Sarah is a 12-year-old girl who has been living with Juvenile Idiopathic Arthritis (JIA) for two years, experiencing pain, stiffness, and swelling in both her knees (more severe in the right one) and her right ankle which affect her mobility. JIA is a long-lasting autoimmune inflammatory condition that affects the joints of children under 16 years old and is characterized by persistent inflammation lasting six weeks or more (Petty et al., 2004). Beside the physical issues, this burdensome condition also leads to psychological issues, such as depression and anxiety, compared to healthy children (Fair et al., 2019). The fear avoidance model suggests that individuals who overestimate the danger of their pain may develop “protective fear responses” (Vlaeyen et al., 2016). Unfortunately, Sarah’s physical and mental well-being caused her to avoid physical activities due to her concern that it could cause more harm to her joints. Her parents’ perception of pain also contributes to this behavior. Research indicates that only 40% of children with JIA engage in the recommended daily 60-minute of physical activity( PA)  (Niewerth et al., 2014, Bohr et al., 2015). This avoidance, in turn, leads to further physical decline, disability, and a decreased quality of life. Low bone mineral density is one of the potential side effects in this cases. All these factors: anxiety, fear of movement, pain contributed to her low physical activity. The SWASY was designed to address these aspects according to the current research on behavior changes, especially in adolescent.  

Exercise therapy considers as an important component of her management (Cavallo et al., 2017),  improving pain, mobility, and quality of life. In a across sectional study conducted on adult with JIA, they found that patient with JIA who were physical active had better health-related quality of life (HQoL) (de Oliveira et al., 2023). The adolescent period is crucial as habits developed during this time tend to persist, making it a key phase for establishing longlasting routines (McGorry et al., 2011). It is important Sarah to establish a heathy level of PA to improve quality of life and prevent further disease and health complications. In order to promote physical activity (PA) and therefore improve adherence to exercise therapy, barrier to PA need to be considered and tackled. Factors that were found to improve and encourage participation to exercise therapy amongst adolescent with JIA were knowledge of its potential benefits and parental support (Sims-Gould et al., 2018). In addition, lack of information about how to manage the disease was one of the challenging of child and their parents (Min et al., 2022).  Education was considered in the SWAY by providing information about the condition in order to change perceived beliefs and threats and the benefits of exercise.  Also, advice and skills training on how to control flare-up was included. That was one arm of the way to behavior change which difficult and complex specially with adolescents (Strömmer et al., 2020).  Parental support plays an important role toward improving physical activity for their children. That was emphasized in the SWAY in a way that Sarah’s parent can encourage her to be active and support her through rebuilding confidence and increasing self-efficacy. Therapist support 

Fear-avoidance model is described how a person responds to their pain (Asmundson et al., 2012). Sarah developed a maladaptive response to her pain- which spirals into a cycle of dependence on others and further increase disability and depression.  A robust cochrane reviews on psychological therapies for chronic pain in children and adolescents of 37 RCTs (n= 2111) shows that   cognitive behavioural treatments are effective in reducing pain intensity and disability. However, none of the included studies evaluated the effectiveness of psychological therapies for children with juvenile idiopathic arthritis, which limits our ability to generalize the results. 
 Acceptance and commitment therapy (ACT) is based on acceptance of pain and enables a transition in life's focus from suffering to items of greater value(Bailey et al., 2010, Delprato, 2001). A randomized control trial conducted on 32 children with chronic pain due to certain pathology including arthritis, to compare the effectiveness of ACT and exposure strategies to a multidisciplinary treatment approach involving amitriptyline (Wicksell et al., 2009). The ACT group experienced significant and long-lasting improvements in various areas such as perceived functional ability, pain-related discomfort, kinesiophobia and quality of life. This concept was adopted in the SWAY for improving Sarah psychological flexibility and helping her engage in satisfying activities- which is physical activity and exercise despite her pain. However, to make this approach more age-appropriate, therefore, she can understand the concept easily, cartoons in a lay language were utilized. Another approach that was incorporated with ACT is gradual exposure therapy. It is a widely utilized behavioral approach to re-engage patient to perform feared activities. Sarah was afraid of return to dancing and stairs climbing. Sarah was introduced to these activities slowly -more details in the SWAY. In addition, these avoided activities had great value for Sarah which could improve adherence toward the therapy. Relaxation techniques was taught to Sarah to cope with the anxiety that comes up with the therapy.

Motivational interviewing (MI) is a client-centered, collaborative approach to behavior change through communication with emphases on change that elicits and reinforces by the clients (Miller and Rollnick, 2012). MI interventions will be utilize  when therapist notice a desire of change using Transtheoretical Model of Change. Given that Sarah is an adolescent who likes to have control over her life, encouraging her towards self-initiated changes would be more appealing for her (Naar and Suarez, 2021) rather than imposing external goals or pressures. Suarez and Mullins (2008)  reviewed several studies and meta-analyses to determine the efficacy of MI in improving pediatric health behaviors. The paper suggests that MI can be effective in improving pediatric health behaviors and outcomes  as a single intervention by itself, or it can be included as a supplementary component in more complex interventions (Suarez and Mullins, 2008). However, JIA was not included in any of these studies, which limits the generalizability. A meta-analysis of MI for paediatric and adolescent  by Gayes and steele (2014) suggests MI appears to be most successful when both the child and the parent participate in the MI sessions and when the practitioner shares a similar cultural background with the family (Gayes and Steele, 2014). These factors will be taken into consideration when applying MI. 
The SWAY represents Collaborative goals that are meaningful and motivating to Sarah. Exercise program was designed to work on these goals and rationales of these exercises were clear and linkage to the goals(Pritchard-Wiart et al., 2019) .  The International Classification of Functioning was utilize as a model to facilitate discussion of the linkage of the prescribed exercise with Sarah and her parent (McDougall and Wright, 2009). Exercise prescription in the SWAY were based on FITT principles, considering frequency, intensity, time and type of exercise. A systematic review and meta-analysis of 114 articles reported physical activity interventions has a small but significant improvement on psychological wellbeing in children and adolescents ( efect size 0.173, 95% confdence interval 0.106–0.239, p <0.001) (Rodriguez-Ayllon et al., 2019). The authors concluded that meeting the recommendation of physical activity (60 mins or more) was associated with significant improvement in compared to those who engaged less than 60 min. Therefore, lifestyle change is important for Sarah to promote psychological well-being which is her barrier. Monitor Sarah progress regularly was considered by using “ moving diary” which is a way to provide visual aids that help with adherence and make physical activity part of her routine. The plan of the exercise was a small steps until meeting the recommendation and achieving her goals. The SWAY included only the exercise program for the first 4 weeks.  Many Factor the affect her bone density which are low physical activity and poor diet- Low BMI of Sarah indicates poor nutrition. Wight bearing exercise is effective in increase bone density in children (Nikander et al., 2010). 

Physical therapist support and feedback is important throughout the therapy. Weekly video meetings with Sarah were arranged out to provide encouragement and provide feedback (Pritchard-Wiart et al., 2019). Verbal positive reinforcement by the therapist during these meetings helped with the adherence and improve self-efficacy. 
I wrote this, is this logical and correct any feedback on this ?