Juvenile Idiopathic Arthritis: Difference between revisions

No edit summary
No edit summary
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* bone oedema, erosions
* bone oedema, erosions


Certain features of JIA will depend on the age of the child affected (e.g. the involvement of epiphyseal growth plates, early physeal fusion or the development of discrepancies in limb length).<ref name=":1" />  
Certain features of JIA will depend on the age of the child affected (e.g. involvement of epiphyseal growth plates, early physeal fusion or the development of discrepancies in limb length).<ref name=":1" />  


Individuals may also experience:<ref name=":2" /><ref>National Institute of Arthritis and Musculoskeletal and Skin Diseases. Juvenile Idiopathic Arthritis (JIA) Basics. Available from: https://www.niams.nih.gov/health-topics/juvenile-arthritis/basics/symptoms-causes (last accessed 1 May 2023).</ref>
Individuals may also experience:<ref name=":2" /><ref>National Institute of Arthritis and Musculoskeletal and Skin Diseases. Juvenile Idiopathic Arthritis (JIA) Basics. Available from: https://www.niams.nih.gov/health-topics/juvenile-arthritis/basics/symptoms-causes (last accessed 1 May 2023).</ref><ref name=":5">Eskay K. Paediatric Conditions – Autism, Developmental Coordination Disorder, Spina Bifida, Juvenile Idiopathic Arthritis, Haemophilia Course. Plus, 2023.</ref>
* pain
* pain and stiffness, including morning stiffness
* fatigue
* fatigue


*[[fever]]
*[[fever]]
* rash
* skin rash
* generally feeling unwell (malaise)
* generally feeling unwell (malaise)
* uveitis (see image)
* uveitis (see image)
* decreased range of motion
* decreased range of motion and soft tissue contractures
* muscle atrophy
* weakness, or reduced muscular endurance
* gait deviations


== Diagnostic Tests ==
== Diagnostic Tests ==
There is no specific test to diagnose JIA,<ref name=":1" /> but the following may be included:<ref name=":1" /><ref name=":2" />
There is no definitive test to diagnose JIA,<ref name=":1" /> so JIA is a diagnosis based on exclusion. The following evaluations are often included:<ref name=":1" /><ref name=":2" />
* medical history
* medical history
* physical examination
* physical examination
Line 85: Line 88:
#* affects females / males equally
#* affects females / males equally
#[[Psoriatic Arthritis|Psoriatic]] JIA
#[[Psoriatic Arthritis|Psoriatic]] JIA
#* causes psoriasis and inflammatory arthritis (can develop at different times)
#* causes psoriasis and inflammatory arthritis (these can develop at different times)
#* more common in females
#* more common in females
#* occurs in preschool-aged children and at around 10 years
#* occurs in preschool-aged children and at around 10 years
Line 97: Line 100:
#* JIA that does not fit into another category
#* JIA that does not fit into another category
== Management ==
== Management ==
Treatment for JIA includes pharmacology, physiotherapy, potentially surgery, and in some cases nutritional and psychosocial support.<ref name=":1" />   
Treatment for JIA includes pharmacology and physiotherapy. Surgery and nutritional and psychosocial support may be required in some cases.<ref name=":1" />   


== '''Pharmacology''' ==
== '''Pharmacology''' ==
'''T'''he choice of medication depends on type and severity of JIA and if there are other conditions. Common medications include analgesics, eye drops, non-steroidal anti-inflammatory drugs ([[NSAIDs in the Management of Rheumatoid Arthritis|NSAIDs]]), corticosteroids, disease modifying anti-rheumatic medications, [[BDMARDs in the Management of Rheumatoid Arthritis|biologics]] and biosimilar medicines.<ref name=":1" /><ref name=":2" />
The choice of medication depends on type and severity of JIA and if there are other conditions present. Common medications include analgesics, non-steroidal anti-inflammatory drugs ([[NSAIDs in the Management of Rheumatoid Arthritis|NSAIDs]]), corticosteroids, disease modifying anti-rheumatic medications, [[BDMARDs in the Management of Rheumatoid Arthritis|biologics]] and biosimilar medicines and eye drops.<ref name=":1" /><ref name=":2" />


== Physiotherapy Management ==
== Physiotherapy Management ==
Physical therapy is an important part of the treatment of JIA. It is important for the child to remain active and involved in sports and activities with their peers and friends. While pain may limit the amount of activity a child can handle it is important to encourage involvement during periods or remission and allow rest and symptom reducing therapies during periods of flare-ups. Regular activity and general exercise programs help to maintain range of motion in affective joints, build and maintain strength, maintain function and can even help with symptom reduction.  
Physiotherapy interventions focus on maintaining joint function and strength and teaching joint preservation strategies. Exercise programmes should incorporate low-impact, weight-bearing exercises (e.g. aquatic or bike programmes, gentle resistance exercises).<ref name=":5" />   


Aspects that should be focused on during a physical therapy session are as follows<ref name="eMedicine">eMedicine.  Disease fact sheet: juvenile rheumatoid arthritis. http://emedicine.medscape.com/article/409980-overview (accessed 10 March 2011)</ref>:  
Rehabilitation might include:<ref name=":5" /><ref name="eMedicine">eMedicine.  Disease fact sheet: juvenile rheumatoid arthritis. http://emedicine.medscape.com/article/409980-overview (accessed 10 March 2011)</ref><ref>Bosques G, Singh MP. Juvenile Idiopathic Arthritis [Internet]. 2011, updated 2020 (cited 1 May 2023). Available from: https://now.aapmr.org/juvenile-idiopathic-arthritis/#rehabilitation-management-and-treatments</ref>
*Muscle tone
*[[Strength Training|strengthening]]
*[[Strength Training|Strengthening]]
*[[Range of Motion|range of motion]] exercises and [[stretching]]
*[[Range of Motion|Range of motion]]
*education on joint protection and pain reducing techniques
*[[Stretching]]
*[[Adherence to Home Exercise Programs|home exercise programme]]
*Education on joint protection  
*muscle relaxation techniques
*[[Adherence to Home Exercise Programs|Home exercise plan]]
*splints / orthotics to help maintain bone and joint alignment / prevent deformities<ref name="NIAMS">National Institute of Arthritis and Musculoskeletal and Skin Diseases. Health information: juvenile arthritis. http://www.niams.nih.gov/Health_Info/Juv_Arthritis/default.asp (accessed 10 March 2011)</ref>
*Education on pain reducing techniques
*adaptive equipment
*Muscle relaxation techniques  
Some modalities that might be used to help reduce symptoms such as pain include:  
*Splints or [[Introduction to Orthotics]] maybe be beneficial to help maintain normal bone and joint growth/prevent deformities during growth<ref name="NIAMS">National Institute of Arthritis and Musculoskeletal and Skin Diseases. Health information: juvenile arthritis. http://www.niams.nih.gov/Health_Info/Juv_Arthritis/default.asp (accessed 10 March 2011)</ref>
*[[Ultrasound therapy|ultrasound]]
Some modalities that can be used to help reduce symptoms such as pain are:  
*paraffin wax dips (primarily for hands and feet)
*[[Ultrasound therapy|Ultrasound]]
*moist compress ([[Thermotherapy|hot packs]])
*Paraffin wax dips (hands and feet primarily)  
*[[Aquatherapy|hydrotherapy]]
*Moist compress ([[Thermotherapy|hot pack]])
*cold packs
*[[Aquatherapy|Hydrotherapy]] (warm)
*Cold packs  


== Differential Diagnosis ==
== Differential Diagnosis ==
Some signs and symptoms of JIA are shared with those of the following diseases<ref name="eMedicine" /><ref name="NCBI">National Center for Biotechnology Information, U.S. National Library of Medicine. Disease fact sheet: http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001487/ (10 March 2011)</ref>:  
Conditions to consider in a differential diagnosis include:<ref name="eMedicine" /><ref name="NCBI">National Center for Biotechnology Information, U.S. National Library of Medicine. Disease fact sheet: http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001487/ (10 March 2011)</ref>   
*[http://www.physio-pedia.com/index.php5?title=Lyme_Disease Lyme Disease]  
*[http://www.physio-pedia.com/index.php5?title=Lyme_Disease Lyme Disease]  
*Rheumatic fever  
*Rheumatic fever  

Revision as of 06:55, 1 May 2023

This article or area is currently under construction and may only be partially complete. Please come back soon to see the finished work! (1/05/2023)

Original Editors - Emily Betz from Bellarmine University's Pathophysiology of Complex Patient Problems project.

Top Contributors - Emily Betz, Lucinda hampton, Jess Bell, Ines Musabyemariya, Admin, Naomi O'Reilly, Khloud Shreif, Kim Jackson, Elaine Lonnemann, Meaghan Rieke, Mande Jooste, Wendy Walker, George Prudden and WikiSysop

Introduction[edit | edit source]

File:JIA-swollenjoint.jpg
Figure.1 Swollen Right Knee in Patient with JIA

Juvenile idiopathic arthritis (JIA) is a term used to describe types of arthritis of unknown cause, where symptoms last for more than 6 weeks, in individuals aged under 16 years at the time of onset.[1]

JIA ranges in severity. It affects the joints, as well as other structures such as the eyes, skin, and organs,[2] and it can be divided into the following subtypes:[2]

  • oligoarticular
  • polyarticular
  • systemic
  • psoriatic
  • enthesitis-related
  • undifferentiated

Aetiology[edit | edit source]

The aetiology of JIA is unclear.[3] The following factors have been proposed:[2]

  • genetic associations
  • autoimmune factors[4]
  • environmental factors (e.g. infectious agents, antibiotics, stress etc) may be risk factors
    • maternal factors (e.g. smoking[2][5]) may be involved, but breastfeeding / having household siblings may reduce risk
  • infectious viruses and bacteria may be causal factors

Epidemiology[edit | edit source]

JIA is the most common chronic heterogenous rheumatologic condition in children.[3][4] It is estimated that around 3 million children and young adults have JIA. The global prevalence is believed to range from 3.8 to 400/100,000; the incidence is estimated to be 1.6 to 23/100,000.[4]

  • Females are at higher risk than males of JIA[4]
  • The oligoarticular subtype is more common[4]

Characteristics and Clinical Presentation[edit | edit source]

File:Uveitis.jpg
Figure.3 Uveitis

Symptoms of JIA vary depending on the type of arthritis.[6] It has an unpredictable course - it can be self-limiting or cause joint damage. But there is a general pattern of inflammatory joint disease in one or more joints:[3][6]

  • synovitis
  • joint effusion
  • swelling of soft tissues
  • osteopenia
  • bone oedema, erosions

Certain features of JIA will depend on the age of the child affected (e.g. involvement of epiphyseal growth plates, early physeal fusion or the development of discrepancies in limb length).[3]

Individuals may also experience:[6][7][8]

  • pain and stiffness, including morning stiffness
  • fatigue
  • fever
  • skin rash
  • generally feeling unwell (malaise)
  • uveitis (see image)
  • decreased range of motion and soft tissue contractures
  • muscle atrophy
  • weakness, or reduced muscular endurance
  • gait deviations

Diagnostic Tests[edit | edit source]

There is no definitive test to diagnose JIA,[3] so JIA is a diagnosis based on exclusion. The following evaluations are often included:[3][6]

  • medical history
  • physical examination
  • laboratory tests - typical inflammatory markers are said to be common, particularly in oligoarthritis[3]
  • imaging
    • radiography for symptomatic joints (in early JIA, there are no detectable changes on x-ray, but indirect signs may be present, increased soft tissue density etc[3])
    • ultrasound
    • MRI (the gold standard)
  • eye examination

Pathology[edit | edit source]

Figure.2 Prevalence of Major Subtypes of JIA[9]

There are several subtypes of JIA:[3][6][10]

  1. Oligoarticular JIA (also known as pauciarticular)
    • affects four or fewer joints in the first six months of disease
    • peak age for oligoarticular JIA is 1-6 years
    • more common in females
    • tends to impact medium and large joints
    • risk of uveitis
  2. Polyarticular JIA
    • affects more than 5 joints
    • peak ages for polyarticular JIA are 1-4 years and 7-10 years
    • more common in females
    • tends to impact small and medium joints
  3. Systemic onset JIA
    • also known as Still's disease
    • associated with fever, other signs of systemic inflammation and arthritis[11]
    • arthritis may begin weeks / months after the initial symptoms[10]
    • affects females / males equally
  4. Psoriatic JIA
    • causes psoriasis and inflammatory arthritis (these can develop at different times)
    • more common in females
    • occurs in preschool-aged children and at around 10 years
    • tends to impact fingers, wrists, toes, but not exclusively
  5. Enthesitis-related JIA
    • inflammation of entheses
    • more common in males
    • tends to occur in older children / adolescents
    • association with acute uveitis
  6. Undifferentiated JIA
    • JIA that does not fit into another category

Management[edit | edit source]

Treatment for JIA includes pharmacology and physiotherapy. Surgery and nutritional and psychosocial support may be required in some cases.[3]

Pharmacology[edit | edit source]

The choice of medication depends on type and severity of JIA and if there are other conditions present. Common medications include analgesics, non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroids, disease modifying anti-rheumatic medications, biologics and biosimilar medicines and eye drops.[3][6]

Physiotherapy Management[edit | edit source]

Physiotherapy interventions focus on maintaining joint function and strength and teaching joint preservation strategies. Exercise programmes should incorporate low-impact, weight-bearing exercises (e.g. aquatic or bike programmes, gentle resistance exercises).[8]

Rehabilitation might include:[8][12][13]

Some modalities that might be used to help reduce symptoms such as pain include:

Differential Diagnosis[edit | edit source]

Conditions to consider in a differential diagnosis include:[12][15]

References[edit | edit source]

  1. ↑ Rigante D, Bosco A, Esposito S. The Etiology of Juvenile Idiopathic Arthritis. Clin Rev Allergy Immunol. 2015 Oct;49(2):253-61.
  2. ↑ 2.0 2.1 2.2 2.3 Zaripova LN, Midgley A, Christmas SE, Beresford MW, Baildam EM, Oldershaw RA. Juvenile idiopathic arthritis: from aetiopathogenesis to therapeutic approaches. Pediatr Rheumatol Online J. 2021 Aug 23;19(1):135.
  3. ↑ 3.00 3.01 3.02 3.03 3.04 3.05 3.06 3.07 3.08 3.09 3.10 Thatayatikom A, Modica R, De Leucio A. Juvenile Idiopathic Arthritis. [Updated 2023 Jan 16]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK554605/
  4. ↑ 4.0 4.1 4.2 4.3 4.4 Al-Mayouf SM, Al Mutairi M, Bouayed K, Habjoka S, Hadef D, Lotfy HM, Scott C, Sharif EM, Tahoun N. Epidemiology and demographics of juvenile idiopathic arthritis in Africa and Middle East. Pediatr Rheumatol Online J. 2021 Dec 2;19(1):166.
  5. ↑ França CMP, Sallum AM, Silva CAA, Aikawa NE, Braga AL, Farhat SC. Risk factors for juvenile idiopathic arthritis: exposure to tobacco and environmental factors during and before pregnancy. Pediatr Rheumatol Online J. 2014 Sep 17;12(Suppl 1):P27.
  6. ↑ 6.0 6.1 6.2 6.3 6.4 6.5 better Health Juvenile Arthritis Available: https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/arthritis-juvenile(accessed 18.10.2021)
  7. ↑ National Institute of Arthritis and Musculoskeletal and Skin Diseases. Juvenile Idiopathic Arthritis (JIA) Basics. Available from: https://www.niams.nih.gov/health-topics/juvenile-arthritis/basics/symptoms-causes (last accessed 1 May 2023).
  8. ↑ 8.0 8.1 8.2 Eskay K. Paediatric Conditions – Autism, Developmental Coordination Disorder, Spina Bifida, Juvenile Idiopathic Arthritis, Haemophilia Course. Plus, 2023.
  9. ↑ Goodman C, Fuller K. Pathology: Implications for the Physical Therapist. 3rd ed. . St. Louis, MO: Saunders, an imprint of Elsevier Inc, 2009.
  10. ↑ 10.0 10.1 Radiopedia JIA Available: https://radiopaedia.org/articles/juvenile-idiopathic-arthritis (accessed 18.10.2021)
  11. ↑ Hedrich CM, Günther C, Aringer M. Morbus Still im Kindes- und Erwachsenenalter [Still's disease in children and adults]. Z Rheumatol. 2017 Sep;76(7):595-608. German.
  12. ↑ 12.0 12.1 eMedicine. Disease fact sheet: juvenile rheumatoid arthritis. http://emedicine.medscape.com/article/409980-overview (accessed 10 March 2011)
  13. ↑ Bosques G, Singh MP. Juvenile Idiopathic Arthritis [Internet]. 2011, updated 2020 (cited 1 May 2023). Available from: https://now.aapmr.org/juvenile-idiopathic-arthritis/#rehabilitation-management-and-treatments
  14. ↑ National Institute of Arthritis and Musculoskeletal and Skin Diseases. Health information: juvenile arthritis. http://www.niams.nih.gov/Health_Info/Juv_Arthritis/default.asp (accessed 10 March 2011)
  15. ↑ National Center for Biotechnology Information, U.S. National Library of Medicine. Disease fact sheet: http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001487/ (10 March 2011)
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