ORADE Grant Recipient: Julie Herrington

Julie Herrington is an AHPA member who received a 2017 ORADE grant. Below is a summary of her learnings from the conference she attended.

I would like to thank the ORA for providing me with funding to attend the Pediatric Rheumatology Symposium (PRSYM) in May 2017 in Houston, TX.

Objectives:

  1. Learn! Find out what is current practice in overall pediatric care, but especially in the rehab and exercise world.
  2. Network! Connect with as many “rehab” professionals as possible.  Create a community of practice to discuss unique pediatric rehab cases.
  3. Enjoy! Exercise, encourage others to exercise and explore Houston.

 

LEARN…A sample of the topics…

  1. The examination of the current classification system of JIA  (by multiple presenters) – the disease is heterogeneous and this system is not as sophisticated as it needs to be – This needs to be a high priority to examine/reclassify in the future.
  2. The diversity of spondyloarthritis – early AS (adults) vs the concept of silent sacroilitis (which may be occurring in 20 -30% of pediatric cases) and to consider how to screen for this (Dr. Robert Colbert, NIAMS/NIH).  (1)
  3. The study of cohorts in the context of assisting with the delivery of prognosis (Dr. Jaime Guzman, BC Children’s Hospital) – Cohort studies have shown that with treatment compatible with the current ACR Recommendations, more than 70% of children attain inactive disease within 2 years of diagnosis, except if they have RF +ve polyarthritis (~50%).  They have also shown at 30 years post diagnosis (n=176), 59% attained remission (the highest being in Oligo at 80% and lowest being in RF+ve at 17%).  (2) To calculate severe disease prediction: https://shiny.rcg.sfu.ca/jia-sdcc/
  4. The concept of implementing T2T in pediatrics – a review of the success in adult rheumatology in theory, (however implementation has been slow) and the strong suggestion that “The way treatment is provided” may be one of the key factors to attaining better outcomes for patients (Dr. Esi Morgan, Cincinnati Children’s Hospital) (3)
  5. Current Lupus Practice –the focus was on the approach to treatment –improve the person’s “life course” through support and a positive outlook – this way of providing care should not be considered an extra, but a necessary piece of treatment (sometimes difficult to manage in a busy physician’s clinic) (Dr. Emily VonScheven, U of C, San Francisco) (4)

While all of this was fantastic to learn, I kept waiting for references to exercise.  Where was the slide on exercise when discussing “State of the Art” treatment for JIA? Where was the reference to exercise when discussing General Prevention tips in Lupus? Why wasn’t exercise listed in a Treatment Box when looking at best protocols for Juvenile Dermatomyositis?

Then… a talk on the second day, called EXERCISE by Dr. Kristin Houghton, (BC Children’s Hospital).  It was here I was able to meet my second objective, “NETWORK”, as like minded people showed up! This is what I learned:

What do we know about JIA and Exercise?

  • Many stop Physical Activity (PA) and sports at diagnosis
  • Less active than peers (more time resting, lower participation in organized sport)
  • Aerobic Capacity in JIA: 22% lower VO2 max than peers – not related to disease activity or severity, but may be to disease duration
  • Anaerobic Capacity in JIA : 65% lower than healthy controls – correlates with function, fatigue, pain and global well being
  • Muscle Health : muscle weakness, atrophy and poor control – not correlated to disease activity, but does relate to function (keep in mind, muscle bulk is not built until puberty.. strength gains primarily come from improved motor control)
  • Bone Health: low bone mass and low bone strength during the critical bone accumulation years – related to disease severity, prednisone use, subtype of JIA

Will Exercise prescription address these issues?

  • EXERCISE will not worsen the condition
  • The power of the research is low, due to numbers and overall poor adherence
  • Exercise will improve aerobic & anaerobic health, ms and bone health not as clear

What are the General Exercise Guidelines for Kids?

-60 min moderate/vigourous activity/day                 – 24 hr guideline from www.csep.ca

How to Assess?

Take the EXERCISE Vital Sign at every visit (this can also be done for adults too!!)

Caution: You are now being asked to examine your personal exercise habits…what you learn may be shocking!

  1. How many days per week do you engage in Moderate Exercise?
  2. On average, how many minutes do you continuously participate in this exercise?

Multiply the numbers and that is your EXERCISE Vital sign.  What is your Number?

Adults: Should be at 150 min/week or higher

Children (<18): 60 min/day or close to 420 min/week

What next?

Recommended for physicians to start to take the Exercise Vital Sign at appointments

WRITE “Exercise” as a prescription, so it is understood to be treatment http://exerciseismedicine.org

Promote increasing Frequency and Time before Intensity

If Disease is Active, Focus on Flexibility and Neuromuscular strength/balance

Future:

Multi center study Linking Exercise, Activity and Pathophysiology in Childhood Arthritis http://www.leapjia.com/   Stay tuned for more results from this project.

I was able to complete my third objective… ENJOY Houston – as well as find time to exercise!  What I particularly enjoyed was meeting up with like minded people in the beautiful gym, amazing pool and out on the streets walking.

My final objective would be to inform you that “The number to treat” (a new term for me) to influence someone to begin an exercise program is 12.  I would love to think that every 12th person who reads this, actually takes their own EXERCISE VITAL SIGN and considers making a change in their own life!

Julie Herrington , PT

References:

  1. Weiss, Pamela F; Xiao, Rui; Biko, David M; and Chauvin , Nancy A. Assessment of Sacroilitis at Diagnosis of Juvenile Spondyloarthritis by Radiography, Magnetic Resonance Imaging, and Clinical Imaging. AC & R 2016.
  2. Inactive disease and remission. Guzman et al. Ann Rheum Dis 2015;74:1854.
  3. Hinze, et al. Management of JIA: hitting the target. Nat Rev Rheumatol, 2015.
  4. Relationship between patient care and damage. Jinoos Yazdany, Arthritis Care & Research, 2016.

References for exercise section include:

  1. Thornton JS et al. Physical activity prescription: a critical opportunity to address a modifiable risk factor for the prevention and management of chronic disease: a position statement by the Canadian Academy of Sport and Exercise Medicine. British Journal of Sports Medicine. 2016 Sep 1;50(18):1109‐14.
  2. Lobelo F, Stoutenberg M, Hutber A. The exercise is medicine global health initiative: A 2014 update. British journal of sports medicine. 2014 Apr 23:bjsports‐2013.
  3. Houghton K. Physical activity, physical fitness, and exercise therapy in children with juvenile idiopathic arthritis. The Physician and sportsmedicine. 2012 Sep 1;40(3):77‐82.