Exercise as it relates to Disease/Hydrotherapy and juvenile idiopathic arthritis

This is an analysis of the journal article 'Aquatic fitness training for children with juvenile idiopathic arthritis' by Takken, van der Net, Kuis and Helders, 2003 (1).

What is the background to this research?
Juvenile Idiopathic Arthritis (JIA) is a common, chronic childhood rheumatic disease that causes great impairments for those affected(2). Statistics show that in 2010, approximately 1 in every 500 Australian children had this disease, and approximately 50% of those cases will have continued into adulthood (3).This study focused on aquatic aerobic fitness training to improve functional ability, quality of life, joint status and physical fitness.

Where is the research from?
Research was carried out in the Netherlands and approved by the human ethical committees of the University Medical Center Utrecht, Wilhelmina Children's Hospital and the University Hospital Groningen, in the Netherlands.

What kind of research was this?
This research is a good example of qualitative research, in that a number of questionnaires were used to gather information from the enlisted participants and their parents. The study also used quantitative research, as performance tests and an assessment were components of gaining data. These methods of gaining data were appropriate to the participants, and were simple and cost effective to the researchers.

What did the research involve?
54 children were enlisted from rheumatology out-patient clinics from the University Medical Center Utrecht, Wilhelmina Children's Hospital and the University Hospital Groningen, the Netherlands, to participate in a 20 week aquatic training program. Patients were randomly assigned to an assessment-only group or a training group, which gives the study reliability. The training group received a one hour per week aquatic training program, delivered by a qualified physical therapist. The study was held over six months in heated pools across the Netherlands, and each participant received approximately 20 sessions. The sessions consisted of a warm-up, aerobic conditioning segments, rest breaks and a cool-down.

Prior to starting the training program, participants were taken through a number of questionnaires, performance tests, and a joint status assessment. The questionnaires were titled as follows:
 * Childhood Health Assessment Questionnaire - for parents
 * Juvenile Arthritis Quality of Life Questionnaire - for participants
 * Child Health Questionnaire - divided into physical and psychosocial health.

The performance tests were:
 * Juvenile Arthritis Functional Assessment Scale
 * Maximal exercise test
 * Sub-maximal 6-minute walking test

The joint status of the participants was assessed by looking at particular joints and checking how tender and swollen they were. Range of motion of the joints were examined using a goniometer and given a score out of 4.

They were re-examined in the middle of the study, and again once it finished. Parents of the participants were also given questionnaires to complete by proxy in the same time frames. Re-examination of the same participants using the same measures is a good example of a valid and reliable study.

What were the basic results?
Questionnaires given to the participants and their parents involved self-reporting. As there is a tendency for self reporting to be biased, results from questionnaires may be skewed. It would also be appropriate to take into account that the average age of participants was 8–9 years of age, and an element of misinterpretation could be possible regarding answering the questionnaires.

Prior to starting the study, no significant differences were found between the assessment only group or the training group. This shows a good baseline for evaluating the effects of the aquatic training program. After 20 weeks of following an aquatic training program, there was no significant improvement in functional ability, quality of life, or physical fitness for the participants in the training group. However, joint status was one thing that was assessed to have improved due to the training program. Participants with higher levels of impairment as recorded through questionnaires and assessments were shown to have a higher benefit of the program than those with lower levels of impairment. Participants in the training group overall improved more than participants in the assessment-only group.

What conclusions should be taken away from this research?
As this study found little effect of aquatic training in children with juvenile idiopathic arthritis, it would seem to be a useless study. Despite not having much effect, the exercise program was safe, as not one participant had a decline in health. Further research will be needed to determine exactly what is needed to see improvements in aquatic training for children with JIA.

What are the implications of this research?
Aquatic training did not have any negative affect on JIA, so perhaps a longer study would have shown improvements. Using more functional assessments rather than self reporting could give the authors more definite results from the training program.