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Running head: JUVENILE IDIOPATHIC ARTHRITIS

Juvenile Idiopathic Arthritis Case Study


Natasha Arastehmanesh, Samantha Burneo, Tonya Dedera, Edith Feld, Cynthia Sanchez & Peter
Wallace
Touro University Nevada

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Introduction

Jason is a 13-year-old boy with polyarticular juvenile idiopathic arthritis (JIA). He was
diagnosed when he was five-years-old, and has since received services from a multitude of
professionals including, but not restricted to occupational and physical therapy. He is part of a
nuclear family with two siblings: an 18-year-old brother Jimmy and 16-year-old sister Amanda.
He is currently in the eighth grade at a regional public junior high school and will be transferring
to a large four year high school next year. Academically Jason is on track with his fellow
classmates, but is unable to participate in any activities that involve sports and require physical
strength, coordination, balance, and endurance. Jason avoids family outings and school trips that
involve physical activities and long commutes. Though he distances himself in those situations,
his family is still extremely supportive and encouraging. They are very open to therapy services
and suggestions for his future development. Children with arthritis have been shown to engage in
less physical activities and has resulted in deconditioning, which has led to an inactive lifestyle
(Grewal, Wright, Bar-or, & Feldman, 2006). This leaves Jason with a feeling of concern as his
goals are to engage in age-appropriate recreational activities with his friends. Jason currently
takes medications such as Naproxen and Methotrexate to control his symptoms.
JIA is a clinical diagnosis in children under 16 years of age displaying arthritic symptoms
for a duration of at least six weeks (Weiss & Ilowite, 2007). These symptoms include swelling
and limited range of motion of the joint accompanied by heat, pain, or tenderness (Weiss &
Ilowite, 2007). JIA is a common diagnosis in children; about one in every 1,000 children develop
it (Abramson, 2013). There are several types of JIA, identified by how many joints are affected.
Polyarticular JIA is a specific type that affects at least five joints and can begin at any age
(Abramson, 2013). Jason experiences active joint inflammation in the knees, ankles, toes,

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elbows, wrists and fingers (i.e., metacarpophalangeal and proximal interphalangeal). Even
though the exact cause of JIA is unknown, JIA is thought to occur due to an immune system
malfunction that targets the synovial membrane of joints and causes inflammation. Currently
there is no known cure for JIA; therefore, the goal of treatment is to manage pain, control
inflammation, and improve quality of life (Abramson, 2013). It is recommended for a child with
JIA to attend occupational and physical therapy in order to restore musculoskeletal health and
function (Hoffart & Sherry, 2010). An increase in active forms of therapy have been
implemented recently and guidelines have included recommendations for fitness and
strengthening exercise in children with JIA to improve function and promote a better quality of
life in concert with physical activity (Grewal, et al, 2006).
Activities of Daily Living
Jason completes a majority of his activities of daily living (ADLs) independently. This
includes but is not limited to dressing, bathing, eating, and donning and doffing his wrist and
hand splints. Jason is responsible for managing his personal care devices. He utilizes orthotics in
his shoes and sleeps with hand and wrist splints nightly. He is fully capable of utilizing eating
utensils when wrist and hands splints are not being worn. Jason walks around his home
independently but his foot pain makes this a cumbersome process.
Instrumental Activities of Daily Living
Despite his foot pain, Jason is able to independently walk to the school bus stop that is
around the corner from his home. He is also able to walk to the neighborhood community center
where he plays different types of games (i.e., board, socialization, and virtual) with friends. Jason
receives care from a rheumatology team at a tertiary care center to manage his arthritis. In
addition, he attends an outpatient therapy facility where he receives services from professionals,

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such as physical and occupational therapists. Even though Jason can independently take his
medications, Naproxen and Methotrexate, his mother needs to constantly remind him to take
them at the appropriate times.
Rest and Sleep
Jason does not currently experience any sleeping difficulties. He gets an average of eight
hours of sleep a night and a two hour nap when he comes home from school. Jason keeps his
wrist and hand splints on before he goes to bed at night and before he takes his nap after school.
This is to avoid contractures and deformities. However, Jason wakes up in the mornings with
stiffness which hinders his ability to engage in early morning activities. Joint stiffness, also
referred to as morning stiffness or gelling occurs after a child has slept or due to a lack of
physical activity (Rogers, 2010).
Education
Jason is in the eighth grade at the regional public junior high school, Canarelli Middle
School, where he is successful academically. His favorite subjects are math, Spanish, and
science. Jason enjoys leisure reading outside of completing schoolwork. He has many school
friends but he does not get involved with any physical activities within or outside of the school.
Jason is part of the annual book fair setup at school each year. He helps divide the books into
categories and design the table displays. His teachers report Jason is an incredibly dedicated and
hardworking student, but tends to spend a lot of time catching up on schoolwork due to his
numerous absences because of his disability. Next year, Jason will transfer to Foothill High
School, a large four-year school that is two stories high. A big concern for Jason is his ability to
keep up with the other students. The school will be larger than what he is use to, therefore
walking across campus to different classrooms may become problematic.

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Work

Jason is responsible for doing moderate chores at home. His main responsibilities are
making his bed, cleaning his room, and helping pick up around the house. Due to his foot pain,
Jason cannot walk their miniature dachshund Rocky around his housing community, but is
responsible for bathing him. He and his siblings, Amanda and Jimmy, share the duties of putting
their clean laundry away and taking out the kitchen garbage. After supper, Jason is responsible
for putting away dishes and cleaning off the dining table.
Play
Jason enjoys being social with his friends and classmates. He wishes he had more energy
to participate in the physical activities his classmates are enrolled in since his condition has
limited him from many extracurricular activities. Jason would also like to play on one of his
schools sports teams. He also enjoys to play the Wii Bowling with his siblings on family game
night because he can sit down during this activity and does not have to expend a lot of energy.
Another activity he enjoys being a part of is his church youth choir group that he meets every
Sunday.
Leisure
Jason would like to join his family when they hike, bike, and ski on their vacations. He
usually will sit in the lodge while his family goes on their adventures because he knows he will
not be able to keep up with them. He has also mentioned how he would like to participate in a
physical activity specifically a sport. He has attended ball games to support his friends, but he
hopes to one day join them out on the field instead of sitting in the bleachers. He enjoys
collecting baseball cards and organizing them in his baseball binder. His favorite baseball team is

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the Dodgers. Jason enjoys playing in his backyard pool with his family especially playing pool
noodle javelin toss.
Social Participation
At Jasons current age, he should be developing more friendships and becoming more
independent from his parents. Due to his disability, he tends to spend more time with his family
because he feels he cannot keep up with his friends in the physical activities they participate in.
Jason and his family attend church on Sunday. He and his siblings are enrolled in the youth
program where Jason has made a few friends. Jason follows many of his friends through social
media when he is too weak to hang out with them.
Assessments
In order to plan the best intervention program for Jason, four assessments were selected
to evaluate Jasons functional ability, participation in activities, and quality of life. The following
assessments are either norm-referenced or criterion-referenced standardized tools, and all of the
assessments are age-appropriate and suitable for children with polyarticular JIA.
The Childrens Assessment of Participation and Enjoyment and the Preferences for
Activities of Children (CAPE/PAC) was selected to assess Jasons participation and preference
for activities. One of the reasons for selecting the CAPE/PAC was Jasons desire to play
recreational sports and participate in other age appropriate activities. The CAPE usually takes
30-45 minutes to administer while the PAC takes 15-20 minutes (Richardson, 2010). The CAPE
and PAC are criterion-referenced assessment tools designed to measure and document a childs
participation, intensity, and enjoyment of many activities. Activity areas within the CAPE and
PAC include Recreational, Physical, Social, Skill-Based, and Self-Improvement, so these
assessments can help Jason find activities that he may be interested in (Richardson, 2010).

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To measure Jasons functional ability, the Juvenile Arthritis Functional Scale (JAFAS)
was selected. The JAFAS measures several areas of functional ability in children seven to 16
years-old with juvenile rheumatoid arthritis (Singh, Athreya, Fries, & Goldsmith, 1994). The
JAFAS is quick and relatively simple to administer, and can be completed in 10 to 15 minutes. It
measures a childs capacity to perform ADLs and IADLs by addressing many activity
components of the International Classification of Functioning, Disability, and Health. The
JAFAS has good validity and reliability, therefore a clients score demonstrates an acceptable
relationship with several widely recognized measures of disease. The JAFAS is an appropriate
evaluation tool for establishing pediatric rehabilitation interventions and assessing day-to-day
functional abilities, and is well suited for assessing children with limited range of motion due to
JIA (Singh et al., 1994). In addition to the JAFAS, the VASCHAQ-38 was used by a previous
therapist and results were added to Jasons file.
The Bruininks-Oseretsky Test of Motor Proficiency, 2nd edition (BOT-2) was selected
to asses Jasons body coordination, strength, and agility. The BOT-2 is a norm-referenced
standardized test that is used to assess motor proficiency (Richardson, 2010). The BOT-2
compares a clients motor skills to that of a normative sample, and is suitable for assessing
Jasons motor proficiency. Jason was formerly assessed with the BOT-2, and his scores were one
to two standard deviations below the mean of the normative sample, falling well below the
average for his age group.
Finally, manual muscle testing and range of motion (ROM) are a type of standardized
test that are commonly used in conjunction with the typical pediatric norm-referenced and
criterion-referenced assessments. Active range of motion (AROM) and passive range of motion
(PROM) are appropriate measures taken for Jason because they are quick and easy ways to

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assess and reassess Jasons affected joints. According to Cakmak and Bolukbas (2005), children
with polyarticular arthritis are much less active than their peers because their chronic pain and
stiffness keep them from performing activities that demand ample exercise capacity. Limited
ROM may keep Jason from participating in many developmentally appropriate activities, so
continually assessing Jasons joint mobility is important in the evaluation process. In addition to
standardized musculoskeletal evaluations, clinical observations of muscle tone, range of motion,
balance, posture, and physical strength are suitable for Jason.
PEOP
The People Environment Occupation Participation (PEOP) model can be used for a wide
variety of disabilities. It looks at the person in their current situation, their environments,
occupations, and performance. This model provides substantial detail about both internal and
external factors to support occupational therapists to analyze the interests, skills and capacities of
the person, the demands of the environment and how they interact to facilitate or inhibit
occupational performance and participation (Turpin & Iwama, 2011, p. 94). By utilizing this
model with Jason we can focus on multiple aspects that will allow us to use a holistic approach.
It can help determine different adaptive equipment to use for Jason by looking at the
environment he is engaged in regularly. For example, having Jason use a backpack that rolls will
allow him to bring all the necessary textbooks to class rather than having him carry them or place
them in a backpack on his back. Using a backpack could cause more strain on his back. We can
also suggest different activities that are low impact to improve his performance and focus on
occupations that are meaningful to him which will be discussed further within this report.
Frames of References

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There are many frames of references that can be utilized in Jasons intervention based on
his diagnosis including psychosocial, compensatory, and biomechanical. The psychosocial frame
of reference would be beneficial for Jason because it would allow him to work on his social
skills, internal and external coping abilities, and social emotional difficulties (Case-Smith, Law,
Missiuna, Pollock & Stewart, 2010). For example, Jason has not been able to participate in
physical peer activities due to his debilitating condition. According to Ding, Hall, Jacobs, &
David (2008), Physical disabilities that are chronic and really hinders a childs daily life
activities, are considered a lifelong threat that will affect a childs psychological functioning ( p.
663). In order to increase his involvement the therapist will use this frame of reference to help
Jason develop strategies to be more involved. The compensatory frame of reference will be
utilized to provide Jason techniques and adaptive equipment to improve his independence in his
occupations (Case-Smith et al., 2010). An example of utilizing this frame of reference would be
to give Jason adaptive equipment such as orthotics to increase mobility in his lower extremities.
Due to Jasons lack of endurance, strength, and range of motion, the biomechanical frame of
reference can focus on improving physical abilities to be more functional in his everyday
activities (Exner, 2010).
Problem Statements
1. Child is unable to sit in a bus for a long time due to stiffness in his neck.
2. Child is unable to hike due to joint inflammation in his ankles and knees, which cause his feet to
hurt overtime.
3. Lower back pain results in an inability to endure sitting at his desk for the entire school day.
4. Frequent visits to the doctor results in absent days at school and more time spent catching up on
school work.
5. His inability to partake in physical education courses and sport teams results in a feeling of
isolation and dismay from his peers.

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Family Goals

1.
2.
3.
4.
5.

Jason wishes to be more involved in outings with his friends.


Jasons parents want Jason to be able to actively participate in family outings.
Jasons parents want Jason to experience less morning stiffness.
Jasons mother wants Jason to independently take his medications at the correct time.
Jason wants to be able to move around school without experiencing high levels of fatigue.
Occupational Therapy Goals

1. Jason will independently go on a school weekend trip with his classmates by the end of the
school year.
Objective 1a: Jason will establish a medication routine to organize all of his medicine
independently by February 2, 2015.
Activity 1: In order to increase time management, Jason will fill out a daily time
log with what medications he needs to take in the therapy session. This will
specifically identify when he has to take the medication and exactly what
medication he will be taking. Jason can then set alarms in his iPhone that are
consistent with this time log.
Activity 2: In order to increase responsibility, Jason will play the board game
What Should You Do? A Game of Consequences to teach Jason the
consequences of his actions. This game requires him to answer multiple choice
questions based on real life scenarios where he can only advance in the game if he
chooses the appropriate answer. If he does not choose the appropriate answer he
will move back spaces and the therapist will discuss with him why that choice
was not appropriate.
Objective 1b: Jason will sit independently on the bus for two hours with a cervical
collar that provides postural stability and comfort in one month.

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Activity 1: Jason will play Wii Bowling while wearing a cervical collar brace
while sitting down. This will allow Jason to sit for a long period of time while
playing a motivating and exciting game that he wants to finish. Playing the Wii
Bowling, or another video game of his choice, will allow him to participate in
something that he finds enjoyable, while becoming comfortable wearing the
brace.
Activity 2: Jason will make a homemade pizza during the therapy session while
sitting down. This entails rolling out the dough with a rolling pin, spreading the
tomato sauce on the dough, sprinkling on the cheese, and adding toppings. This
also requires Jason to preheat the oven prior to making the pizza. He must set the
timer after placing the pizza in the oven and monitor its progress so it does not
burn. Most of this activity will be done sitting with the cervical collar on to build
more postural stability. This activity will also work on strength and range of
motion.
2. Jason will independently join and participate in his communities baseball league with his
friends by June 5, 2015.
Objective 2a: Jason will pitch twelve baseballs forty feet with minimum assistance.
Activity 1: Since Jason does not currently have the ability to combine endurance
and strength activities, playing the game of tetherball on the therapy outdoor
playground will give him the opportunity to work on shoulder strength and range
of motion. This game requires Jason to utilize upper body strength and endurance
while standing in one place.

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Activity 2: Jason will participate in the pool game of Pool Noodle Javelin. This
activity will increase his hand-eye coordination, endurance, and range of motion.
This game entails Jason to throw a pool noodle through a looped noodle structure
held by the occupational therapist.
Activity 3: Jason will utilize the therapy pool basketball hoop to shoot fifteen
baskets with a weighted ball. This requires Jason to use his upper body and core
strength to shoot the heavier ball through the hoop to work on hand-eye
coordination, endurance, and range of motion.
Objective 2b: Jason will independently catch 10 thrown baseballs from the occupational
therapist from forty feet away without dropping any by May 31, 2015.
Activity 1: Jason will participate in throwing a light weight ball against a square
trampoline while standing. This allows the ball to bounce back to Jason, which he
must catch. This requires Jason to use hand-eye coordination, balance, core
strength, shoulder endurance, and track and fixate on the ball as it comes back in
his direction. Jason also has to calibrate the amount of force he uses when
throwing the ball because too much force will cause the ball to shoot back faster.
Activity 2: Jason will participate in a catching activity in the pool while sitting on
a raft. The OT will throw Jason a volleyball from different distances. This will
require Jason to use gross motor skills, core strength, balance, and praxis. It will
also prepare Jason for the diverse situations that he may encounter in baseball.
3. Jason will ride his bike independently on flat paved path outside for 30 minutes without
stopping by July 30, 2015.

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Objective 3a: Jason will walk up and down two flights of stairs at school independently
without holding the railing in two months.
Activity 1: He will stand while participating in a virtual kickboxing game that is
played on the Xbox Kinect system. During this game, Jason has to actively move
his arms and legs in order to mimic what is being performed in the game. For
example, he has to kick or punch at the virtual targets at different positions. This
activity will improve Jasons endurance and is a game he could achieve higher
levels as his endurance and coordination improves.
Activity 2: In order to build leg strength and endurance Jason will kick ten laps in
the therapy pool using a kickboard. The kickboard will provide him support and
buoyancy.
Objective 3b: Jason will exhibit a 10% decrease in his pain level through use of pain
management strategies after physical activity in three weeks.
Activity 1: Before the beginning of a physical activity Jason will get
transcutaneous electrical nerve stimulation (TENS) on his lower back. In addition
heating pads will be placed on his upper and lower back to decrease tension and
stiffness for fifteen minutes. This will require Jason to lay down on a comfortable
table mat with suitable supports without moving for the required time.
Activity 2: After the completion of a physical activity Jason will apply ice packs
to his upper and lower extremity joints. This will alleviate inflammation or any
pain he experienced during the activity.
Environmental Setting

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Jason attends therapy services at Shining Star Therapy, an outpatient pediatric


rehabilitation clinic. The clinic has a therapy gym, therapy pool, kitchen set up, outside
playground, and one-on-one treatment rooms. Clients receive individualized therapy from an
occupational therapist, along with other services, such as physical and speech therapy. The
occupational therapist mainly works with Jason in the therapy pool to improve functional
mobility in the areas of strength, endurance, and range of motion.
SOAP Note
Subjective: Client states that he is excited about his treatment plan. He complained of being tired
while he was swimming on the paddle board. He rated his overall pain as a 3 out of 10 at the end
of the session.
Objective: Client participated in 45-minute OT session in an outpatient rehabilitation pool for
increasing endurance, strength, and range of motion. Jason independently participated in active,
static, and dynamic stretching in the pool to increase range of motion in upper and lower
extremities. Jason participated in kicking on a kickboard independently with two one-minute
breaks to increase lower extremity strength and endurance. Jason participated in upper extremity
resistance band strength exercises independently without any breaks. Jason participated in a
catching activity while sitting on a raft independently with two one-minute breaks. Jason
modified independently participated in a basketball shooting activity with three one-minute
breaks.
Assessment:
Problems: Deficits in strength and endurance limit Jasons ability to complete the resistance band
exercises.

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Progress: The foam noodle assists in Jason's ability to complete the basketball activity by
decreasing weight bearing on his feet.
Potential: Jasons ability to complete the warm-up activities without any brakes shows his
potential in increasing his endurance, strength, and range of motion.
Jason will benefit from aquatic therapy to participate in age-appropriate activities such as team
sports.
Plan: Client will be seen 45 minutes 2x/wk to improve his overall functional mobility. Sessions
will focus on improving strength, range of motion, and endurance.
Movements, Postural Reactions, and Tone
Jason is able to independently maneuver through his environment; however, he
experiences fatigue and foot pain when walking for a long period of time. His coordination,
balance, and endurance are affected by his limited motor control. As a result, this affects his
ability to engage in outdoor activities such as hiking, biking and skiing. Jasons arthritis has
affected his ability to maintain proper posture. It has been noted that he has a 50% decrease in
cervical spine rotation and lateral flexion. This has contributed to Jason experiencing morning
stiffness every morning. It affects his ability to endure desk work and riding in the school bus.
Due to his neck and low back pain, Jason can only sit for twenty minutes at his desk. This adds
another barrier to completing his school work on time and concentrating in class. When sitting,
he displays a posterior pelvic tilt and a forward head tilt. This results in Jason resting his weight
on the desk through his upper extremities. It is difficult for him to sit in a slight anterior pelvic
tilt with his head and neck aligned with his trunk. Jason does not display any primitive reflexes.
Even though Jason displays normal muscle tone and sufficient strength to perform gross and fine

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motor tasks, his lack of endurance, postural stability, and limited range of motion affect his
movements and coordination.
Sensory Integration and Self-Regulation Issues
Jason is hypersensitive and experiences a low threshold for pain, even when a painful
stimulus is absent. This phenomenon he experiences is also known as allodynia. He experiences
acute joint pain in his neck, lower back, feet, toes, wrists, and fingers. This pain impacts his
ability to engage in age appropriate activities, such as going on field trips and engaging in sports.
Jason rates his pain only a 5/10, and emotionally self-regulates by ruminating on his condition.
This maladaptive technique contributes to his overall score of 5/10 on the Quality of my Life
Scale evaluation.
Specific Recommendations
The client will remain at home with his family, but he will continue going to the
rheumatology clinic every six months at St. Marys Childrens Hospital. As for occupational
therapy, the client and family will be educated in joint protection and energy conservation
techniques. An example of energy conservation might consist of sitting while showering, taking
frequent breaks while doing tasks, using the stronger larger joints for tasks, and using a rolling
backpack for school. The occupational therapist would recommend a home exercise program for
the client. This would include range of motion exercises to strengthen muscles, protect the
clients joints, and to maintain joint mobility. The client will perform these exercises as often as
needed to avoid fatigue and assist with stiffness. In order to avoid the client becoming bored
completing the exercise program alone, the occupational therapist would ask the parents to either
incorporate an incentive program or have the entire family participate in the exercise routine. The
occupational therapist will educate the caregivers on how to manage pain, splints, how home

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exercises are beneficial, and how to implement appropriate home modifications. The hand and
wrists splints can be remolded and a lining can be used for comfort to reduce the itchy rash on
his forearm. The occupational therapist would alleviate the clients neck stiffness by addressing
the optimum desk height for the client to perform school work. An electrical blanket, hot bath,
and showers are therapeutic recommendations used to relieve his morning stiffness.
Justification of Treatment
Jasons pain and joint stiffness interfere with his ability to engage in many age
appropriate school, play, and leisure activities. Jason would benefit from therapeutic
interventions that control pain, restore and maintain range of motion, improve muscle strength,
increase endurance, and ultimately increase Jasons functional level. According to Cakmak and
Bolukbas (2005), children with polyarticular arthritis are much less active than their peers
because their chronic pain and stiffness keep them from performing activities that demand ample
exercise capacity. Jasons involvement in physical activity is somewhat of a paradoxical situation
because research supports the need for increased physical activity to decrease pain and stiffness,
but its Jasons abiding joint stiffness, pain, and foot deformities that keep him from participating
in physical activity.
Physical exercise has been the cornerstone of treatment for children with JIA because it
improves muscle strength, endurance, and well-being. Numerous research articles recommend
physical exercise to reduce pain and increase functional range of motion (Anthony &
Schahnberg, 2003; Cakmak & Bolukbas, 2005). Commonly, therapists incorporate aerobic and
strength building exercises of moderate intensity into intervention; however, Jasons current level
of pain and joint flexibility makes it difficult to incorporate exercises of moderate intensity into
his treatment plan.

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Jasons current level of pain and anticipated pain keep him from performing in many
physical activities. Aquatic therapy is a suitable way to introduce physical activity because it
minimizes gravity, adds resistance, and immediately reduces pain. According to Bilberg,
Ahlmn, and Mannerkorpi (2005), aquatic therapy of moderate intensity significantly improves
muscle endurance and reduces pain for patients with rheumatoid arthritis. Al-Qubaeissy, Fatoye,
Goodwin, and Yohannes conducted a systematic review of literature regarding the use of aquatic
therapy for rheumatoid arthritis. This article reviewed a vast amount of literature that suggests
that aquatic therapy significantly improves both physical and psychological functioning for
clients with rheumatoid arthritis (Al-Qubaeissy, Fatoye, Goodwin, & Yohannes, 2013). Aquatic
aerobic exercises and aquatic games, such as the javelin, ball toss, and basketball games included
in our intervention, provide no-impact or low-impact exercises that significantly decreases pain,
induce muscle relaxation, and increase physical function. Aquatic therapy is appropriate for
Jason because it will reduce his pain and joint stiffness and allow him to engage in physical
activities with his family and friends. Jason wants to participate in age appropriate physical
activity; however, he hasnt seen the benefits of physical exercise previously because the
activities hes tried have increased his pain. He would benefit from aquatic therapy exercise
because it has a low impact on his joints and it will help increase his physical endurance and
range of motion while reducing his pain.
Conclusion
In conclusion, polyarticular arthritis is a debilitating condition that affects many aspects
of an individual's life. Though Jasons condition has limited him in participating in physical and
social activities, with the proper treatment he will be able to independently function in age
appropriate activities. Through the services of a multitude of professionals, he can improve his

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performance in many areas of life physically and socially. These constitute, but are not limited to
an array of treatment activities that include range of motion, muscle strengthening, and
endurance through occupational therapy.

References
Abramson, L. S. (2013).

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AlQubaeissy, K. Y., Fatoye, F. A., Goodwin, P. C., & Yohannes, A. M. (2013). The effectiveness
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