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Dynamic Knee Joint Function in Children with Juvenile Idiopathic Arthritis (JIA) Sandra Hansmann1*, Susanne M Benseler1,2† and Jasmin B Kuemmerle-Deschner1†

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Dynamic Knee Joint Function in Children with Juvenile Idiopathic Arthritis (JIA) Sandra Hansmann1*, Susanne M Benseler1,2† and Jasmin B Kuemmerle-Deschner1† Hansmann et al. Pediatric Rheumatology (2015) 13:8 DOI 10.1186/s12969-015-0004-1 RESEARCH Open Access Dynamic knee joint function in children with juvenile idiopathic arthritis (JIA) Sandra Hansmann1*, Susanne M Benseler1,2† and Jasmin B Kuemmerle-Deschner1† Abstract Background: Juvenile idiopathic arthritis (JIA) is a chronic illness with a high risk of developing long-term disability. Disease activity is currently being monitored and quantified by ACR core set. Here, joint inflammation is determined; however joint function is the crucial component for developing disability. The aim of this study was to quantify and compare dynamic joint function in healthy and arthritic knee joints and to evaluate response to improvement. Methods: A single center cohort study of consecutive children presenting to the rheumatology outpatient clinic was performed to measure dynamic knee joint function. Serial measures were performed if possible. Splint fixed electrogoniometers were used to measure dynamic knee joint function including ROM and flexion and extension torque. Results: A total of 54 children were tested including 44 with JIA, of whom eight had to be excluded for non-JIA-related knee problems. The study included 36 JIA patients of whom eight had strictly unilateral knee arthritis, and nine controls. Dynamic joint function ROM and torque depended on age and bodyweight, as demonstrated in healthy joints. ROM and torques were significant lower in arthritic compared to unaffected knee joints in children with unilateral arthritis and across the cohort. Importantly, extension torque was the most sensitive marker of impaired joint function. Follow up measurements detected responsiveness to change in disease activity. Conclusions: Measuring dynamic joint function with electrogoniometers is feasible and objective. Active ROM and torque during flexion and extension of arthritic knee joints were significant lower compared to unaffected. In dynamic joint measurement extension torque is a sensitive marker for disease activity. Keywords: Juvenile idiopathic arthritis, Electrogoniometry, Joint function Key messages of 1/1000. In many children, JIA is a life-long illness with a high risk of disease- and treatment-related morbidity Dynamic knee joint function measurements using [1,2]. Persistent inflammation can result in growth distur- electrogoniometry are feasible in children with JIA bances and deformities [3,4]. Children with JIA are com- Dynamic joint function was dependent on distinct monly less active and have a lower quality of life [5-7]. factors including age and body weight. Reduced physical activity results in decreased muscle Extension torque measurements correlated well with strength [8], osteopenia and an increased fracture risk clinical disease activity in children with JIA. [9-12]. The fundamental therapeutic goal in JIA is achiev- ing inactive joint disease in order to achieve and maintain normal joint function including range of motion (ROM), Background movement, coordination, and muscle strength and bone Juvenile Idiopathic Arthritis (JIA) is the most common stability [13]. chronic rheumatic disease in children with a prevalence Precise assessments of joint function are crucial for * Correspondence: [email protected] treatment decisions in JIA [14]. In clinical practice, the †Equal contributors joint status primarily captures the passive ROM of all 1 Rheumatology, General Pediatrics, Oncology and Hematology University joints plus frequently the child’s gait as a measure of func- Children’s Hospital Tuebingen, Hoppe-Seyler-Str. 1, 72076 Tübingen, Germany tional impact. These assessments are subjective, results Full list of author information is available at the end of the article © 2015 Hansmann et al.; licensee BioMed Central. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Hansmann et al. Pediatric Rheumatology (2015) 13:8 Page 2 of 11 have limited inter-rater reliability. However, the pediatric their dynamic joint function performed including 54 ACR core set -the most widely used tool for treatment re- children with defined rheumatic illnesses, who had at sponsiveness in clinical routine and clinical trials – is least one knee joint measured, which constituted the centred around the physician-assessment derived num- Rheumatology Cohort. ber of active joints and joints with limitation of passive Within this group, all children with JIA according to movement in addition to the physician global assess- the Durban criteria [26] were identified and constituted ment, the patients/parents global assessment, the Child the JIA cohort. Within this group an inception cohort Health Assessment Questionnaire (CHAQ) and labora- was identified, including all children with evidence of tory tests [15,16]. acute unilateral knee arthritis, while the contralateral With increasing availability of highly effective JIA knee being currently and previously unaffected by arth- treatments, objective, sensitive and responsive instru- ritis or trauma. The control group consisted of age- ments are urgently needed for monitoring therapies and matched children presenting to the outpatient clinic of predicting outcomes [17,18]. Hand-held-goniometry, the University Children's Hospital Tuebingen with two hand-held-dynamometry and isokinetic measurements healthy knee joints and no history of arthritis, arthralgia, of muscle strength are tools to measure ROM, static neuromuscular disorders or trauma. grip strength and muscle strength in children with JIA Physical and musculoskeletal examination was per- [8,19]. Jumping mechanography and gait analyses are dy- formed by an independent pediatric rheumatologist not namic measurement tools to quantify a standardised jump involved in this study or unrelated subsequent electrogo- or gait using force plates and camera systems [20-22]. niometric measurements. All data were collected using Both methods were shown to be accurate, however expen- the institutional electronic pediatric rheumatology docu- sive, time consuming and limited to a standardised, simu- mentation system ARDIS (Arthritis und Rheumatologie lated setting, which is not on hand in most clinics. Dokumentation und Informationssystem). The study Limited tools are available to capture joint function protocol was approved by the ethics committee of the reliably and independent of the assessor. In daily prac- Eberhard-Karls-University Tuebingen. tice, manual assessments of passive ROM lack accuracy and do not include the muscle function and torque [23]. Demographics, clinical and laboratory data For disease activity monitoring and outcome assessments Demographic data included age, gender and handedness. other measurements of joint function are urgently needed. Anthropometric measurements captured body weight Electrogoniometry [24,25] is inexpensive, quick and easy and height plus circumference, length, height and width to use. It may offer a feasible and assessor-independent of the lower legs and feet. Disease-related information strategy for the evaluation of the complete joint func- encompassed rheumatologic diagnosis including JIA and tion with ROM, movement velocity, and flexion and ex- its subtypes, and other rheumatic diseases. In addition, tension torque. JIA course, duration of illness and current and previous Theaimsofthestudywere1)todeterminethedy- medications were noted. The joint status differentiated the namic knee joint function in a small group of healthy categories of healthy joint, arthralgia with no evidence children using splint fixed electrogoniometry including of arthritis, inactive arthritis, minimal residual arthritis the impact of age, gender, weight and handedness, 2) to and active arthritis. The number and sites of affected determine the dynamic knee joint function in children joints were noted, as well as the duration of arthritis. with JIA and compare healthy and arthritic knee joints For each joint effusion, swelling, pain and limitation in and 3) to analyze the impact of disease activity on dy- range of motion (ROM) were recognized at routine clin- namic knee joint function in JIA. ical assessments. Leg length discrepancies were deter- mined. Laboratory parameters included inflammatory Methods markers (C-reactive protein, erythrocyte sedimentation Patients rate), Antinuclear antibody, HLA B27 and rheumatoid fac- Consecutive patients presenting to the outpatient clinic of tor. The Child Health Assessment Questionnaire (CHAQ) the Division of Pediatric Rheumatology at the University was completed at each visit. Children's Hospital Tuebingen for joint complaints over a period of 18 months were screened. Patients were eligible for the study, if they were 5 to 20 years of Dynamic knee joint function age and had a height ≤175 cm. All consenting pa- Dynamic knee joint function was defined as active tients underwent electrogoniometric measurements of extent and strength of the knee joint movement into theupperand/orlowerextremity joints dependent flexion and extension. The study captured range of mo- on the location of their major complaint. During the tion (ROM), and dynamic muscle torque during flexion study
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