Critical Issues in School Health Arthritis in the School Setting. Lawrence Zemel MD Tegan Willard RN Connecticut Children s

Transcription

1 Critical Issues in School Health Arthritis in the School Setting Lawrence Zemel MD Tegan Willard RN Connecticut Children s

2 Juvenile Rheumatoid Idiopathic Arthritis

3 Definition of JRA (JIA) Persistent arthritis in one or more joints lasting at least 6 weeks children 16 or less excluding other disorders

4 JIA ~150,000 children affected in the U.S. (300,000 children with arthritis) Girls > boys Ages: 6 mos-16 yrs at onset No seasonal or geographic variation 250 pediatric rheumatologists in this country (5 in CT)

5 Classification of Juvenile Idiopathic Arthritis (JIA) Durban, 1997 Systemic arthritis Oligoarthritis Polyarthritis (RF negative) Polyarthritis (RF positive) Psoriatic arthritis Enthesitis-related arthritis (spondyloarthropathy) Other arthritis

6 Systemic Arthritis Arthritis + fever > 2 wks Plus 1 additional feature: Lymphadenopathy Hepatosplenomegaly Serositis Rash Excluding other febrile illnesses

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8 Oligoarthritis Arthritis affecting 1-4 joints during the first 6 months of illness. After 6 mos: Persistent oligoarth- ritis Extended oligoarth- ritis (>4 joints)

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10 Girls:boys = 5:1 Peak age: 2 years Oligoarthritis Other Features Asymmetric large joint disease: knee, ankle, elbow (almost never hip) ANA seen in 60-75% of children Uveitis (iritis) correlates with +ANA and younger age of onset

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12 Polyarthritis RF negative Arthritis > 6 weeks Absence of IgM RF 5 or more joints during 1 st 6 months Tends to be less symmetric and less erosive RF positive Arthritis > 6 weeks Presence of IgM RF 5 or more joints during 1 st 6 months Tends to be symmetric and erosive

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22 Psoriatic Arthritis Arthritis and psoriasis, or Arthritis and at least 2 of the following: Dactylitis Nail pitting or onycholysis FH of psoriasis in at least one first degree relative

23 Psoriatic Arthritis Sausage digits (dactylitis) common Less erosive than RF+ JIA Arthritis usually precedes psoriasis Spinal arthritis and enthesitis associated with HLA-B27 Other Features

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26 Enthesitis-related Arthritis (ankylosing spondylitis) Arthritis and/or enthesitis, plus 2 of the following: SI tenderness and/or inflammatory back pain Presence of HLA-B27 FH of B27-related disease Anterior uveitis Onset of arthritis in a boy > 8 yrs of age

27 Enthesitis

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29 Systemic Lupus Autoimmune, multi-system disorder Women and girls >>> Men and boys Common triad: fever, rash, arthritis Other systems involved: Kidneys Lungs Nervous system

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34 Juvenile Dermatomyositis: Bohan-Peters Criteria Proximal weakness Enzyme elevation Characteristic rash (Gottron s, heliotrope) Muscle biopsy EMG myopathic changes

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39 Lyme Disease Case Definition Erythema Migrans (at least 5 cm), or One late manifestation, and laboratory confirmation of infection Late manifestations include: arthritis carditis neurologic disease

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47 Pain Amplification/Central Pain Processing and Related Disorders Fibromyalgia Chronic Fatigue Migraine Irritable Bowel Syndrome TMJ disorders Hypermobility syndrome Complex Regional Pain Syndrome (RSD) Chronic Pelvic Pain Premenstrual Syndrome Myofascial Pain syndromes Multiple Chemical Sensitivities Chronic cystitis Dysautonomia/ POTS

48 Juvenile Fibromyalgia (JFS) Widespread MSP for at least 3 months > 5 well-defined tender points 3 of 10 minor criteria < age 16 at onset

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50 Juvenile Fibromyalgia: Minor Criteria Fatigue Sleep problems Anxiety/ tension Subjective swelling Numbness/tingling Lightheadedness/ dizziness Chronic headache Irritable Bowel syndrome Pain modulated by stress Pain modulated by weather Pain modulated by physical activity

51 Juvenile Fibromyalgia 1756 school-aged (pre-adolescent) Finnish children prospectively studied by questionnaire then PE; 1.3% prevalence 338 healthy Israeli 9-15 y/o students studied; 6.2% prevalence 1.3% healthy Mexican 9-15 y/o students

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53 Types of JIA Oligoarticular (persistent and extended) Polyarticular (Rheumatoid Factor negative and Rheumatoid Factor positive) Systemic

54 Differences between RA and JIA Psychosocial and educational needs Growth concerns: height and leg length discrepancy Type of eye involvement More frequent systemic disease Serologic profiles Heterogeneity of disease & immunogenetics

55 Review of Labs CBC ESR ANA Rheumatoid Factor LFTs CCP Antibodies

56 Overview of Medications NSAIDs and COX-2 inhibitors DMARDs (Disease modifying antirheumatic drugs) Steroids (PO, IV, IA) Biologics

57 Enbrel(Etanercept) Biologics Remicade (Infliximab) Humira (Adalimumab) Kineret (Anakinra) Orencia (Abatacept) Rituxan (Rituximab) Actemra (Tocilizumab) Cimzia (Certolizumab)

58 Implications of a Chronic Disease Physical Psychological Social Educational Financial

59 The Nurse s Role Lend an EAR 1. Educate, educate, educate 2. Be an Advocate 3. Be a Resource

60 School Issues Fatigue Pain Feeling different Falling behind in schoolwork Missing out on activities (recess, field trips, phys. ed, sports) Lack of knowledge You don t look sick.

61 Accommodations in the School Setting Late start when flaring Self-limiting in phys. ed. Extra time to take tests Extra time to pass in hallway between classes Locker in close proximity to most classes Second set of books

62 Accommodations (cont d) Rest period in nurse s office Allow to stretch or stand in class Borrow notes from a classmate Avoid repetitive and/or lengthy essay writing if hands are affected Allow use of elevator Schedule classes geographically close together

63 504 Plan Refers to Section 504 in the Rehabilitation Act and the American with Disabilities Act which specifies that no one with a disability can be excluded from participating in federally funded programs or activities, including elementary, secondary or postsecondary schooling

64 Resources The Child With Arthritis in the School Setting in Journal of School Nursing, July 2008 Raising a Child With Arthritis When Your Student Has Arthritis twillard@connecticutchildrens.org arthritis.org