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Effects of Pilates Exercises on Health-Related

Quality of Life in Individuals With Juvenile
Idiopathic Arthritis

Article in Archives of physical medicine and rehabilitation June 2013

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Archives of Physical Medicine and Rehabilitation

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Archives of Physical Medicine and Rehabilitation 2013;94:2093-102

ORIGINAL ARTICLE

Effects of Pilates Exercises on Health-Related Quality

of Life in Individuals With Juvenile Idiopathic Arthritis
Tania M. Mendonca, PT, PhD,a Maria T. Terreri, MD, PhD,b Carlos H. Silva, MD, PhD,c
Morun Bernardino Neto, DSc,d Rogerio M. Pinto, PhD,e Jamil Natour, MD, PhD,f
Claudio A. Len, MD, PhDb
From the aRehabilitation Department, Setor de Reumatologia Pediatrica do Departamento de Pediatria da Universidade Federal de Sao Paulo/
Escola Paulista de Medicina, Sao Paulo, SP; bSetor de Reumatologia Pediatrica do Departamento de Pediatria da Universidade Federal de Sao
Paulo/Escola Paulista de Medicina, Sao Paulo, SP; cSetor de Reumatologia Pediatrica do Departamento de Pediatria da Universidade Federal de
Uberlandia/FAMED, Uberlandia, MG; dInstitute of Genetics and Biochemistry, Universidade Federal de Uberlandia, Uberlandia, MG; eDiscipline
of Rheumatology, Departamento de Medicina da Universidade Federal de Sao Paulo/Escola Paulista de Medicina, Sao Paulo, SP; and f Discipline
of Rheumatology, Departamento de Medicina da Universidade Federal de Sao Paulo/Escola Paulista de Medicina, Sao Paulo, SP, Brazil.

Abstract
Objective: To determine the effects of Pilates exercises on health-related quality of life (HRQOL) in individuals with juvenile idiopathic arthritis
(JIA).
Design: Randomized, prospective, single-blind trial.
Setting: Outpatient clinic of pediatric rheumatology and the rehabilitation department.
Participants: Children (NZ50) with JIA according to the International League of Associations for Rheumatology criteria.
Interventions: Participants were randomly assigned into 2 groups. In group I (nZ25), the participants were given a conventional exercise
program for 6 months. Patients in group II (nZ25) participated in a Pilates exercise program for 6 months.
Main Outcome Measures: The primary outcome measure was HRQOL, as measured by the Pediatric Quality of Life Inventory version 4.0
(PedsQL 4.0). The secondary outcome measures provided an estimate of the clinical relevance of the primary outcome results and included joint
pain intensity (according to a 10-cm visual analog scale), disability (according to the Childhood Health Assessment Questionnaire), joint status
(using the Pediatric Escola Paulista de Medicina Range of Motion Scale), and the total PedsQL 4.0 score.
Results: All participants completed the study. The scores of the PedsQL 4.0 differed significantly between groups, indicating that Pilates
exercises increased these scores when compared with the conventional exercise program. Group II participants showed significant improvements
in the 10-cm visual analog scale-joint pain, Childhood Health Assessment Questionnaire, and Pediatric Escola Paulista de Medicina Range of
Motion Scale.
Conclusions: The use of Pilates exercises had a positive physical and psychosocial impact on HRQOL in individuals with JIA. Future multicenter
studies with a follow-up beyond the period of treatment using more objective parameters will be useful to support the results of the present study.
Archives of Physical Medicine and Rehabilitation 2013;94:2093-102
2013 by the American Congress of Rehabilitation Medicine

Juvenile idiopathic arthritis (JIA) is a chronic disease of
unknown etiology with an age of onset of >16 years.1 JIA is
characterized by persistent arthritis (with a minimum duration of
6wk) and, in some cases, extra-articular manifestations.1 The
No commercial party having a direct financial interest in the results of the research supporting
this article has or will confer a benefit on the authors or on any organization with which the authors
are associated.
disease has an estimated incidence of 16 to 150 per 100,000
children worldwide.2 The disease makes physical activity diffi-
cult for patients and negatively impacts patients health-related
quality of life (HRQOL), as perceived by the patients and their
caregivers.3,4
Exercise programs can be effective at increasing JIA patients
physical activity and abilities and reducing pain.5-10 Based on

0003-9993/13/$36 - see front matter 2013 by the American Congress of Rehabilitation Medicine
http://dx.doi.org/10.1016/j.apmr.2013.05.026
 Author's personal copy
2094
previous studies in adult populations,11-15 it was hypothesized
that a Pilates exercise program would result in a greater
improvement in HRQOL for patients with JIA than a conven-
tional exercise program. Thus, the goal of this study was to
assess the effects of a Pilates exercise program on HRQOL in
individuals with JIA.
Methods
Participants
The participants recruited for this randomized controlled trial
were 8- to 18-year-old patients, who were diagnosed with oli-
goarticular, polyarticular, and systemic subtypes of JIA, according
to the International League of Associations for Rheumatology
criteria,16 from the outpatient clinic of pediatric rheumatology at
the Hospital de Clinicas da Universidade Federal de Uberlandia in
Brazil. The patients and their caregivers were informed of all
aspects of the study, and their written consent was obtained. The
human ethics committee of the Uberlandia Federal University
approved the study.
The sample size and power calculations were performed using
SPSS statistical software version 18.a The calculations were based
on detecting a difference of 4.4 points for the child self-report and
a difference of 4.5 points for the parent proxy report in the
Pediatric Quality of Life Inventory version 4.0 (PedsQL 4.0) total
scale score,17 using a 2-tailed test and assuming an SD of 7 points
and an alpha level equal to .05. This generated a sample size of 25
participants per group.
During the 6 months prior to inclusion in the study (the pre-
baseline period), the participants did not follow any standardized
exercise program, but they did receive local and/or systemic
arthritis-related therapy consisting of nonsteroidal anti-
inflammatory drugs, disease-modifying antirheumatic drugs,
immunosuppressive medication, and/or steroids. No restrictions
were placed on their medication use, and every effort was made to
keep the patients health stable throughout the study. The
importance of using medication to control JIA was explained to
the caregivers to alleviate any parental reluctance to use drug
therapy.18 Patients were excluded from the study if they had
significant cardiac, pulmonary, or metabolic comorbidity or had
an active disease that required therapy modification during
the study.
Arthritis was defined by an increased joint volume and/or
the presence of 2 of the following manifestations: pain, limited
range of movement, or increased temperature. JIA was
considered to be active when arthritis and/or extra-articular
manifestations were present, as observed in the systemic form
of JIA.19
List of abbreviations:
CHAQ Childhood Health Assessment Questionnaire
CI confidence interval
HRQOL health-related quality of life
JIA juvenile idiopathic arthritis
MCID minimal clinically important difference
PedsQL 4.0 Pediatric Quality of Life Inventory version 4.0
pEPM-ROM Pediatric Escola Paulista de Medicina Range of
Motion Scale
RR relative risk
VAS visual analog scale
T.M. Mendonca et al
Randomization and patient groups
Randomization was performed 2 days after the patient recruit-
ment period by 2 hospital staff members who were blinded to
all information pertaining to the patients participation in the
study. One staff member generated 50 random numbers in
a Microsoft Excel spreadsheet.b The second staff member
associated each random number with a patient from a second
list containing the names of the patients listed in the order of
recruitment. The randomization lists were transferred to 2
sealed, opaque envelopes, which were then given to the
research team. The patients were divided into 2 groups. Group I
consisted of the participants associated with the first 25 random
numbers, and group II consisted of the other 25 participants.
For 6 months, group I patients participated in a conventional
exercise program, and group II patients performed the
Pilates exercises.
The 2 physicians who assisted the patients were blinded to the
study. The study personnel responsible for administering fitness
testing, data collection, statistical analysis, and manuscript prep-
aration were blinded to the patient allocation.
All participants were instructed not to reveal information to
other potential participants in the study. Patients who missed
therapy 3 consecutive times during the intervention period were
excluded from the study.
Interventions
Each intervention was performed under the supervision of
a physical therapist trained to provide the same degree of
motivation for each of them. The intervention sessions were 50
minutes in duration and occurred twice per week. Forty-eight
intervention sessions were planned for each patient. The
treatment interventions were standardized to enhance the
internal validity of the design and to allow for the ease of
replication in future clinical trials, in accordance with the 2010
update of the Consolidated Standards of Reporting Trials
statement.20
Appendices 1 and 2 describe the exercises performed by each
group. Supplemental videos 1 and 2 (available online only at
http://www.archives-pmr.org/) demonstrate a Pilates session and
a conventional exercise program, respectively. Both groups per-
formed their exercises in the morning and afternoon in
different locations.
Pilates
A group of general exercises was chosen for the baseline period of
this study, and a paper copy of the exercises was available to
patients (see appendix 1). The exercises followed the Canadian
STOTT-PILATES methodology and included floor exercises21 and
exercises with the Reformer,22 Stability Chair,23 Cadillac,24 and
Ladder Barrel.25
These exercises were adapted to the physical and cognitive
specifications required for the age groups (8e12y and 13e18y)
(fig 1) and the limitations imposed by JIA. The exercises were
introduced in order of increasing difficulty and were performed
with 5 repetitions of each exercise for the first 3 classes, 8 repe-
titions for the next 3 classes, and 10 repetitions in subse-
quent classes.
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Pilates in juvenile idiopathic arthritis
Fig 1 Flow diagram of the participants throughout the course of the study.
Conventional exercise program
The conventional exercise program established in the baseline
period was also adapted for each patient and was available as
a handout to patients. It included a warm-up, a workout, and
a cooling-down period (see appendix 2). The exercises were
performed with a series of 6 to 10 repetitions in the supine, prone,
and seated positions. The stretching exercise positions were
maintained for 30 seconds.
Outcome measures
The preintervention period was designated as t0, 3 months after
the intervention began was designated as t3, and the post-
intervention period was designated as t6.
The outcome measures were collected by a physical therapist
before beginning the interventions (t0), 3 months after the inter-
ventions began (t3), and at the end of the interventions (t6).
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Primary outcome measure: HRQOL assessment
The PedsQL 4.04,26 was used in an interview format to determine
the patients HRQOL. The participants were asked to indicate
values based on the previous week. Standardized instructions were
used to explain the scales. The consistency of the PedsQL 4.0
scores over time or across raters was confirmed using a reli-
ability analysis.
Secondary outcome measures
Secondary outcome measures were used to estimate the clinical
relevance of the primary outcome results. The minimal clinically
important differences (MCIDs) for the visual analog scale (VAS)-
joint pain, the Childhood Health Assessment Questionnaire
(CHAQ), and the total PedsQL 4.0 score (4.4-point difference for
child self-report)17 were assessed for the participants in
each group.
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2096 T.M. Mendonca et al

10-cm VAS-joint pain

Pain intensity was estimated using 10-cm VAS-joint pain scores

ranging from 0 to 10, with 0 representing the absence of pain
and 10 representing very severe pain. This scale has been
demonstrated to provide acceptable levels of reliability and val-
idity when used for individuals with JIA.27 A previous study of
children with rheumatic diseases reported that the MCID on a 10-
cm VAS was .82.27

Functional ability

Each patients functional ability was assessed using the

CHAQ.28,29 The CHAQ has been previously validated in patients
with JIA and has an MCID of no more than
.188.30

Joint range of motion

Using the Pediatric Escola Paulista de Medicina Range of Motion

Scale (pEPM-ROM),31 range of motion was scored at testing
sessions for the following joints: temporomandibular, sternocla-
vicular, shoulder, elbow, wrist, thumb, knee, ankle, and toe.
Adherence and adverse events
The physiotherapists who directed the treatments had frequent
contact with the patients caregivers to encourage patient adher-
ence (treatment frequency). Patient adherence was assessed by
a questionnaire to control the results for the patients participa-
tion frequency.
To ensure patient safety, the Pilates and conventional exercises
were modified if they caused any pain and/or discomfort, and
safety was also evaluated by a joint examination at the
testing sessions.
All 60 patients who were followed at the pediatric rheuma-
tology outpatient clinic at the hospital were invited to participate
in the study. Eight patients did not consent to participate because
of transportation difficulties, and 2 did not consent because they
were <8 years old. Therefore, the study comprised 50 patients, as
reported in figure 2.
Statistical analysis
A chi-square test was used to compare the baseline characteristics
of the patients in groups I and II. This test was also used to
evaluate the frequency of participation during each intervention
(adherence). The use of medications and the occurrence of adverse
events were assessed using the binomial test for the difference of
proportions.
Analysis of variance was used to analyze the effect of each
intervention on HRQOL, CHAQ, pEPM-ROM, and VAS-
joint pain.
Multivariate analysis was used to evaluate possible correlations
between the scores of the predictor variables or independent
variables (CHAQ, pEPM-ROM, and 10-cm VAS-joint pain) and
the scores of the dependent variable, the PedsQL 4.0 value. The
multivariate statistical analyses were performed using multiple
linear regressions, simultaneously grouping all times (t0, t3, and
t6) in a study with 75 mainstreaming observations. An a priori
power analysis was conducted to determine the sample size
Fig 2 Forward step-up exercise, modified according to age: panel 1
is the 8- to 12-year-old group and panel 2 is the 13- to 18-year-old
group).
needed to achieve adequate power. For this analysis, the magni-
tude of the anticipated effect was .15, and a power of .80
was required.
Reliability of the PedsQL 4.0 for patients in groups I and II at
time t6 was analyzed using Cronbach alpha coefficient. A value of
.70 was considered acceptable.32
The MCIDs of the CHAQ, the 10-cm VAS-joint pain, and the
total PedsQL 4.0 scores were compared using relative risk (RR)
ratios with a 95% confidence interval (CI).
Results
Patient characteristics (table 1)
The between-group comparisons of the baseline characteristics of
the participants are shown in table 1.
Primary outcome measure (HRQOL) (table 2)
An improvement in HRQOL is indicated by an increase in the
PedsQL 4.0 score. The improvements observed in the mean
scores  SDs between t0 and t6 for the physical and psychoso-
cial scores of the PedsQL 4.0 scale for group I were 0.95.1
points (PZ0.9) and 7.34.3 points (PZ.33), respectively. The
observed improvement was significantly different between
groups I and II from t0 to t6 for the physical score (PZ.000;
mean difference  SD, 37.45.1; 95% CI, 24.0e50.9) and for
the psychosocial score (PZ.000; mean difference  SD,
36.54.3; 95% CI, 24.2e46.8). The total score decreased by
a mean  SD of 3.83.9 points (PZ.62; 95% CI, 5.6e15.3), as
perceived by the patients in group I. For the group II patients, the
PedsQL 4.0 total score increased by a mean  SD of 38.83.9

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Pilates in juvenile idiopathic arthritis 2097

Table 1 Baseline characteristics Secondary outcome measures (table 3)

Comparison
Pain intensity
Group I Group II Between
Postintervention, the average mean 10-cm VAS-joint pain score
Variable (nZ25) (nZ25) Groups (P)
for group I at time t6 was 0.20.5 points lower than the pre-
Age (y) 11.03.9 11.83.4 .574* intervention score at t0 (PZ0.9). For group II, the reduction in the
Female 16.0 (64.0) 16.0 (64.0) .074y 10-cm VAS-joint pain score during the same period was 2.30.5
Caregiver points (PZ0.0). The decrease in pain intensity was significantly
Mother 24.0 (94.0) 20.0 (90.0) .064y different between t0 and t6 for groups I and II (P<.001; mean
Schooling difference, 3.1mm; 95% CI, 1.85e4.24).
Elementary 19.0 (76.0) 19.0 (76.0) .931y The improvement in the VAS-joint pain score reached the
Secondary 6.0 (24.0) 6.0 (24.0) .931y MCID for 7 group I participants and 18 group II participants
Type of onset (RRZ2.57; 95% CI, 1.37e5.05; PZ.002).
Oligoarticular 10.0 (40.0) 14.0 (56.0) .365y
Polyarticular 8.0 (32.0) 4.0 (16.0) .365y Functional ability
Systemic 7.0 (28.0) 7.0 (28.0) .365y A decrease in disability is indicated by a lower (improved) CHAQ
Type of evolution score. Postintervention, the improvement in the CHAQ score was
Oligoarticular 18.0 (72.0) 14.0 (56.0) .244y significantly greater for group II than group I (P<.0001; mean
Polyarticular 5.0 (20.0) 7.0 (28.0) .244y difference, .83; 95% CI, .35e.91).
Systemic 2.0 (8.0) 4.0 (16.0) .244y The improvement in the CHAQ score reached the MCID for 8
RF 4.0 (16.0) 6.0 (24.0) .212y group I participants and 23 group II participants (RRZ2.88; 95%
Diagnosis (y) 3.32.1 4.52.1 .732y CI, 1.60e5.15; P<.0001).
Active disease 9.0 (34.6) 13.0 (50.0) .261z
Medications
Joint range of motion
Systemic steroids 4.0 (15.8) 5.0 (19.2) 1.00z
A lower pEPM-ROM score indicates an improvement in range of
TNF inhibitors 1.0 (4.0) 1.0 (4.0) 1.00z
motion. For group II, a decrease of 0.40.2 points (P<.00) in the
Methotrexate 8.0 (30.8) 13.0 (50.0) .713z
pEPM-ROM was observed after treatment. A significant differ-
NOTE. Values are mean  SD, n (%), or as otherwise indicated. ence was observed in the pEPM-ROM between groups I and II
Abbreviations: RF, positive rheumatoid factor; TNF, tumor necrosis postintervention (PZ.002; mean difference  SD, .10.20; 95%
factor. CI, .001e.20); group II patients presented with a lower pEPM-
* t test. ROM score than group I.
y
Chi-square test.
z
Binomial test for a difference of proportions.
Adherence and adverse events
Group I participants attended an average of 45.41.1 sessions,
points (PZ.000; 95% CI, 24.3e45.1). The improvement in the and group II participants attended an average of 47.30.8
PedsQL 4.0 total score reached the MCID for 5 group I partic- sessions; there was no significant difference in session compliance
ipants and 23 group II participants (RRZ4.6; 95% CI, 2.08e between the 2 groups (PZ.82).
10.16; P<.0001). No adverse events were reported during the testing or train-
The Cronbach alpha coefficient, used to assess the internal ing sessions. There was no worsening of active joint count,
consistency of the PedsQL 4.0, ranged from 0.7 to 0.9, according pEPM-ROM, CHAQ, or HRQOL in either group during the study
to the assessments of the patients and their caregivers. (see table 3).

Table 2 Follow-up of the physical, mental, and total score components of the PedsQL 4.0 in groups I and II
Group I Group II
Variable t0 t6 t0 t6 P (Time Factor) P (Between Groups) P (Time  Group)
PedsQL 4.0 patients
Physical 53.522.0* 52.615.7* 50.518.4y 90.515.7* .00 .00 .00
PSCS 51.119.0* 43.814.5* 45.714.1y 80.112.8* .00 .00 .00
Total 51.717.6* 46.912.6* 47.412.3y 82.212.6* .00 .00 .00
PedsQL 4.0 caregivers
Physical 48.320.7* 42.614.0* 85.915.1y 81.410.2* .00 .00 .00
PSCS 58.318.7* 44.313.2* 44.412.9y 80.413.9* .00 .00 .00
Total 59.316.3* 45.511.8* 43.114.3y 81.910.1* .00 .00 .00
NOTE. Values are mean  SD or as otherwise indicated.
Abbreviation: PSCS, psychosocial.
* and yMeans followed by the same letter on the lines do not differ statistically between each other at 1% of probability according to analysis of
variance with Tukey test post hoc.

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2098
Table 3 Follow-up of secondary outcome measures in groups I and II
Group 1
Variable t0 t6
y y
10-cm VAS-joint pain 2.92.4 3.12.2
CHAQ 0.90.6y 0.90.5y
PedsQL 4.0-patients 51.717.6y 46.912.6y
pEPM-ROM 0.20.2*y 0.20.2y
NOTE. Values are mean  SD or as otherwise indicated.
Abbreviation: NA, not applicable.
* Significant difference (P<.01) between groups I and II.
y
and zMeans followed by the same superscript symbol do not differ statistically between each other according to analysis of variance with Tukey test
post hoc; P<.01.
Correlations between primary and secondary outcome
measures (table 4)
For patients in the Pilates group, the F values were significant for
the physical (PZ.000), psychosocial (PZ.000), and total
(PZ.000) PedsQL 4.0 scores. The results of the partial regres-
sion coefficients demonstrated that the variable CHAQ correlated
with the physical score (tZ
6.8, PZ.000) and the total PedsQL
4.0 score (tZ
4.3, PZ.000), and the variable pEPM-ROM
correlated with the psychosocial scores (tZ
3.3, PZ.001). For
patients in the conventional exercise program, the F value was
significant for the physical (PZ.000) and total PedsQL 4.0
(PZ.000) scores. Of the secondary outcome measures, the
CHAQ showed the strongest correlation with the physical
(tZ
15.3, PZ.000) and total PedsQL 4.0 (tZ
10.6,
PZ.000) scores.
As shown in table 4, in both patient groups, the adjusted R2
of the physical model (PZ.000, adjusted R2Z0.6 to 0.3 for the
Pilates and the conventional exercise program) demonstrated
a greater predictive capacity for the behavior of the dependent
variable, followed by the full model (PZ.000; adjusted
R2Z0.5 and R2Z0.3 for the Pilates and the conventional
exercise program) and finally the psychosocial model
(PZ.000, adjusted R2Z0.5 for the Pilates program; and
PZ.69, adjusted R2Z0.2 for the conventional exer-
cise program).
Discussion
In this study, we assessed the impact of Pilates exercises versus
a conventional exercise program on HRQOL in patients with JIA.
We found a significant increase in HRQOL scores for JIA
patients, both from the patients and caregivers point of view, in
response to the regular practice of Pilates exercises. The 10-cm
VAS-joint pain, pEPM-ROM, and CHAQ scores revealed
a significant decrease in pain intensity and an improvement in
range of motion and patient functional capacity after performing
Pilates exercises.
The perception of well-being could be detected in the
physical, psychosocial, and total scores of the PedsQL 4.0,
which is a generic instrument for assessing HRQOL, with
a proven reliability for this study population. The PedsQL 4.0
confirmed the hypothesis that Pilates exercises have a positive
impact on HRQOL in children and adolescents with JIA.
T.M. Mendonca et al
Group 2
t0 t6 RR (95% CI)*, P
y z
2.31.8 0.000.00 2.57 (1.31e5.05), <.0001
0.90.5y 0.080.08z 2.88 (1.60e5.15), <.0001
47.412.3y 82.2012.60z 4.60 (2.08e10.16),<.0001
0.50.3*y 0.090.10z NA
Furthermore, none of the participants quit the training program,
and we observed no adverse effect of Pilates exercises,
corroborating the belief that Pilates exercise programs are safe
for children.
This randomized controlled trial study is using Pilates
exercises for the rehabilitation of a pediatric population. The
intention was not to replace the conventional exercise program,
but rather to include Pilates as one of the modalities of kine-
siotherapy. According to Di Lorenzo,33 there is a scientific
basis for the effectiveness of Pilates exercise, but with limited
evidence to support it as a rehabilitative intervention. Clinical
Pilates has been effectively used as therapy for adults with
chronic low back pain12-14,32-34 and other conditions.11,35 Only
the study of Wajeswelner et al,35 which compared the efficacy
of physiotherapy-delivered clinical Pilates and general exercise
for chronic low back, produced similar beneficial effects on
self-reported disability, pain, function, and HRQOL as
a general exercise program in adults with chronic low
back pain.35
The analysis of the sociodemographic, clinical, and HRQOL
data in this study revealed that the patients in the groups were
homogeneous. The homogeneity between the 2 groups confirms
the internal validity of the study, which was further demon-
strated by the results of the analysis of the psychometric
properties.
Study limitations
The present study shows methodologic challenges inherent to the
subjective concept of quality of life and variable characteristics of
the population assessed.
With respect to the Hawthorne effect, by definition, it is
impossible to eliminate it when the participants give their
informed consent to be included in a clinical trial. This effect
cannot be excluded because it was not possible to blind the
patients to the intervention, given the nature of the treatment
approach. Quantitative results based on an objective performance
tend to be less influenced by the Hawthorne effect. In this study,
the use of the pEPM-ROM for the assessment of joint mobility
demonstrated that the patients participating in the Pilates exer-
cises had improved joint movement. Furthermore, the multivar-
iate analysis demonstrated that reducing pain intensity and
improving functional capacity and joint mobility influenced the
improvement of HRQOL scores in patients who per-
formed Pilates.
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Pilates in juvenile idiopathic arthritis 2099

Table 4 Multivariate correlation (multiple linear regression analysis) between primary and secondary outcomes measures
Partial Regression
Group Variables P R2 Adjusted R2 Coefficient t P
PedsQL 4.0-Pilates

3.4
2.7 .010

25.8
6.8 .000
Physical 10cm VAS-joint pain CHAQ pEPM-ROM .000 0.6 0.6
9.9
1.5 .134
PSCS 10cm VAS-joint pain CHAQ pEPM-ROM .000 0.4 0.3
2.1
1.5 .132

9.8
2.5 .015

21.8
3.3 .001
Total 10cm VAS-joint pain CHAQ pEPM-ROM .000 0.5 0.5
2.7
2.3 .028

15.3
4.4 .000

16.4
2.7 .008
PedsQL 4.0-conventional
exercise program
Physical 10cm VAS-joint pain CHAQ pEPM-ROM .000 0.3 0.3
13.3
1.1 .313

15.3
4.7 .000

1.5
1.8 .008
PSCS 10cm VAS-joint pain CHAQ pEPM-ROM .069 0.3 0.2
13.1
1.1 .271

8.4
2.8 .005

1.6
1.9 .005
Total 10cm VAS-joint pain CHAQ pEPM-ROM .000 0.3 0.3
1.4
1.9 .055

10.6
4.1 .001

3.6
0.3 .738
Abbreviation: PSCS, psychosocial.

Another limitation to be considered is the fact that Pilates Corresponding author

exercises are considered to be more motivating,32 and this may
have contributed to the perception of well-being in the group that Tania M. S. Mendonca, PT, PhD, Avenida belo Horizonte, 337,
received this type of intervention. Future studies should be per- Bairro Rezende, Uberla ndia, MG, Brazil. E-mail address:
formed to verify this confounding factor. taniacore@hotmail.com.

Conclusions Acknowledgments

The Pilates exercises had a greater positive physical and psycho-
social impact on HRQOL in children and adolescents with JIA
compared with the conventional exercise program. The use of
Pilates exercises should be considered as part of a rehabilitation
program for patients with JIA.
Future multicenter studies with a follow-up beyond the period
of treatment using more objective parameters will be useful to
further confirm the results of the present study.
Suppliers
a. SPSS Inc, 233 S Wacker Dr, 11th Fl, Chicago, IL 60606.
b. Microsoft, One Microsoft Way, Redmond, WA 98052-6399.
Keywords
Arthritis; Child; Physical education and training; Rehabilitation
We thank Vanessa Resende and Gabriela Nolasco for their help in
applying the techniques in the Pilates exercises and conventional
exercise programs, respectively. We also thank Bethoven Marques
and Beatriz for their help in applying the data collection
instruments.
Appendix 1 Pilates
The patient is supposed to perform exercises twice a week
for 50 minutes and perform 5 to 10 repetitions of
each exercise.
1. The patients should stop performance of an exercise if pain
increases.
2. The patients should perform each exercise slowly and
complete 5 to 10 repetitions without movement of the spine or
rib cage.

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2100 T.M. Mendonca et al

Appendix 1 (continued)

8e12y
- Hip opener: STARTING POSITION: Side-lying with head toward push-through bar. Bottom arm straight, head resting on arm. Bottom leg straight,
reaching to continue line of torso. Ball of foot placed on push-through bar. INHALE: extend knee and plantar flex ankle to press bar toward
ceiling. EXHALE: flex knee to return to starting position.
- Breathing: supine, pelvis and spine neutral. Extend knees, feet on trapeze strap, hands on roll-down bar. INHALE: stay. EXHALE: extend hips to lift
pelvis off bed, creating bridge position from shoulders to knees.
- Arms push prone: prone on chair. Legs straight, adducted and parallel. Hands on pedal, arms straight. INHALE: stay. EXHALE: press pedal down.
Return to starting position.
- Side over: sit sideways on the chair, hooking one leg on the side and keeping the other leg straight and in line with the body. Place the hands on the
pedal. INHALE: laterally flex the trunk, lowering it and pressing the pedal down. EXHALE: lift the trunk, raising the pedal and returning to the start
position.
- Side step-up: standing, facing side. One leg straight with ball of foot on pedal. Other knee flexed with foot flat on chair. Hands holding front handle.
INHALE: dorsiflex ankle of pedal leg. EXHALE: plantar flex ankle of pedal leg and begin to extend knee of chair leg to raise body and allow pedal to lift.
INHALE: continue to extend knee. EXHALE: flex knee of chair leg, reaching other foot to control pedal down to return to starting position.
- Mermaid: STARTING POSITION: seated upright. Facing square to 1 side, knees flexed. One leg internally rotated with lower leg against shoulder rests,
other leg externally rotated with foot against opposite knee. Heel of 1 hand on footbar. Other hand on shoulder rest. INHALE: stay. EXHALE: laterally
flex spine toward footbar. Gesture arm remains overhead. INHALE: adduct arm on footbar to return carriage and simultaneously return spine to
vertical.
- Knee stretches: STARTING POSITION: kneel on carriage with feet against shoulder rests, hands holding footbar. INHALE: stay. EXHALE: stabilize torso
and arms and extend hips and knees to move the carriage out as far as possible without changing pelvis or spine. Return the carriage.
- Footwork: STARTING POSITION: distal of metatarsals on footbar, toes gently flexed around bar without clenching, ankles dorsiflexed. INHALE: keep
heels still in space and extend knees to press carriage out. EXHALE: flex knees and hips, controlling return of carriage.
- Monkey: STARTING POSITION: supine. Arms straight with hands holding bar outside of feet. INHALE: extend knees as far as possible up to full
extension and plantar flex ankles to press bar toward ceiling against resistance of bar. EXHALE: flex knees and roll spine onto bed to return to starting
position.
- Lower and lift: STARTING POSITION: prone on barrel, legs straight, parallel, and adducted. Ankles plantar flexed. Hands on ladder rung to keep upper
body slightly lower than legs. INHALE: lower legs slightly, flexing at hips. EXHALE: extend hips to raise legs only as far as pelvic stability can be
maintained.
- Leg circles: STARTING POSITION: supine, legs straight, adducted, and parallel. Feet in straps. INHALE: keeping sacrum area on carriage. EXHALE:
maintain pelvic stability and abduct legs, circling as they press away from torso to move carriage out. Adduct legs at bottom of circle. Return to
starting position.
13e18y
- Breathing: STARTING POSITION: supine, pelvis and spine neutral. Extend knees, feet on trapeze strap, hands on roll-down bar. INHALE: stay. EXHALE:
extend hips to lift pelvis off bed, creating bridge position from shoulders to knees and press the arms down. Return to starting position.
- Single thigh stretch: STARTING POSITION: lunge, facing footbar. One knee flexed on carriage with foot against shoulder rest. Ball of other foot on
footbar, in line with sit-bones. Hands placed on footbar, on either side of foot. INHALE: stay. EXHALE: press back foot against the ball.
- Side splits: STARTING POSITION: stand on reformer, facing side. One foot on wooden platform, one foot on edge of carriage. Legs straight and
parallel. Arms straight, reaching out to sides, palms down or forward. INHALE: stay. EXHALE: maintain weight equally on both feet; press legs evenly
away from midline to move carriage out. INHALE: return legs evenly toward midline, controlling return of carriage.
- Hundred (prep): STARTING POSITION: supine, legs parallel and adducted elbows flexed by sides of body, hands in straps. Pressing the arms down to
the sides of the body. Return to starting position.
- Sit up combo: STARTING POSITION: supine, with head toward push-through bar. Positioned so that hands are well below shoulder level when reaching
up to hold bar. Legs flexed and adducted. INHALE: stay. EXHALE: initiate from head and sequentially articulate spine through flexion until sacrum
area is just off bed, weight back of sit-bones. INHALE: stay. EXHALE: roll lumbar and lower thoracic onto bed through imprint; maintain upper torso
flexed off bed. INHALE: initiate by sliding rib cage toward pelvis and roll up until sacrum area is just off bed, weight back of sit-bones.
- Beats: STARTING POSITION: supine, arms straight overhead with hands braced against uprights slightly higher than shoulder level. Feet in footstraps
with legs adducted and extended. Extend the legs circling as they press away from torso to move carriage out. Adduct legs at bottom of circle. Return
to starting position.
- Guillotine: supine, neck under push-through bar. Balls of feet securely placed on push-through bar and knees flexed. INHALE: stay. EXHALE: extend
knees and plantar flex ankles bar toward ceiling, initiate from tail to sequentially articulate spine off bed until rest on upper thoracic spine. INHALE:
stay. EXHALE: initiate from thoracic to sequentially articulate spine down to bed until sacrum is touching.
- Cat kneeling: STARTING POSITION: kneel on chair, hands press pedal. INHALE: keep pedal down. EXHALE: return to starting position.
- Crossover press: stand facing side. Foot next to base of chair near back edge. Other leg almost straight and crossed over supporting leg, with foot on
pedal. INHALE: flex knee of pedal leg and allow pedal to lift. Return to starting position.
- Swan dive: prone on barrel, head away from ladder. Arms long, upper torso relaxed over barrel. INHALE: stay. EXHALE: extend spine, reaching chest
toward ceiling and extend hips. Simultaneously, reach arms up toward ceiling. INHALE: return to starting position.
- Hundred: STARTING POSITION: supine, imprinted position. Legs parallel and adducted in air with knees flexed, ankles plantar flexed, toes gently
pointed (tabletop position). Arms long by sides, palms down, scapulae stabilized. INHALE: stay. EXHALE: lift head and shoulders, extend the knees so
that the legs are at a 45 angle to the floor. Inhale and pump the arms, palms down, 3e4 inches off the floor, 5 times. Exhale and pump the arms 5
more times. This is 1 breath cycle (or 1 repetition). Repeat until you have completed 10 breath cycles.

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Pilates in juvenile idiopathic arthritis 2101

Appendix 2 Conventional Exercise Program 2. The patient should stop performance of an exercise if pain
increases.
1. The patient is supposed to perform exercises twice a week for 3. The patient should perform each exercise slowly and without
50 minutes and perform 5 to 10 repetitions of each exercise. movement of the spine or rib cage.

Warm-up
- Speed skips: while skipping forward, the patient accelerates the speed of movement with vigorous arm action with both elbows at 90 of flexion.
- Heel kicks: while moving forward, the patient rapidly kicks the heel toward the buttocks while accelerating the speed of movement and heel kicks.
- Toes in/out: while rapidly hopping forward, the patient turns the toes inward with the heels turned outward and then turns the toes outward with the
heels turned inward. Emphasis is on hip rotation and speed of movement.
- Trunk twists: the patient places both hands behind the head and rapidly hops forward as they twist their hips to the right and left; they maintain an
upright position with the chest forward as they accelerate trunk rotation.
- Push-ups: from a modified push-up position with the knees on a mat and the hands near the chest, the patients perform 3 push-ups at a controlled
speed followed by 3 explosive push-ups in which they attempt to lift their hands and body off the mat.
- High knee skip: while skipping forward, the patients raise the height of each skip; knee is lifted high, with vigorous arm action with both elbows at
90 of flexion.
- Hip circles: with hands on the hips and feet slightly apart, patients make circles with the hip clockwise for 10 repetitions and then counterclockwise.
- Hip twists: patients extend arms out to the sides and twist the torso and hips to the left, shifting the weight to the left foot, then opposite.
- Leg swings: patients stand facing the wall with their hands to the wall. They swing 1 leg to the left and right for 10 repetitions on each leg.
- Lunges: standing tall with both feet together, patients keep their back straight and lunge forward with the right leg approximately 1m. Right thigh
should be parallel to the ground and right lower leg vertical. Then repeat with left leg.
- Ankle bounce: patients lean forward with hands on the wall and all weight on the toes; proceed to lower both heels rapidly while maintaining the
position with the balls of their feet.
- Half squat: patients stand tall with hands out in front for balance, and then bend knees until thighs are parallel to the floor. Once at the lowest point,
fully straighten the legs to return to the starting position.
Workout
- Double knee to chest: supine. Lying on back with both knees slightly bent, hug both knees to chest with assistance of both hands (10 repetitions).
- Single knee to chest: lying on back with 1 knee slightly bent, hug each knee to chest with assistance of both hands (10 repetitions each limb).
- Pelvic tilts: supine. Knees bent, feet flat on the floor. Slowly rock pelvis backward to press part of the back toward the floor. Then slowly rock pelvis
forward to push sacrum toward the floor allowing back to arch (10 repetitions).
- Lower limbs and trunk rotation: supine with legs resting on the ball while rotating the head to the other direction (10 repetitions each direction).
- Hip adductor stretches: in a seated position, bend both legs and put the feet together. Allow the knees to lower to the ground to increase the stretch
(10 repetitions).
- Passive trunk extension: prone. Using arms, raise upper body off the floor while keeping pelvis in contact with the floor (10 repetitions).
- Bridge: supine with knees bent and feet flat on the floor. Place hands on the floor above shoulder level with elbows in the air and slowly raise pelvis
off the floor (10 repetitions).
- Abdominals: supine, curl-ups, contracting the abdominal muscles to lift the head and shoulders off the floor for 5 seconds (three sets of 8
repetitions).
- Sitting against the wall: shoulder flexion; avoid compensatory motions in the cervical, scapulothoracic (10 repetitions).
- Sitting against the wall: upper cervical flexion (10 repetitions).
- Facing a wall: standing facing a wall, slide the arms up the wall and then adduct the scapulae.
Cooling-down
- Stretching quadriceps: while standing, hold onto a counter top or chair back to assist in balance. Bend your knee back by grasping your ankle with 1
hand. Assist in bending your knee back as far as possible. Maintain position for 30 seconds. Return to start position (10 repetitions with each leg).
- Stretching hamstrings: sit on the floor with both legs out straight. Extend your arms and reach forward by bending at the waist as far as possible while
keeping your knees straight.
- Stretching gastrocnemius: stand an arms length from the wall. Lean toward the wall, placing hands on the wall. Place 1 leg forward with knee bent
(this leg will have no weight on it). Keep other leg back with knee straight and heel down. Keeping back straight, move hips toward wall until you feel
a stretch.
- Stretching to gluteals: supine. Cross left foot over right knee. Clasp hands behind right thigh and gently pull the leg in toward you, keeping upper
body relaxed. Switch legs.

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2102 T.M. Mendonca et al

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