Exercise as it relates to Disease/Effects of physical activity on children with chronic arthritis

This page is a critique on the article "Effects of an eight-week physical conditioning program on disease signs and symptoms in children with chronic arthritis" by Susan E. Klepper (1999)

What is the background to this research?

Pain is a predominate feature of childhood arthritis which is one of the major reasons for limited exercise within this particular population with the overall prevalence of juvenile arthritis in the United States ranging from 1.6 to 86.1 people per 100,000. This indicates the prevalence in the geographic location of where the study was done.
This article was undertaken as a partial requirement for a doctoral degree in pediatric physical therapy at Allegheny University of the Health Sciences in Philadelphia, Pennsylvania. Its aim was to investigate the effects of an 8 week, 24 session weight bearing physical conditioning program on disease signs and symptoms in children with chronic arthritis.

Where is the research from?

The group the research was conducted on is important as the subjects consist of individuals with juvenile rheumatoid arthritis. Its main importance is due to the fact that the research was investigating whether a weight bearing program could relieve the signs and symptoms on children who have chronic arthritis. The subjects had to meet the American College of Rheumatology criteria for polyarticular juvenile rheumatoid arthritis. This is used to define the population and consider the results due to the severity of the arthritis.

The author has published previous studies on juvenile rheumatoid arthritis with a number of papers following this particular article relating to children with arthritis and measures of pediatric function. This shows that she has quite extensive knowledge on this particular population and experience working with chronic disease.

This article was supported by a grant from the US Department of Education, Office of Special Education and Rehabilitation Services, but there doesn't seem to be a conflict of interest or bias due to this.

What kind of research was this?

This study had components of both an observational and experimental study. It described changes that happened over the period the study from before the intervention to post intervention. In this research a control group was not included, the reason for this could be due to the fact that no change in signs and symptoms would be present. Although it may have been good to include as those that do not undertake the intervention could experience worsening of arthritis due to inactivity, and a comparison could be made in relation to baseline or control and intervention. It may have also been good to include another group with a different mode of exercise to conclude which had the greatest effects on the population.

What did the research involve?

A number of assessments were carried out in an approach to measure the severity of the participant's joint pain and fitness throughout the study in relation to the exercise program. This included a visual analog scale as well as a 9-minute run-walk test to measure aerobic endurance. The training program consisted of a low impact exercise that aimed to improve participant's aerobic endurance, muscular strength and endurance, and flexibility. Subjects participated in 2 sessions of centre based exercise a week as well as undertaking a 60-minute exercise videotape once a week. The centre based exercise included a 10 minute warm up followed by a low impact peak aerobic exercise, which progressed from 15 minutes in the first week to 25 minutes by the third week. Subjects were to maintain a heart rate between 60-75% of their age-predicted heart rate maximum. This was then followed by 15 minutes of strengthening exercise for the arms, legs and trunk using their body weight, vinyl balls and elastic bands as resistance. The session ended with 10 minutes of cool down and stretching.
One limitation occurred within this study, which was a small sample size. This indicates that changes in disease symptoms must be taken into consideration due to the fact that daily fluctuations in pain and joint motion can occur.

What were the basic results?

Comparisons for individual contrasts among articular severity index scores at the 3 test sessions

Comparison	R1	R2	R1-R2	MSD†
Baseline vs pre-exercise	60	63.5	3.5	16.93
Baseline vs post-exercise	60	26.5	33.5‡	16.93
Pre-exercise vs post-exercise	63.5	26.5	37.0‡	16.93

R = rank total for each test session, †MSD = minimum significant difference, ‡ = P < 0.05

Significant differences were found across the 3 testing sessions in articular severity index (P<0.0001) and joint count (P<0.001). In the visual analog scale, scores decreased by 16% from the start of the study to the post-exercise test. 23 out of the 25 subjects had decreased articular severity index scores following the exercise program, of these 20 had a significant decrease in the severity of joint signs and symptoms. This suggests that majority of subjects had improvements, with only a few participants having little to no improvement. The results that were found supported the hypothesis, suggesting that this study has been successful due to the improved symptoms in the diseased population.
Although all of these results seem positive, the findings may be over emphasized due to the fact that the author focuses mostly on the results that support her hypothesis. Within the discussion section it is then said that in the examination of the pre and post exercise change scores, most participants reported either no change or decreased pain, with only 5 subjects reporting a significant decrease in pain. This suggests that majority of subjects did not have a dramatic change in disease symptoms.

What conclusions can we take from this research?

The findings within this research indicate that increased physical activity, including weight bearing exercise, may play an important role in the management of childhood arthritis. Mean pain scores decreased from the entry of the study to the post-exercise test, with less than half of subjects experiencing no increased pain during the exercise program. With this, it is evident that the training program seems to benefit children with juvenile rheumatoid arthritis but is may also be worth considering other forms of exercise as it may be more beneficial than weight bearing exercises. With this being said there is still evidence that this exercise intervention did improve the disease signs and symptoms after the program was undertaken, but also relays the fact that the total effect of the exercise was different for each subject.

Practical advice

This research suggests that children can benefit with the implementation of exercise to improve disease related symptoms.
Programs for individuals with juvenile rheumatoid arthritis need to focus on improving cardiovascular fitness and strength as well as increasing their joint mobility, whilst taking into consideration their fitness level and severity of disease. Safety considerations should be discussed such as the type of exercise with a GP or exercise physiologist before commencing an exercise program to ensure it appropriate and safe based on the individual.

Further readings

Websites for more information on juvenile chronic arthritis:
https://www.arthritis.org/about-arthritis/types/juvenile-arthritis/
https://www.arthritisact.org.au/?page_id=587
Further readings:
https://onlinelibrary.wiley.com/doi/pdf/10.1002/1529-0131%28200102%2945%3A1%3C81%3A%3AAID-ANR88%3E3.0.CO%3B2-I
https://onlinelibrary.wiley.com/doi/pdf/10.1002/art.11055