Moderate Weightbearing Restrictions Are Associated with Worse Depressive Symptoms and Anxiety in Children Aged 5 to 7 Years with Perthes Disease
Authors: Do Dang-Huy , Valencia Angel A. , Jo Chan-hee , Kim Harry K. W. 
Published: October 2021

Abstract

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 (β regression coefficient = 6 [95% CI 0.3 to 12]; p = 0.04) and anxiety (β = 8 [95% CI 1 to 15]; p = 0.02) T-scores than no restrictions. The mild (β = -7 [95% CI -12 to -1]; p = 0.02), moderate (β = -15 [95% CI -20 to -10]; p < 0.001), and severe (β = -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 (β = 7 [95% CI 0.4 to 13]; p = 0.04). A history of major surgery was associated with worse anger scores (β = 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.