|Year : 2022 | Volume
| Issue : 1 | Page : 1-7
Physiotherapy for juvenile rheumatoid arthritis: A systematic review
Radha Bhende1, Sandeep B Shinde1, Ravindar V Shinde2
1 Department of Musculoskeletal Sciences, Krishna College of Physiotherapy, KIMSDTU, Karad, India
2 Department of Microbiology, Krishna Institute of Medical Sciences, “Deemed To Be University”, Karad Malkapur (Dist. Satara), Maharashtra, India
|Date of Submission||17-Mar-2022|
|Date of Acceptance||10-May-2022|
|Date of Web Publication||12-Aug-2022|
Dr. Sandeep B Shinde
Department of Musculoskeletal Sciences, Krishna College of Physiotherapy, Krishna Institute of Medical Sciences, “Deemed To Be University,” Karad Malkapur, Karad (Dist. Satara), Maharashtra
Source of Support: None, Conflict of Interest: None
Juvenile Rheumatoid Arthritis(JRA) is defined as a heterogeneous group of chronic inflammatory arthritis that begins at childhood usually below age of 16 years. The severity of the damaged joints increases as the kid gets older, and the possibility that the condition will become dormant also decreases. The treatment program for an Juvenile Rheumatoid Arthritis child has to be individualized and likewise requires a team approach. Physiotherapy management for such an individual will provide symptomatic relief and will also prevent long- term complications of the same. Hence the purpose of this article is to review the literature on the role of Physiotherapy in Juvenile Rheumatoid Arthritis. We performed a narrative review on the role of physiotherapy in Juvenile Rheumatoid Arthritis and discuss the evidence-based studies. For the purpose of the review, an electronic search for relevant articles using PUBMED, MEDLINE, Pedro, Research Gate, Google Scholar and CINHAL databases up to September 2021 was done wherein MeSH search terms and free words were used. In addition to the electronic search, articles were searched manually for relevant studies. Articles were selected based on authors expertise, self- knowledge and reflective practice. Articles published on an online electronic database were included. We included studies published the studies which included physiotherapy as a choice of treatment. The current study included 11 articles that fulfilled the inclusion criteria suggesting that physiotherapy does a have major role in treating the individuals with Juvenile Rheumatoid Arthritis. The above reviewed studies provided evidence that physiotherapy as a mode of treatment is definitely effective in Juvenile Rheumatoid Arthritis.
Keywords: Aquatic therapy, juvenile rheumatoid arthritis, massage therapy, physiotherapy
|How to cite this article:|
Bhende R, Shinde SB, Shinde RV. Physiotherapy for juvenile rheumatoid arthritis: A systematic review. J Ayurveda Homeopath Allied Health Sci 2022;1:1-7
|How to cite this URL:|
Bhende R, Shinde SB, Shinde RV. Physiotherapy for juvenile rheumatoid arthritis: A systematic review. J Ayurveda Homeopath Allied Health Sci [serial online] 2022 [cited 2023 Sep 29];1:1-7. Available from: http://www.dpujahas.org/text.asp?2022/1/1/1/353695
| Introduction|| |
“Juvenile rheumatoid arthritis” (JRA) refers to a diverse collection of chronic inflammatory arthritides that begin in childhood and differ from adult rheumatoid arthritis. The age of onset is defined as before the age of 16, and the arthritis would last at least 6 weeks in at least one joint.,
Juvenile Rheumatoid Arthritis is classified into three types: namely Poly-articular where there is symmetric involvement of 5 or more joints like wrist, upper cervical spine or temporomandibular joint and systemic features are usually mild fatigue, low grade fever and occurs either in Rh +ve or Rh -ve individuals. Next one is the Pauciarticular where there is asymmetric involvement of less than 5 joints and mostly involvement of large joints is seen. Lastly the systemic type which is characterized by high spiking fever (104–105° F) for one or more weeks. A centripital Salmon-colored macular rash that covers the trunk and proximal extremities is also prevalent. Lymphedema and splenomegaly are common in these people, but joint involvement is very minimal.
Arthritis is one of the most common clinical manifestations seen in individuals with Juvenile Rheumatoid Arthritis. Joint discomfort, warmth, painful motions and soreness and also morning stiffness are the most common symptoms of arthritis. Another clinical manifestation seen is the anterior atlantoaxial subluxation and impaction in cervical spine wherein eventually, scoliosis develops. Commonly seen deviations in the body are genu valgum, femoral anteversion, tibial torsion and pes cavus.
The treatment program for a Juvenile Rheumatoid Arthritis child has to be individualized and requires a team-approach. Current status in the terms of management of Juvenile Rheumatoid Arthritis states that physiotherapy treatment is a treatment of choice in such individuals. Certain randomized clinical trials have consistently shown that physical therapy has been effective in reducing the muscle spasms, joint pain, improving Range of Motion (ROM) and quality of life in Juvenile Rheumatoid Arthritis.,, Whereas some studies have commented about the specific exercise programs in the form of resistance and strength training, aquatic therapy or massage therapy which have been proven beneficial.,,,,, On the other hand there are studies focusing on the physical activity and effects of exercise on physical activity in such patients.,,
Physical inactivity is highly seen in patients with JRA which in turn aggravates the atrophy,muscle weakness, muscle dysfunction, motor-control disturbance,obesity, chronic fatigue, mood disorders, bone resorption, dyslipidemia. Also on the the other hand, manifestations like chronic stiffness, joint pain and deformities are seen in these individuals get triggered due to inactivity., As a result, in JRA patients, this vicious cycle leads to physical deconditioning and poor Health Related Quality of Life (HRQOL). In this way physical therapy in the form of exercise training will help in halting and improving this deleterious cycle by providing symptomatic relief and will also prevent long- term complications of the same.
Rehabilitation of the children with Juvenile Rheumatoid Arthritis requires knowledge about the pathology of joint inflammation and also an insight into age-dependent psycho-social aspects of the chronic rheumatic disease. The aim of physiotherapy is to maintain and restore the joint function and also the alignment. The appropriate results can be achieved when if the treatment is started early. Rehabilitation should ideally begin at the outset of the disease, in the correctable pain-relieving position, because it is always easier to prevent deformity than to treat it. At first, the therapist should gain the patient’s confidence because treating these children becomes convenient and easy once the child is comfortable and relaxed. Otherwise the fear and pain increases the muscular tension. Specifically in small children the therapy has to be playful yet effective. The physiotherapy sessions should focus primarily on the muscle relaxation and pain relief using passive movements and physical modalities along with the movement expansion and re-integration of the physiologic movement pattern.
However, physiotherapy is not routinely given in individuals with JRA, which could be due to a lack of evidence addressing the specific physical therapy treatment options. Thus, the purpose of this systematic review is to highlight the role of physiotherapy in JRA.
| Materials and Methods|| |
We performed a narrative review on the role of physiotherapy in Juvenile Rheumatoid Arthritis and discuss the evidence-based studies. For the purpose of the review, an electronic search for relevant articles using PUBMED, MEDLINE, Pedro, Research Gate, Google Scholar and CINHAL databases up to September 2021 was done wherein MeSH search terms and free words like “Juvenile Rheumatoid Arthritis”, ‘Physical Therapy”,:Physiotherapy Treatment”, “Massage Therapy’, “Aquatic Therapy”, “Strengthening Exercises”, ‘Resistance Training” were used. In addition to the electronic search, articles were searched manually for relevant studies. Articles were selected based on authors self- knowledge, expertise and reflective practice [Table 1].
|Table 1: Studies summarizing Physiotherapy as a treatment in Juvenile Rheumatoid Arthritis|
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A systematic review was undertaken. We included studies published in English up to September 2021, which focused only on physiotherapy as one of the choice of treatment in individuals with Juvenile Rheumatoid Arthritis. The studies included children below 16 years of age who were diagnosed with Juvenile Rheumatoid Arthritis [Table 2].
Two reviewers separately reviewed each step of the selection and extraction methods. The retrieved references’ titles and abstracts were evaluated. The full texts of relevant papers were reviewed and included if they matched the criteria for inclusion.
| Results|| |
The current study included 11articles that fulfilled the inclusion criteria suggesting that physiotherapy does a have major role in treating the clinical manifestations in individuals with Juvenile Rheumatoid Arthritis.
Ela Tarakci et al; spoke about the effects of land- based home exercise programme for Juvenile Idiopathic Arthritis. An individual land-based home exercise program was designed and given to the intervention group. The individuals in control group were kept on waiting list and were interviewed over a telephone about their clinical status of the condition. All of the outcome variables in the exercise group showed statistically significant improvements (P < 0.001). This study found that an individually tailored LBHE programme can help patients with Juvenile Idiopathic Arthritis enhance their functional abilities and quality of life.
Baydogan SN, et al; carried out a study on effects of Strengthening Versus Balance-Proprioceptive Exercises on Lower Extremity Function in Patients with Juvenile Idiopathic Arthritis wherein ‘group 1’was given warm up exercises followed by stretching and strengthening exercises and on the other hand ‘group 2’ was given warm up exercises followed by balance and propioceptive exercises for the lower extremities. There was a statistically significant improvement in the Pain, passive range of motion, muscle strength, balance, and functional abilities which was assessed using the Numeric Rating Scale, goniometer, handheld dynamometer, Flamingo Balance Test, Functional Reach Test, 10-meter walking test, 10-stair climbing test, and Childhood Health Assessment Questionnaire in the intervention group compared to the control group. Except for muscle strength in the hip and ankle after strengthening exercises in group 1, the intra-group analysis revealed statistically significant improvements (P < 0.001) in all end variables. Except for scores on the NRS resting, CHAQ, PROM, and muscle strength of hip extension and knee flexion (P 0.01), all outcome measures in group 2 exhibited statistically significant improvements (P < 0.01). As a result of this research, balance-proprioceptive exercises were found to be more beneficial than strengthening activities in improving lower extremity function..
A study by Shamekh Mohamed El-Shamy et al; spoke the effect of Long-Term Effect of Pulsed Nd:YAG Laser in JRA wherein one group was given HILT LASER for 3 times a week for 4 weeks with a exercise program and the control group was given a placebo HILT LASER plus exercise program for the same duration. After a 12-week follow-up, statistical analysis revealed statistically significant improvements in both outcome measures, namely pain level as measured by the visual analogue scale (VAS), which decreased post treatment, and gait parameters as measured by the GAITRite® system, which increased post treatment. As a result, among children with JRA, HILT paired with an exercise programme looked to be more helpful than a placebo laser operation combined with exercises..
A study in 2013 by Eva Sandstedt et al; spoke about the effects of physical exercise program on muscle strength, physical fitness and well being in children with juvenile idiopathic arthritis. This study focused on providing a 12-week fitness/exercise programme that includes rope skipping and muscle strength training. Measurement of the outcome The evaluation comprised muscle strength testing using a handheld device and Grip-it, a step-test for fitness with the documentation of heart rate and pain perception, and two well-being questionnaires (CHAQ, CHQ). After a 12-week follow-up, the exercise group demonstrated significant improvements in hip and knee extensor muscle strength. Pain remained continuous in both groups, according to the CHQ Questionnaire. There were changes which were noted in CHQ and CHAQ after training period. There was no significant changes noted in the muscle grip strength and fitness after the exercise program. Hence, this study proved that exercise program can be prescribed to the individuals with JIA as it helps in improving muscle strength in the lower limbs.
So from the above evidences found, it can be stated that physiotherapy in the form of exercise programs or treatment modalities are beneficial for the individuals with Juvenile Rheumatoid Arthritis.
| Discussion|| |
This systematic review summarizes the current literature on the role of Physiotherapy in Juvenile Rheumatoid Arthritis. There is a constant evidence that physiotherapy treatment does help in improving Range Of Motion, reducing pain, increasing muscle strength, functional capability and quality of life in such individuals.
Studies by Valerie J Rhodes, Aysegul Cakmak et al., showed significant improvement in pain, Range Of Motion, strength, gait and functional mobility in such individuals. The physical therapy intervention consisted of various physical therapy modalities like whirlpool, hot packs or warm swimming pools in acute cases so as to help alleviate joint problems, protecting muscle spasm and stiffness, enhancing tissue flexibility in joint capsules and tendons, and reducing discomfort. In cases of hand and feet, Paraffin wax bath was preferred. Also cold packs or ice packs were given which decreased joint pain by providing local anaesthetic effect., Trans-cutaneous Electrical Nerve Stimulation (TENS) was seen to be effective in providing pain relief and also aiding in active movements of the limbs. Short- term electrical stimulation was found to be effective in individuals with muscle atrophy.
Current evidences also state that massage therapy has been proven effective in treating pain and anxiety levels in individuals with JRA. According to studies by Aysegul Cakmak et al. and Tiffany Field et al; they stated that massage therapy daily for a span of 15 minutes to the child reportedly helped in decreasing the anxiety levels in that child, relieved pain, and prevented adhesion in the subcutaneous tissues. Furthermore, there was significant reduction in cortisol levels of saliva., Massage therapy in the form of stroking and squeezing for 15 minutes every night for 30 continuous nights was given. Massage therapy consisted of two phases wherein the first phase began in supine followed by prone being the second one.
Therapeutic exercise programs comprised of all types of exercises ranging from passive range of motion exercises, to isometric exercises, stretching exercises,resistive exercise and aquatic exercises. In one of the studies, Stretching was done with 10 seconds hold for 5–10 times for two times daily and Resistance exercises were accordingly progressed using dumbbells, weights, therabands for 3 times in a week. Whereas other study showed effects of structured exercise training for 30–50 minutes, 2–3 times/week for 12–24 weeks helped in decreasing pain, improving knee strength, range of motion, functional capability, and quality of life in such individuals. Aquatic therapy as a part of physical therapy treatment for 6 weeks is effective in improving the lower limb Range of Motion in JRA individuals.
A study by Mine DoLru Apti et al; included aerobic walking for 4 days a week for 8 weeks and active and passive ROM exercises of affected joints such as shoulder, elbow, wrist, hip, knee, and ankle joints for 10–15 repetitions /set, 2 sets/day, 7 days a week. This study concluded that combining ROM exercises with regular aerobic exercise in the treatment of Juvenile Idiopathic Arthritis may provide significant advantages and should be recommended.
Deborah E. Lechner et al, did a study named “Gait Deviations in Patients with Juvenile Rheumatoid Arthritis” wherein he included 30 children diagnosed with Juvenile Rheumatoid Arthritis where a computerized gait analysis system was used to examine their gait activity. The effects of time and distance on joint angle excursions were investigated. JRA patients had considerably reduced velocity, cadence, and stride length. There was no discernible change in step width or the proportion of time spent in each phase of the gait cycle. Subjects with JRA had a substantial increase in anterior pelvic tilt throughout the gait cycle, as well as hip extension at the end of single-limb stance and ankle plantar flexion after weight release. In terms of knee joint excursion, there was no significant difference between the two groups. Following these changes he also suggested that physical therapy plays a major role in treating these gait deviations noted. In the early stages of the illness, the emphasis of hip ROM exercises should be on extension combined with isometric gluteus maximus muscle activity. He also indicated that using heat and cold modalities, as well as gentle rhythmic joint range of motion exercises, to promote relaxation and reduce joint stiffness, could help to prevent the development of slow joint movement and decreased cadence. Pain alleviation can also be aided by gentle joint mobility using grade one or grade two oscillations. It’s critical to avoid using these therapies on unstable joints..
A study named “Impact of core stability exercises on bone mineralization and functional capacity in children with polyarticular juvenile idiopathic arthritis: a randomized clinical trial” done in the year 2020, involved 33 children with Juvenile Idiopathic Arthritis (JIA) between the ages of 10 and 14, who were divided into two groups at random. The control group received standard Physiotherapy treatment (30 minutes per session, three times per week for three months), while the study group received core stability exercises (three sessions per week), which included a 45-minute lumbar-pelvic/core strength and stability exercise programme consisting of eight exercises, in addition to the standard Physiotherapy treatment. For three months, both the core stability and the traditional Physiotherapy treatment activities were continued. At the baseline and immediately after treatment, the dual-energy X-ray absorptiometry (DXA) equipment and the 6-min walk test (6MWT) were used to assess the bone mineralization and functional capacity. The findings show that in children with polyarticular JIA, core stabilization exercises should be used in conjunction with regular physical therapy to improve bone health and functional performance.
The most commonly preferred surgical interventions in JRA cases are Total Hip Arthroplasty, Knee Synovectomy and Total Knee Replacement surgeries.,,,, Surgeries are advised in JRA individuals when they experience gradual joint destruction, discomfort, and functional impairment., Surgical treatment has been beneficial in improving pain and restoring function thus, helping in improving Quality of Life (QOL).,,, The focus of postoperative physical therapy for patients who have had total hip arthroplasty is on the early mobilisation, with ambulation starting as soon as the next day. A knee immobiliser is preferred postoperatively in the cases of total knee arthroplasty followed by isometric exercises, strengthening exercises and knee active range of motion exercises on the second day. Ambulation and continuous passive motion is also effective for restoring mobility of the knee joint in such individuals.,,
Secondly, Individuals with the primary deformities were prescribed with orthotic management which helped them in relieving the painful pressure points on the joints and also providing a proper alignment. Assistive devices were preferred for post-surgical cases during the short-term rehabilitation goals or severe involvement of the disease to sustain minimal independent ambulation. Likewise, functional mobility was achieved by teaching the transfers and the patterns of movements. Splints were prescribed depending on the type of involvement and severity of the disease. Resting splints were used to rest the joints during acute stage. Wrist splints, finger ring splints, and flexion contracture splints were all given. Functional splints were recommended during the activity or exercising.
Disease Modifying Anti-rheumatic Drugs are usually chosen as the second line of drugs in treatment of JRA.,, The purpose of utilizing the DMARDs is to prevent the disease’s long-term implications by controlling the disease before irreversible damage occurs., Methotraxate, sulfasalazine, and leflunomide are some of the most regularly used DMARDs., Methotraxate causes hepatic cirrhosis, lung toxicity, and bone marrow suppression; sulfasalazine causes nausea, diarrhoea, increased liver enzymes, alopecia, headache, and rash; and leflunomide causes hepatic cirrhosis, pulmonary toxicity, and bone marrow suppression. Various reversible neurological disturbances have been reported with chloroquine which is a slow acting anti-rheumatic drug. Chloroquine has been shown to depress the skeletal muscle contractility and might result in proximal myopathy, particularly involving lower limbs. And a myasthenic syndrome is also seen which appears and disappears early while discontinuing the drug. Also, lowering of seizure threshold and polyneuropathy is most commonly seen after administration of Chloroquine., So from the above given evidences it can be understood that the chronic effects of these drugs makes it necessary for physical therapy to be incorporated in the indviduals with JRA.
Even though there is data available regarding the role of physiotherapy in Juvenile Rheumatoid Arthritis but there is lack of evidence about the structured exercise programs to be prescribed during the course of disease, duration of the therapy session to be given and the total regime of the entire treatment protocol. Future studies should consider following points: RCT study designs with appropriate control groups should focus on all aspects of treatment protocol, such as type, dosage in terms of volume, intensity, and duration, and should be followed by long-term follow-up to verify effects throughout time.
| Conclusion|| |
The above reviewed studies provided literature that physiotherapy as a choice of treatment is effective in individuals with Juvenile Rheumatoid Arthritis. Physical therapy methods that include a patient-centered approach, home exercises and joint-protection instructions, posture, positioning and appropriate recreational activities are effective. JRA can be treated with proper follow-up and treatment techniques, allowing the child to grow into maturity without developing impairments.
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Conflicts of interest
| References|| |
Schneider R, Passo MH Juvenile rheumatoid arthritis. Rheum Dis Clin North Am 2002;28:503-30.
Pertusi RM, Rubin BR, Blackwell D Juvenile rheumatoid arthritis. J Am Osteopath Assoc 1996;96:298-302.
Hahn YS, Kim JG Pathogenesis and clinical manifestations of juvenile rheumatoid arthritis. Korean J Pediatr 2010;53:921-30.
Rhodes VJ Physical therapy management of patients with juvenile rheumatoid arthritis. Phys Ther 1991;71:910-9.
Mendonça TM, Terreri MT, Silva CH, Neto MB, Pinto RM, Natour J, et al
. Effects of pilates exercises on health-related quality of life in individuals with juvenile idiopathic arthritis. Arch Phys Med Rehabil 2013;94:2093-102.
Tarakci E, Yeldan I, Baydogan SN, Olgar S, Kasapcopur O Efficacy of a land-based home exercise programme for patients with juvenile idiopathic arthritis: A randomized, controlled, single-blind study. J Rehabil Med 2012;44:962-7.
Baydogan SN, Tarakci E, Kasapcopur O Effect of strengthening versus balance-proprioceptive exercises on lower extremity function in patients with juvenile idiopathic arthritis: A randomized, single-blind clinical trial. Am J Phys Med Rehabil 2015;94:417-24, quiz 425-8.
Cakmak A, Bolukbas N Juvenile rheumatoid arthritis: Physical therapy and rehabilitation. South Med J 2005;98:212-6.
Field T, Hernandez-Reif M, Seligman S, Krasnegor J, Sunshine W, Rivas-Chacon R, et al
. Juvenile rheumatoid arthritis: Benefits from massage therapy. J Pediatr Psychol 1997;22:607-17.
Bacon MC, Nicholson C, Binder H, White PH Juvenile rheumatoid arthritis aquatic exercise and lower-extremity function. Arthritis & Rheumatism: Official Journal of the American College of Rheumatology 1991;4:102-5.
Elnaggar RK, Elshafey MA Effects of combined resistive underwater exercises and interferential current therapy in patients with juvenile idiopathic arthritis: A randomized controlled trial. Am J Phys Med Rehabil 2016;95:96-102.
Klepper S, Mano Khong TT, Klotz R, Gregorek AO, Chan YC, Sawade S Effects of structured exercise training in children and adolescents with juvenile idiopathic arthritis. Pediatr Phys Ther 2019;31:3-21.
Doğru Apti M, Kasapçopur Ö, Mengi M, Öztürk G, Metin G Regular aerobic training combined with range of motion exercises in juvenile idiopathic arthritis. BioMed Res Int 2014;2014.
Klepper SE Exercise and fitness in children with arthritis: Evidence of benefits for exercise and physical activity. Arthritis Rheum 2003;49:435-43.
Takken T, Van Brussel M, Engelbert RH, Van Der Net J, Kuis W, Helders PJ Exercise therapy in juvenile idiopathic arthritis: A cochrane review. Eur J Phys Rehabil Med 2008;44:287-97.
Risum K, Hansen BH, Selvaag AM, Molberg Ø, Dagfinrud H, Sanner H Physical activity in patients with oligo-and polyarticular juvenile idiopathic arthritis diagnosed in the era of biologics: A controlled cross-sectional study. Pediatric Rheumatolo 2018; 16:1-10.
Gualano B, Sá Pinto AL, Perondi B, Leite Prado DM, Omori C, Almeida RT, et al
. Evidence for prescribing exercise as treatment in pediatric rheumatic diseases. Autoimmun Rev 2010;9:569-73.
Takken T, van der Net J, Kuis W, Helders PJ Physical activity and health related physical fitness in children with juvenile idiopathic arthritis. Ann Rheum Dis 2003;62:885-9.
Häfner R, Truckenbrodt H, Spamer M Rehabilitation in children with juvenile chronic arthritis. Baillieres Clin Rheumatol 1998;12:329-61.
Catania H, Fortini V, Cimaz R Physical exercise and physical activity for children and adolescents with juvenile idiopathic arthritis: A literature review. Pediatr Phys Ther 2017;29: 256-60.
El-Shamy SM, Alayat MS, Abdelgalil AA, Alshehri MA Long-term effect of pulsed Nd: YAG laser in the treatment of children with juvenile rheumatoid arthritis: A randomized controlled trial. Photomedicine and Laser Surgery 2018;36:445-51.
Lechner DE, McCarthy CF, Holden MK Gait deviations in patients with juvenile rheumatoid arthritis. Phys Ther 1987;67:1335-41.
Elnaggar RK, Mahmoud WS, Moawd SA, Azab AR Impact of core stability exercises on bone mineralization and functional capacity in children with polyarticular juvenile idiopathic arthritis: A randomized clinical trial. Clin Rheumatol 2021;40:245-53.
Gandhi R, Mahomed N Juvenile rheumatoid arthritis and total hip arthroplasty. InSeminars in Arthroplasty 2008;19:261-6. WB Saunders.
Kitsoulis PB, Stafilas KS, Siamopoulou A, Soucacos PN, Xenakis TA Total hip arthroplasty in children with juvenile chronic arthritis: Long-term results. Journal of Pediatric Orthopaedics 2006;26:8-12.
Palmer DH, Mulhall KJ, Thompson CA, Severson EP, Santos ER, Saleh KJ Total knee arthroplasty in juvenile rheumatoid arthritis. JBJS 2005;87:1510-4.
Sarokhan AJ, Scott RD, Thomas WH, Sledge CB, Ewald FC, Cloos DW Total knee arthroplasty in juvenile rheumatoid arthritis. JBJS 1983;65:1071-80.
Cage DJ, Granberry WM, Tullos HS Long-term results of total arthroplasty in adolescents with debilitating polyarthropathy. Clin Orthop Relat Res 1992:156-62.
Spencer CH, Bernstein BH Hip disease in juvenile rheumatoid arthritis. Current Opinion in Rheumatology 2002;14:536-41.
Parvizi J, Lajam CM, Trousdale RT, Shaughnessy WJ, Cabanela ME Total knee arthroplasty in young patients with juvenile rheumatoid arthritis. JBJS 2003;85:1090-4.
Guthrie B, Rouster-Stevens KA, Reynolds SL Review of medications used in juvenile rheumatoid arthritis. Pediatr Emerg Care 2007;23:38-46.
Hashkes PJ, Balistreri WF, Bove KE, Ballard ET, Passo MH The long-term effect of methotrexate therapy on the liver in patients with juvenile rheumatoid arthritis. Arthritis Rheum 1997;40:2226-34.
Singsen BH, Goldbach-Mansky R Methotrexate in the treatment of juvenile rheumatoid arthritis and other pediatric rheumatoid and nonrheumatic disorders. Rheum Dis Clin North Am 1997;23:811-40.
Plosker GL, Croom KF Sulfasalazine: A review of its use in the management of rheumatoid arthritis. Drugs 2005;65:1825-49.
Bagnall AW The value of chloroquine in rheumatoid disease: A four-year study of continuous therapy. Can Med Assoc J 1957;77:182-94. PMID: 13446795; PMCID: PMC1824026.
Hicklin JA Chloroquine neuromyopathy. Ann Phys Med 1968;9:189-92.
Dubois EL Antimalarials in the management of discoid and systemic lupus erythematosus. Semin Arthritis Rheum 1978;8:33-51.
Torrey EF Chloroquine seizures. Report of four cases. JAMA 1968;204:867-70.
Whisnant JP, Espinosa RE, Kierland RR, Lambert EH Chloroquine neuromyopathy. Proc Staff Meet Mayo Clin 1963;38:501-13. PMID: 14090994.
[Table 1], [Table 2]