Ibrahim et al. Bulletin of Faculty of Physical Therapy (2020) 25:6 Bulletin of Faculty https://doi.org/10.1186/s43161-020-00008-6 of Physical Therapy ORIGINAL RESEARCH ARTICLE Open Access Efficacy of physical activities on children with juvenile idiopathic arthritis: a randomized controlled trial Mohamed Bedier Ibrahim1, Mahmoud Labib2, Hamed Khozamy3 and Wanees Mohamed Badawy4* Abstract Background: Juvenile idiopathic arthritis (JIA) is one of the serious chronic rheumatic disorders in children and adolescents which results in less physical activities and restlessness hours than their peer. The study aims to assess the efficacy of physical fitness training exercises on aerobic capacity and muscular strength of children with JIA. Sixty-five children with JIA were included in the study, out of a total of 70 children who were screened for eligibility. Children were randomized to a control group (n = 32) who received hot packs, transcutaneous electrical nerve stimulation (TENS), and strengthening exercises, or a study group (n = 33) who received a physical fitness training program (hydrotherapy pool exercises, bicycle ergometer, and treadmill apparatus) in addition to what had been given to the control group. Both groups were engaged in a training program for 12 consecutive weeks for three times per week. Evaluation was done pre- and post-interventions included: peak oxygen uptake (Vo2 peak) during an incremental treadmill test and muscle strength assessed by isokinetic dynamometer. Results: The current study showed that there were significant differences between pre- and post-interventions in both groups (P < 0.05). Comparing the two groups, there were statistically significant differences between children in both groups in favor of the study group (P < 0.05). Conclusions: Physical fitness exercise training resulted in improved aerobic capacity and muscle strength of children with JIA. The obtained results suggested that children with arthritis could participate in formal exercise testing and structural physical fitness program. Trial registration: PACTR, PACTR201907504136763. Registered on May 21, 2019. Retrospectively registered, https:// pactr.samrc.ac.za/TrialDisplay.aspx?TrialID = 8150. Keywords: Juvenile idiopathic arthritis, Fitness testing, Peak oxygen consumption, Isokinetic testing Background joints. The course of JIA may become more intense and Juvenile idiopathic arthritis (JIA) is one of the common continues throughout adulthood increasing cardiovascu- childhood disorders that affects around one in 1000 chil- lar risk, osteoporosis, and obesity in this period of life- dren [1]. It is diagnosed early under the age of 16 with span [3, 4]. Physical deconditioning is seen in children arthritis in one or more joints and persists for at least 6 with JIA as a consequence of weak musculature, joint weeks [2]. The main clinical presentations are lack of pain, contracture, and lower peak oxygen uptake (Vo2 joint movement, pain, and swelling of the involved peak) [5, 6]. Abdul-Sattar et al. [7] conducted a study on Egyptian * Correspondence: [email protected] children and adolescent patients of JIA with age more 4Department of Physical Therapy for Neuromuscular Disorder and its Surgery, than 7 years and duration of disease exceeds 1 year to Faculty of Physical Therapy, Cairo University, 7 Ahmed Elzayad, Dokki, Giza explore the factors that may contribute to increase the 12613, Egypt Full list of author information is available at the end of the article rate of absenteeism and lack of functioning at school. © The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. Ibrahim et al. Bulletin of Faculty of Physical Therapy (2020) 25:6 Page 2 of 8 They found that these factors are the amount of inflam- 6) Children had visual or auditory defects. mation present, the level of functional disability, and psychological deconditioning. Instrumentation Physical therapy was instituted for patients with JIA to For evaluation promote lifetime physical activity through controlling pain and inflammation, maintaining range of motion 1- Weight and height scale: to calculate the body mass (ROM), and muscle strength that play important role in index were measured using an electronic scale increasing joint stability [8]. (Human body Element Analyzer System, Seoul, It was found that patients got more improvements in Korea) their functional abilities than those who live a standard life 2- Tape measurement to assess the degree of effusion care if they joined exercises in a form of aerobic condi- of the affected joints tioning, strengthening, and sport activities [9]. No previ- 3- Digital goniometer (model 12-1027, version 7-08, ous studies investigated the effect of a physical fitness Fabrication Enterprises, Inc., White Plains, NY, training program using validated measures on adolescents USA) to measure the ROM of the shoulder, elbow, suffering from JIA. Therefore, this study was conducted to wrist, hip, knee, and ankle joints assess the efficacy of physical activities on the aerobic cap- 4- Verbal rating scale for pain to assess pain intensity acity and muscle strength of children with JIA. [11] 5- Cardiopulmonary function test via Methods electrocardiograph (ECG) Nihon Kodhen Cardiofax Subjects Engospirometry with integrated stress—ECG Seventy children with JIA were recruited from a pediatric (Model: ISSOK, manufactured by Nihon-Kohden, outpatient clinic and assessed for their eligibility to partici- Japan). Engospirometry is the most comprehensive ’ pate in the study. All participants ages ranged from 8 to test of cardiopulmonary analysis. The peak oxygen 12 years. By using a number generating table, children uptake (Vo peak) was measured during instrumental n 2 were randomly allocated to a study or a control group ( treadmill exercise testing. The ECG was used first at = 35 in each group). Three children from the study group rest and during activity to record heart rate and and two from the control group did not continue the exer- blood pressure. cise program and withdrew from the study. All partici- 6- Isoforce isokinetic dynamometer (TUR GmbH, Berlin, pants were involved in a training program for 12 Germany): was used to assess the isokinetic muscular consecutive weeks for three times per week. The study ex- performance of the knee flexors and extensors tended from January 2019 to April 2019. The JIA children were enrolled according to the following: A- Inclusion criteria: For intervention 1) Medical diagnosis of JIA was conducted by a 1- Hydrotherapy pool, a large swimming pool at the pediatric rheumatologist in agreement of the outpatient clinic supplied with suspended chair and criteria of International League Against plinth, and sidebars. A single-use life jacket was Rheumatology [10]. utilized by each child to be safe in the pool. 2) Children were able to communicate verbally and 2- Bicycle ergometer (TUV/GS:En 957-5, Class A, obey commands and instructions and cooperate Taiwan). It is an electronically braked ergometer ’ with testing and training protocols. with a screen to check the child s heart rate and helps the therapist to control exercise intensity. TM B- Exclusion criteria: 3- Treadmill apparatus (Biodex Gait Trainer 2 ; Biodex Medical Systems, Inc., Shirley, NY, USA) 1) Children do not take drugs regularly and was used for fitness training. complained from severe pain according to verbal 4- Soft weight (exercise balls) and thera-band (elastic pain intensity scale [11]. band) were used to provide resistance. 2) Children had cardiac, pulmonary, or metabolic disease. 3) Children had active features of systemic arthritis. Interventions 4) Children had fixed deformity (bony or soft tissue Procedures for physical intervention for the control group contracture) of both upper and lower limbs. Moist heat Hot packs (40–45 °C) with suitable size to 5) Children had previous surgical interventions which contour the affected joint were applied for 20 min to im- may include soft tissues release, synovectomies, or prove the circulation and decrease the inflammation arthrodesis. [12]. Ibrahim et al. Bulletin of Faculty of Physical Therapy (2020) 25:6 Page 3 of 8 Transcutaneous electrical nerve stimulation (TENS) – The speed was settled on that of the habituation Gymna Uniphy (Pasweg 6A, 3740 Bilzen, Belgium) using session then continued at 60–100 rpm. a frequency of 100 Hz for 30 min on the affected joints – The child was asked to complete pedaling on the was applied in the most relaxed position for each child bicycle ergometer for 8 min in week 1, with the aiming to relieve pain [13]. duration increases by 2 min each week until week 6. Then at the weeks 6–12, the program lasted for 20 Strength exercises Strength training exercise involved min [17]. progressive upper and lower limbs in a form of static and dynamic exercises using exercise balls, soft weights, Treadmill training thera-bands, and elastic bands. Exercises concentrated – The goals of the exercise and the procedure were on the shoulder flexors, abductors, external rotators, made clear to the child before starting the treadmill elbow flexors and extensors, wrist flexors and extensors, training. hip flexors and extensors, abductors and adductors, knee – Any restricted clothes were removed to allow flexors and extensors, ankle dorsi and plantar flexors, walking without difficulty. The child was asked to abdominal muscles, and back muscles.