Rheumatology Advance Access originally published online on June 11, 2008
Rheumatology 2008 47(8):1251-1252; doi:10.1093/rheumatology/ken217
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
LETTERS TO THE EDITOR |
Arthropathy in paediatric inflammatory bowel disease: a cross-sectional observational study
1Department of Rheumatology and 2Department of Gastroenterology, Royal Liverpool Children's Hospital, Liverpool, UK.
Correspondence to: F. McErlane, Department of Rheumatology, Royal Liverpool Children's Hospital, 33 South Drive, Heswall, Wirral Heswall CH60 0BG, Liverpool, UK. E-mail: flora{at}littler3.freeserve.co.uk; flora{at}peterlittler.co.uk
SIR, The prevalence and pattern of musculoskeletal symptoms in children with IBD is poorly described in the literature.
Adults with all types of IBD, particularly those with colonic involvement, are known to be at an increased risk of arthritis. A recent population study (the IBSEN study) identified SpA in 22% of patients with IBD [1]. The evidence for joint involvement in children with IBD is less robust. A large series of 522 children with Crohn's; disease (CD) published in 1979 reported arthritis in 8% overall [2]. A paper published in 1974 described an inflammatory, predominantly large joint arthropathy in 23/136 (17%) of children with IBD [3]. A third series described a predominantly oligoarticular arthritis in 13/102 (12.7%) of children with IBD [4]. All data were obtained via retrospective case note review with no documented rheumatological assessment of patients. It is very difficult to distinguish clearly between arthritis and arthralgia in a retrospective case notes review.
A more recent British Paediatric Surveillance Unit survey documented arthropathy at presentation in 6.7% of children with IBD [5]. The authors were unable to comment on the prevalence of musculoskeletal symptoms in their population.
We undertook a cross-sectional observational study to identify both the prevalence and pattern of musculoskeletal symptoms in British children with IBD. Approval was granted by the local ethics committee.
All children with IBD under the care of the gastroenterology team at the Royal Liverpool Children's Hospital (RLCH) between October 2003 and June 2005 were eligible for inclusion. Informed consent/assent was obtained prior to inclusion.
Families wishing to participate in the study were asked to complete a short questionnaire identifying the presence or absence of joint symptoms. An affirmative response to any question generated an appointment with a single paediatric rheumatologist (J.E.D.) for further assessment.
Musculoskeletal symptoms were assessed in the rheumatology clinic through history and examination. Demographic, diagnostic and therapeutic data were collected from each child's case notes. Children were offered standard treatment programmes where appropriate.
Gastroenterology unit records were used to identify 160 children eligible for inclusion in this study of whom 124 (77.5%) were recruited. Table 1 demonstrates demographic details, disease type and treatment of children with musculoskeletal symptoms. Two families refused further assessment, so 30/32 symptomatic children were investigated further.
|
No association was identified between joint symptoms and IBD flare by 18/30 children (60%). Out of 30 children, 10 (33%) noted musculoskeletal symptoms more commonly at the time of IBD flare and 2/30 (7%) commented that symptoms usually preceded IBD flare.
Arthralgia was identified in 22/30 children with musculoskeletal symptoms (18% of total study group). The knees (18/22) and ankles (13/22) were the most commonly affected joints. A specific cause for the arthralgia was identified in 7/22 (32%) children: four children fulfilled Beighton criteria for hypermobility [6], one child had true leg length discrepancy, one child had anterior knee pain and one child had tight Achilles tendons. These children responded well to standard physiotherapy treatment regimes. No difference was found in age, sex, disease subtype or treatment regime for children with or without an identifiable cause for arthralgia.
Myalgia was described by 5/30 children with musculoskeletal symptoms (4% of the total study group). Three of these children experienced co-existing arthralgia. No child with myalgia had an inflammatory myopathy.
An inflammatory arthropathy was identified in 3/30 children with musculoskeletal symptoms (2.4% of the total study group). Two children had oligoarticular disease and one child had a polyarthropathy. None of these children had a family history of inflammatory joint disease or psoriasis.
Our study found the prevalence of musculoskeletal symptoms in children with IBD to be higher than that previously reported at 26%.
The frequency of musculoskeletal symptoms in children with IBD may reflect the frequency of musculoskeletal symptoms in healthy UK children. Musculoskeletal pain is known to be common in adolescents [7]. A large prospective cross-sectional European study reported musculoskeletal pain in 32.1% schoolchildren [8]. A self-reported questionnaire was completed by 679 11- to 14-yr olds in England. About 36.6% described pain in the past month [9]. Although the frequency of musculoskeletal symptoms may vary with demographic parameters of the cohort and symptom definition, these figures are broadly similar to the frequency noted in our study cohort.
A proportion of musculoskeletal symptoms in children with IBD have an identifiable cause. It is important to identify potential causes as they may be amenable to treatment. Musculoskeletal symptoms are not usually associated with an inflammatory arthropathy. The prevalence of inflammatory arthropathy in children with IBD is considerably lower in this study (2.4%) than previously reported [2–4] and lower than that noted in adult IBD populations [1].
A significant number of the children in this study had been treated with prednisolone (5/32), AZA (14/32) or prednisolone and AZA (6/32). These medications could potentially mask an inflammatory arthritis. It will never be possible to identify an unbiased treatment-naïve cohort of children with established IBD, hence, this is an unavoidable limitation. One further constraint of the study was that rheumatological assessment was only offered to those children reporting joint or muscle pain during the past year. This approach may not have identified children with quiescent or very mild joint symptoms.
This study provides new and important information on the prevalence of musculoskeletal symptoms and inflammatory arthropathy in children with IBD. The data have been collected from one of the largest paediatric (secondary and tertiary) IBD cohorts in the UK. Inflammatory arthropathy is uncommon in children with IBD and a prospective longitudinal study is indicated to accurately determine the incidence and pattern of inflammatory arthritis in children with IBD over time. The results of this study are reassuring and of relevance to both general and specialist paediatricians looking after children with IBD. This study highlights the need for all physicians involved in the care of children with IBD to examine the musculoskeletal system at every available opportunity.
Disclosure Statement: The authors have declared no conflicts of interest.
 |
References |
|---|
 Top References |
|---|
- Palm O, Moum B, Ongre A, Gran JT. Prevalence of ankylosing spondylitis and other spondyloarthropathies among patients with inflammatory bowel disease: a population study (the IBSEN study). J Rheumatol (2002) 29:511–5.
[Abstract/Free Full Text] - Farmer RG, Michener WM. Prognosis of Crohn's disease with onset in childhood or adolescence. Dig Dis Sci (1979) 24:752–7.[CrossRef][Web of Science][Medline]
- Lindsley CB, Green Schaller J. Arthritis associated with inflammatory disease in children. J Pediatr (1974) 84:16–20.[CrossRef][Web of Science][Medline]
- Passo MH, Fitzgerald JF, Brandt KD. Arthritis associated with inflammatory bowel disease in children. Relationship of joint disease to activity and severity of bowel lesion. Dig Dis Sci (1986) 31:492–7.[CrossRef][Web of Science][Medline]
- Sawczenko A, Sandhu BK. Presenting features of inflammatory bowel disease in Great Britain and Ireland. Arch Dis Child (2003) 88:995–1000.
[Abstract/Free Full Text] - Grahame R, Bird HA, Child A. The revised (Brighton 1998) criteria for the diagnosis of benign joint hypermobility syndrome (BJHS). J Rheumatol (2000) 27:1777–9.[Web of Science][Medline]
- Hakala P, Rimpela A, Salminen JJ, Virtanen SM, Rimpela M. Back, neck, and shoulder pain in Finnish adolescents: national cross sectional surveys. Br Med J (2002) 325:743–5.
[Abstract/Free Full Text] - El-Metwally A, Salminen JJ, Auvinen A, Kautiainen H, Mikkelsson M. Prognosis of non-specific musculoskeletal pain in preadolescents: a prospective 4-year follow-up study till adolescence. Pain (2004) 110:550–9.[CrossRef][Web of Science][Medline]
- Adamson G, Murphy S, Shevlin M, Buckle P, Stubbs D. Profiling schoolchildren in pain and associated demographic and behavioural factors: a latent class approach. Pain (2007) 129:295–303.[CrossRef][Web of Science][Medline]
CiteULike 
Connotea 
Del.icio.us What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||