Juvenile idiopathic arthritis (JIA) is one of the most common types of arthritis among children [1-3]. Symptoms, which include joint pain, stiffness, swelling, and fatigue [4-6], can significantly affect most children’s health-related quality of life (HRQOL). Although adolescents in the general population spend on average 57% of their time engaging in sedentary behavior after school [7], youths with JIA tend to be less active than their healthy peers and meet the national recommendations for physical activity (PA) less often [8]. Physical inactivity associated with JIA may lead to poor bone mineral density, increased fatigue, decreased muscle strength, reduced cardiorespiratory fitness capacity, reduced endurance, loss of functional independence, and diminished quality of life [9-13]. Prolonged physical inactivity may increase the risk of coronary heart disease, diabetes, hypertension, and obesity in adolescents with JIA [14,15]. It is important to help ensure that these symptoms are managed and to promote PA to reduce these long-term consequences [16]. According to recent guidelines for PA in JIA based on a systematic review of the literature [16], structured PA interventions compared with a control were, in general, effective in the self-management of JIA for numerous health outcomes, such as a reduced number of active joints [17,18], diminished pain intensity [19], increased joint range of motion [18,19], increased muscle strength [20,21], improved functional status [19,22], and enhanced quality of life [19,22].

Many specific PA programs, such as yoga and aerobic dance, have not yet been studied in this population [16] despite being recommended by several rheumatology organizations such as the Arthritis Foundation and being popular among youths, especially females [23,24]. The fact that yoga and aerobic dance appeal to female adolescents may encourage them to adopt and adhere to these programs longer [23-25].

Yoga has been found to be beneficial for adults of both sexes with rheumatoid arthritis (RA) in reducing pain, pain disability, and swollen and tender joints, increasing functional status and enhancing quality of life, general health, and vitality as well as self-efficacy regarding pain [26-29]. Although no randomized controlled trial (RCT) has demonstrated the effectiveness of yoga in the management of JIA, a single-case design study found yoga (practiced by following a DVD) to be safe and feasible for 2 female adolescents with JIA [25].

There are currently no RCTs on the effectiveness of structured aerobic dance programs for the management of JIA, although it was found that a Zumba program improved the quality of life (P<.001) and aerobic cardiovascular capacity (P<.001) of female college students aged between 19 and 23 years from the general population [30]. Other studies showed that a dance intervention improved self-rated health and reduced emotional distress among adolescent girls with internalizing problems (eg, depressed mood, low self-worth) [24,31].

Although PA interventions may be effective, there is a need to disseminate them to patients in a feasible and cost-effective way. A recent systematic review [32] revealed that information and communication technologies (ICTs) such as a Facebook offer for an exciting dissemination strategy by providing users continuous self-monitoring and self-management as well as real time feedback and information exchange [33-36]. ICTs are particularly appealing to young people as they enhance accessibility and acceptability [34,37-39]. Although ICTs have been successfully used to engage the youth, change behaviors, and provide support and education [32,39-42], few RCTs have used them to deliver information on health-related interventions [43-47]. One study successfully delivered videos of effective PA interventions to adults with arthritis via Facebook [48]. Facebook is one of the most popular and frequently used social media platforms among adolescents [34,38,39,41,49,50]. It has many features that can collect data on content popularity and audience response [51,52]. However, a similar RCT has not been conducted in JIA. Given the high prevalence of JIA among females (ie, 2-4 times more than males) [2,53,54], there is a need to disseminate potentially effective PA activities such as yoga and aerobic dance to this population in an accessible and affordable manner.

The primary objectives of the proposed single-blind three-arm pilot RCT with a parallel group will be to examine (1) the feasibility of a 12-week full-effectiveness trial of two popular types of PA and an electronic pamphlet control group: group A: an online yoga training program and a PA electronic educational pamphlet; group B: an online aerobic dance training program and a PA electronic educational pamphlet; group C: an electronic pamphlet control group (PA electronic educational pamphlet) postintervention; and (2) the acceptability of the yoga and aerobic dance PA interventions. The secondary objective of this pilot RCT will be to examine the initial effectiveness of a yoga training program (group A) and an aerobic dance training program (group B) on pain intensity, participation in PA, morning stiffness, functional status, self-efficacy, fatigue, patient global assessment, disease activity, and adverse events in female adolescents (aged 13 to 18 years) with JIA compared with an electronic pamphlet control group (group C) postintervention.

This study will use a three-arm prospective randomized open-label study. Participants will be randomized to one of the 3 following groups in a ratio of 2:2:1: group A: an online yoga training program (and a PA electronic educational pamphlet; n=10); group B: an online aerobic dance training program (and a PA electronic educational pamphlet; n=10); and group C: an electronic pamphlet control group (PA electronic educational pamphlet; n=5). The total intervention period will be of 12 consecutive weeks. The frequency and duration of the interventions are based on other trials of yoga and PA interventions in pediatric and adult rheumatology [18,20,22,26,58]. As this pilot RCT involves physical interventions (ie, yoga and aerobic dance training programs), the participants and the research coordinator administering the program will not be blinded. However, the use of anonymous online self-reported questionnaires administered at baseline and postintervention will reduce potential detection bias. With training and standard operating procedures in place, it is anticipated that any performance bias due to not blinding will be minimized.

Participants will be included in the study based on the following criteria: (1) female adolescents aged between 13 and 18 years; (2) diagnosis of JIA by a rheumatologist according to the International League of Associations for Rheumatology (ILAR) criteria; (3) absence of serious comorbidities or chronic diseases or of chronic pain that is unrelated to JIA (eg, cancer, fibromyalgia), which may impact the ability to understand and use the exercise program or complete outcome assessments (as determined by the treating rheumatologist); (4) presence of arthritis-related pain during regular activities of at least 30 on a 100-mm visual analog scale (VAS) in the past month; (5) JIA-specific medication regimen not expected to change during the study period; (6) self-reported as not meeting Health Canada’s and American College of Sports Medicine’s guidelines for PA (<60 minutes of moderate-to-vigorous PA per day) and not using physical interventions/treatments other than medication prescribed for JIA pain relief or over-the-counter medication; (7) capable of using and accessing the internet weekly for the study duration; (8) no contraindications to exercise (according to the treating rheumatologist); and (9) ability to understand English. Participants will be excluded from the study if they do not meet the inclusion criteria.

The feasibility of a full trial will be monitored throughout the study (eg, randomization, recruitment and retention of participants, data collection, and self-reported adherence). The acceptability of the interventions will be assessed using online questionnaires at the end of the study.

Clinical outcomes will be evaluated at baseline, weekly, and postintervention (at 12 weeks) through the use of online questionnaires in REDCap (Vanderbilt University). At baseline, pain intensity, functional status, fatigue, and self-efficacy will be assessed. Pain intensity and fatigue will be monitored weekly. Finally, all of these outcomes as well as the patient’s global assessment will be assessed postintervention. Outcomes were selected based on a JIA core set of outcomes to assess in trials [59]. Outcomes that were found to be essential include pain, functional status, patients’ overall well-being (global assessment), joint inflammation signs, and adverse events [59]. Other outcomes that were found to be important but not essential include fatigue, joint stiffness, and PA [59]. Other outcomes need more research to be endorsed, such as coping with the illness, which is related to self-efficacy [59].

The recruitment of a convenience sample of 25 participants (in a ratio of 2:2:1) will be performed at the Children’s Hospital of Eastern Ontario (CHEO) Pediatric Rheumatology Clinic. Rheumatologists at the CHEO Rheumatology Clinic will be provided with the inclusion and exclusion criteria for the study. During regular scheduled visits, treating rheumatologists will identify and direct eligible participants with JIA (and their parents) to the research coordinator who will explain the study in detail. Eligible participants will be invited to complete a screening questionnaire to ensure that they meet the study selection criteria before central randomization. If eligible, participants will be asked to sign either a consent form if they are able to consent or an assent form and their parent/guardian will be asked to sign a consent form. They will also complete a questionnaire that will gather sociodemographic and medical information as well as a validated questionnaire on participation in PA. They will also be asked about their preference in terms of PA.

Once informed consent is obtained, participants will be randomly assigned to one of the 3 groups using the central randomization scheme [60] and based on a sequence of computer-generated random numbers using a blocking factor (randomly varying between 6 and 9). The central stratified randomization process will be based on age (between 13 and 15 years and between 16 and 18 years).

Before running the randomization program, the data manager will document the participant’s initials (first and last names) and date of birth (month and year). After running the program, the data manager will prepare sealed opaque envelopes with the group allocation and study ID number for each patient and will provide it to the research coordinator. Participants will open the sealed opaque envelope containing their group assignment and a confidential link to access their Facebook group page where further instructions can be found. The research coordinator will explain the procedures related to the group assigned and will ask participants to indicate their availability for an initial individual online consultation as well as for virtual group sessions. Participants will be asked not to change their usual level of PA during the study except for following the program to which they were assigned.

At the clinic, participants will complete a questionnaire that will gather the following information:

At baseline, all the participants will be asked to do the following:

Following these steps, participants will be asked to complete the training program:

Groups A and B:

Group C: Participants will be invited via Facebook and email to attend an individual online consultation with the research coordinator using a video-conferencing platform. During this consultation, participants can ask questions related to their group assignment, voice their concerns, and discuss PA in general and their plan for PA in the future. They will also be invited to consult the electronic pamphlet on PA each week. For the remainder of the study duration, participants will be encouraged to attend, when possible, individual weekly 10-min online consultations. During these consultations, participants can discuss their use of PA, as well as facilitators and barriers to participating in PA. Participants will be asked to record their PA using a validated exercise log [61] as well as their pain intensity and fatigue by completing a brief electronic questionnaire that regroups valid instruments on a weekly basis.

Throughout the study, the Facebook pages will provide a means of communication for participants who will be able to share their experiences, post comments on the videos, and ask questions of each other and the research coordinator. Access to Facebook group pages will be restricted to study participants. Adolescents who cannot or do not want (or are not granted parental permission) to access Facebook will be given a link to the CHEO webpage that will contain information related to the study and their group. However, they will not be able to interact (ie, leave comments or questions) using this platform.

At 6 and 12 weeks, all participants will be asked to complete online questionnaires about the program that they were allocated to as well as the acceptability of Facebook to deliver PA programs. They will also be asked if they used any other PA during the study. They will also complete online questionnaires assessing their pain intensity, functional status, fatigue, self-efficacy, and well-being (using a patient global assessment). This will take about 20 to 30 minutes to complete.

As a compensation for the time given by participants, they will receive a US $21.40 gift certificate for completing baseline questionnaires and a US $21.40 gift certificate for completing postintervention questionnaires. They will also receive a personalized certificate of participation (community hours for school).

The electronic questionnaires will be made accessible to all participants on each group's Facebook page with a URL link or on the CHEO webpage for those who do not wish to create a Facebook account. Participants in groups A, B, and C will be emailed the same URL link to access the questionnaires. Using the wall on the Facebook page for all groups, or the CHEO webpage, the research team will provide updates and reminders to all participants regarding deadlines to complete the questionnaires.

The following outcome measures will be used to answer the primary objective:

The following outcome measures will be used to answer the secondary objective:

Descriptive statistics, such as proportions, means, and standard deviations, will be used to summarize the baseline and end-of-study variables across the 3 study groups (groups A, B, and C) and to assess the distributional assumptions of the statistical techniques used. For the primary objective, data on recruitment rate, randomization process, interventions, clinical and ICT outcome measures, dropout rates, and adherence rates for the interventions will be collected. For the secondary objective, a repeated measures analysis of variance with the fixed-factor study group (A, B, or C) and the within-factor assessment time (0, 6, and 12 weeks) will be conducted to compare groups for the clinical outcome measures at 0, 6, and 12 weeks. An intention-to-treat analysis will be conducted and mixed model repeated measures will be considered to accommodate missing data.

The current sample size is adequate for pilot studies involving group comparisons to assess feasibility and to estimate the variance to determine the sample size for a definitive trial [76].

This multidisciplinary and multidimensional rehabilitation study is a rigorous, accessible, single-blind, three-arm pilot RCT using the prospective randomized open blinded endpoint design. It involves web-based, innovative, accessible self-management programs for adolescents with JIA similar to those used in previous studies [41,77,78]. The first strength of this study design is that it will include PA activities that are recommended by several rheumatology organizations and may meet adolescent females’ activity preferences. To our knowledge, this is the first study to assess the effectiveness of aerobic dance and yoga on pain management in female adolescents with JIA. It also aims to reduce daily pain intensity and fatigue severity and improve the functional status, self-efficacy, and PA adherence among female adolescents with JIA. The second major strength of this study is that it will use ICTs to deliver these activities and information to youths. The rapid increase in eHealth will appeal to young participants who are already consulting online resources for self-management [79]. This design will be able to overcome time, geographical, and financial constraints. Furthermore, online questionnaires will increase the accessibility and confidentiality of collected outcome measures.

The involvement of a research coordinator, who will be mentored by a team of rehabilitation specialists, is a strength of the study. Rehabilitation specialists play an essential role in supporting community-based self-management programs targeting youths living with chronic conditions, such as JIA [16].

Separate Facebook group pages and individual online consultations using a video-conferencing platform minimized the potential risk of contamination between comparison study groups. Central randomization is ideal for minimizing the potential risk of biases. This proposed pilot RCT is necessary to address the questions of clinical and scientific importance for rehabilitation specialists in improving the health of female adolescents with JIA through the use of PA-based interventions.

The blinding of participants is impossible in this type of study, as is generally the case with physical rehabilitation RCTs [80].

There is an increased risk of Type 1 error, rejecting the null hypothesis when it is actually true, due to the presence of multiple outcomes (ie, multicollinearity). The results of this study will likely only be generalizable to female adolescents (ie, those aged 13 to 18 years) with JIA who consult at a pediatric rheumatology clinic in a tertiary care center.

Due to financial limitations, we will use low-cost, accessible ICTs. Although a virtual gym with a live PA instructor would be ideal, participants will have access to recorded sessions led by PA instructors and approved by rehabilitation specialists in rheumatology and will receive support from a research coordinator trained in PA at least once a week.

Hospital-based recruitment may attract more severe cases of JIA. However, central randomization will be implemented as it is ideal to minimize the potential risk of biases.

This study will examine the effectiveness of yoga among female adolescents with JIA, as outcomes will be assessed at 12 weeks.

This pilot RCT has substantial potential to enhance our understanding of the potential effectiveness of popular PA interventions disseminated to patients with JIA using ICTs, making it a novel study. This will help understand which PA intervention has the most potential for improved outcomes. It will also help determine whether these PAs and ICTs are acceptable to youths with JIA and whether a larger trial would be feasible. The proposed pilot RCT will contribute to the knowledge of the effect of a specific functional activity on self-reported pain relief, functional status, and self-efficacy as well as PA adherence, daily pain, and fatigue intensity.

This study could also set the standard for community-based care for female adolescents with JIA. Moreover, other rehabilitation or functional interventions could be examined for youths with other chronic diseases.