Working Together to Help Children with Juvenile Idiopathic Arthritis

Lori B. Tucker, M.D.Clinical Associate Professor in Pediatrics

Division of Rheumatology BC Children’s Hospital

Vancouver BC

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To provide general background about juvenile idiopathic arthritis (JIA).

To establish relevance of JIA Module for family physicians.

To review key material in the JIA Module.

Objectives for This Talk

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Improve the early recognition of juvenile arthritis.

Provide clinicians with tools to assist in the diagnosis of MSK complaints in children.

Suggest pathways for referral of children with MSK complaints when needed, and increase awareness among GPs of accessibility of care for children and teens with arthritis in BC.

Goals for the JIA MSK Module

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11 year old girl, living in a rural community in BC

Develops gradual stiffness in fingers, wrists and knees, with increasing pain.

No swelling is seen.

Unable to play the violin, difficulty with writing at school.

Seen in local ER and walk in several times.

Investigation done….and told everything was normal.

› Xrays; ANA, RF, ESR done…….

8 months after symptom onset, grandparents take her to their family dr.

Urgent referral to pediatric rheumatology is placed.

Patient is seen in 3 weeks- dx: polyarticular JIA

Active joint count 18; unable to make a fist.

A true story……MC

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FP ER/walk-in

Paeds RheumOrtho

Paed Rheum

Patient

Other

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What is Juvenile Idiopathic Arthritis?

Most common childhood chronic disease causing disability.

About 7/100,00 newly diagnosed children with JIA per year.

Prevalence about 1/1,000 children = 1,000 children in BC with JIA.

7 subtypes.

Disease begins at any time during childhood or adolescence.

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Child under 16 years old

At least one joint with objective signs of arthritis:

› Swelling, or two of the following: pain with movement, warmth of the joint, restricted movement, or tenderness

Duration of more than 6 weeks

Other causes have been excluded (ex. Infections, Lupus and other connective tissue diseases, malignancies)

Juvenile Idiopathic Arthritis

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Have you seen a case of JIA or other autoimmune disease in a child?

Have you seen a child with a limp or MSK pain?

Why do I need to learn about JIA? I will never see a case of this…….

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81% of Canadians say they know almost nothing about JIA.

Only 30% had ever seen, read, or heard anything about JIA.

› Compared with 45-70% for other chronic conditions such as asthma, cancer, diabetes, HIV, CF, cerebral palsy, heart conditions.

Ipsos-Reid, 2010

Few know that JIA even exists….

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All kids with JIA have fevers.

All kids with JIA have rashes.

A child with joint pain (but no arthritis) must have JIA.

All arthritis is painful.

If a child has a positive rheumatoid factor, they must have arthritis.

If x-rays are normal, there is no arthritis.

Common Diagnostic Myths About Arthritis in Childhood……

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The JIA Module:Helping you with Diagnostic Pathway

Child with MSK complaint presents to GP office

Child with MSK complaint presents to GP office

Medical historyPhysical examination

Red Flags??Laboratory testing and imaging

as indicated

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Assess general health status.

Child friendly approach.

Do a complete physical examination.

All joints should be examined, even if complaints are referred to only one.

Keep developmental norms in mind.

Physical Examination of the Child with an MSK Problem

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Child is unwell.

› Fever, weight loss, weakness

Bone pain or night pain.

Regression of motor milestones.

Significant functional disability.

› Child not ambulating

› Child missing school or activities

Watch for Red Flags

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Evidence based screening MSK assessment for school aged children based on the adult GALS (Gait, Arms, Legs, Spine) screen

Validated with excellent sensitivity and specificity

Basic clinical maneuvers completed in an average of 2 minutes

http://www.arthritisresearchuk.org/health-professionals-and-students/video-resources/pgals.aspx

Foster HE. Arthritis Care Res 2006.55:709-716.

What is pGALS?

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pGALS Screening QuestionsAny Pain? Right knee

Any Difficulty Dressing? No

Any Difficulty Walking? Yes

Appearance Movement

Gait Normal

Arms Normal Normal

Legs Abnormal Abnormal

Spine Normal Normal

Documentation of pGALS Screen

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Gait Observe the child walking and turning

The pGALS Screen

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The pGALS Screen

Arms

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The pGALS Screen

Legs

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The pGALS Screen

Spine

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Child or teen with joint pain, swelling, stiffness, or

dysfunction which has lasted more than 2 weeks and is

unrelated to trauma.

Child with signs and symptoms suggestive of a generalized

connective tissue disease or autoimmune condition.

› Systemic lupus, dermatomyositis, vasculitis, periodic

fever syndromes

When to Refer to a Pediatric Rheumatologist……

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General pediatric evaluation is

often an excellent interim

step.

What if you are not really sure….

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Vancouver:

› David Cabral, Lori Tucker, Jaime Guzman, Kristin Houghton, Kim Morishita, Ross Petty

› Pediatric physiotherapist, occupational therapist

› Social worker

› Pediatric rheumatology nurses Penticton:

› Katherine Gross, M.D.

› Nurse and physio/OT Victoria:

› Roxana Bolaria M.D.

› Nurse and physio/OT

Where can I refer my patients for help?Pediatric Rheumatology Teams in BC

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What about when my patient does have JIA?

Work together as partners to provide care.

› Assist in arranging community services.

› Administer injectable medications i.e. methotrexate

› Monitor for side effects of medications.

› Assist parents with school issues if necessary.

› Provide immunizations, or modify schedule as outlined by pediatric rheumatology team.

Thank you

Questions