Juvenile arthritis: "no child left behind" fits here, too.

Contrary to the perception that arthritic diseases are the domain of older patients, a large share of the pediatric population is afflicted with inflammatory arthritic diseases. Estimates of the prevalence of juvenile inflammatory arthritis have a wide range: Whereas Lawrence et al (1) estimate 30,000 to 50,000 cases of juvenile arthritis in the United States, Australian researchers believe that far more cases go unidentified than are actually diagnosed, (2) suggesting that as many as 250,000 children could be afflicted with a juvenile arthritic process.

The major thrust of medical education, literature, and research in treatment of juvenile arthritides has focused on pharmacologic therapy; indeed, significant advancements have been made in the treatment of juvenile arthritis in the past decade. Although nonsteroidal anti-inflammatory drugs have remained a mainstay, the use of methotrexate and newer biological agents has been increasingly accepted for more aggressive disease and instituted earlier in the disease course. (3)

Despite these advances, many patients may still be receiving inadequate management of their arthritis. One major problem is the limited number of pediatric rheumatologists available to provide care to this patient population. There are fewer than 200 board-certified pediatric rheumatologists in the United States (4); nearly half of the US population lives more than 1 hour from a pediatric rheumatologist. (5) This manpower problem also has an effect on medical education; more than one third of all medical schools have no pediatric rheumatologist, which limits opportunity for those most knowledgeable in the latest therapies to teach medical students and residents. (6) As a result, primary care physicians in training may have only superficial exposure to these diseases and the latest treatments.

Because of the pediatric rheumatology shortage, access may be limited by both sheer numbers and distance. Fortunately, a large number of internist rheumatologists are willing to see and treat children, particularly in areas where pediatric rheumatologists are not available. The internist rheumatologist fills a definite void, since 90% of children live within 1 hour of either a pediatric rheumatologist or internist rheumatologist willing to see juvenile patients. (5)

Although many children may respond adequately to nonsteroidal anti-inflammatory drugs, referral to someone well versed in the use of the latest treatment should be strongly considered if there is any suspicion of a more aggressive disease process. Given the long-term sequelae associated with persistent disease, (7) referral to someone trained in the use of disease-modifying therapies should be early in the course of the disease.

Another trap into which the clinician may fall is relying on medical therapy alone. Contrary to what one would intuitively think, the number of tender joints does not correlate with function disability, (8) and deterioration of physical function may continue despite a perceived excellent response to pharmacologic treatment. (9)

In this issue of the Journal, Cakmak and Bolukbas (10) have discussed an important component of a comprehensive juvenile arthritis treatment program. Two major factors in the development of functional disability in the juvenile arthritic are loss of motion (8) and decreased physical function. (9) A comprehensive physical and occupational therapy program, including splinting, casting, and physical conditioning modalities, will address these and other issues that beset the juvenile arthritic patient.

Some clinicians fear that exercise may worsen the disease status; however, Klepper (11) found that a physical conditioning program may actually have a favorable effect on the disease process.

Irrespective of whether the care is being directed by the primary care physician or a specialist, physical and occupational therapists should be a part of the treatment of children with a juvenile arthritis.

Nonpharmacologic modalities must be a part of any treatment plan to ensure the best possible outcome. (12) Today's youths are beset with far more complex issues than we faced; the addition of a potentially disabling disease necessitates the use of any modality that maximizes the opportunity of a normal life. The longer the disease remains active, the more likely one sees sequelae into adulthood. (7) The treatment of juvenile arthritis must be multifaceted, combining appropriate pharmacologic therapy with physical and occupational therapy and counseling as needed, in the hope that each child gets the best chance for a successful and healthy life.

You can get more with a kind word and a gun than you can with a kind
word alone.
--Al Capone

Accepted October 20, 2004.

Please see "Juvenile Rheumatoid Arthritis: Physical Therapy and Rehabilitation" on page 212 of this issue.

References

1. Lawrence RC, Helmick CG, Arnett FC, et al. Estimates of the prevalence of arthritis and selected musculoskeletal disorders in the United States. Arthritis Rheum 1998;41:778-799.

2. Manners PJ, Diepeveen DA. Prevalence of juvenile chronic arthritis in a population of 12 year old children in urban Australia. Pediatrics 1996;98:84-90.

3. Cron RQ. Current treatment for chronic arthritis in childhood. Curr Opin Pediatr 2002;14:684-687.

4. Hirsch R. Pediatric rheumatology workforce: a status update. Curr Opin Rheum 2004;16:553-554.

5. Mayer ML, Mellins ED, Sandborg CI. Access to pediatric rheumatology care in the United States. Arthritis Rheum 2003;49:759-765.

6. Cassidy JT, Athreya B. Pediatric rheumatology: status of the subspecialty in United States medical schools. Arthritis Rheum 1997;40:1182.

7. Zak M, Pedersen FK. Juvenile chronic arthritis into adulthood: a long-term follow-up study. Rheumatology (Oxford) 2000;39:198-204.

8. Bekkering WP, ten Cate R, van Suijlekom-Smit LW, et al. The relationship between impairments in joint function and disabilities in independent function in children with systemic juvenile idiopathic arthritis. J Rheumatol 2001;28:1099-1105.

9. Miller ML, Kress AM, Berry CA. Decreased physical function in juvenile rheumatoid arthritis. Arthritis Care Res 1999;12:309-313.

10. Cakmak A, Bolukbas N. Juvenile rheumatoid arthritis: physical therapy and rehabilitation. South Med J 2005;98:212-216.

11. Klepper SE. Effects of an eight-week physical conditioning program on disease signs and symptoms in children with chronic arthritis. Arthritis Care Res 1999;12 52-60.

12. Akikusa JD, Allen RC. Reducing the impact of rheumatic diseases in childhood. Best Prac Res Clin Rheum 2002;16:333-345.

Christopher R. Morris, MD

From Arthritis Associates, Kingsport, TN.

Reprint requests to Dr. Christopher Morris, Arthritis Associates, 3 Sheridan Square, Kingsport, TN 37660. Email: [e-mail]