Objective. To determine the relationship between health insurance status and disease outcome in children with juvenile rheumatoid arthritis (JRA). Methods. JRA patients followed at a tertiary pediatric rheumatology center were assessed for the number of active joints and number of joints with limited range of motion. Disease activity, patient well-being, and pain were measured. Disability was assessed by the Childhood Health Assessment Questionnaire, health-related quality of life by the Pediatric Quality of Life Inventory (PedsQL) Generic Core Scale, and the PedsQL Rheumatology Module. Health care resource utilization was estimated based on the number of billing events for health services coded in administrative databases; these databases also provided information on patient health insurance status. Children insured by Medicaid or similar state programs for low-income families were considered to have Medicaid status. Disease outcomes of children with Medicaid status was compared with that of children with private health insurance. Results. Forty (14%) of the 295 children with JRA had Medicaid status. Patients with Medicaid status were more often of nonwhite race (P < 0.04) and more frequently had a polyarticular or systemic disease course (P ‫؍‬ 0.04) compared with other patients (n ‫؍‬ 255). After correction for differences in disease duration, race, JRA onset, and JRA course between groups, children with Medicaid status continued to have significantly higher disability (P < 0.0003), and lower mean PedsQL Generic Core Scale scores (P < 0.05), while health resource utilization appeared similar between groups. Conclusion. Despite apparently similar health resource utilization and joint involvement, Medicaid status is associated with significantly lower health-related quality of life and higher disability in JRA.

Objective. The purpose of this study was to determine if high functioning children with Juvenile Idiopathic Arthritis (JIA) with minimal disease activity have different biomechanics during high loading tasks compared to controls. Patients were included if they had minimal inflammation documented in one or both knees. Methods. The subject groups consisted of eleven patients with JIA and eleven sex, age, height, and weight matched controls. Sagittal plane kinematic and kinetics were calculated during a drop vertical jump maneuver. The Child Health Assessment Questionnaire (CHAQ) was collected on each patient with JIA. Results. The subjects with JIA had increased knee (P = .011) and hip flexion (P < .001) compared to control subjects. Subjects with JIA also demonstrated decreased knee extensor moments during take-off (P = .028) and ankle plantar flexor moments during landing (P = .024) and take-off (P = .004). In the JIA group, increased hip extensor moments were predictive of increased disability (R 2 = .477, S E E = .131). Conclusions. Patients with JIA may demonstrate underlying biomechanical deviations compared to controls. In addition, biomechanical assessment of hip extensor mechanics during dynamic tasks may provide an objective assessment tool to determine overall function in patients with JIA.

Objective Temporomandibular joint (TMJ) involvement is common in Juvenile Idiopathic Arthritis (JIA). Dexamethasone iontophoresis (DIP) uses low-grade electric currents for transdermal dexamethasone delivery into deeper anatomic structures. The purpose of this study was to assess the safety and effectiveness of DIP for the treatment of TMJ involvement in JIA, and to delineate variables that are associated with improvement after DIP. Methods Medical records of all JIA patients who underwent DIP for TMJ involvement at a larger tertiary pediatric rheumatology center from 1997 to 2011 were reviewed. DIP was performed using a standard protocol. The effectiveness of DIP was assessed by comparing the maximal inter-incisor opening (MIOTMJ) and the maximal lateral excursion (MLETMJ) before and after treatment. Results Twenty-eight patients (ages 2– 21 years) who received an average of eight DIP treatment sessions per involved TMJ were included in the analysis. Statistically significant improvement in the median MIOTMJ (p< 0.0001) was observed in 68%. The median MLETMJ (p= 0.03) improved in 69%, and resolution of TMJ pain occurred in 73% of the patients who had TMJ pain at baseline. Side effects of DIP were transient site erythema (86%), skin blister (4%), and metallic taste (4%). Improvement in TMJ range of motion from DIP is associated with lower MIOTMJ, lower MLETMJ, and absence of TMJ crepitus at baseline. Conclusion In this pilot study DIP appeared to be an effective and safe initial treatment of TMJ involvement in JIA, especially among patients with decreased TMJ measurements. Prospective controlled studies are needed.

Background and Purpose. The purpose of this case report is to describe a novel multidisciplinary approach for evaluating and preparing a patient with quiescent juvenile rheumatoid arthritis (JRA) for safe sports participation. Case Description. The patient was a 10-year-old girl with a history of bilateral knee arthritis who desired to participate in soccer and basketball. Range of motion and manual muscle testing of the lower extremity were within normal limits. Neuromuscular testing included kinematic and kinetic testing, isokinetic assessment, and postural stability testing. The patient's gait was near normal; however, she had narrowed step width and increased knee flexion at heel-strike. Landing analysis during a box drop vertical jump task showed increased and imbalanced (right versus left lower extremity) peak impact forces. The testing was followed by specialized neuromuscular training (SNT). Outcomes. Following SNT, heel-strike and step width were within normal limits, peak impact forces on the box drop test decreased by 31%, imbalance decreased by 46%, and vertical jump increased 15%. The isokinetic strength ratio between knee flexors and extensors and the overall balance measures were within normal limits and equal bilaterally. Discussion. Patients with quiescent JRA may have abnormal biomechanics, which could place them at increased risk for injury or future articular cartilage damage. Specialized neuromuscular training may have helped to decrease the patient's risk for future injury or disease progression.

Children with juvenile idiopathic arthritis (JIA) now have well-controlled disease due to improved therapies and management strategies. Children with JIA are more active than in the past and often participate in dynamic, high-loading sports. Standard measures of disease control include examination findings, laboratory values, and patient-directed surveys. However, these standards do not address the subtle deficits in biomechanics and neuromuscular control, which could place affected joints at higher risk for injury. Currently, there are limited evidence-based guidelines to structure conditioning recommendations as to the fitness and mechanics needed to provide safe integration into sports in this population; therefore, tools that objectively measure function with high accuracy and precision may be warranted. Previous work using 3-dimensional motion analysis demonstrated usefulness in guiding physical therapy treatment to correct these deficits. The use of a multidisciplinary team, including physical therapy, rheumatology, and sports medicine, is crucial for preparing these children to return to play. We suggest that the child transition into a sport preparatory-conditioning program to address any underlying deficits. A pediatric exercise specialist who is sensitive to the needs of this population can work with a physical therapist to then appropriately integrate the child safely into sport. Encouraging an active lifestyle is vital to the management of JIA and does not worsen the symptoms associated with childhood arthritis.