Ayurvedic Treatment for Juvenile RA sticks to the basic concept of preserving digestion for the treatment of chronic illness. JRA (juvenile rheumatoid arthritis or juvenile RA) , also known as juvenile idiopathic arthritis (JIA) is a term used to mention many chronic arthritic conditions in children. Though many in number & types, all of these conditions have many clinical features and historical details in common. One or more swollen and inflamed joints, limited range of movements, painful joint(s) when moved, and a rise in temperature of the affected joint(s). These symptoms should last for 6 weeks or more in a child less than 16 years of age.
JRA is the most common chronic joint disorder of paediatrics, and the exact cause(s) is not yet known. Both environmental and genetic influences are known to cause or worsen the condition.
Signs & symptoms
High fevers that peak mostly in the evening
Limping
Acute and severe joint pain
Sore wrist, finger or knee.
Stiffness in neck, hip or any other joints
Stiffness of joint which worsens after rest.
Red, warm, tender and swollen joints.
Skin rashes which are on and off, over one or more area.
Causes
While no specific cause(s) of JRA have been determined, there is strong evidence of both genetic and environmental factors being implicated in the development of the disease.
Chance of JRA in one of the twins indicate the probability of the other one to develop the same.
Though the exact cause is not known, a misdirected or malfunctioning immune system is observed in children with JRA. The cell based and humeral based elements of immunity react against the patient’s own body structures (joints, muscles, eye tissues, etc.). It shows an auto-immune/auto-inflammatory etymology.
Pathophysiology
There are six broad categories of JRA. These include
- Systemic onset JRA,
- Oligoarticular JRA (containing two subgroups),
- Polyarticular JRA (containing two subgroups),
- Psoriatic arthritis
- Enthesitis-related arthritis, and
- Undifferentiated arthritis.
The specific criteria necessary to establish a diagnosis and prognosis for each category are as follows.
One characteristic common to all six forms of JRA is that of “morning stiffness” that improves as the day progresses and by increased movement. Also, specific patterns of flare up s and improvement, independent of therapy are observed.
- Systemic onset JRA
It must have arthritis (swelling, pain, and warmth) of one or more joints associated with a minimum of two weeks with fever on a daily basis. The fever is often greater than 102 F (39 C) and usually spikes once or twice a day and may have the unique pattern of returning to below normal between rises. There will be a salmon-colored rash, swelling of lymph nodes, liver & spleen. Inflammation of the lungs & the pericardium and other organs may occur. During febrile episodes, children appear sick, but once the fever is subsided, they feel better. Systemic onset JRA affects approximately 10%-15% all children suffering from JRA. It affects both boys and girls equally), with symptoms usually starts at 3-5 years of age. There is no unique laboratory test for JRA, but children typically have anemia and elevation of white blood cell, ESR and platelet counts. Complications of systemic onset JRA may include slower than expected growth, fragile bones, liver and lung malfunctions etc. The prognosis is generally noted to depend upon the severity of arthritis with many/most of the systemic symptoms resolving over months to years with a very low mortality rate. Since the diagnosis of systemic onset of JRA is one of exclusion, the chance of infection, malignancy, and rheumatic fever should be considered.
- Oligoarticular JRA: Oligoarticular RA affects four or fewer joints in the first six months of the disease. This form of JRA is seen in half of all cases of pediatric chronic arthritis.
It starts at 2-4 years of age and it affects girls more than boys with a ratio of 3:1.
Single large joint (mostly knee joint) is involved.
Morning stiffness present
The primary complication of oligoarticular JRA is inflammation of the iris of the eye which can lead to complications like clouding of the cornea (cataracts), glaucoma, and vision loss. So, regular check up with an ophthalmologist is advised.
Conditions that should be eliminated prior to establishing a diagnosis of oligoarticular JRA include trauma, infection, malignancy, and arthritis followed by an infection.
It is subdivided into two groups.
– Only four or lesser joints involved in the entire period of disease.
– More than four-joint involved after the first six months of illness.
3. Polyarticular juvenile rheumatoid arthritis:
Five or more joints affected with arthritis during the first six months of their disease.
Polyarticular JRA patients can be divided into two subgroups based upon laboratory findings.
-Rheumatoid Arthritis factor “RA” positive): It affects between 5%-10% of all patients with JRA. Teenage girls are affected mostly. Generally, small joints (such as the hands and feet) are affected, and a severe pathology and symptoms are observed.
– “RA” negative polyarticular JRA affected individuals tend to have a milder course and easier to handle when compared.
Fatigue, anaemia, suboptimal growth, and iritis (to a lesser degree than oligoarticular JRA) are complications. Differential diagnosis of polyarticular JRA includes infection, malignancy, and collagen vascular diseases like SLE.
- Psoriatic arthritis (PsA):
Both large and small joint arthritis and a characteristic psoriatic skin rash present in this type of JRA. Should the rash not be present, two of the following must be present:
(a) family history of psoriasis in an immediate family member,
(b) diffuse swelling of the fingers, and
(c) pitting of the nails.
Children with psoriatic arthritis have the chance to develop iritis and should have ophthalmologic evaluation every six months.
5. Enthesitis -related arthritis (ERA): Enthesitis (inflammation at the site of tendon insertion on the bone) mostly affects boys over 8 years of age and often involves the lower back, sacroiliac joints, and joints of the legs, ankles, and feet. Patients with a particular genetic marker (HLA-B27) may also develop iritis, inflammatory bowel disease, psoriasis, and/or ankylosing spondylitis. Boys to girl’s ratio of incidence is about 7:1.
6. Undifferentiated arthritis:
Two types of children come under this category
- Children who do not fit clearly into the above unique subtypes of JRA
- Those who have symptoms/laboratory studies that overlap more than one subtype.
By their nature, the patients with this form of JRA often present with nonclassical history and/or findings on physical exam and laboratory studies. Providing an accurate prognosis and developing a treatment program seem difficult.
Diagnosis
JRA is considered a diagnosis of exclusion; the diagnosis can only be confidently made
- When the patient’s history, physical exam, and laboratory findings are consistent with the textual reference
- Based upon blood values like RA factor, Total count, ESR, CRP etc.
- Based upon imaging techniques like X ray, USG, CT scan and MRI.
Other conditions to be excluded are: infection, malignancy, trauma, reactive arthritis, immunodeficiency, and other connective tissue/rheumatologic diseases (like SLE).
Treatments
Presently, there is no complete cure for JRA.
An integrated and coordinated approach has been shown to be helpful in lessening the morbidity (nonlethal side effects) of JRA. Aim is management of pain, joint contractures, and growth-related problems. Monitoring is done for complications like iritis.
Therapies for JRA patients include the following:
1. Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used as the first line of therapy due to their positive effect of reducing inflammation in arthritis and relatively few side effects. Medications such as ibuprofen (Advil, Motrin), naproxen (Aleve), and indomethacin (Indocin) are examples of this class.
2. Steroids are another common class of medications for moderate to severe arthritis or nonarthritic inflammatory consequences of JRA. These medications may be administered orally (prednisone, prednisolone ), intravenously (methylprednisolone, dexamethasone, hydrocortisone, or injected directly into an involved joint (methylprednisolone, triamcinolone). Side effects of steroids are considerable, and pediatric rheumatologists prefer to use the lowest possible dosage.
3. Antirheumatic medications (also known as disease-modifying antirheumatic drugs or DMARDs) are needed in approximately two-thirds of children to control the joint changes and prevent damage of JRA. These medications are generally considered when the medications previously described are not providing effective control of the illness. Medicines in this category include methotrexate, now considered the “gold standard” for JRA, sulfasalazine, (Azulfidine), azathioprine, (Imuran), cyclosporine etc. These medications are administered orally or intravenously. Antirheumatic medications are more potent in effect but also can have significant side effects. All of these medications require regular blood testing to monitor for side effects. Problems include immune suppression, which may cause an increased risk of infection, certain cancers, bone marrow toxicity, pulmonary toxicity, liver function abnormalities, abdominal pain, and decrease in appetite.
4. Biologic agents can lessen the morbidity for children with JRA. These agents are administered either by superficial injection under the skin or intravenously. Their general chemical classification is that of “monoclonal antibodies” that work by accurately targeting various mechanisms of the immune system that are overactive and misdirected in JRA. They are associated with an increased risk of infections and (rarely) development of certain malignancies. As such, close clinical monitoring and various laboratory studies are required. Examples of biologics used in the treatment of JRA include etanercept, anakinra, adalimumab, tocilizumab, and abatacept.
5. Autologous stem cell transplantation is reserved only for those children with JRA who have failed the above therapeutic options. This procedure requires hospitalization and is a two-step process. The initial goal is utilization of high-dose immune suppression medications to remove the patient’s lymphocytes (a type of white blood cell) that are attacking the patient’s joint(s). Once removed, new stem cells from the patient (autologous) that were previously harvested and treated are introduced back into the patient’s body via the bloodstream. This process requires expertise and is highly expensive.
Prognosis
Approximately half of children with JRA continue to have active disease into adulthood. They will have significant disability with functional limitations. Outcome depends upon chronicity, number of joints involved, and the need for systemic steroids. In the United States and Canada, death is rare (29 out of 10,000 patients) and is most likely with systemic onset JRA.
Complications
Inflammation of the iris of the eye called iritis and blindness
Growth disturbances like leg-length discrepancy
Joint contractures
Osteoporosis
Emotional stress associated with the chronic illness.
Depression.
Side effects of therapies and medications.
Disease & Ayurveda
Juvenile rheumatoid arthritis-aamavata
Nidana
Incompetent and unwholesome diet with opposite potency
Improper body postures & movements
Loss of appetite & digestive power
Exercise immediately after highly unctuous & oily food
Sedentary lifestyle
Purvaaroopa
Dourballya – Tiredness/Fatigue
Hrudayasya gauravam – Heaviness of chest
Samprapti
The ama produced due to defective digestion & sedentary lifestyle, gets lodged in the site of sleshma (Kapha) like joints with the help of Vaata and produce symptoms of Aamavaata.
Lakshana
Angamarda – bodyache
Aruchi – Loss of taste sensation
Thrishna – Excessive thirst
Alasyam – Lethargy/laziness
Gauravam – Heaviness of the body
Jwara – Fever
Apaaka – Indigestion
Soonata – Oedema
Divisions
It can develop by the vitiation of Vaata, Pitta, Kapha individually (ekadoshaja), or any two of them together(dwidoshaja) or all the three doshas vitiated together(tridoshaja).
Prognosis
Saadhya – only one dosha vitiated
Yaapya – two doshas involved
Asadhya – All doshas involved & the disease affected all over the body.
Chikithsa
Samana
Lepana with rookshadravyas like kolakulathadi choorna
Parisheka with soolaharakwatha like dasmoolakwatha
Aamapachanam with shaddharanam choornam etc
Agnideepanam with gandharvahastadi kwatham etc
Vyadhivipareeta chikithsa
Sodhana
Langhana
Swedana
Virechana
Snehapanam
Vasti especially kshaaravasti
Commonly used medicines
Amruthotharam kashayam
Rasnasaptakam kashayam
Rasnasunthyadi kashayam
Yogarajaguggulu
Shaddharanam choornam
Guggulutiktakam ghrutam
Ashta Churna
Rajanyadi Churna
Agasthya Rasayan
Brands available
AVS Kottakal
Vaidyaratnam Oushadhasala
AVP Coimbatore
SNA oushadhasala
Home remedies
Diet
- To be avoided
Heavy meals and difficult to digest foods – cause indigestion.
Junk foods- cause disturbance in digestion and reduces the bioavailability of the medicine
Carbonated drinks – makes the stomach more acidic and disturbed digestion
Refrigerated and frozen foods – causes weak and sluggish digestion by weakening Agni (digestive fire)
Milk and milk products – increase kapha and cause respiratory problems
Curd – causes vidaaha and thereby many other diseases
- To be added
Light meals and easily digestible foods
Green gram, soups, honey
Freshly cooked and warm food processed with cumin seeds, ginger, black pepper, ajwain etc
Behaviour:
Protect yourself from cold climate.
Better to avoid exposure to excessive sunlight wind rain or dust.
Maintain a regular food and sleep schedule.
Avoid holding or forcing the urges like urine, faeces, cough, sneeze etc.
Avoid sedentary lifestyle.
Yoga
Pavanamuktasana
Nadisudhi pranayama
Bhujangasana
Simple exercises for lungs and heart health
All the exercises and physical exertions must be decided and done under the supervision of a medical expert only.
Research articles
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