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One of the most frequent chronic diseases of children and the most common rheumatological condition in this group is juvenile rheumatoid arthritis. This is not one disorder but a group of interrelated disorders which all exhibit inflammatory changes in the joints. The triggering factors for these diseases have not been uncovered and it has proven hard to delineate one particular type of condition from another due to the complex genetic factors. While it is often called JRA, there is a move to standardise the naming of these diseases into juvenile idiopathic arthritis.

The classification can be approached by describing three main subtypes, systemic onset disease where the problems are widespread, polyarticular arthritis where many joints are affected and pauciarticular where only a few joints are involved. The typical disease course is chronic with remission periods inbetween periods of flare ups, the medical treatment being typically aimed at causing remission and maintaining it over time. The biological treatment agents more recently developed have given a greatly increased effectiveness of treatments for arthritic diseases.

The causative factors and how the arthritis develops is not clearly understood, but a trigger such as trauma or infection may start an autoimmune reaction against the joint tissues. This makes the synovial membrane lining the joint enlarge and develops a chronic inflammation, all of these things likely to occur in children who have a genetic susceptibility. Many genes are thought to be responsible for the onset of the disease and how it presents in each individual. There are wide ranges in the incidence of these conditions as the susceptibility to the disease varies along with the different population groups and exposure to environmental influences.

The oligoarticular type of juvenile chronic arthritis, in which a small number of joints are inflamed, is the commonest disease type, consisting of about half of all patients. Thirty percent have a large number of joint affected, the polyarticular type, and the rest have the systemic form. Sufferers from chronic juvenile arthritis may at some type suffer also from another autoimmune disorders. The severe pain and disability due to the arthritis causes significant psychological distress, behavioural problems, anxiety and depression. The polyarticular and oligoarticular forms occur more often in girls than boys with a frequency of three to four and a half to one. The systemic form occurs equally.

The polyarticular or many affected joint form of arthritis has two peaks of incidence, one covering one to four years of age and another covering six to twelve years. The fewer joint type, the oligoarticular form, tends to occur in children who are two to four years old. The systemic type has no particular age of incidence. The disease pattern over the first six months determines which pattern the individual patient fits into. If four or fewer joints are affected during this period then the diagnosis is the oligoarticular or fewer joint group. More than five joints are symptomatic during the first six months this indicates the polyarticular or many joint diagnosis. Arthritis, rashes and a fever are the typical onset symptoms of the systemic form.

An arthritis must occur for six weeks in a joint to be able to make the diagnosis of juvenile arthritis of the various types. Morning stiffness is a common phenomenon and relates to the fact that the joints stiffen and become more painful after being still for any length of time. The onset of the disease can be slow and gradual or very sudden, with stiffness after resting, joint pain during the day, absences from school and a limp in walking. Inflammatory bowel disease may be associated with these conditions in some cases. Children may not complain particularly about joint pain but rather they may allow a joint to become unused or limp, leading to disuse of the joint or joint contractures.

The type of juvenile chronic arthritis which has a system wide onset has typical symptoms of a fever which spikes regularly once or twice a day with the temperature going back towards normal in between the spikes. This is helpful diagnostically as infections do not behave in this way. A skin rash which lasts a few hours only may appear on the trunk and the limbs, the child may not be well and the larger joints may exhibit pain.

Jonathan Blood Smyth, editor of the Physiotherapy Site, writes articles about Physiotherapist, back pain, orthopaedic conditions, neck pain, injury management and Physiotherapists London. Jonathan is a superintendant physiotherapist at an NHS hospital in the South-West of the UK.

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