1
|
Kotecki M, Gietka P, Posadzy M, Sudoł-Szopińska I. Radiographs and MRI of the Cervical Spine in Juvenile Idiopathic Arthritis: A Cross-Sectional Retrospective Study. J Clin Med 2021; 10:5798. [PMID: 34945094 PMCID: PMC8704570 DOI: 10.3390/jcm10245798] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 12/05/2021] [Accepted: 12/08/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Juvenile idiopathic arthritis (JIA) is the most common rheumatic disease among children. In some patients, cervical spine arthritis remains a serious and chronic manifestation of JIA. The aim of this study was to assess the frequency of cervical spine lesions on radiographs and MRI in JIA patients with clinical signs of cervical spine involvement and to verify if with the addition of MRI, the use of radiographs could be abandoned. METHODS This retrospective study evaluated consecutive 34 children (25 girls; aged 6-18 years, median 15.5 years) with JIA and with clinical involvement of cervical spine. In each patient, both radiographs and MRI of the cervical spine were performed. Imaging findings were correlated with clinical and laboratory data. RESULTS The cervical spine was affected in 35% of patients. The most frequent lesions were subaxial subluxations (SAS; 24%), apophyseal joint ankylosis (9%), and C1/C2 joint lesions (9%). Anterior atlanto-axial subluxation (AAS) was diagnosed only by radiography, and most of the SAS were seen on radiography, whereas only a few on MRI. Reversely, C1/C2 soft tissue involvement were seen on MRI only. Cervical spine involvement was associated with raised ESR (p = 0.012) and CRP (p = 0.014). CONCLUSIONS The cervical spine lesions are still frequent complication of JIA affecting up to 35% of JIA patients. Most of them develop serious complications, such as AAS and ankylosis. Despite advantages of MRI in terms of the imaging of the atlanto-axial region radiography shows superiority in diagnosis of AAS and SAS.
Collapse
Affiliation(s)
- Mateusz Kotecki
- Department of Radiology, National Institute of Geriatrics, Rheumatology and Rehabilitation, 02-637 Warsaw, Poland;
| | - Piotr Gietka
- Department of Pediatric Rheumatology, National Institute of Geriatrics, Rheumatology and Rehabilitation, 02-637 Warsaw, Poland;
| | - Magdalena Posadzy
- Individual Private Practice Magdalena Posadzy, 61-426 Poznan, Poland;
| | - Iwona Sudoł-Szopińska
- Department of Radiology, National Institute of Geriatrics, Rheumatology and Rehabilitation, 02-637 Warsaw, Poland;
| |
Collapse
|
2
|
Huber AM, Ward LM. The impact of underlying disease on fracture risk and bone mineral density in children with rheumatic disorders: A review of current literature. Semin Arthritis Rheum 2016; 46:49-63. [PMID: 27020068 DOI: 10.1016/j.semarthrit.2016.02.003] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Revised: 10/16/2015] [Accepted: 02/20/2016] [Indexed: 11/17/2022]
Abstract
Childhood rheumatic diseases are associated with negative impacts on the skeleton, related to both the underlying illness and complications of therapy. The effects of medications like corticosteroids are well recognized, leading to reductions in bone mineral density and bone strength and concomitant increases in bone fragility and fracture risk. The impact of factors directly attributable to the underlying disease is not as well recognized. In this article, we review relevant literature to identify data which can contribute to an understanding of the impact of childhood rheumatic disease on the skeleton. We conclude that childhood rheumatic diseases are associated with reductions in bone mineral density and increased risk of vertebral and non-vertebral fractures. These data are strongest for juvenile arthritis, while conclusions are more limited for other rheumatic illnesses, like juvenile systemic lupus erythematosus or juvenile dermatomyositis, due to small numbers of patients studied. Finally, we make recommendations for areas in need of further research. These include the need for long-term longitudinal studies and for data to be collected in patients who have not been treated with corticosteroids.
Collapse
Affiliation(s)
- Adam M Huber
- Division of Pediatric Rheumatology, IWK Health Centre and Dalhousie University, 5850 University Ave, Halifax, Nova Scotia, Canada B3K 6R8.
| | - Leanne M Ward
- Division of Pediatric Endocrinology, Children׳s Hospital of Eastern Ontario and University of Ottawa, Ottawa, Ontario, Canada
| |
Collapse
|
3
|
Abstract
Juvenile idiopathic arthritis (JIA) is the most common chronic rheumatic disease in childhood. Persistent pain is the most common and distressing symptom of JIA, and pain in childhood arthritis is multifactorial. Children and adolescents with persistent pain due to JIA experience significantly more problems with physical, emotional, social, and school functioning than healthy individuals. Assessment of pain at each office visit is the cornerstone of effective pain management and should include an evaluation of pain intensity, interference, and coping. Following the biopsychosocial model of pain management, a multi-modal approach is recommended for pain control in children with arthritis. Pharmacologic strategies for the treatment of pain in JIA include aggressive treatment of the underlying disease as well as the use of acetaminophen and systemic and topical non-steroidal anti-inflammatory drugs for persistent mild pain. Opioids can be considered in the case of moderate to severe persistent pain. Physical therapies and psychological interventions such as cognitive behavioral therapy are also key components of pain management in JIA.
Collapse
|
4
|
Abstract of the 35th Scandinavian Congress of Rheumatology, September 20-23, 2014, Stockholm, Sweden. Scand J Rheumatol 2014:1-97. [PMID: 25184497 DOI: 10.3109/03009742.2014.946235] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
5
|
Coulson EJ, Hanson HJM, Foster HE. What does an adult rheumatologist need to know about juvenile idiopathic arthritis? Rheumatology (Oxford) 2014; 53:2155-66. [PMID: 24987157 DOI: 10.1093/rheumatology/keu257] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
JIA is the most common chronic inflammatory arthritis in children and young people and an estimated one-third of individuals will have persistent active disease into adulthood. There are a number of key differences in the clinical manifestations, assessment and management of JIA compared with adult-onset arthritis. Transition and transfer to adult services present significant challenges for many patients, their families and health care professionals. We describe key clinical issues relevant to adult rheumatology health care teams responsible for ongoing care of these young people.
Collapse
Affiliation(s)
- Elizabeth J Coulson
- Rheumatology Department, Freeman Hospital, Newcastle Hospitals NHS Foundation Trust and Musculoskeletal Research Group, Institute for Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Helen J M Hanson
- Rheumatology Department, Freeman Hospital, Newcastle Hospitals NHS Foundation Trust and Musculoskeletal Research Group, Institute for Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Helen E Foster
- Rheumatology Department, Freeman Hospital, Newcastle Hospitals NHS Foundation Trust and Musculoskeletal Research Group, Institute for Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK. Rheumatology Department, Freeman Hospital, Newcastle Hospitals NHS Foundation Trust and Musculoskeletal Research Group, Institute for Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK.
| |
Collapse
|
6
|
Brabnikova Maresova K, Jarosova K, Pavelka K, Stepan JJ. The association between lean mass and bone mineral content in the high disease activity group of adult patients with juvenile idiopathic arthritis. BMC Musculoskelet Disord 2014; 15:51. [PMID: 24558956 PMCID: PMC3974111 DOI: 10.1186/1471-2474-15-51] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2013] [Accepted: 02/12/2014] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND The study is aimed to evaluate body composition and bone status in adolescent and adult patients with active juvenile idiopathic arthritis (JIA) untreated with tumor necrosis factor alpha inhibitors. METHODS Adult patients (12 male and 19 female) with active JIA and 84 healthy age- and gender- matched controls were enrolled into the study. Body composition (tissue mass in grams, lean mass, fat mass and bone mineral content as a fraction of tissue mass) and areal bone mineral density parameters (aBMD) at the lumbar spine, proximal femur, femoral neck, distal radius and total body were assessed using dual energy x-ray absorptiometry (DXA), and correlated with clinical characteristics of the disease and physical performance tests. Disease activity was assessed using high-sensitivity C-reactive protein (hsCRP) and disease activity score 28 (DAS 28). Differences between the groups were tested by t-test, and One-way ANOVA. Correlations were assessed using the Pearson correlation coefficients and multiple linear regression analysis. Significances were counted at the 0.05 level. RESULTS In patients with clinically active JIA (DAS 28, 6.36 ± 0.64, hsCRP, 18.36 ± 16.95 mg/l), aBMD at all measured sites, bone mineral content (BMC) and lean mass were reduced, and fat mass was increased as compared with healthy controls. Significant negative correlations were observed between BMC and disease duration, use of glucocorticoids (GCs), and fat mass, respectively. A positive correlation was found between BMC and lean mass, and between the body fat fraction and the use of GCs. Using multiple linear regression analysis, lean mass was the only significant predictor of BMC of total body both in men and women, and of BMC of legs (only in men). Lean mass was also the only predicting factor of total proximal femur BMD and femoral neck BMD. No significant correlations have been determined among the body composition parameters and DAS 28 or hsCRP endpoints. CONCLUSIONS In adult patients with long-term active JIA, lean mass was the main determining factor of total body and leg BMC, and total proximal femur and femoral neck aBMD.
Collapse
|
7
|
Smith EMD, Foster HE, Beresford MW. Adding to complexity: comorbidity in paediatric rheumatic disease. Rheumatology (Oxford) 2012; 52:22-33. [PMID: 23024018 DOI: 10.1093/rheumatology/kes256] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Novel therapies including biologic agents offer paediatric rheumatologists significant opportunity to improve long-term prognosis for children with rheumatic disease. However, comorbidities related to the diseases themselves and their treatments pose specific challenges to be overcome. Prompt recognition and appropriate management will improve quality of life, effectiveness of treatment and overall prognosis. In this review, we discuss key areas of comorbidity frequently encountered in paediatric rheumatology including cardiovascular, renal, genito-urinary and visual comorbidity, bone health, drug-related issues and the influence of rheumatic disease on growth and puberty.
Collapse
Affiliation(s)
- Eve M D Smith
- Paediatric Rheumatology, Great North Children's Hospital, Queen Victoria Road, Newcastle Upon Tyne NE1 4LP, UK.
| | | | | |
Collapse
|
8
|
Rodd C, Lang B, Ramsay T, Alos N, Huber AM, Cabral DA, Scuccimarri R, Miettunen PM, Roth J, Atkinson SA, Couch R, Cummings EA, Dent PB, Ellsworth J, Hay J, Houghton K, Jurencak R, Larché M, LeBlanc C, Oen K, Saint-Cyr C, Stein R, Stephure D, Taback S, Lentle B, Matzinger M, Shenouda N, Moher D, Rauch F, Siminoski K, Ward LM. Incident vertebral fractures among children with rheumatic disorders 12 months after glucocorticoid initiation: a national observational study. Arthritis Care Res (Hoboken) 2012; 64:122-31. [PMID: 22213727 DOI: 10.1002/acr.20589] [Citation(s) in RCA: 91] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To determine the frequency of incident vertebral fractures (IVF) 12 months after glucocorticoid (GC) initiation in children with rheumatic diseases and to identify children at higher risk. METHODS Children with rheumatic diseases initiating GC were enrolled in a prospective observational study. Annual spine radiographs were evaluated using the Genant semiquantitative method. Spine areal bone mineral density (aBMD) was measured every 6 months. Clinical features, including cumulative GC dose, back pain, disease and physical activity, calcium and vitamin D intake, and spine aBMD Z scores, were analyzed for association with IVF. RESULTS Seven (6%) of 118 children (95% confidence interval 2.9-11.7%) had IVF. Their diagnoses were: juvenile dermatomyositis (n = 2), systemic lupus erythematosus (n = 3), systemic vasculitis (n = 1), and mixed connective tissue disease (n = 1). One child was omitted from the analyses after 4 months because of osteoporosis treatment for symptomatic IVF. Children with IVF received on average 50% more GC than those without (P = 0.030), had a greater increase in body mass index (BMI) at 6 months (P = 0.010), and had greater decrements in spine aBMD Z scores in the first 6 months (P = 0.048). Four (67%) of 6 children with IVF and data to 12 months had spine aBMD Z scores less than -2.0 at 12 months compared to 16% of children without IVF (P = 0.011). CONCLUSION The incidence of VF 12 months following GC initiation was 6%; most children were asymptomatic. Children with IVF received more GC, had greater increases in BMI, and had greater declines in spine aBMD Z scores in the first 6 months.
Collapse
Affiliation(s)
- Celia Rodd
- McGill University, Montreal, Quebec, Canada
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
9
|
Markula-Patjas KP, Valta HL, Kerttula LI, Soini IH, Honkanen VEA, Toiviainen-Salo SM, Mäkitie OM. Prevalence of vertebral compression fractures and associated factors in children and adolescents with severe juvenile idiopathic arthritis. J Rheumatol 2011; 39:365-73. [PMID: 22133619 DOI: 10.3899/jrheum.110305] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVE Vertebral fractures occur in patients with juvenile idiopathic arthritis (JIA), but data on their frequency and causes are scarce. Our cross-sectional study evaluated prevalence of compression fractures and associated factors in a high-risk pediatric population with severe JIA. METHODS Children and adolescents with a history of treatment-resistant polyarticular-course JIA for ≥ 5 years or systemic arthritis for ≥ 3 years were recruited. Clinical examination, dietary recall, laboratory measurements, bone mineral density (BMD) measurement by dual-energy X-ray absorptiometry, and spinal radiography were performed. RESULTS Our study included 50 patients (41 girls), of whom 6 (12%) had systemic arthritis, with a median age of 14.8 years (range 7.0-18.7 yrs) and median disease duration of 10.2 years (range 3.9-16.8 years). Ninety-four percent had used systemic glucocorticoids (GC); the median total duration of GC treatment was 7.1 years (range 0-15.5 yrs). The median weight-adjusted cumulative GC dose for the preceding 3 years was 72 mg/kg (range 0-911 mg/kg). The median bone age-corrected lumbar spine and whole-body areal BMD Z-scores were -0.8 and -1.0, respectively. Twenty-two percent had vertebral fractures, mostly thoracic. Compression fractures were associated with high disease activity, high body mass index (BMI), and high recent cumulative GC dose, but not with disease duration or BMD. Thirty percent had sustained at least 1 peripheral low energy fracture. Twenty-six percent were deemed to have significantly compromised bone health. CONCLUSION Severe JIA is associated with a significant risk of vertebral compression fractures. Associated factors include high disease activity, high BMI, and high recent GC exposure. Further studies are needed to establish optimal prevention and treatment guidelines.
Collapse
|
10
|
Thornton J, Pye SR, O'Neill TW, Rawlings D, Francis RM, Symmons DPM, Ashcroft DM, Foster HE. Bone health in adult men and women with a history of juvenile idiopathic arthritis. J Rheumatol 2011; 38:1689-93. [PMID: 21677004 DOI: 10.3899/jrheum.101232] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Our aim was to determine areal bone mineral density (BMD(a)) and disease-related factors linked with BMD(a) in adults with a history of juvenile idiopathic arthritis (JIA). METHODS Men and women with a history of JIA attending a young adult rheumatology clinic in Newcastle, UK, underwent dual energy x-ray absorptiometry (DEXA) of the lumbar spine and total hip. Information was obtained about disease duration and subtype, previous treatment including corticosteroid and methotrexate therapy, and large-joint replacement. Subjects completed the modified Health Assessment Questionnaire (HAQ). Blood was taken for assessment of C-reactive protein, erythrocyte sedimentation rate, and rheumatoid factor (RF). RESULTS Seventy-one women and 16 men, mean age 28.7 and 31.4 years, and mean disease duration 20.6 and 24.0 years, respectively, were studied. Mean BMD(a) was 0.982 (Z-score = -0.328; 95% CI -0.657, 0.001) and 1.028 g/cm(2) (Z-score = -0.251; 95% CI -1.266, 0.764) in women and men, respectively, at the spine and 0.817 (Z-score = -0.542; 95% CI -0.975, -0.109) and 0.857 g/cm(2) (Z-score = -0.176; 95% CI -2.323, 1.971) at the hip. After adjusting for age and sex, increasing HAQ score was associated with both lower spine BMD(a) and hip BMD(a). Compared with patients with oligoarticular disease, those with enthesitis-related arthritis had higher BMD(a) at the spine, while those with extended oligoarticular and polyarticular RF-negative disease had lower hip BMD(a). Oral corticosteroids and the presence of a large-joint replacement were associated with lower BMD(a) at both the spine and hip. CONCLUSION There was a trend toward low BMD(a) in women with a history of JIA. These patients may be at risk of the complications of osteoporosis including fragility fractures and should be considered for targeted preventive measures.
Collapse
Affiliation(s)
- Judith Thornton
- Arthritis Research UK Epidemiology Unit, The University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | | | | | | | | | | | | | | |
Collapse
|
11
|
Abstract
A number of studies published over the past 10 years have examined the long-term health, functional and quality of life outcomes of adults with childhood-onset rheumatic diseases such as juvenile idiopathic arthritis, systemic lupus erythematosus, juvenile dermatomyositis and localized scleroderma. As increasing numbers of patients with these conditions survive into adulthood, understanding the adult outcomes of these pediatric conditions has become ever-more important. Identifying modifiable risk factors for poor outcomes is vital to improving care for these patients. In addition, as these conditions and their treatments can affect cardiovascular health, bone health and fertility, particular attention needs to be paid to these outcomes. Preparing patients and their families for a successful transition from pediatric to adult rheumatology care is an important first-step in the long-term management strategy for this expanding patient population.
Collapse
|
12
|
Brabnikova Maresova K. Secondary osteoporosis in patients with juvenile idiopathic arthritis. J Osteoporos 2011; 2011:569417. [PMID: 21403891 PMCID: PMC3043287 DOI: 10.4061/2011/569417] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2010] [Accepted: 01/08/2011] [Indexed: 12/31/2022] Open
Abstract
Bone disease in patients with juvenile idiopathic arthritis (JIA) is associated with focal (joint erosion and juxtaarticular osteopenia) and systemic bone loss (generalized osteopenia or reduction of bone mass density). Pathophysiology of bone loss is multifactorial and involves particularly proinflammatory cytokines and deleterious effects of glucocorticoid therapy. Clinical studies in patients with JIA indicate excessive activation of osteoclastogenesis and reduction of bone formation. Reduction of physical activity, muscle atrophy caused by high disease activity, and compulsory restriction in movements are also associated with bone loss. In patients with JIA, the disease can be complicated by growth cartilage involvement and systemic or local growth retardation. In the absence of preventive measures, fragility fractures can occur even at an early age.
Collapse
Affiliation(s)
- Kristyna Brabnikova Maresova
- Institute of Rheumatology, Slupi 4, 128 50, Prague 2, Czech Republic,Department of Rheumatology, First Faculty of Medicine, Charles University in Prague, Kateřinská 32, 121 08 Prague 2, Czech Republic,*Kristyna Brabnikova Maresova:
| |
Collapse
|
13
|
Hämäläinen H, Arkela-Kautiainen M, Kautiainen H, Haapasaari J, Leirisalo-Repo M. Bone mineral content in young adults with active or inactive juvenile idiopathic arthritis and in controls. Scand J Rheumatol 2010; 39:219-22. [DOI: 10.3109/03009740903337885] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
14
|
Santiago RA, Silva CAA, Caparbo VF, Sallum AME, Pereira RMR. Bone mineral apparent density in juvenile dermatomyositis: the role of lean body mass and glucocorticoid use. Scand J Rheumatol 2008; 37:40-7. [PMID: 18189194 DOI: 10.1080/03009740701687226] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To analyse bone mineral density (BMD) in juvenile dermatomyositis (JDM) and its possible association with body composition, disease activity, duration of disease, glucocorticoid (GC) use, and biochemical bone parameters, including osteoprotegerin (OPG) and receptor activator of nuclear factor kappaB (RANKL). METHODS Twenty girls with JDM and 20 controls matched for gender and age were selected. Body composition and BMD were analysed by dual-energy X-ray absorptiometry (DXA) and bone mineral apparent density (BMAD) was calculated. Duration of disease, cumulative GC, and GC pulse therapy use were determined from medical records. Disease activity and muscle strength were measured by the Disease Activity Score (DAS), the Childhood Myositis Assessment Scale (CMAS), and the Manual Muscle Test (MMT). Inflammatory and bone metabolism parameters were also analysed. OPG and RANKL were measured in patients and controls using an enzyme-linked immunosorbent assay (ELISA). RESULTS A lower BMAD in the femoral neck (p<0.001), total femur (p<0.001), and whole body (p = 0.005) was observed in JDM patients compared to controls. Body composition analysis showed a lower lean mass in JDM compared to controls (p = 0.015), but no difference was observed with regard to fat mass. A trend of lower serum calcium was observed in JDM (p = 0.05), whereas all other parameters analysed, including OPG and RANKL, were similar. Multiple linear regression analysis revealed that, in JDM, lean mass (p<0.01) and GC pulse therapy use (p<0.05) were independent factors for BMAD in the hip region. CONCLUSIONS This study has identified low lean mass and GC pulse therapy use as the major factors for low hip BMAD in JDM patients.
Collapse
Affiliation(s)
- R A Santiago
- Department of Paediatrics, University of Sao Paulo, Brazil
| | | | | | | | | |
Collapse
|
15
|
Gannotti ME, Nahorniak M, Gorton GE, Sciascia K, Sueltenfuss M, Synder M, Zaniewski A. Can exercise influence low bone mineral density in children with juvenile rheumatoid arthritis? Pediatr Phys Ther 2007; 19:128-39. [PMID: 17505290 DOI: 10.1097/pep.0b013e318036a25e] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE Low bone mineral density (BMD) is a common secondary condition associated with juvenile idiopathic arthritis (JIA). The purpose of this review was evaluate the literature pertinent to designing an effective, safe weight-bearing exercise program to reduce the risk of low BMD in children with JIA. SUMMARY OF KEY POINTS Thirty-seven articles on the risk of low BMD and children with JIA, weight-bearing interventions to improve BMD in healthy children, or safety and efficacy of exercise interventions with children with JIA were critiqued on the basis of their design. Three highly rated studies confirmed the multifactorial nature of low BMD in children with JIA, two highly rated studies support the efficacy of weight-bearing interventions for increasing BMD in children who are healthy, and one moderately rated study demonstrated the safety of low impact exercise by children with JIA. STATEMENT OF CONCLUSIONS AND RECOMMENDATIONS FOR CLINICAL PRACTICE Weight-bearing activities should be included in exercise programs for individuals with JIA, although more research is needed to determine the amount, duration, and frequency of weight-bearing activity needed to reduce the risk for low BMD.
Collapse
|
16
|
Thornton J, Ashcroft DM, Mughal MZ, Elliott RA, O'Neill TW, Symmons D. Systematic review of effectiveness of bisphosphonates in treatment of low bone mineral density and fragility fractures in juvenile idiopathic arthritis. Arch Dis Child 2006; 91:753-61. [PMID: 16690698 PMCID: PMC2082926 DOI: 10.1136/adc.2006.093997] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/26/2006] [Indexed: 11/04/2022]
Abstract
AIMS To evaluate the currently available evidence for the effectiveness of bisphosphonates in children with low bone mineral density (BMD) and fragility fractures associated with juvenile idiopathic arthritis (JIA), and the safety of bisphosphonates in JIA and other conditions. METHODS Literature databases were searched using a structured search strategy. The effectiveness review included any studies of children with JIA treated with bisphosphonates. The safety review also included studies of osteogenesis imperfecta. Quantitative data analysis was not undertaken because of the heterogeneity of the studies; findings were summarised using tables and narrative synthesis. RESULTS Ninety four studies were identified. Sixteen studies (78 JIA children) were included in the effectiveness review: one randomised controlled trial, three controlled cohort studies, 11 case series, and one case report. At baseline, children had low BMD below the expected values for age and sex matched children. In all studies, treatment with bisphosphonates increased BMD compared with baseline: the mean percentage increase in spine BMD ranged from 4.5% to 19.1%. Overall, studies were heterogeneous and of variable quality. A total of 59 papers were included in the safety review; treatment durations were up to three years. The most common side effect was a flu-like reaction with intravenous treatment. This occurred during the first infusion and was transient; the symptoms were managed with paracetamol and did not occur during subsequent cycles. CONCLUSIONS Bisphosphonates are a promising treatment for low BMD and fragility fractures in children with JIA. However, the quality of the current evidence is variable and better studies are needed to more clearly assess their role.
Collapse
Affiliation(s)
- J Thornton
- Arthritis Research Campaign Epidemiology Unit, Division of Epidemiology and Health Sciences, University of Manchester, UK
| | | | | | | | | | | |
Collapse
|
17
|
Affiliation(s)
- Peter A Nigrovic
- Center for Adults with Pediatric Rheumatic Illness, Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, One Jimmy Fund Way, Smith 356, Boston, MA 02115, USA.
| | | |
Collapse
|
18
|
|
19
|
Lien G, Flatø B, Haugen M, Vinje O, Sørskaar D, Dale K, Johnston V, Egeland T, Førre Ø. Frequency of osteopenia in adolescents with early-onset juvenile idiopathic arthritis: a long-term outcome study of one hundred five patients. ARTHRITIS AND RHEUMATISM 2003; 48:2214-23. [PMID: 12905475 DOI: 10.1002/art.11097] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To determine the frequency of low bone mineral content (BMC) and low bone mineral density (BMD) as long-term complications in adolescents with early-onset juvenile idiopathic arthritis (JIA), and to identify disease variables, patient characteristics, and biochemical bone markers related to low bone mass. METHODS One hundred five (87%) of 121 adolescent patients with early-onset JIA (ages 13-19 years, 80 girls and 25 boys, mean age at onset of JIA 2.8 years), from a cohort first admitted to the hospital between 1980 and 1985, were assessed after a mean disease duration of 14.2 years. BMC and BMD of the total body, the lumbar spine at L2-L4, and the femoral neck were measured by dual-energy x-ray absorptiometry. Age- and sex-specific reference values from a pooled, healthy reference population were used to calculate Z scores. Low bone mass was defined as a Z score less than -1 SD. RESULTS Among the 103 adolescent JIA patients who underwent total-body imaging, 41% had low total-body BMC and 34% had low total-body BMD. Compared with adolescent JIA patients who had normal total-body BMC, those with low BMC had lower mean weight (P < 0.001), height (P < 0.001), lean mass (P < 0.001), and remission rates (P = 0.016), had longer duration of active disease (P = 0.013), had higher numbers of active and mobility-restricted joints (P < 0.001 and P = 0.001, respectively), had more disability (P = 0.011), had higher frequencies of joint erosions (P < 0.001), and had higher erythrocyte sedimentation rates (P = 0.033). In multiple linear regression analyses of total-body BMC, 88% of the variance was explained by the duration of active disease, the number of joints with restricted mobility, the bone area, urinary deoxypyridinoline values, age, weight, and height. CONCLUSION Forty-one percent of the adolescents with early-onset JIA had low bone mass >11 years after disease onset. The development of low total-body BMC was related to the duration of active disease, disease severity, measures of bone resorption, weight, and height.
Collapse
Affiliation(s)
- Gunhild Lien
- Department of Rheumatology, Rikshospitalet University Hospital, Oslo 0027, Norway.
| | | | | | | | | | | | | | | | | |
Collapse
|
20
|
Stewart WA, Acott PD, Salisbury SR, Lang BA. Bone mineral density in juvenile dermatomyositis: assessment using dual x-ray absorptiometry. ARTHRITIS AND RHEUMATISM 2003; 48:2294-8. [PMID: 12905484 DOI: 10.1002/art.11211] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To determine the bone mineral density (BMD) status of our juvenile dermatomyositis (DM) population and to compare the frequency of osteopenia in patients with active disease requiring corticosteroids with that in patients with inactive disease who are not receiving corticosteroids. METHODS Medical charts of all children diagnosed as having juvenile DM at our institution between 1989 and 1999 were reviewed for demographic and clinical data, including disease activity and duration of corticosteroid therapy. BMD measurements of the lumbar spine (L1-L4) were performed using dual x-ray absorptiometry (DXA). Z scores were calculated from the BMD data for comparison with published normative data. RESULTS A total of 15 patients were assessed: 10 with active disease, and 5 with inactive disease who had not taken corticosteroids for an average of 6.0 years (range 3.4-8.1 years). Baseline BMD measurements demonstrated osteopenia or frank osteoporosis in the majority of patients, including 6 of the 10 patients with active disease and 4 of the 5 patients whose disease was in remission. Fourteen patients had serial BMD measurements. Persistent or worsening osteopenia was documented in all patients who had ongoing active disease, except for 3 patients who had been treated with bisphosphonates because of vertebral compression fractures. CONCLUSION Osteopenia is common in patients with juvenile DM, and it usually worsens with ongoing disease. It can persist for many years after the disease enters remission. Bisphosphonates appeared to beneficially affect bone mineralization in our patients. Treatment to prevent the long-term complications of osteoporosis in patients with juvenile DM should be considered and requires further study.
Collapse
Affiliation(s)
- W A Stewart
- Izaak Walton Killam Health Centre, 5850 University Avenue, Halifax, Nova Scotia B3J 3G9, Canada
| | | | | | | |
Collapse
|
21
|
Abstract
Progress in achieving international consensus concerning the classification of juvenile idiopathic arthritis has been made, although further refinement and validation of these criteria is needed. It is hoped that this will facilitate more effective international collaboration in the study of these diseases, because much remains to be learned about genetic susceptibility, causation, pathogenesis, and treatment. Attention to the unique aspects of chronic arthritis in children such as impaired growth and macrophage activation syndrome may help to reduce disease-related morbidity and mortality. New biologic agents have substantially enhanced the treatment of JRA. The identification of reliable predictors of disease course and outcome is important in the rational and timely application of new therapies.
Collapse
Affiliation(s)
- Rayfel Schneider
- Division of Rheumatology, Department of Pediatrics, Hospital for Sick Children, 555 University Avenue, Room 8253, Toronto, ON M5G 1X8, Canada
| | | |
Collapse
|
22
|
Abstract
There is an increasing appreciation among physicians about the importance of bone health in children as a potential modifiable risk factor for development of osteoporosis later in life. Many unanswered questions about normal pediatric bone health make the treatment and clinical investigation of bone disease in children with chronic rheumatic diseases challenging. Understanding normal bone biology along with the epidemiology and diagnosis of osteoporosis is the key to the understanding of the potential for abnormal bone metabolism in the juvenile rheumatic diseases.
Collapse
Affiliation(s)
- C Egla Rabinovich
- Division of Pediatric Rheumatology, Department of Pediatrics, Duke University Medical Center, Box 3212, Durham, NC 27710, USA.
| |
Collapse
|
23
|
Oen K. Long-term outcomes and predictors of outcomes for patients with juvenile idiopathic arthritis. Best Pract Res Clin Rheumatol 2002. [DOI: 10.1053/berh.2002.0233] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
24
|
Cimaz R. Osteoporosis in childhood rheumatic diseases: prevention and therapy. Best Pract Res Clin Rheumatol 2002. [DOI: 10.1053/berh.2002.0236] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
25
|
Gafni RI, McCarthy EF, Hatcher T, Meyers JL, Inoue N, Reddy C, Weise M, Barnes KM, Abad V, Baron J. Recovery from osteoporosis through skeletal growth: early bone mass acquisition has little effect on adult bone density. FASEB J 2002; 16:736-8. [PMID: 11923218 DOI: 10.1096/fj.01-0640fje] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
It is often assumed that bone mineral accretion should be optimized throughout childhood to maximize peak bone mass. In contrast, we hypothesized that bone mineral acquisition early in life would have little or no effect on adult bone mass because many areas of the juvenile skeleton are replaced in toto through skeletal growth. To test this hypothesis, we induced osteoporosis by administering dexamethasone to 5-week-old rabbits for 5 weeks and then allowed them to recover for 16 weeks. Tibial bone mineral density (ash weight/volume) was decreased in the dexamethasone-treated animals at the end of treatment but recovered completely. Bone structure in the femur was assessed by histomorphometry. Trabecular and cortical bone in the distal metaphysis was made osteoporotic by dexamethasone, but was then replaced through endochondral bone formation and recovered. Periosteal bone formation rate in the diaphysis was decreased during dexamethasone treatment but afterwards rebounded above controls and normalized cortical width. Our data suggest that bone mineral acquisition early in life has little effect on adult bone density because the juvenile bone is largely replaced through growth. If this concept generalizes, then interventions to maximize peak bone mass should be directed at adolescents rather than young children.
Collapse
Affiliation(s)
- Rachel I Gafni
- Unit on Growth and Development, Developmental Endocrinology Branch, National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland 20892-1862, USA.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
26
|
Abstract
Bone mass is determined primarily by genetic influences, but exogenous factors may also play a major role. The prevention of osteoporosis can start at childhood. Optimal achievement of peak bone mass during childhood and adolescence is important to minimize future fracture risk. Chronic inflammatory diseases can have a detrimental effect on bone mass through a variety of mechanisms. Different diagnostic methods for detecting osteoporosis (eg, dual x-ray absorptiometry, quantitative computed tomography, ultrasounds) are in use or under investigation. New treatment options are available; among these, the use of bisphosphonates seems to be the more promising approach.
Collapse
Affiliation(s)
- R Cimaz
- Department of Pediatrics, ICP, Clinica Pediatrica, Via Commenda 9, 20122 Milano, Italy.
| | | |
Collapse
|
27
|
Abstract
Osteoporosis is characterized by loss of both bone mass and microarchitectural integrity, resulting in an increased risk of fractures with associated morbidity and mortality. Awareness of this condition is increasing in pediatrics, including pediatric rheumatology. Reduced bone mineral density is now well recognized in children and young adults with juvenile idiopathic arthritis and is multifactorial in origin. The problems of interpretation of bone analysis techniques during childhood and adolescence are highlighted. Recent studies have reported on the use of newer methods of imaging, including quantitative ultrasound and bone single photon emission computed tomography techniques. Attempting to disentangle the relative effects of disease activity, corticosteroids, nutrition, and physical activity in the development of osteoporosis in juvenile idiopathic arthritis is the focus of several studies. Finally, early optimistic reports of the use of bisphosphonates in juvenile idiopathic arthritis are welcome additions to the growing body of literature in this area.
Collapse
Affiliation(s)
- J E McDonagh
- Pediatric Rheumatology, Institute of Child Health, Birmingham Children's Hospital, Birmingham, United Kingdom.
| |
Collapse
|
28
|
Geusens P, Menten J, Vosse D, Vanhoof J, van der Linden S. Recovery from severe glucocorticoid-induced osteoporosis in an adolescent boy. J Clin Densitom 2001; 4:389-94. [PMID: 11748345 DOI: 10.1385/jcd:4:4:389] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2001] [Revised: 03/21/2001] [Accepted: 04/04/2001] [Indexed: 11/11/2022]
Abstract
An 18-yr-old boy presented with extreme back pain as the result of multiple vertebral fractures. At age 16 he had developed a tumor of the mesencephalon. A ventriculoperitoneal shunt was established surgically. One year later, he developed progressive neurologic deficits in his upper and lower limbs with an increase in the size of the tumor. He was treated by irradiation and high doses of glucocorticoids. Although the neurologic deficits progressively improved, he developed severe back pain resulting in complete immobilization for 3 mo in spite of neurologic recovery. Multiple vertebral fractures were diagnosed by X-ray. Bone density was extremely low (Z-score of -5.5 in the spine and -3.1 in the femoral neck). The patient was treated with calcium and vitamin D, calcitonin, bisphosphonates, physiotherapy, and progressive mobilization. Glucocorticoids were decreased and could be stopped as the neurologic deficits fully recovered. After 1 yr of treatment with intermittent i.v. pamidronate, bone density had increased by 40% in the spine and by 25% in the femoral neck despite growth arrest. He progressively recovered from back pain and is now, at age 20, fully ambulant, studying mechanical engineering, without neurologic sequelaes and free of glucocorticoids. Magnetic resonance imaging revealed that the tumor had disappeared. This case proves that treatment of symptomatic glucocorticoid-induced osteoporosis during puberty can be rewarding, even when multiple and invalidating vertebral fractures already exist.
Collapse
Affiliation(s)
- P Geusens
- Biomedical Research Institute, Limburg University Centre, Diepenbeek, Belgium.
| | | | | | | | | |
Collapse
|