Effects of adherence to treatment on short-term outcomes in children with juvenile idiopathic arthritis

Adherence to exercise therapy among children and adolescents with Juvenile idiopathic arthritis: a scoping review

PURPOSE

To identify parameters and measurement methods of exercise therapy adherence, as well as barriers and facilitators affecting adherence among children and adolescents with juvenile idiopathic arthritis (JIA).

METHODS

Studies were eligible for inclusion if patients were 0-18 years of age, had JIA, and the focus of the research was on exercise therapy patterns, measurement/parameters of exercise adherence, and barriers/facilitators for exercise adherence. Two reviewers independently identified and categorized the barriers and facilitators to exercise therapy adherence using the International Classification of Functioning, Disability, and Health (ICF).

RESULTS

Twenty articles were included in this review. Among patients with JIA, 29%-99% adhered to exercise therapy. The most commonly measured parameters of adherence were session completion and behavior component, with a self-report log serving as the most common means of assessment. Time pressure, symptoms related to JIA, lack of enjoyment, and insufficient motivation were the main barriers. Facilitators were commonly identified as adequate motivation, effective symptoms management, and social support.

CONCLUSIONS

Future interventions should consider the identified factors to promote exercise engagement in children and adolescents with JIA. Strategies for promoting exercise adherence in children and adolescents with JIA is needed.

Effect of exercise training on heath, quality of life, exercise capacity in juvenile idiopathic arthritis: a meta-analysis of randomized controlled trials

OBJECTIVE

Little is known about the efficacy and safety of exercise training on juvenile idiopathic arthritis (JIA). This study aims to investigate the effect of exercise on health, quality of life, and different exercise capacities in individuals with JIA.

METHOD

A comprehensive search of Medline, Embase, Web of Science, and the Cochrane Library was conducted from database inception to October, 2023. Included studies were randomized controlled trials (RCTs) reporting the effects of exercise on JIA patients. Two independent reviewers assessed the literature quality using the Cochrane Collaboration's risk of bias tool. Standardized mean differences (SMD) were combined using random or fixed effects models. The level of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach.

RESULT

Five RCTs met the inclusion criteria, containing 216 female participants and 90 males. The meta-analysis results showed that exercise had no significant effect on JIA patients based on the Child Health Assessment Questionnaire (CHAQ) (SMD=-0.32, 95%CI: -0.83, 0.19; I2 = 73.2%, P = 0.011) and Quality of Life (QoL) (SMD = 0.27, 95%CI: -0.04, 0.58; I2 = 29.4%, P = 0.243) and no significant effect on peak oxygen uptake (VO2peak). However, exercise significantly reduced visual analog scale (VAS) pain scores in JIA patients (SMD = 0.50, 95%CI: -0.90, -0.10; I2 = 50.2%, P = 0.134). The quality of evidence assessed by GRADE was moderate to very low.

CONCLUSION

Exercise does not significantly affect the quality of life and exercise capacity in JIA patients but may relieve pain. More RCTs are needed in the future to explore the effects of exercise on JIA.

Using Digital Health Technologies to Monitor Pain, Medication Adherence and Physical Activity in Young People with Juvenile Idiopathic Arthritis: A Feasibility Study

Juvenile idiopathic arthritis can be influenced by pain, medication adherence, and physical activity. A new digital health intervention, InteractiveClinics, aims to monitor these modifiable risk factors. Twelve children, aged 10 to 18 years, received daily notifications on a smartwatch to record their pain levels and take their medications, using a customised mobile app synchronised to a secure web-based platform. Daily physical activity levels were automatically recorded by wearing a smartwatch. Using a quantitative descriptive research design, feasibility and user adoption were evaluated. The web-based data revealed the following: Pain: mean app usage: 68% (SD 30, range: 28.6% to 100%); pain score: 2.9 out of 10 (SD 1.8, range: 0.3 to 6.2 out of 10). Medication adherence: mean app usage: 20.7% (SD, range: 0% to 71.4%), recording 39% (71/182) of the expected daily and 37.5% (3/8) of the weekly medications. Pro-re-nata (PRN) medication monitoring: 33.3% (4/12), one to six additional medications (mean 3.5, SD 2.4) for 2-6 days. Physical activity: watch wearing behaviour: 69.7% (439/630), recording low levels of moderate-to-vigorous physical activity (mean: 11.8, SD: 13.5 min, range: 0-47 min). To conclude, remote monitoring of real-time data is feasible. However, further research is needed to increase adoption rates among children.

Factors associated with medication adherence among children with rheumatic diseases

Introduction: Failure to take medications regularly leads to poorer health outcomes. The Pediatric Rheumatology Adherence Questionnaire (PRAQ) is an effective tool for assessing medication adherence in rheumatic patients. Therefore, we aimed to determine the factors associated with poor medication adherence among children with rheumatic diseases. Methods: This was a cross-sectional study. Patients with rheumatic diseases who had taken at least one medication and had been followed up at our pediatric rheumatology clinic were included in the study, together with their caregivers. Patients with poor medication adherence were characterized as those who had taken less than 80% of their prescribed drugs, as determined using the pill count method. The original PRAQ was translated and validated in Thai language and was completed by caregivers and literate patients over age 13 years. Interviewing for additional problems with taking medications was conducted. We performed descriptive and logistic regression analyses. Results: From 210 patients, 52.86% had juvenile idiopathic arthritis (JIA), and 46.19% had connective tissue diseases. The mean patient age was 14.10 ± 4.74 years, with a median (interquartile range) disease duration of 4.33 (2.08-6.98) years. PRAQ scores in the group with poor adherence were significantly higher than scores in the group with good adherence (11.00 ± 3.47 vs. 9.51 ± 3.16, p = 0.004). Enthesitis-related arthritis (ERA) (odds ratio [OR] 9.09, 95% confidence interval [CI] 1.25-66.18; p = 0.029) and polyarticular JIA (OR 6.43, 95% CI 1.30-31.75; p = 0.022) were associated with poor treatment adherence. Disease duration ≥5 years (OR 3.88, 95% CI 1.17-12.87; p = 0.027), active disease (OR 6.49, 95% CI 1.76-23.99; p = 0.005), PRAQ scores ≥12 (OR 6.48, 95% CI 1.76-23.82; p = 0.005), forgetting to take medications (OR 14.18, 95% CI 4.21-47.73; p < 0.001), and unawareness about the importance of the medicines (OR 44.18, 95% CI 11.30-172.73; p < 0.001) were predictors of poor drug adherence. Conclusion: In the present study, poor medication adherence was found in one-fourth of children with rheumatic illnesses, particularly those with ERA, polyarticular JIA, longer disease duration, active disease, and high PRAQ scores. The most frequent reasons for inadequate medication adherence were forgetfulness and unawareness about the importance of disease control and consistency with treatment.

Adherence, helpfulness and barriers to treatment in juvenile idiopathic arthritis - data from a German Inception cohort

OBJECTIVES

To develop and evaluate German versions of the Parent Adherence Report Questionnaire (PARQ) and Child Adherence Report Questionnaire (CARQ) and to evaluate adherence in patients with juvenile idiopathic arthritis (JIA).

METHODS

The PARQ and CARQ were translated into German, cross-culturally adapted and administered to patients (age ≥ 8 years) and their parents enrolled in the Inception Cohort Study of newly diagnosed JIA patients (ICON). The psychometric issues were explored by analyzing their test-retest reliability and construct validity.

RESULTS

Four hundred eighty-one parents and their children with JIA (n = 465) completed the PARQ and CARQ at the 4-year follow-up. Mean age and disease duration of patients were 10.1 ± 3.7 and 4.7 ± 0.8 years, respectively. The rate of missing values for PARQ/CARQ was generally satisfactory, test-retesting showed sufficient reliability. PARQ/CARQ mean child ability total scores (0-100, 100 = best) for medication were 73.1 ± 23.3/76.5 ± 24.2, for exercise: 85.6 ± 16.5/90.3 ± 15.0, for splints: 72.9 ± 24.2/82.9 ± 16.5. Construct validity was supported by PARQ and CARQ scores for medications, exercise and splints showing a fair to good correlation with the Global Adherence Assessment (GAA) and selected PedsQL scales. Adolescents showed poorer adherence than children. About one third of the parents and children reported medication errors. Perceived helpfulness was highest for medication, and adverse effects were reported the greatest barrier to treatment adherence.

CONCLUSIONS

The German versions of the PARQ and CARQ appear to have a good reliability and sufficient construct validity. These questionnaires are valuable tools for measuring treatment adherence, identifying potential barriers and evaluating helpfulness of treatments in patients with JIA.

"Every Little Furrow of Her Brow Makes Me Want To Stop": An Interpretative Phenomenologic Analysis of Mothers' Experiences With Juvenile Idiopathic Arthritis Treatments

OBJECTIVE

Children with juvenile idiopathic arthritis (JIA) are faced with a complex medical journey requiring consistent adherence to treatments to achieve disease management. Parents are intimately involved in JIA treatments; however, little is known about their experiences in this role. This is relevant as many treatments necessitate procedural pain (e.g., self-injections) or side effects (e.g., nausea), which may impact a parents' ability to follow treatment plans. The objective of this study was to explore the lived experiences of parents who identified challenges with their child's JIA treatments.

METHODS

Parents of children with JIA who identified challenges with their child's treatments were invited to take part in semistructured interviews. Data were analyzed using interpretative phenomenological analysis.

RESULTS

Ten mothers of children with JIA (60% female with a mean age of 11.83 years [range 4-16 years]) participated. Four superordinate themes were present in mothers' experiences: 1) treatments altered mothers' roles within the family, increasing their caregiver burden and advocacy; 2) treatments positively and negatively impacted their relationships (e.g., increased support from others, decreased time with others); 3) treatments elicited various emotional responses (e.g., frustration, grief), which affected their well-being; and 4) treatments were at times a source of internal conflict, affecting mothers' actions and adherence.

CONCLUSION

Mothers' experiences with their child's JIA treatments affects them in various ways that can subsequently impact treatment adherence. Results highlight the value of supporting parents through these complex treatment regimens and incorporating their experiences in treatment decisions to help promote optimal outcomes for children with JIA and their families.

The iCanCope pain self-management application for adolescents with juvenile idiopathic arthritis: a pilot randomized controlled trial

OBJECTIVES

To evaluate the feasibility and preliminary effectiveness of iCanCope with Pain (iCanCope), a smartphone-based pain self-management program, in adolescents with JIA. iCanCope featured symptom tracking, goal-setting, pain coping skills and social support.

METHODS

A two-arm pilot randomized controlled trial was used to evaluate the iCanCope app compared with a version with symptom tracking only. Primary (feasibility) outcomes were: participant accrual/attrition rates, success of app deployment, acceptability and adherence. Secondary (preliminary effectiveness) outcomes were: pain intensity, pain-related activity limitations and health-related quality of life. Outcomes were assessed at baseline and 8 weeks. Adherence was defined as the proportion of completed symptom reports: 'low' (≤24%); 'low-moderate' (25-49%); 'high-moderate' (50-75%); or 'high' (76-100%). Linear mixed models were applied for preliminary effectiveness analyses as per intention-to-treat.

RESULTS

Adolescents (N = 60) were recruited from three paediatric rheumatology centres. Rates of accrual and attrition were 82 and 13%, respectively. Both apps were deployed with high success (over 85%) and were rated as highly acceptable. Adherence was similar for both groups, with most participants demonstrating moderate-to-high adherence. Both groups exhibited a clinically meaningful reduction in pain intensity (≥1 point) that did not statistically differ between groups. There were no significant changes in activity limitations or health-related quality of life.

CONCLUSION

The iCanCope pilot randomized controlled trial was feasible to implement in a paediatric rheumatology setting. Both apps were deployed successfully, with high acceptability, and were associated with moderate-to-high adherence. Preliminary reductions in pain intensity warrant a future trial to evaluate effectiveness of iCanCope in improving health outcomes in adolescents with JIA.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02764346.

Sticking to It: A Scoping Review of Adherence to Exercise Therapy Interventions in Children and Adolescents With Musculoskeletal Conditions

OBJECTIVE

To identify and categorize barriers, facilitators, and strategies to boost exercise therapy adherence in youth with musculoskeletal conditions to inform research and clinical practice.

STUDY DESIGN

Scoping review.

LITERATURE SEARCH

We searched MEDLINE, CINAHL, SPORTDiscus, Scopus, PEDro, and ProQuest from inception to October 1, 2019.

STUDY SELECTION CRITERIA

Studies written in English, with original data featuring an adherence barrier, facilitator, or boosting strategy for exercise therapy in youth (age, 19 years or younger) with musculoskeletal conditions, were included.

DATA SYNTHESIS

Arksey and O'Malley's framework and the PRISMA Extension for Scoping Reviews guided data synthesis. Study quality was assessed with the Mixed Methods Appraisal Tool. Descriptive consolidation included study and sample characteristics, exercise therapy details, and adherence measurement specifics. Inductive thematic analysis of adherence barriers, facilitators, and boosting strategies followed Braun and Clarke's 6-step guide.

RESULTS

Of 5705 potentially relevant records, 41 studies, representing 2020 participants (64% girls; age range, 2-19 years) with 12 different musculoskeletal conditions and multiple exercise therapy interventions, were included. Despite poor reporting of adherence concepts, time constraints, physical environment (eg, location), and negative exercise experiences were commonly identified barriers. Social support and positive exercise experiences were frequently identified facilitators. Reinforcement, exercise program modification, and education were recurring boosting strategies, despite being infrequent barriers or facilitators.

CONCLUSION

A diversity of barriers to and facilitators of exercise therapy for youth with musculoskeletal conditions were identified. Efforts to link adherence-boosting strategies to an individual's needs should be considered. Making exercise enjoyable, social, and convenient may be important to maximizing adherence in this population. J Orthop Sports Phys Ther 2020;50(9):503-515. Epub 1 Aug 2020. doi:10.2519/jospt.2020.9715.

Teens Taking Charge: A Randomized Controlled Trial of a Web-Based Self-Management Program With Telephone Support for Adolescents With Juvenile Idiopathic Arthritis

Background

Juvenile idiopathic arthritis (JIA) is a serious and potentially debilitating pediatric illness. Improved disease self-management may help to improve health outcomes.

Objective

This study aimed to evaluate the effectiveness of the Teens Taking Charge Web-based self-management intervention in reducing symptoms and improving health-related quality of life (HRQL) in adolescents with JIA compared with a Web-based education control condition.

Methods

Adolescents with JIA aged 12 to 18 years were recruited from 11 Canadian pediatric rheumatology centers. Caregivers were invited to participate along with their child. In addition to standard medical care, participants were randomized to receive either (1) the Teens Taking Charge self-management intervention or (2) a Web-based education control condition for a period of 12 weeks. Adolescents in the intervention group completed website modules addressing cognitive behavioral coping skills, stress management, and other self-management topics, while also receiving monthly telephone calls from a trained health coach. Adolescents in the education control group were instructed to view a series of preselected public JIA educational websites and received monthly calls from a coach who asked about their own best efforts at managing JIA. Caregivers in the intervention group completed website modules related to promoting independence and disease self-management in their child. Caregivers in the education control group were instructed to view a series of preselected public JIA educational websites. Outcome assessment occurred at baseline, 12 weeks (posttreatment), and at 6 and 12 months postrandomization. The primary outcomes were pain intensity, pain interference, and HRQL. Secondary outcomes were emotional symptoms, adherence, coping, knowledge, and self-efficacy.

Results

In total, 333 adolescents and 306 caregivers were enrolled. Significant overall reductions in pain intensity (P=.02) and pain interference (P=.007) were observed for intervention group participants compared with those in the education control group, after adjusting for baseline levels. There was a significant overall improvement in HRQL related to problems with pain (P=.02) and problems with daily activities (P=.01). There was also a significant difference in the intervention group over time (P=.008) for HRQL related to treatment problems, with the intervention group participants demonstrating improved HRQL by 12 months compared with education control group participants. Both groups showed nonsignificant improvements compared with baseline in other primary outcomes. There were no significant differences between the groups in any secondary outcomes or caregiver-reported outcomes.

Conclusions

The results of this randomized trial suggest that the Teens Taking Charge Web-based intervention is effective at reducing both pain intensity and pain interference, as well as improving HRQL in adolescents with JIA, compared with education control. These effects are sustained for up to 12 months following program completion. The Teens Taking Charge program is now publicly available at no cost.

Trial Registration

ClinicalTrials.gov NCT01572896; https://clinicaltrials.gov/ct2/show/NCT01572896

The effect of patient compliance on remission rates in pediatric noninfectious uveitis

PURPOSE

To identify barriers to compliance in pediatric noninfectious uveitis, and to examine its association with achieving steroid-free remission.

METHODS

A retrospective analysis was performed on pediatric patients with noninfectious uveitis on immunomodulatory therapy treated at the University of Texas Southwestern Medical School and Children's Medical Center (Dallas, TX) between September 2015 and March 2017. Compliance barriers were identified and rates of achieving steroid-free remission were calculated.

RESULTS

A total of 57 patients with noninfectious uveitis requiring immunosuppressive therapy met inclusion criteria. Thirty-three (58%) of patients were compliant. Notable barriers to compliance included regimens requiring >3 medications, patient/parent negligence, transportation issues, family strife, and presence of an associated systemic autoimmune disease (P < 0.050). At a median follow-up of 24 months, a total of 28 (49%) achieved steroid-free remission. The presence of 3 or more compliance barriers was associated with decreased remission rates (P < 0.050). Poor compliance was associated with decreased rates of steroid-free remission (21% vs 79% [P = 0.002]).

CONCLUSIONS

Noncompliant patients with noninfectious pediatric uveitis requiring immunomodulatory therapy were found to have a lower rate of achieving steroid-free remission compared to patients who exhibited full compliance.

Treatment Satisfaction With and Adherence to Disease-Modifying Antirheumatic Drugs in Adult Patients With Juvenile Idiopathic Arthritis

OBJECTIVE

To examine medication satisfaction and adherence and their relationships to disease variables and health-related quality of life (HRQoL) in adults with juvenile idiopathic arthritis (JIA).

METHODS

Patients (n = 96, mean age 25 years, 67% female) completed questionnaires about their health status 19 years after disease onset. Patients receiving biologic disease-modifying antirheumatic drugs (bDMARDs) or methotrexate (MTX) were assessed with the 8-item Morisky Medication Adherence Scale (MMAS-8) and the Treatment Satisfaction Questionnaire for Medication (TSQM), including dimensions of effectiveness, side effects, convenience, and global satisfaction.

RESULTS

DMARDs were received by 52 patients (54%) (mean age 25 years, 75% female), of which 28 received MTX and 37 received bDMARDs. Patients receiving combination therapy of MTX and bDMARDs (n = 15) reported higher satisfaction with bDMARDs than MTX in the dimensions of side effects and global satisfaction (mean ± SD 92.9 ± 15.5 versus 56.2 ± 30.9, and mean ± SD 67.6 ± 19.8 versus 47.1 ± 21.7; P < 0.001 and P = 0.016, respectively). Patients receiving either bDMARDs (n = 22) or MTX (n = 13) reported higher satisfaction with bDMARDs than MTX for the dimensions of effectiveness and global satisfaction (mean ± SD 78.7 ± 15.4 versus 60.2 ± 19.9, and mean ± SD 73.6 ± 17.7 versus 52.3 ± 23.9; P = 0.004 and P = 0.005, respectively). Nearly one-half of patients (46%) reported low adherence (MMAS-8 score <6) and 25% high adherence (MMAS-8 score = 8). Higher levels of pain, psychological distress, more active joints, and current MTX use were the strongest correlates of lower medication satisfaction. Perceived medication effectiveness and global satisfaction correlated positively with physical and mental HRQoL.

CONCLUSION

Patients with JIA were more satisfied with bDMARDs than MTX, and 46% reported low adherence. Higher medication satisfaction was associated with better HRQoL.

EARLY DETECTION OF POOR ADHERENCE TO TREATMENT OF PEDIATRIC RHEUMATIC DISEASES: PEDIATRIC RHEUMATOLOGY ADHERENCE QUESTIONNAIRE - A PILOT STUDY

Objective:

To develop a questionnaire that allows the early detection of patients at risk for poor adherence to medical and non-medical treatment in children and adolescents with chronic rheumatic diseases.

Methods:

The Pediatric Rheumatology Adherence Questionnaire (PRAQ) was applied in recently diagnosed patients within a period of one to four months after confirmation of the rheumatic disease. After six months, the patients’ adherence to the medical and non-medical treatment was assessed. An internal consistency analysis was conducted to eliminate redundant questions in the PRAQ.

Results:

A total of 33 patients were included in the pilot study. Six months after the PRAQ had been applied, poor global adherence was observed in seven (21.2%) patients and poor adherence to medical treatment in eight (24.2%) patients. No correlation was observed between the PRAQ scores and the percentages of adherence, as well as the stratification for each index, except for a tendency to a correlation between socioeconomic index and poor adherence to medical treatment (p=0.08). A new PRAQ questionnaire with 25 of the 46 original questions was generated as a result of the reliability analysis.

Conclusions:

The usefulness of this questionnaire in clinical practice should be still evaluated. Due to the importance of a tool for the early detection of rheumatic patients at risk of poor adherence to treatment, the new PRAQ questionnaire should be reviewed and applied in a larger study to better define its validity and reliability.

Feasibility of a musculoskeletal ultrasound intervention to improve adherence in juvenile idiopathic arthritis: a proof-of concept trial

BACKGROUND

Non-adherence is a prevalent and modifiable issue in juvenile idiopathic arthritis (JIA) that currently lacks provider-based intervention. Education surrounding disease status is one way in which families remain engaged in their care. Musculoskeletal ultrasound is one such form of demonstrative, real-time education that may impact the way patients and caregivers self-manage their disease. The aims of this study are to 1) assess the feasibility, acceptability and perceived usefulness of musculoskeletal ultrasound as a non-adherence intervention tool and 2) to examine changes in methotrexate adherence in adolescents with JIA following the ultrasound.

METHODS

Eight adolescents with polyarticular or extended oligoarticular JIA and their caregivers completed this 12 week study. A within subject design was used to compare baseline and post-intervention adherence, quality of life and disease activity indices. Adherence measures included electronic measurement of methotrexate in addition to self-reported adherence questionnaires. The ultrasound intervention included a one-time, rheumatologist provided, educational examination of three or more currently or historically active joints.

RESULTS

The ultrasound intervention was found to be both feasible and acceptable. One hundred percent of eligible participants completed the ultrasound intervention. The ultrasound was well received by patients and caregivers, with most believing this to be a helpful tool. Baseline adherence was 75.3% among participants, with half of the participants being classified as non-adherent. Electronically measured and self-reported adherence measures did not show significant changes during the post-intervention period. Two participants improved, four participants maintained, and two participants decreased adherence. On ultrasound, 18/27 (66.7%) of the examined joints displayed abnormalities, with 63% being discrepant and additive to the rheumatologist's physical examination.

CONCLUSIONS

While our intervention did not show any changes in adherence, quality of life or disease activity indices in this proof-of-concept trial, the intervention does show promise in acceptability measures and merits future study in a more robust trial design. An additional study benefit was that the musculoskeletal ultrasound intervention was able to demonstrate subclinical disease, leading to clinically impactful therapeutic changes in several participants.

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/.

Physical activity in patients with oligo- and polyarticular juvenile idiopathic arthritis diagnosed in the era of biologics: a controlled cross-sectional study

BACKGROUND

Knowledge about objectively measured levels of physical activity (PA) and PA participation (included facilitators and barriers for PA) in patients with juvenile idiopathic arthritis (JIA) diagnosed in the era of biologics is limited. We aimed to compare objectively measured PA in patients with oligo- and polyarticular JIA diagnosed in the biologic era with controls and to examine associations between PA and disease variables; furthermore, to explore participation in PA, physical education (PE) and facilitators and barriers for PA participation in patients and controls.

METHODS

The study cohort included 60 patients (30 persistent oligo JIA/30 poly-articular disease) and 60 age- and sex-matched controls. Age range was 10-16 years and 83% were female. PA was measured with accelerometry for seven consecutive days. Disease activity, current treatment, disease duration, functional ability, pain and fatigue were assessed. Structured interviews were applied to explore participation in PA and PE, and PA facilitators and barriers.

RESULTS

Patients spent less time in daily vigorous PA than controls, (mean(SE) 21(2) min vs. 26(2) min, p = 0.02), while counts per minute (cpm), steps daily, sedentary time and light and moderate PA did not differ. No differences were found between JIA subgroups. The use of biologic medication was associated with higher cpm and lower sedentary time. Most patients and controls participated in organized or unorganized PA and PE, and enjoyment was the most reported facilitator for PA participation. More patients than controls reported pain as a PA barrier.

CONCLUSION

The PA levels and participation in patients with oligo- and polyarticular JIA are mostly comparable to controls, but patients still need to be encouraged to increase vigorous PA. Enjoyment is the most important facilitator for PA participation in patients with JIA.

Barriers to Adherence in Juvenile Idiopathic Arthritis: A Multicenter Collaborative Experience and Preliminary Results

OBJECTIVE

Nonadherence is currently an underrecognized and potentially modifiable obstacle to care in juvenile idiopathic arthritis (JIA). The purpose of our study was to design and implement a standardized approach to identifying adherence barriers for youth with JIA across 7 pediatric rheumatology clinics through the Pediatric Rheumatology Care and Outcomes Improvement Network (PR-COIN) and to assess the frequency of adherence barriers in patients and their caregivers across treatment modalities.

METHODS

An iterative process using coproduction among parents and providers of patients with JIA was used to design the Barriers Assessment Tool to screen for adherence barriers across 4 treatment modalities (i.e., oral medications, injectable medications, infusions, and physical/occupational therapy). This tool was implemented in 7 rheumatology clinics across the United States and patient responses were collected for analysis.

RESULTS

Data were collected from 578 parents and 99 patients (n = 44 parent-child dyads). Seventy-seven percent (n = 444) of caregivers and 70% (n = 69) of patients reported at least 1 adherence barrier across all treatment components. The most commonly reported adherence barriers included worry about future consequences of therapy, pain, forgetting, side effects, and embarrassment related to the therapy. There was no significant difference between endorsement of barriers between parents and adolescents.

CONCLUSION

Implementing a standardized tool assessing adherence barriers in the JIA population across multiple clinical settings is feasible. Systematic screening sheds light on the factors that make adherence difficult in JIA and identifies targets for future adherence interventions in clinical practice.

Developing and Evaluating JIApp: Acceptability and Usability of a Smartphone App System to Improve Self-Management in Young People With Juvenile Idiopathic Arthritis

BACKGROUND

Flare-ups in juvenile idiopathic arthritis (JIA) are characterized by joint pain and swelling and often accompanied with fatigue, negative emotions, and reduced participation in activities. To minimize the impact of JIA on the physical and psychosocial development and well-being of young people (YP), it is essential to regularly monitor disease activity and side effects, as well as to support self-management such as adherence to treatment plans and engagement in general health-promoting behaviors. Smartphone technology has the potential to engage YP with their health care through convenient self-monitoring and easy access to information. In addition, having a more accurate summary of self-reported fluctuations in symptoms, behaviors, and psychosocial problems can help both YP and health care professionals (HCPs) better understand the patient's condition, identify barriers to self-management, and assess treatment effectiveness and additional health care needs. No comprehensive smartphone app has yet been developed in collaboration with YP with JIA, their parents, and HCPs involved in their care.

OBJECTIVES

The objective of this study was to design, develop, and evaluate the acceptability and usability of JIApp, a self-management smartphone app system for YP with JIA and HCPs.

METHODS

We used a qualitative, user-centered design approach involving YP, parents, and HCPs from the rheumatology team. The study was conducted in three phases: (1) phase I focused on developing consensus on the features, content, and design of the app; (2) phase II was used for further refining and evaluating the app prototype; and (3) phase III focused on usability testing of the app. The interview transcripts were analyzed using qualitative content analysis.

RESULTS

A total of 29 YP (aged 10-23, median age 17) with JIA, 7 parents, and 21 HCPs were interviewed. Major themes identified as the ones that helped inform app development in phase I were: (1) remote monitoring of symptoms, well-being, and activities; (2) treatment adherence; and (3) education and support. During phase II, three more themes emerged that informed further refinement of the app prototype. These included (4) adapting a reward system to motivate end users for using the app; (5) design of the app interface; and (6) clinical practice integration. The usability testing during phase III demonstrated high rates of overall satisfaction and further affirmed the content validity of the app.

CONCLUSIONS

We present the development and evaluation of a smartphone app to encourage self-management and engagement with health care for YP with JIA. The app was found to have high levels of acceptability and usability among YP and HCPs and has the potential to improve health care and outcomes for this age group. Future feasibility testing in a prospective study will firmly establish the reliability, efficacy, and cost-effectiveness of such an app intervention for patients with arthritis.

Medication adherence in patients with juvenile idiopathic arthritis

OBJECTIVE

The aim of this study was to investigate pharmacological treatment adherence of patients with juvenile idiopathic arthritis, attended in an outpatient pharmacy at a tertiary hospital in northeastern Brazil.

METHODS

The analysis of adherence was performed along with caregivers, through a structured questionnaire based on Morisky, Green and Levine, which enabled the categorization of adherence in "highest", "moderate" or "low" grades, and through evaluating medication dispensing registers, which classified the act of getting medications at the pharmacy as "regular" or "irregular". Drug Related Problems (DRP) were identified through the narrative of caregivers and classified according to the Second Granada Consensus. Then, a pharmaceutical orientation chart with information about the therapeutic regimen was applied, in order to function as a guide for issues that influenced adherence.

RESULTS

A total of 43 patients was included, with a mean age of 11.12 years, and 65.1% (n=28) were female. Applying the questionnaire, it was found "highest" adherence in 46.5% (n=20) patients, "moderate" adherence in 48.8% (n=21), and "low" adherence in 4.7% (n=2). Through an analysis of the medication dispensing registers, a lower level of adherence was observed: only 25.6% (n=11) of the participants received "regularly" the medications. Twenty-six DRP was identified, and 84.6% (n=22) were classified as real. There were no significant associations between socio-demographic variables and adherence, although some caregivers have reported difficulty in accessing the medicines and in understanding the treatment.

CONCLUSION

Our findings showed problems in the adherence process related to inattention, forgetfulness and irregularity in getting medicines, reinforcing the need for the development of strategies to facilitate a better understanding of treatment and to ensure adherence.

Medication adherence in patients with juvenile idiopathic arthritis

OBJECTIVE

The aim of this study was to investigate pharmacological treatment adherence of patients with juvenile idiopathic arthritis, attended in an outpatient pharmacy at a tertiary hospital in northeastern Brazil.

METHODS

The analysis of adherence was performed along with caregivers, through a structured questionnaire based on Morisky, Green and Levine, which enabled the categorization of adherence in "highest", "moderate" or "low" grades, and through evaluating medication dispensing registers, which classified the act of getting medications at the pharmacy as "regular" or "irregular". Drug Related Problems (DRP) were identified through the narrative of caregivers and classified according to the Second Granada Consensus. Then, a pharmaceutical orientation chart with information about the therapeutic regimen was applied, in order to function as a guide for issues that influenced adherence.

RESULTS

A total of 43 patients was included, with a mean age of 11.12 years, and 65.1% (n=28) were female. Applying the questionnaire, it was found "highest" adherence in 46.5% (n=20) patients, "moderate" adherence in 48.8% (n=21), and "low" adherence in 4.7% (n=2). Through an analysis of the medication dispensing registers, a lower level of adherence was observed: only 25.6% (n=11) of the participants received "regularly" the medications. Twenty-six DRP was identified, and 84.6% (n=22) were classified as real. There were no significant associations between socio-demographic variables and adherence, although some caregivers have reported difficulty in accessing the medicines and in understanding the treatment.

CONCLUSION

Our findings showed problems in the adherence process related to inattention, forgetfulness and irregularity in getting medicines, reinforcing the need for the development of strategies to facilitate a better understanding of treatment and to ensure adherence.

Current Treatment Modalities of JIA-associated Uveitis and its Complications: Literature Review

Uveitis is a common and serious complication of juvenile idiopathic arthritis. Up to 75% of all cases of anterior uveitis in childhood are associated with juvenile idiopathic arthritis. Despite the remarkable progress in early detection and treatment of inflammation, vision-threatening complications of uveitis still occur in almost 60% of patients. Structural complications include band keratopathy, maculopathy (macular edema, macular cysts, and epiretinal membrane), glaucomatous optic neuropathy, and cataracts. The management of complications in juvenile idiopathic arthritis is usually complex and requires early surgical intervention. In this paper, we review the general concepts of common ocular complications seen in patients with JIA-associated uveitis, with special attention to the recent diagnostic and preferred treatment approaches at the Massachusetts Eye Research and Surgery Institution. Received 9 March 2015; revised 30 September 2015; accepted 30 October 2015; published online 14 January 2016.

Participation in Leisure Activities among Canadian Children with Arthritis: Results from a National Representative Sample

OBJECTIVE

To describe the level of participation in leisure activities among children and youth with arthritis, as well as to identify the sociodemographic (age, sex, family income), disease-related (functional limitations, disease duration, pain, medication use, child's need for assistance), and contextual factors (use of rehabilitation services, proximity of local recreation facilities, cost of activities) that may be associated.

METHODS

Data from the Participation and Activity Limitation Survey (PALS) 2006, a Canadian postcensus survey, was analyzed. Bivariate and multivariable linear regression analyses were applied to examine the associations between the sample's level of participation in leisure activities, and sociodemographic, disease-related, and contextual characteristics.

RESULTS

In Canada in 2006, an estimated 4350 children ranging in age from 5 to 14 years were living with arthritis. Fifty-six percent of parents reported that arthritis restricted their child's participation in leisure activities. Bivariate analysis showed that the availability of local recreational facilities, the affordability of activities, and the child not requiring any assistance were all associated (modified Bonferroni correction α < 0.005) with greater participation in various types of leisure activities. Multiple linear regressions showed that higher family income (β 0.47, 95% CI 0.09, 0.85) and greater perceived pain (β 0.59, 95% CI 0.07, 1.10) were positively associated with involvement in informal leisure.

CONCLUSION

Our findings underline the importance of considering contextual factors in developing treatment plans aimed at improving participation in leisure activities among children with arthritis. Future longitudinal studies targeting children living with arthritis could provide pertinent information on participation over fluctuations in disease status.

Impact of JIA on parents' work absences

OBJECTIVE

Children with JIA have long-term morbidity and require extensive parental assistance. This study aimed to evaluate the impact of having a child with JIA on parents' missed work time, which can lead to decreased work productivity.

METHODS

The Truven Health MarketScan Commercial Database (2000-9) was accessed to identify a cohort of parents having a child with newly diagnosed JIA. For comparison, a cohort of parents having no children with JIA was identified and matched with the preceding cohort. Parents' work absences were analysed using descriptive statistics and multivariable regression. Estimates were weighted to be generalizable to the US employer-sponsored insurance population.

RESULTS

The study identified 108 parents having a child with newly diagnosed JIA (mean age 42.5 years), representing an estimated 3335 (weighted) parents nationally. Most of them were from the South (45%), male (71%) and employed in the transportation and utilities industry (58%). The demographic characteristics of the control cohort of parents were generally similar. Children with JIA (mean age 10.6 years) represented an estimated 3528 cases nationally. The mean number of reported missed work-time hours was 281.81 (s.e. 40.50) in a 9 year period for parents having a child with JIA compared with other parents 183.36 (28.55). Work-time loss was significantly related to having a child with JIA, sex and geographical region of residence. Parents having a child with JIA were 2.78 times more likely to report work-time loss [odds ratio (OR) 2.78 (95% CI 1.47, 5.26)] than those having no children with JIA.

CONCLUSION

Parents having a child with JIA report significant work-time loss compared with parents with no children having JIA, particularly during the year following the child's diagnosis.

Importance of adherence in the outcome of juvenile idiopathic arthritis

Medical treatment of juvenile idiopathic arthritis (JIA) has advanced in the last decade, and improved prognosis is a reality in daily clinical practice. Despite this improvement in the quality of treatment, the outcome can still be compromised by modifiable factors, including delayed referral to a specialist, delayed drug treatment, poor adherence to treatment, and early interruption of drug treatment. In this review we discuss the most relevant aspects related to adherence to treatment in JIA, with emphasis on: factors that affect adherence to treatment; effect of poor adherence to treatment on JIA prognosis; when to suspect and how to assess poor adherence to treatment; and strategies to promote adherence to treatment, with an emphasis on information-reinforcement education. Besides presenting the findings of other authors, we also try to report our experience of this subject, which is still a challenge for health professionals.

An exploration of parents' preferences for foot care in juvenile idiopathic arthritis: a possible role for the discrete choice experiment

Background

An increased awareness of patients’ and parents’ care preferences regarding foot care is desirable from a clinical perspective as such information may be utilised to optimise care delivery. The aim of this study was to examine parents’ preferences for, and valuations of foot care and foot-related outcomes in juvenile idiopathic arthritis (JIA).

Methods

A discrete choice experiment (DCE) incorporating willingness-to-pay (WTP) questions was conducted by surveying 42 parents of children with JIA who were enrolled in a randomised-controlled trial of multidisciplinary foot care at a single UK paediatric rheumatology outpatients department. Attributes explored were: levels of pain; mobility; ability to perform activities of daily living (ADL); waiting time; referral route; and footwear. The DCE was administered at trial baseline. DCE data were analysed using a multinomial-logit-regression model to estimate preferences and relative importance of attributes of foot care. A stated-preference WTP question was presented to estimate parents’ monetary valuation of health and service improvements.

Results

Every attribute in the DCE was statistically significant (p < 0.01) except that of cost (p = 0.118), suggesting that all attributes, except cost, have an impact on parents’ preferences for foot care for their child. The magnitudes of the coefficients indicate that the strength of preference for each attribute was (in descending order): improved ability to perform ADL, reductions in foot pain, improved mobility, improved ability to wear desired footwear, multidisciplinary foot care route, and reduced waiting time. Parents’ estimated mean annual WTP for a multidisciplinary foot care service was £1,119.05.

Conclusions

In terms of foot care service provision for children with JIA, parents appear to prefer improvements in health outcomes over non-health outcomes and service process attributes. Cost was relatively less important than other attributes suggesting that it does not appear to impact on parents’ preferences.

Regular aerobic training combined with range of motion exercises in juvenile idiopathic arthritis

OBJECTIVE

To assess the effects of regular aerobic training combined with range of motion (ROM) exercises on aerobic capacity, quality of life, and function in children with juvenile idiopathic arthritis (JIA).

METHODS

Thirty patients with JIA and 20 healthy age-matched controls (mean age ± SD, 11.3 ± 2.4 versus 11.0 ± 2.3, resp.; P > 0.05) were included. All patients performed aerobic walking (4 days a week for 8 weeks) and active and passive ROM exercises of involved joints. All patients completed the childhood health assessment questionnaire (CHAQ) and the child health questionnaire. ROM measurements of joints were performed by using universal goniometer. Aerobic capacity was determined by measuring peak oxygen uptake (VO2peak) during an incremental treadmill test.

RESULTS

Peak oxygen uptake and exercise duration were significantly lower in JIA group than in controls (32.5 ± 6.6 versus 35.9 ± 5.8 and 13.9 ± 1.9 versus 15.0 ± 2.0, resp.; P < 0.05 for both). Eight-week combined exercise program significantly improved exercise parameters of JIA patients (baseline versus postexercise VO2peak and exercise duration, 32.5 ± 6.6 to 35.3 ± 7.9 and 13.9 ± 1.9 to 16.3 ± 2.2, resp.; P < 0.001 for both). Exercise intervention significantly improved CHAQ scores in JIA patients (0.77 ± 0.61 to 0.20 ± 0.28, P < 0.001).

CONCLUSION

We suggest that regular aerobic exercise combined with ROM exercises may be an important part of treatment in patients with JIA.

Treatment preferences in juvenile idiopathic arthritis - a comparative analysis in two health care systems

BACKGROUND

Variations in the treatment of juvenile idiopathic arthritis (JIA) may impact on quality of care. The objective of this study was to identify and compare treatment approaches for JIA in two health care systems.

METHODS

Paediatric rheumatologists in Canada (n=58) and Germany/Austria (n=172) were surveyed by email, using case-based vignettes for oligoarticular and seronegative polyarticular JIA. Data were analysed using descriptive statistics; responses were compared using univariate analysis.

RESULTS

Total response rate was 63%. Physicians were comparable by age, level of training and duration of practice, with more Canadians based in academic centres. For initial treatment of oligoarthritis, only approximately half of physicians in both groups used intra-articular steroids. German physicians were more likely to institute DMARD treatment in oligoarthritis refractory to NSAID (p<0.001). Canadian physicians were more likely to switch to a different DMARD rather than a biologic agent in polyarthritis refractory to initial DMARD therapy. For oligoarthritis and polyarthritis, respectively, 86% and 90% of German physicians preferred regular physiotherapy over home exercise, compared to 14% and 15% in Canada. Except for a Canadian preference for naproxen in oligoarthritis, no significant differences were found for NSAID, intra-articular steroid preparations, initial DMARD and initial biologic treatment.

CONCLUSIONS

Treatment of oligo- and polyarticular JIA with DMARD is mostly uniform, with availability and funding obviously influencing physician choice. Usage of intra-articular steroids is variable within physician groups. Physiotherapy has a fundamentally different role in the two health care systems.

Assessment and management of pain in juvenile idiopathic arthritis

Juvenile idiopathic arthritis (JIA) is a common chronic childhood illness. Pain is the most common and distressing symptom of JIA. Pain has been found to negatively impact all aspects of functioning, including physical, social, emotional and role functions. Children with arthritis continue to experience clinically significant pain despite adequate doses of disease-modifying antirheumatic drugs and anti-inflammatory agents. The present article reviews the prevalence and nature of pain in JIA, the biopsychosocial factors that contribute to the pain experience, current approaches to assessing pain in this population, and ways of managing both acute and persistent pain using pharmacological, physical and psychological therapies. Finally, new approaches to delivering disease self-management treatment for youth with JIA using the Internet will be outlined.

Methotrexate and Injectable Tumor Necrosis Factor-α Inhibitor Adherence and Persistence in Children with Rheumatic Diseases

Objective.

To measure adherence and persistence with methotrexate (MTX) and injectable tumor necrosis factor-α (iTNF-α) inhibitors (etanercept, adalimumab) among children prescribed these medications by a rheumatologist.

Methods.

Data were obtained from a US pharmacy benefits management firm. Children were included if they were < 18 years of age, had ≥ 1 prescription claim between January 2009 and December 2010 for MTX or an iTNF-α inhibitor that was prescribed by an adult or pediatric rheumatologist. The medication possession ratio (MPR) was calculated for each medication, with MPR ≥ 80% indicating good adherence. MPR were compared by route of administration, age, and by new users versus continuing users. Persistence was measured for new users of each medication from initiation until discontinuation, or for a maximum of 1 year.

Results.

A total of 1964 children were included. The majority of children had MPR < 80%. Children taking subcutaneous MTX had the lowest mean MPR [46.9%; median 44.9%; interquartile range (IQR) 23%–69.6%] and the lowest persistence, with 26% of children continuing the medication at 1 year. Mean MPR was highest for iTNF-α (65.7%; median 70.1%; IQR 46%–89.3%), as was persistence, with 52% of children continuing the medication at 1 year. Children age < 13 years tended to have higher MPR, but this was statistically significant only for oral MTX (61.1% vs 54.9% in children age ≥ 13 yrs; p = 0.02).

Conclusion.

Adherence and persistence in this cohort varied by medication and route of administration. Both outcomes are important considerations for physicians prescribing these medications in routine clinical care and for the assessment of treatment effectiveness in the research setting.

Physical activity, physical fitness, and exercise therapy in children with juvenile idiopathic arthritis

Arthritis in childhood can be associated with low levels of physical activity and poor physical fitness. Children with arthritis may have decreased aerobic and anaerobic fitness, muscle weakness, low bone mass, and low bone strength. Suboptimal physical activity and exercise capacity may contribute to further deconditioning and disability, placing children with arthritis at risk for poor health outcomes. Recent studies suggest that exercise therapy is safe and does not worsen arthritis. Exercise therapy may improve function, quality of life, and physical fitness. However, little is known about the exercise prescription that is most effective to improve clinical outcomes in children with arthritis. This article reviews the current literature on physical activity, physical fitness, and exercise therapy in children with juvenile idiopathic arthritis.

Each type of cause that initiates rheumatoid arthritis or RA flares differentially affects the response to therapy

The autoimmune disease rheumatoid arthritis (RA) presents difficulty in diagnosis, commonly observed flare ups, polycyclical nature of RA progression, and variable response to therapies. Congruent with multiple causes, literature has documented various infectious agents, environmental factors, physical trauma, silica and food sensitivities as potential causes of RA or RA flares in different populations. We propose that these>36 events can initiate RA or RA flares which complicates treatment decisions. Each pharmaceutical medicine benefits 15-82% of RA patients. Predictive factors are needed. Because the initiating cause of RA or RA flare affects the type of joint damage, initial inflammatory response, adaptive immune response, and potential molecular mimicry, we propose the "RA cause affects response to therapy" (RACART) theory. The potential cause combined with confounding factors such as genetic risk factors, nutritional status, epigenetic status, inflammatory levels, and detoxification ability may help predict responses to various therapies.

Predictors of disability and pain six months after the end of treatment for fibromyalgia

OBJECTIVES

The goal of this study was to identify factors associated with decreased disability and lower pain scores 6 months after a multimodal treatment program for fibromyalgia (FM).

METHODS

Forty-six patients with FM were assessed after having participated in a 3-month outpatient program integrating physiotherapy, occupational therapy, nursing, and cognitive-behavior therapy. A physician examined the patients before treatment and patients who completed a battery of psychosocial questionnaires at baseline, during treatment, at the end of treatment, and 3 and 6 months after the end of treatment. Two separate multivariable linear regression models were built to identify predictors of improvements in disability and pain.

RESULTS

Two predictors for improvement in disability were found: an increase in self-efficacy for pain during treatment and better general adherence during treatment. Similarly, one predictor for improvement in pain intensity was found: an increase in self-efficacy for pain during treatment.

DISCUSSION

Self-efficacy and adherence are 2 modifiable factors that influence disability and pain intensity in FM. These psychosocial factors need to be addressed in FM treatment programs to assist patients in maintaining posttreatment improvements.

Living with Juvenile Idiopathic Arthritis: Parents' Experiences of Treatment Regimens and Home Exercise Programmes

The parents of children with juvenile idiopathic arthritis have been identified as pivotal facilitators of children's involvement in treatment regimens, including home exercise programmes. As such, parents' perspectives regarding the factors that influence participation in their children's treatment regimens, and in particular home exercise programmes, are addressed in this study. In depth, semi-structured interviews were conducted with 16 families. Rigour was ensured through a rich description of participants, peer and member checking, field journals and audit trails.

Four key topics related to the process — the experience of the child's diagnosis, community access and participation, treatment regimens and the impact of these regimens on the parent's roles and relationships — and were addressed. Seven key themes emerged, namely the difficult process of diagnosis, the emotional toll, medications, exercises, life revolves around arthritis, parents' relationship with their child and other family members, and parents and paid work. The implications for clinical practice and future research are discussed.