Currently, we found no evidence that directly supports a safe, effective weight-bearing program for children with JIA to reduce the risk of low BMD. This review was limited by the lack of literature directly related to the issue of reducing the risk of low BMD in children with JIA via a weight-bearing program, literature that used three different classification systems of JIA, and heterogeneity among studies in quantifying bone density. Yet, foundational information does exist, and can guide clinicians and researchers who work with children with JIA. For children with JIA who are at greater risk for low BMD, prescribing an exercise regime to increase physical activity and weight bearing activities is indicated.
Nonetheless, more information is needed about the influence of exercise on bone mass in children with JIA. The primary question that needs to be addressed by researchers is: what intensity and duration of physical activity and weight-bearing forces are necessary to reduce the risk for low BMD in children with JIA? An immediate concern of clinicians is the compression forces generated by weight bearing and the potential for increasing joint pain and swelling. The goal is to prescribe an exercise program that provides enough GRF to improve BMD, but that does not aggravate the joints of children with JIA. Klepper73 demonstrated that children with polyarticular JIA can participate in a low impact exercise program three times a week for eight weeks without injury or disease exacerbation. One question to be addressed by clinicians and researchers is whether this program provides enough GRF to address the risk for low BMD in children with JIA.
High impact exercise (eg, jumping off a 61-cm box) provided the largest treatment effect and the bone accrued was sustained over time.33,72 Studies that used weight-bearing sports or lower impact jumping, such as step aerobics, tuck jumps, hopping, skipping, still had a impact on bone accrual, but showed a smaller effect size.69–71 Participation in high-impact exercise does not seem feasible for children with JIA. However, participation in weight-bearing activities, such as jumping rope, skipping, step aerobics, and tuck jumps, does seem reasonable. Another avenue of investigation would be a replication of the interventions by Bradney et al,70 Heinonen et al,69 or McKay et al71 with children with JIA. Replication of interventions shown to have a small effect size would necessitate a large sample size for statistical power. Obtaining a large sample of prepubescent children with JIA may be difficult.
Although the assumption is widely held that high-intensity weight-bearing forces are contraindicated for children with JIA, the success of the low-impact exercise program designed by Klepper73 provides evidence that low-intensity long-duration forces are tolerable. Likewise, Westby et al75 performed a randomized controlled trial with adult women with rheumatoid arthritis and a weight-bearing program to maintain BMD, and all women were able to tolerate the program and maintained BMD. On the other hand, Ward et al76 describe a randomized controlled pilot study of the impact of six months of standing for 10 minutes on an active or placebo vibrating plate on the tibial BMD of children with disabilities. There was a mean increase in tibial bone density in children who stood on the active plates and a decrease in those who stood on the placebo plates.
A low-intensity, daily jumping program could provide a simple, low technology, cost effective measure to minimize the risk of low BMD in prepubescent children with JIA. Pilot or preliminary studies need to be done to establish a safe, effective program. As a result of the multifactorial nature of BMD, any intervention study would require careful planning and coordination between multiple team members: rheumatologist, bone physiologist, dietician, exercise physiologist, and physical therapist. Because of the impact of medication on bone physiology, it would be ideal if medication during the intervention time was stabilized. This may be possible for only short durations, e.g., six months. Although BMD would be the outcome variable, standardized validated measurement of other intervening variables such as daily physical activity, physical fitness, daily intake of calcium and vitamin D, disease severity and duration, body size, bone resorption, and medication intake would need to occur. Ongoing consultation with a rheumatologist would be necessary to insure that the children are not in a constant active disease state and to ensure ongoing disease management. Random assignment of study participants would need to occur in blocks by disease subtype, e.g., oligioarthritis or polyarthritis. Intervention and control groups should have similar characteristics in age and gender. Finally, the relationship of sample size and attrition as it relates to the intervention effect size would need to be carefully considered as the population of children with JIA is relatively small in most geographic regions.
Using exercise to address the risk of low BMD in children with JIA is within the scope of practice for pediatric physical therapists. Clinicians should be aware of the factors that place children with JIA at increased risk for low BMD. Low-impact exercise has been shown to be safe with children with JIA73 and should be incorporated into a daily exercise regime. In the conjunction with proper medical management of disease activity, designing exercise programs that promote weight bearing in prepubescent years may be a way to reduce the risk of low BMD in children with JIA.
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Seven Subtypes of Juvenile Idiopathic Arthritis as Classified by the International League of Associations for Rheumatology77
Arthritis in one or more joints preceded by fever of at least of two weeks’ duration, and daily for three days, and accompanied by one or more of the following: a rash, enlarged lymph nodes, hepato- or spleno-megaly, and/or serositis.
Exclusions: a, b, c, d.
Arthritis affecting one to four joints during the first six months of the disease. Two subtypes are recognized: extended and persistent.
Exclusions: a, b, c, d, e.
Polyarthritis (Rheumatoid Factor Negative).
Arthritis affecting five or more joints during the first six months, with a negative rheumatoid factor test.
Exclusions: a, b, c, e.
Polyarthritis (Rheumatoid Factor Positive).
Arthritis affecting five more joints during the first six months, with two or more tests in the first six months positive for rheumatoid factor.
Exclusions: a, b, c, e.
Arthritis and psoriasis and at least two of the following: dactylitis, nail pitting or detached/loose nails, or psoriasis in a first-degree relative.
Exclusions: b, c, d, e.
Arthritis and enthesitis, or arthritis or enthesitis with two or more or the following: sacroiliac or lumbosacral pain/inflammation, presence of human leukocyte antigen (HLA-B27), onset in arthritis in a male over six years of age, acute anterior uveitis, and history of inflammatory bowel disease, Reiter’s disease, or conditions listed above in a first degree relative.
Exclusions: a, d, e.
Arthritis that does not meet the criteria for the aforementioned categories or meets criteria for two or more categories.
The categories are mutually exclusive. The list of possible exclusions is as follows:
- Psoriasis or a history of psoriasis in the patient or first degree relative.
- Arthritis in an HLA-B27 positive male beginning after the sixth birthday.
- Ankylosing spondylitis, enthesitis related arthritis, sacroilitis with inflammatory bowel disease, Reiter’s syndrome, or acute anterior uveitis, or a history of one of these disorders in a first degree relative.
- The presence of IgM rheumatoid factor on at least two occasions at least three months apart.
- The presence of systemic JIA in the patient.
* Three classification systems exist for chronic childhood arthritis issued by the following authorities: the American College of Rheumatology,15 the European League Against Rheumatism,16 and the International League of Associations for Rheumatology (ILAR).13 In this work, the ILAR classification scheme is used when discussing the subtypes of JIA because it is more specific and detailed than the other two classification systems.