumatoid factor. Unfortunately, the rheumatoid factor is not present in all children with JIA. Moreover in most children the blood work is usually normal. X rays are obtained to ensure that the joint pain is not from a fracture, cancer, infection or a congenital abnormality.

In most cases, fluid from the joint is aspirated and analyzed. This test often helps in making a diagnosis of JIA by ruling out other causes of joint pain

Treatment :
The treatment of JIA is best undertaken by an experienced team of health professionals, including pediatric rheumatologists, nurse specialists, physiotherapists, and occupational therapists. Many others in the wider health and school communities also have valuable roles to play, such as ophthalmologists, dentists, orthopaedic surgeons, school nurses and teachers, careers advisors and, of course local general practitioners, paediatricians and rheumatologists. It is essential that every effort is made to involve the affected child and their family in disease education and balanced treatment decisions.

The major emphasis of treatment for JIA is to help the child regain normal level of physical and social activities. This is accomplished with the use of physical therapy, pain management strategies and social support.

There have been very beneficial advances in drug treatment over the last 20 years. Most children are treated with non-steroidal anti-inflammatory drugs and intra-articular corticosteroid injections. Methotrexate is a powerful drug which helps suppress joint inflammation in the majority of JIA patients with polyarthritis  (though less useful in systemic arthritis). Newer drugs have been developed recently, such as TNF alpha blockers, such as etanercept.  There is no controlled evidence to support the use of alternative remedies such as specific dietary exclusions, homeopathic treatment or acupuncture. However, an increased consumption of omega-3 fatty acids proved to be beneficial in two small studies.

Celecoxib has been found effective in one study.

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Other aspects of managing JIA include physical and occupational therapy. Therapists can recommend the best exercise and also make protective equipment. Moreover, the child may require the use of special supports, ambulatory devices or splints to help them ambulate and function normally.

Surgery is only used to treat the most severe cases of JIA. In all cases, surgery is used to remove scars and improve joint function.

Home remedies that may help JIA includes getting regular exercises to increase muscle strength and joint flexibility. Swimming is perhaps the best activity for all children with JIA. Stiffness and swelling can also be reduced with application of cold packs but a nice warm bath or shower can also improve joint mobility

Complications:
JIA is a chronic disorder which if neglected can lead to serious complications. Proper follow up with health professionals can significantly reduce the chance of developing complications.

Eyes can be affected in some types of JIA. The inflamed eyes if left untreated can result in glaucoma, scars, cataracts and even blindness. Often the eye inflammation occurs without symptoms and thus it is important for all children to get regular eye checkups from an eye physician.

Growth retardation is common in children with JIA. Moreover, the medications (corticosteroids) used to treat JIA have potent side effects that can limit growth.

Children who delay treatment or do not participate in physical therapy can often develop joint deformities of the hand and fingers. Over time hand function is lost and almost impossible to recover.

Occupational therapy:
The best approach to treating a child with JIA involves a team of medical professionals including a rheumatologist, occupational therapist (OT), physical therapist, nurse and social worker.

The role of the OT is to help children participate as fully and independently as possible in their daily activities or “occupations”,  by preventing psychological and physical dependency. The aim is to maximize quality of life, and minimize disruption to the child’s and family’s life. OTs work with children, their families and schools, to come up with an individualized plan which is based on the child’s condition, limitations, strengths and goals. This is accomplished by ongoing assessments of a child’s abilities and social functioning. The plan may include the use of a variety of assistive devices, such as splints, that help a person perform tasks. The plan may also involve changes to the home, encouraging use of uninvolved joints, as well as providing the child and their family with support and education about the disease and strategies for managing it.  OT interventions will be changed depending on the progression and remission of JIA, in order to promote age-appropriate self-sufficiency. Early OT involvement is essential.

Self-care:
OTs can provide many strategies to assist children in their dressing routine. Clothes with easy openings and Velcro, as well as devices, such as buttonhooks and zipper pulls can be used. For children who have difficulty bending, a long handled reacher and sock aid is recommended. OTs may also show children how to sit during dressing so less strain is put on their joints.

OTs can help children maintain cleanliness through recommending assistive devices. For children who have trouble reaching all areas of their body, a long handled sponge with a soft grip can be provided. If children find it difficult to sit in a bath or stand in a shower, an OT can prescribe a bath bench or bath seat to be installed to help the child remain in a pain free position. If tooth brushing is challenging, a toothbrush with a larger, soft grip or an electric toothbrush may be recommended. For flossing, a flosser with an adapted handle may be provided.  Long handled hairbrushes may be used by children who have difficulty reaching the back of their head. Razors handles can be adapted for easier grip, or an electric razor may be used for shaving. The OT can also show girls wishing to use make-up, ways of increasing the sizes of the handles of make-up application tools for easier grip.

For children with pain in their hands and wrists, utensils and devices that are lightweight with large handles as well as other devices (such as angled knives, strap-on utensils, jar and bottle openers, turning handles, door knob extensions, etc.) can be provided to make the task easier, less painful and more enjoyable.[32] Tilted glasses can be used for children who have neck stiffness. Education can be provided about good eating habits that help control bone loss caused by inactivity and drug side effects. Occupational therapists provide a myriad of strategies to assist children with JIA in performing self-care tasks.

Leisure:
One of the best ways OTs can help children with JIA participate in activities with their friends is by helping them make their home exercise programs into play. Exercises are prescribed by both physiotherapists and OTs to increase the amount a child can move a joint and strengthen the joint to decrease pain and stiffness and prevent further limitations in their joint movements. OTs can provide children with age appropriate games and activities to allow the children to practice their exercises while playing and socializing with friends. Examples are crafts, swimming and non-competitive sports.

OTs will often prescribe custom made orthotics which are devices that support and correct body position and function. Orthotics help keep the child’s body in good alignment. Orthotics reduce discomfort in the legs and back when the child participates in physical activities such as sports. Splints can be used to support the joints during activity, to reduce the child’s pain and increase participation in their preferred leisure activities. Resting splints may be prescribed for children to wear during the night to reduce swelling and stiffness in joints, allowing children to have less pain and stiffness while participating in play activities.Furthermore, working splints are used to support the joint and relieve pain while working the with hands such as during crafts. A series of casts might be used to gradually extend shortened muscles allowing for increased participation in leisure activities.

OTs can help a child learn how to interact with their classmates and friends by collaboratively brainstorming strategies, role playing and modeling. OTs also help children see what activities they are good at and which ones give them difficulty. Furthermore, OTs can help children learn to communicate their pain to others. Benefits of OT treatment include: improved social interaction, improved self-confidence and a positive self-image. OTs can help children build friendships with other children suffering from similar diseases to help them feel less alone or less different from others. Many OTs run summer camps for children with similar diseases so children can get to know others with their disease. Education sessions on JIA and leisure, and activities such as swimming, canoeing and nature trails are common.

For children who find that cool or damp weather make it hard to play with friends outside, OTs can give ideas for clothing that will keep the child warm and dry without limiting movement. An example of this is biking gloves which allow children to move their fingers while still keeping their hands warm, as opposed to large winter gloves which limit hand function. Warm pajamas and electric blankets can reduce pain and improve sleep.

Prognosis:
With proper therapy, some children do improve with time and lead normal lives. However, severe cases of JIA which are not treated promptly can lead to poor growth and worsening of joint function. In the last two decades, significant improvements have been made in treatment of JIA and most children can lead a decent quality of life. The prognosis of JIA depends on prompt recognition and treatment. Finally, it is important for both the child and family member to be educated about the disorder. The more educated the person, the better the care you can receive. Chronic JIA is no longer the dreaded disease where one remains home bound. Many children with JIA have gone on to play professional sports and have a variety of successful careers

Disclaimer: This information is not meant to be a substitute for professional medical advise or help. It is always best to consult with a Physician about serious health concerns. This information is in no way intended to diagnose or prescribe remedies.This is purely for educational purpose

Resources:
http://www.bbc.co.uk/health/physical_health/conditions/in_depth/arthritis/aboutarthritis_children.shtml
http://en.wikipedia.org/wiki/Juvenile_idiopathic_arthritis
http://www.healthline.com/channel/juvenile-rheumatoid-arthritis_symptoms
http://www.seattlecca.org/diseases/juvenileidiopathicarthritis-overview.cfm?gclid=CLCm7aSepakCFcO8Kgodl2kxyQ

http://apps.ashland.edu/index.php/File:Arthritic_joints.jpg

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