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PhysicalFitness,ActivityandTraininginChildren
withJuvenileIdiopathicArthritis
TimTakken
PediatrHealth.20104(5):499507.

AbstractandIntroduction
Abstract

Physicalactivityandfitnessareincreasinglyrecognizedasimportantoutcomesinthefollowupandtreatmentof
patientswithjuvenileidiopathicarthritis.Inthepast,majorconcernswereonthedetrimentaleffectsofphysical
exercisenowevidenceisgrowingonthebeneficialeffectsofexercise.Thepurposeoftheseexerciseprogramsisto
promoteamoreactivelifestyleand/orenhancephysicalfitness.Thisarticlewillreviewthefindingsofrecentstudiesin
juvenileidiopathicarthritisintheareaofphysicalfitness,physicalactivityandtraining.Itisadvisedthatcliniciansare
discussingappropriatelevelsofphysicalactivity(dailyparticipationin>60minofmoderatetovigorousphysicalactivity)
withtheirpatientsinclinicalconsultations.
Introduction

Nowadays,pediatrichealthprofessionalshaveacknowledgedtheuseofexerciseintheprevention,diagnosisand
treatmentofchronicchildhoodconditionsandrelatedhealthproblems.Physicalfitnessisaprincipalelementofclinical
exercisephysiologyandisamultidimensionalconceptthathasbeendefinedasasetofattributesthatpeoplepossess
orachievetoperformphysicalactivity. [1]Incurrentpediatricresearch,physicalfitnesshasbecomesynonymouswith
cardiorespiratoryoraerobicfitness.Ingeneral,aerobicfitnessisexpressedasthemaximaloxygenuptake(VO2max)
andiswidelyrecognizedasthebestsinglemeasureofaperson'saerobicfitness. [2]
Asopposedtohealthychildren,childrenwithachronicconditionoftenareconstrainedfromparticipationinphysical
activitiesorsportsprogramsasaconsequenceofrealorperceivedlimitationsimposedbytheircondition.The
conditionitselfoftencauseshypoactivity,whichleadstoadeconditioningeffect,areductioninthefunctionalability
andtofurtherhypoactivity. [3]Physicalactivitycanbemeasuredusingdifferentmethods.Allmethodshavetheirpros
andcons.Forexample,doublylabeledwatercanbeusedtoestimatetheactivityenergyexpenditurewithgreat
precisionovera2weekperiodhowever,thecostsarehighandeaseofmeasurementislow.Ontheotherhand,
activityestimatesfromquestionnairesandactivityrecallsarerelativelyeasytoobtainbuttheprecisionofthese
methodsarelow.Activitymonitoring,usingsmalldeviceswornatthehip,wristoranklethatrecordaccelerationofa
bodysegment,seemstobeapromisingmethodtoobjectivelyassessandprofilephysicalactivity, [46]andseemsto
bemorevalidthanindirectassessments(e.g.,questionnairesandactivitylogs). [7]
Physicalfitnesscanalsobemeasuredusingdifferentmethods.Forexamplethereareseveraldifferentexercisetesting
methodstodirectlymeasurepeakoxygenuptakethegoldstandardofaerobicfitness,suchasgradedtreadmillor
cycleergometertestswithrespiratorygasanalysis.Inaddition,therearealsoteststoestimatetheaerobicfitness
from,forexample,endurancetime(e.g.,Brucetreadmilltest [8])ortimetocompleteatask(e.g.,9minrun/walk[9]).
Fortheseteststhereisalsoatradeoffbetweeneaseofmeasurementandprecision.Directmeasurementofoxygen
uptakeduringpeakexerciseismoreprecisethanestimatesofaerobicfitnessfromfieldtests.
Sufficientlevelsofphysicalactivityandphysicalfitnessarejustasimportantforthehealthstatusofchildrenwith
juvenileidiopathicarthritis(JIA)asitisforhealthychildren.
Physicalfitnessisnotonlyanimportantindicatorforhealth,itisalsoanimportantdeterminantoffunctionalcapacity
ofasubject.Unfitand/orinactivechildrenareatadditionalriskforavarietyofhealthconditionsassociatedwitha
hypoactivelifestyle(e.g.,cardiovascularconditions,obesityandprediabetes).Furthermore,sufficientlevelsofphysical
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activityisnecessaryforanoptimalphysical,psychologicalandemotionaldevelopmentofachild.
However,childrenwithJIAmighthaveareducedphysicalfitness[10]andbelessactivethanpeers, [1113]whichcauses
anunnecessaryriskforthedevelopmentofcardiovasculardiseaseaswellasariskforreducedpsychosocialand
physicalfunctioning.Thelinkbetweenphysicalactivity,healthrelatedfitnessandhealthisdescribedbyBouchardand
coworkersinthemodelshowninFigure1. [14]

Figure1.

ThemodelbyBouchardandcoworkerslinkingphysicalactivity,healthrelatedfitnessandhealth.
Reproducedwithpermissionfrom[14].

PhysicalFitness
HealthrelatedFitness

Physicalfitnesscanbedividedinvariouscomponents,namelyhealthrelatedfitness(peakoxygenuptakeVO2peak),
andperformancerelatedfitness(i.e.,musclestrengthandanaerobiccapacity).VO2peakismostfrequentlyassessed
usingprogressivegradedexercisetestsonacycleergometerwithrespiratorygasanalysisinchildrenwithJIA, [10]
althoughsomeresearchershaveusedtreadmilltestinginchildrenwithJIA. [15,16]
ThereisalargebodyofevidencedemonstratingthattheVO2peakofchildrenandadolescentswithJIAislower
comparedwithhealthypeers.IntherecentstudiesinJIA,betweentheages6.718years,VO2peak(L/min)and
VO2peaknormalizedforbodymass(VO2peak/kginml/kg/min)were,respectively,69.8and74.8%inchildrenand83
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and80%ofpredictedvaluesforVO2peakandVO2peak/kgforhealthypeers. [17,18]Theseobservationsconfirmthe
resultsofapreviousmetaanalysisdemonstratingthatVO2peakperkgbodymasswasonaverage21.8%lowerin
childrenwithJIAcomparedwithhealthycontrolsubjectsorreferencevalues. [10]WerecentlystudiedtheVO2peakina
groupof12youngadultswithJIAandobservedasignificantlyreducedVO2peak(ZscoreforVO2peak/kgwas1.0
2.13),whichwasnotsignificantlydifferentfromvaluesobservedinchildrenandadolescentswithJIA[vanPeltPA,
TakkenT,vanBrusselM,KruizeA,WulffraatN:Associationbetweenaerobiccapacityanddiseaseactivityin
adolescentsandyoungadultswithJIA.Submitted].Thereisaneedforlongitudinalfollowupstudiesinphysicalfitness
levelsinJIA.TheresultsofthepreviouslymentionedstudysuggeststhatthephysicalfitnesslevelsofJIAisnot
improvingovertime.ThiswasalsorecentlyobservedinasmallgroupofpatientswithJIAwhounderwentautologous
stemcelltransplantation. [19]AsshowninFigure2,onaveragethereisnoimprovementovertime.Inaddition,several
patientshadanexacerbationoftheJIAfollowingautologousstemcelltransplantation,whichisobservedinthesudden
dropsinVO2peak/kg.

Figure2.

ChangesovertimeinVO2peak/kginchildrenwithjuvenileidiopathicarthritiswhounderwentanautologous
stemcelltransplantation.Thedifferentsymbolsandlinesindicateobservationsfromindividualpatients.Thedotted
lineindicatesthetrendlineoftheindividualvaluesovertime.
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ASCT:Autologousstemcelltransplantation.
Datatakenfrom[19].
Fromtheseobservations,itcanbehypothesizedthatchildrenandadolescentsremainhypoactivewhendiseasegoes
intoremissionwithorwithoutmedication.Thefactthatyoungadultstreatedintheprebiologictreatmenteraandthat
youngerchildrenwhoarecurrentlybeingtreatedwithnewerbiologicalsarenotscoringbetteronaerobicfitness,
suggeststhatwehaveobservedhardlyanypositiveeffectofthedevelopmentsinmedicaltreatmentoverthelast
decadeonphysicalfitness.RecentunpublisheddatafromourgroupindicatedthatJIApatientswithahistoryofanti
TNFbiologicalusehadaloweraerobiccapacitycomparedtononusers[TakkenT,UnpublishedData].Thismightbe
duetothefactthatintheNetherlandsantiTNFisonlyprescribedforpatientswithapolyarticulardiseasecoursewho
failedearliertreatmentorhaduntreatablesideeffectsonhighdosemethotrexate[vanPeltPA,TakkenT,vanBrussel
M,KruizeA,WulffraatN:Associationbetweenaerobiccapacityanddiseaseactivityinadolescentsandyoungadults
withJIA.Submitted].
Itisprobablethatexercisetherapyandphysicalactivitypromotioncanfurtherenhanceaerobicfitnessandexercise
participationinpatientswithJIA,especiallyinthecaseswithseveredisease. [19]
GianniniandProtasalsofoundthatchildrenwithJIAhadsignificantlylowerpeakworkrate(amountofWattthata
subjectcangenerateduringagradedexercisetestonacycleergometer),peakexerciseheartrate(HRpeak)and
exercisetimethanhealthycontrolsubjectsmatchedforage,genderandbodysize. [20,21]Recentlypublished
observationsin91childrenwithJIAdemonstratedthatchildrenwithJIAhadonaverageaHRpeakof18114bpm, [22]
whilehealthychildrenhaveonaverageaHRpeak1937bpmduringcycleergometryinourlaboratory. [23]Someofthe
childrenwithJIAstoppedtheexercisetestbecauseoffatigueand/ormusculoskeletalcomplaints,andnotbecauseofa
cardiopulmonarylimitationduringexercise.OwingtotherangeinHRpeak,itisimportanttomeasuretheHRpeakofa
subjectduringagradedexercisetestandnottouseageneralprediction,suchas220age.
ManycentersdonothavetheequipmenttoperformrespiratorygasanalysistomeasureVO2peak.However,peakwork
load(Wpeak)duringagradedbicycletestcanbeusedasasurrogatemeasureforVO2peak,sinceanexcellent
correlationbetweenWpeakandVO2peak(r=0.95,p<0.0001)hasbeenobservedin91childrenwithJIA. [22]VO2peak
canbepredictedfromWpeak,weightandgenderusingthefollowingequation: [22]

Thisequationwasestablishedusingastepwiseincreasedprotocolwithanincreaseof20W/min.Inyoungchildren
withaheightlessthan120cm,incrementsof10W/mincanbeusedandinchildrenbetween120and150cm,15W
incrementspermincanbeused. [24]Theserapidincreasingprotocolsaretobepreferredaboveslowerincreasing
protocols,suchastheGianniniprotocol,withincreasesof20Wper3min. [20]Slowincrementalprotocolsoftentake
quitelong,approximately20min,anditismyexperiencethatchildrenwillstopbecauseofperipheralmusclefatigue
andnotbecauseofcardiopulmonarylimitation. [25]
ImpairedVO2peakdoesnotappeartobesignificantlyrelatedtotheseverityofjointdisease,butmaybedueto
hypoactivitysecondarytodiseasesymptoms,especiallyinchildrenwithlongstandingarthritis. [4,9,10]Physiologic
factors,includinganemia,muscleatrophy,generalizedweaknessandstiffness,resultinginpoormechanicalefficiency
mayalsolimitthechild'sperformance.
FitnessinotherRheumaticConditions
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Oftheotherpediatricrheumatoidconditions,physicalfitnesslevelsinchildrenwithjuveniledermatomyositis,systemic
lupuserythematosisandrecentlythefitnesslevelsamongchildrenwithmixedconnectivetissuediseasewerereported.
TheirresultsareshowninFigure3.Asreference,thevaluesasobservedinchildrenwithchronicfatiguesyndrome
(significantoverlapwithfibromyalgia)isprovided.

Figure3.

TheZscoreforVO2peak/kgofpatientswithjuveniledermatomyositis,systemiclupuserythematosis,mixed
connectivetissuediseaseandchronicfatiguesyndrome.
CFS:ChronicfatiguesyndromeJDM:JuveniledermatomyositisJIA:JuvenileidiopathicarthritisMCTD:Mixed
connectivetissuediseaseSLE:Systemiclupuserythematosis.
Datatakenfrom[17,2629].
Itisimminentthatarheumaticdiseasethatprimarilyattacksthemusclewillresultinthelowestscoreinphysical
fitness,anoverlapsyndrome,suchasmixedconnectivetissuediseaseandJIAturnsouttoshowalmostequal
outcomesinphysicalfitness.Interestingly,recentlydiagnosedchildrenwithchronicfatiguesyndromehaveonaverage
anormalscoreinphysicalfitnesscomparedwithhealthypeersFigure3. [17,2629]
PerformancerelatedFitness
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Aspreviouslymentioned,performancerelatedfitnessincludescomponents,suchasmusclestrengthandanaerobic
capacity.Impairmentsofmusclestrengthincludeweaknessinhipextensionandabduction,kneeextension,plantar
flexion,shoulderabductionandflexion,elbowflexionandextension,wristextensionandgrip.Musclebulk,strength
andenduranceshouldbeexaminedatdiseaseonsetandmonitoredregularly.Bilateralmeasurementsof
circumferencequantifyasymmetriesinmusclebulk.Functionalmusclestrengthcanbeestimatedinyoungchildrenby
observingtheirperformanceofageappropriatemotortasksoractivitiesofdailyliving.Inolderchildren,manualmuscle
testingcanbedonetomeasureisometricstrength,especiallyifthechildhaspainwhilemovingthelimbagainst
resistance.Instrumentedmeasurementsusingahandheldorisokineticdynamometerormodifiedsphygmomanometer
[vanPeltPA,TakkenT,vanBrusselM,KruizeA,WulffraatN:Associationbetweenaerobiccapacityanddisease
activityinadolescentsandyoungadultswithJIA.Submitted] [18]provideconsistentandreliableinformationinpatients
witharthritis.Bothisometricandisokineticstrengthhavebeenshowntobevalidandreliablemeasuresofmuscle
strengthinnormalchildren.InJIAthereliabilityofisometricstrengthmeasurementofthelowerlimbmuscleshasbeen
assessed[30]andreportedtohaveasufficientintraandinterraterreliability. [30]Severalstudieshavedemonstrated
thatmusclestrengthissignificantlyreducedinchildrenwithJIAcomparedwithhealthypeers. [3135]
LindehammarandSandstedtreportedinalongitudinalstudythatmusclestrengthdiminishesrapidlynearaninflamed
joint. [32]Thisisprobablycausedbyatrophyofthemuscle,whichisinfluencedbylocalarthritis.Onestudysuggested
thatmuscleweaknessmaycontributetoactivityrestrictionsinchildrenwitharthritis.Fanandcolleaguesfounda
significantrelationshipbetween50mruntimesandlowerextremityChildhoodHealthAssessmentQuestionnaire
(CHAQ)scoresingirlswithJIA. [36]
However,musclestrengthtestinginchildrenwithJIA,especiallyhandhelddynamometryusingthe'break'technique,
mightbeproblematicinsomecases,becausechildrenmightgivewayduetopaininsteadofthelimitsinmuscle
strength.Moreover,insomecaseschildrencanexperienceincreasedkneepainandswelling. [34]
Anaerobiccapacitycanbeassessedusingshorttermexercisetests.Usuallyanaerobiccapacityismeasuredusinga30
salloutcycleergometertest,theWingateAnaerobicTest. [37]Childrenhavetocycleasfastastheycanagainsta
fixedresistance,andbasedonthenumberofrevolutionspersecond,thepoweroutputisrecorded. [37]
TworecentstudiesinvestigatingtheanaerobiccapacityinchildrenandadolescentswithJIAreportedsignificantlylower
valuesofanaerobiccapacityinsubjectswithJIA. [6,7]Anaerobiccapacitywasreducedtothesameextentcompared
withaerobicfitness(VO2peak).Previouslyithasbeenfoundthatthereducedanaerobiccapacitywassignificantly
correlatedtoCHAQscoresin18childrenwithJIA,ages714years. [38]Thisisnotsurprising,sincethetypicalphysical
activitybehaviorofchildrenshortburstsofintenseactivitiesseparatedbyperiodsofrestisanaerobicinnature. [39]
GiventheapparentlysimilardeficitsinanaerobiccapacityofyouthwithJIA,exercisetrainingoftheanaerobicenergy
system(e.g.,highintensityintervaltraining)mightbeequallyvaluableastrainingoftheaerobicsystemand,therefore,
warrantedinchildrenwitharthritis.However,thistrainingmodalityhasnotyetbeenstudied.
Anotherwidelyusedperformancerelatedfitnesstestisthe6minwalktest(6MWT).Inthistestchildrenhavetocover
asmuchdistanceastheycanin6minwhilewalking(notrunning).Thistestisusedindifferentpatientgroups,suchas
JIA,spinabifida,cerebralpalsyandhemophilia. [4042]Lelieveldetal.foundalowcorrelationbetweenwalking
distanceandVO2peakinchildrenwithJIA. [43]Inaddition,Paapetal.foundthatchildrenwithJIAwereexercisingat
8085%oftheirHRpeakandVO2peakduringthe6MWT,indicatingthatitisanintensive,submaximalexercisetestto
measurefunctionalexercisecapacityinchildrenwithJIA. [44]Furthermore,thesedataindicatetheexerciseintensityat
theendofthe6MWTcanbeusedfortheprogrammingofexerciseintensityduringaerobicexercisetraininginchildren
withJIA,becausethisexerciseintensityissufficienttoimprovefitnesslevels.TheHRattheendofa6MWTcanthus
beusedforexerciseprogramming.However,the6MWTdistancecannotbeusedasameasureofVO2peakinchildren
withJIA. [45]

FitnessTraining
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AerobicCapacity

InarecentCochranereviewitwasidentifiedthatonlythreepublishedrandomizedcontrolledstudiesinvestigatedthe
effectsofexercisetrainingforchildrenwithJIA. [46]However,noneofthesestudiesfoundimprovementsinVO2peak
followingtheaerobictrainingprogram.Thislackofeffectcanbecanbeduetoalowexercisefrequency(e.g.,oncea
week),lowexerciseintensity(intensityofexercisehastobeabovetheintensityofdailyactivities),alowexercise
adherence(childrenwouldoftenskipexercisesessions)ortheydidnotperformtheprescribedhomeexercises.These
factorsareessentialforimprovingphysicalfitness.
However,aerobicfitnessisimportanttoimprovethechild'sendurancefordailyphysicalactivitiesandplay.Inaddition,
aerobicfitnessaidstherecoveryfollowingintensiveexercise.Basedontheavailableliterature,itisrecommendedthat
childrenwithJIAandadeficitinaerobicfitnessshouldtrainatleasttwiceaweek,withamoderatetovigorous
intensity(6085%HRpeak),for4560minpersessionforatleast612weeks. [12,13]Thespecificmodeofexercise
appearstobelessimportantthantheintensity,durationandfrequency.However,weightbearingexerciseisnecessary
tomaintainoptimalbonegrowthanddensity.Lowimpactactivitiestoimproveproprioceptivefunction,balanceand
coordinationcanbeincorporatedintoaerobicconditioningprograms.Furthermore,largemusclegroupsshouldbeused
forimprovingVO2peakastheexercisemodeoftestingshouldbecomparablewiththetrainingmode(e.g.,a
walking/joggingexerciseprogramshouldbeevaluatedusingtreadmilltestingandnotusingcycleergometrytesting).
Forchildrenwithactivediseaseitisadvisedtorefrainfromanyformalexercisetrainingwhentheyhavefever(i.e.,
rectalcoretemperature>38.3C).Inaddition,whentheyhaveactivejointsinthelowerextremities,itisadvisedtodo
onlylowtomoderateintensityexercisewithoutintensiveloadingofthejoints(e.g.,runningorjumping). [47]Forchildren
withactivediseaseinthewristforexample,itisrecommendedtoweara(dynamic)splintduringexercisetoprotectthe
jointfromhighimpactforces.Activitiesthatcausepainandincreaseswellinginjointswithactivearthritisshouldbe
stoppedormodifiedtolessenstresstothejoint. [47]
AnaerobicCapacity

InarecentstudyvanBrusseletal., [29]hypothesizedthattrainingoftheanaerobicenergysystem(e.g.,highintensity
intervaltraining)mightbeequallyvaluableastrainingoftheaerobicsystemand,therefore,warrantedinchildrenwith
JIA.Although,thistrainingmodalityhasnotyetbeenstudiedinchildrenwithJIA,improvementshavebeenobserved
infunctionandfitnesswithanaerobicexercisetraininginchildrenwithotherchronicconditions(e.g.,cysticfibrosisand
cerebralpalsy). [48,49]Particularlyinchildrenwithalargerreductioninanaerobiccapacitycomparedwithaerobic
capacity,thistrainingmodalitymightbeeffective.Inaddition,childrenpreferthisanaerobictypeofexercise,compared
withtheadulttypeofcontinuousenduranceexercise.Suggestedexercisesetsconsistofseveral(five)15boutsof
highintensity(orallout)1530ssprintinterchangeswith12minofactiverest(cyclingwithlowresistance).Atraining
sessioncouldconsistofthreeoftheseexercisesets,with5minofactiverestforrecoverybetweenthethreesetsof
intervaltraining.
MuscleStrength

ThereislittleevidenceconcerningtheeffectivenessofstrengthtrainingforchildrenwithJIA.Thereisonlyonestudy,
whichisonlypublishedinanabstractformthatstudiedmusclestrengthtraininginchildrenwithJIA.Fisherand
colleaguesexaminedtheeffectsofresistanceexerciseusingisokineticequipmentin19childrenwithJIAofages614
years,whotrainedasagroupthreetimesaweekfor8weeks. [50]Eachchild'sprogramwasindividualizedand
progressedbasedontheirinitialtestresultsandresponsetotraining.Subjectsdemonstratedsignificantimprovements
inquadricepsandhamstringstrengthandendurance,contractionspeedofthehamstrings,functionalstatus,disability
andperformanceoftimedtasks.ControlsubjectswithJIAwhodidnotexercisehadrelativelynochangetoaslight
decreaseinmusclefunctionduringthesametimeperiod. [50]
Todate,therearenootherpublishedreportsinvestigatingtheeffectsofstrengthtraininginchildrenwithJIA.
However,recommendationsforhealthychildrencanbefollowedforuseinchildrenwithJIA.Forimprovingmuscle
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strengthchildrenshouldperformresistanceexercisesfor23timesperweekatanintensityof6075%oftheirone
repetitionmaximum.Thelatterwillbeapproximately1315repetitionsofanexerciseuntilfatigue.Thetimeper
sessionwillbe3045min.Itisadvisedtousetheentirerangeofmotionofapatient(orwithinpainlimits).The
programshouldincreaseinintensityfrom60%oftheonerepetitionmaximumwith13sets,toahigherintensityof
75%with34sets.Itisrecommendedthattheresistanceisonlyincreasedwhen15ormorerepetitionscanbemade
withasufficienttechnique,andresistancewillonlybeincreasedwith5to10%per3weeks.Awarmupperiodoflight
activity,suchascyclingshouldprecedestrengthtesting.
EncouragingActiveHealthyLiving

SeveralstudieshaveidentifiedahypoactivelifestyleofchildrenwithJIA. [1618]Asignificantassociationhasbeen
reportedbetweenaccelerometrymeasuredphysicalactivityandhealthrelatedfitness(VO2peak)inchildrenwithJIA, [12]
suggestingacauseeffectrelationship.Inaddition,noadverseeffectsofregularsportactivityhavebeenobservedon
jointscoresinchildrenwithJIA. [51]However,themostfrequentlyparticipatedsportsactivityinthatstudywascycling
andswimming(nonweightbearingactivities). [51]Ontheotherhand,acontrolledweightbearingexerciseintervention
studyfoundimprovementsinjointstatusfollowing8weeksoftraininginchildrenwithJIA. [9]Adultdataindicatethat
exercisecanhaveanantiinflammatoryeffectinarthritispatients[52]aswellasinotherinflammatorydiseases. [53]
Thelinkbetweenthephysicalactivitylevelsofchildrenandmotorperformance[54]suggeststhatthephysicalactivity
levelsofchildrenwithJIAmightbeenhancedthroughtheimprovementofthereducedmotorproficiencyobservedin
childrenwithJIA. [55]Furthermore,giventhefactthatadultphysicalactivitylevelsareestablishedinyouth,itis
importanttoencouragechildrenandfamiliesofchildrenwithJIAtoparticipateinregularphysicalactivity.Regular
physicalactivitycanhelpinthepreventionofcardiovascularriskfactors,obesity,reducedbonehealthandreduced
healthrelatedqualityoflifeinyouthswithJIA.
RecentlyLelieveldetal.performedarandomizedcontrolledstudytoinvestigateaninternetbasedactivitypromotion
programamong33JIApatient(10.81.5yearsold). [8]This17weekwebbasedelearningprogramwascombined
withfourgroupsessions.Thefollowingstrategieswereusedtopromotephysicalactivity:healtheducationexplanation
ofbenefitsofphysicalactivityreinforcementofselfefficacyinfluenceoffamilyandschoolisrecognizedandusedto
promotephysicalactivityphysicalactivityoptionsindailylifeareexploredandencouragedandsmartgoalsareset
(e.g.,'Iamgoingtocycletoschoolthreetimesaweekinsteadofgoingbycar,forthecoming2months').They
observedthefollowingchangesinphysicalactivity:energyexpenditurefromphyscicalactivitywasimprovedby+1.24
MJ/day,theamountofmoderatetovigorousphysicalactivityimprovedwith1hperdayandthenumberofdayswith
morethan1hofmoderatetovigorousphysicalactivityincreasedwith1.2dayperweek.Theyobservedthelargest
effectsinchildrenwithlowphysicalactivitylevelsatbaseline.
Althoughexercisecapacity,asmeasuredusingtheendurancetimeontheBrucetreadmilltest,improvedsignificantly
thisimprovementwasonly26s,whichcouldbehardlyrecognizedasclinicallyrelevant(effectsizeof0.33).Thisisnot
surprising,sincetherelationshipbetweenphysicalactivityandphysicalfitnessislowinJIA [12]aswellasinother
childhoodconditions,suchascongenitalheartdisease. [56]Itmightbemoreeffectivetocombineformalexercise
trainingwithaphysicalactivitypromotionprogramtoincreaseactivityaswellasphysicalfitnessinchildrenwithJIA.

Recommendations
Cliniciansshouldstimulateanactivehealthylifestyleassoonaspossibleafterdiagnosis.
Ingeneral,childrenwithJIAshouldbeadvisedtocomplywithpublichealthrecommendationsofdailyparticipationin
60minormoreofmoderatetovigorousphysicalactivitythatisdevelopmentallyappropriate,enjoyableandinvolvesa
varietyofactivities. [57]Moreover,childrenwithJIAareadvisedtoperformlessthan2hofsedentaryactivitiesduring
theirleisuretime(e.g.,TVwatching,browsingtheinternetandcomputergamesamongothers)perday. [57]
Cliniciansshouldbeawareofthedetrimentaleffectsofinactivityandsedentarybehaviorandstimulatephysicalactivity
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inchildrenwithJIA.Adviceregardingappropriatelevelsofphysicalactivityshouldbeimplementedinclinical
consultations.
Inaddition,cliniciansareadvisedtoprovidewrittenadvices(includingrestrictionsandpermissions)tobothprimarycare
providersaswellasparentsregardingappropriatelevelsofphysicalactivity.Futurestudiesshoulddeterminethemost
effectiveapproachtopromotephysicalactivityandincreasephysicalfitnessinchildrenwithJIA.

Conclusion
ChildrenwithJIAareoftenrestrictedintheiractivitiesofdailyliving,havelowerphysicallyactivitylevelscomparedwith
theirhealthypeers,andhaveareducedphysicalfitness.Noneofthecurrentlyperformedrandomizedstudiesregarding
exercisetraininginchildrenwithJIAhaveobservedclinicallysignificantimprovementsinphysicalfitness,andonlyone
studyhasobservedsignificantandclinicallyrelevantimprovementsinphysicalactivity.Itisadvisedthatclinicians
discussappropriatelevelsofphysicalactivitywiththeirpatientsinclinicalconsultations.FurthermorechildrenwithJIA
shouldadherewithpublichealthrecommendationsofdailyparticipationin60minormoreofmoderatetovigorous
physicalactivity.

FuturePerspective
Oneofthemajorneedsinthisfieldisaspecificcoresetofoutcomemeasuresforrehabilitationresearchinchildren
witharheumaticcondition.Currentstudiesareusingalargevarietyofoutcomemeasuresthatimpedescomparability
ofthefindings.Thedevelopmentofsuchacoresetisneededinthenextdecade.Furthermore,theuseofinternet
basedexerciseinterventionswillbecomemorewidespreadaswellasbehavioralinterventionstostimulatephysical
activityparticipationinthispatientgroup.Moreover,therewillbemoreattentionforthephysicalfitness,activityand
riskfactorsforcardiovasculardiseaseinyoungadultswithJIA.Finally,implementationofexercisetrainingandphysical
activitypromotionprogramsinclinicalcareshouldbeestablished.

Sidebar
ExecutiveSummary

Alargebodyofevidenceindicatesthatchildrenwithjuvenileidiopathicarthritis(JIA)arelessphysicallyfit
comparedwithhealthypeers.
ChildrenwithJIAarealsolessactiveandareoftennotmeetingpublichealthguidelinesforphysicalactivity
participation.
Effectsofformalexercisetrainingprogramsseemspromisinghowever,adherenceisoftenlimitingthe
effectiveness.
Physicalactivitypromotionprogramsseemspromisingandfeasiblehowever,longtermeffectivenessshouldbe
established.
CosteffectivenessofexerciseandphysicalactivitypromotionprogramsshouldbeestablishedinJIA.
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Financial&competinginterestsdisclosure
Theauthorhasnorelevantaffiliationsorfinancialinvolvementwithanyorganizationorentitywithafinancialinterestin
orfinancialconflictwiththesubjectmatterormaterialsdiscussedinthemanuscript.Thisincludesemployment,
consultancies,honoraria,stockownershiporoptions,experttestimony,grantsorpatentsreceivedorpending,or
royalties.
Nowritingassistancewasutilizedintheproductionofthismanuscript.
PediatrHealth.20104(5):499507.2010FutureMedicineLtd.

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