12/13/2016

1

The Evolving Role for

Physical Therapy for

Patients with Rheumatic

Diseases.

Amber Richards, PTJill Blitz, PT, DPT, ATP

Disclosures

• We have no relevant financial relationships with

the manufacturer(s) of any commercial product(s)

and/or provider(s) of commercial services

discussed in this CME.

• We do not intend to discuss an unapproved or

investigative use of a commercial product or

device in this presentation.

Key References

1. Prado DM; Benatti FB; de Sa-Pinto, AL, et al. Exercise training in childhood-onset systemic lupus erythematosus: a controlled randomized trial. Arthritis Res Ther. (2013) 15(2):R46

2. Poole J. Musculoskeletal rehabilitation in the person with scleroderma. Curr Opin Rheumatol 22:205-212 (2010)

3. Omari, C, et al. "Exercise Training in Juvenile Dermatomyositis." Arthritis Care & Research 64, no. 8 August 2012: 1186-1194.

4. Klepper, S. Exercise in Pediatric Rheumatic Diseases. Cur OpinRheumatol. 2008;20; 619-624

5. Schenck, S; Niewerth, M; Sengler, C; et al. Prevalence of overweight in children and adolescents with juvenile idiopathic arthritis. Scandinavian Journal of Rheumatology. 2015. 44:288-295.

Objectives

1. Identify the clinical presentation of the

diagnoses presented.

2. Recognize appropriate assessments and

interventions based on knowledge gained

from the clinical update.

3. Describe the evolving role of the PT from

interventionist to preventionist with these

diagnoses.

Systemic Lupus

Erythematosis

(SLE)

Lupus

• 10-20% have onset in childhood and adolescence

• More severe course

• Varying presentation

• Chronic multi-system inflammatory disease involving mostly skin, joints, kidneys, CNS, serous membranes and hematological system (Silva)

• Childhood onset presents < 18 years old

• Survival has increased due to earlier diagnosis and better approaches to treatment

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SLE Classification System Clinical Presentation

• Large variability in presentation

• Higher need to measure QOL due to outcome measures of health status, disease activity

• Mortality rates have decreased due to advances in management, but increase in long term co-morbidities

• Cardiovascular disease

• Long term corticosteroid use

• Systemic inflammation

• Autonomic dysfunction

• Hypertension

• Physical inactivity induces chronic fatigue, obesity and weakness/atrophy

Rashes of SLE

Photosensitive Rash Malar Rash

Assessment

• ROM

• MMT

• Cardiorespiratory exercise test

• Systemic Lupus Erythematosus Disease Activity Index (SLEDAI)

• Childhood Health Assessment Questionnaire (CHAQ)

• Pediatric Quality of Life Inventory Rheumatology module

• Simple Measure of the Impact of LE in Youngsters (Silva, 11)

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Scleroderma

Scleroderma

• Incidence of 0.3-2.8 cases per 100,000/year

(european countires)

• Most common between 30-50 yo

• Affects females (80%)

• Characterized by excessive collagen deposition

and vascular changes in different organs and

body systems

Clinical Presentation

• Insidious course, aggressive

• Repercussions on integumentary, musculoskeletal, GI,

kidneys and cardiopulmonary system

• 80% of cases have myositis, myopathy, calcification

and arthritis

• Involvement of vascular system causes insufficiency

• Hand deformities are the most observable and

common MS impairment

Clinical Presentations

Skin changes on the

faceLinear Scleroderma

Clinical Presentations

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Linear SclerodermaLinear Scleroderma

of the Face

Assessment

• ROM

• MMT

• Joint count

• Functional assessment

• QOL

Authors Pils et al Muguii et al Maddali, Bongi Seeger and

Furst

Subjects n=16 n= 42

(mean age

48.6)

n=40

(mean age

57.8)

n=19

(mean age 48)

Exercise

Intervention

• 12 paraffin wax

treatments

• Randomized into

no wax vs wax x

3 months

• Self

administered

stretching

• 3-10 reps x

10 seconds

each

• Connective

tissue

massage

• McMennell

joint

manipulation

• ROM HEP

• Dynamic

splints worn

8 hrs/day x

2 months

Outcome

Measures/

Results

• Improvement

shown in joint

motion and skin

stiffness

• significantly

improved

total passive

joint motion

in all fingers

• No change in

HAQ

• Significant

improvemen

t for fist

closure, joint

motion,

hand

function and

QOL

• ROM in PIP

joint did not

change

significantly

Discussion • Improvement

maintained >3

months in

intervention

group

• Improvement

in ROM

maintained

for 1 year

• ROM group

also

improved in

fist closure

• No

significant

change

Juvenile

Dermatomyositis

(JDM)

Juvenile Dermatomyositis

• Inflammatory disease of the

muscle (myositis), skin (derm)

and blood vessels

• Affects about 1.9-4.1 million

children each year

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Clinical Presentations

• Muscle weakness

• Limited range of motion (ROM)

• Difficulty with functional activities

• Decreased endurance

• Calcinosis

• Skin rashes

Calcinosis

Skin Rashes

Heliotrope Gottron’s PapulesAssessment

Physical Therapy Evaluation

• Range of Motion (ROM)

• Manual Muscle Test (MMT)

• Childhood Health Assessment Questionnaire

(CHAQ)

• 6 Minute Walk Test (6MWT)

• Childhood Myositis Assessment Scale (CMAS)

CMAS

Scoring Sheet

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CMAS Activities

1. Head lift

2. Leg raise/touch object

3. Straight leg lift/duration

4. Supine to prone

5. Sit-ups

6. Supine to sit

7. Arm raise/straighten

8. Arm raise/duration

9. Floor sit

10. All fours maneuver

11. Floor rise

12. Chair rise

13. Stool step

14. Pick up

Interpreting the CMAS

score.

Physical Disability CMAS score

Moderate 30 to 38

Mild to Moderate 39 to 44

Mild 45 to 47

None >48

(Huber 2004)

Interpreting the CMAS score

CMAS >48

CMAS 45-47

Mild to no ROM issues

CMAS 39 to 44

and/or decreased ROM

CMAS *12-38

CMAS <10

Things to consider with the

CMAS

• Healthy younger children ages 4 to 9 do not receive the full score (Rennebohm 2004, Quinoes 2013)

• Younger children may have a hard time following directions or cooperating

• Must perform on the right lower extremity (LE)

• May have a ceiling affect or may not be sensitive to slight weakness (Rider 2011)

Exercise and Treatment

Approaches

Author and Year Study Design LevelDisease

Stage

Age of

Patients (yrs)

Omori 2012 Quasiexperimental II

Active,

remission and

chronic

7 to 13

Takken 2008 Quasiexperimental IIActive vs

remission11.2 + 2.6

Hicks 2002 Quasiexperimental II

Remission to

moderately

active

11.2 + 3.0

Maillard 2005 Quasiexperimental II

Active,

remission,

controls

Age of onset 6

Rissager 2013 Quasiexperimental II Remission 16 to 42

Omori 2010 Case study VActive vs

control7

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Interventions

Exercise programs: 1 session up to12 weeks

Cycle ergometer (Hicks 2002, Riisager 2013, Takken 2008)

Open chain-concentric and eccentric LE (Maillard 2005)

SLR, sitting MAQ, sidelying hip add/abd, prone hamstring curls, back extensor, sit ups and heel raises (Maillard 2005)

Treadmill (Omari 2010)

Resistance training: bench-press, leg press, lat pull down, leg extension and seated row exercises (Omari 2010)

Stretches (Omari 2010)

Outcome Measures

OUTCOME MEASURETREATMENT

EFFECTAUTHORS

CMASImproved

No Change

Omori 2010

Riisanger 2013

VO2 Peak ImprovedTakken 2008, Omari 2010,

Riisanger 2013

Timed up and go/Stand Improved Omari 2010

Peds QL Improved Omari 2010

Disease Activity Score Improved Omari 2010

Blood Serum Levels

(CK and LDH)No Change Maillard 2005

Outcome Measures

OUTCOME

MEASURES

TREATMENT

EFFECTAUTHORS

Strength/MMTImproved

No Change

Omori 2010

Riisanger 2013

Bone Density Improved Omori 2010

Resting HR Improved Omori 2010

6MWT Improved Riisanger 2013

MRI muscle

inflammationNo Change Maillard 2005

Aerobic Conditioning Improved Omari 2010

Factors Limiting Exercise

Pain inflammation, calcinosis, change in muscle architecture

Weakness pathological changes to muscle tissue

Decreased V02 peak

• 30 to 40% decrease(Takken 2008)

Pulmonary issues chest muscle weakness

Calcinosis pain, skin ulcerations, nerve entrapment, joint contractures

Skin rash

Treatment GuidelinesACUTE REHAB OUTPATIENT

ROM

• AAROM

• PROM

• Splinting

• AROM • Stretching

Strengthenin

g

• Strength to

tolerance

• Isometric

• Light weights

• Light resistance

bands

• Core strengthening

• Isotonic

• Concentric/eccentric

• Weights

• Resistance bands

Endurance• Consult with

Respiratory

Therapist

• Stationary bike

• Treadmill

• Community distance for

ambulation

Functional

Activities

• Bed mobility • Transitions

• Ambulation

• Community based

activities

Wound Care • Yes • Yes • Yes

Juvenile Idiopathic

Arthritis (JIA)

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JIA Classification(Petty 2004) Clinical Presentations

• Joint swelling and stiffness

• Limited joint motion with morning stiffness

• Fatigue and limited endurance

• Muscle atrophy

• reduced isometric quad strength

• Secondary osteopenia related to long term oral steroid use

• Uveitis

Clinical Presentations Clinical Presentations

Assessment

Physical Therapy Evaluation

• Large focus on participation and activity restrictions

• Pain- VAS

• ROM/MMT

• Joint count and structure

• Gait and functional movement analysis

• Childhood Health Assessment Questionnaire (CHAQ)

• 6 minute walk (6MWT)

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CHAQ

Scoring Sheet

CHAQ

• Ages 1-19

• Assesses the health status and function in children with

JIA, JDMS, SLE, children with chronic musculoskeletal

pain, spina bifida

• Includes the International Classification of Functioning,

Disability and Health

• Body function

• Activities and participation

• Overall health status

CHAQ

Scoring: Disability Index (DI)

• 30 items in 8 domains

• Dressing and grooming

• Arising

• Eating

• Walking

• Hygiene

• Reach

• Grip

• Activities

Scored on a 4-point scale

• 0=without any difficulty

• 1=with some difficulty

• 2=with much difficulty

• 3= unable to do

Interpreting the CHAQ(Dempster 2001)

Physical Function CHAQ Score

Moderate 1.53

Mild to moderate 0.71

Mild disability 0.24

No disability 0

Things to consider with the

CHAQ

Takes about 10 minutes to complete

Easy to use in clinic or for research

There is a ceiling effect in children with mild disease (Klepper

2011)

There is another version that may reduce ceiling effect( Groen

2010)

CHAQ38CAT

Exercise and Treatment

Approaches

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Exercise and Treatment

Approaches (Klepper 2007)

1) Early referral to rehabilitation services

*baseline measurements

*recommendations for maintaining active lifestyle

2) Assessment of exercise capacity or performance

*reassess periodically during periods of active and

inactive disease

3) Identify goals that are important for child and parent

4) Provide information on importance of exercise

Authors Tarakci

(2012)

Singh-Grewal

(2008)

Apti

(2014)

Subjects • 81 children with JIA

ages 5-17 y/o

• 80 children with

JIA ages 8-16

y/o

• 47 children with

JIA 8-16 y/o

Exercise

Intervention

• 12 week land based

HEP (1x/wk at

hospital as well)

• Individually based

• Compared to

controls

• Moderate

intense aerobic

exercise vs.

qigong program

• 12 weeks, 1x

supervised, 2x

at home

• Aerobic walking

4x/week for 8

weeks

• Active and

passive ROM to

involved joints

• Compared to

controls

Outcome

Measures/Results

• Improvement shown

in 6MWT, CHAQ,

pain, PedsQL

• VO2 max and

peak power

showed no

changed

• improved CHAQ

• Improved

exercise

parameters

• Improved

CHAQ

• Improved ROM

Discussion • Home based,

supervised program

proved beneficial

• Qigong group

more compliant

• No exacerbation

of disease

• ROM and

aerobic

exercise proved

beneficial

Staging Exercise(table adapted from Klepper 2008)

(adapted from Klepper

2008)

Acute Disease Subacute and

Chronic

Inactive and

Remission

ROM and Flexibility

AROM or AAROM

• 1-2 reps

• 1-2x/day

AROM

• 1-2 reps 1x/day

• Active flexibility

exercises

• Modified Yoga

poses

AROM

• 1-2 reps 1x/day

• Active stretching

• Modified yoga

Aerobic activity

• Balance rest with

low intensity PA

• Reduce load on

inflamed joints

-aquatic

-bike

• Increased WB PA

• Walking, low

impact aerobic

dance activities,

swimming ,water

aerobics

• Accumulate 60

min/day of

moderate to

vigorous PA

• Aerobic dance,

swimming, etc..

Neuromuscular Training

• Strength

• Endurance

• Power

• Neuromuscular control

-proprioception

-postural control

-coordination

- agility

-speed

• Submaximal

isometric-pain

free ROM

*1 set of 1-6 reps

* ramp up for 2sec,

hold for 6secs, ramp

down for

2s/repetitions

*20sec rest between

reps

• Dynamic

exercises

• -8-10 reps against

gravity (no pain

and good form)

• Use light weights

• Increase muscle

endurance by

adding 15-20 reps

• Resistance

exercise

• Determine

starting weight

based on 6-10

reps

• Closed chain

activities for bone

health and

proprioception

• Coordination,

speed and agility

Orthotics

Common foot issues with JIA( Hendry 2012)

• Synovisitis

• Tenosynovitis

• Enthesitis

• Pain

• Stiffness

• Deformity

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Splinting for ROM

Knee Extension

SplintWrist Cock-up Splint

NoYes

Does the child have the physical attributes for safe and successful

participation? Yes No

Considerations for Sports and

Physical Activity (Rice 2008)

• Systemic or polyarticular JIA who have a history of C-spine involvement

• require x-ray of C1 and C2

• Systemic or HLA-B27 associated arthritis

• require cardiovascular assessment

• Micrognathia (open bite and exposed teeth)

• require mouth guards

• Uveitis

• ophthalmologic assessment recommended

Considerations for Sports

and Physical Activity Static and Dynamic Postural Balance (Houghton 2013)

• Decreased single limb balance

• Mild impairments in double limb balance

Kinematics and Kinetics of Lower Extremities (Hartmann 2010)

• Decreased walking speed and step length

• Differences in kinematic, kinetic and spatio-temporal patterns

Land-Jump Performance (Ford 2009)

• Differences compared to controls with drop vertical jump maneuver

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The Evolving Role of

PT in the Biologic Era

Biologics-

What are they?

• First introduced in 1999 to treat children

• They change how your immune system works by stopping the chain that causes inflammation at different stages

• Why the term “biologic”?

-because they are genetically engineered as opposed to chemically engineered

Effectiveness of Biologics

Assessed (Sawhney 2010)

1. Physician global assessment of disease activity

2. Parent/patient assessment of overall wellbeing

3. Functional ability

4. Number of joints with active arthritis

5. Number of joints with limited ROM

6. Erythrocyte sedimentation rate

How Has The Presentation Changed

• Decreased active joint count (Boiu 2012, Shepherd 2016)

• Improved physician global assessment (Boiu 2012 , Shepherd 2016)

• More cases of inactive disease (Boiu 2012, Shepherd 2016)

• Improved functional ability (Boiu 2012, Ungar 2013, Klotsche 2014, Callhoff 2013)

• Improved quality of life (Lovell 2015)

• Decreased pain ( Shepherd 2016, Klotsche 2014)

Biologic Effectiveness Clinical

Presentations

Reference

Etanercept 80% ACR Pedi 30

72% ACR Pedi 50

44% ACR Pedi 70

Improved CHAQ

Improved Joint ROM

Less morning

stiffness

Decreased pain

Woo (2007)

Shepherd

(2016)

Adalimumab 30-63% ACR Pedi 30

63-74% ACR Pedi 50

52-63% ACR Pedi 70

42% ACR Pedi 90

Woo (2007)

Shepherd

(2016)

Abataceot 84.5% ACR Pedi 30

79.3% ACR Pedi 50

55.2% ACR Pedi 70

41.4% ACR Pedi 90

31% inactive disease

Improved

CHAQ/QAL

Decreased pain

Improved

participation

Lovell (2015)

Tocilizumab 89.9% ACR Pedi 30

82.3% ACR Pedi 50

48.4% ACR Pedi 70

Fan (2016)

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Survey Methods

• 3 listservs• APTA pediatric section listerv

• Rehab directors listserv

• Pediatric Rheumatology bulletin board list serve

• Contacted pediatric hospitals and other pediatric therapists directly

• >40 hospitals

• 2 clinics

• 85 therapists (100% answered all questions)

Institutions Who Participated

Alberta Children's

Hospital (2)

Shriners Hospital for

Children Chicago (2)

McLane Children's

Hospital (1)

Legacy Salmon Creek

Hospital (2)

Health Sciences Centre

Winnipeg - Child Health

(2)

Children's Hospitals and

Clinics of Minnesota (2)

Children's National

Medical Center (2)

Sydney Children’s

Hospital Randwick

Australia (1)

All Children's Hospital (1)

Children’s Hospital

Charite (1)

The Hospital for Sick

Children (2)

Children's of Alabama (1)

Children's Hospital of

Philadelphia (2)

Primary Children's

Hospital (2)

Le Bonheur Children's

Hospital (1)

Mattel Children’s

Hospital, UCLA (1)

Mary Pack Arthritis

Service (1)

The Children's Institute of

Pittsburgh (5)

Cincinnati Children's

Hospital (1)

Duke Children's

Hospital (1)

Children's Hospital of

Michigan (1)

Medical University of

South Carolina (4)

Hackensack University

Medical Center (1)

Vanderbilt Children's

Hospital (1)

Johns Hopkins All

Children's Hospital (5)

National Institutes of

Health (1)

Gillette Children's

Specialty Healthcare (1)

Montreal Children's

Hospital (2)

Glenrose Rehabilitation

Hospital (2)

Connecticut Children's

Medical Center (4)

The Children's Hospital

at Westmead (1)

Children’s Hospital Los

Angeles(1)

University Hospitals of

Cleveland (1)

Riley Hospital for

Children (1)

“Other”

Hospitals (7)

California Children’s

Services (16)

Regional Distribution

15%

4% 2%

46%

9%

13%

9%

2%

Canada

Australia

Germany

Northeastern US

Western US

Southwestern US

Midwestern US

Southeastern US

Are you a PT or OT?

58

27

0 10 20 30 40 50 60 70

Physical Therapist

Occupational Therapist

How many years have you been a

pediatric PT or OT?

0 10 20 30 40 50 60

< 1 year

1-2 years

3-5 years

6-10 years

>10 years

< 1 year

1-2 years

3-5 years

6-10 years

>10 years

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0 10 20 30 40

PT

OT

PT and OT

Neither

We do not have a Rheum Clinic

Do you have PT and/or OT in the

rheumatology clinic at your institution?

0 5 10 15 20 25 30

never

1-2 per year

1-2 per month

1-2 per week

> 2 per week

other

How frequently do you see pediatric

patients with rheumatic diseases?

0

5

10

15

20

25

30

Always

Frequently

Sometimes

Rarely

Never

Always/frequentl

Sometimes

Sometimes/rarel

Sometimes/rarel

y

Sometimes

Never

Which types of pediatric diagnoses do

you treat?When you get a referral or

evaluation, what do recommend?

01020304050607080

active PTand/or OT

communityactivities

homeexerciseprogram

other

most frequent

more

less

least frequent

What do your treatment

sessions include?

Stretching20%

Active ROM21%

Strengthening21%

Building endurance

19%

Casting3%

Splinting9%

Other7%

How has your practice

changed in the biologic era?

0 10 20 30 40 50

No changes

Decrease need for PT/OT

Increase need for PT/OT

I see fewer patients with rheumdiagnoses

The focus of treatment haschanged

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How has the focus changed?

0 2 4 6 8 10 12

less splinting/casting

monitor

participation in community activities

shorter episodes of care

less need for assistive devices

assessment of medications

Key Points

• Evolving role for PT and OT

• Decreased casting/splinting- (ie seeing less

contractures)

Patients With JIA Are Still

Less Active Than Their

Peers

Authors Bohr, et al

(2015)

Bos et al

(2016)

Gueddari, et

(2014)

Subjects *133 pts - 7-20 y/o

*Moderate to severe

JIA

*Denmark

*76 pts- 8-13 y/o

*JIA

* 50 pts - 8-17

years

Outcome

Measures

accelerometer,

JADAS, global

disease activity,

CHAQ, pain

Joint counts,

disease activity,

CHAQ, pain,

activity diary

Activity diary, MET,

CHAQ, JADAS

Results activity

level of activity

PAL

MVPA

sedentary

MET

MVPA

sedentary

Discussion *active disease not a

factor in PA

*Did no meet PA

requirements

*4% meet PA

requirements

*higher CHAQ

less PA

*active disease or

functional ability not

a factor in PA

Patients with JIA spend

More Time Participating

in Sedentary Leisure

Activities

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Why are they less active??

• Severe fatigue among adolescents (Nijhof 2016)

• Can pain still be an issue? (Limenis 2014)

• Decreased aerobic capacity (Takken 2002)

• Proprioception and balance issues (Houghton 2013)

• Expectations of the parents or fears of patients (Akikusa 2002)

• Impaired motor performance in preschool aged (van der Net

2008)

• Is there something we are missing?

Gross Motor Proficiency

Factors Associated With Physical Activity in

Older Children with Juvenile Idiopathic Arthritis

(Horonjeff 2015)

Exercise is Good For JIA

• Exercise is safe and does not exacerbate disease (Epps 2005, Sing-

Grewal 2007)

• Improves BMD (Sandstedt 2012)

• Improves quality of life (Mendonca 2013, Tarakci 2012, Apti 2014)

• Decrease disability in adulthood (Long 2010)

• WB exercises can help combat musculoskeletal changes (Long

2010)

• Socialize and interact with peers (Murphy 2008)

• Improved aerobic capacity (Apti 2014)

• Improved ROM (Apti 2014)

Therapists acting as

“Preventionists”

American Physical Therapy

AssociationPractice statement (2015)

The American Physical Therapy Association advocates for prevention, wellness, fitness, health promotion and management of disease and disability

• Appropriate physical activity and exercise goals and objectives put forth by government and other nationally recognized agencies and organizations

• Consumer recognition of the value of the physical therapist to provide services for

prevention, wellness, fitness and health promotion, and for the management of disease and disability for all populations and conditions

• Physical education, physical conditioning and wellness instruction at all levels of education, from preschool to higher education

• Physical therapists making healthy personal lifestyle choices that include meeting national guidelines for participation in physical activity and exercise

Intervention vs Prevention

Education is key

Limited by medical model

Both are still important

Intervention

Agree in the prevention model

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Survey results

How do we implement

this?

Physical Activity Promoting

Approaches (Bezner 2015)

• Educate patients about the health benefits of

exercise

• Make clients aware of the current

recommendations

• Explore perceived barriers

• Promote self efficacy

• Encourage goals setting

What didn’t work

Impact of a Pediatric Rheumatology Wellness

Education Program to Improve Fitness and

Activity Levels

What did work

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New Directions

• Community activities

• Sports participation (Taxter 2012)

• Preparing appropriately for sports

• Encouraging physical activity (accountability?)

• Go for 100%

• Movement

• Strength

• Function

• Participation

Audience Participation

What are your thoughts on the “preventionists”

role?

Should this be our part of our practice?

What has been your experience?

Contact Information

Amber Richards

arichards@chla.usc.edu

Jill Blitz

jblitz@chla.usc.edu

References

SLE and Scleroderma1. Prado DM, Gualano B, Pinto AL, et al. Exercise in a child with systemic lupus erythematosus and

antiphospholipid syndrome. Med Sci Sports Exer. (2011); 43(12) 2221-2223

2. Prado DM; Benatti FB; de Sa-Pinto, AL, et al. Exercise training in childhood-onset systemic lupus erythematosus: a controlled randomized trial. Arthritis Res Ther. (2013) 15(2):R46

3. Ruperto N et al. Health related quality of life in juvenile-onset systemic lupus erythematosus and its relationship to disease activity and damage. Arthritis and Rheumatism Vol 51. No 3 June 15, 2004. pp 458-464

4. Silva C, Aikawa N et al. Management considerations for childhood onset systemic lupus erythematosus patients and implications on therapy. Expert Review of Clinical Immunology, 201512:3, 301-313

5. Mancuso T, Poole J. The effect on paraffin and exercise on hand function in persons with scleroderma: a series of single case studies. J Hand Therapy (2009); 22:71-78

6. Poole J. Musculoskeletal rehabilitation in the person with scleroderma. Curr Opin Rheumatol 22:205-212 (2010)

.

References

JDM7. Bohan, A, and JB Peter. "Polymyositis and dermatomyositis." New England Journal of Medicine, 1975: 344-347.

8. Carstens, PO, and J Schmidt. "Diagnosis, pathogenisis and treatment of myositis: recent advances." Clinical & Experimental Immunology 175 2013: 349-358.

9. Hickes, J, B Drinkard, R Summers, and L Rider. "Decreased Aerobic Capacity in Children With Juvenile Dermatomyositis." Arthritis & Rheumatism 47, no. 2 April 2002: 118-123.

10. Huber, A, et al. "Validation and Clinical Significance of the Childhood MyosistisAssessment Scale for the Assessment of Muscle Function in the Juvenile Idiopathic Inflammatory Myopathies." Arthritis & Rheumatism 50, no. 5 May 2004: 1595-1603.

11. Maillard, S, et al. "Quantitative Assessments of the Effects of a single exercise Session on Muscles in Juvenile Dermatomyositis." Arthritis & Rheumatism 53, no. 4 August 2005: 558-564.

12. Omari, C, et al. "Exercise Training in Juvenile Dermatomyositis." Arthritis Care & Research 64, no. 8 August 2012: 1186-1194.

References

JDM13. Omari, C, et al. "Responsiveness to exercise training in juvenile dermatomyositis: a

twin case study." BMC Musculoskeletal Disorders 11, no. 270 2010.

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