Bone health in children and adolescents with juvenile idiopathic arthritis and the influence of short-term physical exercise

Level and correlates of physical activity among children and adolescents with juvenile idiopathic arthritis compared to controls: results from a German nationwide prospective observational cohort study

BACKGROUND

Physical active lifestyles are essential throughout growth and maturation and may offer potential preventive and therapeutic benefit in patients with juvenile idiopathic arthritis (JIA). Insufficient physical activity (PA), in contrast, can lead to aggravation of disease-related symptoms. This study aimed to i) examine PA levels in children and adolescents with JIA compared to general population controls and ii) investigate correlates of pronounced physical inactivity in order to identify risk groups for sedentary behaviour.

METHODS

Data from children and adolescents with JIA and population controls aged 3 to 17 years documented in the National Pediatric Rheumatologic Database (NPRD) and the German Health Interview and Examination Survey for Children and Adolescents (KiGGS) were used. Self-reported PA was collected from parents/guardians of children up to 11 years of age or adolescents 12 years of age and older. To compare PA-related data, age- and sex-specific pairwise analyses were conducted considering NPRD/KiGGS participants' data from 2017. Correlates of physical inactivity among patients were identified using a linear regression model.

RESULTS

Data of 6,297 matched-pairs (mean age 11.2 ± 4.2 years, female 67%, patients' disease duration 4.5 ± 3.7 years, persistent oligoarthritis 43%) were available for evaluation. Almost 36% of patients aged 3-17 years (vs. 20% of controls) achieved the WHO recommended amount of PA, while PA steadily decreased with age (18% of patients aged ≥ 12 years) and varied between JIA categories. Female adolescents and patients with enthesitis-related arthritis were least likely to achieve the minimum recommended level of PA. Physical inactivity was associated with female sex, higher age at disease onset, longer disease duration, more functional disability (C-HAQ) and higher disease activity (cJADAS-10).

CONCLUSIONS

Depending on JIA category, children and adolescents with JIA were similarly or even more likely to achieve the WHO recommended minimum level of PA compared to general population controls. However, since a large proportion of young JIA patients appear to be insufficiently physically active, engagement in targeted efforts to promote PA is urgently needed.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Health-related quality of life, continuity of care and patient satisfaction: long-term outcomes of former patients of the Tuebingen Transition Program (TTP) - a retrospective cohort study

BACKGROUND

A significant number of patients in pediatric rheumatology suffer from ongoing disease activity into adulthood and thus need to be transferred into adult care. Transition as a structured individual process of preparation and patient empowerment can reduce risks of adverse long-term outcomes. The aim of this study was to measure long-term transition outcomes such as health-related quality of life (HR-QoL), patient satisfaction, and continuity of care in former patients of the interdisciplinary Tuebingen Transition Program (TTP).

METHODS

In an iterative team process, a standardized questionnaire was developed including the EQ-5D-5L to measure HR-QoL, visual analogue scales to measure various items of patient satisfaction, further questions on continuity of care and physical activity and physician global assessment (PGA) to determine disease activity. HR-QoL and physical activity were compared to data from the average German population. Data was analyzed descriptively, and a logistic regression analysis was performed to identify possible predictive factors for negative outcomes.

RESULTS

Response rate was 28.8% (85/295), 70.6% were female and median age was 24.1 years. 70.6% were diagnosed with juvenile idiopathic arthritis (JIA). Overall, HR-QoL was high (79.8 on the EQ VAS), yet lower than in the average population. The study cohort was more physically active than the respective average age groups. Mean patient satisfaction with pediatric care (8.4; standard deviation (SD) 1.7) and with the transition program (7.9; SD 2.6) was higher than with adult care (7.7; SD 2.2). 76.5% of participants received regular rheumatologic care after transfer. After excluding all participants in remission, the drop-out rate was 4.7%. A low PGA at the time of transfer was associated with higher HR-QoL and patient satisfaction after transfer.

CONCLUSIONS

HR-QoL of adult patients after successful transfer to adult rheumatology is reduced compared to the general population but physical activity and achievement of clinical remission could help to prevent negative long-term outcomes. Patient satisfaction and self-management of TTP patients were generally high, whereas youth-specific issues and their impact on the disease mandate greater attention. Treatment discontinuation rates were low and mostly due to remission. Further studies should focus on the identification of early predictors of long-term outcome to improve the process and outcome of transition.

Bone Mineral Density and Serum 25OHD in Children and Adolescents With Juvenile Idiopathic Arthritis

Low bone mass is one of the complications of juvenile idiopathic arthritis (JIA). However, a study focusing on the low bone mass in children and adolescents with JIA in Southeast Asian countries is limited. This study aimed to evaluate the bone mineral density (BMD) of Thai patients with JIA and identify factors correlated with BMD. A cross-sectional study was conducted at a tertiary-care center. The BMD of the lumbar spines (BMDLS) and the total body (BMDTB) were measured by dual-energy X-ray absorptiometry. Thirty-eight patients were enrolled between July 2015 and January 2016. No patient had low BMDLS, and only 2 (5.3%) had low BMDTB. Serum 25-hydroxyvitamin D (25OHD) levels were significantly positively correlated with the BMDTB Z-score (coefficient: 0.047; 95% confidence interval = 0.011-0.082; P = .012). Our study demonstrated a very low prevalence of low bone mass. Optimization of the serum 25OHD level should be encouraged.

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.

Yoga and Aerobic Dance for Pain Management in Juvenile Idiopathic Arthritis: Protocol for a Pilot Randomized Controlled Trial

Background

Juvenile idiopathic arthritis (JIA) is one of the most common types of arthritis among children. According to JIA guidelines for physical activity (PA), structured PA interventions led to improved health outcomes. However, many PA programs, such as yoga and aerobic dance, have not been studied in this population despite being popular among youth. Web-based PA programs could provide patients with accessible and affordable interventions.

Objective

The primary aims of the proposed pilot randomized controlled trial (RCT) are to examine (1) the feasibility of conducting a full-scale RCT to evaluate the effectiveness of two popular types of PA: a yoga training program and an aerobic dance training program, in female adolescents (aged 13-18 years) with JIA compared with an electronic pamphlet control group; and (2) the acceptability of these interventions.

Methods

A three-arm prospective randomized open-label study with a parallel group design will be used. A total of 25 female adolescents with JIA who have pain will be randomized in a ratio of 2:2:1 to one of the 3 groups: (1) online yoga training program (group A: n=10); (2) online aerobic dance training program (group B: n=10); and (3) electronic pamphlet control group (group C: n=5). Participants in groups A and B will complete 3 individual 1-hour sessions per week using online exercise videos, as well as a 1-hour virtual group session per week using a videoconferencing platform for 12 weeks. Participants from all groups will have access to an electronic educational pamphlet on PA for arthritis developed by the Arthritis Society. All participants will also take part in weekly online consultations with a research coordinator and discussions on Facebook with participants from their own group. Feasibility (ie, recruitment rate, self-reported adherence to the interventions, dropout rates, and percentage of missing data), acceptability, and usability of Facebook and the videoconferencing platform will be assessed at the end of the program. Pain intensity, participation in general PA, morning stiffness, functional status, fatigue, self-efficacy, patient global assessment, disease activity, and adverse events will be assessed using self-administered electronic surveys at baseline and then weekly until the end of the 12-week program.

Results

This pilot RCT has been funded by the Arthritis Health Professions Association. This protocol was approved by the Children’s Hospital of Eastern Ontario Research Ethics Board (#17/08X). As of May 11, 2020, recruitment and data collection have not started.

Conclusions

To our knowledge, this is the first study to evaluate the effectiveness of yoga and aerobic dance as pain management interventions for female adolescents with JIA. The use of online programs to disseminate these 2 PA interventions may facilitate access to alternative methods of pain management. This study can lead to a full-scale RCT.

International Registered Report Identifier (IRRID)

PRR1-10.2196/12823

Impact of core stability exercises on bone mineralization and functional capacity in children with polyarticular juvenile idiopathic arthritis: a randomized clinical trial

BACKGROUND

Juvenile idiopathic arthritis (JIA) is the most prevalent rheumatic disease in children. The core stability exercises ensure proper muscular strength and balance around the lumbo-pelvic-hip complex.

OBJECTIVE

This study evaluated whether the use of core stability exercises would increase the effectiveness of conventional physical therapy (PT) in enhancing bone mineralization and improving functional capacity in children with polyarticular JIA.

METHODS

Thirty-three children with polyarticular JIA (age; 10-14 years) assigned randomly into two groups: the control group (n = 16) received the conventional PT, and the study group (n = 17) received the core stability exercises in addition to the same conventional PT program. Both core stability and conventional PT exercises continued for 3 months. The measures of bone mineralization and functional ability were investigated by dual-energy X-ray absorptiometry (DXA) device and 6-min walk test (6MWT), respectively, at baseline and immediately post-treatment.

RESULTS

Analysis of covariance (ANCOVA) revealed significant differences between groups in favor of the study group regarding measures of bone mineralization of lumbar spine and femoral neck regions as P < 0.05, except for volumetric bone mineral density of lumbar spine the P > 0.05. There was a significant difference between the two groups concerning functional capacity measured in 6MWT (P < 0.05), where children in the study group walked 531.71 ± 90.59 m compared with the control group 509.31 ± 73.10 m.

CONCLUSION

Core stability exercises are an effective adjunctive therapy to enhance bone health status and improve functional capacity in children with polyarticular JIA. Key Points • In addition to conventional physical therapy, core stability exercises had a definite effect on improving bone health status and quality of life in children with polyarticular juvenile idiopathic arthritis. • Improved bone mineralization and functional capacity due to core stability exercises contain two parts: strengthening training and controlling equilibrium.

Physical Fitness in Patients With Oligoarticular and Polyarticular Juvenile Idiopathic Arthritis Diagnosed in the Era of Biologics: A Controlled Cross-Sectional Study

OBJECTIVE

To perform a comprehensive evaluation of and identify correlates for physical fitness in consecutive patients with juvenile idiopathic arthritis (JIA) who have been diagnosed in the era of biologics and to compare the results with those obtained in healthy controls.

METHODS

The study cohort included 60 patients with JIA (50 girls) ages 10-16 years and 60 age- and sex-matched controls. The JIA group included 30 patients with persistent oligoarticular JIA and 30 patients with extended oligoarticular or polyarticular disease. Measures of physical fitness included cardiorespiratory fitness (CRF) by peak oxygen uptake (Vo_2peak ) during a continuous graded treadmill exercise test, muscle strength by isokinetic and isometric knee and hand grip evaluations, and bone mineral density (BMD) and body composition by dual-energy x-ray absorptiometry. Physical activity was assessed by accelerometry.

RESULTS

Forty-two percent of the patients were being treated with biologic drugs. Patients with JIA demonstrated lower muscle strength and total body BMD compared to controls, but there were no differences in CRF and body composition. Physical fitness was comparable between the persistent oligoarticular and extended oligoarticular/polyarticular-JIA groups. In patients with JIA, we identified associations between higher vigorous physical activity and higher CRF and muscle strength, but did not find any association between physical fitness and disease variables.

CONCLUSION

In this cohort of patients with JIA, we found suboptimal muscle strength and BMD compared to controls, but no differences in CRF and body composition. Vigorous physical activities appeared important for optimizing muscle strength and CRF in patients with JIA; the importance of such activities should be highlighted in patient education.

Participation in school sports among children and adolescents with juvenile idiopathic arthritis in the German National Paediatric Rheumatologic Database, 2000-2015: results from a prospective observational cohort study

BACKGROUND

Regular school sports can help adolescents achieve the recommended amount of daily physical activity and provide knowledge, attitudes and behavioral skills that are needed in order to adopt and maintain a physically active lifestyle. Furthermore, it reaches all children including those that are at risk for engaging in more sedentary types of behavior. Since adolescents with juvenile idiopathic arthritis (JIA) are less involved in physical and social activities than their healthy peers, the objectives were to (1) estimate the prevalence of participation in school sports among patients with JIA; (2) determine the correlates associated with school sports absenteeism; and (3) investigate whether attendance in school sports has changed in the era of biologics.

METHODS

Data from schoolchildren with JIA recorded in the German National Paediatric Rheumatologic Database (NPRD) in the years 2000 to 2015 were considered for the analyses. Data from the year 2015 were inspected to analyze correlates of school sports absenteeism. Whether school sports participation had changed between 2000 and 2015 was determined using linear mixed models.

RESULTS

During the 15-year period, the participation rates in school sports were determined in 23,016 patients. The proportion of patients who participated in school sports almost always steadily increased from 31% in 2000 to 64% in 2015 (β = 0.017, 95% confidence interval (CI) 0.015, 0.020), whereas the exemption rate simultaneously decreased from 44% in 2000 to 16% in 2015 [β = - 0.009, 95% CI -0.011, - 0.007]. In 2015, the data from 5879 patients (mean age 13.1 ± 3.3 years, female 65%, disease duration 5.9 ± 4.0 years, persistent oligoarthritis 37%) were available for evaluation. Full exemption from school sports (in 16.1% of cases) was associated with functional limitations, disease activity and any use of DMARDs, intra-articular glucocorticoid injections or physiotherapy.

CONCLUSIONS

School sports attendance among children and adolescents with JIA has increased significantly over the past 15 years. Possible explanations include improved functional ability probably due to better treatment options. The integration of patients with child acceptable symptom states who have previously been fully exempted from school sports needs to be addressed in the future.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Effects of Structured Exercise Training in Children and Adolescents With Juvenile Idiopathic Arthritis

PURPOSE

To examine safety and efficacy of exercise training (ET) for juvenile idiopathic arthritis (JIA) to improve physical fitness, pain, functional capability, and quality of life.

METHODS

Ovid Medline, PubMed, CINAHL, PEDro, and Web of Science were searched from 1995 to April 2018 to find English-language articles examining effects of ET in JIA, ages 4 to 21 years. Quality of evidence/strength of clinical recommendations were assessed using the Cochrane GRADE (Grading of Recommendations, Assessment, Development and Evaluation) system. Results were reported using the 2009 Preferred Reporting Items for Systematic Reviews and meta-Analyses (PRISMA) checklist for health care interventions.

RESULTS

Nine papers met inclusion criteria. A total of 457 individuals with JIA, ages 4 to 19.9 years, received ET or alternate activity, wait-list, or no intervention. Moderate-quality evidence supports Stott Pilates and underwater knee-resistance exercise. No adverse effects of ET were reported.

CONCLUSIONS

Moderate-quality evidence exists for ET (30-50 minutes, 2-3 times/week, 12-24 weeks) to decrease pain, improve range of motion, knee strength, functional capability, and quality of life in JIA.

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 Fitness, Adiposity, and Diets as Surrogate Measures of Bone Health in Schoolchildren: A Biochemical and Cross-Sectional Survey Analysis

This study aimed to investigate the associations between adiposity, muscular fitness (MF), diet, sun exposure, and physical activity profiles as surrogate measures with bone health status in a sample of schoolchildren aged 8-18 yr old. A total of 250 Egyptian schoolchildren aged 8-18 yr were randomly invited to participate in these cross-sectional survey analyses. Calcaneal broadband ultrasound attenuation (c-BUA), bone mineral density (BMD), and bone formation markers (total calcium, serum bone alkaline phosphatase, and osteocalcin) were measured as markers of bone health. Adiposity profile, MF, physical activity (PA), sun exposure, Ca, and vitamin D dietary intake as related cofactors of bone health were measured by using prevalidated questionnaires and standard analytical techniques. A total of 85% (n = 213) of the study population showed normal bone health and 14.8% (n = 37) had abnormal bone health; most of them are girls (67.6%) classified according to BMD and c-BUA Z-scores into osteopenia (9.6%) and osteoporosis (5.2%). Compared with boys, higher correlations between c-BUA, bone mineral content, and BMD measures in the femoral neck, lumbar spine, whole body, and bone markers were reported in girls with lower bone mass. There was a positive significant correlation between body mass index, adiposity, sun exposure, MF, PA status, Ca and vitamin D intake, and c-BUA and BMD score analyses. These parameters were shown to be associated with about ~57.3%-88.4% of bone health characteristics of children and adolescents with osteopenia and osteoporosis. In children and adolescents, sun exposure, Ca and vitamin D diets, adiposity, PA, and changes in the levels of Ca, osteocalcin, and serum bone alkaline phosphatase were shown to be associated with bone health. Also, a significant correlation was reported between c-BUA score, dual-energy X-ray absorptiometry-BMD measures, and bone markers at clinically important bone sites of girls and boys. However, further clinical trials should be studied to consider c-BUA and bone markers as the benchmark estimates of bone mass for diagnostic purposes in young ages.

Do pedometers with or without education on exercise increase functional walking capacity and physical activity level in adolescents with juvenile idiopathic arthritis?

To evaluate the impact of pedometer use on the physical activity (PA) and functional walking capacity (FWC) of adolescents with juvenile idiopathic arthritis (JIA) and lower extremity (LE) involvement. Twenty-seven adolescents, aged 11-19 years with JIA and LE involvement, participated in the three-phase pedometer study that introduced the use of a pedometer and an education seminar at 6 weeks. Measurements were taken at the baseline first visit and at weeks 6, 12, and 20. The primary outcome measure was the 6-minute walk test (6MWT). Thirteen completed the study. Six-minute walk distance (6MWD) significantly increased from baseline (458.0 ± 70.8 m) to the end of phase 1 (501.4 ± 59.8 m) (p = 0.035), prior to receiving the pedometer; and from baseline to the end of study (p = 0.0037). No significant changes in 6MWD were found between weeks 6 and 12 (intervention) (p = 0.77) or between weeks 12 and 20 (follow through phase) (p = 0.27). In adolescents with LE JIA, consistent guidance and support by rheumatology professionals appears to positively influence PA and measures of FWC as seen through improved 6MWD. There was insufficient evidence to show that pedometers further increased FWC or PA.

Physical and Mechanical Therapies for Lower-Limb Problems in Juvenile Idiopathic ArthritisA Systematic Review with Meta-Analysis

BACKGROUND

Juvenile idiopathic arthritis (JIA), a chronic, autoimmune, inflammatory joint disease, is the most common arthritis affecting children younger than 16 years. Children with JIA commonly experience lower-limb dysfunction and disability. We systematically reviewed the effectiveness of physical and mechanical therapies for lower-limb problems in JIA.

METHODS

Randomized controlled trials of physical and mechanical interventions for lower-limb problems in children with JIA were included. Primary outcome was pain. Secondary outcomes included disability, functional ability, and health-related quality of life. Several databases were searched for eligible studies. Authors of included studies and researchers in the field were contacted to identify additional studies.

RESULTS

Two studies evaluating the effectiveness of customized/custom foot orthoses in treating foot and ankle pain in children with JIA (N = 100) were included. One study also evaluated simple cushioned inserts. Meta-analyses for comparisons between custom/customized foot orthoses and a control intervention after 3 months were not significant for the outcomes of pain (mean difference, -8.97; 95% confidence interval [CI], -18.01 to 0.07), child-rated health-related quality of life (mean difference, 4.38; 95% CI, -3.68 to 12.44), and parent-rated health-related quality of life (mean difference, 1.77; 95% CI, -6.35 to 9.90). Meta-analyses were supported by sensitivity analyses.

CONCLUSIONS

There is a paucity of research evaluating physical and mechanical therapies for lower-limb problems in JIA. No physical therapy has been evaluated in randomized controlled trials, and mechanical therapy evaluation is limited to foot orthoses and shoe inserts for foot and ankle pain. The existing research is hampered by small sample sizes. Until further research is conducted, the effectiveness of mechanical and physical therapies for lower-limb problems in JIA remains unclear.

Joint cartilage thickness and automated determination of bone age and bone health in juvenile idiopathic arthritis

BACKGROUND

BoneXpert is an automated method to calculate bone maturation and bone health index (BHI) in children with juvenile idiopathic arthritis (JIA). Cartilage thickness can also be seen as an indicator for bone health and arthritis damage. The objective of this study was to evaluate the relation between cartilage thickness, bone maturation and bone health in patients with JIA.

METHODS

Patients with JIA diagnosed according ILAR criteria included in a previous ultrasonography (US) study were eligible if hand radiographs were taken at the same time as the US examination. Of the 95 patients 67 met the inclusion criteria.

RESULTS

Decreased cartilage thickness was seen in 27% of the examined joints. Decreased BHI was seen in half of the JIA patient, and delayed bone maturation was seen in 33% of patients. A combination of decreased BHI and bone age was seen in 1 out of 5 JIA patients. Decreased cartilage thickness in the knee, wrist and MCP joint was negatively correlated with delayed bone maturation but not with bone health index.

CONCLUSION

Delayed bone maturation and decreased BHI were not related to a thinner cartilage, but a thicker cartilage. No relation with JADAS 10 was found. The rheumatologist should remain aware of delayed bone maturation and BHI in JIA patients with cartilage changes, even in the biologic era.

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.

The impact of underlying disease on fracture risk and bone mineral density in children with rheumatic disorders: A review of current literature

Childhood rheumatic diseases are associated with negative impacts on the skeleton, related to both the underlying illness and complications of therapy. The effects of medications like corticosteroids are well recognized, leading to reductions in bone mineral density and bone strength and concomitant increases in bone fragility and fracture risk. The impact of factors directly attributable to the underlying disease is not as well recognized. In this article, we review relevant literature to identify data which can contribute to an understanding of the impact of childhood rheumatic disease on the skeleton. We conclude that childhood rheumatic diseases are associated with reductions in bone mineral density and increased risk of vertebral and non-vertebral fractures. These data are strongest for juvenile arthritis, while conclusions are more limited for other rheumatic illnesses, like juvenile systemic lupus erythematosus or juvenile dermatomyositis, due to small numbers of patients studied. Finally, we make recommendations for areas in need of further research. These include the need for long-term longitudinal studies and for data to be collected in patients who have not been treated with corticosteroids.

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.

Ottawa Panel Evidence-Based Clinical Practice Guidelines for Foot Care in the Management of Juvenile Idiopathic Arthritis

OBJECTIVE

To create evidence-based guidelines evaluating foot care interventions for the management of juvenile idiopathic arthritis (JIA).

DATA SOURCES

An electronic literature search of the following databases from database inception to May 2015 was conducted: MEDLINE (Ovid), EMBASE (Ovid), Cochrane CENTRAL, and clinicaltrials.gov.

STUDY SELECTION

The Ottawa Panel selection criteria targeted studies that assessed foot care or foot orthotic interventions for the management of JIA in those aged 0 to ≤18 years. The Physiotherapy Evidence Database scale was used to evaluate study quality, of which only high-quality studies were included (score, ≥5). A total of 362 records were screened, resulting in 3 full-text articles and 1 additional citation containing supplementary information included for the analysis.

DATA EXTRACTION

Two reviewers independently extracted study data (intervention, comparator, outcome, time period, study design) from the included studies by using standardized data extraction forms. Directed by Cochrane Collaboration methodology, the statistical analysis produced figures and graphs representing the strength of intervention outcomes and their corresponding grades (A, B, C+, C, C-, D+, D, D-). Clinical significance was achieved when an improvement of ≥30% between the intervention and control groups was present, whereas P>.05 indicated statistical significance. An expert panel Delphi consensus (≥80%) was required for the endorsement of recommendations.

DATA SYNTHESIS

All included studies were of high quality and analyzed the effects of multidisciplinary foot care, customized foot orthotics, and shoe inserts for the management of JIA. Custom-made foot orthotics and prefabricated shoe inserts displayed the greatest improvement in pain intensity, activity limitation, foot pain, and disability reduction (grades A, C+).

CONCLUSIONS

The use of customized foot orthotics and prefabricated shoe inserts seems to be a good choice for managing foot pain and function in JIA.

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.

Leisure in children and adolescents with juvenile idiopathic arthritis: a systematic review

The aim of this systematic review is to describe participation in social and physical leisure activities among children and adolescents with JIA, as well as identify potential determinants of leisure participation.

METHODS

Electronic databases were systematically searched for articles published up until June 2013 pertaining to participation in leisure activities among youth with JIA and other rheumatic diseases. Studies were included if they measured involvement in either social or physical leisure activities. Selection and quality appraisal of articles were completed independently by two authors.

RESULTS

Eight hundred and ninety-three articles were found through electronic and reference search. One hundred and nine full articles were reviewed to assess for eligibility. Twelve articles met inclusion criteria and findings were reviewed. Most focused on describing participation in physical rather than social activities. Results suggest that youth with JIA participated less in both social and physical leisure activities as compared to healthy peers, and those with JIA did not meet national recommendations for physical activity. Potential determinants of leisure participation were socio-demographic (age, sex), anthropometric (height, weight) and disease-related (JIA subtype, disease duration, pain, number of swollen or painful joints, stiffness, fatigue, well-being) factors.

CONCLUSION

Characterization of leisure activity remains limited and mostly focused on physical activity in JIA. Assessment of more comprehensive outcome measures is warranted to obtain a better description of leisure in this population. Evidence of the influence of contextual factors as potential determinants of involvement in leisure among children with pediatric rheumatologic diseases is needed.

Muscle strength, physical fitness and well-being in children and adolescents with juvenile idiopathic arthritis and the effect of an exercise programme: a randomized controlled trial

BACKGROUND

Decreased muscle strength, fitness and well-being are common in children and adolescents with juvenile idiopathic arthritis (JIA) compared to healthy peers. Biological drugs have improved health in children with JIA, but despite this pain is still a major symptom and bone health is reported as decreased in the group. The improvement made by the biological drugs makes it possible to more demanding exercises. To jump is an exercise that can improve bone heath, fitness and muscle strength. The aim of the study was to see if an exercise programme with jumps had an effect on muscle strength, physical fitness and well-being and how it was tolerated.

METHODS

Muscle strength and well-being were studied before and after a 12-week exercise programme in 54 children and adolescents with JIA, 9-21 years old. The participants were randomized into an exercise and a control group. Muscle strength, fitness and well-being were documented before and after the training period and at follow-up after 6 months. Physical activity in leisure time was documented in diaries. The fitness/exercise programme was performed at home three times a week and included rope skipping and muscle strength training exercises.Assessment included measurement of muscle strength with a handheld device, and with Grip-it, step-test for fitness with documentation of heart rate and pain perception and two questionnaires (CHAQ, CHQ) on well-being.

RESULTS

There were no differences between exercise and control group regarding muscle strength, grip strength, fitness or well-being at base line. Muscle weakness was present in hip extensors, hip abductors and handgrip. For the exercise group muscle strength in hip and knee extensors increased after the 12-week exercise programme and was maintained in knee extensors at follow-up. There was no change in fitness tested with the individually adapted step-test. The CHQ questionnaire showed that pain was common in the exercise group and in the control group. There were only small changes in the CHAQ and CHQ after the training period. The fitness/exercise programme was well tolerated and pain did not increase during the study.

CONCLUSIONS

A weight bearing exercise programme, with muscle strength training with free weights and rope skipping was well tolerated without negative consequences on pain. It also improved muscle strength in the legs and can be recommended for children and adolescents with JIA.