Juvenile rheumatoid arthritis: Causes, Symptoms and Treatment
Juvenile rheumatoid arthritis (JRA) includes a number of different conditions, all of which affect children and all of which have immune-mediated joint inflammation as their major manifestation.
Juvenile Rheumatoid Arthritis is also known as juvenile idiopathic arthritis or JIA.
What is Juvenile rheumatoid arthritis (JRA)?
In Juvenile Rheumatoid Arthritis, the synovial membrane becomes intensely inflamed. Usually thin and delicate, the synovium becomes thick and stiff, with numerous infoldings on its surface. The membrane becomes invaded by white blood cells, which produce a variety of destructive chemicals. The cartilage along the articular surfaces of the bones may be attacked and destroyed, and the bone, articular capsule, and ligaments may begin to be worn away (eroded). These processes severely interfere with movement in the joint.
Juvenile Rheumatoid Arthritis specifically refers to chronic arthritic conditions that affect a child under the age of 16 years and that last for a minimum of three to six months. Juvenile Rheumatoid Arthritis is often characterized by a waxing and waning course, with flares separated by periods of without noted symptoms (remission). Some literature refers to JRA as juvenile rheumatoid arthritis, although most types of JRA differ significantly from the adult disease called rheumatoid arthritis, in terms of symptoms, progression, and prognosis.
Causes of Juvenile rheumatoid arthritis (JRA)
A number of different causes have been sought to explain the onset of Juvenile Rheumatoid Arthritis. There appears to be a genetic link; the tendency to develop Juvenile Rheumatoid Arthritis sometimes runs in particular families, and certain genetic markers are more frequently found in patients with Juvenile Rheumatoid Arthritis and other related diseases. Research has shown that several autoimmune diseases, including Juvenile Rheumatoid Arthritis, share a common genetic link. In other words, patients with Juvenile Rheumatoid Arthritis might share common genes with family members who have other autoimmune diseases such as rheumatoid arthritis, systemic lupus, multiple sclerosis, and others.
Joint symptoms of arthritis may include stiffness, pain, redness, warmth of the joint, and swelling. Bone in the area of an affected joint may grow too quickly or too slowly resulting in limbs that are of different lengths. When the child tries to avoid moving a painful joint, the muscle may begin to shorten from disuse, which is called a contracture.
Types and symptoms of Juvenile rheumatoid arthritis (JRA)
Symptoms of Juvenile Rheumatoid Arthritis depend on the particular subtype. According to criteria published by the American College of Rheumatology (ACR) in 1973 and modified in 1977, Juvenile Rheumatoid Arthritis is classified by the symptoms that appear within the first six months of the disorder:
1. Pauciarticular Juvenile Rheumatoid Arthritis: The most common and the least severe type of Juvenile Rheumatoid Arthritis, affecting about 40–60% of all Juvenile Rheumatoid Arthritis patients, Pauciarticular Juvenile Rheumatoid Arthritis affects fewer than four joints, usually the knee, ankle, wrist, and/or elbow.
Other more general (systemic) symptoms are usually absent, and the child’s growth usually remains normal. Very few children (less than 15%) with pauciarticular Juvenile Rheumatoid Arthritis end up with deformed joints. Some children with this form of Juvenile Rheumatoid Arthritis experience painless swelling of the joint.
Others have a serious inflammation of structures within the eye, which if left undiagnosed and untreated could lead to blindness. This condition, known as uveitis, affects about 20% of children diagnosed with Juvenile Rheumatoid Arthritis.
While many children have cycles of flares and remissions, in some children the disease completely and permanently resolves within a few years of diagnosis.
2. Polyarticular Juvenile Rheumatoid Arthritis: About 50% of all cases of Juvenile Rheumatoid Arthritis are of this type. Polyarticular Juvenile Rheumatoid Arthritis is most common in children up to age three or after the age of 10 and affects girls more often than boys.
Polyarticular Juvenile Rheumatoid Arthritis affects five or more joints simultaneously. This type of Juvenile Rheumatoid Arthritis usually affects the small joints of both hands and both feet, although other large joints may be affected as well. Some patients with arthritis in their knees experience a different rate of growth in each leg. Ultimately, one leg grows longer than the other.
About half of all patients with polyarticular Juvenile Rheumatoid Arthritis have arthritis of the spine and/or hip. Others with polyarticular Juvenile Rheumatoid Arthritis have other symptoms of a systemic illness, including anemia (low red blood cell count), decreased growth rate, low appetite, low-grade fever, and a slight rash.
The disease is most severe in those children who are diagnosed in early adolescence. Some of these children test positive for rheumatoid factor (RF), a marker present in other autoimmune disorders. RF is found in adults who have rheumatoid arthritis. Children who are positive for RF tend to have a more severe course, with a disabling form of arthritis that destroys and deforms the joints.
This type of arthritis is thought to be the adult form of rheumatoid arthritis occurring at a very early age.
3. Systemic onset Juvenile Rheumatoid Arthritis: Sometimes called Still’s disease (after a physician who originally described it), this type of Juvenile Rheumatoid Arthritis occurs in about 10% of children with arthritis.
Boys and girls are equally affected, and diagnosis is usually made between the ages of five and 10. The initial symptoms are not usually related to the joints. Instead, these children have high fevers; a rash; decreased appetite and weight loss; severe joint and muscle pain; swollen lymph nodes, spleen, and liver; and serious anemia.
Some children experience other complications, including inflammation of the sac containing the heart (pericarditis), inflammation of the tissue lining the chest cavity and lungs (pleuritis), and inflammation of the heart muscle (myocarditis). The eye inflammation often seen in pauciarticular Juvenile Rheumatoid Arthritis is uncommon in systemic onset Juvenile Rheumatoid Arthritis.
Symptoms of actual arthritis begin later in the course of systemic onset Juvenile Rheumatoid Arthritis, and they often involve the wrists and ankles. Many of these children continue to have periodic flares of fever and systemic symptoms throughout childhood. Some children go on to develop a polyarticular type of Juvenile Rheumatoid Arthritis.
4. Spondyloarthropathy: This type of Juvenile Rheumatoid Arthritis most commonly affects boys aged eight years and older. The arthritis occurs in the knees and ankles, moving over time to include the hips and lower spine. Inflammation of the eye may occur occasionally but usually resolves without permanent damage.
5. Psoriatic Juvenile Rheumatoid Arthritis: This type of arthritis usually shows up in fewer than four joints but goes on to include multiple joints (appearing similar to polyarticular Juvenile Rheumatoid Arthritis).
Hips, back, fingers, and toes are frequently affected. A skin condition called psoriasis accompanies this type of arthritis. Children with this type of Juvenile Rheumatoid Arthritis often have pits or ridges in their fingernails. The arthritis usually progresses to become a serious, disabling problem.
How to Diagnose Juvenile rheumatoid arthritis (JRA)?
Diagnosis of Juvenile Rheumatoid Arthritis is often made on the basis of the child’s collection of symptoms. Laboratory tests often show normal results. Some nonspecific indicators of inflammation may be elevated, including white blood cell count, erythrocyte sedimentation rate, and a marker called C-reactive protein. As with any chronic disease, anemia may be noted. Children with an extraordinarily early onset of the adult type of rheumatoid arthritis have a positive test for rheumatoid factor.
How to Treat Juvenile rheumatoid arthritis (JRA)?
Range-of-motion and muscle-strengthening exercises are among the best natural therapies for Juvenile Rheumatoid Arthritis. Research has shown that exercise can decrease inflammatory agents while increasing anti-inflammatory compounds in the body, thereby improving immune function. However, physical activity can be challenging when patients are experiencing symptoms of pain.
Physical or occupational therapists can provide supervised exercises to teach proper technique, and these exercises should be practiced as recommended at home.
To reduce morning stiffness, the child can take a hot bath or shower or apply a heating pad.
Diet is also believed to play a role in treating Juvenile Rheumatoid Arthritis.
A number of autoimmune disorders, including Juvenile Rheumatoid Arthritis, seem to have a relationship to food allergies. Patients may experience symptom relief after identifying and eliminating food allergens from the diet, which can trigger inflammation. Following a diet low in saturated fats may also help reduce the inflammatory response, which can be increased by a diet high in saturated fats. A strict vegetarian diet low in fats and free of glutens may also be helpful. Including foods rich in calcium and vitamin D is also important to build bone mass and reduce the risk of fractures.
Massage has been shown to benefit children with Juvenile Rheumatoid Arthritisby reducing anxiety and stress, reducing pain, and reducing morning stiffness.
The use of juice therapy in treating Juvenile Rheumatoid Arthritis
Alternative treatments that have been suggested for arthritis include juice therapy, which can work to detoxify the body, helping to reduce Juvenile Rheumatoid Arthritis symptoms.
Some recommended fruits and vegetables are carrots, celery, cabbage, potatoes, cherries, lemons, beets, cucumbers, radishes, and garlic. Tomatoes and other vegetables in the nightshade family (potatoes, eggplant, and red and green peppers) are discouraged.
The use of aromatherapy in treating Juvenile Rheumatoid Arthritis
As an adjunct therapy, aromatherapy preparations include cypress, fennel, and lemon. Massage oils include rosemary, benzoin, chamomile, camphor, juniper, eucalyptus, and lavender.
Other types of therapy that have been used are acupuncture, acupressure, and body work.
Also shown to be effective in some cases are the essential fatty acids: omega-3 fatty acids in fish oil, and the omega-6 fatty acid Gamma Liolenic Acid (GLA) found in borage oil, current seed oil, and evening primrose oil.
Several alternative medicine doctors suggest there may be some benefit in taking cartilage supplements, although no definitive studies had been done as of 2008 on this treatment. Anti-inflammatory spices such as turmeric, ginger, and cayenne may be helpful.
Natural remedies such as yucca, burdock root, horsetail, devil’s claw, sarsaparilla, and white willow bark also can be helpful since they have anti-inflammatory and analgesic properties.
The use of nutritional supplement in treating Juvenile Rheumatoid Arthritis
Nutritional supplements that may be beneficial include large amounts of antioxidants (vitamins C, A, E, zinc, selenium, and flavonoids), as well as B vitamins and a full complement of minerals (including boron, copper, manganese). One study showed 1,800 International Units (IU) of vitamin E a day could be helpful in relieving symptoms.
Other nutrients that assist in detoxifying the body, including methionine, cysteine, and other amino acids, may also be helpful.
Constitutional homeopathy can also work to quiet the symptoms of Juvenile Rheumatoid Arthritis and bring about balance to the whole person.
Allopathic treatment for Juvenile Rheumatoid Arthritis
Treating Juvenile Rheumatoid Arthritis involves efforts to decrease the amount of inflammation, in order to preserve movement.
Nonsteroidal anti-inflammatory agents (such as ibuprofen, naproxen, diclofenac, and celecoxib) are usually the first line of treatment for Juvenile Rheumatoid Arthritis to reduce inflammation.
Analgesics, including acetaminophen and tramadol, may provide pain relief but do not reduce inflammation.
Patients should ask their doctor about using analgesics in combination with their other arthritis medications.
Steroid medications are effective but have many serious side effects with long-term use. Injections of steroids into an affected joint can be helpful. Steroid eye drops are used to treat eye inflammation. Drugs that act on the immune system may be added when NSAID monotherapy is not effective in treating symptoms. These include:
- methotrexate (Rheumatrex),
- azathioprine (Imuran),
- leflunomide (Arava),
- cyclosporine (Sandimmune),
- sulfasalazine (Azulfidine), and
- hydroxychloroquine (Plaquenil).
Glucocorticoids are stronger medications that may be used in select cases of Juvenile Rheumatoid Arthritis in low doses for short-term treatment.
Tumor Necrosis Factor (TNF) antagonists represent a newer class of biologic drugs used to treat Juvenile Rheumatoid Arthritis.
These drugs include etanercept (Enbrel);
- infliximab (Remicade), which is usually given with methotrexate; and
- adalimumab (Humira)
These drugs ease joint pain, reduce swelling, and improve mobility and may be associated with less severe side effects than other medications.
Physical therapy and exercises are often recommended in order to improve joint mobility and strengthen supporting muscles. Occasionally, splints are used to rest painful joints and to prevent or improve deformities.
Research has confirmed that the blood serum of patients with Juvenile Rheumatoid Arthritis contained elevated levels of interleukin-6, a cytokine (nanoantibody protein) that is critical to regulation of the immune system and blood cell formation. Because interleukin-6 is also associated with inflammation, researchers have suggested that compounds inhibiting the formation of interleukin-6 may provide new treatment options for Juvenile Rheumatoid Arthritis.
Expected results when treating Juvenile Rheumatoid Arthritis
Treatment and continued physical activity can prevent loss of function, provide pain relief, and maintain joint mobility. Most children with Juvenile Rheumatoid Arthritis can attend a regular school and benefit from being with children of the same age.
The prognosis for pauciarticular Juvenile Rheumatoid Arthritis is quite good, as is the prognosis for spondyloarthropathy.
Polyarticular Juvenile Rheumatoid Arthritis carries a slightly worse prognosis.
RF-positive polyarticular Juvenile Rheumatoid Arthritis carries a difficult prognosis, often with progressive, destructive arthritis and joint deformities. Systemic onset Juvenile Rheumatoid Arthritis has a variable prognosis, depending on the organ systems affected, and the progression to polyarticular Juvenile Rheumatoid Arthritis.
About 1 to 5% of all Juvenile Rheumatoid Arthritis patients die of such complications as infection, inflammation of the heart, or kidney disease.
Prevention
Little is known about the causes of Juvenile Rheumatoid Arthritis; therefore, there are no recommendations available for how to avoid developing it.
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