Juvenile idiopathic arthritis (JIA) is the most common form of chronic rheumatic disease in childhood and adolescence. It has an estimated incidence of 16 to 150 per 100 000 children worldwide1 and is a disease of unknown etiology, which begins before the sixteenth birthday and persists for at least greater than 6 weeks.2
In association with swelling, joint stiffness after periods of inactivity is typical, especially after the nighttime sleep. The severity and duration of symptoms depend on the number and type of affected joints, pain, functional limitations, and possibly deformity, which may present in later stages.3
Children and adolescents with JIA may experience significant short- and long-term disability because of muscle weakness, joint pain, contracture, and reduced mobility.4 Disability can influence school performance, physical training, family life, and activities with peers during leisure time.5 The reduced activity and fitness are probably multifactorial in origin. They may be the result of active disease or long-term joint damage. They are influenced by the attitudes of parents, teachers, and physicians. The children and adolescents themselves often may feel that excessive activity is, in some way, the cause of the arthritis, and may worsen or provoke further joint damage.6 Such patterns are further exacerbated by a downward spiral of inactivity and deconditioning. It is important to interrupt this cycle and to help children and their families enjoy the short- and long-term benefits of physical activity and fitness.7
The aim of treatment in JIA is to control the disease, preserve the physical and psychological integrity of the child or adolescent, and prevent long-term negative consequences of the disease.8
Klepper9 and Long10 state that the aim of physical therapy is to manage pain and inflammation, preserve range of motion (ROM), maintain muscle strength, and limit strain on the arthritic joints.
Physical therapy treatments include thermotherapy (cold packs, moist heat packs, hot bath), hydrotherapy, relaxation techniques, kinesiotherapy (ROM exercises, muscle strengthening and lengthening, motor and functional pattern re-education), massage, pulley therapy, postural re-education and therapy, functional motor activities, rehabilitation orthoses, and equipment.
Exercise therapy is considered a regimen or plan of physical activities designed and prescribed for specific therapeutic goals. Its purposes are to restore normal musculoskeletal function or to reduce pain caused by diseases or injuries.11 Physical activity is defined as any bodily movement produced by skeletal muscles that result in energy expenditure.12 These are basically considered nontherapeutic activities for the healthy population as primary prevention, but can become therapeutic exercise when planned for individuals with medical conditions. The physical therapist is involved in the initial clinical assessment and goal setting, the evaluation of the type and intensity of the physical activity, the monitoring of participation, and the measurement of outcome.
Minor stated that physical activity and strengthening exercise improve function and promote lifetime physical fitness in children with JIA.13 However, a Cochrane review14 concluded that there was no clinical importance or statistically significant evidence that exercise therapy improves functional ability, quality of life, aerobic capacity, or reduces pain. The authors highlighted that the low number of available randomized controlled trials (RCTs) limited generalizability and that it was difficult to recommend exercise therapy as an effective treatment for JIA.14
The Cochrane review analyzed 3 RCTs reporting benefits of exercise training in patients with JIA. Epps et al15 attributed an improvement with land-based physical therapy (stretching, strengthening, and active movements, functional, and aerobic activities) and a combination of hydrotherapy and land-based physical therapy. Patients in the combined group showed greater improvements in physical aspects of health-related quality of life. In another study, Singh-Grewal et al16 randomized children in 2 groups and proposed a vigorous land-based aerobic exercise or Qigong, a gentle relaxation program similar to Tai Chi. Both groups showed significant and clinically important improvement in the Child Health Assessment Questionnaire (CHAQ) assessment, but no significant difference was found between the groups on CHAQ or fitness outcomes, suggesting that high-intensity exercise did not confer any additional benefit. In a study by Takken et al,17 patients were randomly assigned to an assessment-only group or to an aquatic aerobic exercise. The exercise group demonstrated no significant improvements. None of the 3 studies reported negative effects associated with exercise.
Previous studies highlight benefits of exercise and physical activity, but the best therapeutic exercise program for children with JIA is unknown.
A recent study by Rochette et al18 reported that physical activity has anti-inflammatory effects and improves quality of life and symptoms in patients with JIA, even if the mechanisms of action remain unclear.
Previous studies have indicated that children with JIA derive some benefit from an aquatic exercise program, which did not worsen the health status.17
We conducted this study to appraise recent evidence on the efficacy of exercise therapy and physical activity and the indications for treatment in children with JIA.
Part 1 of this study is a literature review on exercise therapy and physical activity used in treatment of children with JIA. Part 2 describes indications for the type and amount of effective exercise therapy and physical activity.
The search was conducted with 4 types of electronic databases: General databases: Medline, through PubMed search engine; PEDro, Google Scholar; Guidelines databases: National Guideline Clearinghouse, Sistema Nazionale Linee Guida, National Institute for Health and Care Excellence, Scottish Intercollegiate Guidelines Network, The Royal Australian College of General Practitioners; Systematic review databases: The Cochrane Library, Centro Cochrane Italiano; Poster databases: F1000Posters.
Study inclusion criteria were controlled and uncontrolled experimental studies, reviews, single cases, original articles, editorials, guidelines, analytical and descriptive observational studies, RCTs that included physical exercise with children with JIA (aged 0-18 years); published in English, French, or Italian; from 2008, excluding the 2008 Cochrane Review. References of all articles were searched for additional studies.
The following search terms were used: “Arthritis, Juvenile”[Mesh] AND (“Physical Therapy Modalities”[Mesh] OR “Physical Therapy Specialty”[Mesh] OR “Physical Therapists”[Mesh]); “juvenile idiopathic arthritis” AND (“physical exercise” OR exercise* OR “physical activity” OR “physical activities” OR sport* OR gymnast*) (“Arthritis, Juvenile”[Mesh]) AND “Motor Activity”[Mesh]; “juvenile idiopathic arthritis” AND “exergam*”. The search also included guideline, systematic review, and poster databases using the terms “juvenile idiopathic arthritis” both individually and combined with “exercise” and “physical activity.”
Two reviewers individually identified studies on the basis of title and abstract to determine the eligibility of the studies or full texts as necessary. Differences of opinion between the 2 examiners were resolved by discussion.
Search results are included in Supplemental Digital Content 1 (available at: https://links.lww.com/PPT/A166). Through the search terms “Arthritis, Juvenile”[Mesh] AND (“Physical Therapy Modalities”[Mesh] OR “Physical Therapy Specialty”[Mesh] OR “Physical Therapists”[Mesh]) 21 articles were obtained. Fourteen articles were excluded from the analysis because of treated adults and other rheumatic diseases. Seven articles were included.
Through the search terms “juvenile idiopathic arthritis” AND (“physical exercise” OR exercise* OR “physical activity” OR “physical activities” OR sport* OR gymnast*), 78 articles were obtained and 60 articles were excluded because they did not match the inclusion criteria: treated other diseases, the text was not available in the inclusion criteria languages, and published before 2008. Eighteen articles were included.
Through the search terms “Arthritis, Juvenile”[Mesh]) AND “Motor Activity”[Mesh], 27 articles were obtained and 19 articles were excluded from the analysis because they treated adults and other rheumatic diseases or did not talk about physical activity. Eight articles were included.
The search strategy using terms “juvenile idiopathic arthritis” AND “exergam*” did not identify studies.
In the Sistema Nazionale Linee Guida Italiana database, only guidelines approved by the Consiglio Sanitario Regionale Toscana for Rheumatology were identified. In the Royal Australian College of General Practitioners database, a clinic guideline manual for the diagnosis and management of JIA was identified.
Twenty-three eligible articles were included. A manual search was conducted on the bibliographic entries of the included articles but did not yield additional studies.
In summary, the following were collected: 7 RCTs19–25 (Supplemental Digital Content 2, available at: https://links.lww.com/PPT/A167), 8 reviews9,10,18,26–30 (Supplemental Digital Content 3, available at: https://links.lww.com/PPT/A168), 2 analytical observational studies31,32 and 1 uncontrolled experimental study33 (Supplemental Digital Content 4, available at: https://links.lww.com/PPT/A169), 3 descriptive observational studies,34–36 and 2 guidelines37,38 (Supplemental Digital Content 5, available at: https://links.lww.com/PPT/A170).
The RCTs were assessed using the PEDro scale.39 The PEDro scale assigns a numerical score (PEDro score) to the quality of the study (Supplemental Digital Content 6, available at: https://links.lww.com/PPT/A171).
Analyses of RCTs support the following (Supplemental Digital Content 2, available at: https://links.lww.com/PPT/A167): effectiveness of balance-proprioceptive exercise,19 resistive underwater exercise and interferential current,20 Pilates exercise,21 weight-bearing exercise program for improving muscle strength22 and function of lower extremity,19 balance,19 endurance,25 bone mineral density,24 and quality of life.21,23 It is important to focus on an individually planned land-based23 or Internet-based25 program lasting 12 weeks.
Reviews (Supplemental Digital Content 3, available at: https://links.lww.com/PPT/A168) recommend moderate fitness, flexibility, and strengthening exercises, aerobic and anaerobic training and sports for children with JIA26–28 for the positive effect on improvement in ROM, increased muscle strength, clinical symptoms (decrease in joint count, pain), and quality of life.10,30 Physical activity induces short-term pro-inflammatory and short- and long-term anti-inflammatory systemic effects.18 The physical training protocols described vary in length, intensity, duration, frequency, and medium9,27; high- and low-intensity programs are equally effective and safe.27 Children with JIA may safely participate in physical activities or sport without risking disease exacerbation or fracture.28,29 The contraindications to physical exercise are fever, anemia, acute renal failure, carditis, serositis, and ischemic response to the treadmill test, noncontrolled arrhythmias and arterial hypertension, severe malnourishment with body weight loss over 35%, increase of joint pain, and excessive swelling.27,28
Analytical observational studies and uncontrolled experimental studies (Supplemental Digital Content 4, available at: https://links.lww.com/PPT/A169) support that regular aerobic exercise combined with ROM exercises32 or a home-based resistance training program33 may be an important part of treatment in patients with JIA. A study31 reports no different levels of endothelial and progenitor cells between the exercise group (moderate- and high-intensity exercise) and the healthy group.
Descriptive observational studies (Supplemental Digital Content 5, available at: https://links.lww.com/PPT/A170) support the importance to carry out sports safely, without risk of exacerbations. It is useful to combine a training program characterized by balance exercises, stretching, and strengthening.34 It is important in exercise therapy, and especially in the pediatric age group, to determine specific and individualized interventions.35 Although there has been an increase in the number of studies examining the benefits of physical activity in the management of JIA, there remains a paucity of information about which types of activity are best.36
The Region of Tuscany Rheumatology Guidelines37 describe the management of patients with JIA but without reference to exercise.
The Australian Guidelines of the Royal Australian College of General Practitioners38 recommend both on land and water exercises with level of evidence C (A, excellent evidence: body of evidence can be trusted to guide practice; B, good evidence: body of evidence can be trusted to guide practice in most situations; C, some evidence: body of evidence provides some support for recommendation but care should be taken in its application; D, weak evidence: body of evidence is weak and recommendation must be applied with caution38).
Children and adolescents with JIA may experience significant short- and long-term disability because of muscle weakness, joint pain, contracture, and reduced mobility.
The aim of treatment in JIA is to control the disease, preserve the physical and psychological integrity of the child or adolescent, and prevent long-term negative consequences of both the disease and therapy.
The physical therapist is involved in the initial clinical assessment and goal setting, the evaluation of the type and intensity of the physical activity, and the monitoring of participation and the measurement of outcomes.
Physical activity and exercise therapy programs, combined with pharmacotherapy, have shown positive results, such as reducing the number of active, inflamed joints, the intensity of pain, and improving ROM, muscle strength, functional status, and quality of life.
Many studies included a variety of physical therapy treatments, some only using ROM exercises, other muscle strengthening and stretching, others using interferential current therapy.
Generally, instrumental physical therapy is rarely used in the pediatric age group and, although the study results were good, additional, in-depth investigation would be recommended.
In almost all considered RCTs,19,20,22–24 the strengthening exercise scored statistically significant improvements, showing that improving muscular strength decreases stress on the joints.
We agree that muscle strengthening should be included in the physical therapy program and to include the combination of strengthening, stretching, proprioceptive, balance exercises, and water exercise to rehabilitate the musculoskeletal system, which is compromised by the disease.
Several studies10,19,34–36 show that a specific water exercise program can make positive changes both in the physical and psychological spheres; hydrotherapy is considered a safe form of exercise.38
We consider it is essential that the exercise program is specific and individualized to better monitor the course of disease.
The duration, the frequency, and the type of exercise have an effect on aerobic activity; these provide better muscular and functional reinforcement, decrease disease activity, improve self-confidence, energy levels, and quality of life, and reduce pain and the use of drugs.
Some RCTs included a large number of subjects and proposed an exercise program for a variable period (12-24 weeks) with and average frequency of 3 times a week. In agreement with reviewed studies,19–25,32,33,35 we propose an intensive 12-week program of exercises with an average frequency of 3 times a week.
Exercises were individually carried out and supervised by the physical therapist or parents. The exercise program can be managed by parents with surveillance by the physical therapist, who educates the family about the illness and the AIG management by supporting adherence to the treatment.
A limit in this review is that few studies25,31,33 included the stage of the disease; thus, it is difficult to recommend an intensive program in the active phase of the disease.
We want to emphasize the contraindications to physical exercise for children and adolescents with pediatric rheumatic disease, fever, anemia, acute renal failure, carditis, serositis, ischemic response to the treadmill test, noncontrolled arrhythmias, and arterial hypertension; malnourishment with body weight loss greater than 35%.
Exercise therapy and physical activity are therapeutic agents for JIA. In addition to drug treatment, exercise therapy and physical activity program may be recommended to children and adolescents with JIA with demonstrated benefits such as the reduction of the number of active joints and intensity of pain as well as the improvement of joint ROM, muscle strength, functional status, and quality of life.
In conclusion, based on the results of this literature review, we propose an individualized, specific, and intensive 12-week program of exercises with an average frequency of 3 times a week. The program, supervised by parents, consists of strengthening exercises associated with stretching, proprioceptive, balance exercises, and hydrotherapy. This program should not be offered in the active phases of the disease since, at present, the literature does support whether this would be beneficial or harmful. More studies are necessary to investigate the active phase of the disease and exercise.
It is essential to establish solid, clinical evidence-based practice. In future studies the following points should be considered: RCT study designs with proper control groups, definition of valid and standardized outcome measures and of the characteristics of treatment protocol (type and dosage in terms of volume, intensity, and duration), together with long-term follow-up to verify the effects over time. It is important to evaluate whether there are differences in effectiveness between therapeutic exercise and physical activity.
The authors thank physical therapist Adrienne Davidson and all the staff at the Rehabilitation Department of Meyer Children's Hospital for their trust and precious support to this project.
1. Manners PJ, Bower C. Worldwide prevalence of juvenile arthritis why does it vary so much? J Rheumatol. 2002;29:1520–1530.
2. Petty RE, Southwood TR, Manners P, et al. International League of Associations for Rheumatology. International League of Associations for Rheumatology classification of juvenile idiopathic arthritis: second revision, Edmonton, 2001. J Rheumatol. 2004;31(2):390–392.
3. Campbel SK, Palisano RJ, Orlin MN. Physical Therapy for Children. St Louis, MO: Elsevier; 2012.
4. Tarakci E, Yeldan I, Kaya Mutlu E, Baydogan SN, Kasapcopur O. The relationship between physical activity
level, anxiety, depression, and functional ability in children and adolescents with juvenile idiopathicarthritis. Clin Rheumatol. 2011;30:1415–1420.
5. Andersson Gare B, Fasth A, Wiklund I. Measurement of functional status in juvenile chronic arthritis; evaluation of a Swedish version of the Child Health Assessment Questionnaire. Clin Exp Rheumatol. 1993;11:569–576.
6. Buffart LM, Westendorp T, Van den Berg-Emons R, Stam HJ, Roebroeck ME. Perceived barriers to physical activity
in young adults with childhood onset physical disabilities. J Rehab Med. 2009;41:881–885.
7. Singh-Grewal D. Exercise Testing and Fitness Training in Juvenile Idiopathic Arthritis. Utrecht, the Netherlands: Utrecht University Repository; 2010.
8. Ravelli A, Martini A. Juvenile idiopathic arthritis. Lancet. 2007;369:767–778.
9. Klepper SE. Exercise in pediatric rheumatic diseases. Curr Opin Rheumatol. 2008;20(5):619–624.
10. Long AR, Rouster-Stevens KA. The role of exercise therapy in the management of juvenile idiopathic arthritis. Curr Opin Rheumatol. 2010;22(2):213–217.
11. Caspersen CJ, Powell KE, Christenson GM. Physical activity
, exercise, and physical fitness: definitions and distinctions for health-related research. Public Health Rep. 1985;100(2):126–131.
12. NCBI. Exercise Therapy. http://www.ncbi.nlm.nih.gov/mesh/68005081/
. Accessed January 18, 2016.
13. Minor MA. Exercise and arthritis “we know a little bit about a lot of things...” 2002 Exercise and Physical Activity
Conference, St Louis, Missouri. Arthritis Rheum. 2003;49:1–2.
14. Takken T, Van Brussel M, Engelbert RH, Van Der Net J, Kuis W, Helders PJ. Exercise therapy in juvenile idiopathic arthritis: a Cochrane review. Eur J Phys Rehabil Med. 2008;44(3):287–297.
15. Epps H, Ginnelly L, Utley M, et al. Is hydrotherapy cost-effective? A randomised controlled trial od combined hydrotherapy programs compared with physical therapy land techniques in children with juvenile idiopathic arthritis. Health Tecnol Assess. 2005;9(suppl 39):S1–S59.
16. Singh-Grewal D, Schneiderman-Walker J, Wright V, et al. The effects of vigorous exercise training on physical function in children with arthritis: a randomized, controlled, single-blinded trial. Arthritis Rheum. 2007;57:1202–1210.
17. Takken T, Van Der Net J, Kuis W, Helders PJ. Aquatic fitness training for children with juvenile idiopathic arthritis. Rheumatology. 2003;42(suppl 11):1408–1414.
18. Rochette E, Duché P, Merlin E. Juvenile idiopathic arthritis and physical activity
: possible inflammatory and immune modulation and tracks for interventions in young populations. Autoimmun Rev. 2015;14(8):726–734.
19. Baydogan SN, Tarakci E, Kasapcopur O. Effect of strengthening versus balance -proprioceptive exercise on lower esìxtremity function in patients with juvenile idiopathic arthritis: a randomized, single-blind clinical trial. Am J Phys Med Rehabil. 2015;94(6):417–424.
20. Elnaggar RK, Elshafey MA. Effects of combined resistive underwater exercises and interferential current therapy in patients with juvenile idiopathic arthritis: a randomized controlled trial. Am J Phys Med Rehabil. 2016;95(2):96–102.
21. Mendonça TM, Terreri MT, Silva CH, et al. Effects of Pilates exercise on health-relates quality of life in individuals with juvenile idiopathic arthritis. Arch Phys Med Rehabil. 2013;94(11):2093–2102.
22. Sandstedt E, Fasth A, Eek MN, Beckung E. Muscle strength, physical fitness and well-being in children and adolescents with juvenile idiopathic arthritis and the effect of an exercise program: a randomized controlled trial. Pediatr Rheumatol Online J. 2013;11(1):7.
23. Tarakci E, Yeldan I, Baydogan SN, Olgar S, Kasapcopur O. Efficacy of a land-based home exercise program for patients with juvenile idiopathic arthritis: a randomized, controlled, single-blind study. J Rehabil Med. 2012;44(11):962–927.
24. Sandstedt E, Fasth A, Fors H, Beckung E. Bone health in children and adolescents with juvenile idiopathic arthritis and the influence of short-term physical exercise. Pediatr Phys Ther. 2012;24(2):155–161.
25. Lelieveld OT, Armbrust W, Geertzen JH, et al. Promoting physical activity
in children with juvenile idiopathic arthritis through an internet-based program: results of a pilot randomized controlled trial. Arthritis Care Res (Hoboken). 2010;62(5):697–703.
26. Houghton K. Physical activity
, physical fitness, and exercise therapy in children with juvenile idiopathic arthritis. Phys Sportsmed. 2012;40(3):77–82.
27. Gualano B, Pinto AL, Perondi MB, et al. Therapeutic effects of exercise training in patients with pediatric rheumatic disease. Rev Bras Reumatol. 2011;51(5):490–496.
28. Van Brussel M, van der Net J, Hulzebos E, Helders PJ, Takken T. The Utrecht approach to exercise in chronic childhood conditions: the decade in review. Pediatr Phys Ther. 2011;23(1):2–14.
29. Philpott J, Houghton K, Luke A. Physical activity
recommendations for children with specific chronic health conditions: juvenile idiopathic arthritis, hemophilia, asthma and cystic fibrosis. Paediatr Child Health. 2010;15(4):213–225.
30. Gualano B, Sá Pinto AL, Perondi B, et al. Evidence for prescribing exercise as treatment in pediatric rheumatic disease. Autoimmun Rev. 2010;9(8):569–573.
31. Obeid J, Nguyen T, Cellucci T, Larché MJ, Timmons BW. Effect of acute exercise on circulating endothelial and progenitor cells in children and adolescents with juvenile idiopathic arthritis and healthy controls: a pilot study. Pediatr Rheumatol Online J. 2015;13(1):4.
32. Doğru Apti M, Kasapçopur Ö, Mengi M, Öztürk G, Metin G. Regular aerobic training combined with range of motion exercises in juvenile idiopathic arthritis. Biomed Res Int. 2014;2014:748972.
33. Van Oort C, Tupper SM, Rosenberg AM, Farthing JP, Baxter-Jones AD. Safety and feasibility of a home-based six week resistance training program in juvenile idiopathic arthritis. Pediatr Rheumatol Online J. 2013;11(1):46.
34. LeBlanc CM, Lands LC. Can I play? Pediatr Ann. 2014;43(12):e316–e324.
35. Fragala-Pinkham MA, Dumas HM, Barlow CA, Pasternak A. An aquatic physical therapy program at a pediatric rehabilitation hospital: a case series. Pediatr Phys Ther. 2009;21(1):68–78.
36. Brosseau L, Maltais DB, Kenny GP, et al. What we can learn from existing evidence about physical activity
for juvenile idiopathic arthritis? Rheumatology (Oxford). 2016;55(3):387–388.
38. The Royal Australian College of General Practitioners. Clinical guideline for the diagnosis and management of juvenile idiopathic arthritis. http://www.ipts.org.il/_Uploads/dbsAttachedFiles/cp119-juvenile-arthritis.pdf
. Published 2009. Accessed October 28, 2015.
39. PEDro. Italiano. https://www.pedro.org.au/italian/
. Accessed November 26, 2015.