One branch of arthritis that we never really discussed in
class is juvenile rheumatoid arthritis, or JRA. JRA is the most common type of
arthritis affecting children under the age of seventeen. As it does in adults,
JRA causes persistent joint pain, stiffness and swelling (usually noticed first
in the larger joints). Although it does particularly affect the joints, JRA can
affect the entire body and manifest with swollen lymph nodes, rashes and fever.
Some patients may develop symptoms in flare-ups and only experience them for a
short time, while others can remain symptomatic the rest of their lives. Some
forms of JRA can result in serious complications such as growth retardation and
eye inflammation (which can lead to blindness).
The causes of JRA remain in question. Like adult-onset RA,
it occurs when the immune system begins to attack the patient’s own tissues,
particularly the synovial tissue surrounding the joints. It is believed that
there are both hereditary and environmental contributions to the onset and
symptoms of the disease.
Much research has gone into determining the best treatment
plans for children with JRA, with the focus being to control pain, improve
function and prevent joint damage.
Because children with RA may struggle to grow up and live
normal, fully functional lives, multidisciplinary therapy appears to be the
best approach. NSAID (non-steroidal anti-inflammatory drugs), DMARD
(disease-modifying antitrheumatic drugs), and biologic treatments do well to
minimize symptoms or slow the progression of JRA, but recently more pediatric rheumatologists
are prescribing physical and occupational therapy in addition to traditional
therapies in order to maintain joint flexibility, range of motion and muscle
strength.
A comprehensive rehabilitation program needs to start early
to restore any present loss of function as well as prevent progression to
permanent disability. Physical therapy in addition to pharmaceutical therapy
has been found to prevent the fates of contractures, osteoporosis, and loss of
function that often befall JRA patients. Also, this type of treatment is
typically less time-consuming, painful and expensive than having to treat
patients after such complications have developed.
The foremost issue that physical therapists come across in
JRA patients is the tendency to keep the ailed joints in the “most comfortable
position.” This means that patients seek comfort and relief by placing the
joint in a position where joint volume is maximal, and the swollen synovium has
little to no weight placing pressure on it. Typically, this position is having
the joint in flexion. Maintaining flexion results in weakness of extensor
muscles, and contracture of flexor muscles can rapidly develop. Basically, what
this means is that the muscles that extend the extremities become weak and
those that flex become “stuck” in their contracted position. This contributes
to the child’s stiffness as well as pain in movement, and often limping and
compensatory movement patterns results. Physical therapy focuses closely on
this problem, utilizing exercises to strengthen the weakened muscles and
correct the ones that develop contractures.
Growth retardation in children with RA is common, and can
result in balance deficiencies. This is
another concentration in physical therapy treatment. JRA patients with these
deficiencies will fall frequently due to decreases in fine motor skills and
issues in joint development. PT treatment for these problems would include
neurodevelopmental and neurosensory stimulation in the hopes to train the
balance control mechanisms.
Finally, another major concern with children suffering from
JRA is the development of osteoporosis as a result of extensive steroid
treatment, nutritional disorders and of course decreased load bearing by the
joints. Two studies, one by Cetin et al and another by Celiker et al reported
that lumbar vertebral bone density was much lower in children with JRA when
compared to a control group. This fact was especially evident in those JRA
children who were on steroid treatment. Exercise is essential for anyone to
prevent osteoporosis, and is especially crucial for small children who are
still growing and whose bones are still fairly malleable. PT programs would
integrate weight-bearing and resistance type exercises to encourage improved
bone density.
What this information and research has shown us is that
treatment for JRA as well as other chronic diseases should be all encompassing.
Patients appear to experience the most improvement and the least suffering when
their treatment plan includes physical or occupational therapy programs in
which they are not just exercising but learning how their bodies and their
disease work. Pharmaceutical treatments do well to relieve patients of
debilitating symptoms, as well as slow the progression. However, it is clear
that medication is not enough to maintain functionality and quality of life.
Sources:
Cakmak, Aysegul, and Nalan Bolukbas. "Juvenile Rheumatoid
Arthritis: Physical Therapy and Rehabilitation." Southern Medical
Journal 98.2 (2005): 212-16. Web. 10 Nov. 2014.
"Juvenile Rheumatoid Arthritis." Mayo Clinic.
N.p., n.d. Web. 10 Nov. 2014.
Celiker R, Bal S, Bakkaloglu A, et al. “Factors playing a role in
the development of decreased bone mineral density in juvenile chronic
arthritis.” Rheumatology International
2003;23:127-129. Web.10 Nov. 2014.
Cetin A, Celiker R, Dincer F, et al. “Bone mineral density in
children with juvenile chronic arthritis.” Clinical
Rheumatology 1998;17:551-553. Web.10 Nov. 2014.
Hi Amanda. Thank you for sharing this information about juvenile rheumatoid arthritis. I can see how physical therapy programs could be very beneficial for children with these symptoms, especially when they are in pain and are just trying to protect themselves by staying in the most comfortable position. There is something to understanding your disease to help lessen the impact. Knowledge is very empowering and the mental confidence that children (or RA patients in general) can gain from being taught about their disease can help them overcome physical pain and suffering to some degree. Stretching may cause pain now, but it can prevent problems in the future.
ReplyDeleteI really like that you discussed a form of arthritis that we did not get the chance to discuss in class. From what you discussed, it definitely does seem that an all inclusive treatment is the way to go. I was also wondering if the use of yoga would be beneficial for these patients? Maybe if they use it in addition to their PT, it would allow them to work on strength and flexibility that in the long run might be helpful. Thanks for the new information!
ReplyDeleteIts interesting you brought that up! At my clinic a one time we had one of our PTAs teach a yoga-like stretching and balance class and it seemed to appeal to our arthritis patients! Since yoga involves strength, flexibility, and balance it seems like it would be a great fit, especially for newly diagnosed patients who are not so progressed.
DeleteI was not aware that there was such thing as JRA. I know that adult RA symptoms and pain increases each year after they are diagnosed, so I cannot imagine developing JRA at such a young age. I think the best approach is to continuously work the joints with PT, like you had mentioned so they do not lose their functionality. I know with muscle soreness, it helps when you keep moving around so I think this would have the same sort of effect.
ReplyDeleteI found this article very interesting because my best friend growing up had JRA, I don't think it was nearly as severe as other patients as she didn't have growth retardation or any issues with her sight, however she did receive shots every week (which as I grow older I assume were steroids- let me know if you know any different) and her JRA became so bad it prevented her from maintaining a basketball scholarship throughout college. What I do like about this article, and what I really agree with is using physical therapy as a first mechanism of treatment before turing to pharmacological treatments. She actually didn't do any physical therapy throughout her childhood years and after reading this article I question if doing so would have made a vast difference in how bad her arthritis is as a 21 year old.
ReplyDeleteThanks for bringing up JRA, Amanda. I was actually wondering if it would be brought up in class since I have a friend who was diagnosed with JRA. I mean, at first, I thought that she was just being paranoid since she has a weak body and immune system to begin with. She had to stop her education for a little while due to pneumonia, a lung cancer scare (which turned out to be negative, thank god), and many other illnesses. So I thought that her arthritis-like symptoms were stemming from the illnesses she already had in the past. And I had believed that arthritis only affected the elderly. So thank you for this informative article. It really helped strengthen my understanding in terms of arthritis.
ReplyDeleteLike all other juvenile diseases, JRA has drastic effects on the life of affected children, I personally know someone who was diagnosed with JRA and has struggled for the past decade. Some days are better than others, she can usually tell what kind of day it will be when she wakes up in the morning, since sleeping overnight in the same position allows for synovial inflammation to proceed, which in turn reduces her mobility. You wouldn't believe how often she needs to call out from work to go see her rheumatologist. Perhaps a tailored made combination of treatment is what every patient needs, and is actively trying to get, but simple things like setting alarms in the middle of the night for a quick stretch to 'discourage' inflammation could go a long way.
ReplyDeleteIt was refreshing to see a discussion of treatment which both alleviates symptoms and prevents disease progression. Physical therapy is particularly well suited for this in arthritis patients for a number of reasons. Encouraging movement and building proper muscle strength will prevent contracture and maintain joint mobility. The potential complication of osteoporosis is also avoided; PT exercises can help build peak bone mass while providing relief for current symptoms. Osteoporosis seems like a very real risk in arthritis patients whose limited mobility may decrease their peak bone density, which may be compounded by medications that decrease bone density. Using PT as part of arthritis treatment may prevent expensive and painful future complications.
ReplyDeleteI really liked your informative and in-depth description of Juvenile Rheumatoid Arthritis, a condition I had never heard of before. It seems that the early onset of JRA leads to even more health and lifestyle complications than patients with RA. The early onset would likely leave a patient with osteoporosis in his/her late 20s... a lifestyle I couldn't even picture. My mom works as a physical therapist and helped me with some rehab on me knee, and the results have been outstanding... although going to an occupational therapist for help with JRA would be a whole different lifestyle. As Jen mentioned, this type of exercise and treatment is essential to allow for a normal lifestyle in patients with JRA.
ReplyDeleteThank you for the post, Amanda! Its so sad to see debilitating diseases in children like this. Hopefully we'll have effective treatments sooner rather than later. We talked a lot in class about having too much focus on downstream therapeutic targets but I think arthritis should have a strong focus on both upstream and downstream targets. Because of the complexity and variance of arthritis pathophysiology, until we can cure the cause of all kinds of arthritis at the source we will have to treat symptoms. For example, a high school friend of mine had her wrist severely injured in a fishbowl accident (seriously) when she was young that led to arthritis in that hand. She has all the same downstream targets of other arthritis patients while having few (if any) upstream effectors. That being said I don't know much about trauma induced arthritis so the situation is likely more complex than I described.
ReplyDeleteThere is a lot to be said for physical therapy and the benefits it poses. This clearly speaks for itself that physical therapy is not just for injury. It can be used for a wide variety of disease and pathology in order to recover or to promote quality of life. The neurodevelopmental side of PT is very interesting to me and is definitely something I am looking forward into exploring in graduate school. To me, it offers a long term solution to the issue whereas pharmaceuticals are mostly short term or for symptom management. Im glad you brought up flexibility and range of motion as well as increasing muscle strength. Out of these, I feel that flexibility and stretching are often overlooked, but are essential parts of being healthy. I actually didn't know that there was such a thing as arthritis in young children. I always associated it as only being in the elderly.
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