The role of exercise therapy in the management of juvenile idiopathic arthritis

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.

Cardiorespiratory fitness assessed with cardiopulmonary exercise testing in patients with juvenile idiopathic arthritis: a systematic review and meta-analysis

OBJECTIVES

JIA is the most common type of arthritis in children and adolescents, causing joint damage, chronic pain and disability. Deconditioning is also prevalent in patients with JIA due to both inactivity and the disease progression, resulting in reduced cardiorespiratory fitness (CRF). We aimed to evaluate CRF of patients with JIA compared with healthy controls.

METHODS

This is a systematic review and meta-analysis of studies using cardiopulmonary exercise testing (CPET) to examine differences in determinants of CRF between patients with JIA vs healthy controls. The primary outcome was peak oxygen uptake (VO2peak). Literature search involved PubMed, Web of Science and Scopus databases, manual search of article references and grey literature. Quality assessment was undertaken with Newcastle-Ottawa Scale.

RESULTS

From 480 literature records initially retrieved, eight studies (538 participants) were included in final meta-analysis. VO2peak was significantly lower in patients with JIA compared with controls [weighted mean difference (WMD): -5.95 ml/kg/min (95% CI -9.26, -2.65)]. Exercise duration and VO2peak (% predicted) were found to be significantly impaired in patients with JIA compared with controls [standardized mean difference: -0.67 (95% CI -1.04, -0.29) and WMD: -11.31% (95% CI -20.09, -2.53), respectively], while no significant differences were found in maximum heart rate.

CONCLUSION

VO2peak and other CPET variables were lower in patients with JIA compared with controls, indicating reduced CRF in the former. Overall, exercise programs for patients with JIA should be promoted as part of their treatment to improve physical fitness and reduce muscle atrophy.

PROSPERO REGISTRATION

CRD42022380833.

Physical activity as a promising alternative for young people with juvenile idiopathic arthritis: Towards an evidence-based prescription

Juvenile idiopathic arthritis (JIA) is the most common rheumatic disease in young people. Although biologics now enable most children and adolescents with JIA to enjoy clinical remission, patients present lower physical activity and spend more time in sedentary behavior than their healthy counterparts. This impairment probably results from a physical deconditioning spiral initiated by joint pain, sustained by apprehension on the part of both the child and the child's parents, and entrenched by lowered physical capacities. This in turn may exacerbate disease activity and lead to unfavorable health outcomes including increased risks of metabolic and mental comorbidities. Over the past few decades, there has been growing interest in the health benefits of increased overall physical activity as well as exercise interventions in young people with JIA. However, we are still far from evidence-based physical activity and / or exercise prescription for this population. In this review, we give an overview of the available data supporting physical activity and / or exercise as a behavioral, non-pharmacological alternative to attenuate inflammation while also improving metabolism, disease symptoms, poor sleep, synchronization of circadian rhythms, mental health, and quality of life in JIA. Finally, we discuss clinical implications, identify gaps in knowledge, and outline a future research agenda.

Physical Activity Influences Health-Related Quality of Life in Adults with Juvenile Idiopathic Arthritis

This cross-sectional study aimed to evaluate the impact of physical activity and physical fitness on the health-related quality of life (HQoL) of adult patients with Juvenile Idiopathic Arthritis (JIA). Fifty-nine JIA patients and sixty healthy individuals participated in this study. All individuals had the following evaluations performed: body composition (electrical bioimpedance), physical fitness (6 min walk test (6MWT)), physical activity level (International Physical Activity Questionnaire (IPAQ)), and HQoL (Quality of Life Questionnaire in relation to Health-Short Form (SF36)). Thirty-nine (66%) JIA patients were considered sedentary compared with 15 (25%) in the control group (p < 0.01). JIA patients had a lower HQoL compared with the control group in all variables studied (p < 0.05). JIA patients who were very physically active had better HQoL conditions in the categories of functional capacity (p = 0.001), limitations by physical aspects (p = 0.003), and emotional aspects (p = 0.002) compared with sedentary patients. JIA patients had more cardiovascular abnormalities and walked shorter distances compared with healthy controls in the 6MWT. In conclusion, we observed that HQoL was reduced in adults with JIA. A high percentage of JIA patients were sedentary with lower physical fitness, but physically active patients had a better HQoL than sedentary patients. The duration of physical activity, rather than intensity, influenced the mental aspects of HQoL.

Increased Relapse Rate During COVID-19 Lockdown in an Italian Cohort of Children With Juvenile Idiopathic Arthritis

OBJECTIVE

Changes of routine disease management associated with COVID-19 lockdown might have potentially affected the clinical course of juvenile idiopathic arthritis (JIA). The aim of our study was to assess the rate of disease flare before and during COVID-19 lockdown to investigate its impact on disease course in children with JIA.

METHODS

A single-center retrospective study was conducted, including patients presenting with inactive JIA between September 1, 2018 and March 9, 2019 (group A) and between September 1, 2019 and March 9, 2020 (group B). For each patient, demographic and clinical data were collected. The rate of JIA flare from March 10, 2019 to June 30, 2019 for group A and from March 10, 2020 to June 30, 2020 for group B was compared.

RESULTS

Group A included 126 patients, and group B 124 patients. Statistical analysis did not show significant differences among the 2 cohorts with respect to age, sex, age at JIA onset, JIA subtype, co-occurrence of uveitis, antinuclear antibody positivity, and past or ongoing medications. The rate of disease flare during lockdown at the time of the first COVID-19 pandemic wave was significantly higher in comparison to the previous year (16.9% versus 6.3%; P = 0.009).

CONCLUSION

Our study showed that COVID-19 lockdown was associated with a higher rate of joint inflammation in children with JIA. This finding has a considerable clinical implication, as restrictive measures may be necessary in order to contain pandemics. Our data highlight the need for rearrangement in the home and health care management of children with JIA during lockdowns.

Physical Activity Interventions in Children with Juvenile Idiopathic Arthritis: A Systematic Review of Randomized Controlled Trials

Introduction

Children with juvenile arthritis (JA) experience pain, stiffness, fatigue, and decreased motion leading to difficulties with daily activities and low physical activity (PA). PA is critical to improve health and function and mitigate JA-associated symptoms. This study evaluated the evidence for PA interventions in children with JA.

Materials and Methods

A systematic review of randomized controlled trials (RCTs) of PA interventions in children with JA was conducted. Ovid (Medline), Cochrane Library, EMBASE, and CINAHL databases were searched for papers published in English between 1/1/1946 and 9/1/2021. Studies which concurrently assessed medical interventions were excluded. Participant and intervention characteristics and outcomes were extracted. Study internal validity and intervention attributes were assessed.

Results

A total of 555 studies were identified, with 13 studies from 10 countries included. Data from 672 children diagnosed with juvenile idiopathic arthritis (JIA) (range of mean ages, 8.7 to 16.1 years) were analyzed. Fifty-two percent of intervention arms incorporated strengthening exercise alone or combined with other exercise, with 61.9% performed 3x/week. About 43.5% of sessions lasted >45 to ≤60 minutes and 65.2% of programs were ≥12 to <28 weeks. PA interventions improved function and symptoms without adverse events. Intervention details were missing especially regarding PA intensity, reasons for dropouts, and adherence. Only two studies incorporated strategies to promote adherence.

Discussion

RCTs of PA interventions in JA only include JIA. Available RCTs used mixed modes of interventions. Reporting of PA interventions lacks sufficient detail to discern the dose-response relationship. Strategies to motivate engagement in PA and to support families to promote PA are lacking, as are studies of long-term outcomes.

Conclusion

There are limited RCTs of PA interventions in JIA. Adherence was better with low intensity programs. PA interventions for JIA yield positive health benefits but better reporting of PA intervention details is needed to generate more high-quality evidence and inform clinical practice.

Prospero Registration

Maura Iversen, Johan von Heideken, Marie Andre. Physical Activity in Children with Rheumatic Diseases: a systematic review. PROSPERO 2021 CRD42021274634 Available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021274634.

Association of Anxiety With Pain and Disability but Not With Increased Measures of Inflammation in Adolescent Patients With Juvenile Idiopathic Arthritis

Objective

To explore whether anxiety and depression are associated with clinical measures of disease for adolescent patients with juvenile idiopathic arthritis (JIA) and whether anxiety and depression are associated with increased peripheral proinflammatory cytokine levels in adolescent patients with JIA and in healthy adolescent controls.

Methods

A total of 136 patients with JIA and 88 healthy controls ages 13–18 years completed questionnaires on anxiety and depressive symptoms. For patients with JIA, pain, disability, physician global assessment (using a visual analog scale [VAS]), and number of joints with active inflammation (active joint count) were recorded. In a subsample, we assessed lipopolysaccharide‐stimulated interleukin 6 (IL‐6) production from peripheral blood mononuclear cells, serum IL‐6, cortisol, and C‐reactive protein levels. Data were analyzed by linear regression analysis.

Results

Levels of anxiety and depressive symptoms in patients with JIA were not significantly different than those in healthy controls. For patients with JIA, anxiety was significantly associated with disability (β = 0.009, P = 0.002), pain (β = 0.029, P = 0.011), and physician global assessment VAS (β = 0.019, P = 0.012), but not with active joint count (β = 0.014, P = 0.120). Anxiety was not associated with any laboratory measures of inflammation for JIA patients. These relationships were also true for depressive symptoms. For healthy controls, there was a trend toward an association of anxiety (but not depressive symptoms) with stimulated IL‐6 (β = 0.004, P = 0.052).

Conclusion

Adolescent patients with JIA experience equivalent levels of anxiety and depressive symptoms as healthy adolescents. For adolescent patients with JIA, anxiety and depressive symptoms are associated with pain, disability, and physician global assessment VAS, but not with inflammation.

[Back to school physical education despite rheumatism : Development and testing of a sport scientific-based physical education certification]

BACKGROUND

Taking part in physical education is an important element of social participation for children with chronic diseases. Nevertheless, children suffering from rheumatism mostly receive recommendations to stop sport activities either completely or partially, without underlying scientific guidelines.

OBJECTIVE

The aim was the development of an IT-tool based on scientific data in order to create individualized recommendations for sport activities plus verification of its practical feasibility.

MATERIAL AND METHODS

An interdisciplinary group of experts developed and approved a prototype of the rheumatism and sports compass (Rheuma und Sport Kompass, RSK) based on the literature and own experience. They considered individual health factors and biomechanics of sports functions. The prototype was tested, revised and reconsidered in an interim evaluation. The resulting RSKv1 was evaluated in a clinical observation phase with 61 patients. The results were subsequently incorporated into the final version of RSK during an interdisciplinary decision-making process. This was verified in a feasibility study with a follow-up survey of rheumatic patients with a RSK partial participation certification for physical education including: clinical assessment during 8 lessons of physical education and after 8 lessons of physical education. Teachers rated the RSK online after 8 lessons. The evaluation was descriptive and differences in mean values were tested.

RESULTS AND DISCUSSION

In this study 50 patients and 31 teachers were evaluated. The affliction of pain decreased in terms of frequency, amount and duration after physical education with RSK. No worsening in health was reported after participation in sports. The teachers rated the RSK as understandable, practicable and they felt confident to allow the patients to participate in classes. The RSK was rated significantly better than a standard certification text. With the RSK, patients can be advised to safely take part in physical education.

A wearable activity tracker intervention for promoting physical activity in adolescents with juvenile idiopathic arthritis: a pilot study

BACKGROUND

Children and adolescents with juvenile idiopathic arthritis (JIA) are less physically active than their healthy peers and are at high risk of missing out on the general health benefits of physical activity. Wearable activity trackers are a promising option for intervening in this population with potential advantages over traditional exercise prescriptions. The objectives of this study were to: (1) determine the feasibility of a wearable activity tracker intervention in adolescents with JIA; and (2) estimate the variability in response to a wearable activity tracker intervention on the physical activity levels of adolescents with JIA.

METHODS

Participants aged 12-18 years with JIA were recruited during their routine rheumatology clinic visits at a tertiary care hospital. Participants completed the 3-Day Physical Activity Recall self-reported questionnaire at baseline, 1 week and 5 week follow-up. At the 1 week follow up, participants were instructed to start wearing an activity tracker for 28 consecutive days. Participants completed a feasibility questionnaire at their end of study visit. Participant demographics, adherence rates and feasibility outcomes were summarized using descriptive statistics. The effect of wearing a tracker on moderate-to-vigorous physical activity (MVPA) and total metabolic equivalents (METs) per day were analyzed using a paired t-test.

RESULTS

Twenty-eight participants (74% female; median age 15.1, range 12.8-18.6) were included in the analysis. All of the participants were able to synchronize the activity tracker to a supported device, use the activity tracker correctly and complete the study measurements. On average, participants had activity logged on their smartphone application for 72% of the intervention period. The standard deviation of the change in mean METs/day was 12.148 and for mean MVPA blocks/day was 3.143 over the study period.

CONCLUSION

Wrist worn activity tracking is a feasible intervention for adolescent patients with JIA. More research is needed to examine the effect of activity tracking on physical activity levels.

TRIAL REGISTRATION

Not an applicable clinical device trial as per the criteria listed on ClinicalTrials.gov as the primary objective is feasibility.

Depressive symptoms, pain and disability for adolescent patients with juvenile idiopathic arthritis: results from the Childhood Arthritis Prospective Study

Objectives

To determine if depressive symptoms assessed near diagnosis associate with future measures of pain, disability and disease for adolescent patients diagnosed with JIA.

Methods

Data were analysed from JIA patients aged 11–16 years recruited to the Childhood Arthritis Prospective Study, a UK-based inception cohort of childhood-onset arthritis. Depressive symptoms (using the Mood and Feelings Questionnaire; MFQ), active and limited joint count, disability score (Childhood Health Assessment Questionnaire), pain visual analogue scale and patient’s general evaluation visual analogue scale were collected. Associations between baseline measures (first visit to paediatric rheumatologist) were analysed using multiple linear regression. Linear mixed-effect models for change in the clinical measures of disease over 48 months were estimated including MFQ as an explanatory variable.

Results

Data from 102 patients were analysed. At baseline, median (IQR) age was 13.2 years (11.9–14.2 years) and 14.7% scored over the MFQ cut-off for major depressive disorder. At baseline, depressive symptoms significantly associated with all clinical measures of disease (P ⩽ 0.01). High baseline depressive symptoms scores predicted worse pain (P ⩽ 0.005) and disability (P ⩽ 0.001) 12 months later but not active and limited joint counts.

Conclusions

Adolescent patients with JIA and depressive symptoms had more active joints, pain and disability at the time of their first specialist appointment. The associations between baseline depression and both pain and disability continued for at least one year, however, this was not the case for active joint count.

General Nutrition and Fitness for the Child with Rheumatic Disease

As a result of new medications and therapeutic approaches, most children with rheumatic diseases are no longer at risk for growth failure which results from chronic inflammation and prolonged corticosteroid treatment. However, obesity, poor nutrition, and insufficient exercise are still problems which increase risks for poor bone, cardiovascular, and general health. Diet should be monitored and modified as appropriate; supplemental calcium and Vitamin D should be provided. Obesity and poor physical fitness can be ameliorated by an exercise program that should become part of a more healthy lifestyle.

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.

Sensitivity of a juvenile subject-specific musculoskeletal model of the ankle joint to the variability of operator-dependent input

Subject-specific musculoskeletal modelling is especially useful in the study of juvenile and pathological subjects. However, such methodologies typically require a human operator to identify key landmarks from medical imaging data and are thus affected by unavoidable variability in the parameters defined and subsequent model predictions. The aim of this study was to thus quantify the inter- and intra-operator repeatability of a subject-specific modelling methodology developed for the analysis of subjects with juvenile idiopathic arthritis. Three operators each created subject-specific musculoskeletal foot and ankle models via palpation of bony landmarks, adjustment of geometrical muscle points and definition of joint coordinate systems. These models were then fused to a generic Arnold lower limb model for each of three modelled patients. The repeatability of each modelling operation was found to be comparable to those previously reported for the modelling of healthy, adult subjects. However, the inter-operator repeatability of muscle point definition was significantly greater than intra-operator repeatability (p < 0.05) and predicted ankle joint contact forces ranged by up to 24% and 10% of the peak force for the inter- and intra-operator analyses, respectively. Similarly, the maximum inter- and intra-operator variations in muscle force output were 64% and 23% of peak force, respectively. Our results suggest that subject-specific modelling is operator dependent at the foot and ankle, with the definition of muscle geometry the most significant source of output uncertainty. The development of automated procedures to prevent the misplacement of crucial muscle points should therefore be considered a particular priority for those developing subject-specific models.

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.

Physical Exercise and Physical Activity for Children and Adolescents With Juvenile Idiopathic Arthritis: A Literature Review

PURPOSE

This is a review of studies that investigate the efficacy of exercise therapy and physical activity for children with juvenile idiopathic arthritis since the 2008 Cochrane Review.

METHOD

Studies were identified that investigated the use of physical activity and exercise therapy in the treatment of children and adolescents with juvenile idiopathic arthritis, excluding the Cochrane Review. Two reviewers individually analyzed the results of the search to determine the eligibility of studies. The randomized controlled trial study designs were evaluated using PEDro scales.

CONCLUSIONS AND RECOMMENDATIONS FOR CLINICAL PRACTICE

Recent literature supports the importance of the combination of strengthening, stretching, proprioceptive, and balance exercises and activities in water. Many of the reviewed studies proposed an intensive program of physical activity and exercise therapy, conducted 3 times a week for 12 weeks.

A study on the physical fitness of children with juvenile rheumatoid arthritis

[Purpose] This study was conducted to assess the physical fitness of children with juvenile rheumatoid arthritis (JRA). [Subjects and Methods] In total, 26 children with juvenile rheumatoid arthritis (JRA) and 25 healthy controls participated in this study. Using the physical fitness measurement instruments, the Inbody 720 and Quark b2, the elements of physical fitness that were assessed included muscular strength, muscular endurance, flexibility, lung capacity, and body composition. [Results] The results revealed significant differences in muscular strength, muscular endurance, lung capacity, body composition, functional ability, and health-related quality of life between the children with juvenile rheumatoid arthritis (JRA) and the control group. [Conclusion] These results suggested that children with juvenile rheumatoid arthritis (JRA) have inferior physical fitness when compared to healthy children. The present study was conducted to develop an accurate evaluation standard to assess the physical fitness of children with juvenile rheumatoid arthritis (JRA).

Effect of Intraarticular Corticosteroid Foot Injections on Walking Function in Children With Juvenile Idiopathic Arthritis

OBJECTIVE

To evaluate gait dynamics and self-reported foot-related disability before and after treatment with intraarticular corticosteroid injections (IACI) in children with juvenile idiopathic arthritis (JIA) and foot involvement, and determined whether children with polyarticular and oligoarticular disease responded similarly to IACI treatment.

METHODS

Forty-three children (35 girls and 8 boys) with JIA were consecutively recruited (mean ± SD age 11.1 ± 4.2 years, mean disease duration 4.5 ± 3.6 years). Sixty-five percent were diagnosed with polyarthritis. All children received IACI treatment for ankle and/or foot joint synovitis. Fifty-eight percent received additional injections in the knee and/or hip joint. Forty healthy children, matched by age and sex, comprised the control group. Gait dynamics and foot-related disability were assessed before IACI treatment and at 3 weeks and 3 months following the injections.

RESULTS

Foot-related disability and inflammatory joint symptoms improved following treatment. Gait dynamics were compromised before treatment and did not improve following treatment (mean ± SD nondimensional walking speed 0.49 ± 0.05 in the control group; 0.44 ± 0.07 in the JIA group pretreatment; 0.43 ± 0.10 in the JIA group 3 weeks following treatment; and 0.43 ± 0.07 in the JIA group 3 months following treatment) (P = 0.001 in controls versus pretreatment JIA group, P = 0.45 JIA over time). Mean ± SD ankle power was 3.81 ± 0.67 in the control group; 3.01 ± 1.19 in the JIA group pretreatment; 3.19 ± 1.30 in the JIA group 3 weeks after treatment; and 3.22 ± 1.03 in the JIA group 3 months after treatment (P < 0.001 in controls versus pretreatment JIA group, P = 0.51 JIA over time). The ankle power to hip power ratio was reduced (P = 0.01 in controls versus pretreatment JIA group), indicating a power shift from the ankles to the hips, which was more prominent in children with polyarthritis.

CONCLUSION

As a result of IACI treatment, improvements were found in self-reported foot-related disability and inflammatory joint symptoms, but gait dynamics were unchanged. Children with polyarticular disease and those with greater self-reported walking difficulties prior to IACI treatment demonstrated worse outcomes, and children in these groups should be monitored carefully after treatment.

Perspectives on Active Video Gaming as a New Frontier in Accessible Physical Activity for Youth With Physical Disabilities

This perspective article explores the utility of active video gaming as a means of reducing sedentary behavior and increasing physical activity among youth with physical disabilities and limitations in lower extremity function who typically are excluded from mainstream exercise options. Youth with physical disabilities are disproportionately affected by health problems that result from sedentary behavior, lack of physical activity, and low fitness levels. Physical, programmatic, and attitudinal barriers have a synergistic and compounded impact on youths' ability to participate in physical activity. A recent health and wellness task force recommendation from the American Physical Therapy Association's Section on Pediatrics supports analyzing individualized health behaviors and preferences that are designed to improve fitness, physical activity, and participation in pediatric rehabilitation. This recommendation represents an opportunity to explore nontraditional options to maximize effectiveness and sustainability of pediatric rehabilitation techniques for youth with disabilities who could best benefit from customized programming. One new frontier in promoting physical activity and addressing common physical activity barriers for youth with physical disabilities is active video games (AVGs), which have received growing attention as a promising strategy for promoting health and fitness in children with and without disabilities. The purpose of this article is to discuss the potential for AVGs as an accessible option to increase physical activity participation for youth with physical disabilities and limitations in lower extremity function. A conceptual model on the use of AVGs to increase physical activity participation for youth with physical disabilities is introduced, and future research potential is discussed, including a development project for game controller adaptations within the Rehabilitation Engineering Research Center on Interactive Exercise Technologies and Exercise Physiology for People With Disabilities (RERC RecTech) at the University of Alabama at Birmingham (UAB)/Lakeshore Foundation Research Collaborative.

The Effects of Orthopedic Manual Physical Therapy in the Management of Juvenile Idiopathic Arthritis: A Case Report

PURPOSE

Juvenile idiopathic arthritis (JIA) is a cause of disability in childhood. Little research exists concerning physical therapy management, and no evidence exists for orthopedic manual physical therapy (OMPT) for JIA. The purpose of this case report is to describe the use of OMPT in combination with therapeutic exercise in the successful treatment of a child with oligoarticular JIA.

KEY POINTS

A 6-year-old girl with oligoarticular JIA presented with elbow pain and stiffness interfering with function. Treatment consisted of OMPT in combination with therapeutic exercise and a home exercise program.

CONCLUSIONS

Improvements were demonstrated in elbow range of motion, pain, Childhood Health Assessment Questionnaire, Pediatric Outcomes Data Collection Instrument, and the Patient Specific Functional Scale.

RECOMMENDATIONS FOR CLINICAL PRACTICE

Orthopedic manual physical therapy may be considered as a treatment of a child with JIA.

RECOMMENDATIONS

We provide evidence that OMPT may be considered as a treatment of a child with JIA.

A Patient-Specific Foot Model for the Estimate of Ankle Joint Forces in Patients with Juvenile Idiopathic Arthritis

Juvenile idiopathic arthritis (JIA) is the leading cause of childhood disability from a musculoskeletal disorder. It generally affects large joints such as the knee and the ankle, often causing structural damage. Different factors contribute to the damage onset, including altered joint loading and other mechanical factors, associated with pain and inflammation. The prediction of patients’ joint loading can hence be a valuable tool in understanding the disease mechanisms involved in structural damage progression. A number of lower-limb musculoskeletal models have been proposed to analyse the hip and knee joints, but juvenile models of the foot are still lacking. This paper presents a modelling pipeline that allows the creation of juvenile patient-specific models starting from lower limb kinematics and foot and ankle MRI data. This pipeline has been applied to data from three children with JIA and the importance of patient-specific parameters and modelling assumptions has been tested in a sensitivity analysis focused on the variation of the joint reaction forces. This analysis highlighted the criticality of patient-specific definition of the ankle joint axes and location of the Achilles tendon insertions. Patient-specific detection of the Tibialis Anterior, Tibialis Posterior, and Peroneus Longus origins and insertions were also shown to be important.

Juvenile idiopathic arthritis and physical activity: possible inflammatory and immune modulation and tracks for interventions in young populations

Juvenile idiopathic arthritis (JIA) is a chronic inflammatory disease characterized by persistent joint inflammation that manifests as joint pain and swelling and limited range of joint motion. In healthy subjects, the literature reports that physical activity has an anti-inflammatory effect. In JIA patients, exercise could be used as a therapeutic tool to counteract disease-related inflammation and thereby improve clinical symptoms, although transient flare of pain could be the price to pay. Indeed, in patients with a chronic inflammatory disease, physical activity is prone to exacerbate underlying inflammatory stress. Physical activity improves quality of life and symptoms in JIA patients, but the mechanisms of action remain unclear. This review focuses on the mechanisms underlying exercise-induced immune and hormonal changes. Data on the impact of acute and chronic physical activities on the secretion of hormones and other molecules such as miRNA or peptides involved in the inflammatory process in JIA was compiled and summarized, and the key role of the biological effect of muscle-derived interleukin 6 in the exercise-induced modulation of pro/anti-inflammatory balance is addressed. We also go on to review the effect of training and type of exercise on cytokine response. This review highlights the beneficial effect of physical exercise in children with JIA and potential effect of exercise on the balance between pro- and anti-inflammatory response.

Can I play?

Physical activity and participation in sports are important for the well being of children and youth and should be encouraged by health care providers. Individuals with chronic diseases are often less active, which can have a negative impact on their health. This article will review the effects of exercise on a few chronic medical conditions including juvenile arthritis, cystic fibrosis, and hypertension. The clinician's role in providing advice about sport participation will also be addressed.

Glucocorticoid-associated osteoporosis in chronic inflammatory diseases: epidemiology, mechanisms, diagnosis, and treatment

Children with chronic illnesses such as Juvenile Idiopathic Arthritis and Crohn's disease, particularly when taking glucocorticoids, are at significant risk for bone fragility. Furthermore, when childhood illness interferes with achieving normal peak bone mass, life-long fracture risk is increased. Osteopenia and osteoporosis, which is increasingly recognized in pediatric chronic disease, likely results from numerous disease- and treatment-related factors, including glucocorticoid exposure. Diagnosing osteoporosis in childhood is complicated by the limitations of current noninvasive techniques such as DXA, which despite its limitations remains the gold standard. The risk:benefit ratio of treatment is confounded by the potential for spontaneous restitution of bone mass deficits and reshaping of previously fractured vertebral bodies. Bisphosphonates have been used to treat secondary osteoporosis in children, but limited experience and potential long-term toxicity warrant caution in routine use. This article reviews the factors that influence loss of normal bone strength and evidence for effective treatments, in particular in patients with gastrointestinal and rheumatologic disorders who are receiving chronic glucocorticoid therapy.

The clinical translation gap in child health exercise research: a call for disruptive innovation

In children, levels of play, physical activity, and fitness are key indicators of health and disease and closely tied to optimal growth and development. Cardiopulmonary exercise testing (CPET) provides clinicians with biomarkers of disease and effectiveness of therapy, and researchers with novel insights into fundamental biological mechanisms reflecting an integrated physiological response that is hidden when the child is at rest. Yet the growth of clinical trials utilizing CPET in pediatrics remains stunted despite the current emphasis on preventative medicine and the growing recognition that therapies used in children should be clinically tested in children. There exists a translational gap between basic discovery and clinical application in this essential component of child health. To address this gap, the NIH provided funding through the Clinical and Translational Science Award (CTSA) program to convene a panel of experts. This report summarizes our major findings and outlines next steps necessary to enhance child health exercise medicine translational research. We present specific plans to bolster data interoperability, improve child health CPET reference values, stimulate formal training in exercise medicine for child health care professionals, and outline innovative approaches through which exercise medicine can become more accessible and advance therapeutics across the broad spectrum of child health.

Functional capacity, strength, and quality of life in children and youth with familial Mediterranean fever

PURPOSE

To examine functional capacity and muscle strength in children and youth with familial Mediterranean fever (FMF) as compared with controls, and to assess whether these factors influence quality of life (QOL) in FMF.

METHODS

A total of 100 subjects with FMF and 55 control subjects (8-18 years old) without known health issues were enrolled in the study. The 6-Minute Walk Test (6MWT) was used to evaluate functional capacity. Quadriceps strength was measured with a hand-held dynamometer. Quality of life was evaluated with the Pediatric Quality of Life Inventory 4.0 (PedsQL 4.0).

RESULTS

Significant differences were found between subjects with FMF and controls in the 6MWT and strength test. PedsQL scores of subjects with FMF were significantly lower than the scores of the controls. The 6MWT and quadriceps strength were weakly correlated with the PedsQL.

CONCLUSION

Subjects with FMF displayed lower functional capacity and QOL than peers who are healthy. Decreased functional capacity was correlated with decreased QOL in those with FMF.

Safety and feasibility of a home-based six week resistance training program in juvenile idiopathic arthritis

BACKGROUND

Juvenile idiopathic arthritis (JIA), among the most common chronic diseases of childhood, can be associated with attenuated physical activity levels, reduced fitness, decreased functionality and pain. This pilot study aimed to determine the safety, feasibility and effect of a six week resistance training program in children with JIA.

METHODS

Youth (8-18 years) with JIA participated in a home-based resistance training program. Participants reported pain on an electronic diary once a day for one week prior to training, then once a day on non-exercise days and three times a day (before-exercise, after-exercise, and end-of-day) on exercise days for the subsequent six weeks of training. Secondary outcome measures included inflammation (assessed by ultrasound), muscle size (assessed by ultrasound), muscle strength (assessed by dynamometer) and functional ability (assessed by childhood health assessment questionnaire), measured at baseline and post-training. Participants were also instructed to wear an accelerometer one week prior to training to estimate baseline physical activity levels. Statistical analyses included safety (pain changes and any adverse events), feasibility (adherence to program and modifications made to exercises) and effect of program (differences in secondary measures pre and post training). An alpha level of p < 0.05 was accepted as significant.

RESULTS

Seven participants completed an average of 12.7 ± 3.4 (range 8-17) exercise sessions out of a possible 18 (70.6%). No adverse events were reported and pain did not increase over the seven weeks. Secondary measures revealed a significant increase in vastus lateralis thickness from pre to post training (p < 0.05). End-of-day pain intensity was correlated to end-of-day stiffness, fatigue and mood (r = .864, r = .581, r = -.637, respectively, p < 0.001). Pain intensity was also correlated with ratings of perceived exertion of the exercise (r = 0.324, p < 0.01). Only two children met the recommended 60 minutes of moderate to vigorous physical activity per day.

CONCLUSIONS

A six week home-based resistance training program is both safe (absence of pain changes or adverse events over the six weeks) and feasible (comparable adherence rates to other exercise studies involving JIA and individually modifiable) in children with JIA.

The Relationship Between Physical Activity Levels and Pain in Children with Juvenile Idiopathic Arthritis

Objective.

Pain and reduced physical activity levels are common in children with juvenile idiopathic arthritis (JIA). Currently, there is no consensus about the role of physical activity in managing pain in JIA. The purpose of our study was to assess the relationship between physical activity level and pain in children ages 11 to 18 years with JIA.

Methods.

A random sample of 50 patients with JIA were approached by mailed questionnaires. Physical activity was determined using the Physical Activity Questionnaire (PAQ). Pain measures included the Numerical Rating Scale (pain severity), SUPER-KIDZ body diagram (number of painful areas), and the Child Activities Limitations Inventory-21 (pain interference). Generalized linear models were used to assess the relationship between physical activity and pain, as well as the roles of sex and age.

Results.

The response rate was 84%. Thirty-four respondents completed the questionnaire package. The median age was 15 years. The mean PAQ score was 2.16/5. Physical activity declines with increasing age in youth with JIA (r = 0.53, p = 0.0014). Lower physical activity is associated with greater pain interference (r = 0.39, p = 0.0217) and more severe pain (r = 0.35, p = 0.0422).

Conclusion.

Children with JIA report significantly less activity than healthy children based on PAQ scores, with physical activity declining throughout adolescence. Physical activity is inversely related to pain interference and severity in children with JIA. Our findings suggest that physical activity interventions may play an important role in the management of pain in JIA.

The challenge of obtaining information necessary for multi-criteria decision analysis implementation: the case of physiotherapy services in Canada

BACKGROUND

As fiscal constraints dominate health policy discussions across Canada and globally, priority-setting exercises are becoming more common to guide the difficult choices that must be made. In this context, it becomes highly desirable to have accurate estimates of the value of specific health care interventions.Economic evaluation is a well-accepted method to estimate the value of health care interventions. However, economic evaluation has significant limitations, which have lead to an increase in the use of Multi-Criteria Decision Analysis (MCDA). One key concern with MCDA is the availability of the information necessary for implementation. In the Fall 2011, the Canadian Physiotherapy Association embarked on a project aimed at providing a valuation of physiotherapy services that is both evidence-based and relevant to resource allocation decisions. The framework selected for this project was MCDA. We report on how we addressed the challenge of obtaining some of the information necessary for MCDA implementation.

METHODS

MCDA criteria were selected and areas of physiotherapy practices were identified. The building up of the necessary information base was a three step process. First, there was a literature review for each practice area, on each criterion. The next step was to conduct interviews with experts in each of the practice areas to critique the results of the literature review and to fill in gaps where there was no or insufficient literature. Finally, the results of the individual interviews were validated by a national committee to ensure consistency across all practice areas and that a national level perspective is applied.

RESULTS

Despite a lack of research evidence on many of the considerations relevant to the estimation of the value of physiotherapy services (the criteria), sufficient information was obtained to facilitate MCDA implementation at the local level.

CONCLUSIONS

The results of this research project serve two purposes: 1) a method to obtain information necessary to implement MCDA is described, and 2) the results in terms of information on the benefits provided by each of the twelve areas of physiotherapy practice can be used by decision-makers as a starting point in the implementation of MCDA at the local level.

Juvenile idiopathic arthritis and athletic participation: are we adequately preparing for sports integration?

Children with juvenile idiopathic arthritis (JIA) now have well-controlled disease due to improved therapies and management strategies. Children with JIA are more active than in the past and often participate in dynamic, high-loading sports. Standard measures of disease control include examination findings, laboratory values, and patient-directed surveys. However, these standards do not address the subtle deficits in biomechanics and neuromuscular control, which could place affected joints at higher risk for injury. Currently, there are limited evidence-based guidelines to structure conditioning recommendations as to the fitness and mechanics needed to provide safe integration into sports in this population; therefore, tools that objectively measure function with high accuracy and precision may be warranted. Previous work using 3-dimensional motion analysis demonstrated usefulness in guiding physical therapy treatment to correct these deficits. The use of a multidisciplinary team, including physical therapy, rheumatology, and sports medicine, is crucial for preparing these children to return to play. We suggest that the child transition into a sport preparatory-conditioning program to address any underlying deficits. A pediatric exercise specialist who is sensitive to the needs of this population can work with a physical therapist to then appropriately integrate the child safely into sport. Encouraging an active lifestyle is vital to the management of JIA and does not worsen the symptoms associated with childhood arthritis.

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.

Exercise in inflammatory myopathies, including inclusion body myositis

Exercise is an important part of treatment in patients with idiopathic inflammatory myopathies. Improved functioning, ability to perform activities of daily living, and health-related quality of life have been reported in adult polymyositis, dermatomyositis, and also recently inclusion body myositis following different exercise regimens, with no signs of increased muscle inflammation. Intensive resistance training could reduce clinical disease activity and reduce expression of genes regulating inflammation and fibrosis in chronic polymyositis and dermatomyositis. Today, exercise research in adult myositis is focused on understanding mechanisms for muscle impairment and improved muscle function in relation to exercise and verifying results from small, open studies in larger settings. There are no studies evaluating the effects of exercise over weeks or months in juvenile dermatomyositis, other than a case report; however, there is to our knowledge an ongoing effort to evaluate the safety and effects of exercise in patients with juvenile dermatomyositis.

Medical and orthopedic conditions and sports participation

The presence of certain medical or orthopedic conditions need not preclude adolescents from being physically active and participating in sports. The benefits of continued physical activity far outweigh any concerns for potential complications for most such conditions. This article reviews sport participation guidelines for adolescents with conditions that include juvenile chronic arthritis, eye injures, solitary kidney, skin conditions, scoliosis, and spondylolysis.