Question

Children Case Study

Subjective

Medical History

Mr. ST, a 16 yr old Caucasian boy, who was previously diagnosed with juvenile idiopathic arthritis (JIA) at the age of 12, has recently been determined to be in remission. Previously this patient did not respond well to a number of nonsteroidal anti-inflammatories. After a period of trial and error, the patient responded well to azathioprine and seems to have better control of his disease now. Is has been a concern of the parents and primary care physician that, although this patient seems to be in remission, he has failed to increase his activity and has poor dietary habits, and as such he is beginning to develop other potential chronic health issues. Mr. ST’s latest physical exam and lab work has noted that body weight status is in the 95th percentile, with elevated resting blood glucose and triglycerides. The parents are concerned that if these poor health indicators continue, their son will have to deal with more than his JIA. The family physician wants the boy to begin a structured exercise program as well as to begin following the DASH diet plan.

Objective and Laboratory Data

Exercise testing was not requested.

Assessment and Plan

Diagnosis

JIA with overweight/obese weight status and prediabetes

Exercise Prescription

Mr. ST was referred to Exercise Medical Clinic to meet with an exercise physiologist. In consultation with the child’s parents it was determined that the child would begin with a programmed exercise routine developed by the exercise physiologist and would be administered here at the clinic. The patient will come to the clinic 3 d per week for the first 4 wk. At week 5 the child will move to completing his exercise program from home. At week 8 the child will come to the clinic to be assessed on his ability to maintain his at-home exercise program. If the child is compliant then adjustments will be made to the program for intensity, duration, frequency, and mode. If the child is struggling then it may be appropriate to have him exercise in the structured environment for 2 wk to help him get back on track.

Finally, it would be beneficial to have the child’s parents begin an exercise program as well. This will help them but would also provide positive role models for their child. Additionally, the parents and child should be referred to a dietitian to help them with their meal planning and diet plans.

Discussion

A patient such as this, with JIA, is often in poor physical condition due to the adoption of a sedentary lifestyle, possibly due to the discomfort accompanying the disease. Although drug therapy has improved the quality of life for children with JIA, increasing physical activity may help to enhance it further.

Case Study Discussion Questions

1. What would your initial exercise prescription look like for this patient? Include the mode, intensity, and duration (or volume) you would prescribe. Include your rationale for your choices.
2. What modifications to your program would you make at week 5 when the patient starts a home based exercise program? Explain.
3. Assuming the patient is making progress at week 8, how would you progress your program. Explain.

Answer 1

Juvenile idiopathic arthritis (JIA)is a chronic rheumatic disease. In most cases, the onset of the disease is before the age of 16 and hence the term juvenile in this condition. This is an autoimmune disease and causes inflammation of the joints.JIA is characterised by persistent swelling and pain in the affected joint. Swelling and pain causes limited movement of the affected joint.

In order to increase the physical activity, the exercise for a patient like Mr.ST the initial exercise is as follows

1. Cycling: It is a low impact exercise. Initially, cycling should limit to a small distance and for a limited time with limited frequency and speed and gradually increase the distance frequency speed and time. This cycling increases the fluid production in the joints and thereby increasing the lubrication of the joints.

2. Stretching exercise like yoga: Help in reducing symptoms like stiffness, inflammation and pain. Initially once daily and once the patient is comfortable with the exercise can change to twice daily. Yoga increases flexibility of the joints.

3.Swimming: Strengthening of the muscles.

4. Walking: Go for a regular walk a good exercise for JIA, walking for15 to 30 minutes per day. This will strengthen the muscles and bone.

5.Physiotherapy

The following modification should be made after 5 weeks.

At home exercise along with the following exercises home exercise like arm raise, neck stretch, head raises, leg raises etc should be done.

After 8 weeks if there is progress and reduction in pain and swelling in the joint ask the patient to continue the exercise and we reduce the frequency of medication.