EFFECTS OF EXERCISE THERAPY ON JUVENILE RHEUMATOID ARTHRITIS AND ADAPTED PHYSICAL ACTIVITIES

written by Alexis Adler, Undergraduate Student, University of Florida

Background

Juvenile Arthritis is the most common form of Arthritis in children under 16. "JRA is an auto-immune disorder, which means that the body mistakenly identifies some of its own cells and tissues as foreign" (National Institute of Arthritis and Musculoskeletal and Skin Diseases (U.S.) 2001).

The cause is still unknown by scientists, however, family history and environment are thought to play a large role. The complications and long term outlook of Juvenile Rheumatoid Arthritis depends on the amount of joints affected. Individual cases of the disease are classified by degree of severity into one of three categories: Pauciarticular, Polyarticular, and Systemic.

Pauciarticular Juvenile Rheumatoid Arthritis affects four or less joints and does not usually convey any symptoms (Stopka, 2008). The most common type of the three, Polyarticular Juvenile Rheumatoid Arthritis, affects five or more joints. The most severe of the three, Systemic Juvenile Rheumatoid Arthritis involves widespread joint damage throughout the body and can cause major damage and debilitation if not treated properly. Doctors can create an effective plan of treatment appropriate for each child with Juvenile Rheumatoid Arthritis.

There is currently no cure for Juvenile Rheumatoid Arthritis, however, there are several treatment options that have been found to greatly improve the prognosis. Treatment usually involves pharmacological intervention, psychosocial management, and adaptive physical and occupational therapy (Ravelli, 2007).

There are a number of drugs that doctors may prescribe to help reduce inflammation and flare-ups; these include: Nonsteroidal Anti-inflammatory Drugs (NSAIDs), Disease-modifying Antirheumatic Drugs (DMARDs), and Corticosteroids (National Institute of Arthritis and Musculoskeletal and Skin Diseases (U.S.) 2001). Although patients do benefit from taking these drugs, it is important that the child remains physically active by engaging in routine physical therapy.

Studies have shown that physical activity plays a crucial role in slowing the progression of the disease and in reducing the amount of long-term consequences related to Juvenile Rheumatoid Arthritis. Historically, physical activity was a concept shunned by the medical community out of fear that exercise might lead to further damage of the joints (Takken, Van Der Net, Kuis, and Helders, 2003). As a result bed rest became a popular method of treating children with Juvenile Rheumatoid Arthritis.

It was only until the last century that exercise started being used as a form of treatment. Incorporating an exercise regimen forms a foundation of motor skills necessary to improve quality of life and control of the disease. "Maintaining and improving physical fitness better prepares children and adolescents with a chronic disease for entering adulthood, providing a sound basis for their future health and preventing diseases induced by inactivity" (Takken, et. al., 2003, p885).

Lower fitness levels are associated with higher rates of mortality, earlier onset of disability, and a greater chance of developing other serious conditions later in life including cancer, obesity, diabetes, and hypertension.

In the case of Juvenile Rheumatoid Arthritis, lack of movement contributes to limited range of motion and can cause a great deal of pain, disability and contractures (Stopka, 2008). Exercise therapy should combine a variety of adaptive physical activities that optimize range of motion, strengthen muscles surrounding joints, increase aerobic capacity, and improve quality of life and well being.

Range of Motion Exercises

In patients with Juvenile Rheumatoid Arthritis, pain is often a result of stiff joints due to lack of movement or exercise. "The Synovial fluid is thickened with waste products from the immune system attacking the Synovial membranes” (Stopka, 2008, p63). By incorporating these movements into daily routine permanent crippling, as well as control of the disease, can be achieved. "Adequate therapy is necessary to avoid permanent deformities and minimize the effects of adult onset Rheumatoid Arthritis in middle age and beyond" (Stopka, 2008, pg63).

Range of Motion exercises (ROM) are an excellent way to improve daily living and prevent further damage to the joints. There are ten common ROM techniques that can be tailored to fit the needs of the patients' treatment plan. They include: "…cervical spine (rotation); shoulder (abduction); wrist (flexion and extension); thumb (flexion metacarpophalangeal); hip (internal and external rotation); knee (extension); and ankle (dorsiflexion and plantar flexion)” (Takken, et al., 2003, p886).

Strengthening Exercises

Children with Juvenile Rheumatoid Arthritis are significantly less active than their peers. Muscle atrophy, or the shrinking of muscle tissue, often occurs from the lack of exercise. Osteoporosis is not uncommon either due to the loss of bone density from limited movement. The more muscle mass there is surrounding a joint, the better able a child is to produce efficient movement and minimize injury. Strength training, therefore, is crucial for improving the condition of patients with Juvenile Rheumatoid Arthritis.

There are many activities, that when practiced correctly under the supervision of a trained professional, can improve muscle strength significantly in children with Juvenile Rheumatoid Arthritis. Weight bearing activities can include recreational weights, weight machines, isometric exercises, elastic bands, and ankle weights (Maes and Kravitz, (2004). ROM exercises should be done prior to engaging in strength training to prevent injury and muscle spasms.

Aerobic Exercise

Aerobic exercise can improve muscle endurance and cardiovascular endurance for patients with Juvenile Arthritis. The goal of aerobic exercise is to increase cardiovascular endurance and peak physical activity (ACSM 2007). There are many activities that the child can participate in that best suits their condition. Some moderate forms of aerobic exercise include: water walking, swimming, aquatic exercise, dance, cycling, and brisk walking. Prior to engaging in aerobic activity, ROM exercises should be done to prevent injury and muscle spasms.

Alternative Forms of Exercise Therapy

Hydrotherapy, or a form of supervised exercise that occurs in water, is a non-pharmacological treatment option for patients with Juvenile Rheumatoid. Water immersion takes the stress off of the joints due to the force of gravity, and it provides some form of resistance training, while building strength and ultimately muscle mass. As a result, hydrotherapy is not only less painful, but is also an enjoyable treatment option that builds muscle strength and muscle endurance (Cakmak and Bolukbas, 2005).

Although there have been many studies on the effects of Yoga and Tai Chi on adults with Rheumatoid Arthritis, only a handful have shown how they affect children with Juvenile Rheumatoid Arthritis. Recent studies have shown that Yoga increased quality of life, concentration, motor speed, reaction time, hand strength, endurance and improved mood of pediatric patients (Long, et. al., 2010). Tai Chi has also been known to reduce stress, improve cardiopulmonary function, and joint stability. More studies need to be done to examine whether or not children with Juvenile Rheumatoid Arthritis can benefit from these activities.

Conclusion

Juvenile Rheumatoid Arthritis is a serious condition and therefore should be treated appropriately with a multi-faceted approach. Many anti-inflammatory drugs do help reduce pain and flare-ups; however, there is a substantial amount of evidence, suggesting that exercise can and does improve condition and prognosis for children with Juvenile Rheumatoid Arthritis.

"JRA is a disease that can be managed by close follow-up and timely application of appropriate treatment modalities, enabling children to reach adult ages without development of disabilities. Early diagnosis, appropriate treatment, education, and teamwork of the family, patient, and physicians are factors that increase the chances of success" (National Institute of Arthritis and Musculoskeletal and Skin Diseases (U.S.) 2001).

REFERENCES

Biography: Alexis Adler graduated from the University of Florida in 2010 with a B.A. in Sociology. During her undergraduate degree she completed a variety of coursework but grew increasingly interested in the health sciences. Her community involvement, and volunteer work at a local hospital inspired her to pursue a career as a health professional. She currently resides in Washington DC, and will be applying to Physician Assistant programs in the Fall of 2012.

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