ISSN 0972-978X 

  About COAA








Long-Term Outcome In Patients With Juvenile Idiopathic Arthritis

Amine Bouchra1, Ibn Yacoub Yousra1, Rostom Samira1, Abouqal Redouane2, 
Hajjaj-Hassouni Najia 1-2
1: Department of Rheumatology (Pr N. Hajjaj-Hassouni), 
     El Ayachi hospital, University Hospital of Rabat-Sale, Morocco
2: Laboratory of biostatistics, clinical research and epidemiology, 
    Faculty of Medicine and Pharmacy, Rabat, Morocco

Address for Correspondence:
Yousra Ibn Yacoub
Department of Rheumatology,
El Ayachi hospital,
University Hospital of Rabat-Sale,
11000, Sale.

Phone : 00-212-537-78-29-19 / 17-14;
Fax     :
E-mail :


Objective: To describe the long-term outcome of juvenile idiopathic arthritis (JIA) in Moroccan patients.
Patients and methods:
Cross-sectional study including patients with JIA according to the ILAR criteria for the diagnosis of JIA, old of more than 18 years, followed into hospital or consultation. The evaluation included a clinical evaluation (articular mobility, activity of the disease), functional estimation (HAQ) and structural analyze (Steinbrocker).
:Fifty one patients were recruited (27 women and 24 men), of average age 27.60 years ± 7.35 [18-46]. Subtypes at inclusion were: 15% enthesitis related arthritis, 12% seronegative polyarthritis, 11% seropositive polyarthritis, 5% systemic arthritis, 5% oligoarthritis and 3% psoriatic arthritis. After on average 15.06 ± 8.88 years [3-39] disease onset, forty two patients (82.35%) had an active disease. Our patients had a disabled functional status with a median of HAQ higher than 1.0. Half of our patients had a stage III or IV of Steinbrocker. The pain visual analogue scale, health assessment questionnaire and erythrocyte sedimentation rate were significantly higher among patients having an active disease at the time of study. The duration of evolution and the delay of diagnosis were the major factors associated with a pejorative outcome at adulthood.
This study showed that more than 80% of our Patients with JIA remained active at the adulthood and were generating of a disability and a structural destruction. The interest carried to the early treatment of the infantile diseases must also include, in our country, that of the JIA.

J.Orthopaedics 2010;7(3)e9


long-term outcome; juvenile idiopathic arthritis; HAQ,;SF-36; Steinbrocker; quality of life.


Juvenile idiopathic arthritis (JIA) can persist over many years with children that could experience disability and dysfunction in adulthood [1]. Despite a well conducted medical treatment, that could have a beneficial effect on joint inflammation, it is not curative and induces occasionally remission. The outcome of juvenile arthritis is generally regarded as good, with the possibility of a spontaneous remission. However, clinical experience suggests that JIA is not a benign disease, and a review of the literature indicates that the outcome in adulthood is variable [5-26]. At least one-third of children could keep an active disease into, and many will have great limitations in their daily activities [19,20,23,25]. However, studies of the outcome of juvenile arthritis are often not comparable because of disease definition differences’ (i.e., JRA or JCA) and treatment differences (reflecting changes in the approach to management over several decades). In addition, different measures of outcome have been used with a variable duration of follow-up. Nonetheless, these outcome studies showed that approximately one-third of patients have marked functional disability and many patients (10-45%) have ongoing active disease at 10 years. The prognosis of chronic arthritis varies quite a lot, and the perception of different dimensions and the prognosis may vary depending on cultures and societies. There are few published studies about outcome of JIA in no industrialized countries [2-4]. The aim of our study was to describe clinical and functional features on adult Moroccan patients with long-standing JIA.

Materials and Methods:


Patients were enrolled at rheumatology department of university hospital of Rabat in Morocco on a period of 08 months. Eligibility criteria included patients with a diagnosis of JIA according to the International League of Association of Rheumatology (ILAR) criteria [27]. All patients were over 18 years old and gave informed consent to tacking part in the study, which also received the approval of the local ethics committee. Patients were assessed individually. Subsequently, a full review of the patient's clinical notes was performed. Disease subtype was determined retrospectively. Previous medical history was specified, including medication use, concurrent diseases and surgery. All patients were assessed using joint counts (number of joints with swelling (range 0–62); number of joints with tenderness/pain on passive motion (range 0–75) and number of joints with limited range of motion (range 0–67)). Patients completed a self-rated 10-cm VAS for pain, based on their pain experience during the week before the clinical assessment. Laboratory tests included erythrocyte sedimentation rate (ESR; Westergren method) and rheumatoid factor. A patient was considered to be in remission if at follow-up if he or she had no symptoms or objective signs of disease activity, in the presence of normal ESR for more than two consecutive years without any anti-rheumatic treatment. Joint symptoms due to JIA sequelae were not considered. A modified Steinbrocker functional class was used to allow comparison with older [28]. The health assessment questionnaire (HAQ) [29] was used as specific measure of functional disability, and the medical outcomes study 36-item Short Form (SF-36) [30-33] was used to assess health status and QOL; both of these tools are translated and validated into Moroccan dialect. Additional questionnaires regarding educational experience and employment status were collected including items regarding current employment status and highest level of education attained.


The statistical package for the social sciences (SPSS) version 13.0 was used for the analysis. Data for patients were expressed as mean and standard deviations for continuous variables and number and frequencies for categorical variables. To compare the median scores between the study groups, we used the Mann-Whitney U test for nonparametric data. Pearson's correlation coefficients were calculated to evaluate linear correlation between two numerical variables. Using the variables with p < 0.05., multiple linear regression analysis was performed. Significance level was set as p < 0.05.

Results :

51 patients with JIA were included in this cross sectional study. Patients’ characteristics are presented in table I. The median age was 27.5 years (range 18-46); median disease duration was 15 years (range 3-39). There were no recorded deaths in this group. JIA subtypes were: oligoarticular onset (18 patients, 3 with persistent disease and 2 with extended disease), polyarticular onset (20 patients, 11 of whom were rheumatoid factor [RF] positive), systemic onset (5 patients), psoriatic (3 patients), and enthesitis-related arthritis (5patients). Uveitis resulting in visual impairment occurred in 2 patients (a persistent oligoarticular pattern in 1 patients and an enthesitis-related pattern in 1 patient).

Table I: Patient demographics

Age, mean (range) years

Sex, no. women/men

Age at diagnosis, median ± SD years

Disease duration, median (range) years

No.(%) patients with active joint disease

HAQ score, median (range)

Self-reported pain score on VAS, mean (range)

27.60 [18-46]


12.55 ± 3.66 [4-16]

15 [3-39]

42 [82.35]

1.29 [0-3]

50 [0-90]

HAQ = Health Assessment Questionnaire; VAS = visual analog scale.

Outcome measures:

Disease activity:

Only 9 of our patients (17.65%) had a remission. The mean active joint count was 4.3 (range 0-24), and the mean restricted joint count was 6.4 (range 0-26). Among the 23 patients with polyarticular-onset disease, 20 had active disease and 10 were RF positive. Only one patient with a RF-positive polyarticular disease had inactive disease. Disease-modifying antirheumatic drugs (DMARDs) were used by 33 of the 51 patients (methotrexate [n = 17], sulfasalazine [n = 12], hydroxychloroquine in combination with methotrexate [n = 1] and 3 patients had a biologic treatment).

Functional disability and QOL

The median HAQ score was 1.29 (range 0-3; higher scores correspond to a greater degree of functional disability). There was a significant difference in the HAQ scores according to disease duration (P = 0.01) and early onset of disease (P = 0.01). The HAQ scores (2.6, range 0-3) was greater in patients with active disease rather than patients with inactive disease (0.62, range 0-3) (P = 0.03). The SF-36 scores compared to healthy age- and sex-matched controls are shown in Table II. Results show a major impact of JIA on health status. Our patients had low scores for all physical domains (physical functioning, vitality, bodily pain, general health); social functioning and emotional role in the mental domains, compared to controls. Table III summarizes the PSS (physical summary score), MSS (mental summary score), and HAQ scores, stratified by age. The SF-36 scores were lower with increasing age. HAQ scores were higher, indicating worse functional disability, in older patients. There were no statistically significant differences in HAQ, PSS and MSS scores between subtypes of JIA (ANOVA variance analysis-results not shown). Also, the educational level and work status didn’t influence the health status (p>0.05). We’ve found high statistically significant correlations between HAQ scores and all domains of SF-36 (p<0.001). For all domains of QoL, a severe functional disability was associated with an impaired QoL. The Steinbrocker functional class distribution was represented: 20 (39.4%) patients were in functional class I, 5 (10.6 %) in functional class II, 10 (19.2%) in functional class III and 16 (30.8 %) in functional class IV. A statistically significant correlation was found between Steinbrocker functional class and disease duration (P < 0.001) and polyarticular subtype (P < 0.001). In multiple linear regression, disease duration was the most important parameter that influences negatively function, QoL and Steinbrocker functional class.

Table II: QOL as measured by the SF-36 in adults with juvenile arthritis and age- and sex-matched controls






   Physical functioning


   Bodily pain

   General health


   Physical role

   Social functionning

   Emotional role

   Mental health


30.84 (10-100)

29.96 (62-95)

30.05 (0-100)

27.99 (15-90)


27.20 (5-94)

28.43 (2-87)

27.80 (3-79)

27.05 (9.5-95)


71.56 (58.85-99)

72.46 (5-90)

72.37 (71-97)

74.47 (74-97)


75.28 (75-99)

74.02 (74-97)

74.66 (74-95)

74.43 (6.9-9.5)


< 0.001

< 0.001

< 0.001

< 0.001


< 0.001

< 0.001

< 0.001

< 0.001

Values are the mean score (range) for each domain. The higher the score, the better the quality of life for that particular domain. P values were determined by the Mann-Whitney U test. QOL = quality of life; SF-36 = Short Form 36; NS = not significant.


Table III: Functional disability (HAQ) and summated quality of life (SF-36) scores in adults with juvenile arthritis


Age < 30 years


Age ≥30 years




HAQ score

29.98 ± 3

30.89 ± 5

1.16 ± 0.3

20.08 ± 2

20.08 ± 4

0.85 ± 0.3

Values are the mean ± SD. Statistical analysis by Kruskal-Wallis one-way analysis of variance showed statistical significance when comparing PSS, MSS, or HAQ scores between age groups with p = 0.007, 0.02, 0.008 successivly. HAQ = Health Assessment Questionnaire; SF-36 = Short Form 36; PSS = physical summation score; MSS = mental summation score.

Discussion :

In this cross-sectional study, the majority of patients with JIA had unfavourable outcome at adulthood. More than 80% of our patients had active disease after median disease duration of 15years. Those results concord with the findings of Aggarwal and al [2].But in that Indian study the disease duration was lower (6 years). In contrast, in a Sweden population of 124 JIA, only 49% of patients had active disease at median disease duration of 7 years [2]. In majority of previous follow-up studies [5-11], the follow-up time has ranged between 5 and 15 years and only in three studies has exceeded 15 years. In two of the later studies, about 30-50% of patients had active disease. According to our results and in comparison with results of Zak and al [12]; disease activity persisting into adulthood is perhaps one of the most important outcome parameters in JIA. In our study, Enthesitis related arthritis and seronegative polyarthritis are the most representative subtypes in our patients. Patients with persistent oligoarticular disease, who are generally regarded as having the best prognosis, are underrepresented in our study thing that could explain the high proportion of patients with active disease [2, 5, 12]. According to Aggarwal and al study [2], among 506 patients with JIA, rates remission were 45% for oligoarticular-onset disease for only 20% in the polyarticular group. Also, Guillaume and al reported [13] that patients with oligoarticular-onset disease were most often in remission, probably because of the heterogeneity of this group. In the same study, the authors reported that among patients with oligoarticular-onset JIA, the probability of a polyarticular course was 50% [13]. In addition the high proportion of patients with active disease in our patients in which the polyarticular onset en Enthesitis related arthritis are the most representative, concords with results of Guillaume and al in which only 18% of patients with Enthesitis related to arthritis had remission [13]. Many (64%) of our patients were taking DMARDs. This observation is consistent with other outcome studies [13-18].

On the other hand, our patients had a disabled functional status with a median of HAQ higher than 1.0 and more than 30% of patients were in Steinbrocker functional class IV. Our results are comparable with the findings of Minden and al [5] who state that 6.5% of patients had an HAQ score of 1.0 or higher, and 10% were severely disabled according to Steinbrocker functional class status [10, 19, 20, 21, 22]. In our patients, the subtype of the JIA didn’t influence the functional disability. In the present study, there was a significant difference in the HAQ scores according to disease duration and early onset of disease. In patients with active disease, the median HAQ score was higher. Other long-term studies have shown that the fraction of disabled patients clearly increased in association with longer time-span to follow-up [2, 5, 6, 12, 23 and 24]. In Minden and al study [5], disease activity had the strongest influence on functional status but disease duration was not significantly correlated with the HAQ score. Zak and al [12] confirmed that disease duration was the strongest predictor of an unfavourable disease outcome but also patients with polyarticular affection, history of systemic steroid treatment and long disease duration had experienced major discomfort with deteriorated HAQ and functional class [25, 26].

The results of our study are important because the present study is one of few others in which the SF-36 was used as a validated measure of health status and QoL and which the International League of Associations for Rheumatology criteria for JIA were applied [6, 23, 27-29]. In the present study, SF-36 scores were low for all JIA subtypes compared with controls. Our patients had worse scores on the SF-36 compared with those of the patients described by Foster et al [6] or by Peterson and al [23], which can be explained by the low proportion of the oligoarticular-onset group. Measures of SF-36 demonstrate poor global outcome for patients and showed lower scores in the older patients suggesting the impact of the disease duration. We’ve found a high correlation between domains of SF-36 and HAQ but the subtype of the JIA didn’t influence the QoL. In discordance of our results, Foster and al [6, 29] demonstrated significant differences in outcome between the subgroups of JIA. The authors noticed that patients with seropositive polyarticular-onset and systemic-onset JIA had worst functional outcome. Many of our patients had persistent active disease, significantly worse HAQ scores than those without active disease; and many were taking DMARDs. Our patients had evidence of multiple joint involvement and we’ve found a significant correlation between disease activity and number of active joints, which can have an impact on physical status on QoL that may not be adequately assessed by the HAQ. Finally, we didn’t found significant differences in SF-36 or HAQ scores between subtypes of JIA or according to educational and work status of patients. Those results contraries the study results of Foster and al who suggested that employed patients had higher scores of SF-36 than the scores of those who were unemployed [21, 25].

In the current study we found that the majority of patients with JIA had unfavourable outcome in adulthood. 82% of the participants had active disease and disease activity was suggested to be the strongest outcome parameter in JIA. Our study results suggest in concordance with other studies results that polyarticular subtype and also Enthesitis related to arthritis were associated with disease persisting into adulthood and that the degree of functional residua (HAQ) and functional class (Steinbrocker) increased with time. Also, all of our patients have a deteriorated quality of life with decreased SF-36 scores that are influenced by an increased HAQ score.


  1. Gare BA, Fasth A. The natural history of juvenile chronic arthritis: a population based cohort study.II.Outcome. J Rheumatol 1995; 22: 308-19.

  2. Amita Aggarwal, Vikas Agarwal and al. Outcome in juvenile rheumatoid arthritis in India. Indian Padiatrics 2004; 41, 17: 180-4.

  3. Bruns A, Hilario MOE, Jennings F, Silva CA, Jamil. Quality of life and impact of the disease on primary caregivers of juvenile idiopathic arthritis patients. In press Joint Bone Spine.

  4. Duarte-Salazar C, Guzman-Vazquez S, Soto-Molina H and al. Disability impact on quality of life in Mexican adults with juvenile idiopathic arthritis and juvenile ankulosing spondylitis. Clin Exp Rheumatol 2007; 25 (6): 922-7.

  5. Minden K, Niewerth M, Listing J, Biedermann Th, Bollow M, Schontube M and Zink  A.Long-Term outcome in patients with juvenile idiopathic arthritis. Arth rheum 2002, 46 (9): 2392-2401.  

  6. Foster. H, Marshall N, Myers A, Dunkley P and Griffiths I. Outcome in adults with juvenile idiopathic arthritis. Arth rheum 2003, 48(3): 767-775.

  7. Calabro JJ, Holgerson WB, Sonpal GM, Khoury MI. Juvenile rheumatoid arthritis: a general review and report of 100 patients observed for 15 years. Semin Arthritis Rheum 1976; 5: 257-98.

  8. Goel KM, Shanks RA. Follow-up study of 100 cases of juvenile rheumatoid arthritis. Ann Rheum Dis 1974; 33: 25-31.

  9. Stoeber E. Prognosis in juvenile chronic arthritis: follow-up of 433 chronic rheumatic children. Eur J Pediatr 1981; 135: 225-8.

  10. Flato B, Aasland A, Vinje O, Forre O. Outcome and predictive factors in juvenile rheumatoid arthritis and juvenile spondyloarthropathy. J Rheumatol 1998; 25: 366-73.

  11. Jeremy R, Schaller J, Arkless R, Wedgwood R, Healey LA. Juvenile rheumatoid arthritis persisting into adulthood. Am J Med 1968; 45: 419-34.

  12. Zak M, Pedersen FK. Juvenile chronic arthritis into adulthood: a long-term follow-up study. Rheumatol 2000; 39: 198-204.

  13. Guillaume S, Prieur A-M, Coste J, Job-Deslandre C.Long-Term outcome and prognosis in oligoarticular-onset juvenile idiopathic arthritis. Arthritis Rheum 2000;43:1858-65.

  14. Miller M, Cassidy J. Juvenile rheumatoid arthritis. In: Behrmann RL , Kliegman RM , Jenson HB , editors. Nelson textbook of paediatrics. 16th ed. Philadelphia: Saunders; 2000. p. 707-9.

  15. Lindbjerg IBF. Juvenile rheumatoid arthritis. Arch Dis Child 1964; 39: 576-83.

  16. Laaksonen AL. A prognostic study of juvenile rheumatoid arthritis: analysis of 544 cases. Acta Paediatr Scand 1966; 166: 1-163.

  17. Schaller J, Wedgwood RJ. Juvenile rheumatoid arthritis: a review. Pediatrics 1972; 50: 940-53.

  18. Hill RH, Herstein A, Walters K. Juvenile rheumatoid arthritis: follow-up into adulthood - medical, sexual and social status. Can Med Assoc J 1976; 114: 790-6.

  19. Gare BA, Fasth A. The natural history of juvenile chronic arthritis: a population based cohort study. II. Outcome. J Rheumatol 1995; 22: 308-19.

  20. Doherty E, Rooney M, Conroy R, Bresnihan B. Health status of functionally independent young adults with chronic arthritis since childhood. J Orthopaed Rheumatol 1988; 1: 51-8

  21. David J, Cooper C, Hickey L, Lloyd J, Dore C, McCullough C, et al. The functional and psychological outcomes of juvenile chronic arthritis in young adulthood. Br J Rheumatol 1994; 33: 876-81.

  22. Dougados M, van der LeindenS, and al. The Europeen Spondylarthropathy Study Group preliminary criteria for the classification of spondylarthropathy. Arthritis Rheum 1991; 34: 1218-21.Ruperto N, Ravelli A, Levinson JE, Shear ES, Murray K, Link Tague B, et al. Long-term health outcomes and QOL in American and Italian inception cohorts of patients with juvenile rheumatoid arthritis. I. Outcome status. J Rheumatol 1997; 24: 945-51.

  23. Peterson LS, Mason T, Nelson AM, O'Fallon WM, Gabriel SE. Psychological outcomes and health status of adults who have had juvenile rheumatoid arthritis: a controlled, population-based study. Arthritis Rheum 1997; 40: 2235-40.

  24. Marshall N, Hayes J, Foster HE. Juvenile idiopathic arthritis: an assessment of health outcome from the patients' point of view [abstract]. Ann Rheum Dis 1999; 58 Suppl 1: 358.

  25. David J, Cooper C, Hickey L et al. The functional and psychological outcomes of juvenile chronic arthritis in young adulthood. Br J Rheumatol 1994;33:876–81.

  26. Fries JF, Spitz P, Kraines G, Holman HR. Measurement of patient outcome in arthritis. Arthritis Rheum 1980; 23: 137-45.

  27. Garratt AM, Ruta DA, Abdalla MI, Buckingham JK, Russell IT. The SF36 health survey questionnaire: an outcome measure suitable for routine use within the NHS? BMJ 1993; 306: 1440-4.

  28. Ware JE, Snow KK, Kosinski M, Gandek B. SF-36 health survey manual and interpretation guide. Boston: The Health Institute; 1993.

  29. Ware JE, Kosinski M, Bayliss M, McHorner CA, Rogers WH, Raczek A. Comparison of methods for the scoring and statistical analysis of SF-36 health profile and summary measures: summary of results from the Medical Outcomes Study

This is a peer reviewed paper 

Please cite as: Yousra Ibn Yacoub: Long-Term Outcome In Patients With Juvenile Idiopathic Arthritis

J.Orthopaedics 2010;7(3)e9





Arthrocon 2011

Refresher Course in Hip Arthroplasty

13th March,  2011

At Malabar Palace,
Calicut, Kerala, India

Download Registration Form

For Details
Dr Anwar Marthya,
Ph:+91 9961303044



Powered by



© Copyright of articles belongs to the respective authors unless otherwise specified.Verbatim copying, redistribution and storage of this article permitted provided no restrictions are imposed on the access and a hyperlink to the original article in Journal of Orthopaedics maintained. All opinion stated are exclusively that of the author(s).
Journal of Orthopaedics upholds the policy of Open Access to Scientific literature.