Arthritis

C hapter

11

Arthritis Acupuncture |May Loo Aromatherapy |Maura A. Fitzgerald

Homeopathy |Janet L. Levatin   gatha P. Colbert, Deborah Risotti Magnet  Therapy |A

Chiropractic |Anne Spicer Herbs—Western |Alan D. Woolf, Paula M. Gardiner,

Massage  Therapy |Mary C. McLellan Nutrition |Joy A. Weydert

Lana Dvorkin-Camiel, Jack Maypole

Osteopathy | Jane Carreiro

  P EDIATRIC DIAGNOSIS   AND TREATMENT Juvenile rheumatoid arthritis (JRA) refers to a group of disorders characterized by chronic arthritis. It is the most common chronic rheumatic illness in children and is a significant cause of short- and long-term disability.1,2 The incidence of JRA is approximately 13.9/100,000 children/year among children 15 years or younger, with an overall prevalence of approximately 113/100,000 children.3 The clinical characteristic is an idiopathic synovitis of the peripheral joints, associated with soft tissue swelling and effusion. The American College of Rheumatology (ACR) classifies JRA as a category of diseases with three principal types of onset: (1) oligoarthritis, fewer than five inflamed joints; (2) polyarthritis, five or more inflamed joints; and (3) systemic-onset disease, arthritis with characteristic fever. Nine distinct course subtypes have also been identified. Additional criteria include: age < 16 years at onset; arthritis (swelling or effusion, or presence of two or more of the following signs: limitation of range of motion, tenderness or pain on motion, and increased heat) in one or more joints; duration of disease 6 weeks or longer; and onset type defined by type of disease in the first 6 months and exclusion of other forms of juvenile arthritis.4,5 The precise etiology for JRA is unknown, but it is generally thought to occur in immunogenetically susceptible children exposed to an external, presumably environmental, trigger.3,6 Specific HLA subtypes have been identified in at-risk children: HLA-DR4 is associated with polyarticular disease; pauciarticular JRA has been associated with HLA alleles at the DR8 and DR5 loci, the strongest associations with the HLADRB1 alleles.7 Possible external triggers for JRA include certain viruses (e.g., parvovirus B19, rubella, Epstein-Barr virus), host hyperreactivity to specific self-antigens (type II collagen), and enhanced T-cell reactivity to bacterial or mycobacterial heat shock proteins. T-cell activation results in a cascade of events leading to release of proinflammatory cytokines, resulting in tissue damage in joints.3 The diagnosis of JRA is based on the ACR classification criteria with the exclusion of other articular diseases. There is no single pathognomonic finding for these diseases in ­children.4,5

The diagnosis is based on a history of inflammatory joint disease, physical examination that confirms the presence of arthritis, and characteristic laboratory abnormalities for inflammation that include an elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), leukocytosis, thrombocytosis, and the anemia of chronic disease.3 Elevated antinuclear antibody (ANA) titers are present in at least 40% to 85% of all children with pauciarticular or polyarticular JRA but are unusual in children with systemic-onset disease. Detectable ANA, usually with homogeneous or speckled pattern, is ­associated with increased risk for the development of chronic uveitis, but the precise specificities for various ANA patterns have not been determined. A positive rheumatoid ­factor (RF) may be associated with onset of the disease in an older child with polyarticular involvement (approximately 8%) and the development of rheumatoid nodules, with a poor overall ­prognosis and eventual functional disability.3 Early radiographic changes include soft tissue swelling, osteoporosis, and periostitis around the affected joints. Characteristic late radiographic changes of JRA are seen in the hands and cervical spine, most frequently in the neural arch joints at C2-C3.3 The wide variety of imaging modalities are crucial for the diagnosis and follow-up of arthritis.8,9 Quantita­ tive computed tomography can show decreased muscle mass and abnormal bone geometry.10 Magnetic resonance imaging allows direct visualization of the inflamed synovium and pannus and may detect early cartilage changes.8,10 Although the disorder is chronic and not life-threatening, early institution of treatment is crucial, as poorly controlled JRA can profoundly affect growth, development, and quality of life in children.11 Medication treatment should follow a pyramid approach beginning with a combination of the least toxic medications (usually nonsteroidal antiinflammatory drugs [NSAIDs]) and proceeding through sulfasalazine, methotrexate, and possibly etanercept or immunosuppressive or experimental drugs. Azathioprine and cyclophosphamide are reserved for the very few children who do not respond to less aggressive therapy, whereas glucocorticoids are used for overwhelming inflammatory or systemic illness.3 Routine slit-lamp ophthalmological examination is important for all patients with JRA to monitor for development of asymptomatic uveitis, a common extraarticular manifestation that occurs in 20% to 30% of JRA 153

�

154  Common Pediatric Conditions patients.12,13 Parental education, dietary evaluation to ensure appropriate calcium intake, physical and occupational therapy, and psychotherapeutic intervention to help families cope with the stress of a debilitating chronic illness are also important to implement in the treatment regimen.2,3 Prognosis varies according to the type, age of onset, laboratory findings, and other factors as summarized in Table 11-1. Currently, there is active international interest in advancing clinical studies in pediatric rheumatology. A number of collaborative groups have formed, the best known of which are the Pediatric Rheumatology Collaborative Study Group in North America and the Paediatric Rheumatology International Trials Organization in Europe, South America, and Asia.15

  CAM  T HERAPY RECOMMENDATIONS Acupuncture Chinese medicine explains arthritis as an “obstruction syndrome,” meaning that the pain and swelling is due to an obstruction of flow of Qi and Blood through the channels, usually associated with or secondary to a pathogenic influence such as Wind, Cold, and/or Dampness. Oligoarthritis is usually due to Dampness or Cold blockage, whereas polyarthritis with symptoms that appear at different joints at different times is more compatible with wind blockage.1

In TCM, joints are important areas of entry, convergence, and exit of Qi and Blood; a meeting place of Yin and YangQi. The predisposing factors for development of arthritis are genetic vulnerability, the child’s Qi, underlying Blood or Yin deficiency, overuse, and emotional problems. Genetic vulnerability suggests that the strength of the Kidney Qi can affect the physiology of the joints. When the child’s Qi is weak relative to the force of pathogenic influence, Wind, Cold, or Damp can accumulate in the joints. Blood or Yin deficiency leads to malnourishment of the channels and joints such that they become more vulnerable to external pathogenic factors. Overuse (e.g., excessive sports) can lead to arthritic symptoms. Emotional problems can lead to Qi stagnation and Qi and Blood depletion. Persistent obstruction in the joints can lead to muscle atrophy and bony deformities. Acupuncture treatment is directed toward eliminating or expelling the pathogenic factors, alleviating pain, and treating the root cause of the arthritic or obstructive symptoms.1,2 The analgesic effect of acupuncture is discussed in detail in Chapter 6. The various mechanisms include biomechanical tissue response, “blocking” pain signals by rapid transmission of signals along small myelinated type II and III afferent nerve fibers, by stimulating the release of opioids and other neurotransmitters to modulate pain, and by influencing immune response. Acupuncture also increases blood flow both centrally and peripherally,3 thereby augmenting the supply of oxygen and nutrients to arthritic joints. Acupuncture further helps

  Tab le 11-1 

Prognosis of Juvenile Rheumatoid Arthritis by Type of Onset Onset Type

Course Subtype

Subsequent Clinical Manifestations

Outcome

Polyarthritis

RF-seropositive

Female Older age Hand/wrist Erosions Nodules Unremitting Female Young age — Female Young age Chronic anterior uveitis (iridocyclitis) Polyarthritis Erosions Unremitting Male Older age — — Erosions

Poor

ANA-seropositive

Oligoarthritis

Seronegative ANA-seropositive

RF-seropositive

HLA-B27-positive

Systemic disease

Seronegative Oligoarthritis Polyarthritis

From Cassidy JT, Petty RE, editors: Textbook of pediatric rheumatology, ed 4, Philadelphia, 2001, Saunders. ANA, Antinuclear antibody; RF, rheumatoid factor.

Good Variable Excellent (except eyes)

Poor

Good Good Good Poor

Arthritis  155 arthritis through modulation of the inflammatory response, with a decrease in vascular permeability and modulation of proinflammatory neuropeptides. Recent information demonstrates that acupuncture modulates mediators of inflammation via common pathways as analgesia.4 Acupuncture released β-endorphin interacts with some cytokines by diminishing proinflammatory cytokines, such as IL-1β and tumor necrosis factor (TNF)-α, and by increasing levels of antiinflammatory interleukins, such as interleukin (IL)-2, IL-4, IL-6, and IL-10 levels, and (24±27)5 plasma interferon (IFN)-γ.5 Clinical application of the antiinflammatory effect includes increasing IL-2 in arthritis.6

Rheumatoid Arthritis Evidence-Based Information Although there is extensive evidence of acupuncture efficacy in pain relief, the utility and efficacy of acupuncture in treating rheumatoid arthritis (RA) has not been demonstrated in large, randomized controlled trials (RCTs) in adults or children.7 Clinical reports indicate that as much as 70% successful pain elimination or modulation can occur in patients with various chronic pain syndromes, including arthritis.8,9 ST36 and LI4 are the two most widely used acupoints in experimental studies for acupuncture analgesia.10,11 A ­clinical report from Taiwan indicates that needling at Hoku (LI4) resulted in increase of regional blood flow and increase in temperature.12 Acupuncture at Hoku point produced analgesia that peaked at 20 to 40 minutes after the needle insertion and diminished 45 minutes after the needles were removed, with a half-life of 16.2 ± 1.9 minutes. A greater increase in pain threshold was produced when both Hoku and Zusanli points were stimulated simultaneously than when either was stimulated alone.11 A clinical study from China of 12 adults with RA demonstrated modulation of immunoglobulins by decreasing IgG, IgA, and IgM.13 A small randomized controlled grial from China showed that the IL-2 levels—a very important signal for regulating immune response—were lower in patients with RA. After acupuncture treatment, the IL-2 level increased significantly.14 A clinical trial from Russia demonstrated that multimodal treatment including acupuncture was found to be effective in treating adult RA.15 Another Russia study using laser therapy produced insignificant effect on 82 children with active JRA, whereas adults with moderate RA responded well.16 An animal study from China demonstrated laser acupuncture treatment on ipsilateral Kun-Lun BL60 point for 10 minutes every day for 5 days reduced pain and swelling in the ankle.17 An animal study from China applied electroacupuncture (EA) at 100 Hz and 15 Hz on bilateral Yanglingpuan GB34 acupoints and demonstrated 15-Hz EA was effective for analgesia and significantly lowered spinal glutamic acid content, which suggests that modulation of spinal glutamic acid may be an analgesic effect of EA.18

Suggestions for Acupuncture Treatment of Arthritis Specific acupuncture treatment for JRA should be carried out by a practitioner experienced in assessing the underlying predisposing factor, the specific channel(s) involved with the

joints, and the pathogenic influences. The following suggestions are for simple, general pain relief.

General pain relief Use ST36 and LI4 for general pain relief. A word of caution in applying LI4 in children: Because LI4 is a very strong dispersing (sedating) point, it would not be advisable to use it alone, especially in children who are deficient. ST36 and LI4 together can be a potent combination for stimulating immunity as well. General points according to pathogenic etiology: • Wind: BL17 • Cold: GV14, BL23 • Dampness: BL202

Regional pain relief For local treatment of affected areas: Fingers: Ba Xie, TE5, SI52 Wrist: TE4, TE5, SI4, P7, LI51 Hip: GB30—the most important local point SP12—use in addition to GB30 when pain extends to the groin2 Knee: local points: ST34, GB33, ST36, SP10, LR8, SP91 Ankle: SP5,2 BL6017 Immunostimulant points: LI4, LI11, ST36, SP6, BL11, BL20, BL23, CV1219 Aromatherapy Analgesic and antiinflammatory essential oils are recommended to aid in the reduction of symptoms in RA.1,2 These include German chamomile (Matricaria recutita), rosemary (Rosmarinus officinalis), black pepper (Piper nigrum), eucalyptus (Eucalyptus sp.), lavender (Lavandula angustifolia) and lemongrass (Cymbopogon citratus). Essential oils are applied by massage, in a warm or cold compress over a painful area, or in the bath. In a small pilot study, nine adults with RA were randomly assigned to one of three groups: control, treatment with massage, and treatment with lavender aromatherapy massage. The results were contradictory: Although self-assessment by visual analog scale revealed no change in pain or sleep, interview data indicated that subjects in the aromatherapy massage group reported a reduced intake of analgesics and improvement in sleep.3 Chiropractic A single case is found in the literature referring to chiropractic management of arthritis: a 51-year-old female, who did not respond to a wide variety of pharmaceuticals and dietary modifications, underwent chiropractic care and had complete elimination of pain within 8 weeks of her initial visit.1 It is important to note that arthritic conditions commonly lead to subluxation complex (SC) in affected individuals. The medical subluxation is commonly understood to result from arthridites.2,3 The spine (especially cervical) of the person with arthritis will likely require more frequent attention.4 Brainstem compression may follow upper cervical subluxation resulting from translocation of the odontoid secondary to arthritic changes.5,6 Cord compression may lead to the development of

156  Common Pediatric Conditions quadriplegia, headache, paresthesia, and perhaps even sudden death.3 The chiropractor must take care to identify such extreme subluxation and modify any corrective technique accordingly. Adjustments are specifically recommended in cases of juvenile chronic arthritis.7 Stretches and exercises that endeavor to maintain normal ranges of motion at affected joints may diminish degenerative changes.8 Omega-3 fatty acids (EPA/DHA) may inhibit cartilaginous degeneration.9 It is also advisable to eliminate trans fats, as they compete for essential fatty acid sites and establish a pro­ inflammatory process. Glucosamine sulfate has been shown to enhance joint function and cartilaginous resilience.10 Chiropractors recommend avoidance of NSAIDs because of the destructive effects on joints and other organ systems.11 A trial of gluten elimination may reduce symptoms.12 Hair analysis, comprehensive blood profile, digestive stool analysis, and urine analysis may be productive in identifying a particular agent, deficiency, or condition contributing to the problem. Herbs—Western JRA is a chronic disease that may require an integrative approach of therapy including nonsteroidal and/or steroidal antiinflammatory medications as well as antirheumatic drugs. Providers are urged to use caution with patients identified as using herbal therapies in light of potential interactions or side effects of drugs or herbal products. Turmeric (Curcuma longa) may be applied topically or orally. It is a common ingredient in foods and is believed to be safe.1 Turmeric’s major active constituents include curcumin (diferuloylmethane), a yellow pigment for which a single study suggested may have some effects in adult individuals with RA.2 There is no evidence to establish its effectiveness in children with RA. The root and rhizome of ginger (Zingiber officinale) are thought to possess antiinflammatory properties that make it an oral treatment for individuals with RA. Active ingredients such as gingerol, gingerdione, and shogaol are believed to be active in suppressing inflammation via the cyclooxygenase pathway3 and other cytokine pathways. Although generally regarded as safe by the Food and Drug Administration, there are no studies to gauge its effectiveness for children with RA and little evidence to support its use for adults with symptoms of RA. When administered orally, the ingredients found in evening primrose oil (Oenothera biennis)—γ-linoleic acid, linoleic acid, and vitamin E—are thought to possess antiinflammatory properties. There is no evidence to support its effectiveness in children. Limited evidence in adult studies also shows no clear benefit regarding symptoms of RA in children.4-6 Evaluation of the extract of willowbark (see Chapter 39, Headache, discussion of salicin) in a double-blind controlled trial of adult patients with RA did not find it to be effective for pain control or arthritis symptoms (dose 240 mg/day).7 Salicylates are sometimes used for RA in children. Willowbark

is a natural source for this herbal ingredient, but there is no evidence for its use and efficacy in children. Owing to concerns about Reye’s syndrome and associated fatty hepatitis and encephalopathy, families should consult a physician regarding ongoing use of willowbark. Recent double-blind studies have shown some benefit of borage oil in treatment in adults of rheumatoid arthritis.8,9 In RCTs of adults, 1.4 g/day γ-linolenic acid in borage seed oil was necessary to derive the expected benefits.8 TNF-α has been shown to be a central mediator of inflammatory and joint destructive processes in rheumatoid arthritis.10 There are no studies regarding the effectiveness of this therapy in children. Homeopathy Before using this section, please see Appendix A, Homeopathy, for definitions of practitioner expertise categories and for general information on prescribing homeopathic medicines.

Practitioner Expertise Category 3 There are no controlled clinical trials of homeopathic treatment for arthritis, although the homeopathic literature contains evidence for its use in the form of accumulated clinical experience. Homeopathic treatment can be used safely for arthritis, either alone or in combination with other treatment modalities. Because arthritis is a complex medical problem, often involving autoimmune processes or infectious agents, successful homeopathic treatment usually requires extensive training in the art and science of homeopathy. Any one of many homeopathic medicines may be used to treat arthritis, depending on the characteristics of the patient being treated. Sophisticated homeopathic analysis and long-term follow-up are required. For these reasons, specific medicines for treating arthritis are not presented here. Interested readers are referred to the homeopathic literature for further study. Magnet  Therapy When only one joint is involved, the labeled bionorth side of a 3950-gauss ceramic block magnet should be applied to one side of the joint and the opposite (biosouth) side of a similar magnet to the other side of the involved joint. The size of the magnets used should be proportionate to the size of the child’s involved joint. The two magnets should be positioned so as to attract each other, creating a concentrated field within the joint. Magnets can be secured in position with an elastic wrap and left in place for up to 48 hours, and the treatment may be repeated two times per week. Magnets may be obtained from Painfree Lifestyles (800-480-8601) or AHSM (800-635-7070). Massage Therapy Studies have concluded that massage is an effective therapy for the management of chronic and acute pain. Research has shown elevated plasma β-endorphin levels following massage therapy,1 which may explain some of its pain-reducing properties. Theorists have postulated that massage therapy may decrease substance P levels during massage treatment, but controlled studies have yet to be done. A systematic review of

Arthritis  157 22 articles on the effects of massage therapy on relaxation and comfort indicated significantly decreased anxiety or perception of tension in 8 of 10 studies; physiological relaxation was produced in 7 of 10 studies, and massage effectively reduced pain in 3 studies.2 The efficacy of massage therapy to decrease pain scores in acute postoperative pain management has also been demonstrated.3-7 A randomized controlled study in children with JRA who received 15 minutes daily parental massage reported lower parental and child anxiety scores, lower salivary cortisol levels, decreased self-reported pain, parental reports of decreased pain, and physician reports of less pain and morning stiffness compared with a control group who received relaxation interventions.8 Swedish massage is an effective, gentle treatment for children with arthritic pain; it is also relatively easy to teach parents and caregivers. It is recommended not to massage directly over areas of acute inflammation; however, massage can be performed on areas of chronic inflammation. Effleurage and petrissage to the long, broad muscles of the body can help relieve pain in the joints associated with these muscle groups, as massage directly on the affected joints may be uncomfortable for children. For example, both massage strokes could be applied to the quadriceps and the hamstrings to help relieve hip pain; for knee pain, both of these muscle groups plus the lower leg muscles (the peroneals, dorsiflexors, soleus, and gastrocnemius) should be massaged. If a child is affected by knee pain, massage to the arches of the feet can help relax the peroneal and dorsiflexor muscles, which insert into the knee. Massage should never be done on the back of the knee, as this is considered an endangerment site. Similarly, for joint involvement of the upper extremities, the same approach should be used. For shoulder pain, massage to the upper arm muscles (triceps and biceps) and the shoulder muscles (latissimus dorsi, deltoid, and pectorals) using effleurage and petrissage may be helpful. Care should be taken not to put the shoulder into hyperextension, which puts an inflamed joint at risk for dislocation. Care should also be taken not to massage in the axillae, as this is an endangerment site. In older children, areas of breast tissue should be avoided when trying to massage the pectoral muscles, as these areas may be tender for both genders. Avoidance may be accomplished by using localized effleurage strokes directly along the sternum and just below the clavicle out toward the shoulder joint. Some older children may prefer to do this stroke themselves for improved comfort levels. Elbow pain may be relieved by the mentioned massage strokes applied to the muscles of the upper arm (biceps and triceps) as well as brachioradialis. Massage specifically to the brachioradialis is best accomplished using flat, broad effleurage, as deeper strokes may be uncomfortable for that muscle grouping. Massage to the digits can best be done with a distal to proximal and back motion (“give me the money sign” gesture) along each bicep muscle of the fingers or toes. This will help avoid the joint areas and have the most impact. It will also help massage the muscles of the digits rather than the tendons and tissue located in the lateral aspects of the digits.

If a child does not have symmetrical joint involvement, an alternative to massaging near affected areas is to massage the mirror opposite of the area. For example, if the right knee is acutely inflamed and the leg is painful to touch, massage to the muscles of the left leg can help reduce pain on the right (see Chapter 3). For children who suffer from morning stiffness, parental massage to the affected extremities prior to the child arising in the morning may help to warm up the body tissues and decrease immediate pain caused by movement and stiffness. Nutrition

Discussion As RA is caused by a pathological immune response to some environmental insult, a link to food triggers has been studied. It is theorized that certain food allergies may trigger an antibody response forming immune complexes that damage the intestinal wall, causing increased permeability. This increased permeability allows for the absorption of microbial antigens similar to protein found in the joint tissues. The body recognizes these antigens as foreign and attacks these proteins, but it also attacks the protein in joint tissues.1 Studies have shown that dietary changes can decrease the symptoms of arthritis. Fasting from food, followed by a vegetarian diet, has been studied extensively in patients with RA. A systematic review of controlled studies that lasted for at least 3 months showed a statistically and clinically significant long-term beneficial effect to this dietary approach.2 This review concluded that fasting for 7 to 10 days followed by a vegetarian diet might be a useful treatment for RA. Further study into the mechanism of this strategy found that a vegetarian diet produced a reduction in the level of proteus antibody.3 High anti-proteus antibodies in serum and proteus found in urine are isolated in higher numbers in patients with RA and are thought to play an etiopathogenic role.4 Supplementing the diet with fish oil fatty acids (omega-3 combination of EPA/DHA) demonstrated a decrease in symptoms of RA and a reduction in neutrophil leukotriene B-4 production.5 A subsequent study found greater effects with higher doses of EPA and DHA, with no increase of side effects. This second study also demonstrated a decrease in macrophage IL-1 production as well as improved clinical measures.6 A more recent study investigated the effects of a vegetarian diet (considered an antiinflammatory diet [A-ID] providing an arachidonic acid intake of less than 90 mg/day) alone or in combination with supplemental fish oil capsules. This was compared with a conventional western diet (WD) (considered high in arachidonic acid) with and without fish oil supplementation. A-ID patients had a 14% reduction of tender and swollen joints during the fish oil placebo phase when compared with the WD. This change increased to 34% when fish oil was added to the A-ID. Compared with baseline, a 34% decrease in leukotriene B formation, 15% decrease in 11-dehydro-thromboxane-B level, and 21% decrease in prostaglandin metabolites were observed. This study concluded that an antiinflammatory diet augmented the beneficial effects of fish oil supplementation.7

158  Common Pediatric Conditions Other studies have considered the effects of allergic foods on RA. The most common offenders are wheat, corn, milk, beef, and foods from the night shade family (e.g., tomato, potato, eggplant, pepper, tobacco). RA patients with a positive skin-prick test to food extracts were compared with patients with negative tests. Both groups fasted from the most common allergenic foods for 12 days and were then challenged with various allergenic foods for 12 days. Re-elimination was carried out before the next challenge. Results of this study found significant increases in pain, stiffness, and number of tender swollen joints and increases in TNF-α, IL-β, ESR, and CRP levels with the food challenges in the patients with positive skin prick tests. No significant change in any of the variables except pain was found in the skin prick–negative group. The researchers conclude that individualized diet revisions may regulate TNF-α and IL-1β levels in selected patients with RA.8

Treatment Nutritional management for RA might include the following recommendations: • Fasting is not generally recommended for children and ado­ lescents; however, a medically supervised antiinflammatory diet could be started to lower the intake of arachidonic acids. A diet high in fresh fruits and vegetables provide the best sources of dietary antioxidant, which neutralizes free radicals involved in the inflammatory process. Pineapple is a rich source of bromelain, a mixture of enzymes that block the production of the inflammatory kinins. Bromelain also breaks down immune complexes that cause tissue ­destruction. • Supplement the diet with fish oil capsules using approximately 54 mg/kg of EPA and 36 mg/kg of DHA per day. • The diet should also be supplemented with vitamin B12, as this is not present in a vegetarian diet. • Investigate for food allergies, and eliminate foods that test positive in that individual. Osteopathy Arthritis in children has typically been described as inflammatory, metabolic, or infectious. Recently the incidence of functional musculoskeletal pain syndromes including fibromyalgia and chronic fatigue has increased in older children, teenagers, and young adults. In all of these conditions, musculoskeletal pain and stiffness are primary complaints. General osteopathic management includes appropriate medical care where indicated, complemented by osteopathic procedures to address the pain and lost mobility. The pain of arthritis is twofold: the inflammation within the articular compartment activates joint nociceptors, which in turn generate a reflexive contraction of the muscle stabilizers of the involved joint. The maintained ­contraction produces irritation of the muscle afferents, alters joint mechanics, and increases unit load across the articular surface. As a result the child has pain from the primary etiology of the arthritis in addition to pain from the compensatory responses of the surrounding tissues. Although different pathologies require slightly different approaches and goals of treatment, in general osteopathic manipulation is used to decrease the nociceptive drive from the surrounding tissues and

normalize joint mechanics. The choice of techniques employed depends upon the etiology of the problem, the child’s age, and associated comorbidities. Usually the child is encouraged to practice age-appropriate postural rebalancing exercises to reinforce the changes made in the treatment. Examples of postural rebalancing or core stabilization activities might include martial arts, yoga, or horseback riding for an older child. A younger child might benefit from a “gymboree” program. Infectious arthropathies need to be treated with appropriate antibiotics. In the acute phase, the osteopathic practitioner employs the respiratory-circulatory model as a framework for the use of osteopathic manipulation to improve lymphatic and venous drainage from the area and perfusion and antibiotic delivery to the involved tissues. Lymphatic, myofascial, and most indirect techniques are appropriate in these children. Once appropriate tissue levels of the antibiotics are obtained and the condition is stable, osteopathic management is directed at maintaining range of motion and preventing intraarticular adhesions. In all cases, articulatory and direct techniques are avoided in the acute phase. Reports on the efficacy of osteopathic manipulation in the management of infectious arthritis are anecdotal. Metabolic arthritis is usually painful and involves joint stiffness. Needless to say, the underlying pathology must be addressed. Osteopathic treatment is directed at improving fluid mechanics and venous and arterial flow to the area, decreasing nociceptive drive, and rebalancing abnormal compensatory patterns in the surrounding tissue. There is only one published case study on the efficacy of osteopathic manipulative therapy in metabolic arthritis. The patient was an adult, and although the report1 had a positive outcome, it is rather out of date and poorly written by today’s standards. Inflammatory arthritis in children may be part of a rheumatological disorder, a spondyloarthropathy, or a reactive ­process to an infection or other antigen exposure. In all cases, the problem can be viewed as dysregulation of the immune system. Treatment goals include decreasing the nociceptive drive from the surrounding tissues and normalizing joint mechanics. In addition, the pathology of rheumatoid disease requires that the osteopath also address tissue dysfunction in areas that might be contributing to neuroendocrine imbalance or an increased allostatic load.2 Alterations in the neuroendocrine-immune (NEI) network are associated with rheumatological diseases.3-5 Nociceptive or pain input plays a role in the modulation of the hypothalamic-pituitary-adrenal axis6-8 and consequently in the function of the NEI network. Consequently, the osteopathic approach to a child with RA would take into consideration all the possible influences on the NEI network. Physical stress in the form of pain is only one of the possible drives on this system; social and emotional stress that may or may not be related to the child’s diagnosis may also influence neuroendocrine ­balance. In the case of reactive arthritis, the underlying condition needs to be addressed. Osteopathic manipulation may be used in conjunction to decrease pain, improve range of motion, and facilitate lymphatic function. Spondyloarthropathies, particularly ankylosing spondylitis and psoriatric arthritis, require a long-term treatment plan aimed at minimizing pain and prolonging maximum mobility. All inflammatory

Arthritis  159 arthritic conditions may benefit from interdisciplinary app­ roaches in which pharmaceutical, homeopathic, herbal, and osteopathic interventions are used concurrently. Although there are no published data, many osteopaths find combining osteopathic treatment with homeopathy or acupuncture to be beneficial for patients with inflammatory diseases. Musculoskeletal pain syndromes involve the articular and myofascial tissues and are usually multifocal or diffuse. Tender points and trigger points are often present. The symptoms are usually accompanied by fatigue, and the child may also have headaches. Osteopathic management includes emphasis on decreasing nociceptive activity and improving functional mobility. However, because of their suspected roles in the etiology of these conditions, stress and the NEI need to be addressed. Gentle direct techniques and indirect techniques are usually employed. There are no randomized controlled studies evaluating the efficacy of osteopathic manipulation in children with arthritis. A recent small randomized controlled adult study reported significant improvement in measures of pain threshold, perceived pain, attitude toward treatment, activities of daily living, and perceived functional ability in fibromyalgia patients treated with osteopathic manipulative therapy.9 There are also several case reports and articles in the older osteopathic literature. However, none would meet criteria for publication today. Ref erences Pediatric Diagnosis and Treatment   1. Weiss JE, Ilowite NT: Juvenile idiopathic arthritis, Pediatr Clin North Am 52:413-442, vi, 2005.   2. Cakmak A, Bolukbas N: Juvenile rheumatoid arthritis: physical therapy and rehabilitation, South Med J 98:212-216, 2005.   3. Behrman R, Kliegman RM, Jenson HB, editors: Nelson’s textbook of pediatrics, Philadelphia, 2004, Saunders.   4. Cassidy JT, Levinson JE, Bass JC et al: A study of classification criteria for a diagnosis of juvenile rheumatoid arthritis, Arthritis Rheum 29:274-281, 1986.   5. Juvenile rheumatoid arthritis (JRA): criteria for JRA. Available at www.reheumatology.org. Accessed December 2004.   6. Manners PJ: Epidemiology of the rheumatic diseases of childhood, Curr Rheumatol Rep 5:453-457, 2003.   7. Nepom BS, Glass DN: Juvenile rheumatoid arthritis and HLA: re­port of the Park City III workshop, J Rheumatol Suppl 33:70-74, 1992.   8. Azouz EM: Arthritis in children: conventional and advanced imaging, Semin Musculoskelet Radiol 7:95-102, 2003.   9. Babyn P, Doria AS: Radiologic investigation of rheumatic diseases, Pediatr Clin North Am 52:373-411, vi, 2005. 10. Lovell DJ, Ruth NM: Pediatric clinical research, Curr Opin Rheumatol 17:265-270, 2005. 11. Reiff AO: Developments in the treatment of juvenile arthritis, Expert Opin Pharmacother 5:1485-1496, 2004. 12. Kotaniemi K, Savolainen A, Karma A et al: Recent advances in uveitis of juvenile idiopathic arthritis, Surv Ophthalmol 48: 489-502, 2003. 13. Petty RE, Smith JR, Rosenbaum JT: Arthritis and uveitis in children. A pediatric rheumatology perspective, Am J Ophthalmol 135:879-884, 2003. 14. Cassidy JT, Petty RE: Juvenile rheumatoid arthritis. In Textbook of pediatric rheumatology, ed 4, Philadelphia, 2001, Saunders. 15. Feldman BM: Treating children with arthritis: towards an evidence-based culture, J Rheumatol Suppl 72:33-35, 2005.

Acupuncture 1. O’Connor J, Bensky D, editors: Acupuncture, a comprehensive text, Seattle, 1981, Eastland Press. 2. Maciocia G: The practice of Chinese medicine, the treatment of diseases with acupuncture and Chinese herbs, London, 1994, Churchill Livingstone. 3. Liu Q: Effects of acupuncture on hemorheology, blood lipid content and nail fold microcirculation in multiple infarct dementia patients, J Tradit Chin Med 24:219-223, 2004. 4. Gollub RL, Hui KK, Stefano GB: Acupuncture: pain management coupled to immune stimulation, Zhongguo Yao Li Xue Bao 20:769-777, 1999. 5. Bonta IL: Acupuncture beyond the endorphin concept? Med Hypotheses 58:221-224, 2002. 6. Lau BHS, Wong DS, Slater JM: Effect of acupuncture on allergic rhinitis: clinical and laboratory evaluations, Am J Chin Med 3: 263-270, 1975. 7. Berman BM, Swyers JP, Ezzo J: The evidence for acupuncture as a treatment for rheumatologic conditions, Rheum Dis Clin North Am 26:103-115, ix-x, 2000. 8. Ulett GA, Han J, Han S: Traditional and evidence-based acupuncture: history, mechanisms, and present status, South Med J 91:1115-1120, 1998. 9. Ng DK, Chow PY, Ming SP et al: A double-blind, randomized, placebo-controlled trial of acupuncture for the treatment of childhood persistent allergic rhinitis, Pediatrics 114:1242-1247, 2004. 10. Wu MT, Hsieh JC, Xiong J et al: Central nervous pathway for acupuncture stimulation: localization of processing with functional MR imaging of the brain—preliminary experience, Radiology 212:133-141, 1999. 11. Ulett G, Han S, Han JS: Electroacupuncture: mechanisms and clinical application, Biol Psychiatry 44:129-138, 1998. 12. Kuo TC, Lin CW, Ho FM: The soreness and numbness effect of acupuncture on skin blood flow, Am J Chin Med 32:117-129, 2004. 13. Guan ZJ, Zhang J: Effects of acupuncture on immunoglobulins in patients with asthma and rheumatoid arthritis, Tradit Chin Med 15:102-105, 1995. 14. Xiao J, Liu X, Sun L et al: Experimental study on the influence of acupuncture and moxibustion on interleukin-2 in patients with rheumatoid arthritis [in Chinese], Zhen Ci Yan Jiu 17:126-128, 132, 1992. 15. Zherebkin VV: The use of acupuncture reflexotherapy in treating patients with rheumatoid arthritis [in Russian], Lik Sprava NovDec:175-177, 1997. 16. Polushina ND, Grinzaid IuM, Shliapak EA et al: A clinical and experimental analysis of the effects of laser therapy [in Russian], Vopr Kurortol Fizioter Lech Fiz Kult Jul-Aug:14-16, 1997. 17. Zhu L, Li C, Ji C et al: The effect of laser irradiation on arthritis in rats [in Chinese], Zhen Ci Yan Jiu 15:71-76, 1990. 18. Cao W, Deng Y, Dong X et al: Effects of electroacupuncture at different frequencies on the nociceptive response and central contents of GABA and glutamic acid in arthritic rats [in Chinese], Zhen Ci Yan Jiu 18:48-52, 1993. 19. Rogers PA, Schoen AM, Limehouse J: Acupuncture for immunemediated disorders. Literature review and clinical applications, Probl Vet Med 4:162-193, 1992.

Aromatherapy 1. Battaglia S: The complete guide to aromatherapy, Virginia, Queensland, Australia, 1995, The Perfect Potion. 2. Buckle J: Clinical aromatherapy: essential ols in practice, ed 2, ­Ediburgh, 2003, Churchill Livingstone. 3. Brownfield A: Aromatherapy in arthritis: a study, Nurs Stand 13:34, 1998.

160  Common Pediatric Conditions Chiropractic 1. Nelson WA: Rheumatoid arthritis: a case report, Chiro Tech 2: 17-19, 1990. 2. Matthews JA: Atlanto-axial subluxation in rheumatoid arthritis: a five-year follow-up study, Ann Rheum Dis 33:526-531, 1974. 3. Robinson HS: Rheumatoid arthritis—atlanto-axial subluxation and its clinical presentation, Can Med Assoc J 94:470-477, 1966. 4. Lantz CA: Inflammation hypothesis. In Leach RA, editor: The chiropractic theories, Baltimore, 2004, Lippincott Williams and Wilkins. 5. Leach RA: Instability hypothesis. In Leach RA, editor: The chiropractic theories, Baltimore, 2004, Lippincott Williams and Wilkins. 6. Davidson RC, Horn JR, Herndon JH et al: Brain stem compression in rheumatoid arthritis, J Am Med Assoc 238:2633-2634, 1977. 7. Perussi RM, Rubin BR, Blackwell D: Juvenile rheumatoid arthritis, J Am Osteopath Assoc 96:298-301, 1996. 8. Koes BW, Bouter LM, van Mameren H et al: A randomized clinical trial of manual therapy and physiotherapy for persistent low back and neck complaints: subgroup analysis and relationship between outcome measure, J Manipulative Physiol Ther 16: 211-219, 1993. 9. Curtis CL, Hughes CD, Falnnery CR et al: n-3 fatty acids specifically modulate catabolic factors involved in articular cartilage degradation, J Biol Chem 275:721-724, 2000. 10. Gottlieb MS: Conservative management of spinal osteoarthritis with glucosamine sulfate and chiropractic treatment, J Manipulative Physiol Ther 20:400-414, 1997. 11. Leach RA, Lantz CA: Immobilization degeneration hypothesis. In Leach RA, editor: The chiropractic theories, Baltimore, 2004, Lippincott Williams and Wilkins.

Herbs—Western 1. U.S. Food and Drug Administration: EAFUS: a food additive database. Available at http://vm.cfsan.fda.gov/~dms/eafus.html. Accessed January 25, 2005. 2. Deodhar SD, Sethi R, Srimal RC: Preliminary study on antirheumatic activity of curcumin (diferuloyl methane), Indian J Med Res 71:632-634, 1980. 3. Srivastava KC, Mustafa T: Ginger (Zingiber officinale) and rheumatic disorders, Med Hypoth 29:25-28, 1989. 4. Belch JJ, Ansell D, Madhok R et al: Effects of altering dietary essential fatty acids on requirements for non-steroidal anti-inflammatory drugs in patients with rheumatoid arthritis: a double blind placebo controlled study, Ann Rheum Dis 47:96-104, 1988. 5. Belch J, Hill A: Evening primrose oil and borage oil in rheumatologic conditions, Am J Clin Nutr 71:352S-356S, 2000. 6. Hansen TM, Lerche A, Kassis V et al: Treatment of rheumatoid arthritis with prostaglandin E1 precursors cis-linoleic acid and gamma-linolenic acid, Scand J Rheumatol 12:85-88, 1983. 7. Biegert C, Wagner I, Ludtke R et al: Efficacy and safety of willow bark extract in the treatment of osteoarthritis and rheumatoid arthritis: results of 2 randomized double-blind controlled trials, J Rheumatol 31:2121-2130, 2004. 8. Leventhal LJ, Boyce EG, Zurier RB: Treatment of rheumatoid arthritis with gammalinolenic acid, Ann Intern Med 119:867-873, 1993. 9. Kremer JM: n-3 Fatty acid supplements in rheumatoid arthritis, Am J Clin Nutr 71(Suppl):349S-351S, 2000. 10. Kast RE: Borage oil reduction of rheumatoid arthritis activity may be mediated by increased cAMP that suppresses tumor necrosis factor-alpha, Int Immunopharmacol 1:2197-2199, 2001.

11. Blumenthal M, editor: The complete German Commission E monographs: therapeutic guide to herbal medicines, Boston, 1998, American Botanical Council (Translation by S Klein). 12. Frondoza CG, Sohrabi A, Polotsky A et al: An in vitro screening assay for inhibitors of proinflammatory mediators in herbal extracts using human synoviocyte cultures, In Vitro Cell Dev Biol Anim 40:95-101, 2004. 13. Yoshida S, Takayama Y: Licorice-induced hypokalemia as a treatable cause of dropped head syndrome, Clin Neurol Neurosurg 105:286-287, 2003.

Homeopathy 1. ReferenceWorks Pro 4.2, San Rafael, Calif, 2008, Kent Homeopathic Associates.

Massage Therapy 1. Kaada B, Torsteinbo O: Increase of plasma endorphins in connective tissue massage, Gen Pharmacol 20:487-489, 1989. 2. Field T, Hernandez-Reif M, Seligman S et al: Juvenile rheumatoid arthritis benefits from massage therapy, J Pediatr, Psychol 22:607617, 1997. 3. LeBlanc-Louvry I, Costaglioli B, Boulon C et al: Does mechanical massage of the abdominal wall after colectomy reduce postoperative pain and shorten the duration of ileus? Results of a randomized study, J Gastrointest Surg 6:43-49, 2002. 4. Piotrowski MM, Paterson C, Mitchinson A et al: Massage as adjunctive therapy in the management of acute postoperative pain: a preliminary study in men, J Am Coll Surg 197:1037-1046, 2003. 5. Taylor AG, Galpner DI, Taylor P et al: Effects of adjunctive Swedish massage and vibration therapy on short-term postoperative outcomes: a randomized, controlled trial, J Altern Complement Med 9:77-89, 2003. 6. van der Dolder PA, Roberts DL: A trial into the effectiveness of soft tissue massage in the treatment of shoulder pain, Aust J Physiother 49:183-188, 2003. 7. Mitchinson AR, Kim HM, Rosenberg JM et al: Acute postoperative pain management using massage as an adjuvant therapy: a randomized trial, Arch Surg 142:1158-1167, 2007. 8. Field T, Hernandez-Reif M, Seligman S et al: Juvenile rheumatoid arthritis benefits from massage therapy, J Pediatr Psychol 22: 607-617, 1997.

Nutrition 1. Pizzorno LU, Pizzorno JE, Murray MT: Natural medicine: instructions for patients, London, 2002, Churchill Livingstone. 2. Muller H, deToledo FW, Resch KL: Fasting followed by vegetarian diet in patients with rheumatoid arthritis: a systematic review, Scand J Rheumatol 30:1-10, 2001. 3. Kjeldsen-Kragh J, Rashid T, Dybwad A et al: Decrease in antiProteus mirabilis but not anti-Escherichia coli antibody levels in rheumatoid arthritis patients treated with fasting and a one year vegetarian diet, Ann Rheum Dis 54:221-224, 1995. 4. Wilson C, Thakore A, Isenberg D et al: Correlation between antiProteus antibodies and isolation rates of P. mirabilis in rheumatoid arthritis, Rheumatol Int 16:187-189, 1997. 5. Kremer JM, Jubiz W, Michalek A et al: Fish-oil fatty acid supplementation in active rheumatoid arthritis. A double-blinded, controlled, crossover study, Ann Intern Med 106:497-503, 1987. 6. Kremer JM, Lawrence DA, Jubiz W et al: Dietary fish oil and olive oil supplementation in patients with rheumatoid arthritis. Clinical and immunologic effects, Arthritis Rheum 33:810-820, 1990.

Arthritis   161 7. Adam O, Beringer C, Kless T et al: Anti-inflammatory effects of a low arachadonic acid diet and fish oil in patients with rheumatoid arthritis, Rheumatol Int 23:27-36, 2003. 8. Karatay S, Erdem T, Yildirim K et al: The effect of individualized diet challenges consisting of allergenic foods on YNF-alpha and IL-1 beta levels in patients with rheumatoid arthritis, Rheumatol (Oxford) 43:1429-1433, 2004.

Osteopathy 1. DeShazer JD, Davis LB: Gout, J Osteopath 9:126, 1902. 2. Seeman TE, Singer BH, Rowe JW et al: Price of adaptation— allosteric load and its health consequences, Arch Intern Med 157: 2259-2268, 1997. 3. Sternberg EM, Chrousos GP, Wilder RL et al: The stress response and the regulation of inflammatory disease, Ann Intern Med 117:854-866, 1992. 4. Sternberg EM: Neuroendocrine factors in susceptibility to inflammatory disease: focus on the hypothalamic-pituitary-adrenal axis, Horm Res 43:159-161, 1995.

5. Sternberg EM, Licinio J: Overview of neuroimmune stress interactions—implications for susceptibility to inflammatory disease, Ann NY Acad Sci 771:364-371, 1995. 6. Donnerer J: Nociception and the neuroendocrine-immune system. In Willard FH, Patterson M, editors: Nociception and the neuroendocrine-immune connection, Indianapolis, 1992, American Academy of Osteopathy. 7. Esterling B: Stress-associated modulation of cellular immunity. In Willard FH, Patterson M, editors: Nociception and the neuroendocrine-immune connection, Indianapolis, 1992, American Academy of Osteopathy. 8. Vaccarino AL, Couret LC Jr: Relationship between hypothalamic-pituitary-adrenal activity and blockade of tolerance to morphine analgesia by pain: a strain comparison, Pain 63: 385-389, 1995. 9. Gamber RG, Shores JH, Russo DP et al: Osteopathic manipulative treatment in conjunction with medication relieves pain associated with fibromyalgia syndrome: results of a randomized clinical pilot project, J Am Osteopath Assoc 102:321-325, 2002.