Exercise as it relates to Disease/Juvenile idiopathic arthritis and effective exercise treatments

Juvenile Idiopathic Arthritis (JIA) is a chronic autoimmune inflammatory joint disease that affects juveniles from the age of birth up to 16 years (1). It is a form of chronic arthritis in one or more joints that persists for six or more weeks. There are seven subtypes of JIA, the most common being oligoarticular JIA, which attacks four or less individual joints. It accounts for some 30 per cent of JIA. (2) While the causes of JIA are unknown, scientists believe there might be a link in genetics and that environmental factors, such as viral infections, might trigger the arthritis in genetically predisposed individuals. (3) While there is currently no cure for JIA, it can be diagnosed by a general practitioner (GP) or a rheumatologist, and a range of treatments are available to minimise pain, reduce loss of function and increase the quality of life for those affected.

Prevalence and Effects of JIA

JIA affects at least 1 in 1000 Australian children at any one time. (4) The most common onset ages are one, two and three years (5). For many years it was believed that juveniles would outgrow JIA. However, today it is known that half of the children who develop JIA will still have a form of active arthritis 10 years after diagnosis unless treated properly. (2) Symptoms will vary from day to day depending on how active the JIA is. The most common symptoms of JIA include joint swelling, pain and stiffness of the knees, hands and feet (2),(6). Individuals diagnosed with JIA are also at an increased risk of developing osteoporosis, osteopenia and obesity later in life, as the pain associated with JIA often results in a reluctance to move. Those diagnosed with JIA might also experience social and psychological hardship. For example, to the extent that JIA affects a child’s mobility, it will affect the child’s ability to participate in important activities, such as team sports, which have recognised physical and social benefits

Recommended Treatments by Exercise

Exercise is advocated as a form of treatment for JIA for a number of reasons (2). Primarily due to the ability too keep muscles strong. Strong muscles are important because they provide the joints with more support, in turn will have less stress on the joint when it moves and this will help to improve function and relieve pain. Exercise will also help the joints to regain or retain the range of motion (ROM) lost from periods of inactivity caused by JIA. To the extent that exercise reduces pain and increases functionality, it will also help to reduce obesity, delay mortality from chronic diseases, improve an individual’s sense of well-being and quality of life. The effects of physical activity indicate benefits from both water and land bases exercise:

Aquatic Programs

• Commonly recommended because it is believed that buoyancy places less stress on the joints.
• Benefits of aquatic programs include increased ROM, strength, mobility and fitness, without increased pain or damage to inflamed sites.
• Frequently recommended by GPs and rheumatologist as the buoyancy of the water placing less stress on the joints.
• A 6-week program, 2x sessions/ week may help reduce disease symptoms, such as obesity, and improve general exercise endurance. (7)

Weight baring activities

• Weight baring activities have been scientifically proven to optimise bone mineral density (BMD) in children with JIA, without exacerbating the symptoms of the disease. (8) (9)
• Strengthening exercises are also encouraged because they have the ability build up muscle strength and muscular endurance at the site of pain, which helps to support the joint and improves its functionality (13).
• The benefits of weight baring activities are long term, especially for those who go on to suffer oesteopenia or osteoporosis as a result of the JIA.
• A study by Fisher et al. reported an increase in functional movement, performance on timed tasks and disability after lower extremity resistance training. (10)

Isometric exercises

• Isometric exercises are safer and more comfortable to perform, especially when the joint is swollen
• Isometric exercises will improve muscle strength, which will help to support the joints.

Isotonic exercises

• Involve the patient moving the muscle and the joint through a ROM with or without weighted control. (11)
• Beneficial during acute episodes of JIA, as the exercises help to maintain muscle strength.
• Resistance can be added with the use of the child’s own body, external weights or elastic exercise bands
• These exercises will improve activation of a muscle, in turn supporting the movement of joints

Sports and Recreational Activities

• Recreational activities will help to build confidence in the child’s ability to participate in socially and physically demanding environments. (11)
• Cardiovascular fitness will help a child to maintain a healthy weight, and improve sleep patterns, energy levels and mood swings
• Group activities will also see the development of social and psychological confidence of being active and living with JIA.

The overwhelming emphasis on exercise is to ensure that everyday activities such as walking or dressing become easier. While exercise is primarily advocated to treat JIA, other treatments are also available.

Other Treatments

Pharmalogical Treatments	Nutrition	Thermotherapy	Physiotherapy
Paracetamol or codeine for more mild pain symptoms. (11)	Appropriate calcium intake needed to decrease the risk of osteoporosis and ostepenia. (3)	A warm bath in the morning can reduce morning stiffness, pain, muscle spasm and allow the patient to exercise. (5)	Physiotherapy is used to treat the pain, weakness, limited ROM and reduced physical ability associated with ROM. (2)

Other Readings and Websites

Clinical guideline for the diagnosis and management of juvenile idiopathic arthritis, Arthritis Queensland, YouTube: JIA, a perspective from a surgeon.

References

1. Merckmanuals.com. 2013. Juvenile Idiopathic Arthritis (JIA): Joint Disorders. [online] Available at: http://www.merckmanuals.com/professional/musculoskeletal_and_connective_tissue_disorders/joint_disorders/juvenile_idiopathic_arthritis_jia.html?qt=&sc=&alt [Accessed: 22 Oct 2013].
2. Clinical guideline for the diagnosis and management of juvenile idiopathic arthritis. 2009. [e-book] The Royal Australian College of General Practitioners. pp. 1–24. http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/cp119-juvenile-arthritis.pdf [Accessed: 20 Sep 2013].
3. Accessmedicine.com. 2013. AccessMedicine | Juvenile Idiopathic Arthritis. [online] Available at: http://accessmedicine.com/content.aspx?aid=56826190 [Accessed: 30 Sep 2013].
4. Arthritis Queensland, A. 2013. Juvenile Idiopathic Arthritis (JIA) - Arthritis Queensland - Arthritis and Osteoporosis Information. [online] Available at: http://www.arthritis.org.au/page/Arthritis/Juvenile_Idiopathic_Arthritis_JIA/ [Accessed: 1 Oct 2013].
5. Thefreelibrary.com. 2013. Juvenile rheumatoid arthritis: physical therapy and rehabilitation. [online] Available at: http://www.thefreelibrary.com/Juvenile+Rheumatoid+arthritis%3A+physcial+therapy+and+rehabilitation.-a0130400520 [Accessed: 14 Oct 2013]
6. Goldmuntz, E. 2006. Juvenile Idiopathic Arthritis: A Review for the Pediatrician. Pediatrics in Review, 27 (4), pp. e24-e32. Available from: doi: 10.1542/pir.27-4-e24 [Accessed: 12 Oct 2013].
7. J Philpott, A. 2010. Physical activity recommendations for children with specific chronic health conditions: Juvenile idiopathic arthritis, hemophilia, asthma and cystic fibrosis. Paediatrics & Child Health, 15 (4), p. 213. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2866314/ [Accessed: 12 Oct 2013].
8. Ncbi.nlm.nih.gov. 1999. Weight-bearing physical activity, calcium intake, systemic glucocorticoids, chronic inflammation, and body constitution as determinants of lumbar and femoral bone mineral in juvenile chronic arthritis. [online] Available at: http://www.ncbi.nlm.nih.gov/pubmed/10092160 [Accessed: 14 Oct 2013].
9. J Philpott, A. 2010. Physical activity recommendations for children with specific chronic health conditions: Juvenile idiopathic arthritis, hemophilia, asthma and cystic fibrosis. Paediatrics & Child Health, 15 (4), p. Abstract. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2866314/ [Accessed: 16 Oct 2013].
10. Rehabphys.sphhp.buffalo.edu. 2013. Rehabilitation Physiology Lab: Recent Publications. [online] Available at: http://rehabphys.sphhp.buffalo.edu/abstracts/JA/Effects%20of%20resistance%20exercise%20on%20children%20with%20juvenile%20arthritis.htm [Accessed: 19 Oct 2013].
11. Arthritis.org. 2013. Juvenile Arthritis Exercise. [online] Available at: http://www.arthritis.org/ja-treatments/ja-exercise/ [Accessed: 20 Oct 2013].