The fewer joint affected type of arthritis (oligoarticular) is characterised by having four or fewer joints affected, with the larger joints more typically affected such as the knees and ankles. These children usually appear well even though they may limp on walking. If only one hip seems affected this is very unusual for this type of arthritis and a different condition such as Perthes disease should be suspected. If the joints, such as the knees, are affected over a long period then the large extensor muscles of the thighs can weaken and waste, with tight hamstrings leading the flexion contractures of the knees. If the legs are affected asymmetrically then the length of the legs can develop a discrepancy.

With a larger number of joints affected, a minimum of five or more, the child has the many joint or polyarticular form of arthritis, with typically joints affected on both sides, a so called symmetrical involvement. A mild fever may be present and there can be significant muscle weakness and limitation of normal functioning if the joints have a severe limitation in their ranges of motion. A complete physical examination of the patient is vital to ensure that the diagnosis is juvenile arthritis, in what areas the physical limitations exist and which type of arthritis the patient is suffering from.

Settling on the diagnosis of juvenile arthritis depends on a joint showing an effusion which is the presence of inflammatory fluid within the joint, along with other symptoms and signs such as warmth, redness, limited range of motion and pain. Some joints may have an effusion which is not apparent such as the hip, but they can still show limited movement of the joint and pain. It may not be possible to establish the diagnosis of juvenile arthritis as the fever and rashes may come on initially without the arthritis at the time, with the arthritis appearing later by several months. Enlargement of lymph nodes and the liver and tenderness of muscles may be evident.

In the many jointed polyarticular form of juvenile arthritis the weight bearing joints are typically affected in a symmetrical pattern, as are the small joints of the hand. There may be loss of the articular cartilage with areas of cartilage erosion and in some cases a fusion across the joint, with thickening of the synovial membranes and effusions within the joints. Long term changes in a joint which is arthritic can include partial dislocation, joint stiffness and contractures, bony enlargement and deformities, especially of the fingers. Other findings can be loss of bone stock around the joints and narrowing of the joint spaces due to cartilage loss.

A reduction of extension in the neck may not produce any symptoms but it is important to identify this as it can indicate arthritic changes in the cervical spine which can lead to partial dislocation (subluxation) of the upper neck bones, a potentially dangerous situation. The neck bones can also fuse together along the posterior structures. The jaw joints, the tempero-mandibular joints, may also be affected and lead to reduced amount of growth in the lower jaw with inability to open the mouth as wide as normal. There may also be involvement of the eyes in the inflammatory process.

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.

These patients do not routinely require surgical care although steroid injections into some joints can be useful. Knee and hip arthritis in polyarticular arthritic patients may be managed by joint replacement once bone growth has ceased at skeletal maturity. Resting for long periods is unhelpful and patients should be encouraged to keep active for a better end result.

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

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Juvenile Rheumatoid Arthritis is the commonest rheumatological disease which occurs in children and one of the commonest child chronic diseases. It covers a number of individual disorders which all have chronic joint inflammation in common. The causes of these conditions are not apparent and the underlying genetic reasons are complicated in that different types of arthritis cannot easily be distinguished. Juvenile idiopathic arthritis is gradually becoming more widely used, indicating the unknown reasons for this condition.

Three main divisions of juvenile rheumatoid arthritis can be described, that affecting many joints which is called polyarticular, that involving few joints and termed pauciarticular and a more body wide disease onset known as systemic arthritis. The arthritis is a chronic disease which flares up at times and then goes into remissions, with targeting of the medical treatment towards the induction and maintenance of a remission. Recent advances in the development of drugs have produced the biological agents which are much more effective for arthritic diseases.

The triggering factors for juvenile rheumatoid arthritis have not been clearly identified, with a possible trigger of trauma or infection developing an autoimmune attack against joint tissues. The synovial lining of the joint increases in bulk and develops chronic inflammation, with perhaps some genetic vulnerability contributing to this process. A group of genes are understood to be involved in the pattern of disease presentation and the nature of its onset. There are many factors which influence the incidence of these types of arthritic diseases, such as how susceptible individuals are and the population types involved.

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.

In terms of age, the few joint (oligoarticular) type occurs most commonly in children of two to four years in age, while the many joint (polyarticular) peaks at one to four years and also at six to twelve years. The systemic type can occur right through the childhood years. The division of juvenile chronic arthritis that a child belongs in is determined by the pattern of onset of the disease over the first six months. If four joints or fewer are involved then the child is classified into the oligoarticular chronic arthritis group. If a child has more than five joints affected in the six month period then they are recognised as being in the polyarticular type. The type which presents with a systemic onset comes on with the arthritis, fever and rashes.

If a diagnosis of juvenile arthritis of some form is to be made then the patient should have arthritis of some of their joints for at least six weeks. Stiffness in the morning or after periods when the joint has been kept still is a typical complaint. The start of the disease can be very sudden and dramatic or may come on slowly over some time, with common symptoms including stiffness of the joints as mentioned, joint pain in the day, periods of absence from school and a limping gait. Some patients also suffer from inflammatory disease of the bowel. A child may not always report actual pain in a joint but instead they may just allow the joint to go unused and develop atrophy or a joint contracture.

In the systemic form of juvenile arthritis the child suffers from fevers which spike once or twice a day at around the same time, the temperature typically returning back to normal each time. This pattern is different from infections so helps to distinguish what the patient is suffering from. These patients usually show a short lasting rash over the trunk and limbs, joint pain often in the bigger joints and appear to be unwell.

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

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Hampstead Heath this morning was beautiful but treacherous and all of a sudden, as is usual with such things, I fell over on the ice. One minute I was walking along chatting and the next minute I was on my bottom as my wrist, forearm, shoulder and buttock took a bash. I slid sideways fast in the fall, thereby distributing the blow to several parts of my body and reducing its impact, entirely by luck. So I escaped joining the legions of people who, over the UK Christmas festivities, suffered a fall as the weather managed to concoct a particularly tricky combination of sub-zero temperatures and sharp showers.

The increasing and continual ageing of the populations of many countries throws up many challenges around falls which are important and independent of the weather. We learn very early to keep our balance when walking or running and take it for granted ever since, forgetting that this skill relies on functional abilities which typically reduce as we age. Within elderly populations the issue of falls is increasing in importance as falls take up many medical and surgical resources and are risky in terms of individual independence. The clinical work and costs which result from large numbers of falls is an issue in many medical systems in the world.

We need a variety of both physical and mental skills to manage to maintain our physical state of equilibrium when conditions become challenging. As we age our limb muscles gradually lose their strength and we use less and less of our potential joint movements as we walk. Older people gradually adopt a more restricted gait as they increase the number of shorter steps and decrease the amount of joint movement they employ in each gait cycle. If keeping balance suddenly needs a much bigger joint movement this may not be possible any longer or they may not be able to perform the movement in time to complete the required task.

One of our vital abilities is that which tells our brains continually where the segments of our limbs and trunk are located and whether they are moving in a certain direction. This is joint position sense or proprioception and is essential for normal movement and posture. Losing this sense or more widespread sensation loss from part of or a whole leg stops critical information getting to the brain, meaning it is unable to plan the next movement as it is unsure where the limb is to start with. Function can be more severely affected by loss of position sense than by weakness as people cope with weakness if they have good position sense.

Central nervous system abilities which contribute strongly to the ability to maintain balance whilst moving about include vision, balance pathways, coordination systems and cognitive systems such as understanding and logical thought. Good vision is very important as it alerts us to the changing nature of the terrain we are facing and enables us to judge which movements we need to make and whether these movements are being effective in reducing the risk of falling. Closing our eyes makes our balance significantly worse and loss of some vision combined with poor joint position awareness can lead to a very vulnerable state.

To achieve the correct reactions to balance challenges demands various brain systems to be working effectively as the balance organs and the eyes provide the required input. Loss of accurate input from the balance organs of the ears can cause problems or make a person dizzy on movement of the head and so make falling more likely from loss of balance. As we age our neural abilities reduce in efficiency and the cerebellar part of the brain which deals with coordination can also suffer from this process.

Awareness of what is around us in our environment is vital in permitting us to make the quick and correct decisions to keep our balance. Being alert to what is going on means we can make early plans for managing the presenting circumstances such as other people’s actions, sudden obstacles and wet or slippery surfaces. Maintaining our minds in a mentally active and alert state allows integration of complex information and the formulation of plans to keep our balance.

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

Tags: Alternative medicine, back injury, back pain, back pain relief, Frozen Shoulder, Health, injury management, pain management, physical fitness, physiotherapists, physiotherapy, Piriformis Syndrome, sciatica