Moderate Weightbearing Restrictions Are Associated with Worse Depressive Symptoms and Anxiety in Children Aged 5 to 7 Years with Perthes Disease.

BACKGROUND: Perthes disease most commonly affects children 5 to 7 years old, and nonoperative management, such as weightbearing and activity restrictions, is generally recommended. In earlier research in children aged 8 to 14 years who had Perthes disease, we found that the restrictions were associated with worse mobility, but mental health or social health measures were not linked. However, Perthes disease most commonly affects children 5 to 7 years old who are more emotionally and cognitively immature. Children in this age group are beginning school and organized sports experiences while developing meaningful social relationships for the first time. Because of such different life experiences, it is important to understand the psychosocial consequences of weightbearing and activity restrictions on this specific age group, as they may help guide choices about weightbearing restrictions and mental health support. QUESTIONS/PURPOSES: In patients aged 5 to 7 years with Perthes disease, we asked: (1) Are weightbearing and activity restrictions associated with worse mental health, evaluated with the Patient-reported Outcome Measurement Information System (PROMIS) depressive symptoms, anxiety, and anger questionnaires? (2) Are weightbearing and activity restrictions associated with worse social health (PROMIS peer relationships measure)? (3) Are weightbearing and activity restrictions associated with worse physical health measures (PROMIS mobility, pain interference, and fatigue measures)? (4) What other factors are associated with mental, social, and physical health measures in these patients? METHODS: Data were collected from 97 patients with a diagnosis of Perthes disease. Inclusion criteria were age 5 to 7 years at the time the PROMIS was completed, English-speaking patients and parents, in the active stage of Perthes disease (Waldenstrom Stages I, II, or III) who were recommended weightbearing and activity restrictions because of worsening hip pain, poor hip ROM, femoral head deformity, as a postoperative regimen, or if there was substantial femoral head involvement on MRI [23]. Based on their weightbearing and activity restriction regimen, patients were categorized into one of four activity restriction groups (no, mild, moderate, and severe restriction). The following pediatric parent-proxy PROMIS measures were obtained: depressive symptoms, anxiety, anger, peer relationships, mobility, pain interference, and fatigue. We excluded five patients who did not meet the inclusion criteria. Of the remaining 92 patients, 21 were in the no restriction group, 21 were in the mild restriction group, 28 were in the moderate restriction group, and 22 were in the severe restriction group at the time of PROMIS administration. ANOVA was used to compare differences between the mean PROMIS T-scores of these four groups. T-scores are computed from PROMIS survey responses, and a T-score of 50 represents the age-appropriate mean of the US population with an SD of 10. A higher T-score means more of that measure is being experienced and a lower score means less of that measure is being experienced. To address the possibility of confounding variables such as Waldenstrom stage, gender, age at diagnosis, and history of major surgery, we performed a multivariable analysis to compare the association of different weightbearing regimens and the seven PROMIS measures. This allowed us to answer the question of whether weightbearing and activity restrictions are associated with worse physical, mental, and social health measures in Perthes patients aged 5 to 7 years, while minimizing the possible confounding of the variables listed above. RESULTS: After controlling for confounding variables such as Waldenstrom stage, gender, age at diagnosis, and history of major surgery, we found that moderate activity restriction was associated with worse depressive symptoms (ß regression coefficient = 6 [95% CI 0.3 to 12]; p = 0.04) and anxiety (ß = 8 [95% CI 1 to 15]; p = 0.02) T-scores than no restrictions. The mild (ß = -7 [95% CI -12 to -1]; p = 0.02), moderate (ß = -15 [95% CI -20 to -10]; p < 0.001), and severe (ß = -23 [95% CI -28 to -18]; p < 0.001), restriction groups had worse mobility T-scores than the no restriction group. Weightbearing and activity restrictions were not associated with anger, peer relationships, pain interference, and fatigue measures. Waldenstrom Stage II disease was associated with worse pain interference than Waldenstrom Stage III (ß = 7 [95% CI 0.4 to 13]; p = 0.04). A history of major surgery was associated with worse anger scores (ß = 18 [95% CI 3 to 33]; p = 0.02). The child's gender and age at diagnosis had no association with any of the seven PROMIS measures. CONCLUSION: Moderate weightbearing and activity restrictions are associated with worse depressive symptoms and anxiety in patients with Perthes disease aged 5 to 7 years, after controlling for Waldenstrom stage, gender, age at the time of diagnosis, and history of surgery. Considering the discoveries in this study and in our previous study, for patients 5 to 7 years old, we recommend that providers discuss the potential for mental health changes with moderate weightbearing restrictions with patients and their families. Furthermore, providers should monitor for worsening mental health symptoms at each follow-up visit and refer patients to a clinical child psychologist for support when appropriate. Future studies are needed to assess the effects of these restrictions on mental health over time and after patients are allowed to return to normal activities. LEVEL OF EVIDENCE: Level III, therapeutic study.

PROMIS Paediatric Mobility tool is correlated with accelerometer-measured physical activity in children with hip diseases.

AIMS: The reduction in mobility due to hip diseases in children is likely to affect their physical activity (PA) levels. Physical inactivity negatively influences quality of life and health. Our aim was to objectively measure PA in children with hip disease, and correlate it with the Patient-Reported Outcomes Measurement Information System (PROMIS) Mobility Score. METHODS: A total of 28 children (12 boys and 16 girls) with hip disease aged between 8and 17 years (mean 12 (SD 3)) were studied between December 2018 and July 2019. Children completed the PROMIS Paediatric Item Bank v. 2.0 - Mobility Short Form 8a and wore a hip accelerometer (ActiGraph) for seven consecutive days. Sedentary time (ST), light PA (LPA), moderate to vigorous PA (MVPA), and vigorous PA were calculated from the accelerometers' data. The PROMIS Mobility score was classified as normal, mild, and moderate functions, based on the PROMIS cut scores on the physical function metric. A one-way analysis of covariance (ANCOVA) was used to assess differences among mobility (normal; mild; moderate) and measured PA and relationships between these variables were assessed using bivariate Pearson correlations. RESULTS: Children classified as normally functioning on the PROMIS had less ST (p = 0.002), higher MVPA, (p = 0.002) and VPA (p = 0.004) compared to those classified as mild or moderate function. A moderate correlation was evident between the overall PROMIS score and daily LPA (r = 0.462, n = 28; p = 0.013), moderate-to-vigorous PA (r = 0.689, n = 28; p = 0.013) and vigorous PA (VPA) (r = 0.535, n = 28; p = 0.013). No correlation was evident between the mean daily ST and overall PROMIS score (r = -0.282, n = 28; p = 0.146). CONCLUSION: PROMIS Pediatric Mobility tool correlates well with experimentally measured levels of physical activity in children with hip disease. We provide external validity for the use of this tool as a measure of physical activity in children. Cite this article: Bone Joint J 2021;103-B(2):405-410.

Weightbearing and Activity Restriction Treatments and Quality of Life in Patients with Perthes Disease.

BACKGROUND: Weightbearing and activity restrictions are commonly prescribed during the active stages of Perthes disease. These restrictions, ranging from cast or brace treatment with nonweightbearing to full weightbearing with activity restrictions, may have a substantial influence on the physical, mental, and social health of a child. However, their impact on the patient's quality of life is not well-described. QUESTIONS/PURPOSES: After controlling for confounding variables, we asked (1) are restrictions on weightbearing and activity associated with physical health measures (as expressed by the Patient-Reported Outcome Measurement Information System [PROMIS] mobility, PROMIS pain interference, and PROMIS fatigue) of children in the active stages of Perthes disease? (2) Are these restrictions associated with poorer scores for mental health measures (PROMIS depressive symptoms and PROMIS anxiety)? (3) Are these restrictions associated with poorer scores for social health measures (PROMIS peer relationships)? METHODS: Between 2013 and 2020, 211 patients with Perthes disease at a single institution were assigned six PROMIS measures to assess physical, mental, and social health. Patients who met the following eligibility criteria were analyzed: age 8 to 14 years old, completion of six PROMIS measures, English-speaking, and active stage of Perthes disease (Waldenstrom Stage I, II, or III). Weightbearing and activity restrictions were clinically recommended to patients in the initial through early reossification stages of Perthes disease when patients had increasing pain, loss of hip motion, loss of hip containment, progression of femoral head deformity, increased hip synovitis, and femoral head involvement on MRI or as a postoperative regimen. Patients were categorized into four intervention groups based on weightbearing and activity regimen. We excluded 111 patients who did not meet the inclusion criteria. The following six pediatric self-report PROMIS measures were assessed: mobility, pain interference, fatigue, depressive symptoms, anxiety, and peer relationships. Of the 100 patients, 36 were categorized into the no-restriction regimen, 27 into the mild-restriction regimen, 25 into the moderate-restriction regimen, and 12 into the severe-restriction regimen at the time of PROMIS administration. The median (range) age at diagnosis was 8 years old (range 2 to 13 years). There were 85 boys and 15 girls. Eleven patients had hips in Waldenstrom Stage I, 10 were in Stage II, and 79 were in Stage III. Forty-four patients had hips classified as lateral pillar B and 47 patients as lateral pillar C. Nine patients had not reached the mid-fragmentation stage for appropriate lateral pillar classification by the time they took the PROMIS survey. ANOVA was used to compare differences between the mean PROMIS T-scores of these weightbearing/activity regimens. Results were assessed with a significance of p < 0.05 and adjusted for Waldenstrom stage, gender, age at diagnosis, and history of major surgery using multivariate regression analysis. RESULTS: After controlling for confounding variables, the mild- (ß regression coefficient -15 [95% CI -19 to -10]; p < 0.001), moderate- (ß -19 [95% CI -24 to -14]; p < 0.001), and severe- (ß -25 [95% CI -30 to -19]; p < 0.001) restriction groups were associated with worse mobility T-scores compared with the no-restriction group, but no association was detected for the pain interference or fatigue measures. Weightbearing and activity restrictions were not associated with mental health measures (depressive symptoms and anxiety). Weightbearing and activity restrictions were not associated with social health measures (peer relationships). Earlier Waldenstrom stage was associated with worse pain interference (ß 10 [95% CI 2 to 17]; p = 0.01) and peer relationships scores (ß -8 [95% CI -15 to -1]; p = 0.03); female gender was linked with worse depressive symptoms (ß 7 [95% CI 2 to 12]; p = 0.005) and peer relationships scores (ß -6 [95% CI -12 to 0]; p = 0.04); and earlier age at diagnosis was associated with worse peer relationships scores (ß 1 [95% CI 0 to 2]; p = 0.03). History of major surgery had no connection to any of the six PROMIS measures. CONCLUSION: We found that weightbearing and activity restriction treatments are associated with poorer patient-reported mobility in the active stages of Perthes disease after controlling for Waldenstrom stage, gender, age at diagnosis, and history of surgery. Weightbearing/activity restrictions, however, are not associated with pain interference, fatigue, depressive symptoms, anxiety, and peer relationships. Understanding how these treatments are associated with quality of life in patients with Perthes disease can aid in decision-making for providers, help set expectations for patients and their parents, and provide opportunities for better education and preparation. Because of the chronic nature of Perthes disease, future studies may focus on longitudinal trends in patient-reported outcomes to better understand the overall impact of this disease and its treatment. LEVEL OF EVIDENCE: Level III, therapeutic study.

The outcomes of Perthes' disease.

AIMS: To identify a suite of the key physical, emotional, and social outcomes to be employed in clinical practice and research concerning Perthes' disease in children. METHODS: The study follows the guidelines of the COMET-Initiative (Core Outcome Measures in Effectiveness Trials). A systematic review of the literature was performed to identify a list of outcomes reported in previous studies, which was supplemented by a qualitative study exploring the experiences of families affected by Perthes' disease. Collectively, these outcomes formed the basis of a Delphi survey (two rounds), where 18 patients with Perthes' disease, 46 parents, and 36 orthopaedic surgeons rated each outcome for importance. The International Perthes Study Group (IPSG) (Dallas, Texas, USA (October 2018)) discussed outcomes that failed to reach any consensus (either 'in' or 'out') before a final consensus meeting with representatives of surgeons, patients, and parents. RESULTS: In total, 23 different outcome domains were identified from the systematic review, and a further ten from qualitative interviews. After round one of the Delphi survey, participants suggested five further outcome domains. A total of 38 outcomes were scored in round two of the Delphi. Among these, 16 outcomes were scored over the prespecified 70% threshold for importance (divided into six main categories: adverse events; life impact; resource use; pathophysiological manifestations; death; and technical considerations). Following the final consensus meeting, 14 outcomes were included in the final Core Outcome Set (COS). CONCLUSION: Core Outcome Sets (COSs) are important to improve standardization of outcomes in clinical research and to aid communication between patients, clinicians, and funding bodies. The results of this study should be a catalyst to develop high-quality clinical research in order to determine the optimal treatments for children with Perthes' disease. Cite this article: Bone Joint J 2020;102-B(5):611-617.

Validation of Pediatric Self-Report Patient-Reported Outcomes Measurement Information System (PROMIS) Measures in Different Stages of Legg-Calvé-Perthes Disease.

OBJECTIVES: Patient-reported outcomes (PRO) assessing health-related quality of life (HRQoL) are important outcome measures, especially in Legg-Calvé-Perthes disease (LCPD) where symptoms (pain and limping), activity restrictions, and treatments vary depending on the stage of the disease. The purpose of this study was to investigate the validity of the Patient-reported Outcomes Measurement Information System (PROMIS) for measuring HRQoL of patients with LCPD in various stages of the disease. METHODS: This is a multicenter validity study. Patients with LCPD between 4 and 18 years old were included and classified into modified Waldenström stages of disease: Early (1 or 2A), Late (2B or 3), or Healed (4). Seven PROMIS domains were collected, including Pain Interference, Fatigue, Mobility, Depression, Anger, Anxiety, and Peer Relationships. Convergent, discriminant, and known group validity was determined. RESULTS: A total of 190 patients were included (mean age: 10.4±3.1 y). All 7 domains showed the worst scores in patients in the Early stage (known group validity). Within each domain, all domains positively correlated to each other (convergent validity). Patients who reported more anxiety, depression, and anger were associated with decreased mobility and increased fatigue and pain. Peer relationships had no to weak associations with other domains (discriminant validity). CONCLUSIONS: PROMIS has construct validity in measuring the HRQoL of patients in different stages of LCPD, suggesting that PROMIS has potential to serve as a patient-reported outcome tool for this population. LEVEL OF EVIDENCE: Diagnostic level III study.

Crisis sociales y trauma. Su impacto en la relación terapéutica / Impact of trauma and social crises on the therapeutic relationship

A través de este artículo, los autores buscan hacer una reflexión sobre la importancia del buen conocimiento de la contratransferencia y la honestidad terapéutica en nuestra práctica clínica. Más aún a tener en cuenta en las situaciones en donde pacientes y terapeutas forman parte de un sistema social en crisis. Es en dichas situaciones, potencialmente traumáticas, en donde sólo a través de una buena capacidad de análisis y conocimiento de dicha contratransferencia, el terapeuta podrá crear un espacio para pensar y salir de esta trampa social. Este acercamiento a la profundidad de los sentimientos del terapeuta (como objeto de proyección de lo vivido por el paciente) le permitiría al terapeuta una mayor comprensión y protección del paciente y, con ello, del espacio terapéutico como un lugar de creación

In this article, the authors seek to ponder on the importance of clear knowledge and recognition of countertransference and therapeutic honesty in the daily clinical practice.More importantly, to be aware of situations in which patients and therapists form part of a society in crisis. Only with an accurate analysis and recognition of countertransference in these potentially traumatic situations, can the therapist create a thinking space to escape this social hurdle. The approach to the therapist's depth of feelings as the objet of the projection of the patient's life experiences, will allow increased understanding and protection of said patient and in turn, of the therapeutic space as a place for creation

Legg-Calvé-perthes disease: quality of life, physical activity, and behavior pattern.

BACKGROUND: Legg-Calvé-Perthes disease (LCPD) is a disease in children leading to deformation of the femoral head and can be a promoter for early dysfunction of the hip and early osteoarthritis of the hip. The study of health-related quality of life, physical activity, and behavior patterns in patients with LCPD can reveal its consequences later in life and also contribute to a better understanding of the etiology of the disease. PATIENTS AND METHODS: We identified 145 patients with LCPD diagnosed and treated at Uppsala University Hospital between 1978 and 1995. A total of 116 patients answered questionnaires regarding health-related quality of life (EQ-5D-3L), physical activity [International Physical Activity Questionnaire (IPAQ)], and hyperactive/inattentive behavior pattern [ADHD self-reporting symptom checklist (ASRS v1.1)] by interview. Patients were asked to report on fractures or soft-tissue injuries that required medical care. Medical charts were reviewed to determine age at onset of LCPD and treatment received. RESULTS: Patients with LCPD had significantly lower EQ-5D-3L and EQ VAS scores than the Swedish general population in all age groups. A total of 28% of our patient group had ASRS scores indicating they are likely or highly likely to have an ADHD diagnosis. A lower EQ-5D-3L score was significantly correlated with a higher total ASRS v1.1 score (ρ=-0.309**). Over 90% of our patient group was physically active on a moderate or high level, despite 52% reporting either some or severe problems with pain according to the EQ-5D-3L questionnaire. Patients with high ASRS v1.1 scores (>16) had a significantly higher incidence of soft-tissue injuries than those with lower ASRS v1.1 scores. CONCLUSION: The consequence of LCPD in adulthood was expressed in a lower quality of life compared with the Swedish general population. Despite this, the patients in our study reported a higher level of physical activity than the general population. A tendency toward hyperactive behavior pattern and high physical activity level may be present even in childhood and could contribute to the etiology of LCPD. LEVEL OF EVIDENCE: A retrospective study, level II.

Hyperactivity and the psychological burden of Perthes disease: a case-control study.

BACKGROUND: Legg-Calve-Perthes Disease (LCPD) is a childhood precursor to hip osteoarthritis, for which the etiology is unknown. There is a widespread belief that affected individuals are "hyperactive," propagating a theory that such children may have sustained an epiphyseal injury that precipitated the onset of LCPD. This study seeks to quantify the association with hyperactivity, and the wider psychological burden of the disease. METHODS: A case-control study was conducted among 146 cases of LCPD and 142 hospital controls, frequency matched by age and sex. Psychological domains were measured using the Strength and Difficulties Questionnaire. Adjustment was made for age, sex, and socioeconomic deprivation. Results were stratified by the time elapsed since LCPD was diagnosed. RESULTS: Significant associations (P<0.05) existed with the majority of the psychological domains captured by the Strength and Difficulties Questionnaire [odds ratio (OR) for "high" level of difficulties-Emotion OR 3.2, Conduct OR 2.1, Inattention-Hyperactivity OR 2.7, Prosocial Behavior OR 1.9]. Hyperactivity was especially marked among individuals within 2 years of diagnosis (OR 8.6; P<0.001), but not so among individuals over 4 years from diagnosis. Emotional symptoms persisted long after resolution of the active phase of disease. CONCLUSIONS: There was a marked psychological burden among individuals with LCPD, which was most marked amongst individuals with a recent diagnosis. The breadth and inferred temporality of these disturbances may be a function of the disease process, through restriction of activities and disability, or may be a fundamental disease characteristic related directly to disease or to its etiological determinant.

[Patients functioning after surgical treatment for Perthes disease]. / Funkcjonowanie pacjentów po przebytej chorobie perthesa leczonych operacyjnie.

INTRODUCTION: Perthes disease appears in children and affects hip joints. The proximal head of the femur is damaged, which results in deformation of the femoral ball and loss of its spherical shape. Instant diagnosis and introduction of treatment is crucial for maintaining the femoral head in the hip socket, which facilitates recovery to its spherical shape. To assess the quality of life of patients who have undergone surgical treatment. The factors examined were: state of functioning and occurrence of pain in affected hip joint. MATERIAL AND METHODS: 61 participants underwent the examination. The duration and type of disease were established on the basis of a radiogram. The patients were treated with varus derotation osteotomy in the 2 and 3 degree of the Reinberg scale. A Modified Oxford Hip Score was used to assess the patients' quality of life. RESULTS: Subjective assessment of the quality of life after recovering from the disease was regarded as very good and good. CONCLUSION: According to the patients' own evaluation the disease and the treatment did not affect their everyday life.

Psychosocial development and premorbid skeletal growth in Legg-Calvé-Perthes disease: a study of nineteen patients.

We studied psychosocial development and skeletal growth in 19 newly diagnosed patients with Legg-Calvé-Perthes disease (LCPD). Eleven patients had problems in visuospatial skills and five of 12 school-aged children had learning difficulties. The growth velocity of the patients was evaluated from 4 years before until 2 years after the diagnosis was made. Eight patients had a catch-up growth with +1.2 (0.9-1.7) delta SDS score (SDS: mean and ranges) before the diagnosis. Four patients with short stature and retarded bone age slightly diminished their growth velocity. Overnight serum growth hormone (GH) concentration and insulin-like growth factor I (IGF-I) levels were examined in the first nine consecutive patients. One patient had a high and another had a low mean GH concentration level, whereas all patients had IGF-I levels within normal limits. These results suggest that different kinds of growth disturbances may be associated with LCPD.

Behavioral characteristics of children with Legg-Calvé-Perthes disease.

We explored the behavioral characteristics of 24 children with Perthes' disease. Parents completed standard psychological self-administered questionnaires regarding their child's behavior: the Conners Parent Symptom Questionnaire and the Achenbach Child Behavior Checklist. One third (33%) of the children had abnormally high scores in profiles associated with attention deficit hyperactivity disorder (ADHD) (impulsive, hyperactive, and psychosomatic categories), much higher than the 3-5% incidence of ADHD in the general population. They also tended to have difficulties with school and social interaction skills. Certain epidemiologic characteristics of Perthes' disease (sex ratio, socioeconomic status, geographic location, and associated congenital anomalies) are also similar to those of ADHD, suggesting a correlation between the two disorders.

Behavioral sequelae of bracing versus surgery for Legg-Calvé-Perthes disease.

The Louisville Behavioral Checklist was administered to 23 white boys between the ages of 7 and 12 years who completed treatment for Perthes disease by bracing or surgery at the Florida Elks Children's Hospital. The groups were comparable, with 11 children in the surgery group and 12 in the bracing group. Results indicated statistically significant differences (p = 0.05) between the groups in three areas. Patients in the bracing group were more likely to demonstrate deficits in social, academic, and sexual behavior as compared with patients in the surgery group.

[Perthes disease--choice of therapy with reference to psychosocial aspects]. / Morbus Perthes--Wahl der Therapieform unter Berücksichtigung psychosozialer Aspekte.

Within the scape of a comparative long-term study between conservative and operative therapy of Perthes'-disease the effort was made to estimate the dimension of the psychic and social detraction in addiction to the method of treatment by a detailed inquiry of 116 patients as well as of their accompanying parents. This happened because of the opinion, that not only the formal result should decide on the choice of therapy, but also in a justifiable dimension the way of treatment should be orientated on patients. The analysis of the anamnestic particulars showed, that also under psycho-social aspects the immediate surgical procedure has the advantage over conservative methods of treatment at Perthes' disease.