Juvenile Idiopathic Arthritis: Difference between revisions

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'''Image 1:  Swollen right knee in JIA patient'''
'''Image 1:  Swollen right knee in JIA patient'''


Juvenile idiopathic arthritis (JIA) reflects a group of clinically heterogeneous, [[Autoimmune Disorders|autoimmune disorders]] in children and teens under the age of 16, characterized by chronic [[arthritis]] and hallmarked by elevated levels of circulating immune complexes (CICs) and associated complement activation by-products in their sera.<ref>Moore TL. [https://www.frontiersin.org/articles/10.3389/fimmu.2016.00177/full Immune complexes in juvenile idiopathic arthritis.] Frontiers in immunology. 2016 May 20;7:177.Available:https://www.frontiersin.org/articles/10.3389/fimmu.2016.00177/full (accessed 18.10.2021)</ref>  
Juvenile idiopathic arthritis (JIA) reflects a group of clinically heterogeneous, [[Autoimmune Disorders|autoimmune disorders]] in children and teens under the age of 16, characterized by chronic [[arthritis]] and hallmarked by elevated levels of circulating immune complexes (CICs) and associated [[Complement System|complement]] activation by-products in their sera.<ref>Moore TL. [https://www.frontiersin.org/articles/10.3389/fimmu.2016.00177/full Immune complexes in juvenile idiopathic arthritis.] Frontiers in immunology. 2016 May 20;7:177.Available:https://www.frontiersin.org/articles/10.3389/fimmu.2016.00177/full (accessed 18.10.2021)</ref>  


JIA can appear in many different ways and can range in severity. It mostly affects the joints and the surrounding tissues, although it can affect other organs like the eyes.   
JIA can appear in many different ways and can range in severity. It mostly affects the [[Joint Classification|joints]] and the surrounding tissues, although it can affect other organs like the eyes.   


Symptoms of JIA include joint pain, swelling and stiffness.<ref name=":2">better Health [https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/arthritis-juvenile Juvenile Arthritis] Available: https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/arthritis-juvenile<nowiki/>(accessed 18.10.2021)</ref>  
Symptoms of JIA include joint [[Pain Behaviours|pain]], swelling and stiffness.<ref name=":2">better Health [https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/arthritis-juvenile Juvenile Arthritis] Available: https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/arthritis-juvenile<nowiki/>(accessed 18.10.2021)</ref>  


== Etiology ==
== Etiology ==
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4. Enthesitis-related JIA
4. Enthesitis-related JIA


5. Psoriatic JIA
5. [[Psoriatic Arthritis|Psoriatic]] JIA


6. Undifferentiated JIA<ref name=":2" />.<sup></sup>'''Image 2: Prevalence of major subtypes of JIA'''<ref name="Pathology" />  
6. Undifferentiated JIA<ref name=":2" />.<sup></sup>'''Image 2: Prevalence of major subtypes of JIA'''<ref name="Pathology" />  
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* pain, swelling and stiffness in one or more joints
* pain, swelling and stiffness in one or more joints
* skin over the affected joints may be warm or red
* [[skin]] over the affected joints may be warm or red
* mental and physical tiredness, or fatigue.
* mental and physical tiredness, or fatigue.
* Less common symptoms include:
Less common symptoms include:
* fever
* [[fever]]
* rash
* rash
* feeling generally unwell  
* feeling generally unwell
* eye inflammation (uveitis)<ref name=":2" />,see '''image 3.'''
* eye inflammation (uveitis)<ref name=":2" />,see '''image 3.'''


== Treatment ==
== Treatment ==
Treatment of JIA requires anti-inflammatory and immunomodulatory drugs and physical therapy, and eventually, surgery, nutritional support, and psychosocial support may be needed. The choice of pharmacological treatment depends on the disease subtypes, disease severity and damage, associated disease, and family acceptance. Nonsteroidal anti-inflammatory drugs (NSAIDs) are the mainstay of initial symptomatic treatment for all subtypes. The NSAID use in JIA has decreased over time with modern aggressive treatment, including methotrexate and biologics.<ref name=":1" />
Treatment of JIA requires anti-inflammatory and immunomodulatory drugs and physical therapy, and eventually, surgery, nutritional support, and psychosocial support may be needed.  
 
The choice of pharmacological treatment depends on the disease subtypes, disease severity and damage, associated disease, and family acceptance. Nonsteroidal anti-inflammatory drugs ([[NSAIDs in the Management of Rheumatoid Arthritis|NSAIDs]]) are the mainstay of initial symptomatic treatment for all subtypes. The NSAID use in JIA has decreased over time with modern aggressive treatment, including methotrexate and [[BDMARDs in the Management of Rheumatoid Arthritis|biologics]].<ref name=":1" />


The main treatments for arthritis include:
The main treatments for arthritis include:
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* eye drops – to treat eye inflammation
* eye drops – to treat eye inflammation
* non-steroidal anti-inflammatory drugs (NSAIDs) – to control inflammation and provide pain relief  
* non-steroidal anti-inflammatory drugs (NSAIDs) – to control inflammation and provide pain relief  
* corticosteroids – used to quickly control or reduce inflammation. They can be taken as tablets or given by injection directly into a joint, muscle or other soft tissue
* [[Corticosteroids in the Management of Rheumatoid Arthritis|corticosteroids]] – used to quickly control or reduce [[Inflammation Acute and Chronic|inflammation]]. They can be taken as tablets or given by injection directly into a joint, muscle or other soft tissue
* disease modifying anti-rheumatic medications (DMARDs) – work on controlling the immune system. These medications help relieve pain and inflammation, and can also reduce or prevent joint damage
* disease modifying anti-rheumatic medications ([[DMARDs in the Management of Rheumatoid Arthritis|DMARDs]]) – work on controlling the immune system. These medications help relieve pain and inflammation, and can also reduce or prevent joint damage
* biologics and biosimilar medicines (bDMARDs) – are also a type of disease modifying drug. They also work on controlling the immune system. However unlike other disease modifying drugs, biologics target specific cells and proteins that are causing the inflammation and damage, rather than suppressing the entire immune system.  
* biologics and biosimilar medicines (bDMARDs) – are also a type of disease modifying drug. They also work on controlling the immune system. However unlike other disease modifying drugs, biologics target specific cells and proteins that are causing the inflammation and damage, rather than suppressing the entire immune system.  


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* medical history
* medical history
* physical examination
* physical examination
* blood tests – however, most children diagnosed with juvenile idiopathic arthritis do not have rheumatoid factor in their blood, so blood tests do not eliminate juvenile idiopathic arthritis  
* [[Blood Tests|blood tests]] – however, most children diagnosed with juvenile idiopathic arthritis do not have rheumatoid factor in their blood, so blood tests do not eliminate juvenile idiopathic arthritis
* x-rays and scans
* x-rays and scans
* eye examination.<ref name=":2" />
* eye examination.<ref name=":2" />

Revision as of 10:49, 18 October 2021

Introduction[edit | edit source]

Image 1: Swollen right knee in JIA patient

Juvenile idiopathic arthritis (JIA) reflects a group of clinically heterogeneous, autoimmune disorders in children and teens under the age of 16, characterized by chronic arthritis and hallmarked by elevated levels of circulating immune complexes (CICs) and associated complement activation by-products in their sera.[1]

JIA can appear in many different ways and can range in severity. It mostly affects the joints and the surrounding tissues, although it can affect other organs like the eyes.

Symptoms of JIA include joint pain, swelling and stiffness.[2]

Etiology[edit | edit source]

The cause and trigger of chronic arthritis in JIA remain unclear.

  1. Abnormal immune responses triggered by the interactions between environmental factors in a genetically susceptible individual is speculative.
  2. JIA is not hereditary – it is not passed on from parent to child. It is rare for two children in the same family to have JIA, although this can happen[3].
  3. Some environmental factors such as antibiotic exposure and C-section deliveries are potential risks; however, breastfeeding and household siblings are possible protectives.[4]

Epidemiology[edit | edit source]

JIA is the most common rheumatic disease reported in children of the Western world. The incidence and prevalence are varied among 1.6 to 23 new cases for 100000 children[4].

  • JIA affects 30,000 to 50,000 children in the United States.[5]
  • JIA affects at least one child in every 1,000 in Australia[3]. For unknown reasons, it has been shown to be more prevalent in Norway and Australia.[6]
  • Effects more than twice as many girls as their male counterparts.
  • The mean age of onset is 1-3 years old.[6]

Pathology[edit | edit source]

There are several subtypes of JIA:

1.Oligoarticular JIA (Pauciarticular)

  • affected ≤4 joints in the first six months of illness
  • peak age: 1-6 years
  • mainly affects medium and large joints

2. Polyarticular JIA (pJIA)

  • ≥5 joints are affected
  • peak age: 1-4 years; 7-10 years
  • mainly affects small and medium joints

3. Systemic onset JIA (Still's disease, not to be confused with adult onset Still's disease)

  • arthritis may present weeks to months after the onset of systemic symptoms[7]

4. Enthesitis-related JIA

5. Psoriatic JIA

6. Undifferentiated JIA[2].Image 2: Prevalence of major subtypes of JIA[5]

Characteristics/Clinical Presentation[edit | edit source]

The symptoms the child experiences will depend on the type of arthritis they have. Common symptoms include:

  • pain, swelling and stiffness in one or more joints
  • skin over the affected joints may be warm or red
  • mental and physical tiredness, or fatigue.

Less common symptoms include:

  • fever
  • rash
  • feeling generally unwell
  • eye inflammation (uveitis)[2],see image 3.

Treatment[edit | edit source]

Treatment of JIA requires anti-inflammatory and immunomodulatory drugs and physical therapy, and eventually, surgery, nutritional support, and psychosocial support may be needed.

The choice of pharmacological treatment depends on the disease subtypes, disease severity and damage, associated disease, and family acceptance. Nonsteroidal anti-inflammatory drugs (NSAIDs) are the mainstay of initial symptomatic treatment for all subtypes. The NSAID use in JIA has decreased over time with modern aggressive treatment, including methotrexate and biologics.[4]

The main treatments for arthritis include:

  • medications to control the inflammation (including tablets, injections, infusions, eye drops)
  • exercises to keep the joints moving well and the muscles strong
  • splints to support the joints
  • joint injections to reduce inflammation in particular joints
  • pain management strategies to reduce pain and to help your child cope with pain[3]

Medications

The doctor will always start with the simplest medications at the smallest doses and work their way up to more complex medications and larger doses depending on how the child’s condition responds to the treatments.

The most common types of medications used for JIA are:

  • pain-relievers (analgesics) – for temporary pain relief
  • creams and ointments – can be rubbed into the skin over a painful joint to provide temporary pain relief
  • eye drops – to treat eye inflammation
  • non-steroidal anti-inflammatory drugs (NSAIDs) – to control inflammation and provide pain relief
  • corticosteroids – used to quickly control or reduce inflammation. They can be taken as tablets or given by injection directly into a joint, muscle or other soft tissue
  • disease modifying anti-rheumatic medications (DMARDs) – work on controlling the immune system. These medications help relieve pain and inflammation, and can also reduce or prevent joint damage
  • biologics and biosimilar medicines (bDMARDs) – are also a type of disease modifying drug. They also work on controlling the immune system. However unlike other disease modifying drugs, biologics target specific cells and proteins that are causing the inflammation and damage, rather than suppressing the entire immune system.  

Diagnostic Tests[edit | edit source]

JIA is diagnoses according to patient and family medical history, symptoms, number of joints involved, lab tests and sometimes imaging.

Juvenile idiopathic arthritis is diagnosed using a number of tests including:

  • medical history
  • physical examination
  • blood tests – however, most children diagnosed with juvenile idiopathic arthritis do not have rheumatoid factor in their blood, so blood tests do not eliminate juvenile idiopathic arthritis
  • x-rays and scans
  • eye examination.[2]

Physical Therapy Management[edit | edit source]

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.

Aspects that should be focused on during a physical therapy session are as follows[6]:

  • Muscle tone
  • Strengthening
  • Range of motion
  • Stretching
  • Education on joint protection
  • Home exercise plan
  • Education on pain reducing techniques
  • Muscle relaxation techniques
  • Splints or orthotics maybe be beneficial to help maintain normal bone and joint growth/prevent deformities during growth[8]

Some modalities that can be used to help reduce symptoms such as pain are:

  • Ultrasound
  • Paraffin wax dips (hands and feet primarily)
  • Moist compress (hot pack)
  • Hydrotherapy (warm)
  • Cold packs

Differential Diagnosis[edit | edit source]

Some signs and symptoms of JIA are shared with those of the following diseases[6][9]:

Case Reports/ Case Studies[edit | edit source]

Resources[edit | edit source]

Clinical Trials:

References[edit | edit source]

see adding references tutorial.

  1. Moore TL. Immune complexes in juvenile idiopathic arthritis. Frontiers in immunology. 2016 May 20;7:177.Available:https://www.frontiersin.org/articles/10.3389/fimmu.2016.00177/full (accessed 18.10.2021)
  2. 2.0 2.1 2.2 2.3 better Health Juvenile Arthritis Available: https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/arthritis-juvenile(accessed 18.10.2021)
  3. 3.0 3.1 3.2 Arthritis org. JIA Available:https://www.arthritisact.org.au/juvenile-arthritis/ (accessed 18.10.2021)
  4. 4.0 4.1 4.2 Thatayatikom A, De Leucio A. Juvenile Idiopathic Arthritis. StatPearls [Internet]. 2020 Aug 10. Available: https://www.ncbi.nlm.nih.gov/books/NBK554605/(accessed 18.10.2021)
  5. 5.0 5.1 Goodman C, Fuller K. Pathology: Implications for the Physical Therapist. 3rd ed. . St. Louis, MO: Saunders, an imprint of Elsevier Inc, 2009.
  6. 6.0 6.1 6.2 6.3 eMedicine. Disease fact sheet: juvenile rheumatoid arthritis. http://emedicine.medscape.com/article/409980-overview (accessed 10 March 2011)
  7. Radiopedia JIA Available: https://radiopaedia.org/articles/juvenile-idiopathic-arthritis (accessed 18.10.2021)
  8. 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)
  9. 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)

[[Category:Paediatrics]