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Chronic Arthritis of Childhood – Part Two
When a smaller number of joints are affected (the oligoarticular type) there are four or fewer joints exhibiting arthritic symptoms with the larger joints being preferentially affected. Such children do not present as unwell although they may limp when asked to walk. Arthritis may be confined to one hip but if the symptoms are limited to this joint then an alternative diagnosis should be sought as this is much more common, with Perthes disease a typical outcome. Arthritis over some time develops weakness and loss of bulk in the main knee muscles and a knee bend contracture partly due to tightening of the hamstrings. A discrepancy in length of legs can develop if arthritis affects only one leg.
The polyarticular type of juvenile arthritis, which has a larger number of joints affected, is indicated by five or more joints becoming inflamed in a symmetrical manner, the same joints being inflamed on both sides. A low level fever may be present and if the joints are badly limited in terms of range of motion there is likely to be weakness of the associated muscles and a limitation in function. Examining the patient thoroughly is crucial to determine if they do have the diagnosis of juvenile arthritis, where they have particular difficulties and which form of arthritis they possess.
To establish the diagnosis of arthritis on the examination of a joint an effusion (swelling fluid within the joint capsule) must be present along with other likely signs and symptoms such as redness, warmth, pain and limited joint movement. Effusion of a joint may not be apparent in many joints such as the hips but in those cases the limited joint motions and pain will be apparent. The diagnosis may not be apparent initially as the arthritis can come on at the time of the fevers and the rash but it can also be delayed for some months. Liver and lymph node enlargement can be evident with tender muscles on examination. One joint is often affected in the fewer joint form of juvenile arthritis.
In the polyarticular form of arthritis where many joints are inflamed, it is common for there to be a symmetrical involvement of the weight bearing joints as well as smaller ones of the hand. The joint cartilage may be reduced in thickness with eroded areas and in some joints the formation of a fusion across them. With more chronic changes there can be thickened synovial membranes and joint effusions, subluxations (partial dislocations), joint contractures and stiffness, bony deformity (particularly the fingers) and bony enlargements. The joints can also lose bone mass and suffer narrowing of the joint spaces as the cartilage thins.
A loss of cervical extension may not be symptomatic for the patient but is an important finding as it implies the cervical spine has suffered arthritic changes which can develop into subluxation (partial dislocation) of the high neck vertebrae which can be dangerous for the spinal cord. Fusion of the posterior neck structures may also occur. The tempero-mandibular joints of the jaw may also suffer from arthritic attack and this can cause reduced lower jaw growth and a reduction in the ability to open the mouth. Inflammatory changes can also affect the eyes in a low proportion of arthritics.
Juvenile arthritis and other complex conditions are best managed by a specialised multidisciplinary team due to the numerous problems which patients have to do with family and patient education and schooling, drug treatments, physiotherapy and occupational therapy. It is rarely if ever successful to give isolated treatments to this patient group. Reviewing patients at regular intervals allows the drug treatments to be fine tuned towards a reduction in the morning stiffness and towards fewer affected joints until no symptomatic joints remain. A typical team to manage these conditions may include a physiotherapist, occupational therapist, social workers, a paediatric rheumatologist and nurse.
Surgical care is not typically engaged although joint injections of steroids may be useful in some cases. Joint replacement can be used for hip or knee arthritis in patients with polyarticular arthritis but is usually delayed until skeletal maturity means bone growth has stopped. Activity is usually encouraged as long term rest is unhelpful and increased activity indicates a better outcome.
Jonathan Blood Smyth, editor of the Physiotherapy Site, writes articles about Physiotherapists, physiotherapy, Physiotherapy Croydon, back pain, orthopaedic conditions, neck pain and injury management. Jonathan is a superintendant physiotherapist at an NHS hospital in the South-West of the UK.
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Filed under back pain by on Mar 30th, 2010. 
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