Effectiveness of eHealth Interventions Promoting Physical Activity in Children and Adolescents: Systematic Review and Meta-Analysis

BACKGROUND

eHealth interventions have been postulated as a feasible, acceptable, and possibly effective tool to promote physical activity (PA) among children and adolescents; however, a comprehensive quantitative analysis of the effects of eHealth interventions promoting PA is lacking.

OBJECTIVE

This study aims to conduct a systematic review and meta-analysis on experimental studies reporting the effects of eHealth interventions aimed at promoting PA on PA parameters and sedentary behavior parameters in children and adolescents.

METHODS

The CENTRAL, MEDLINE, Embase, and Web of Science databases were searched from inception to February 2022 for randomized controlled trials that analyzed the effects of eHealth interventions aimed at promoting PA on PA and sedentary parameters in children and adolescents. The Hartung-Knapp-Sidik-Jonkman random effects method was used to determine the mean differences (MDs) with their respective 95% CIs. The risk of bias was assessed using the Risk of Bias 2 (RoB2; Cochrane) tool and its extension for cluster randomized controlled trials. The certainty of evidence was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) tool.

RESULTS

A total of 20 trials reporting the effects of different eHealth interventions aimed at promoting PA were included. Results for each parameter were as follows: counts per minute (MD -16.11 counts, 95% CI -122.76 to 90.53; k=3; n=402; I2=69%; favoring control), steps per day (MD 593.46 steps, 95% CI -2102.27 to 3289.19; k=2; n=152; I2=0%; favoring intervention [FI]), moderate to vigorous PA (MD -1.99 min/d, 95% CI -8.95 to 4.96; k=14; n=2336; I2=86%; favoring control), light PA (MD 3.28 min/d, 95% CI -15.48 to 22.04; k=5; n=355; I2=67%; FI), screen time (MD -31.48 min/d, 95% CI -68.62 to 5.65; k=5; n=904; I2=0%; FI), and sedentary time (MD -33.12 min/d, 95% CI -57.27 to -8.97; k=8; n=819; I2=75%; FI). Our results should be interpreted cautiously because of important limitations such as the scarcity of evidence, overall risk of bias, and low to very low certainty of evidence.

CONCLUSIONS

We did not find conclusive evidence regarding the impact of PA-targeted eHealth interventions on PA parameters, but the very low certainty of evidence suggests that eHealth interventions may reduce sedentary time in children and adolescents. Our results may have important scientific implications as they highlight that the rapid development of eHealth interventions to promote PA lacks robust supporting evidence.

TRIAL REGISTRATION

PROSPERO CRD42020211020; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=211020.

Physical activity and education about physical activity for chronic musculoskeletal pain in children and adolescents

BACKGROUND

Chronic pain is a major health and socioeconomic burden, which is prevalent in children and adolescents. Among the most widely used interventions in children and adolescents are physical activity (including exercises) and education about physical activity.

OBJECTIVES

To evaluate the effectiveness of physical activity, education about physical activity, or both, compared with usual care (including waiting-list, and minimal interventions, such as advice, relaxation classes, or social group meetings) or active medical care in children and adolescents with chronic musculoskeletal pain.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, PEDro, and LILACS from the date of their inception to October 2022. We also searched the reference lists of eligible papers, ClinicalTrials.gov, and the World Health Organization (WHO) International Clinical Trials Registry Platform.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that compared physical activity or education about physical activity, or both, with usual care (including waiting-list and minimal interventions) or active medical care, in children and adolescents with chronic musculoskeletal pain.

DATA COLLECTION AND ANALYSIS

Two review authors independently determined the eligibility of the included studies. Our primary outcomes were pain intensity, disability, and adverse events. Our secondary outcomes were depression, anxiety, fear avoidance, quality of life, physical activity level, and caregiver distress. We extracted data at postintervention assessment, and long-term follow-up. Two review authors independently assessed risk of bias for each study, using the RoB 1. We assessed the overall certainty of the evidence using the GRADE approach. We reported continuous outcomes as mean differences, and determined clinically important differences from the literature, or 10% of the scale.

MAIN RESULTS

We included four studies (243 participants with juvenile idiopathic arthritis). We judged all included studies to be at unclear risk of selection bias, performance bias, and detection bias, and at high risk of attrition bias. We downgraded the certainty of the evidence for each outcome to very low due to serious or very serious study limitations, inconsistency, and imprecision. Physical activity compared with usual care Physical activity may slightly reduce pain intensity (0 to 100 scale; 0 = no pain) compared with usual care at postintervention (standardised mean difference (SMD) -0.45, 95% confidence interval (CI) -0.82 to -0.08; 2 studies, 118 participants; recalculated as a mean difference (MD) -12.19, 95% CI -21.99 to -2.38; I² = 0%; very low-certainty evidence). Physical activity may slightly improve disability (0 to 3 scale; 0 = no disability) compared with usual care at postintervention assessment (MD -0.37, 95% CI -0.56 to -0.19; I² = 0%; 3 studies, 170 participants; very low-certainty evidence). We found no clear evidence of a difference in quality of life (QoL; 0 to 100 scale; lower scores = better QoL) between physical activity and usual care at postintervention assessment (SMD -0.46, 95% CI -1.27 to 0.35; 4 studies, 201 participants; very low-certainty evidence; recalculated as MD -6.30, 95% CI -18.23 to 5.64; I² = 91%). None of the included studies measured adverse events, depression, or anxiety for this comparison. Physical activity compared with active medical care We found no studies that could be analysed in this comparison. Education about physical activity compared with usual care or active medical care We found no studies that could be analysed in this comparison. Physical activity and education about physical activity compared with usual care or active medical care We found no studies that could be analysed in this comparison.

AUTHORS' CONCLUSIONS

We are unable to confidently state whether interventions based on physical activity and education about physical activity are more effective than usual care for children and adolescents with chronic musculoskeletal pain. We found very low-certainty evidence that physical activity may reduce pain intensity and improve disability postintervention compared with usual care, for children and adolescents with juvenile idiopathic arthritis. We did not find any studies reporting educational interventions; it remains unknown how these interventions influence the outcomes in children and adolescents with chronic musculoskeletal pain. Treatment decisions should consider the current best evidence, the professional's experience, and the young person's preferences. Further randomised controlled trials in other common chronic musculoskeletal pain conditions, with high methodological quality, large sample size, and long-term follow-up are urgently needed.

Online pain management programs for chronic, widespread musculoskeletal conditions: A systematic review with meta-analysis

Face-to-face pain management programs demonstrate positive clinical outcomes in the chronic pain population by improving pain intensity and attitudes, depression, and functional disability scores. The effects of this modality carried out online is less known, particularly in subgroups of chronic pain. This systematic review assessed the effects of online pain management programs in chronic, widespread musculoskeletal conditions on pain measurements (intensity, interference, coping, and catastrophizing), health-related quality of life, depression, and anxiety scores immediately post-intervention. Five electronic databases (Embase, Medline, CINAHL, Scopus, and PEDro) were searched with 3546 studies identified. Eighteen randomized controlled trials fulfilled the inclusion criteria. Included studies had moderate methodological quality (using the Effective Public Health Practice Project (EPHPP) quality assessment tool) but high risk of bias (using the revised Cochrane risk-of-bias tool for randomized trials (RoB 2)). There were significant improvements in pain intensity (11 studies, 1397 participants, SMD -0.30, 95% CI -0.50 to -0.10, p = 0.004), health-related quality of life (eight studies, 1054 participants, SMD 0.41, 95% CI 0.08 to 0.75, p = 0.02), and depression (nine studies, 1283 participants, SMD -0.32, 95% CI -0.55 to -0.08, p = 0.008). However, effect sizes were small and did not meet their respective measure's minimal clinically important change score. Guided interventions (regular interaction with an instructor) appeared to be superior to self-completed interventions. Future research should standardize outcome measures for assessing pain, use active control groups, and analyze other outcome measures such as cost and long-term effects. This study was registered with Prospero on August 15, 2021 (CRD42021267565).

Effectiveness of eHealth and mHealth Interventions Supporting Children and Young People Living With Juvenile Idiopathic Arthritis: Systematic Review and Meta-analysis

BACKGROUND

Juvenile idiopathic arthritis (JIA) management aims to promote remission through timely, individualized, well-coordinated interdisciplinary care using a range of pharmacological, physical, psychological, and educational interventions. However, achieving this goal is workforce-intensive. Harnessing the burgeoning eHealth and mobile health (mHealth) interventions could be a resource-efficient way of supplementing JIA management.

OBJECTIVE

This systematic review aims to identify the eHealth and mHealth interventions that have been proven to be effective in supporting health outcomes for children and young people (aged 1-18 years) living with JIA.

METHODS

We systematically searched 15 databases (2018-2021). Studies were eligible if they considered children and young people (aged 1-18 years) diagnosed with JIA, an eHealth or mHealth intervention, any comparator, and health outcomes related to the used interventions. Independently, 2 reviewers screened the studies for inclusion and appraised the study quality using the Downs and Black (modified) checklist. Study outcomes were summarized using a narrative, descriptive method and, where possible, combined for a meta-analysis using a random-effects model.

RESULTS

Of the 301 studies identified in the search strategy, 15 (5%) fair-to-good-quality studies met the inclusion criteria, which identified 10 interventions for JIA (age 4-18.6 years). Of these 10 interventions, 5 (50%) supported symptom monitoring by capturing real-time data using health applications, electronic diaries, or web-based portals to monitor pain or health-related quality of life (HRQoL). Within individual studies, a preference was demonstrated for real-time pain monitoring over recall pain assessments because of a peak-end effect, improved time efficiency (P=.002), and meeting children's and young people's HRQoL needs (P<.001) during pediatric rheumatology consultations. Furthermore, 20% (2/10) of interventions supported physical activity promotion using a web-based program or a wearable activity tracker. The web-based program exhibited a moderate effect, which increased endurance time, physical activity levels, and moderate to vigorous physical activity (standardized mean difference [SMD] 0.60, SD 0.02-1.18; I²=79%; P=.04). The final 30% (3/10) of interventions supported self-management development through web-based programs, or apps, facilitating a small effect, reducing pain intensity (SMD -0.14, 95% CI -0.43 to 0.15; I²=53%; P=.33), and increasing disease knowledge and self-efficacy (SMD 0.30, 95% CI 0.03-0.56; I²=74%; P=.03). These results were not statistically significant. No effect was seen regarding pain interference, HRQoL, anxiety, depression, pain coping, disease activity, functional ability, or treatment adherence.

CONCLUSIONS

Evidence that supports the inclusion of eHealth and mHealth interventions in JIA management is increasing. However, this evidence needs to be considered cautiously because of the small sample size, wide CIs, and moderate to high statistical heterogeneity. More rigorous research is needed on the longitudinal effects of real-time monitoring, web-based pediatric rheumatologist-children and young people interactions, the comparison among different self-management programs, and the use of wearable technologies as an objective measurement for monitoring physical activity before any recommendations that inform current practice can be given.

Juvenile Idiopathic Arthritis: A Review of Novel Diagnostic and Monitoring Technologies

Juvenile idiopathic arthritis (JIA) is the most common rheumatic disease of childhood and is characterized by an often insidious onset and a chronic relapsing-remitting course, once diagnosed. With successive flares of joint inflammation, joint damage accrues, often associated with pain and functional disability. The progressive nature and potential for chronic damage and disability caused by JIA emphasizes the critical need for a prompt and accurate diagnosis. This article provides a review of recent studies related to diagnosis, monitoring and management of JIA and outlines recent novel tools and techniques (infrared thermal imaging, three-dimensional imaging, accelerometry, artificial neural networks and fuzzy logic) which have demonstrated potential value in assessment and monitoring of JIA. The emergence of novel techniques to assist clinicians' assessments for diagnosis and monitoring of JIA has demonstrated promise; however, further research is required to confirm their clinical utility.

Cardiovascular Health in Pediatric Rheumatologic Diseases

Cardiovascular disease risk is evident during childhood for patients with juvenile systemic lupus erythematosus, juvenile dermatomyositis, and juvenile idiopathic arthritis. The American Heart Association defines cardiovascular health as a positive health construct reflecting the sum of protective factors against cardiovascular disease. Disease-related factors such as chronic inflammation and endothelial dysfunction increase cardiovascular disease risk directly and through bidirectional relationships with poor cardiovascular health factors. Pharmacologic and nonpharmacologic interventions to improve cardiovascular health and long-term cardiovascular outcomes in children with rheumatic disease are needed.

Physical activity and exercise in patients with pediatric rheumatic disease: A systematic search and review

Childhood rheumatic diseases are a group of diseases that can affect many organs and systems, resulting in pain, joint stiffness, muscle atrophy and weakness. Physical inactivity has been reported in many childhood rheumatic diseases. There are many studies in the literature comparing the effectiveness of exercise programs in children with juvenile idiopathic arthritis. Exercise and physical activity are considered major parts of the treatment of children with rheumatic disease. The aim of this review is to systematically present studies on physical activity and exercise programs in children with rheumatism from the last 5 years. An internet-based search of three databases-PubMed, PEDro and Medline- was conducted to find relevant studies. Two reviewers individually identified studies on the basis of their title, abstract or full text-as necessary-to determine their eligibility. Differences of opinion between the two examiners were resolved by discussion. Scientific studies of children with different rheumatic diagnoses have shown that physical activity and exercise have a significant effect on reducing the symptoms of the disease. However, the duration, frequency, method and evaluation of the exercises are still being discussed in the literature.

Effectiveness of web-based and mobile health interventions designed to enhance adherence to physical activity for people with inflammatory arthritis: a systematic review

Objective

The aim of this systematic review was to assess the evidence from randomized controlled trials (RCTs) and cohort studies for the effectiveness of digital interventions designed to enhance adherence to physical activity (PA) for people with inflammatory arthritis and describe the intervention content using established coding criteria.

Methods

Six electronic databases were searched for published and unpublished studies. Independent data extraction and quality assessment (Cochrane risk of bias II or ROBINS-I) were conducted by two reviewers. The primary outcome was self-reported adherence to PA post-intervention. Secondary outcomes included self-reported adherence to PA at other time points, level of PA or engagement with intervention at any follow-up time point. Intervention content was assessed using the Consensus on Exercise Reporting Template and the Behaviour Change Techniques Taxonomy version 1.

Results

From 11 136 citations, four moderate risk of bias studies (three RCTs and one cohort study) including 1160 participants with RA or JIA were identified. Owing to heterogeneity of outcomes, a narrative synthesis was conducted. Only one RCT reported a small between-group difference in adherence to PA [mean difference (95% CI) −0.46 (−0.82, −0.09)] in favour of the intervention. There were no between-group differences in any secondary outcomes. Interventions included between 3 and 11 behaviour change techniques but provided minimal information on exercise prescription.

Conclusion

There is currently limited moderate-quality evidence available to provide confident evaluation of the effect of web-based and mobile health interventions on adherence to PA or level of PA post-intervention in people with inflammatory arthritis.

Usability of eHealth and Mobile Health Interventions by Young People Living With Juvenile Idiopathic Arthritis: Systematic Review

BACKGROUND

Considering the changing landscape of internet use and rising ownership of digital technology by young people, new methods could be considered to improve the current model of juvenile idiopathic arthritis (JIA) management.

OBJECTIVE

This systematic review aims to evaluate the usability of eHealth and mobile health (mHealth) interventions currently available for young people living with JIA.

METHODS

The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were used to oversee this review. We systematically searched 15 databases for 252 potential studies; 2 authors independently screened all quantitative studies reporting the use of eHealth and mHealth interventions for young people (aged 1-18 years) diagnosed with JIA. Studies were excluded if they did not report outcome measures or were reviews, commentaries, or qualitative studies. Study methodological quality was scored using the Down and Black (modified) checklist. A narrative descriptive methodology was used to quantify the data because of heterogeneity across the studies.

RESULTS

A total of 11 studies were included in this review, reporting 7 eHealth and mHealth interventions for young people (aged 4-18 years) living with JIA, targeting health issues such as pain, health-related quality of life, physical activity, and chronic disease self-management. The usability of the interventions was facilitated through training and ongoing support. The engagement was promoted by a combination of persuasive influences, and barriers preventing adherence were removed through personal reminders and flexible program schedules to cater to JIA and non-JIA illnesses or other commonly seen activities in childhood. The feedback obtained was that most young people and their parents liked the interventions.

CONCLUSIONS

The results of this review need to be considered cautiously because of the lack of rigorous testing and heterogeneity, which limits the detailed descriptions of data synthesis. Further research is needed to consider gender differences, associated costs, and the effectiveness of the interventions on health outcomes to better support young people living with JIA.

Adolescents’ social needs living with juvenile idiopathic arthritis and their views about digital resources

Background

Juvenile Idiopathic Arthritis (JIA) and its related symptoms (e.g. pain) have been associated with interference in the daily life of adolescents with JIA including their friendships. There is little research in that sense and in consequence, interventions designed to improve this area. The objectives of this study are 1) to gain knowledge about the needs of adolescents with JIA, particularly focused on their friendships; 2) to explore the potential of the Internet to help them, and 3) to determine what kind of online resource would be the best and what elements it should include.

Methods

To achieve the proposed objectives we designed a qualitative study including two phases: the first one exploratory (semi-structured interviews) and the following, confirmatory (online focus group).

Results

14 adolescents were interviewed and 7 participated in the focus group. They reported some social challenges related to their illness: feeling different, criticized by peers, or not believed. Additionally, they specified some of the coping strategies they used, such as disclosing to others that they have JIA, using communication skills, maintaining activities with friends, trying to minimize pain, and ignoring negative comments. Adolescents considered an online resource useful and mentioned that they would like to find general information and to have the possibility to interact with others. They considered Instagram and WhatsApp as good platforms to implement the online resource.

Conclusions

According to their perceptions, adolescents with JIA can benefit from an online resource which delivers information, strategies and facilitates interaction with others.

Effectiveness of Serious Games to Increase Physical Activity in Children With a Chronic Disease: Systematic Review With Meta-Analysis

Background

Physical activity (PA) is important for children with a chronic disease. Serious games may be useful to promote PA levels among these children.

Objective

The primary purpose of this systematic review was to evaluate the effectiveness of serious games on PA levels in children with a chronic disease.

Methods

PubMed, EMBASE, PsycINFO, ERIC, Cochrane Library, and CINAHL were systematically searched for articles published from January 1990 to May 2018. Both randomized controlled trials and controlled clinical trials were included to examine the effects of serious games on PA levels in children with a chronic disease. Two investigators independently assessed the intervention, methods, and methodological quality in all articles using the Cochrane risk of bias tool. Both qualitative and quantitative analyses were performed.

Results

This systematic review included 9 randomized controlled trials (886 participants). In 2 of the studies, significant between-group differences in PA levels in favor of the intervention group were reported. The meta-analysis on PA levels showed a nonsignificant effect on moderate to vigorous PA (measured in minutes per day) between the intervention and control groups (standardized mean difference 0.30, 95% CI –0.15 to 0.75, P=.19). The analysis of body composition resulted in significantly greater reductions in BMI in the intervention group (standardized mean difference –0.24, 95% CI –0.45 to 0.04, P=.02).

Conclusions

This review does not support the hypothesis that serious games improve PA levels in children with a chronic disease. The meta-analysis on body composition showed positive intervention effects with significantly greater reductions in BMI in favor of the intervention group. A high percentage of nonuse was identified in the study of serious games, and little attention was paid to behavior change theories and specific theoretical approaches to enhance PA in serious games. Small sample sizes, large variability between intervention designs, and limited details about the interventions were the main limitations. Future research should determine which strategies enhance the effectiveness of serious games, possibly by incorporating behavior change techniques.

Electronic Health Interventions for Preventing and Treating Negative Psychological Sequelae Resulting From Pediatric Medical Conditions: Systematic Review

BACKGROUND

Pediatric medical conditions have the potential to result in challenging psychological symptoms (eg, anxiety, depression, and posttraumatic stress symptoms [PTSS]) and impaired health-related quality of life in youth. Thus, effective and accessible interventions are needed to prevent and treat psychological sequelae associated with pediatric medical conditions. Electronic health (eHealth) interventions may help to meet this need, with the capacity to reach more children and families than in-person interventions. Many of these interventions are in their infancy, and we do not yet know what key components contribute to successful eHealth interventions.

OBJECTIVE

The primary objective of this study was to conduct a systematic review to summarize current evidence on the efficacy of eHealth interventions designed to prevent or treat psychological sequelae in youth with medical conditions.

METHODS

MEDLINE (PubMed) and PsycINFO databases were searched for studies published between January 1, 1998, and March 1, 2019, using predefined search terms. A total of 2 authors independently reviewed titles and abstracts of search results to determine which studies were eligible for full-text review. Reference lists of studies meeting eligibility criteria were reviewed. If the title of a reference suggested that it might be relevant for this review, the full manuscript was reviewed for inclusion. Inclusion criteria required that eligible studies (1) had conducted empirical research on the efficacy of a Web-based intervention for youth with a medical condition, (2) had included a randomized trial as part of the study method, (3) had assessed the outcomes of psychological sequelae (ie, PTSS, anxiety, depression, internalizing symptoms, or quality of life) in youth (aged 0-18 years), their caregivers, or both, (4) had included assessments at 2 or more time points, and (5) were available in English language.

RESULTS

A total of 1512 studies were reviewed for inclusion based on their title and abstracts; 39 articles qualified for full-text review. Moreover, 22 studies met inclusion criteria for the systematic review. Of the 22 included studies, 13 reported results indicating that eHealth interventions significantly improved at least one component of psychological sequelae in participants. Common characteristics among interventions that showed an effect included content on problem solving, education, communication, and behavior management. Studies most commonly reported on child and caregiver depression, followed by child PTSS and caregiver anxiety.

CONCLUSIONS

Previous research is mixed but suggests that eHealth interventions may be helpful in alleviating or preventing problematic psychological sequelae in youth with medical conditions and their caregivers. Additional research is needed to advance understanding of the most powerful intervention components and to determine when and how to best disseminate eHealth interventions, with the goal of extending the current reach of psychological interventions.

Predictability of exercise capacity following pediatric burns: a preliminary investigation

PURPOSE

Describe the course of exercise capacity in pediatric burn patients during the initial 6 months after hospital discharge, and examine whether its recovery can be predicted from burn characteristics, sociodemographic characteristics, and/or prior assessment.

MATERIALS AND METHODS

Exercise capacity was assessed at discharge, and 6 weeks, 3 months, and 6 months after discharge using the Steep Ramp Test (SRT).

RESULTS

Twenty-four pediatric patients with burns affecting 0.1-34% of total body surface area were included. At group level, exercise capacity was low at discharge and did not reach healthy reference values within 6 months, despite significant improvement over time. At individual level, the course of exercise capacity varied widely. Six months after discharge, 48% of participants scored more than one standard deviation below healthy age- and sex-specific reference values. SRT outcomes at 6 weeks and 3 months were the best predictors of exercise capacity 6 months after discharge, explaining, respectively, 76% and 93% of variance.

CONCLUSIONS

Forty-eight percent of participants did not achieve healthy reference values of exercise capacity and were therefore considered "at risk" for diminished functioning. Our preliminary conclusion that early assessment of exercise capacity with the SRT can timely identify those patients, needs to be strengthened by further research.IMPLICATIONS FOR REHABILITATIONPediatric burns can be considered as a chronic medical condition because of the lifelong consequences.Exercise capacity is reduced following- even minor -pediatric burns.Recovery patterns vary widely: some pediatric burn patients achieve healthy levels of exercise capacity without specific intervention, while others do not.The Steep Ramp Test can be used to assess exercise capacity, identifying those "at risk" for adverse outcomes at an early stage.Patients "at risk" should be encouraged to play sports and adopt an active lifestyle.

Participation in school and physical education in juvenile idiopathic arthritis in a Nordic long-term cohort study

BACKGROUND

The aim of the study was to describe school attendance and participation in physical education in school among children with juvenile idiopathic arthritis (JIA).

METHODS

Consecutive cases of JIA from defined geographical areas of Finland, Sweden and Norway with disease onset in 1997 to 2000 were followed for 8 years in a multi-center cohort study, aimed to be as close to population-based as possible. Clinical characteristics and information on school attendance and participation in physical education (PE) were registered.

RESULTS

Participation in school and in PE was lowest initially and increased during the disease course. Eight years after disease onset 228/274 (83.2%) of the children reported no school absence due to JIA, while 16.8% reported absence during the last 2 months due to JIA. Full participation in PE was reported by 194/242 (80.2%), partly by 16.9%, and none by 2.9%. Lowest participation in PE was found among children with ERA and the undifferentiated categories. Absence in school and PE was associated with higher disease activity measures at the 8-year visit. School absence > 1 day at baseline predicted use of disease-modifying anti-rheumatic drugs, including biologics (DMARDs) (OR 1.2 (1.1-1.5)), and non-remission off medication (OR 1.4 (1.1-1.7) 8 years after disease onset.

CONCLUSION

School absence at baseline predicted adverse long-term outcome. In children and adolescents with JIA participation in school activities is mostly high after 8 years of disease. For the minority with low participation, special attention is warranted to promote their full potential of social interaction and improve long-term outcome.

Physical activity for children with chronic disease; a narrative review and practical applications

BACKGROUND

Physical activity (PA) is associated with a diverse range of health benefits. International guidelines suggest that children should be participating in a minimum of 60 min of moderate to vigorous intensity PA per day to achieve these benefits. However, current guidelines are intended for healthy children, and thus may not be applicable to children with a chronic disease. Specifically, the dose of PA and disease specific exercise considerations are not included in these guidelines, leaving such children with few, if any, evidence-based informed suggestions pertaining to PA. Thus, the purpose of this narrative review was to consider current literature in the area of exercise as medicine and provide practical applications for exercise in five prevalent pediatric chronic diseases: respiratory, congenital heart, metabolic, systemic inflammatory/autoimmune, and cancer.

METHODS

For each disease, we present the pathophysiology of exercise intolerance, summarize the pediatric exercise intervention research, and provide PA suggestions.

RESULTS

Overall, exercise intolerance is prevalent in pediatric chronic disease. PA is important and safe for most children with a chronic disease, however exercise prescription should involve the entire health care team to create an individualized program.

CONCLUSIONS

Future research, including a systematic review to create evidence-based guidelines, is needed to better understand the safety and efficacy of exercise among children with chronic disease.

Feasibility and safety of a 6-month exercise program to increase bone and muscle strength in children with juvenile idiopathic arthritis

BACKGROUND

Arthritis in childhood can be associated with muscle weakness around affected joints, low bone mass and low bone strength. Exercise is recognized as an important part of management of children with juvenile idiopathic arthritis (JIA) but the exercise prescription to best promote bone and muscle health is unknown. We therefore aimed to: 1. assess feasibility and safety of a 6-month home- and group-based exercise program for children with JIA; 2. estimate the effect of program participation on bone mass and strength, muscle function and clinical outcomes and 3. determine if any positive changes in bone and muscle outcomes are maintained 6 months later.

METHODS

We recruited 24 children with JIA who were part of the Linking Exercise, Physical Activity and Pathophysiology in Childhood Arthritis (LEAP) study to participate in a 6-month home-based exercise program involving jumping and handgrip exercises, resistance training and one group exercise session per month. We assessed lumbar spine bone mass (dual energy X-ray absorptiometry), distal tibia and radius bone microarchitecture and strength (high-resolution peripheral quantitative computed tomography), muscle function (jumping mechanography, dynamometry) and clinical outcomes (joint assessment, function, health-related quality of life) at baseline, 6- and 12-months. Adherence was assessed using weekly activity logs.

RESULTS

Thirteen children completed the 6-month intervention. Participants reported 9 adverse events and post-exercise pain was rare (0.4%). Fatigue improved, but there were no other sustained improvements in muscle, bone or clinical outcomes. Adherence to the exercise program was low (47%) and decreased over time.

CONCLUSION

Children with JIA safely participated in a home-based exercise program designed to enhance muscle and bone strength. Fatigue improved, which may in turn facilitate physical activity participation. Prescribed exercise posed adherence challenges and efforts are needed to address facilitators and barriers to participation in and adherence to exercise programs among children with JIA.

TRIAL REGISTRATION

Data of the children with JIA are from the LEAP study (Canadian Institutes of Health Research (CIHR; GRANT# 107535 ). http://www.leapjia.com/.

Patient's experiences with the care for juvenile idiopathic arthritis across Europe

BACKGROUND

To assess the views of juvenile idiopathic arthritis (JIA) patients and their parents on the care and treatment they receive in referral pediatric rheumatology centers throughout Europe.

METHODS

In a collaboration between physicians and patient associations, a questionnaire was developed, covering various domains of JIA care, including demographics, diagnosis, referrals to various health care professionals, access to pain and fatigue management and support groups, information they received about the disease and awareness of and participation in research. The questionnaire was translated and distributed by parent associations and pediatric rheumatologists in 25 countries, 22 of which were European. After completion the replies were entered on the PRINTO website. Replies could either be entered directly by parents on the website or on paper. In these cases, the replies were scanned and emailed by local hospital staff to Utrecht where they were entered by I.R. in the database.

RESULTS

The survey was completed by 622 parents in 23 countries. The majority (66.7%) of patients were female, with median age 10-11 years at the completion of the questionnaire. Frequencies of self-reported JIA categories corresponded to literature. Some patients had never been referred to the ophthalmologist (22.8%) or physiotherapist (31.7%). Low rates of referral or access to fatigue (3.5%) or pain management teams (10.0%), age appropriate disease education (11.3%), special rehabilitation (13.7%) and support groups (20.1%) were observed. Many patients indicated they did not have contact details for urgent advice (35.9%) and did not receive information about immunizations (43.2%), research (55.6%) existence of transition of care clinics (89,2%) or financial support (89.7%). While on immunosuppressive drugs, about one half of patients did not receive information about immunizations, travelling, possible infections or how to deal with chickenpox or shingles.

CONCLUSIONS

Low rates of referral to health care professionals may be due to children whose illness is well managed and who do not need additional support or information. Improvements are needed, especially in the areas of supportive care and information patients receive. It is also important to improve doctor patient communication between visits. Physicians can be instrumental in the setting up of support groups and increasing patients' awareness of existing support. Suggestions are given to convey crucial pieces of information structurally and repeatedly to ensure, among other things, compliance.

Fatigue in patients with Juvenile Idiopathic Arthritis: relationship to perceived health, physical health, self-efficacy, and participation

BACKGROUND

Fatigue is common in patients with JIA and affects daily life negatively. We assessed the presence and severity of fatigue in patients with JIA, including factors presumed associated with fatigue (e.g., disease activity, disability, pain, physical activity, exercise capacity, and self-efficacy), and whether fatigue is related to participation in physical education classes, school attendance, and sports frequency.

METHODS

The current study used baseline data of 80 patients with JIA (age 8-13) who participated in an intervention aimed at promoting physical activity. Primary outcome measurements were fatigue, assessed using the Pediatric-Quality-of-Life-Inventory (PedsQl)-Fatigue-scale and energy level assessed using a VAS scale. Other outcome measurements were disease activity (VAS Physician Global Assessment Scale), disability (Childhood Health Assessment Questionnaire), physical activity (accelerometer), exercise capacity (Bruce treadmill test), self-efficacy (Childhood Arthritis Self-Efficacy Scale), and participation (self-report).

RESULTS

Sixty percent of patients with JIA suffered from daily low-energy levels; 27% suffered from very low-energy levels more than half the week. Low energy levels were best predicted by disability and low physical activity. Fatigue measured with the PEDsQL was higher compared to the control-population. Disability and low self-efficacy were main predictors of fatigue. Self-efficacy was a predictor of fatigue but did not act as moderator. Fatigue was a predictor for sports frequency but not for school attendance.

CONCLUSION

Fatigue is a significant problem for JIA patients. Interventions aimed at reducing perceived disability, stimulating physical activity, and enhancing self-efficacy might reduce fatigue and thereby enhance participation.

TRIAL REGISTRATION

Trial number ISRCTN92733069.