Juvenile Rheumatoid Arthritis: Types and Treatments

Introduction Juvenile rheumatoid arthritis (JRA)

The etiology is largely unknown. In contrast to adult rheumatoid arthritis, which lasts a lifetime, children often outgrow the disease. Nevertheless, JRA can affect the bone development in the growing child.

The signs and symptoms of JRA and the degree to which they are affected vary from child to child. Although the most likely age for development of JRA is between one and three years, it can affect children of any age. The most common features of JRA include joint inflammation, joint contracture, joint stiffness following rest and joint damage. Other related symptoms include weakness in muscles and soft tissues around the affected joints, and reduced activity level. As there is no conclusive test for JRA, the diagnosis is made when there has been persistent arthritis in one or more joints for at least 6 weeks after exclusion of other possible causes. Early diagnosis and subsequent appropriate treatment gives the maximum prospect for a favorable outcome.
 

Types of Juvenile rheumatoid arthritis (JRA)

There are three main types of JRA categorized based on the number of and which joints are involved, the symptoms and their duration, and the presence of certain antibodies produced by the immune system. Some types of this disease can cause serious complications such as growth problems and eye inflammation.

The three types of JRA are:

Pauciarticular JRA

Also known as oligoarticular, this form which is found in about fifty percent of all children with JRA, affects four or lesser joints. Large joints such as the shoulder, hip, knees and elbows are usually affected. Symptoms include pain, stiffness, or swelling in the joints. This arthritis often affects girls younger than age seven, and boys older than eight years of age. In addition, children affected with this arthritis may develop inflammatory eye problems. Although not painful, if not detected and treated, the inflammation may lead to scarring of the lens and permanent visual damage, or even blindness.

Polyarticular JRA

This type involves five or more joints, and affects girls more often than boys. Polyarticular JRA can begin at any age and accounts for about thirty percent of cases of JRA. The small joints of the hands and feet are mostly affected but it can affect the large joints as well, and the involvement is often distributed in a symmetrical bilateral pattern. The arthritis may be accompanied by low grade fevers.

Systemic JRA

This type which accounts for twenty percent of JRA cases affects many systems of the body. It involves one or more joints and causes inflammation of internal organs such as the heart, liver, spleen and lymph nodes. Children may have high fevers, skin rashes, and problems caused by inflammation of the internal organs. The spiking fever typically occurs once or twice each day, about the same time of day, and the temperature returns to the normal or below normal. The rash is characteristically non-itchy, macular, and salmon-colored (in contrast to the usual brightly erythematous rashes of other causes) and affects the trunk and extremities. Rarely, the rash may be severely itchy, and resistant to antihistamine treatment.

 

Treatment of Juvenile rheumatoid arthritis (JRA)

Treatment of JRA focuses on control of pain, improvement of joint function and prevention of further damage to the affected joints. Although medication is the cornerstone in the management of JRA, treatment may not be successful if the child is not given adequate emotional counseling, appropriate physical therapy, and further school assistance.


Medications

The immediate aim of drug therapy is to reduce pain and swelling, and to improve function. The long-term goals are to alter the progress of the disease and to prevent further damage to the bones, cartilage and soft tissues. Medication dosages in children must be carefully calculated based on their weight and body size and adjusted at regular intervals as the child grows.
The typical medications used in the management of JRA include the following:

Nonsteroidal anti-inflammatory drugs (NSAIDs)

• Medications such as ibuprofen and naproxen help to reduce pain and swelling.

Disease-modifying antirheumatic drugs (DMARDs)

• These may be used when NSAIDs alone fail to relieve symptoms of joint pain and swelling. These medications which include methotrexate and sulfasalazine are given along with NSAIDs and are used to slow the progress of JRA. They are also known as slow-acting anti-rheumatic drugs (SAARDs).

Tumor necrosis factor (TNF) blockers

• Medications such as etanercept and infliximab can help to reduce pain, morning stiffness and swollen joints. However, these drugs tend to increase the risk of development of cancers such as lymphoma, and infections, mainly in the lungs.

Corticosteroids

• These medications are used in children with severe JRA in order to control symptoms until a DMARD takes effect or to prevent complications. Corticosteroids can interfere with normal growth and increase susceptibility to infection, and therefore, should be used for the shortest possible duration.

Read More: New Genetlic Links To Juvenile Idiopathic Arthritis Found

Physical Therapy

Standard physical therapy methods include heat-cold treatment, massage, electrical stimulation, and ultrasound. These are aimed to relieve pain and stiffness, prepare for exercise programs, reduce contractures, and provide training for specific muscle groups.
Exercise is an important component in the treatment of JRA. Exercise helps to keep the joints mobile and muscles strong, regain lost movement or strength in a joint, and improve general fitness. Therapeutic exercise can restore lost motion in a joint and make it easier for children to carry out day to day activities such as writing, eating and walking.

As children may experience pain during routine physical activities, swimming and water aerobics (hydrotherapy) are ideal exercise for these children as both do not place much stress on the joints. A regular physical therapy that focus on stretching exercises, pain avoidance, and joint protection, can help a child with JRA to be as active as possible.


Splints

Splints help to reduce pain and to maintain the joints in the correct functional position. Splints which are commonly used include knee extension splints that prevent flexion contracture, wrist splints and ring splints for fingers.


Surgery

In very severe cases of JRA, surgery can be used to relieve pain, release joint contractures and replace a damaged joint. A joint replacement surgery is used mainly in older children whose growth is almost complete and whose joints are badly damaged by arthritis.


Diet

Children with arthritis sometimes have poor appetites, leading to weight loss and poor growth. In addition, side effects of medications such as steroids may cause excessive weight gain.

A combination of appropriate exercise and a well-balanced diet can help an arthritic child to maintain a normal body weight. Many children with arthritis require additional calcium and vitamin D supplements in order to help strengthen their bones.