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Regular aerobic training combined with range of motion exercises in juvenile idiopathic arthritis.
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PMID:  24579086     Owner:  NLM     Status:  In-Data-Review    
Abstract/OtherAbstract:
Objective. To assess the effects of regular aerobic training combined with range of motion (ROM) exercises on aerobic capacity, quality of life, and function in children with juvenile idiopathic arthritis (JIA). Methods. Thirty patients with JIA and 20 healthy age-matched controls (mean age ± SD, 11.3 ± 2.4 versus 11.0 ± 2.3, resp.; P > 0.05) were included. All patients performed aerobic walking (4 days a week for 8 weeks) and active and passive ROM exercises of involved joints. All patients completed the childhood health assessment questionnaire (CHAQ) and the child health questionnaire. ROM measurements of joints were performed by using universal goniometer. Aerobic capacity was determined by measuring peak oxygen uptake (VO2peak) during an incremental treadmill test. Results. Peak oxygen uptake and exercise duration were significantly lower in JIA group than in controls (32.5 ± 6.6 versus 35.9 ± 5.8 and 13.9 ± 1.9 versus 15.0 ± 2.0, resp.; P < 0.05 for both). Eight-week combined exercise program significantly improved exercise parameters of JIA patients (baseline versus postexercise VO2peak and exercise duration, 32.5 ± 6.6 to 35.3 ± 7.9 and 13.9 ± 1.9 to 16.3 ± 2.2, resp.; P < 0.001 for both). Exercise intervention significantly improved CHAQ scores in JIA patients (0.77 ± 0.61 to 0.20 ± 0.28, P < 0.001). Conclusion. We suggest that regular aerobic exercise combined with ROM exercises may be an important part of treatment in patients with JIA.
Authors:
Mine Doğru Apti; Ozgür Kasapçopur; Murat Mengi; Gülnur Oztürk; Gökhan Metin
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Publication Detail:
Type:  Journal Article     Date:  2014-01-22
Journal Detail:
Title:  BioMed research international     Volume:  2014     ISSN:  2314-6141     ISO Abbreviation:  Biomed Res Int     Publication Date:  2014  
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Created Date:  2014-02-28     Completed Date:  -     Revised Date:  -    
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Nlm Unique ID:  101600173     Medline TA:  Biomed Res Int     Country:  United States    
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Languages:  eng     Pagination:  748972     Citation Subset:  IM    
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Journal Information
Journal ID (nlm-ta): Biomed Res Int
Journal ID (iso-abbrev): Biomed Res Int
Journal ID (publisher-id): BMRI
ISSN: 2314-6133
ISSN: 2314-6141
Publisher: Hindawi Publishing Corporation
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Copyright © 2014 Mine Doğru Apti et al.
open-access:
Received Day: 17 Month: 4 Year: 2013
Revision Received Day: 13 Month: 11 Year: 2013
Accepted Day: 18 Month: 11 Year: 2013
Print publication date: Year: 2014
Electronic publication date: Day: 22 Month: 1 Year: 2014
Volume: 2014E-location ID: 748972
PubMed Id: 24579086
ID: 3919112
DOI: 10.1155/2014/748972

Regular Aerobic Training Combined with Range of Motion Exercises in Juvenile Idiopathic Arthritis
Mine Doğru Apti1
Özgür Kasapçopur2
Murat Mengi3
Gülnur Öztürk4
Gökhan Metin1*
1Department of Sports Medicine, Istanbul Faculty of Medicine, Istanbul University, 34093 Istanbul, Turkey
2Department of Pediatric Rheumatology, Cerrahpasa Faculty of Medicine, Istanbul University, 34098 Istanbul, Turkey
3Department of Physiology, Cerrahpasa Faculty of Medicine, Istanbul University, 34098 Istanbul, Turkey
4Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Trakya University, 22030 Edirne, Turkey
Correspondence: *Gökhan Metin: gmetin1@gmail.com
[other] Academic Editor: Roya Kelishadi

1. Introduction

Juvenile idiopathic arthritis (JIA) usually occurs before 16 years of age and mainly affects peripheral joints leading to pathological changes [1, 2]. Therefore, the importance of starting and maintaining therapeutic exercises in early periods in order to improve range of motion (ROM) in arthritic joints is constantly stressed [35]. However, daily activity level and cardiopulmonary capacity of patients with JIA are significantly lower when compared to healthy peers [610]. Interestingly, lower physical capacity in children with JIA was shown to be unrelated to disease status whether active or in remission [8]. Besides reduced cardiopulmonary capacity, forced adjourning physical functions during active disease state are an important factor among the reasons of inactivity. In addition, lack of adequate knowledge on the benefits of exercise and considering exercise as harmful to joints result in self-limitation even during remission period [11, 12]. Furthermore, it was suggested that fear and social isolation seen in chronic diseases might lead to inactivity in JIA patients [13].

There are conflicting results from recent studies that investigated the effects of exercise programs on cardiopulmonary capacity in this group of patients. Some studies reported beneficial effects of exercise on joint ROMs and cardiopulmonary and functional capacities [1417], whereas, at a lesser extent, several studies reported opposite results [18, 19]; thus there is no consensus on this subject. Previous studies also differ in terms of duration, frequency, and content of exercise programs applied to patients with JIA [14, 1621]. In this study, we aimed to determine aerobic capacities of children with JIA by using exercise tests. And also we aimed to investigate the effects of regular aerobic training combined with active and passive exercises addressing functional impairment resulting both systemic effects of the disease and joint involvement.


2. Methods
2.1. Subjects

Forty-seven JIA patients (M/F, 18/29; age range, 8–16 years) were included in the study. Twenty healthy children (M/F, 9/11; age range, 9–13 yr) served as controls. Prior to testing, parents of subjects read and signed a consent form that was approved by the University's Policy and Review Committee on Human Research. Controls had a sedentary lifestyle and did not participate in any regular sportive activities. Patients were diagnosed by a pediatric rheumatologist (ÖK) according to the criteria of International League Against Rheumatology [22]. Patient group consisted of systemic (n = 2), polyarticular (n = 24), oligoarticular (n = 16), enthesitis related arthritis (n = 1), and psoriatic (n = 4) types of JIA. The Turkish version of childhood health assessment questionnaire (CHAQ) and the child health questionnaire [23] were completed by the parents or the guards of children after giving information and answering the questions raised by parents. Fourteen patients declined to undergo exercise program and withdrew from the study, 2 patients were lost to follow-up, and 1 patient was dropped due to hospitalization for other reasons. At the end, 30 patients completed the whole study protocol and were included in final statistical analyses.

2.2. Anthropometry and ROM Measurements

Body mass was measured on a balance beam medical scale (Fairbanks) to the nearest 0.1 kg. Stature was measured on a stadiometer (Holtain, UK) to an accuracy of ±0.5 cm with the subject barefoot, feet together, and head level. ROM values in shoulder, elbow, wrist, hip, knee, and ankle joints were measured; triple and average results were recorded. For normal ROM values of joints, Kendall-McCreary norms were used [24].

2.3. Experimental Protocol

The peak oxygen uptakes (VO2peak) of all subjects were measured during incremental exercise testing. Each child first underwent a comprehensive physical examination which included a 12-lead electrocardiogram (ECG) recording and blood pressure measurement at rest. Prior to exercise tests, all participants underwent pulmonary function tests (Ocean Win Spiro 2.36 B software with Spirobank; Medical International Research, Italy). All tests were performed in an air-conditioned laboratory room at 20–22°C and 40% relative humidity of air, to minimize thermal stress. Subjects had a light breakfast 2 hours before exercise and abstained from strenuous exercise for a week prior to test protocol.

2.4. Cardiopulmonary Exercise Testing (CPET)

All the subjects exercised on a motorized treadmill ergometer. A modified Bruce exercise protocol [25] was used with an additional stage 0 (3 min; speed, 1.7 mph; 5% gradient). The treadmill protocol is a commonly used exercise test to assess exercise capacity and the electrocardiographic response to exercise stress in children and adults. The test protocol is suitable for stressing healthy subjects and patients [26, 27]. Each test was terminated by subject fatigue or maximal exercise level. It was considered maximal level if the subject achieved two of the three following test criteria: (1) the plateau of oxygen uptake with increasing work load, (2) a respiratory exchange ratio (RER) of 1.00 or higher, and (3) heart rate reaching 85% of age-predicted maximal heart rate (Max HR). This parameter was calculated by subtracting subject's age from 220 (Max HR = 220 − age). During exercise test, a full 10-electrode, 12-lead ECG was monitored. In all cases, a Quinton 5000 recorder and lead system (Quinton Instrument Company, Seattle, USA) were utilized to monitor and record ECG. Heart rate was monitored from ECG. Blood pressure was measured every three minutes using cuff manometer for children (ERKA, Germany).

2.5. Direct Measurements of Peak Oxygen Uptake

Ventilation (VE), oxygen uptake (VO2), and carbon dioxide production (VCO2) were monitored continuously, breath-by-breath, at rest, during exercise, and for 3 minutes of recovery after exercise, using a CPET system (Cortex MetaLyzer 3B, Cortex Biophysik GmbH, Leipzig, Germany). The system was calibrated before each test with standard gases of known O2 and CO2 concentrations. The most elevated VO2 measured over 30 seconds during the last period of the exercise was considered as the VO2peak. RER was calculated as VCO2/VO2.

2.6. Exercise Training Program

Patients performed aerobic type walking (4 days a week) and active and passive ROM exercises (10–15 repeat/set, 2 sets/day, 7 days/week) in combination for 8 weeks. Program was started under supervision of specialists (MDA, MM) with 30 minutes walking during the first 2 weeks. Then, the exercise duration was incremented 5 minutes for each week. Exercise intensity adjustment was based on anaerobic threshold (AT) determined by CPET for each patient. Before and after aerobic exercise, stretching exercises were performed for warming up and cooling down.

2.7. Statistical Analysis

In all comparisons P values < 0.05 were considered statistically significant. Physical characteristics and CPET results of JIA and control groups were compared using “independent samples t-test” (Table 1). Changes in CHAQ scores and CPET results (Table 2), as well as goniometric measurements (Table 3) before and after exercise program were compared by using the paired samples t-test.


3. Results

JIA and control groups were age matched. However, there were significant differences in the mean weight and height values between the two groups (Table 1). In comparison of cardiopulmonary exercise test results, there were statistically significant differences in VO2peak, VEpeak, RER, maximal heart rate, % predicted heart rate, exercise duration, and VO2AT between the patient and control groups (Table 1). To determine the effects of exercise program, we compared exercise parameters before and after completion of exercise program. There were significant differences in VO2peak, VEpeak, RER, maximal heart rate, % predicted heart rate, % predicted VO2, exercise duration, AT VO2, resting heart rate, and resting SBP (Table 2).

Comparison of ROM values before and after exercise program showed that shoulder abduction and flexion, wrist flexion and extension, elbow flexion, hip flexion, knee flexion and extension, and ankle plantar flexion and dorsiflexion were significantly changed in both extremities (Table 3).


4. Discussion

Juvenile idiopathic arthritis patients were consistently found to have lower cardiopulmonary exercise capacity compared to healthy peers. In a meta-analysis of 144 patients from 16 different studies, the mean VO2peak was found to be 21.8% lower in JIA patients than in healthy controls [6]. Metin et al. [8], reported significant reductions of VO2peak and %predicted VO2 in 34 patients with JIA with respect to controls. Similarly, van Brussel et al. [9] showed that the mean VO2peak values of 62 JIA patients were significantly lower than control subjects. In addition, Lelieveld et al. [7] found lower cardiopulmonary capacities in JIA patients when compared to healthy peers.

In our study (Table 1), exercise duration of JIA group, VO2peak, VO2AT, VEpeak, RER, Max HR, and % predicted HR values were significantly lower compared to healthy controls. Therefore, our results were in accordance with the previous data mentioned in the former paragraph [69].

As known, in polyarticular juvenile idiopathic arthritis (PJIA) five or more joints are affected within the first 6 months of disease occurrence. Thus, joint destruction, ankylosis, and ROM limitation in PJIA patients start earlier with respect to oligoarticular juvenile idiopathic arthritis (OJIA) and progress during the course of disease [1, 28]. In several studies, age of disease onset and number of affected joints were reported as the most important factors playing role in development of functional limitation in the long term [2931].

In a study of healthy children, physical activity and peak VO2 showed poor correlation [32]. In addition, healthy children may exert a small improvement in peak VO2 by increasing physical activity (ceiling effect) [33, 34]. However, Takken et al. [35], demonstrated significant correlation between the daily physical activity and peak VO2 in patients with JIA which was different from healthy children. These authors suggested that children with low physical capacity due to chronic disease may not be limited by the ceiling effect and increasing physical activity may contribute to development of peak VO2 [35].

In our study, examination of cardiopulmonary exercise tests of the group having exercise program showed significant differences in metabolic parameters after the program with respect to basal values. These changes were significant in % predicted VO2 (P < 0.05), moderately significant in VO2peak, RER, VO2AT, resting heart rate, and resting systolic blood pressure (P < 0.01) and highly significant in VEpeak, Max HR, % predicted HR, and exercise duration (P < 0.001) (Table 2).

Recently, the first randomized, controlled trial of Takken et al. [18] reported that, following an exercise program CHAQ score, VO2peak and distance of a six-minute walk test were similar between exercise and control groups. Singh-Grewal et al. [19] reported similar significant improvements in CHAQ scores of high intensity (dance, cardio, and karate) and low intensity (Qi-Gong-Tai Chi, etc.) exercise groups, whereas VO2peak showed no change. Similarly, Epps et al. [20] reported significant improvements in CHAQ scores and % predicted HR values of combined (water and land exercise) or land exercise program groups. Exercise duration showed no difference. Recently, our group showed that a land-based home exercise program improved both physical function and quality of life in patients with JIA [36]. Besides physical disability, psychological alterations or psychiatric conditions such as depression may occur during the course of this condition [37]. This may also affect the quality of life.

In our study, exercise group showed significant improvement in CHAQ scores (Table 2) which is in parallel with previous studies [19, 20]. On the other hand, JIA patients who underwent an exercise program showed improvements in VO2peak and exercise duration and these results are not in accordance with the above-mentioned three studies [1820]. In another study conducted via the Internet, patients were encouraged to exercise and their exercise duration was significantly increased [15]. Furthermore, Moncur et al. [16], reported significant increases in VO2peak and exercise duration after a regular exercise program. Klepper [14] reported significant increase in the distance taken in a 9-minute walk test after a planned exercise program.

Although frequency and intensity may differ in different subgroups, it has been well known that JIA patients may show ROM limitations due to joint destruction, synovial effusion, and muscle spasm. Besides, studies reporting the effects of exercise programs addressing ROM limitations are very limited, although these exercises are used widely in management of JIA patients. Bacon et al. [17] reported increased hip mobility of children with JIA after water exercises. Epps et al. [20] reported decrease in number of limited joints but the difference failed to reach statistically significance level. Similarly, Takken et al. [18] found that joint ROM values did not differ before and after an exercise program. Exercise programs of those three studies [17, 18, 20] and our exercise program were different. Previous researchers used exercise programs addressing cardiopulmonary capacity rather than joint mobility. They did not include therapeutic programs addressing affected joints.

There are several limitations to this study that deserve comment. A control group from JIA patients without exercise intervention could improve the validity of our results. On the other hand, we felt that it might be ethically problematic not to apply exercise program, although we knew that it was useful.

We combined ROM exercises and aerobic program which significantly improved shoulder abduction and flexion of both extremity, wrist flexion and extension, elbow flexion, hip flexion, knee flexion and extension, and plantar flexion and dorsiflexion in JIA patients (Table 3). In addition, we also found elbow extension and hip external rotation on the right side, and hip internal rotation on the left side reached physiological limits. Cardiopulmonary capacity in our JIA group was lower than healthy peers. With the aid of exercise program, their cardiopulmonary capacity was also increased (Table 2). In addition, changes in CHAQ scores and ROM levels suggest that exercise programs also affect joint involvement and functional status (Tables 2 and 3).


5. Conclusion

We suggest that combination of ROM exercise and regular aerobic exercise in JIA treatment may offer important benefits and should be prescribed as an additional module. Physicians should discuss with and give adequate information to family members of JIA patients. Patient's interest, cardiopulmonary capacity, and joint involvement should also be considered.


Conflict of Interests

The authors declares that there is no conflict of interests regarding the publication of this paper.


References
1. Cassidy JT,Petty RE,Laxer RM,Lindsley CBTextbook of Pediatric RheumatologyYear: 20116th editionPhiladelphia, Pa, USAElsevier Saunders Company
2. Sarma PK,Misra R,Aggarwal A. Physical disability, articular, and extra-articular damage in patients with juvenile idiopathic arthritisClinical RheumatologyYear: 20082710126112652-s2.0-5154912098618500441
3. Cakmak A,Bolukbas N. Juvenile rheumatoid arthritis: physical therapy and rehabilitationSouthern Medical JournalYear: 20059822122162-s2.0-1404426948315759952
4. Klepper S. Making the case for exercise in children with juvenile idiopathic arthritis: what we know and where we go from hereArthritis Care and ResearchYear: 20075768878902-s2.0-3454778865317665461
5. Feldman DE,de Civita M,Dobkin PL,Malleson PN,Meshefedjian G,Duffy CM. Effects of adherence to treatment on short-term outcomes in children with juvenile idiopathic arthritisArthritis Care and ResearchYear: 20075769059122-s2.0-3454782186017665485
6. Takken T,Hemel A,van der Net J,Helders PJM. Aerobic fitness in children with juvenile idiopathic arthritis: a systematic reviewJournal of RheumatologyYear: 20022912264326472-s2.0-003689629312465166
7. Lelieveld OTHM,van Brussel M,Takken T,van Weert E,van Leeuwen MA,Armbrust W. Aerobic and anaerobic exercise capacity in adolescents with juvenile idiopathic arthritisArthritis Care and ResearchYear: 20075768989042-s2.0-3454776262217665473
8. Metin G,Öztürk L,Kasapçopur Ö,Apelyan M,Arisoy N. Cardiopulmonary exercise testing in juvenile idiopathic arthritisJournal of RheumatologyYear: 2004319183418392-s2.0-444426812415338509
9. van Brussel M,Lelieveld OTHM,van der Net J,Engelbert RHH,Helders PJM,Takken T. Aerobic and anaerobic exercise capacity in children with juvenile idiopathic arthritisArthritis Care and ResearchYear: 20075768918972-s2.0-3454778758217665476
10. Lelieveld OTHM,Armbrust W,van Leeuwen MA,et al. Physical activity in adolescents with juvenile idiopathic arthritisArthritis Care and ResearchYear: 20085910137913842-s2.0-5494911792418821655
11. Henderson CT,Lovell DJ,Specker BL,Campaigne BN. Physical activity in children with juvenile rheumatoid arthritis: quantification and evaluationArthritis Care and ResearchYear: 1995821141192-s2.0-00290197617794985
12. Malleson PN,Bennett SM,MacKinnon M,et al. Physical fitness and its relationship to other indices of health status in children with chronic arthritisJournal of RheumatologyYear: 1996236105910652-s2.0-00300065668782141
13. Bar-Or O. Pediatric Sports Medicine for the PractitionerYear: 19831 editionNew York, NY, USASpringer
14. Klepper SE. Effects of an eight-week physical conditioning program on disease signs and symptoms in children with chronic arthritisArthritis Care and ResearchYear: 199912152602-s2.0-003270668110513491
15. Lelieveld OTHM,Armbrust W,Geertzen JHB,et al. Promoting physical activity in children with juvenile idiopathic arthritis through an internet-based program: results of a pilot randomized controlled trialArthritis Care and ResearchYear: 20106256977032-s2.0-7795175468820191468
16. Moncur C,Marcus R,Johnson S. Pilot project of aerobic conditioning of subjects with juvenile arthritisArthritis Care & ResearchYear: 19903, article S16
17. Bacon MC,Nicholson C,Binder H,White PH. Juvenile rheumatoid arthritis: aquatic exercise and lower-extremity functionArthritis Care and ResearchYear: 1991421021052-s2.0-002604831711188589
18. Takken T,van der Net J,Kuis W,Helders PJM. Aquatic fitness training for children with juvenile idiopathic arthritisRheumatologyYear: 20034211140814142-s2.0-024252461112832708
19. Singh-Grewal D,Schneiderman-Walker J,Wright V,et al. The effects of vigorous exercise training on physical function in children with arthritis: a randomized, controlled, single-blinded trialArthritis Care and ResearchYear: 2007577120212102-s2.0-3534890210417907238
20. Epps H,Ginnelly L,Utley M,et al. Is hydrotherapy cost-effective? A randomised controlled trial of combined hydrotherapy programmes compared with physiotherapy land techniques in children with juvenile idiopathic arthritisHealth Technology AssessmentYear: 20059391592-s2.0-33644822158
21. Fisher NM,Venkatraman JT,'Neil KM O. Effects of resistance exercise on children with juvenile arthritisArthritis & RheumatismYear: 199942, supplement 9, article S396
22. Petty RE,Southwood TR,Manners P,et al. International league of associations for rheumatology classification of juvenile idiopathic arthritis: second revision, Edmonton, 2001Journal of RheumatologyYear: 20043123903922-s2.0-1074423048414760812
23. Özdoğan H,Ruperto N,Kasapçopur Ö,et al. The Turkish version of childhood health assessment questionnaires (CHAQ) and the child health questionnaireClinical and Experimental RheumatologyYear: 200119, supplemet 4158162
24. Kendall PF,Mc Creary EK. Joint motionMuscles Testing and FunctionYear: 19934 editionBaltimore, Md, USAWilliam and Wilkins
25. Bruce RA,Blackman JR,Jones JW,Strait G. Exercise testing in adult normal subjects and cardiac patientsPediatricsYear: 1963327427562-s2.0-3375018630014070531
26. Petrella NJ,Montelpare WJ,Nystrom M,Plyley M,Faught BE. Validation of the FAST skating protocol to predict aerobic power in ice hockey playersApplied Physiology, Nutrition and MetabolismYear: 20073246937002-s2.0-34848888107
27. Strassnig M,Brar JS,Ganguli R. Low cardiorespiratory fitness and physical functional capacity in obese patients with schizophreniaSchizophrenia ResearchYear: 20111261–31031092-s2.0-7995200848621146958
28. Klippel JH,Stone JH,Crofford LJ,White PH. Primer on the Rheumatic DiseasesYear: 200812 editionAtlanta, Ga, USAArthritis Foundation
29. Magni-Manzoni S,Pistorio A,Labò E,et al. A longitudinal analysis of physical functional disability over the course of juvenile idiopathic arthritisAnnals of the Rheumatic DiseasesYear: 2008678115911642-s2.0-4794910795017965116
30. Ruperto N,Ravelli A,Levinson JE,et al. Longterm health outcomes and quality of life in American and Italian inception cohorts of patients with juvenile rheumatoid arthritis. II. Early predictors of outcomeJournal of RheumatologyYear: 19972459529582-s2.0-00306125819150088
31. Flatø B,Lien G,Smerdel A,et al. Prognostic factors in juvenile rheumatoid arthritis: a case-control study revealing early predictors and outcome after 14.9 YearsJournal of RheumatologyYear: 20033023863932-s2.0-1224429273612563700
32. Morrow JR,Freedson PS. The relationship between habitual physical activity and aerobic fitness in adolescentsPediatric Exercise ScienceYear: 19946315329
33. Rowland TW,Boyajian A. Aerobic response to endurance exercise training in childrenPediatricsYear: 1995964 I6546582-s2.0-00290860127567326
34. Alexander GJM,Hortas C,Bacon PA. Bed rest, activity and the inflammation of rheumatoid arthritisBritish Journal of RheumatologyYear: 19832231341402-s2.0-00206208686347304
35. Takken T,van der Net J,Kuis W,Helders PJM. Physical activity and health related physical fitness in children with juvenile idiopathic arthritisAnnals of the Rheumatic DiseasesYear: 20036298858892-s2.0-004238635012922964
36. Tarakci E,Yeldan I,Baydogan N,Olgar S,Kasapcopur O. Efficacy of a land-based home exercise programme for patients with juvenile idiopathic arthritis: a randomized, controlled, single-blind studyJournal of Rehabilitation MedicineYear: 20124496296723027068
37. Tarakci E,Yeldan I,Kaya Mutlu E,Baydogan SN,Kasapcopur O. The relationship between physical activity level, anxiety, depression, and functional ability in children and adolescents with juvenile idiopathic arthritisClinical RheumatologyYear: 20113011141514202-s2.0-8075517589821887489

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