Physiotherapy and physical activity in children with Perthes' disease : an international survey of recommendations from paediatric orthopaedic surgeons.

Aims: In the absence of clear and consistent clinical guidelines, this study aims to survey the current international consensus on recommendations for physiotherapy (PT), physical activity (PA), and weightbearing in patients with Perthes' disease. Additionally, the study seeks to identify factors influencing these recommendations, and to determine at which stage possible restrictions on physical activity are typically lifted. Methods: An online international cross-sectional survey using a purpose-designed questionnaire with a general section, and three cases of Perthes' disease, was distributed to surgeons through paediatric orthopaedic societies and research groups. Results: A total of 160 paediatric orthopaedic surgeons from 43 different countries (seven continents) participated. There was general agreement that impaired range of motion (ROM) and pain were important when prescribing PT, while the child's sex was not important. There was disagreement on whether age and Waldenström or Lateral Pillar classification were important factors in determining the need for PT. There was widespread agreement that stretching in the early stages of Perthes' disease was important, although Western and Southern Europe and the British Isles differed. There was considerable disagreement about strengthening exercises. 'Weightbearing as tolerated' in the early and fragmentation stages was generally recommended in the British Isles and Scandinavia (both > 90%), whereas other regions showed large variation. Regarding PA, there was broad agreement in allowing swimming and cycling, and discouraging high-impact activities including school sports in all stages. Conclusion: Maintaining ROM was crucial for most participants, with strong consensus to discourage high-impact activities during initial and fragmentation stages. Swimming and cycling were often allowed, but no clear consensus emerged on weightbearing restrictions or when to resume full activities. Consensus within the British Isles, Scandinavia, and Eastern Europe was high for both for PT and PA, but recommendations differed between countries. Recommendations from the British Isles and Scandinavia were less restrictive than their Eastern European counterparts.