Juvenile Idiopathic Arthritis Flashcards
What is JIA?
- Childhood disease→ swelling, inflamm, pain about jts
- Formerly→ Juvenile Rheumatoid Arthritis (America) and Juvenile Chronic Arthritis (Europe)
JIA Defined:
aka what makes it a JIA dx?
- Arthritis lasting @ least 6wks
- 1 or more jts
- Children <16yo
- WHEN ALL OTHER CAUSES R/O!!!
No neural insult, BUT contractures?
Potential Dx and what to do?
Osteoarthritis?
Refer to ortho!!!
JIA Dx:
- NO true Dx test*
- Mostly clinical and often delayed
- Non-specific signs:
- Mild anemia, elevated erythrocyte sedimentation rate (ESR), radiograph evidence jt swelling, osteopenia
JIA Incidence/Prevalence
Age of onset/gender vary by type
Girls>Boys
JIA Etiology
Unclear BUT…
-
Theory of autoimmune inflammatory disorder:
- External trigger→ trauma, bact/virus
- virus/bacterial infx usually precedes onset
- phys. trauma
Types of JIA:
5:
- Olioarticular (former→ Pauciarticular)
- Polyarticular
- Systemic
- Enthesitis-related
- Psoriatic
Olioarticular JIA
fun fact to KNOW!
Usually one-side only
Olioarticular
- 50-60% cases
- Girls <6yo
- Sx’s:
-
Mild inflamm in 4 or fewer jt→ KNEE MOST COMMON*
- ankles, elbows
- *hip/sm. jts of hands not impacted
- Joints→ swollen, warm, not too painful
-
Mild inflamm in 4 or fewer jt→ KNEE MOST COMMON*
- EXCELLENT PROGNOSIS*
Olioarticular prognosis
EXCELLENT!!!
Polyarticular
*less common
- 25-28%, 5 or more jts
-
Symmetric→ large AND small jts
- MAY include CS and TMJ*
- Jts→ swollen, warm, echymosis
- *Mild systemic sx’s→ low grade fever, hepatosplenomegaly, lymphadenopathy
- Prognosis→ guarded 2* comps: weakness, contractures
Polyarticular prognosis
Guarded (unsure) 2* comps may arise→ weakness, contractures
MOST SERIOUS JIA
SYSTEMIC
Dx marker of Systemic JIA
High fever
Systemic JIA
- 10-12%, MOST serious
- Pain in many jts
- Dx marker==> high fever**
- Rash→ trunk, limbs, face, palms, soles feet
- S/S:
- Pleuritis, pericarditis, myocarditis, hepatosplenomegaly, lymphadenopathy
- Prognosis→ mod-poor: more severe+more jts
Systemic prognosis
Mod-poor bc more severe+many jts
Enthesis-related JIA
- Effects Enthesis→ area where tendons+ligs attach to bone
- jts also maybe affected
Psoriatic JIA
- Combination→ Jt tenderness + inflammation w/ psoriasis of skin OR probs w/ nails
Cardinal signs of Inflammatory Response:
- Swelling, End range stress pain, 2* swelling and protective mm spasms, Jt stiffness, Chronic inflammation==INCd synovial fluid→
- All==> DECd phys activity and low bone density + use of corticosteroids==> INCd fx risk
Cardinal signs of Inflammatory Response:
More on Jt Stiffness
MOST noted upon waking (AM stiff) OR after prolonged sitting
Cardinal signs of Inflammatory Response:
More on Inflamm==> INCd synovial fluid
- Stretches/weaknes jt capsule + adj. structures
- Overgrowth, pannus (see pic), spreads/erodes art. cart.==> changes bone surfaces
- Compromises align, symmetry and stability of jts==> contractures
Medical Mgmt JIA:
Goals→
- Control arthritis, prevent jt erosions, manage extra-articular manifestations
Medical Mgmt JIA:
Coordination w/ drugs
-
NSAIDs→ most widely used first line
- SEs=> GI issues
- dec fever, pain, inflamm→ DO NOT alter dis. course
Medical Mgmt JIA:
Methotrexate (MTX)
- MOST COMMON used to modify dis. itself***
- Children w/ systemic and polyarticular
Medical Mgmt JIA:
Last 3 medical mgmt techniques
Steroids, Total jt replaces, PT***
PT Exam/Physical Manifestations of JIA:
- Jt swell/stiff, pain, limtd mob; soft tissue contractures, AM stiff (better t/o day), mm atrophy/weakness/poor mm endurance, fatigue, decd aerobic cap, osteopenia, gait devs, diff w/ ADLs, act/part restrictions
2 Standardized Measures specific to JIA:
Articular Severity Score (ASS)
Global Range of Motion Score (GROMS)
ASS and GROMS***
Jt Examination: JIA
- Active Jt Motion→ observe child thru series mvmts
- ***Goniometry recommended!!!
Jt Examination: Stick figure method
- Jt counts for swelling and ROM limits
- Add X’s into circles
MM Structure and Function
Mm atrophy and weakness near inflamed joints…
SPECIFICALLY WHERE?
PROXIMALLY
MM Structure and Function
- MM atrophy and weakness→ proximally
- may persist AFTER flare up controlled
- Measure/Monitor→ MM bulk, strength, endurance
Strength Testing: JIA
-
Functional MM Strength→ observe motor skills and ADLs→ younger children
- MMT/dynamometry
- Dynamic strength test once flare-ups controlled***
- Endurance→ how many reps/timed tasks
Aerobic Capacity and Function: JIA
Tests/Assessments to use?
- 6MWT, Peds RPE***
- LOWER peak workload, peak ex. HR, ex. time vs healthy peers
MAJOR cause of act. limits in JIA
PAIN
Pain and JIA
- MAJOR cause act. limits****, more prev. as child ages
-
Ongoing pain assess:
- pain hx
- Pt self-report→ 4yrs and older
- Behaviors→ guarding, bracing, rubbing, rigidity*
Pt self-report pain @ what age?
4 yrs +
Pain and JIA
Pain Scales:
Wong Baker Faces Scale, Oucher, Body Map (color),
Children 7yo and older→ VAS
Varni/Thompson Peds Pain Questionnaire (PPQ)→ parent AND child reports***
VAS can be used WHEN for children w/ pain?
7yrs and older
Varni/Thompson PPQ
What to remember?
Parent AND Child reports of pain
Growth Disturbance/Postural Abnorms JIA
- Reduction in growth w/ ext’d pds of active disease**
- systemic steroids exacerbate this
- Osteoporosis
- LLDs common→ asymmetrical, premature closure growth plates
- Observe posture/alignment in sitting AND standing!!!
Gait Impairments in JIA
- Decd velocity, Decd cadence, Limtd stride length, Incd APT,
- Decd hip EXT and PF @ TSt and lack of push-off
- Maybe→ developed weakness, loss of ROM from scar tissue
- USE→ gait labs, pedographs, video
Role of PT in JIA
Depends on ______ and _______
Type; Severity
Role of PT depends highly on type and severity of JIA
Oliarticular vs Poly
- Oliarticular→ FEW functional limits, if any
- Poly→ need assist w/ basic ADLs, moving bw pos’s, stairs, bike, playground w/ peers, etc.
Standardized Assessments that examine child’s w/ JIA’s Activity:
2:
-
Childhood Health Assessment Questionnaire:
- 1-19yo
- 30 activities
- parent OR child answers
- Has areas to assess length of time for morning stiff and VAS for pain
-
Juvenile Arthritis Functional Assessment Index (JASI) and Juvenile Arthritis Functional Assessment Report (JAFAR)
- Measures physical function**
Participation and Activity Limits contd
2 more assessments:
- SFA→ diff @ school
-
Juvenile Arthritis Functional Assessment Scale (JAFAS)
- observed and timed on 10 tasks
Participation/Activity Limits
QoL Measures to use:
- Juvenile Arthritis Quality of Life Questionnaire (JAQQ)
- Pediatric Quality of Life Questionnaire (PedsQL)
PT Interventions:
Goals + guidelines
- Goals→ prevent/min. impairs, maint or improve function, edu/support for pt and fam
- Phys activity and graded exercise
- Adherence to HEP CRUCIAL!!!
PT Rx for Pain Control
- Anti-inflamms→ may take time
- Intra-articular steroid injections
-
PRICE:
- Pain control
- Rest
- Ice
- Compression
- Elevation
PT Rx for Pain Control
Modalities:
- Superficial heat (20 mins), paraffin, biofeedback, imagery/meditation, imagination play
- *NOTE: US NOT USED FOR THIS POPULATION!!!
Education on _________ is super important!!!!
Prevention of AM stiffness***
EDUCATE! EDUCATE! EDUCATE!
- Regarding prevention of AM stiffness*** (KNOW FOR TEST!!!)
- Night splints, main. body heat t/o night, pre-bed exercises or parental massage, AM warm bath/mvmt before school
- sleeping bags, extra layers
Managing Joint Impairments
Utilizing ROM program
- “Motion is Lotion”→ Daily ROM program
- thru FULL ROM 1-2x/day
- AROM preferable, AAROM if weakness
- Gental manual stretch when arthritis under control
- brief 60s, contract release
- Child moves limb thru full ROM after stretch bc mm in lengthened state
- Serial casting, spinting/orthoses→ prolonged stretch/pos’ing in more severe/contracted jts
Strengthening in JIA
- Target mm’s surrounding effected jts**
-
During acute inflamm:
- ISOMETRIC only, but caution long holds → may inc intra-articular pressure
- Dynamic ex’s w/ resolution of inflamm.
- Bikes, yoga, pilates, aquatics, developmental play, aerobic acts for CV endurance
Functional Mobility GOAL for JIA
Get children walking again ASAP!!!
Functional Mobility and JIA
- Wt bearing/ambulation→ CRUCIAL for bone growth, jt health, mm development
-
Goal→ get children walking again ASAP!!!
- maybe aides/orthotics initially
- most do not req. AD but may use AD for long dist’s bc flare-ups
Self-Care
Modifications for children:
- Adaptations for grip strength defs
- Adapted toys/utensils/writing tools
- replace door knobs/faucets, velcro on shoes, button hooks/zippers
- Home→ ramps, HRs for tub, raised toilet seat
Children w/ JIA undergo Sx procedures for improvement in jt deformity
3 Types Sx:
- Soft tissue lengthening
- Synovectomy
- TJA (Total Jt Arthroplasty)
Pre-Op PT for JIA:
Improve strength, maintain range
Post-Op PT for JIA:
Return to PLOF!!!
School Considerations for JIA Children
- Tardiness due to morning stiffness, Freq. absence 2* systemic issues or f/u appts
- Incd time for hygiene or getting to class, aide for note taking, untimed tests, mods for gym class
- All leads to decd social interactions and feelings of isolation***
Recreational Activities:
- Stay active and social!
- Swimming/water or LOW impact aerobics, cycling, yoga→ great acts to promote!
- *NOTE: AVOID high impact or contact → more inflammatory
