Assessment of the Clinical Effects of Aquatic-Based Exercises in the Treatment of Children With Juvenile Dermatomyositis: A 2¥2 Controlled-Crossover Trial

Objectives: This study aims to compare the effect of aquatic-based exercises (AQBEs) and land-based exercises (LBEs) on muscle strength, fatigue and quality of life (QoL), and skin disease activity in children with juvenile dermatomyositis (JDM). Patients and methods: The design of the study was an assessor-blinded, controlled 2x2 crossover trial. Fourteen children (4 boys, 10 girls; mean age 11.7±2.2 years; range, 10 to 16 years) were evaluated. AQBEs and LBEs were applied through two treatment sequences as half of the children received AQBEs first while the second half received LBEs first. Isometric muscle strength, fatigue level and QoL (Pediatric Quality of Life Inventory Multidimensional Fatigue Scale [PedsQL-MFS]), and skin disease activity score (DASskin) were measured at four occasions for each treatment sequence. Results: The AQBEs had significant superiority over LBEs with improved hip flexors’ strength (p=0.007) and hip abductors’ strength (p=0.001), while both types of treatment had the same effect in increasing strength of shoulder flexors and abductors (p


1. Wedderburn LR, Rider LG. Juvenile dermatomyositis: new developments in pathogenesis, assessment and treatment. Best Pract Res Clin Rheumatol 2009;23:665-78.

2. McCann LJ, Juggins AD, Maillard SM, Wedderburn LR, Davidson JE, Murray KJ, et al. The Juvenile Dermatomyositis National Registry and Repository (UK and Ireland)--clinical characteristics of children recruited within the first 5 yr. Rheumatology (Oxford) 2006;45:1255-60.

3. Ravelli A, Trail L, Ferrari C, Ruperto N, Pistorio A, Pilkington C, et al. Long-term outcome and prognostic factors of juvenile dermatomyositis: a multinational, multicenter study of 490 patients. Arthritis Care Res (Hoboken) 2010;62:63-72.

4. Mendez EP, Lipton R, Ramsey-Goldman R, Roettcher P, Bowyer S, Dyer A, et al. US incidence of juvenile dermatomyositis, 1995-1998: results from the National Institute of Arthritis and Musculoskeletal and Skin Diseases Registry. Arthritis Rheum 2003;49:300-5.

5. Symmons DP, Sills JA, Davis SM. The incidence of juvenile dermatomyositis: results from a nation-wide study. Br J Rheumatol 1995;34:732-6.

6. Martin N, Krol P, Smith S, Murray K, Pilkington CA, Davidson JE, et al. A national registry for juvenile dermatomyositis and other paediatric idiopathic inflammatory myopathies: 10 years’ experience; the Juvenile Dermatomyositis National (UK and Ireland) Cohort Biomarker Study and Repository for Idiopathic Inflammatory Myopathies. Rheumatology (Oxford) 2011;50:137-45.

7. Cea G, Bendahan D, Manners D, Hilton-Jones D, Lodi R, Styles P, et al. Reduced oxidative phosphorylation and proton efflux suggest reduced capillary blood supply in skeletal muscle of patients with dermatomyositis and polymyositis: a quantitative 31P-magnetic resonance spectroscopy and MRI study. Brain 2002;125:1635-45.

8. Zong M, Lundberg IE. Pathogenesis, classification and treatment of inflammatory myopathies. Nat Rev Rheumatol 2011;7:297-306.

9. Hicks JE, Drinkard B, Summers RM, Rider LG. Decreased aerobic capacity in children with juvenile dermatomyositis. Arthritis Rheum 2002;47:118-23.

10. Rider LG, Wu L, Mamyrova G, Targoff IN, Miller FW. Environmental factors preceding illness onset differ in phenotypes of the juvenile idiopathic inflammatory myopathies. Rheumatology (Oxford) 2010;49:2381-90.

11. Poetker DM, Reh DD. A comprehensive review of the adverse effects of systemic corticosteroids. Otolaryngol Clin North Am 2010;43:753-68.

12. Harris-Love MO. Physical activity and disablement in the idiopathic inflammatory myopathies. Curr Opin Rheumatol 2003;15:679-90.

13. Omori CH, Silva CA, Sallum AM, Rodrigues Pereira RM, Lúciade Sá Pinto A, Roschel H, et al. Exercise training in juvenile dermatomyositis. Arthritis Care Res (Hoboken) 2012;64:1186-94.

14. Alexanderson H, Dastmalchi M, Esbjörnsson- Liljedahl M, Opava CH, Lundberg IE. Benefits of intensive resistance training in patients with chronic polymyositis or dermatomyositis. Arthritis Rheum 2007;57:768-77.

15. Arnardottir S, Alexanderson H, Lundberg IE, Borg K. Sporadic inclusion body myositis: pilot study on the effects of a home exercise program on muscle function, histopathology and inflammatory reaction. J Rehabil Med 2003;35:31-5.

16. Elnaggar RK, Elshafey MA. Effects of Combined Resistive Underwater Exercises and Interferential Current Therapy in Patients with Juvenile Idiopathic Arthritis: A Randomized Controlled Trial. Am J Phys Med Rehabil 2016;95:96-102.

17. Cole AJ, Becker BE. Comprehensive aquatic therapy. Philadelphia: Butterworth-Heinemann; 2004.

18. Bohan A, Peter JB. Polymyositis and dermatomyositis (first of two parts). N Engl J Med 1975;292:344-7.

19. Brown VE, Pilkington CA, Feldman BM, Davidson JE. An international consensus survey of the diagnostic criteria for juvenile dermatomyositis (JDM). Rheumatology (Oxford) 2006;45:990-3.

20. Ruperto N, Pistorio A, Ravelli A, Rider LG, Pilkington C, Oliveira S, et al. The Paediatric Rheumatology International Trials Organisation provisional criteria for the evaluation of response to therapy in juvenile dermatomyositis. Arthritis Care Res (Hoboken) 2010;62:1533-41.

21. Nikiphorou E, Radner H, Chatzidionysiou K, Desthieux C, Zabalan C, van Eijk-Hustings Y, et al. Patient global assessment in measuring disease activity in rheumatoid arthritis: a review of the literature. Arthritis Res Ther 2016;18:251.

22. Bohannon RW. Make tests and break tests of elbow flexor muscle strength. Phys Ther 1988;68:193-4.

23. Al-Gamal E, Long T. The psychometric properties of an Arabic version of the PedsQL multidimensional fatigue scale tested for children with cancer. Compr Child Adolesc Nurs 2017;40:188-99.

24. Varni JW, Burwinkle TM, Szer IS. The PedsQL Multidimensional Fatigue Scale in pediatric rheumatology: reliability and validity. J Rheumatol 2004;31:2494-500.

25. Bode RK, Klein-Gitelman MS, Miller ML, Lechman TS, Pachman LM. Disease activity score for children with juvenile dermatomyositis: reliability and validity evidence. Arthritis Rheum 2003;49:7-15.

26. Sallum AM, Kiss MH, Sachetti S, Resende MB, Moutinho KC, Carvalho Mde S, et al. Juvenile dermatomyositis: clinical, laboratorial, histological, therapeutical and evolutive parameters of 35 patients. Arq Neuropsiquiatr 2002;60:889-99.

27. Takken T, van der Net J, Engelbert RH, Pater S, Helders PJ. Responsiveness of exercise parameters in children with inflammatory myositis. Arthritis Rheum 2008;59:59-64.

28. Takken T, van der Net J, Helders PJ. The reliability of an aerobic and an anaerobic exercise tolerance test in patients with juvenile onset dermatomyositis. J Rheumatol 2005;32:734-9.

29. de Salles Painelli V, Gualano B, Artioli GG, de Sá Pinto AL, Bonfá E, Lancha Junior AH, et al. The possible role of physical exercise on the treatment of idiopathic inflammatory myopathies. Autoimmun Rev 2009;8:355-9.

30. Maillard SM, Jones R, Owens CM, Pilkington C, Woo PM, Wedderburn LR, et al. Quantitative assessments of the effects of a single exercise session on muscles in juvenile dermatomyositis. Arthritis Rheum 2005;53:558-64.

31. Faigenbaum AD, Kraemer WJ, Blimkie CJ, Jeffreys I, Micheli LJ, Nitka M, et al. Youth resistance training: updated position statement paper from the national strength and conditioning association. J Strength Cond Res 2009;23:S60-79.

32. Gorter JW, Currie SJ. Aquatic exercise programs for children and adolescents with cerebral palsy: what do we know and where do we go? Int J Pediatr 2011;2011:712165.

33. Lai CJ, Liu WY, Yang TF, Chen CL, Wu CY, Chan RC. Pediatric aquatic therapy on motor function and enjoyment in children diagnosed with cerebral palsy of various motor severities. J Child Neurol 2015;30:200-8.

34. Salem Y, Gropack SJ. Aquatic therapy for a child with type III spinal muscular atrophy: a case report. Phys Occup Ther Pediatr. 2010;30:313-24.

35. Davison PG, Loiselle FB, Nickerson D. Survey on current hydrotherapy use among North American burn centers. J Burn Care Res 2010;31:393-9.

Kaynak Göster

304 120