Pain In Juvenile Idiopathic Arthritis Research Articles

An explorative study on proteomic analyses related to inflammation and pain in children with juvenile idiopathic arthritis

BackgroundOur aim was attempting to find proteins involved in the pain process and correlating with pain but not degree of inflammation in children with juvenile idiopathic arthritis (JIA), using a proteomics panel.MethodsA total of 87 plasma samples were collected from 51 children with JIA (51 at diagnosis in a higher disease activity state, 18 at follow-up in a lower disease activity state) and 18 healthy controls. Relative levels of 92 proteins related to a wide range of biological processes in inflammation were obtained using a proximity extension assay panel. Comparisons between children with and without JIA, in different disease categories, by juvenile disease activity score (JADAS27) and degree of pain on a visual analogue scale (VAS), were performed using parametric and non-parametric statistical methods.ResultsNineteen proteins involved in arthritic inflammation, such as interleukin 6 (IL-6) and S100 protein A12, were higher in patients with JIA than controls, seven decreased significantly during treatment, and 18 correlated significantly with JADAS27. Three proteins correlated with pain VAS scores in unadjusted analyses: the glial cell line-derived neurotrophic factor (GDNF), transforming growth factor beta, and IL-18R1. Levels of GDNF correlated significantly with pain VAS scores but not with JADAS27.ConclusionsPlasma levels of 18 of 92 tested proteins correlated with degree of disease activity. Levels of three proteins correlated with pain, and levels of one, GDNF, originating from neural cells, correlated with pain without correlating with inflammatory degree, suggesting that it may play a role in pain in JIA. Further studies in larger cohorts are warranted.

Diagnosis Does Not Automatically Remove Stigma for Young People with Invisible Illness.

Thank you for the invitation to comment on this interesting and important paper. As a pediatric rheumatologist and a pediatric psychologist, we meet many young people affected by invisible illnesses including juvenile idiopathic arthritis (JIA), amplified pain syndromes (APS), hypermobility-related conditions, and dysautonomia, among others. Wakefield et al. (2023) evaluated the experience of pain-related stigma in young people with JIA and their findings reveal several assumptions often made by the medical community which bear further discussion. We explore reasons the medical community may perceive that diagnosis “validates” symptoms and yet this may not affect a young person’s experience of stigma from their social environment. Further, recent research suggests that even for a well-understood pain-related pathophysiology like inflammatory pain in JIA, pain is an important treatment target and may not correlate as directly with disease activity as expected. Finally, we suggest that for young people experiencing painful invisible illness, lessons learned from the treatment of idiopathic chronic pain may provide support that minimizes impairment from symptoms and may even help the symptoms.

Total Knee Arthroplasty In Patients With Juvenile Idiopathic Arthritis

Medical and surgical management of knee pain in juvenile idiopathic arthritis (JIA) is rapidly evolving. It is important for the orthopaedic surgeon to remain informed. In this review, we discuss the recent trends in surgical management of JIA in light of recent medical advances for the disease. The purpose of this article is to summarize current recommendations for TKA in patients with JIA.

A multidisciplinary assessment of pain in juvenile idiopathic arthritis

IntroductionPain is prevalent in juvenile idiopathic arthritis (JIA). Unknowns regarding the biological drivers of pain complicate therapeutic targeting. We employed neuroimaging to define pain-related neurobiological features altered in JIA. Methods16 male and female JIA patients (12.7 ± 2.8 years of age) on active treatment were enrolled, together with age- and sex-matched controls. Patients were assessed using physical examination, clinical questionnaires, musculoskeletal MRI, and structural neuroimaging. In addition, functional magnetic resonance imaging (fMRI) data were collected during the resting-state, hand-motor task performance, and cold stimulation of the hand and knee. ResultsPatients with and without pain and with and without inflammation (joint and systemic) were evaluated. Pain severity was associated with more physical stress and poorer cognitive function. Corrected for multiple comparisons, morphological analysis revealed decreased cortical thickness within the insula cortex and a negative correlation between caudate nucleus volume and pain severity. Functional neuroimaging findings suggested alteration within neurocircuitry structures regulating emotional pain processing (anterior insula) in addition to the default-mode and sensorimotor networks. ConclusionsPatients with JIA may exhibit changes in neurobiological circuits related to pain. These preliminary findings suggest mechanisms by which pain could potentially become dissociated from detectable joint pathology and persist independently of inflammation or treatment status.

"Reluctant to Assess Pain": A Qualitative Study of Health Care Professionals' Beliefs About the Role of Pain in Juvenile Idiopathic Arthritis.

ObjectiveReducing pain is one of the main health priorities for children and young people with juvenile idiopathic arthritis (JIA); however, some studies indicate that pain is not routinely assessed in this patient group. The aim of this study was to explore health care professionals’ (HCPs) beliefs about the role of pain and the prioritization of its assessment in children and young people with JIA.MethodsSemi‐structured interviews were conducted with HCPs who manage children and young people with JIA in the UK (including consultant and trainee pediatric rheumatologists, nurses, physical therapists, and occupational therapists). Data were analyzed qualitatively following a framework analysis approach.ResultsTwenty‐one HCPs participated. Analyses of the data identified 6 themes, including lack of training and low confidence in pain assessment, reluctance to engage in pain discussions, low prioritization of pain assessment, specific beliefs about the nature of pain in JIA, treatment of pain in JIA, and undervaluing pain reports. Assessment of pain symptoms was regarded as a low priority and some HCPs actively avoided conversations about pain.ConclusionThese findings indicate that the assessment of pain in children and young people with JIA may be limited by knowledge, skills, and attitudinal factors. HCPs’ accounts of their beliefs about pain in JIA and their low prioritization of pain in clinical practice suggest that a shift in perceptions about pain management may be helpful for professionals managing children and young people with this condition.

Orofacial pain in juvenile idiopathic arthritis is associated with stress as well as psychosocial and functional limitations

BackgroundThe aim of this study was to investigate relations between psychosocial factors, signs and symptoms of orofacial pain and jaw dysfunction in patients with juvenile idiopathic arthritis (JIA).MethodsForty-five patients with JIA (median age 12 years) and 16 healthy matched controls (median age 13 years) were examined according to the diagnostic criteria for temporomandibular disorders (DC/TMD). The subjects answered the DC/TMD questionnaires regarding psychosocial factors (pain intensity, pain–related disability, depression, stress, catastrophizing, pain locations and jaw function).ResultsJIA patients with orofacial pain had higher degree of stress, depression, catastrophizing and jaw dysfunction compared to subjects without. In turn, these factors were associated with orofacial pain intensity. Also, patients with orofacial pain had higher systemic inflammatory activity.ConclusionsOrofacial pain in patients with JIA is associated with stress, psychological distress, jaw dysfunction and loss of daily living activities. Pain intensity seems to be the major pain aspect related to these factors. In addition, systemic inflammatory activity appears to be an important factor contributing to orofacial pain in JIA.

P08 Beliefs about pain in juvenile idiopathic arthritis are significantly associated with higher reported pain and more negative affect in children and young people

Abstract Background Persistent, unpredictable pain is one of the most burdensome features of juvenile idiopathic arthritis (JIA) which is a relapsing-remitting inflammatory musculoskeletal condition presenting in children and young people under 16 years. Recent research into perceptions of illness in young people has found that conceptualisations of long-term disease are mainly about the most salient features and symptoms, not of the illness as a whole. Particularly in young people with JIA, perceptions of pain are central to the individuals’ beliefs about the chronic condition. In paediatric pain research in general, the study of pain beliefs has mainly focused on pain catastrophising. Associations between other potentially important pain beliefs and pain outcomes (e.g. reporting pain or well-being) have not been explored to date. The aim of this study was to explore a wide range of pain perceptions in young people with JIA and to investigate whether these pain beliefs were associated with pain severity or well-being. Methods Cross-sectional data from the largest UK cohort study of children with JIA were analysed (the Childhood Arthritis Prospective Study- CAPS). Participants aged over 11 years completed ‘The Pain Perceptions Questionnaire for Young People (PPQ–YP)’ which assesses pain beliefs corresponding to the Common Sense-Self Regulatory framework first proposed by Leventhal and colleagues in the 1980s. Self-reported pain severity scores were captured using a Visual Analogue Scale (VAS). Emotional well-being was assessed using the Positive and Negative Affect Scale (PANAS). Associations were explored using Spearman’s Rank Correlation. Results 223 participants (64% female) completed the PPQ-YP. 38.2% of participants had a diagnosis of oligoarthritis, 29.6% had polyarthritis and equal proportions of participants had systemic, psoriatic or enthesitis related JIA (7.3%). Higher reported pain severity was significantly correlated with stronger beliefs about the greater impact of pain on life (rho=0.494, p < 0.001), pain unpredictability (rho=0.369, p < 0.001) and pain persistence (rho=0.278,p<0.001). Higher pain controllability beliefs (that pain was controllable) were significantly associated with lower self-reported pain severity (rho=-0.526, p < 0.001). Stronger beliefs about the impact of pain on life (rho=0.425,p=0.001) and pain coherence (poorer understanding about own pain: rho=-0.295,p=0.021) were significantly associated with more negative mood. Conclusion Pain beliefs (particularly about consequences, unpredictability, persistence and understanding) are linked to levels of pain severity and well-being in children with JIA. Adding to the evidence base on the link between pain catastrophising and illness outcomes, this research enhances our understanding of long-term illness and pain perceptions in young people through the implication of a wider range of pain beliefs and cognitions on illness outcomes. The PPQ-YP identified salient pain beliefs which should be considered in the design of potential interventions to improve pain outcomes in this group. Future research should aim to explore whether these perceptions can predict other important illness outcomes. Conflicts of Interest The authors declare no conflicts of interest.

Early Self‐Reported Pain in Juvenile Idiopathic Arthritis as Related to Long‐Term Outcomes: Results From the Nordic Juvenile Idiopathic Arthritis Cohort Study

To study self-reported pain early in the disease course of juvenile idiopathic arthritis (JIA) as a predictor of long-term disease outcomes. Consecutive cases of JIA with disease onset from 1997 to 2000 from defined geographical areas of Norway, Sweden, Finland, and Denmark were prospectively enrolled in this population-based cohort study. Self-reported, disease-related pain was measured on a 10-cm visual analog scale (VAS pain). Inclusion criteria were a baseline visit with a pain score 6 months after disease onset, followed by an 8-year study visit. Remission was defined according to Wallace etal (2004) preliminary criteria. Functional disability was measured by the Childhood Health Assessment Questionnaire and the Child Health Questionnaire Parent Form if the child was age <18 years and by the Health Assessment Questionnaire if age ≥18 years. Damage was scored using the Juvenile Arthritis Damage Index. The final study cohort consisted of 243 participants, and 120 participants (49%) had oligoarticular onset. At baseline, 76% reported a VAS pain score >0 compared to 57% reporting at 8 years. Half of those who reported baseline pain also reported pain at 8 years but at a lower intensity. Compared to no pain, higher pain intensity at baseline predicted more pain at 8 years, more functional disability, more damage, and less remission without medication. Baseline pain predicted more use of disease-modifying antirheumatic drugs/biologics during the disease course. Participants with oligoarticular JIA reporting pain at baseline were more likely to develop extended oligoarticular JIA or other JIA categories with an unfavorable prognosis. Early self-reported, disease-related pain among children and adolescents with JIA is common and seems to predict persistent pain and unfavorable long-term disease outcomes.

Pain in School: Patterns of Pain-Related School Impairment among Adolescents with Primary Pain Conditions, Juvenile Idiopathic Arthritis Pain, and Pain-Free Peers.

Children with chronic pain frequently experience impairment in the school setting, but we do not yet understand how unique these struggles are to children with primary pain conditions compared to peers with disease-related pain or those without chronic pain symptoms. The objective of this study is to examine school functioning, defined as school attendance rates, overall quality of life in the school setting, and school nurse visits among adolescents with primary pain conditions, those with juvenile idiopathic arthritis (JIA)-related pain, and healthy peers. Two hundred and sixty adolescents participated in the study, including 129 with primary pain conditions, 61 with JIA, and 70 healthy comparison adolescents. They completed self- and parent-reported measures of school function. Findings show that as a group, youth with primary pain conditions reported more school absences, lower quality of life in the school setting, and more frequent school nurse visits compared to both adolescents with JIA-related pain and healthy peers. We conclude that compared to those who experience pain specific to a disease process, adolescents with primary pain conditions may face unique challenges in the school setting and may require more support to help them succeed in school in spite of pain.

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.

Neural mechanisms underlying the pain of juvenile idiopathic arthritis

Pain is the most common symptom of juvenile idiopathic arthritis (JIA) and is arguably a more important factor in disability than the progression of the disease itself. Studies have highlighted the extent of this pain and its persistence in some young patients despite effective disease control. Understanding and effective management of pain in JIA is limited, and improved diagnosis and treatment would benefit from increased knowledge of the mechanisms underlying pain in childhood. This Review focuses upon the developmental neurobiology of pain, reviewing studies in animal models that increase clinical understanding and inform treatment of the painful manifestations of JIA. Pain processing in the juvenile nervous system differs from that in adults: nociceptive thresholds are lower and endogenous pain control systems are slow to mature. Furthermore, increasing evidence points to tissue injury in childhood having prolonged effects upon the developing pain system. Injury, inflammation and stress in early life can 'prime' peripheral nociceptors and central pain circuits, such that the pain associated with tissue inflammation is exacerbated in later life. A developmental, mechanism-based approach towards developing novel targets for the treatment of pain in JIA might therefore benefit the patient both as a child and as an adult if the disease recurs or persists.

The Relationship Between Physical Activity Levels and Pain in Children with Juvenile Idiopathic Arthritis

Pain and reduced physical activity levels are common in children with juvenile idiopathic arthritis (JIA). Currently, there is no consensus about the role of physical activity in managing pain in JIA. The purpose of our study was to assess the relationship between physical activity level and pain in children ages 11 to 18 years with JIA. A random sample of 50 patients with JIA were approached by mailed questionnaires. Physical activity was determined using the Physical Activity Questionnaire (PAQ). Pain measures included the Numerical Rating Scale (pain severity), SUPER-KIDZ body diagram (number of painful areas), and the Child Activities Limitations Inventory-21 (pain interference). Generalized linear models were used to assess the relationship between physical activity and pain, as well as the roles of sex and age. The response rate was 84%. Thirty-four respondents completed the questionnaire package. The median age was 15 years. The mean PAQ score was 2.16/5. Physical activity declines with increasing age in youth with JIA (r = 0.53, p = 0.0014). Lower physical activity is associated with greater pain interference (r = 0.39, p = 0.0217) and more severe pain (r = 0.35, p = 0.0422). Children with JIA report significantly less activity than healthy children based on PAQ scores, with physical activity declining throughout adolescence. Physical activity is inversely related to pain interference and severity in children with JIA. Our findings suggest that physical activity interventions may play an important role in the management of pain in JIA.

Juvenile Idiopathic Arthritis and Pain — More Than Simple Nociception

Pain is a very common and sometimes limiting symptom in patients with juvenile idiopathic arthritis (JIA). Nonetheless, there remain many unanswered questions regarding pain perception in JIA and the neurobiology of pain in this disease. In this edition of The Journal , Leegaard, et al 1 report their findings of lowered pain threshold in patients with JIA that add to our understanding of a fundamental aspect of this disease manifestation in JIA. The disease pattern for JIA tends to follow a course of quiescent periods with disease activity flares superimposed. Some children have unrelenting disease activity that may be resistant to therapeutic interventions. Treatment of JIA is often complex and relies on medications, allied health interventions, and multidisciplinary expertise, ideally delivered in a coordinated manner in a predominantly ambulatory setting. JIA may have a profound influence on children’s lives and their experience of pain may be central to this2,3. Studies have found that reduced quality of life and functional outcome (social, emotional, and physical), lowered mood, and poor sleep are all associated with higher levels of pain perception in JIA4,5,6. Pain in JIA has historically been underreported, under-recognized, and underresearched, with clinical and research focus on inflammation, damage, and function. There are few specific or multidimensional and reliable pain assessment tools7, which has limited clinical research. Thus, the evidence base for pain management has traditionally relied upon extrapolation from adult medicine8. By enriching our understanding of the neurobiology of pain pathways in JIA, the predictive factors for those young people most vulnerable to pain, in conjunction with a focus on developing effective treatments, we will make inroads into one of the most significant symptoms for our patients with JIA. While there are many studies … Address correspondence to Dr. Singh-Grewal; E-mail: davinder.singhgrewal{at}health.nsw.gov.au

Assessment and management of pain in juvenile idiopathic arthritis.

Juvenile idiopathic arthritis (JIA) is a common chronic childhood illness. Pain is the most common and distressing symptom of JIA. Pain has been found to negatively impact all aspects of functioning, including physical, social, emotional and role functions. Children with arthritis continue to experience clinically significant pain despite adequate doses of disease-modifying antirheumatic drugs and anti-inflammatory agents. The present article reviews the prevalence and nature of pain in JIA, the biopsychosocial factors that contribute to the pain experience, current approaches to assessing pain in this population, and ways of managing both acute and persistent pain using pharmacological, physical and psychological therapies. Finally, new approaches to delivering disease self-management treatment for youth with JIA using the Internet will be outlined.

Pain in Child Health

Correspondence: Dr Patrick McGrath, Pediatrics and Psychiatry, Dalhousie University; IWK Health Centre and Capital District Health Authority, Halifax, Nova Scotia. 5850 University Avenue, Halifax, Nova Scotia B3K 6R8. Telephone 902-470-6511, fax 902-470-6767, e-mail patrick.mcgrath@iwk.nshealth.ca The challenges of complex and recurrent pain in children and youth are beginning to yield to systematic investigation. The current issue of Pain Research and Management contains a special series on pediatric pain based on keynote addresses presented by world-renowned clinicians and scientists at the International Forum on Pediatric Pain held at White Point Beach, Nova Scotia, in October 2011. The articles reflect the increasing sophistication of research and practice in the area and the application of rigorous science in the service of more effective pain control. Goldschneider (pages 386-390) summarizes the knowledge regarding complex regional pain in children and youth, and integrates what is known from adult and pediatric studies to arrive at a new perspective on this debilitating disorder. Stinson et al (pages 391-396) review pain in juvenile idiopathic arthritis, including the novel use of Internet interventions. Asmundson et al (pages 397-405) develop and apply a pediatric version of the very productive fear-avoidance model of pain. This extension of the model opens up new ways of approaching treatment. Logan et al (pages 407411) focus on the context of chronic pain and elucidate the implications of an ecological perspective for understanding the development of chronic pain and broad strategies for intervention. Finally, Levy and van Tilburg (pages 413-417) review the history and new developments in chronic recurrent abdominal pain. In the next decade, a more theoretically sophisticated understanding of chronic and recurrent pediatric pain will emerge. Models that integrate biological, psychological and social aspects will be used in multicentre studies of typical patients, with longer follow-up. These articles provide the basis for major advances in this important field. editorial

Pain in Juvenile Idiopathic Arthritis—A Family Matter

The purpose of this study was to identify the associations between parental and child psychosocial factors and pain in juvenile idiopathic arthritis (JIA). The sample comprised 142 patients with JIA and the attending parent. Explorative factor analysis was used to identify higher-order factors reflecting the interaction between the parent (parental anxiety and depressive symptoms, parental illness management, and parental self-efficacy) and child (trait anxiety, depression, functional disability, pain, and self-efficacy) variables. Linear multiple regression analysis was used to investigate the extent to which these common factors might account for variance in the levels of pain experienced by children diagnosed with JIA. One of the higher-order factors comprised both parental and child variables. This and two additional factors were uniquely associated with the children's pain reports in the regression analysis. Research and clinical implications are discussed in light of the findings of the study.

Parent Pain Responses as Predictors of Daily Activities and Mood in Children with Juvenile Idiopathic Arthritis: The Utility of Electronic Diaries

The present study used electronic diaries to examine how parent responses to their child's pain predict daily adjustment of children with juvenile idiopathic arthritis (JIA). Nine school-aged children with JIA along with one of their parents completed thrice-daily assessments of pain-related variables, activity participation, and mood using handheld computers (Palm pilots) for 14 days, yielding a potential of 42 child and parent assessments for each dyad. Children provided information on current pain level, mood, and participation in social, physical, and school activities. Parents independently rated their own mood as well as their behavioral responses to their child's pain at the same time points using a separate handheld computer. Results of multilevel modeling analyses demonstrated that use of "protective" pain responses by parents significantly predicted decreases in child activity and positive mood, with an even stronger inverse relationship between protective pain response and positive mood observed in children with higher than average disease severity. Protective pain responses were not found to be significantly predictive of daily negative mood in children. The use of "distracting" responses by parents significantly predicted less child activity restrictions but only in children having higher disease severity. There also was an unexpected trend in which parent use of more distracting pain responses tended to be associated with lower child positive mood. These preliminary findings suggest the importance of the parent in influencing adjustment in children with JIA and lend support to the incorporation of parents into comprehensive pain management approaches. The potential benefits of using electronic daily diaries as a strategy to examine pain and adjustment in children with JIA pain are discussed.

Depression, anxiety and pain in juvenile idiopathic arthritis

Results There was no statistically significant difference in between the disease subtype groups and between the pain groups as to the sociodemographic features. The frequency of depression and anxiety diagnosis which were made according to the DSM-IV criteria was %31 and %17.7 in 45 JIA patients. For the 45 patients the average CDI score was 7.60 and the average Trait Anxiety Inventory score was 34.31. For the 42 patients which were aloocated into pain groups, the average CDI score was 7.67 and the average Trait Anxiety Inventory score was 34.10. There was no statistically significant difference between the groups as to the depression and anxiety scale scores. Pain was not correlated with depression and anxiety scores.

Custom-made foot orthoses for the treatment of foot pain

Custom foot orthoses are commonly recommended for the treatment of foot pain. To evaluate the effectiveness of custom foot orthoses for different types of foot pain. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2007, Issue 2), MEDLINE (from January 1966), EMBASE (from January 1980), CINAHL (from January 1982) and the Physiotherapy Evidence Database (PEDro) (to June 2007). We also contacted authors of included trials and known researchers in the field and checked the reference lists of included trials to identify trials. No language or publication restrictions were applied. Randomised controlled trials and controlled clinical trials evaluating custom-made foot orthoses for any type of foot pain. Outcomes included quantifiable levels of foot pain, function, disability, health-related quality of life, participant satisfaction, adverse effects and compliance. Two authors independently selected trials, rated methodological quality and cross checked data extraction. Data were analysed separately for different diagnoses of foot pain and follow-up time points. Eleven trials involving 1332 participants were included: five trials evaluated custom-made foot orthoses for plantar fasciitis (691 participants); three for foot pain in rheumatoid arthritis (231 participants); and one each for foot pain in pes cavus (154 participants), hallux valgus (209 participants) and juvenile idiopathic arthritis (JIA) (47 participants). Comparisons to custom-made foot orthoses included sham orthoses; no intervention; standardised interventions given to all participants; non-custom (prefabricated) foot orthoses; combined manipulation, mobilisation or stretching; night splints; and surgery. Follow up ranged from one week to three years. Custom-made foot orthoses were effective for painful pes cavus (NNTB:5), rearfoot pain in rheumatoid arthritis (NNTB:4), foot pain in JIA (NNTB:3) and painful hallux valgus (NNTB:6); however, surgery was even more effective for hallux valgus and non-custom foot orthoses appeared just as effective for JIA but the analysis may have lacked sufficient power to detect a difference in effect. It is unclear if custom-made foot orthoses were effective for plantar fasciitis or metatarsophalangeal joint pain in rheumatoid arthritis. Custom-made foot orthoses were a safe intervention in all studies. There is limited evidence on which to base clinical decisions regarding the prescription of custom-made foot orthoses for the treatment of foot pain. Currently, there is gold level evidence for painful pes cavus and silver level evidence for foot pain in JIA, rheumatoid arthritis, plantar fasciitis and hallux valgus.

Treatment of pain in juvenile idiopathic arthritis: A survey of pediatric rheumatologists

To assess the opinions and current practice of pediatric rheumatologists regarding treatment of chronic pain in children with juvenile idiopathic arthritis (JIA). Standardized questionnaires were distributed to pediatric rheumatologists who are members of the Children's Arthritis and Rheumatology Research Alliance. Demographic data, opinions, and attitudes were solicited about pain assessment, current treatment of JIA with residual pain, and actual use of opioids to treat pain in children with JIA. Of 99 rheumatologists who were contacted, 53 responses were received (53.5%). No significant demographic differences were found in attitudes about pain management and use of opioids. A total of 77.3% of respondents agreed that there are patients who continue to have significant pain despite adequate treatment. However, 59.6% disagreed with the use of opioid analgesics for treatment of those patients. Cross tabulations showed significant relationships between attitudes about opioid use and concerns for side effects, including drowsiness, fatigue, and constipation (chi(2) = 1.16, P > 0.05), as well as addiction (chi(2) = 5.51, P = 0.019). Thirty percent of those who strongly disagreed with opioid use and 52.4% of those who disagreed had in fact prescribed opioids in the past year. The most commonly prescribed opioids were codeine and oxycodone. Practitioners' perceived knowledge of the drugs significantly affected their likelihood to prescribe them. Pediatric rheumatologists are divided in their attitudes regarding treatment of residual pain in children with JIA. Concern for side effects appears to be a major factor in the decision to prescribe these analgesics. More data are needed to facilitate clearer cost-benefit analyses in the decision to prescribe opioids to this clinical population.