Physical activity for paediatric rheumatic diseases: standing up against old paradigms

Key Points

  • Patients with paediatric rheumatic diseases can be hypoactive, which can be detrimental to disease symptoms and function

  • Several symptoms experienced by patients with paediatric rheumatic diseases might be mitigated by increasing physical activity levels

  • The systemic benefits of exercise training clearly outweigh the potential risks in paediatric rheumatic diseases

  • Health professionals are advised to assess and track physical activity levels and sedentary behaviour on a routine basis, as they are invaluable health risk parameters

  • The concept that 'exercise is medicine' should be extended to the field of rheumatology and officially embraced by its scientific and professional organizations


Over the past 50 years it has become clear that physical inactivity is associated with chronic disease risk. For several rheumatic diseases, bed rest was traditionally advocated as the best treatment, but several levels of evidence support the imminent paradigm shift from the prescription of bed rest to physical activity in individuals with paediatric rheumatic diseases, in particular juvenile systemic lupus erythematosus, juvenile idiopathic arthritis, juvenile fibromyalgia, and juvenile dermatomyositis. Increasing levels of physical activity can alleviate several symptoms experienced by patients with paediatric rheumatic diseases, such as low aerobic fitness, pain, fatigue, muscle weakness and poor health-related quality of life. Moreover, the propensity of patients with paediatric rheumatic diseases to be hypoactive — often due to social self-isolation, overprotection, and fear and/or ignorance on the part of parents, teachers and health practitioners — can be detrimental to general disease symptoms and function. In support of this rationale, a growing number of studies have demonstrated that the systemic benefits of exercise training clearly outweigh the risks in these diseases. In this sense, health professionals are advised to assess, track and fight against physical inactivity and sedentary behaviour on a routine basis, as they are invaluable health risk parameters in rheumatology.

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Figure 1: A vicious cycle of physical inactivity and/or sedentary lifestyle and systemic dysfunction.


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We would like to thank Fundação de Amparo à Pesquisa do Estado de São Paulo (process 2015/03756-4), Conselho Nacional de Desenvolvimento Científico e Tecnológico (processes 305068/2014-8, 301805/2013-0, 303422/2015-7), Federico Foundation, Núcleo de Apoio à Pesquisa “Saúde da Criança e do Adolescente” da USP (NAP-CriAd), and Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) for supporting the authors' work. We thank B. Saunders for proofreading this article. Also, we are grateful to all current and former students, health care providers and researchers working at the Laboratory of Assessment and Conditioning in Rheumatology (School of Medicine, University of São Paulo, Brazil), especially A. L. de Sá Pinto and F. Rodrigues Lima, who conceived and created this laboratory, which is primarily dedicated to investigate the effects of physical activity in rheumatologic diseases. We are also indebted to the patients and their parents who have taken part in our studies throughout the years.

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All authors researched the data for the article, provided a substantial contribution to discussions of the content, contributed to writing the article and reviewed and/or edited the manuscript before submission.

Corresponding author

Correspondence to Bruno Gualano.

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Physical inactivity

The failure to meet the specific physical activity guideline of ≥60 min of moderate-to-vigorous physical activity per day for paediatric populations.

Physical activity

Any bodily movement produced by the skeletal muscles that results in energy expenditure.


A physical activity that is planned, structured, repetitive and purposeful, in the sense that improvement or maintenance of one or more components of physical fitness is an objective.

Sedentary behaviour

Any waking behaviour that is characterized by an energy expenditure ≤1.5 metabolic equivalents (METs) while in a sitting or reclining posture.


A physical activity level that is lower than that of healthy peers matched by age, sex and cultural and socioeconomic background.


An athletic activity, often of a competitive nature, requiring skill or physical prowess.

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Gualano, B., Bonfa, E., Pereira, R. et al. Physical activity for paediatric rheumatic diseases: standing up against old paradigms. Nat Rev Rheumatol 13, 368–379 (2017).

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