The State of Research on Complementary and Alternative Medicine in Pediatric Rheumatology

Effect of joint hypermobility on outcomes of children with juvenile idiopathic arthritis

BACKGROUND

Juvenile idiopathic arthritis (JIA) is common in pediatric rheumatology. Despite treatment, many patients experience persistent disease activity. Joint hypermobility (JH), defined by an excessive range of motion across multiple joints, is prevalent in children and adolescents and may influence disease outcomes in JIA.

OBJECTIVE

This study examines the impact of JH on symptoms in youth and young adults with JIA.

METHODS

Data were obtained from the PR-COIN network and included patients under 21 years old with a diagnosis of JIA. Patients with JIA and JH were matched with those having JIA-only based on age, sex assigned at birth, JIA subtype, and medication exposure. Clinical data, including disease activity measures, patient well-being, and pain ratings, were collected at baseline and follow-up visits.

RESULTS

The sample included 420 patients with JIA + JH and 2100 with JIA only. The JIA + JH group exhibited higher disease activity at baseline, more active arthritis joints, elevated physician global assessment of disease activity scores, and worse patient-reported well-being. These differences persisted over time. The JIA + JH group had a 19-20% greater likelihood of maintaining high disease activity scores and worsening over subsequent visits, indicating a significant impact of JH on disease progression.

CONCLUSION

JH in youth with JIA is associated with higher and persistent disease activity, suggesting that JH significantly contributes to the disease burden in patients with JIA and should be considered in treatment strategies. Future research should further explore the mechanisms by which JH influences disease activity and investigate comprehensive management approaches to improve outcomes for this population. Key Points • Children with JIA and joint hypermobility (JH) exhibit significantly higher disease activity at baseline compared to those with JIA only, including more active arthritis joints and elevated physician global assessment scores. • The presence of JH in JIA patients is associated with poorer patient-reported well-being and higher overall disease activity scores, which persist over time despite treatment. • JIA + JH patients have a 19-20% greater likelihood of maintaining high disease activity and worsening over subsequent visits, indicating a significant impact of JH on disease progression. • The study suggests that JH should be considered an important clinical factor in the management of JIA, with targeted interventions needed to address the increased disease activity and improve overall patient outcomes.

A systematic review and meta-analysis focusing on the use of ayurvedic medicine in cerebral palsy

Integrative practices have been incorporated into palliative care to provide holistic and multidimensional care for patients. This study aims to identify the scope of integrative practices, specifically whole medical systems, and demonstrate its safety and efficacy, specially in children with cerebral palsy. Key databases, including Embase, Cochrane, Medline/PubMed, Scopus, Google Scholar, Lilacs and Scielo were searched using specific terms. Only randomized and non-randomized clinical trials were included for meta-analysis purposes. Case-control, cohort, cross-sectional or retrospective observational studies were also included for the systematic review. Participants included children aged 0-18 years receiving palliative care for cerebral palsy and undergoing Ayurvedic Medicine practices. Descriptive analysis was conducted, including data such as year; author; design; sample size; intervention and comparison; outcomes and conclusion. Two interventional studies compared Ayurvedic practices with each other or with physiotherapy in children with cerebral palsy. The meta-analysis demonstrated an improvement in spasticity for children using Ayurvedic medicine. However, there were limitations in terms of heterogeneity in interventions, control groups, and assessed outcomes. Integrative practices, including Ayurvedic medicine have the potential to improve quality of life, manage disease symptoms and provide emotional support. However, more robust evidence is needed to support their widespread use. The use of Ayurvedic medicine showed evidence of improvement in spasticity for children with cerebral palsy. REGISTRATION NUMBER: Prospero CRD 42020198399.

Complementary and alternative medicine for children with sickle cell disease: A systematic review

BACKGROUND

Complementary and alternative medicine (CAM) is a popular alternative to opioid and other analgesics in sickle cell disease (SCD). We review the effectiveness, prevalence, and factors associated with CAM use in the pediatric SCD population.

METHODS

The review protocol was created based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A literature search was conducted in MEDLINE, Embase, Cochrane Library, PubMed, and Web of Science.

RESULTS

Twenty-four studies were examined. The prevalence of CAM use in pediatric patients with SCD ranged from 36 to 84.5%. Common inpatient CAM interventions were yoga, virtual reality, and acupuncture, which decreased pain scale scores. Outpatient CAMs were consisted of cognitive behavioral therapy, massage therapy, and guided-imagery, which increased pain tolerability and decreased pain scale scores.

CONCLUSIONS

CAM modalities can decrease pain scale scores. However, the impact of specific CAM modalities on emergency department visits, hospitalizations, and school absences were inconclusive.

Teaching Acupuncture: The Brazilian Medical Residency Programme

Acupuncture has had a successful story in Brazil. With its use in the public health system supported by legislation since 1988, its recognition as a medical specialty in 1995 enabled the introduction of an annual board examination and the creation of an official Medical Residency Programme. Since then, medical acupuncture has developed considerably, mostly through its massive spread into the Brazilian public health system. Brazil is the only country outside China that has created a Medical Residency Programme on Acupuncture. The 2-year programme consists of 5760 training hours, beginning with major clinical areas (internal medicine, neurology, orthopaedics and gynaecology) during 24 weeks in the first year. The residents study and practice acupuncture using the traditional Chinese Medicine approach and also the biomedical model. Specialists educated by this programme are therefore expected to have an optimum knowledge of both Western and Eastern medicine. Since it was first created, nine public health institutions have adopted the residency programme on acupuncture so, rather than being an alternative therapy, acupuncture has become an easily accessible and well-accepted conventional medical resource in Brazil.

General Nutrition and Fitness for the Child with Rheumatic Disease

As a result of new medications and therapeutic approaches, most children with rheumatic diseases are no longer at risk for growth failure which results from chronic inflammation and prolonged corticosteroid treatment. However, obesity, poor nutrition, and insufficient exercise are still problems which increase risks for poor bone, cardiovascular, and general health. Diet should be monitored and modified as appropriate; supplemental calcium and Vitamin D should be provided. Obesity and poor physical fitness can be ameliorated by an exercise program that should become part of a more healthy lifestyle.

Current Treatment Options for Peripheral Nerve Hyperexcitability Syndromes

PURPOSE OF REVIEW

Peripheral nerve hyperexcitability (PNH) syndromes are divided into primary and secondary groups based on the presence or absence of demonstrable peripheral nerve disease. In this review, we systematically evaluate the evidence for current therapies and supportive managements based on autoimmune, paraneoplastic, and genetic components in pathophysiology reported in the literature.

RECENT FINDINGS

Current therapy options are based on symptomatic management as well as focusing the underlying immune/genetic/paraneoplastic pathology by immunosuppressants, chemotherapy, and surgery. Further research is desired to provide treatment options geared specifically towards addressing PNH. Supportive care can also be an area for future research.

Assessment and management of pain in juvenile idiopathic arthritis

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.

Acupuncture for Pediatric Pain

Chronic pain is a growing problem in children, with prevalence as high as 30.8%. Acupuncture has been found to be useful in many chronic pain conditions, and may be of clinical value in a multidisciplinary treatment program. The basic principles of acupuncture are reviewed, as well as studies exploring basic mechanisms of acupuncture and clinical efficacy. Conditions commonly treated in the pediatric pain clinic, including headache, abdominal pain, fibromyalgia, juvenile arthritis, complex regional pain syndrome, cancer pain, as well as perioperative pain studies are reviewed and discussed. Areas in need of further research are identified, and procedural aspects of acupuncture practice and safety studies are reviewed. Acupuncture can be an effective adjuvant in the care of pediatric patients with painful conditions, both in a chronic and an acute setting. Further studies, including randomized controlled trials, as well as trials of comparative effectiveness are needed.

Complementary and alternative medicine use in adolescents with inflammatory bowel disease and juvenile idiopathic arthritis

Background

The use of complementary alternative medicine (CAM) is potentially prevalent among paediatric patients with chronic diseases but with variable rates among different age groups, diseases and countries. There are no recent reports on CAM use among paediatric patients with inflammatory bowel disease (IBD) and juvenile idiopathic arthritis (JIA) in Europe. We hypothesized that CAM use associates with a more severe disease in paediatric IBD and JIA.

Methods

A cross-sectional questionnaire study among adolescent outpatients with IBD and JIA addressing the frequency and type of CAM use during the past year. The patients were recruited at the Children’s Hospital, University of Helsinki, Finland.

Results

Of the 147 respondents, 97 had IBD (Crohn’s disease: n = 46; median age 15.5, disease duration 3.4 years) and 50 had JIA (median age 13.8, disease duration 6.9 years). During the past 12 months, 48% regularly used CAM while 81% reported occasional CAM use. Compared to patients with JIA, the use of CAM in IBD patients tended to be more frequent. The most commonly used CAM included probiotics, multivitamins, and mineral and trace element supplements. Self-imposed dietary restrictions were common, involving 27.6% of the non-CAM users but 64.8% of all CAM users. Disease activity was associated with CAM use in JIA but not in IBD.

Conclusions

CAM use is frequent among adolescents with IBD and JIA and associates with self-imposed dietary restrictions. Reassuringly, adherence to disease modifying drugs is good in young CAM users. In JIA, patients with active disease used more frequently CAM than patients with inactive disease. As CAM use is frequent, physicians should familiarise themselves with the basic concepts of CAM. The potential pharmacological interaction or the toxicity of certain CAM products warrants awareness and hence physicians should actively ask their patients about CAM use.

Considerations for use of acupuncture as supplemental therapy for patients with allergic asthma

This study examines the clinical and immunomodulatory effects of acupuncture in the treatment of patients with allergic asthma. The acupuncture points GV14, BL12, and BL13 were selected based on the theory of traditional Chinese medicine in treating asthma. Manual acupuncture was performed once every other day (three times per week) for 5 weeks. The needles were twisted approximately 360° evenly at the rate of 60 times/min for 20 s, manipulated every 10 min and withdrawn after 30 min. Concentrations of sIgA and total IgA in secretions were determined by the combination of sucrose density gradient ultracentrifugation and RIA. Levels of cortisol in the plasma were measured by RIA. Total IgE in the sera was examined by ELISA. Flow cytometry was used to detect the numbers of CD3+, CD4+, CD8+, and IL-2R + T lymphocytes in the peripheral blood. The absolute and differential numbers of eosinophils in peripheral blood were counted with eosin staining. The total efficacy of the acupuncture treatment in patients with allergic asthma at the end of one course of treatment was 85 %. After treatment, the concentrations of sIgA and total IgA in the saliva (P<0.01, P<0.02) and nasal secretions (P<0.02, P<0.02) were significantly decreased in patients with allergic asthma. The levels of total IgE in sera (P<0.001), the counts of IL-2R + T lymphocytes (P<0.001), and the absolute and differential numbers of eosinophils (P<0.01, P<0.01) in the peripheral blood were also significantly decreased. The numbers of CD3+, CD4+, and CD8+ T lymphocytes in the peripheral blood were significantly increased in the allergic asthmatics treated by acupuncture (P<0.001, P<0.01, and P<0.001, respectively). The concentration of cortisol in the plasma of asthmatic patients did not change significantly after the acupuncture treatment (P>0.05). Acupuncture has regulatory effects on mucosal and cellular immunity in patients with allergic asthma and may be an adjunctive therapy for allergic asthma.