Are fibrous cortical defect (FCD) and non-ossifying fibroma (NOF) only a radiological finding? Relationship between radiological/clinical findings and physical activity in children and adolescents: A cross-sectional study

Are fibrous cortical defect (FCD) and non-ossifying fibroma (NOF) only a radiological finding? 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Relationship between radiological/clinical findings and physical activity in children and adolescents: A cross-sectional study Erhan Berk, Rabia Aydogan Baykara This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4817840/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Fibrous cortical defect (FCD) and non-ossifying fibroma (NOF) are incidentally recognised and benign developmental lesions. The objective of this study was to ascertain the clinical manifestations and symptoms of FCD/NOF in children and adolescent patients, to characterise the lesions radiologically using X-ray and MRI techniques, and to determine the relationship between physical activity and the condition. Materials and Methods: The study included patients under the age of 18 with radiological lesions on their extremities. The lesions were classified as FKD or NOF in accordance with the distinctive imaging features. For each lesion, the bone involved, the site involved, the size of the lesion, and the type of lesion according to the Ritschl classification were recorded. In the anamnesis, the patient's presenting complaint, the character of the pain, if any, and the level of activity were investigated. Pain was quantified using the visual analogue scale (VAS) and the 21-Numbered Circle VAS.(21-NCVAS) The 21-Numbered Circle Activity Scale(21-NCAS) and the International Physical Activity Questionnaire (IPAQ) were employed for the assessment of physical activity. Results: 34 lesions in 28 children (14 girls/14 boys) were included in the study. Age was not different between girls and boys (p = 0.45). According to Ritschl classification, 18 (52.9%) lesions were stage A, 9 (26.5%) were stage B and 7 (20.6%) were stage C. The lesion size increased with increasing Ritschl stage (p<0.02). The main presenting complaint was pain (n = 13, 49.9%). In 21.4% of the children (n=6), lesions were detected incidentally on radiographs. According to IPAQ, 39.3% of the children were physically inactive. There was a significant negative correlation between 21-NCAS and Ritschls stage (r= -.51, p<.05). Activity decreased as the Ritschl stage increased. There was a significant negative correlation between 21-NCAS and VAS (r=-.69, p<.05). Conclusion: Spontaneous pain was observed in 49.9% of patients diagnosed with FCD/NOF. No correlation was identified between lesion size and the presence or severity of pain. As the severity of pain and Ritschl stage increased, there was a corresponding decrease in physical activity. Health sciences/Medical research Health sciences/Medical research/Paediatric research Health sciences/Rheumatology/Musculoskeletal system/Bone fibrous cortical defect (FCD) non-ossifying fibroma (NOF) clinical findings physical activity children adolescents 21-numbered circle activity scale IPAQ 21-numbered circle VAS Figures Figure 1 Figure 2 Introduction Fibrous cortical defect (FCD) and non-ossifying fibroma (NOF) are benign lesions that occur with the presence of osteoclast-like multinucleated giant cells accompanied by fibroblast proliferation on pathological examination[ 1 , 2 ] Although their histopathology is similar, the terminology differ such that lesions smaller than 2 cm and remains confined to the bone cortex, are named as “fibrous cortical defect”, whereas bigger lesions and with variable endo medullary extension are named as “non-ossifying fibroma”[ 2 – 5 ]. Accordingly, the two aforementioned conditions were consolidated into a single category, designated as FCD/NOF, for the purposes of this study. These lesions are regarded as developmental variations, manifesting predominantly during the first and second decades of life. [ 2 , 6 ]. These lesions represent the most common benign lesions of the skeletal system, with an estimated prevalence of 30–40% in skeletally immature children[ 5 – 8 ]. A study of the Japanese population demonstrated a prevalence of NOF of 2.3% and FCD of 7.0%. NOF was more prevalent in boys, while FCD was more prevalent in girls[ 7 ] Genetic predisposition for NOF was confirmed by DNA sequencing and MAP kinase signalling[ 2 ]. Additionally, Nelson et al. reported chromosomal translocation bands in a patient diagnosed with NOF[ 9 ]. X-ray is used as the first imaging method in the evaluation of FCD and NOF and is generally diagnostic.[ 4 , 10 ] Characteristic imaging findings of the lesions include being eccentric within the bone and adjacent to the cortex, moving close to the physis or towards the metaphysis during growth, and having a sclerotic margin[ 6 ]. The long axis of the lesions is parallel to the long axis of the bone, while lesions are most commonly localized around the knee, including the distal femur and proximal medial tibia[ 6 ], [ 11 ], and very rarely in the mandible [ 12 ]. Although direct X ray is used for diagnostic, computed tomography and magnetic resonance imaging are alternative diagnostic evaluation options of these lesions[ 3 ]. [ 4 ] When evaluated clinically, FCD is usually asymptomatic and is detected incidentally on an X-ray taken for another reason, and does not require any intervention. [ 7 ] [ 3 ]. NOF is rarer, more eccentric and symptomatic compared to FCD, while these lesions usually disappear spontaneously with age. Sometimes the lesions may be palpably swollen, compress adjacent muscle or neurovascular structures, and expand the cortex, causing damage to adjacent bone[ 2 , 3 ]. Symptoms are generally described as pain, swelling and tenderness, and sometimes fracture, and treatment is usually conservative, but if trauma is present and causes symptoms and bone weakening, prophylactic treatment may be required [ 12 – 14 ]. Fractures are often seen in the lower extremity, at the distal end of the tibia. In addition, if the lesion covers more than 50% of the bone in 2 projections and is longer than 33 mm, the risk of bone fracture is considered high, and surgical bone grafting and local intralesional curettage are sufficient in its treatment [ 5 , 12 , 13 , 15 ] Nevertheless, a more recent series of studies demonstrated that 59% of NOF cases exceeded the aforementioned threshold measurements without fracture [ 15 ]. Pain and limitation of movement can negatively affect growth and development in children and adolescents, while pain, fractures and other symptoms caused by FCD/NOF might hinder activity and increase physical inactivity which might negatively effect both physical and psychosocial development in children and young adolescents [ 16 ]. According to WHO 2020 guidelines, physical activity is necessary for healthy growth and development, mental health, social skills development, attention concentration and learning ability in children and adolescents [ 17 ]. [Thus, symptoms of NOF/FCD might reduce the level of physical activity required for healthy development in children, and increase physical inactivity. The aim of this study is to determine the symptoms occurring in children diagnosed with FCD/NOF, to reveal the characteristics of the Xray and MRI images of the lesions, and to evaluate the relationship of physical activity. Material and Methods Patient Selection The study population consisted of patients who were enrolled between January 2020 and August 2021. The sample was selected from patients with imaging records in the system for the previous five years and who were under the age of 18 at the time of diagnosis. The patients were identified by searching the diagnosis records in the hospital database for the keywords "fibrous cortical defect" and "non-ossifying fibroma." The same search was conducted in the radiology reports. The patients were contacted by telephone. Those who agreed to participate were invited to the hospital, where they signed a consent form. Demographic data, reason for admission to the hospital, trauma history, and extensive anamnesis were collected. The same physician performed an examination, and the patients' activity levels were assessed. The questionnaires were administered to the patients individually, but parents were permitted to contribute to the process. The imaging findings of the children's lower extremities, as well as the standard anteroposterior and lateral X-ray images and MRI images, were obtained from the hospital records as previously mentioned and within the specified time interval. Patients were included in the study according to the criteria; (1) being patient aged 10–18 years, and (2) patients who underwent standard antero-posterior and lateral view radiography and/or (3) MRI. Exclusion criteria; (1) diagnosed metabolic and endocrine diseases, other diseases affecting bone metabolism, rheumatological diseases, neurological diseases, patients with a history of fractures and operations other than FCD/NOF, and (2) patients whose radiological imaging quality is not sufficient for the study. were excluded from the research. Radiological evaluation of NOF/FCD For all lesions, the intraosseous involvement and size of the lesion were evaluated and lesions were classified according to the Ritschl classification; Stage A : Small, oval to slightly polycyclic in shape, without a sclerotic border, in the cortex near the epiphyseal end plate, Stage B : Lesions at variable distance from the epiphysis, polycyclic in shape, with thin but clearly sclerotic borders and a thin cortex occasionally protruding above the surface in an hourglass shape without periosteal reaction, Stage C : lesion with partial sclerosis Stage D : lesion with complete sclerosis[ 18 ]. The Ritschl classification is based on the clinical course of the healing process and these stages are proportional to the age of the patient. Stage B lesions have an increased risk of fracture, therefore follow-up until reaching Stage C is recommended[ 6 ]. Data collection Patients selected for the study were identified in the hospital registry system and contacted by phone call. After explaining the study, consent have been obtained by patients verbally and volunteers were invited for clinical evaluation. Demographic data of patients such as age, gender, education, and other variables such as initial complaint, complaint duration, comorbidity, family history of rheumatological disease, on screen time were recorded. Pain Assessment For pain assessment, both 10-centimeter horizontal line visual analog scales(VAS) [ 19 ] and 21-numbered circle visual analog scales(21-VAS) were used described elsewhere in detail [ 19 , 20 ]. The Likert-type scale, which increases in 0.5 cm intervals, has an unhappy face emoji on the 0 side and a smiling face emoji on the side where 10 is placed. This scale is more useful in children as it is completed faster and shows remission better than the standard 10 cm VAS [ 19 , 20 ]. The main complaints were categorized as: 1) Pain, a) Pain with movement b) Pain at rest c) Night Pain, d) Pain while running, 2) Swelling and Tenderness, 3) Chronic Pain 3 month<, 4) Difficulty in walking, 5) Instability in weight bearing 6)Fracture. Morning stiffness, shifting pain in the hip, fatigue, as well as time on screen time were questioned in the anamnesis. In the examination swelling, increase in body temperature and tenderness were evaluated. Physical Activity Scale: 21-numbered circle activity scale(21-NCAS) There is “no activity” on the 0 side of the Likert-type scale, increasing at 0.5 cm intervals, and “Maximum activity” expressions are on the 10 side. High scores indicate that the activity can be performed easily. International Physical Activity Questionnaire (IPAQ) : The last seven days of activity were evaluated with the questionare. Walking and activity is evaluated as duration (minutes) and frequency (days) and total score is classified as “very active”, “moderate active” or “inactive”. Sitting: 1.5 MET, walking: 3.3 MET, moderate physical activity: 4.0 MET, vigorous physical activity: 8.0 MET. For example, for a person who walks for 7 days and 30 minutes, the METmin/week score is calculated as: 3.3x7x30 = 693 MET-min/week [ 21 ] Statistical analyses The data analysis was conducted by using IBM SPSS 25 statistical software package, and data’s conformity to normal distribution was tested by using the Kolmogorov-Smirnov test. Descriptive statistics were presented as mean ± SD, median (range), and n (%). Independent Student t-test and chi-square test were used to compare two groups, while One-Way ANOVA test was used to compare more than 2 groups, while Tukey t Test has been used for post-Hoc analysis at significance level of p < 0.05. The study also encompassed correlation analyses using the Pearson correlation method. For the evaluation of categorical data, cross-tabulation was used in conjunction with the chi-square test. Before participating in the study, written informed consent was obtained from all participants. The study had been previously approved by the Local Clinical Research Ethics Committee of the Council of Europe guidelines and the Helsinki Declaration, under decision number:E-30785963-020-222774/2024/43. Results A total of 34 lesions (Three children had more than one lesion) in 28 children (14 girls/14 boys) with the mean age of 14.5 ± 1.8 years for girls, and 15.14 ± 2.5 years for boys, were included in the study (p = 0.45). Clinical Evaluation The Patients applied to the hospital presented pain n = 13(49.9%), Instability in weight bearing n = 6(21.4%), pain with movement (n = 10, 35.7%), Pain while running(n = 4, 14.3%) night pain (n = 6, 21.4%), pain at rest ( n = 7, 25%), morning stiffness (n = 4, 14.3%), chronic pain (lasting more than 3 months) (n = 8, 28.6%), fatigue (n = 4, 14.3%), tenderness on examination (n = 16,%57.1). The lesions of 21.4% (n = 6) of 28 children were detected incidentally on radiographs, while complaints of boys and girls did not differ when they came to the hospital (p > 0.05), but pain at rest was more common in boys compared to girls when symptoms were questioned (p < 0.05) (Table.1) According to IPAQ, 39.3% of the children were inactive, 39.3% minimally active and 21.4% very active, while no statistically significant difference was observed in physical activity between boys and girls (p > 0.05). The IPAQ MET mean was calculated as 1455 ± 1215) presented in detail in Table.2. According to the results for correlation analysis, there was a negative significant relationship between the 21-NCAS score and the scores of VAS, 21-VAS and the Ritschls stage, (r = − 0.69, r= -0.56, r-0.51) respectively (p .05). There was no difference between the time spent in front of the screen and parameters such as exercise scales (activity scale number 21 and IPAQ) and Ritschl stage (Table. 3). As Ritschl stage and pain level increase, physical activity level decreases. However, no correlation was identified between pain level and Ritschl stage. According to the radiological evaluation results, 34 lesions had X-ray scans available in the archive of the hospital. One of the patients had 3 lesions, and 2 patients had 2 lesions, while the rest had only one lesion, summarized as 34 lesions in 28 patients. All lesions were eccentrically located within the metaphysis of a long bone such that 22 lesions in Femur and 12 lesions in tibia, while 18 of the lesions were on the left side ( Fig. 1 , 2 ). Only 4 lesions were examined with contrast enhanced MRI; from these 3 had peripheral and only 1 had heterogeneous contrast enhancement after intravenous contrast media injection ( Fig. 1 , 2 ). The mean size of the lesions were 3.68±4.75. (0.12–21.74) cm 3 . According to the Ritschl’s classification; 18 (%52.9) lesions were stage A, 9 (%26.5) lesions were stage B, 7 (%20.6), lesions were stage C. Lesion size in Stage C was higher compared to Stage A and Stage B, while lesion size increases as the Ritschl Stage increased from Stage A to StageB and to Stage C continuesly (p < 0.02). All groups showed a statistically significant difference when compared to each other (p < 0.05). and as, the lesion size also increased (p 0.05) (Table.4) Discussion This study is the first to investigate the relationship between the radiological characteristics and clinical evaluation of FCD/NOF and the physical activity level in children. In our study, we observed that FCD/NOF lesions occurred incidentally in 21.4% of patients. Despite the assertion in the existing literature that lesions are predominantly identified on radiographs obtained for reasons unrelated to the detection of such lesions, our study revealed that the most frequently reported symptom was pain, accounting for 49.9% of cases. Similarly, in a prevalence study, half of the patients with FCD had spontaneous pain complaints [ 7 ][ 5 ]. When complaints were compared between boys and girls, no significant difference was found between them, but pain at rest was seen to be more common in boys. The physical activity levels of children and adolescents were classified as either very inactive or moderately active, a finding that was consistent with that of previous published literature.[ 22 ] Paralel findings were found in a large-scale study conducted by Guthold, R et al., covering 1.6 million childern and young adolescents, stating that 81% of the students aged between 11–18 years (Boys: 77.6% / Girls: 84.7%) were not physically active [ 22 , 23 ][ 20 , 21 ]. A further noteworthy finding of the study was that, while the physical activity levels of boys and girls with FCD/NOF were similar, there was a decline in physical activity as Ritschl Stage increased. Moreover, physical activity was associated negatively to pain scores. Thus, pain is considered as a condition that limits physical activity. Similar to our findings, a study evaluating pain and physical activity bidirectionally in adolescents found that the experience of pain limits physical activity on a daily basis. In a study comparing adolescents with chronic pain and their healthy peers, physical activity was measured objectively via actigraphy, and it was found that those with pain had lower levels of physical activity as well as decreased physical functionality [ 24 ]. However, in adolescents with chronic pain, the pain intensity was lower at the end of the day in those with higher levels of physical activity [ 25 ]. Findings of our study showed that there is no relationship between the Ritschl stage and the pain scores, In our study, lesion size increased with increasing Ritsch stage. Based on this information, it can be considered that increasing lesion size is not associated with pain, as Emori et al. reported that lesion size is not associated with spontaneous pain.[ 7 ]. On the other hand, the use of technology may cause a decrease in physical activity because it hinders children's daily activities. In previous studies, physical activity was found to be low in children who spent long time on using technology [ 26 , 27 ]. In our study, the majority of children with FCD/NOF had more than 2 hours of on screen time in both genders, but on screen time was not assocciated to physical activity level. Paralel results were obtained in the study conducted by Karaca et al., which showed that on screen time was not correlated with physical activity in children without any disease[ 28 ], and Nilsson et al. reported that increasing exercise time was not correlated to shortening TV watching[ 29 ]. An international study conducted by Melkevich et al., showed that on screen time is negatively correlated to physical activity in countries where the average physical activity level is high. However, across geographic regions and genders with generally lower levels of physical activity, it has been shown that there is no consistent association with levels of screen-based sedentary behavior spent more than 2 hours per day [ 30 ]. According to our radiological findings, Stage A lesion was the most detected lesion classified according to Ritschl's classification, which was consistent with the findings of the study conducted by Emori et al.[ 7 ]. Additionally, our study showed that size of FCD or NOF increases with the increasing stage according to Ritschl's classification, while Herget et al. Also reported that the size of the lesions increased with the increase in the stage of the lesions [ 6 ]. In contrast to the study of Herget et al. who reported an increase in age with increasing Ritschl stage, we did not find any significant difference between Ritschl stages according to age. Blaz et al. also agreed that the average age of patients increased with increasing Ritschl stage [ 4 , 6 ], both studies include adult in addition to children in their study sample. Thus different results in our study might be due to the younger age group of patients and also using different imaging methods for evaluation. In our study, 9 patients were in Stage B, while one of them had a pathological fracture, which is consistent with the literature stating that patients with Stage B lesions have an increased risk of suffering a pathological fracture. Similarly, Herget et al. reported pathological fractures in 6 out of 87 patients[ 12 ], while Emori et al., reported that fractures were detected in 2.1% of patients with Ritschl classification Stage B [ 5 ]. Moreover, 3 children had more than one lesion in our study which is also consistent with literature stating that 5–8% of patients have multiple lesions [ 6 , 7 , 31 ]. This study has several limitations that has to be stated; Firstly, the patients' exercise barriers, which might affect the phycial activity level, have not been questioned in detail. Moreover, some physical activity parameters such as intensities, type of exercise (i.e. aerobic and muscle and bone strengthening activities) has not been identified. Secondly; Children were also not evaluated regarding sleep duration and psychological impact. Finally; Although we classified lesions according to Ritschl's classification, a longitudinal study that follows patients over the long term could show the progression of X-ray and MRI findings over time. The Ritschl staging system is based on the clinical course of the healing process, as the stage increases, the lesion is expected to mature and then heal. The progression of the Ritschl stage with increasing child age has been documented [ 6 ]. The absence of Ritschl stage D in our sample (because stage D cases over 18 years of age were not included in the study) and the small sample size can be considered as other limitations. The first outcome of the research; The study revealed physical activity, radiological imaging and clinical status in children diagnosed with FCD/NOF. The clinical background of this pathology, known as "touch-free lesion" in the literature, was evaluated. Secondly; The relationship between pain and other symptoms and physical activity was examined, and attention was drawn to physical activity affecting the growth and development of children. It was determined that pain was the main complaint in half of the patients and was responsible for restricting the mobility, and thereby decreased physical activity in patients. In addition, as the Ritschl stage increased, physical activity decreased. Therefore, it is recommended to inform the child and the family about the decrease of physical activity and to provide support from experts when necessary. Declarations Institutional Review Board Statement: Approval was obtained from local Clinical Research Ethics Committee (Approval number:E-30785963-020-222774/2024/43 ). Informed Consent Statement: Informed consent was obtained from all participants included in the study. Data Availability Statement: The datasets are not publicly available but are available from the corresponding author upon reasonable request. Conflicts of Interest: The authors declare no conflict of interest. Declaration of Figures Authenticity : All figures submitted have been created by the authors who confirm that the images are original with no duplication and have not been previously published in whole or in part Author Contribution E.B and R.AB :Conceptualization, RAB. and EB.; methodology, RAB. and EB.; software, RAB.; validation, RAB. and EB.; formal analysis, RAB. and EB.; investigation, RAB. and EB.; resources, RAB. and EB.; data curation, RAB. and EB.; writing—original draft preparation, RAB. and EB.; writing—review and editing, RAB and EB.; visualization, RAB and EB.; supervision, RAB.; project administration, RAB funding acquisition, RAB . References Schajowicz, F., Histological typing of bone tumours . 2012: Springer Science & Business Media. Baumhoer, D. and D. Rogozhin, Non-ossifying fibroma. Soft tissue and bone tumours. WHO classification of tumours series, 5th ed. International Agency for Research on Cancer, Lyon, 2020. 163. 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Comparison of patients according to pain and clinical evaluation Gender Total p Girls(n(%)) Boys(n(%)) Complaints Pain 5(35.7) 8(57.1) 13(49.9) 0.25 Night Pain 2(14.3) 4(28.6) 6(21.4) 0.35 Pain at Rest 1(7.1) 6(42.9) 7(25.0) 0.02 * Pain with Movement 2(14.3) 1(7.1) 3(10.7) 0.35 Pain while Running 2(14.3) 2(14.3) 4(14.3) 0.35 Chronic Pain 3 m< 2(14.3) 6(42.9) 8(28.6) 0.09 Difficulty in walking 1(7.1) 1(7.1) 2(7.1) 0.35 Instability in weight bearing 3(21.4) 3(21.4) 6(21.4) 0.35 Morning Stiffness 2(14.3) 2(14.3) 4(14.3) 1 Fatigue 2(14.3) 2(14.3) 4(14.3) 1 Fracture 0.0 1(7.1) 1(3.6) 0.35 No complaint, coincidence 5(35.7) 1(7.1) 6(21.4) 0.35 Sensitivity in examination 6(42.9) 10(71.4) 16(57.1) 0.12 On Screen Time # 2h 11(78.6) 12(85.7) 23(82.1) Pearson chi Square was considered significant at p<0.05. #On Screen time is divided into two groups: more than 2 hours or less than 2 hours, m:Month Table.2 Comparison of physical activity level according to gender measured by IPAQ scale Gender IPAQ Girls(n(%)) Boys(n(%)) Total(n(%)) p Inactive 4(28.6) 7(50) 11(39.3) .19 Moderate active 9(64.3) 2(14.3) 11(39.3) Very active 1(7.1) 5(35.7) 6(21.4) Total 14(100) 14(100) 28(100) Pearson chi Square was considered significant at p<.05 , IPAQ: International Physical Activity Questionnaire Table.3. Correlation of Pain scales, Physical Activity scales, on screen time and Ritschl classification IPAQ 21-NCAS VAS 21-VAS SET RITSCHL IPAQ r 1 -.001 -.094 -.024 -.186 -.138 p .996 .633 .902 .343 .483 21-NCAS r 1 -.697 -.563* .039 -.514* p <.001 .002 .844 .005 VAS r 1 .867* .087 .359 p <.001 .661 .061 21-VAS r 1 .105 .359 p .593 .061 SET r 1 .201 p .305 RITSCHL r 1 Correlation is significant at the 0.05 level (2-tailed) IPAQ: International Physical Activity Questionnaire SET: On Screen Time, 21-Numbered Circle VAS.(21-VAS), VAS:Visual analog scale, 21-Numbered Circle Activity Scale(21-NCAS), RİTSCHL; Ritschl’s classification stage Table. 4. Size of lesions and age according to Ritschl classificiation Number of Lesion Size(cm 3 ) Mean( ± SD) Min-Max P # Mean( ± SD) Min-Max p & Stage A 18 1.63(±0.30) 0.32-3.4 0.022 1 14.2 (±2.17) 10-17 0.13 Stage B 9 5.96(±1.67) 0.39-15.10 0.022 2 14.6(±1.6) 11-16 Stage C 7 6.22(±7.56) 0.35-21.74 0.026 3 15.8(±1.6) 13-18 Total 34 3.68(±4.75) 0.12-21.74 18 P # value is the result of comparison of three group(Stage A,B,C), post hoc results for comparison;1:Stage B-C, 2:Stage A-C, 3:Stage A-B, p & value is the result of comparison of three group(Stage A,B,C), One way ANOVA was used Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4817840","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":347940922,"identity":"b155bd22-b7c9-415b-93ce-fe1d07b0807a","order_by":0,"name":"Erhan Berk","email":"","orcid":"","institution":"Malatya Turgut Özal Üniversitesi","correspondingAuthor":false,"prefix":"","firstName":"Erhan","middleName":"","lastName":"Berk","suffix":""},{"id":347940923,"identity":"9fdba096-d221-4f4e-a13c-88bf07029cf4","order_by":1,"name":"Rabia Aydogan Baykara","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABA0lEQVRIiWNgGAWjYDCCAwwMzAwGIFYCiLABYsbGA6RoSQNpaSBCCwNcy2GYIG7Ad/vsw88FBXbyBseTD7/4ueO83dr2w0BbamyicWmRPJduLD3DINlww5lnaZa9Z24nbzuTCNRyLC23AYcWgzNsDNI8BsyMG27kmBnwtt1ONjsA1MLYcBifFubfPAb19iAthn/bziWbnX9IUAsb0JbDiUAtxo952w7Ymd0gYIskUIv1DKDfZwL9wizblpxgdgNoSwIev/ABHXa74E+1bR8wxD6+bbOzNzuf/vDBhxobnFrgQOEAA5sEkE4Eq0wgpBwE5BsYmD8AaXtiFI+CUTAKRsHIAgDQY2iwJp8HfAAAAABJRU5ErkJggg==","orcid":"","institution":"Malatya Turgut Özal Üniversitesi","correspondingAuthor":true,"prefix":"","firstName":"Rabia","middleName":"Aydogan","lastName":"Baykara","suffix":""}],"badges":[],"createdAt":"2024-07-28 18:23:19","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4817840/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4817840/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":64385183,"identity":"26dc67cb-63aa-432c-836f-61828176892a","added_by":"auto","created_at":"2024-09-12 12:24:38","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":70690,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eA: \u003c/strong\u003e14 year-old girl with multiple fibrous cortical defects around knee. Direct x-ray of knee in anteroposterior and lateral aspects show eccentrically located posteromedial and posterolateral lytic lesions with sclerotic rim consistent with fibrous cortical defect.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eB:\u003c/strong\u003e Coronal and axial proton dansity and axial T1 weighted MR sections show lesions in posterior and posteromedial aspects of both femurs consistent with fibrous cortical defects. These lesions were classified as stage A according to Ritschl’s classification.\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4817840/v1/d4f513e8ccd74a522f9d9fb0.jpg"},{"id":64385181,"identity":"77c40793-1b6d-4f8b-b2ab-3b45c0e02780","added_by":"auto","created_at":"2024-09-12 12:24:37","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":58579,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eA:\u003c/strong\u003e Lateral and anteroposterior direct X-ray of a 16 year-old patient shows lytic lesion with sclerotic rim in distal medial metaphysis of tibia consistent with FCD.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eB:\u003c/strong\u003e Axial T1 weighted, coronal proton density, and coronal contrast enhanced fat saturated T1 weighted magnetic resonance images show sclerotic, non \u0026nbsp;contrast enhancing areas within the lesion. This lesion was classified as stage C according to Ritschl’s classification\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4817840/v1/d02c6cb53867013698213c78.jpg"},{"id":65869686,"identity":"e8d6e228-69ac-4144-8531-d2b07a3a7449","added_by":"auto","created_at":"2024-10-03 19:01:32","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":893312,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4817840/v1/443acc08-6f74-4fed-9be9-efb0dbdb77fe.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Are fibrous cortical defect (FCD) and non-ossifying fibroma (NOF) only a radiological finding? Relationship between radiological/clinical findings and physical activity in children and adolescents: A cross-sectional study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eFibrous cortical defect (FCD) and non-ossifying fibroma (NOF) are benign lesions that occur with the presence of osteoclast-like multinucleated giant cells accompanied by fibroblast proliferation on pathological examination[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] Although their histopathology is similar, the terminology differ such that lesions smaller than 2 cm and remains confined to the bone cortex, are named as \u0026ldquo;fibrous cortical defect\u0026rdquo;, whereas bigger lesions and with variable endo medullary extension are named as \u0026ldquo;non-ossifying fibroma\u0026rdquo;[\u003cspan additionalcitationids=\"CR3 CR4\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Accordingly, the two aforementioned conditions were consolidated into a single category, designated as FCD/NOF, for the purposes of this study.\u003c/p\u003e \u003cp\u003eThese lesions are regarded as developmental variations, manifesting predominantly during the first and second decades of life. [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. These lesions represent the most common benign lesions of the skeletal system, with an estimated prevalence of 30\u0026ndash;40% in skeletally immature children[\u003cspan additionalcitationids=\"CR6 CR7\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. A study of the Japanese population demonstrated a prevalence of NOF of 2.3% and FCD of 7.0%. NOF was more prevalent in boys, while FCD was more prevalent in girls[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] Genetic predisposition for NOF was confirmed by DNA sequencing and MAP kinase signalling[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Additionally, Nelson et al. reported chromosomal translocation bands in a patient diagnosed with NOF[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eX-ray is used as the first imaging method in the evaluation of FCD and NOF and is generally diagnostic.[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] Characteristic imaging findings of the lesions include being eccentric within the bone and adjacent to the cortex, moving close to the physis or towards the metaphysis during growth, and having a sclerotic margin[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The long axis of the lesions is parallel to the long axis of the bone, while lesions are most commonly localized around the knee, including the distal femur and proximal medial tibia[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], and very rarely in the mandible [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Although direct X ray is used for diagnostic, computed tomography and magnetic resonance imaging are alternative diagnostic evaluation options of these lesions[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eWhen evaluated clinically, FCD is usually asymptomatic and is detected incidentally on an X-ray taken for another reason, and does not require any intervention. [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. NOF is rarer, more eccentric and symptomatic compared to FCD, while these lesions usually disappear spontaneously with age. Sometimes the lesions may be palpably swollen, compress adjacent muscle or neurovascular structures, and expand the cortex, causing damage to adjacent bone[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Symptoms are generally described as pain, swelling and tenderness, and sometimes fracture, and treatment is usually conservative, but if trauma is present and causes symptoms and bone weakening, prophylactic treatment may be required [\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Fractures are often seen in the lower extremity, at the distal end of the tibia. In addition, if the lesion covers more than 50% of the bone in 2 projections and is longer than 33 mm, the risk of bone fracture is considered high, and surgical bone grafting and local intralesional curettage are sufficient in its treatment [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] Nevertheless, a more recent series of studies demonstrated that 59% of NOF cases exceeded the aforementioned threshold measurements without fracture [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePain and limitation of movement can negatively affect growth and development in children and adolescents, while pain, fractures and other symptoms caused by FCD/NOF might hinder activity and increase physical inactivity which might negatively effect both physical and psychosocial development in children and young adolescents [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. According to WHO 2020 guidelines, physical activity is necessary for healthy growth and development, mental health, social skills development, attention concentration and learning ability in children and adolescents [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. [Thus, symptoms of NOF/FCD might reduce the level of physical activity required for healthy development in children, and increase physical inactivity.\u003c/p\u003e \u003cp\u003eThe aim of this study is to determine the symptoms occurring in children diagnosed with FCD/NOF, to reveal the characteristics of the Xray and MRI images of the lesions, and to evaluate the relationship of physical activity.\u003c/p\u003e"},{"header":"Material and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatient Selection\u003c/h2\u003e \u003cp\u003eThe study population consisted of patients who were enrolled between January 2020 and August 2021. The sample was selected from patients with imaging records in the system for the previous five years and who were under the age of 18 at the time of diagnosis. The patients were identified by searching the diagnosis records in the hospital database for the keywords \"fibrous cortical defect\" and \"non-ossifying fibroma.\" The same search was conducted in the radiology reports. The patients were contacted by telephone. Those who agreed to participate were invited to the hospital, where they signed a consent form. Demographic data, reason for admission to the hospital, trauma history, and extensive anamnesis were collected. The same physician performed an examination, and the patients' activity levels were assessed. The questionnaires were administered to the patients individually, but parents were permitted to contribute to the process.\u003c/p\u003e \u003cp\u003eThe imaging findings of the children's lower extremities, as well as the standard anteroposterior and lateral X-ray images and MRI images, were obtained from the hospital records as previously mentioned and within the specified time interval. Patients were included in the study according to the criteria; (1) being patient aged 10\u0026ndash;18 years, and (2) patients who underwent standard antero-posterior and lateral view radiography and/or (3) MRI.\u003c/p\u003e \u003cp\u003eExclusion criteria; (1) diagnosed metabolic and endocrine diseases, other diseases affecting bone metabolism, rheumatological diseases, neurological diseases, patients with a history of fractures and operations other than FCD/NOF, and (2) patients whose radiological imaging quality is not sufficient for the study. were excluded from the research.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eRadiological evaluation of NOF/FCD\u003c/h2\u003e \u003cp\u003eFor all lesions, the intraosseous involvement and size of the lesion were evaluated and lesions were classified according to the Ritschl classification; \u003cb\u003eStage A\u003c/b\u003e: Small, oval to slightly polycyclic in shape, without a sclerotic border, in the cortex near the epiphyseal end plate, \u003cb\u003eStage B\u003c/b\u003e: Lesions at variable distance from the epiphysis, polycyclic in shape, with thin but clearly sclerotic borders and a thin cortex occasionally protruding above the surface in an hourglass shape without periosteal reaction, \u003cb\u003eStage C\u003c/b\u003e: lesion with partial sclerosis \u003cb\u003eStage D\u003c/b\u003e: lesion with complete sclerosis[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. The Ritschl classification is based on the clinical course of the healing process and these stages are proportional to the age of the patient. Stage B lesions have an increased risk of fracture, therefore follow-up until reaching Stage C is recommended[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eData collection\u003c/h2\u003e \u003cp\u003ePatients selected for the study were identified in the hospital registry system and contacted by phone call. After explaining the study, consent have been obtained by patients verbally and volunteers were invited for clinical evaluation. Demographic data of patients such as age, gender, education, and other variables such as initial complaint, complaint duration, comorbidity, family history of rheumatological disease, on screen time were recorded.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003ePain Assessment\u003c/h2\u003e \u003cp\u003e \u003cb\u003eFor pain assessment, both 10-centimeter horizontal line visual analog scales(VAS)\u003c/b\u003e [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] and \u003cb\u003e21-numbered circle visual analog scales(21-VAS)\u003c/b\u003e were used described elsewhere in detail [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. The Likert-type scale, which increases in 0.5 cm intervals, has an unhappy face emoji on the 0 side and a smiling face emoji on the side where 10 is placed. This scale is more useful in children as it is completed faster and shows remission better than the standard 10 cm VAS [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe main complaints were categorized as: 1) Pain, a) Pain with movement b) Pain at rest c) Night Pain, d) Pain while running, 2) Swelling and Tenderness, 3) Chronic Pain 3 month\u0026lt;, 4) Difficulty in walking, 5) Instability in weight bearing 6)Fracture. Morning stiffness, shifting pain in the hip, fatigue, as well as time on screen time were questioned in the anamnesis. In the examination swelling, increase in body temperature and tenderness were evaluated.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003ePhysical Activity Scale:\u003c/h2\u003e \u003cp\u003e \u003cstrong\u003e21-numbered circle activity scale(21-NCAS)\u003c/strong\u003e \u003cp\u003eThere is \u0026ldquo;no activity\u0026rdquo; on the 0 side of the Likert-type scale, increasing at 0.5 cm intervals, and \u0026ldquo;Maximum activity\u0026rdquo; expressions are on the 10 side. High scores indicate that the activity can be performed easily.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eInternational Physical Activity Questionnaire (IPAQ)\u003c/b\u003e: The last seven days of activity were evaluated with the questionare. Walking and activity is evaluated as duration (minutes) and frequency (days) and total score is classified as \u0026ldquo;very active\u0026rdquo;, \u0026ldquo;moderate active\u0026rdquo; or \u0026ldquo;inactive\u0026rdquo;. Sitting: 1.5 MET, walking: 3.3 MET, moderate physical activity: 4.0 MET, vigorous physical activity: 8.0 MET. For example, for a person who walks for 7 days and 30 minutes, the METmin/week score is calculated as: 3.3x7x30\u0026thinsp;=\u0026thinsp;693 MET-min/week [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eStatistical analyses\u003c/strong\u003e \u003cp\u003eThe data analysis was conducted by using IBM SPSS 25 statistical software package, and data\u0026rsquo;s conformity to normal distribution was tested by using the Kolmogorov-Smirnov test. Descriptive statistics were presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD, median (range), and n (%). Independent Student t-test and chi-square test were used to compare two groups, while One-Way ANOVA test was used to compare more than 2 groups, while Tukey t Test has been used for post-Hoc analysis at significance level of p\u0026thinsp;\u0026lt;\u0026thinsp;0.05. The study also encompassed correlation analyses using the Pearson correlation method. For the evaluation of categorical data, cross-tabulation was used in conjunction with the chi-square test.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e Before participating in the study, written informed consent was obtained from all participants. The study had been previously approved by the Local Clinical Research Ethics Committee of the Council of Europe guidelines and the Helsinki Declaration, under decision number:E-30785963-020-222774/2024/43.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 34 lesions (Three children had more than one lesion) in 28 children (14 girls/14 boys) with the mean age of 14.5\u0026thinsp;\u0026plusmn;\u0026thinsp;1.8 years for girls, and 15.14\u0026thinsp;\u0026plusmn;\u0026thinsp;2.5 years for boys, were included in the study (p\u0026thinsp;=\u0026thinsp;0.45).\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eClinical Evaluation\u003c/strong\u003e \u003cp\u003eThe Patients applied to the hospital presented pain n\u0026thinsp;=\u0026thinsp;13(49.9%), Instability in weight bearing n\u0026thinsp;=\u0026thinsp;6(21.4%), pain with movement (n\u0026thinsp;=\u0026thinsp;10, 35.7%), Pain while running(n\u0026thinsp;=\u0026thinsp;4, 14.3%) night pain (n\u0026thinsp;=\u0026thinsp;6, 21.4%), pain at rest ( n\u0026thinsp;=\u0026thinsp;7, 25%), morning stiffness (n\u0026thinsp;=\u0026thinsp;4, 14.3%), chronic pain (lasting more than 3 months) (n\u0026thinsp;=\u0026thinsp;8, 28.6%), fatigue (n\u0026thinsp;=\u0026thinsp;4, 14.3%), tenderness on examination (n\u0026thinsp;=\u0026thinsp;16,%57.1). The lesions of 21.4% (n\u0026thinsp;=\u0026thinsp;6) of 28 children were detected incidentally on radiographs, while complaints of boys and girls did not differ when they came to the hospital (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05), but pain at rest was more common in boys compared to girls when symptoms were questioned (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) (Table.1)\u003c/p\u003e \u003c/p\u003e \u003cp\u003eAccording to IPAQ, 39.3% of the children were inactive, 39.3% minimally active and 21.4% very active, while no statistically significant difference was observed in physical activity between boys and girls (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). The IPAQ MET mean was calculated as 1455\u0026thinsp;\u0026plusmn;\u0026thinsp;1215) presented in detail in Table.2.\u003c/p\u003e \u003cp\u003eAccording to the results for correlation analysis, there was a negative significant relationship between the \u003cb\u003e21-NCAS\u003c/b\u003e score and the scores of VAS, \u003cb\u003e21-VAS\u003c/b\u003e and the Ritschls stage, (r\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.69, r= -0.56, r-0.51) respectively (p\u0026thinsp;\u0026lt;\u0026thinsp;.05). There was no difference between boys and girls in terms of Ritchl stage (p\u0026thinsp;\u0026gt;\u0026thinsp;.05). There was no difference between the time spent in front of the screen and parameters such as exercise scales (activity scale number 21 and IPAQ) and Ritschl stage (Table. 3).\u003c/p\u003e \u003cp\u003eAs Ritschl stage and pain level increase, physical activity level decreases. However, no correlation was identified between pain level and Ritschl stage.\u003c/p\u003e \u003cp\u003eAccording to the radiological evaluation results, 34 lesions had X-ray scans available in the archive of the hospital. One of the patients had 3 lesions, and 2 patients had 2 lesions, while the rest had only one lesion, summarized as 34 lesions in 28 patients. All lesions were eccentrically located within the metaphysis of a long bone such that 22 lesions in Femur and 12 lesions in tibia, while 18 of the lesions were on the left side ( Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e1\u003c/span\u003e, \u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e2\u003c/span\u003e ). Only 4 lesions were examined with contrast enhanced MRI; from these 3 had peripheral and only 1 had heterogeneous contrast enhancement after intravenous contrast media injection ( Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e1\u003c/span\u003e, \u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e2\u003c/span\u003e ).\u003c/p\u003e \u003cp\u003eThe mean size of the lesions were 3.68\u0026plusmn;4.75. (0.12\u0026ndash;21.74) cm\u003csup\u003e3\u003c/sup\u003e. According to the Ritschl\u0026rsquo;s classification; 18 (%52.9) lesions were stage A, 9 (%26.5) lesions were stage B, 7 (%20.6), lesions were stage C. Lesion size in Stage C was higher compared to Stage A and Stage B, while lesion size increases as the Ritschl Stage increased from Stage A to StageB and to Stage C continuesly (p\u0026thinsp;\u0026lt;\u0026thinsp;0.02). All groups showed a statistically significant difference when compared to each other (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). and as, the lesion size also increased (p\u0026thinsp;\u0026lt;\u0026thinsp;0.02). The age variable did not show any si-gnificant difference among groups of the Ritchsl stage (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05) (Table.4)\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study is the first to investigate the relationship between the radiological characteristics and clinical evaluation of FCD/NOF and the physical activity level in children. In our study, we observed that FCD/NOF lesions occurred incidentally in 21.4% of patients. Despite the assertion in the existing literature that lesions are predominantly identified on radiographs obtained for reasons unrelated to the detection of such lesions, our study revealed that the most frequently reported symptom was pain, accounting for 49.9% of cases. Similarly, in a prevalence study, half of the patients with FCD had spontaneous pain complaints [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e][\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWhen complaints were compared between boys and girls, no significant difference was found between them, but pain at rest was seen to be more common in boys. The physical activity levels of children and adolescents were classified as either very inactive or moderately active, a finding that was consistent with that of previous published literature.[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] Paralel findings were found in a large-scale study conducted by Guthold, R et al., covering 1.6\u0026nbsp;million childern and young adolescents, stating that 81% of the students aged between 11\u0026ndash;18 years (Boys: 77.6% / Girls: 84.7%) were not physically active [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e][\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. A further noteworthy finding of the study was that, while the physical activity levels of boys and girls with FCD/NOF were similar, there was a decline in physical activity as Ritschl Stage increased. Moreover, physical activity was associated negatively to pain scores. Thus, pain is considered as a condition that limits physical activity. Similar to our findings, a study evaluating pain and physical activity bidirectionally in adolescents found that the experience of pain limits physical activity on a daily basis. In a study comparing adolescents with chronic pain and their healthy peers, physical activity was measured objectively via actigraphy, and it was found that those with pain had lower levels of physical activity as well as decreased physical functionality [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. However, in adolescents with chronic pain, the pain intensity was lower at the end of the day in those with higher levels of physical activity [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Findings of our study showed that there is no relationship between the Ritschl stage and the pain scores, In our study, lesion size increased with increasing Ritsch stage. Based on this information, it can be considered that increasing lesion size is not associated with pain, as Emori et al. reported that lesion size is not associated with spontaneous pain.[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOn the other hand, the use of technology may cause a decrease in physical activity because it hinders children's daily activities. In previous studies, physical activity was found to be low in children who spent long time on using technology [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. In our study, the majority of children with FCD/NOF had more than 2 hours of on screen time in both genders, but on screen time was not assocciated to physical activity level. Paralel results were obtained in the study conducted by Karaca et al., which showed that on screen time was not correlated with physical activity in children without any disease[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e], and Nilsson et al. reported that increasing exercise time was not correlated to shortening TV watching[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. An international study conducted by Melkevich et al., showed that on screen time is negatively correlated to physical activity in countries where the average physical activity level is high. However, across geographic regions and genders with generally lower levels of physical activity, it has been shown that there is no consistent association with levels of screen-based sedentary behavior spent more than 2 hours per day [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAccording to our radiological findings, Stage A lesion was the most detected lesion classified according to Ritschl's classification, which was consistent with the findings of the study conducted by Emori et al.[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Additionally, our study showed that size of FCD or NOF increases with the increasing stage according to Ritschl's classification, while Herget et al. Also reported that the size of the lesions increased with the increase in the stage of the lesions [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. In contrast to the study of Herget et al. who reported an increase in age with increasing Ritschl stage, we did not find any significant difference between Ritschl stages according to age. Blaz et al. also agreed that the average age of patients increased with increasing Ritschl stage [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], both studies include adult in addition to children in their study sample. Thus different results in our study might be due to the younger age group of patients and also using different imaging methods for evaluation.\u003c/p\u003e \u003cp\u003eIn our study, 9 patients were in Stage B, while one of them had a pathological fracture, which is consistent with the literature stating that patients with Stage B lesions have an increased risk of suffering a pathological fracture. Similarly, Herget et al. reported pathological fractures in 6 out of 87 patients[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], while Emori et al., reported that fractures were detected in 2.1% of patients with Ritschl classification Stage B [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Moreover, 3 children had more than one lesion in our study which is also consistent with literature stating that 5\u0026ndash;8% of patients have multiple lesions [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis study has several limitations that has to be stated; Firstly, the patients' exercise barriers, which might affect the phycial activity level, have not been questioned in detail. Moreover, some physical activity parameters such as intensities, type of exercise (i.e. aerobic and muscle and bone strengthening activities) has not been identified. Secondly; Children were also not evaluated regarding sleep duration and psychological impact. Finally;\u003c/p\u003e \u003cp\u003eAlthough we classified lesions according to Ritschl's classification, a longitudinal study that follows patients over the long term could show the progression of X-ray and MRI findings over time. The Ritschl staging system is based on the clinical course of the healing process, as the stage increases, the lesion is expected to mature and then heal. The progression of the Ritschl stage with increasing child age has been documented [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The absence of Ritschl stage D in our sample (because stage D cases over 18 years of age were not included in the study) and the small sample size can be considered as other limitations.\u003c/p\u003e \u003cp\u003eThe first outcome of the research; The study revealed physical activity, radiological imaging and clinical status in children diagnosed with FCD/NOF. The clinical background of this pathology, known as \"touch-free lesion\" in the literature, was evaluated.\u003c/p\u003e \u003cp\u003eSecondly; The relationship between pain and other symptoms and physical activity was examined, and attention was drawn to physical activity affecting the growth and development of children.\u003c/p\u003e \u003cp\u003eIt was determined that pain was the main complaint in half of the patients and was responsible for restricting the mobility, and thereby decreased physical activity in patients. In addition, as the Ritschl stage increased, physical activity decreased. Therefore, it is recommended to inform the child and the family about the decrease of physical activity and to provide support from experts when necessary.\u003c/p\u003e "},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eInstitutional Review Board Statement:\u003c/strong\u003e Approval was obtained from local Clinical Research Ethics Committee (Approval\u0026nbsp;number:E-30785963-020-222774/2024/43\u0026nbsp;).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed Consent Statement:\u003c/strong\u003e Informed consent was obtained from all participants included in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability Statement:\u003c/strong\u003e The datasets are not publicly available but are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of Interest:\u003c/strong\u003e The authors declare no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eDeclaration of Figures Authenticity\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e:\u003c/em\u003e \u003cem\u003eAll figures submitted have been created by the authors who confirm that the images are original with no duplication and have not been previously published in whole or in part\u003c/em\u003e\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eE.B and R.AB :Conceptualization, RAB. and EB.; methodology, RAB. and EB.; software, RAB.; validation, RAB. and EB.; formal analysis, RAB. and EB.; investigation, RAB. and EB.; resources, RAB. and EB.; data curation, RAB. and EB.; writing\u0026mdash;original draft preparation, RAB. and EB.; writing\u0026mdash;review and editing, RAB and EB.; visualization, RAB and EB.; supervision, RAB.; project administration, RAB funding acquisition, RAB .\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSchajowicz, F., \u003cem\u003eHistological typing of bone tumours\u003c/em\u003e. 2012: Springer Science \u0026amp; Business Media.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBaumhoer, D. and D. Rogozhin, \u003cem\u003eNon-ossifying fibroma.\u003c/em\u003e Soft tissue and bone tumours. WHO classification of tumours series, 5th ed. International Agency for Research on Cancer, Lyon, 2020. 163.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMankin, H.J., et al., \u003cem\u003eNon-ossifying fibroma, fibrous cortical defect and Jaffe-Campanacci syndrome: a biologic and clinical review\u003c/em\u003e. Chir Organi Mov, 2009. 93(1): p. 1\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBłaż, M., et al., \u003cem\u003eCortical fibrous defects and non-ossifying fibromas in children and young adults: The analysis of radiological features in 28 cases and a review of literature\u003c/em\u003e. Pol J Radiol, 2011. 76(4): p. 32\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBetsy, M., L.M. Kupersmith, and D.S. Springfield, \u003cem\u003eMetaphyseal fibrous defects\u003c/em\u003e. J Am Acad Orthop Surg, 2004. 12(2): p. 89\u0026ndash;95.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHerget, G.W., et al., \u003cem\u003eNon-ossifying fibroma: natural history with an emphasis on a stage-related growth, fracture risk and the need for follow-up\u003c/em\u003e. BMC Musculoskelet Disord, 2016. 17: p. 147.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEmori, M., et al., \u003cem\u003eNon-ossifying fibromas and fibrous cortical defects around the knee - an epidemiologic survey in a Japanese pediatric population\u003c/em\u003e. BMC Musculoskeletal Disorders, 2022. 23(1): p. 378.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSontag, L.W. and S.I. Pyle, \u003cem\u003eThe appearance and nature of cyst-like areas in the distal femoral metaphyses of children\u003c/em\u003e. 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Head Neck Pathol, 2013. 7(2): p. 203\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHernanz L\u0026oacute;pez, P., P. Moreno Cano, and C. Bello Gonz\u0026aacute;lez, \u003cem\u003e[Non-ossifying fibroma]\u003c/em\u003e. Semergen, 2018. 44(7): p. 521\u0026ndash;522.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRogozhin, D.V., et al., \u003cem\u003e[Non-ossifying fibroma (metaphyseal fibrous defect)]\u003c/em\u003e. Arkh Patol, 2016. 78(2): p. 36\u0026ndash;40.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEasley, M.E. and J.S. Kneisl, \u003cem\u003ePathologic fractures through nonossifying fibromas: is prophylactic treatment warranted?\u003c/em\u003e J Pediatr Orthop, 1997. 17(6): p. 808\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSampasa-Kanyinga, H., et al., \u003cem\u003eCombinations of physical activity, sedentary time, and sleep duration and their associations with depressive symptoms and other mental health problems in children and adolescents: a systematic review\u003c/em\u003e. Int J Behav Nutr Phys Act, 2020. 17(1): p. 72.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChaput, J.P., et al., \u003cem\u003e2020 WHO guidelines on physical activity and sedentary behaviour for children and adolescents aged 5\u0026ndash;17 years: summary of the evidence\u003c/em\u003e. Int J Behav Nutr Phys Act, 2020. 17(1): p. 141.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRitschl, P., F. Karnel, and P. Hajek, \u003cem\u003eFibrous metaphyseal defects\u0026ndash;determination of their origin and natural history using a radiomorphological study\u003c/em\u003e. Skeletal Radiol, 1988. 17(1): p. 8\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFilocamo, G., et al., \u003cem\u003eEvaluation of 21-numbered circle and 10-centimeter horizontal line visual analog scales for physician and parent subjective ratings in juvenile idiopathic arthritis\u003c/em\u003e. J Rheumatol, 2010. 37(7): p. 1534\u0026ndash;41.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePincus, T., et al., \u003cem\u003eVisual analog scales in formats other than a 10 centimeter horizontal line to assess pain and other clinical data\u003c/em\u003e. J Rheumatol, 2008. 35(8): p. 1550\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSavcı, S., et al., \u003cem\u003ePhysical activity levels of university students\u003c/em\u003e. Archives of the Turkish Society of Cardiology, 2006. 34(3): p. 166\u0026ndash;172.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGuthold, R., et al., \u003cem\u003eGlobal trends in insufficient physical activity among adolescents: a pooled analysis of 298 population-based surveys with 1\u0026middot;6 million participants\u003c/em\u003e. Lancet Child Adolesc Health, 2020. 4(1): p. 23\u0026ndash;35.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTremblay, M.S., et al., \u003cem\u003eCanadian 24-Hour Movement Guidelines for Children and Youth: An Integration of Physical Activity, Sedentary Behaviour, and Sleep\u003c/em\u003e. Appl Physiol Nutr Metab, 2016. 41(6 Suppl 3): p. S311-27.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWilson, A.C. and T.M. Palermo, \u003cem\u003ePhysical activity and function in adolescents with chronic pain: a controlled study using actigraphy\u003c/em\u003e. J Pain, 2012. 13(2): p. 121\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRabbitts, J.A., et al., \u003cem\u003eBidirectional associations between pain and physical activity in adolescents\u003c/em\u003e. Clin J Pain, 2014. 30(3): p. 251\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlotaibi, T., et al., \u003cem\u003eThe Relationship between Technology Use and Physical Activity among Typically-Developing Children\u003c/em\u003e. Healthcare (Basel), 2020. 8(4).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcDougall, J. and M.J. Duncan, \u003cem\u003eChildren, video games and physical activity: An exploratory study\u003c/em\u003e. International Journal on Disability and Human Development, 2008. 7(1): p. 89\u0026ndash;94.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKaraca, A., et al., \u003cem\u003eScreen time of adolescents in an economically developing country: the case of Turkey\u003c/em\u003e. Ann Hum Biol, 2011. 38(1): p. 28\u0026ndash;33.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNilsson, A., et al., \u003cem\u003eCorrelates of objectively assessed physical activity and sedentary time in children: a cross-sectional study (The European Youth Heart Study)\u003c/em\u003e. BMC Public Health, 2009. 9: p. 322.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMelkevik, O., et al., \u003cem\u003eIs spending time in screen-based sedentary behaviors associated with less physical activity: a cross national investigation\u003c/em\u003e. Int J Behav Nutr Phys Act, 2010. 7: p. 46.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoser, R.P., Jr., et al., \u003cem\u003eMultiple skeletal fibroxanthomas: radiologic-pathologic correlation of 72 cases\u003c/em\u003e. Skeletal Radiol, 1987. 16(5): p. 353\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable.1. \u0026nbsp; Comparison of patients according to pain and clinical evaluation\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"600\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.833333333333332%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"15.5%\" colspan=\"2\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"22.333333333333332%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.333333333333334%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"13.166666666666666%\" rowspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.833333333333333%\" rowspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.232067510548525%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"19.620253164556964%\" colspan=\"2\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"28.270042194092827%\" valign=\"bottom\"\u003e\n \u003cp\u003eGirls(n(%))\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.877637130801688%\" valign=\"bottom\"\u003e\n \u003cp\u003eBoys(n(%))\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.833333333333332%\"\u003e\n \u003cp\u003e\u003cstrong\u003eComplaints\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.666666666666668%\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.166666666666666%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.333333333333334%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.166666666666666%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.833333333333333%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.833333333333332%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.666666666666668%\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003ePain\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.166666666666666%\" valign=\"bottom\"\u003e\n \u003cp\u003e5(35.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.333333333333334%\" valign=\"bottom\"\u003e\n \u003cp\u003e8(57.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.166666666666666%\" valign=\"bottom\"\u003e\n \u003cp\u003e13(49.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.833333333333333%\" valign=\"top\"\u003e\n \u003cp\u003e0.25\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.833333333333332%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.666666666666668%\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eNight Pain\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.166666666666666%\" valign=\"bottom\"\u003e\n \u003cp\u003e2(14.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.333333333333334%\" valign=\"bottom\"\u003e\n \u003cp\u003e4(28.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.166666666666666%\" valign=\"bottom\"\u003e\n \u003cp\u003e6(21.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.833333333333333%\" valign=\"top\"\u003e\n \u003cp\u003e0.35\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.833333333333332%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.666666666666668%\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003ePain at Rest\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.166666666666666%\" valign=\"bottom\"\u003e\n \u003cp\u003e1(7.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.333333333333334%\" valign=\"bottom\"\u003e\n \u003cp\u003e6(42.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.166666666666666%\" valign=\"bottom\"\u003e\n \u003cp\u003e7(25.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.833333333333333%\" valign=\"top\"\u003e\n \u003cp\u003e0.02\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.833333333333332%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.666666666666668%\" colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003ePain with Movement\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.166666666666666%\" valign=\"bottom\"\u003e\n \u003cp\u003e2(14.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.333333333333334%\" valign=\"bottom\"\u003e\n \u003cp\u003e1(7.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.166666666666666%\" valign=\"bottom\"\u003e\n \u003cp\u003e3(10.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.833333333333333%\" valign=\"top\"\u003e\n \u003cp\u003e0.35\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.833333333333332%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.666666666666668%\" colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003ePain while Running\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.166666666666666%\" valign=\"bottom\"\u003e\n \u003cp\u003e2(14.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.333333333333334%\" valign=\"bottom\"\u003e\n \u003cp\u003e2(14.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.166666666666666%\" valign=\"bottom\"\u003e\n \u003cp\u003e4(14.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.833333333333333%\" valign=\"top\"\u003e\n \u003cp\u003e0.35\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.833333333333332%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.666666666666668%\" colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eChronic Pain 3 m\u0026lt;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.166666666666666%\" valign=\"bottom\"\u003e\n \u003cp\u003e2(14.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.333333333333334%\" valign=\"bottom\"\u003e\n \u003cp\u003e6(42.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.166666666666666%\" valign=\"bottom\"\u003e\n \u003cp\u003e8(28.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.833333333333333%\" valign=\"top\"\u003e\n \u003cp\u003e0.09\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.833333333333332%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.666666666666668%\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eDifficulty in walking\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.166666666666666%\" valign=\"bottom\"\u003e\n \u003cp\u003e1(7.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.333333333333334%\" valign=\"bottom\"\u003e\n \u003cp\u003e1(7.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.166666666666666%\" valign=\"bottom\"\u003e\n \u003cp\u003e2(7.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.833333333333333%\" valign=\"top\"\u003e\n \u003cp\u003e0.35\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.833333333333332%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.666666666666668%\" colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eInstability in weight bearing\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.166666666666666%\" valign=\"bottom\"\u003e\n \u003cp\u003e3(21.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.333333333333334%\" valign=\"bottom\"\u003e\n \u003cp\u003e3(21.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.166666666666666%\" valign=\"bottom\"\u003e\n \u003cp\u003e6(21.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.833333333333333%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.35\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.833333333333332%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.666666666666668%\" colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eMorning Stiffness\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.166666666666666%\" valign=\"bottom\"\u003e\n \u003cp\u003e2(14.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.333333333333334%\" valign=\"bottom\"\u003e\n \u003cp\u003e2(14.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.166666666666666%\" valign=\"bottom\"\u003e\n \u003cp\u003e4(14.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.833333333333333%\" valign=\"bottom\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.833333333333332%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.666666666666668%\" colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eFatigue\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.166666666666666%\" valign=\"bottom\"\u003e\n \u003cp\u003e2(14.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.333333333333334%\" valign=\"bottom\"\u003e\n \u003cp\u003e2(14.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.166666666666666%\" valign=\"bottom\"\u003e\n \u003cp\u003e4(14.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.833333333333333%\" valign=\"bottom\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.833333333333332%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.666666666666668%\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eFracture\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.166666666666666%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.333333333333334%\" valign=\"bottom\"\u003e\n \u003cp\u003e1(7.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.166666666666666%\" valign=\"bottom\"\u003e\n \u003cp\u003e1(3.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.833333333333333%\" valign=\"top\"\u003e\n \u003cp\u003e0.35\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.833333333333332%\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo complaint, coincidence\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.666666666666668%\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.166666666666666%\" valign=\"bottom\"\u003e\n \u003cp\u003e5(35.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.333333333333334%\" valign=\"bottom\"\u003e\n \u003cp\u003e1(7.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.166666666666666%\" valign=\"bottom\"\u003e\n \u003cp\u003e6(21.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.833333333333333%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.35\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.833333333333332%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003eSensitivity in examination\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.666666666666668%\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.166666666666666%\" valign=\"bottom\"\u003e\n \u003cp\u003e6(42.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.333333333333334%\" valign=\"bottom\"\u003e\n \u003cp\u003e10(71.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.166666666666666%\" valign=\"bottom\"\u003e\n \u003cp\u003e16(57.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.833333333333333%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.12\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.833333333333332%\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eOn Screen Time\u003csup\u003e#\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.666666666666668%\" colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003e2h\u0026lt;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.166666666666666%\" valign=\"bottom\"\u003e\n \u003cp\u003e3(21.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.333333333333334%\" valign=\"bottom\"\u003e\n \u003cp\u003e2(14.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.166666666666666%\" valign=\"bottom\"\u003e\n \u003cp\u003e5(17.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.833333333333333%\" rowspan=\"2\"\u003e\n \u003cp\u003e0.62\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"38.3419689119171%\" colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003e2h\u0026gt;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.466321243523318%\" valign=\"bottom\"\u003e\n \u003cp\u003e11(78.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.72538860103627%\" valign=\"bottom\"\u003e\n \u003cp\u003e12(85.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.466321243523318%\" valign=\"bottom\"\u003e\n \u003cp\u003e23(82.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003ePearson chi Square was considered significant at p\u0026lt;0.05. #On Screen time is divided into two groups: more than 2 hours or less than 2 hours, m:Month\u003c/p\u003e\n\u003cp\u003eTable.2 Comparison of physical activity level according to gender measured by IPAQ scale\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"578\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.40901213171577%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"38.128249566724435%\" colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.0103986135182%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.452339688041595%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.40901213171577%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eIPAQ\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.197573656845755%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eGirls(n(%))\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.930675909878683%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eBoys(n(%))\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.0103986135182%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal(n(%))\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.452339688041595%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ep\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.40901213171577%\" valign=\"bottom\"\u003e\n \u003cp\u003eInactive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.197573656845755%\" valign=\"bottom\"\u003e\n \u003cp\u003e4(28.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.930675909878683%\" valign=\"bottom\"\u003e\n \u003cp\u003e7(50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.0103986135182%\" valign=\"bottom\"\u003e\n \u003cp\u003e11(39.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.452339688041595%\" rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e.19\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.0187265917603%\" valign=\"bottom\"\u003e\n \u003cp\u003eModerate active\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.662921348314608%\" valign=\"bottom\"\u003e\n \u003cp\u003e9(64.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.53558052434457%\" valign=\"bottom\"\u003e\n \u003cp\u003e2(14.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.782771535580526%\" valign=\"bottom\"\u003e\n \u003cp\u003e11(39.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.0187265917603%\" valign=\"bottom\"\u003e\n \u003cp\u003eVery active\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.662921348314608%\" valign=\"bottom\"\u003e\n \u003cp\u003e1(7.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.53558052434457%\" valign=\"bottom\"\u003e\n \u003cp\u003e5(35.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.782771535580526%\" valign=\"bottom\"\u003e\n \u003cp\u003e6(21.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.40901213171577%\" valign=\"bottom\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.197573656845755%\" valign=\"bottom\"\u003e\n \u003cp\u003e14(100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.930675909878683%\" valign=\"bottom\"\u003e\n \u003cp\u003e14(100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.0103986135182%\" valign=\"bottom\"\u003e\n \u003cp\u003e28(100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.452339688041595%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003ePearson chi Square\u0026nbsp;\u003c/em\u003ewas considered significant at \u003cem\u003ep\u0026lt;.05 ,\u0026nbsp;\u003c/em\u003eIPAQ: International Physical Activity Questionnaire\u003c/p\u003e\n\u003cp\u003eTable.3. Correlation of Pain scales, Physical Activity scales, on screen time and Ritschl classification\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"490\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"15.478615071283096%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.7026476578411405%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.830957230142566%\"\u003e\n \u003cp\u003e\u003cstrong\u003eIPAQ\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.256619144602851%\"\u003e\n \u003cp\u003e\u003cstrong\u003e21-NCAS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.405295315682281%\"\u003e\n \u003cp\u003e\u003cstrong\u003eVAS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.441955193482688%\"\u003e\n \u003cp\u003e\u003cstrong\u003e21-VAS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.830957230142566%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSET\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.052953156822811%\"\u003e\n \u003cp\u003e\u003cstrong\u003eRITSCHL\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"15.478615071283096%\"\u003e\n \u003cp\u003e\u003cstrong\u003eIPAQ\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.7026476578411405%\"\u003e\n \u003cp\u003er\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.830957230142566%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.256619144602851%\"\u003e\n \u003cp\u003e-.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.405295315682281%\"\u003e\n \u003cp\u003e-.094\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.441955193482688%\"\u003e\n \u003cp\u003e-.024\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.830957230142566%\"\u003e\n \u003cp\u003e-.186\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.052953156822811%\"\u003e\n \u003cp\u003e-.138\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"15.478615071283096%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"5.7026476578411405%\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.830957230142566%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.256619144602851%\"\u003e\n \u003cp\u003e.996\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.405295315682281%\"\u003e\n \u003cp\u003e.633\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.441955193482688%\"\u003e\n \u003cp\u003e.902\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.830957230142566%\"\u003e\n \u003cp\u003e.343\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.052953156822811%\"\u003e\n \u003cp\u003e.483\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"15.478615071283096%\"\u003e\n \u003cp\u003e\u003cstrong\u003e21-NCAS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.7026476578411405%\"\u003e\n \u003cp\u003er\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.830957230142566%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.256619144602851%\" valign=\"bottom\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.405295315682281%\"\u003e\n \u003cp\u003e-.697\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.441955193482688%\"\u003e\n \u003cp\u003e-.563*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.830957230142566%\"\u003e\n \u003cp\u003e.039\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.052953156822811%\"\u003e\n \u003cp\u003e-.514*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"15.478615071283096%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"5.7026476578411405%\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.830957230142566%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.256619144602851%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.405295315682281%\"\u003e\n \u003cp\u003e\u0026lt;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.441955193482688%\"\u003e\n \u003cp\u003e.002\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.830957230142566%\"\u003e\n \u003cp\u003e.844\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.052953156822811%\"\u003e\n \u003cp\u003e.005\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"15.478615071283096%\"\u003e\n \u003cp\u003e\u003cstrong\u003eVAS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.7026476578411405%\"\u003e\n \u003cp\u003er\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.830957230142566%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.256619144602851%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.405295315682281%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.441955193482688%\"\u003e\n \u003cp\u003e.867*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.830957230142566%\"\u003e\n \u003cp\u003e.087\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.052953156822811%\"\u003e\n \u003cp\u003e.359\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"15.478615071283096%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"5.7026476578411405%\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.830957230142566%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.256619144602851%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.405295315682281%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.441955193482688%\"\u003e\n \u003cp\u003e\u0026lt;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.830957230142566%\"\u003e\n \u003cp\u003e.661\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.052953156822811%\"\u003e\n \u003cp\u003e.061\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"15.478615071283096%\"\u003e\n \u003cp\u003e\u003cstrong\u003e21-VAS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.7026476578411405%\"\u003e\n \u003cp\u003er\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.830957230142566%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.256619144602851%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.405295315682281%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.441955193482688%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.830957230142566%\"\u003e\n \u003cp\u003e.105\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.052953156822811%\"\u003e\n \u003cp\u003e.359\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"15.478615071283096%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"5.7026476578411405%\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.830957230142566%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.256619144602851%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.405295315682281%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.441955193482688%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.830957230142566%\"\u003e\n \u003cp\u003e.593\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.052953156822811%\"\u003e\n \u003cp\u003e.061\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"15.478615071283096%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSET\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.7026476578411405%\"\u003e\n \u003cp\u003er\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.830957230142566%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.256619144602851%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.405295315682281%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.441955193482688%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.830957230142566%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.052953156822811%\"\u003e\n \u003cp\u003e.201\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"15.478615071283096%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"5.7026476578411405%\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.830957230142566%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.256619144602851%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.405295315682281%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.441955193482688%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.830957230142566%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.052953156822811%\"\u003e\n \u003cp\u003e.305\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"15.478615071283096%\"\u003e\n \u003cp\u003e\u003cstrong\u003eRITSCHL\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.7026476578411405%\"\u003e\n \u003cp\u003er\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.830957230142566%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.256619144602851%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.405295315682281%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.441955193482688%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.830957230142566%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.052953156822811%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eCorrelation is significant at the 0.05 level (2-tailed)\u0026nbsp;IPAQ:\u0026nbsp;International Physical Activity Questionnaire\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;SET: On Screen Time, 21-Numbered Circle VAS.(21-VAS), VAS:Visual analog scale, 21-Numbered Circle Activity Scale(21-NCAS), \u0026nbsp;RİTSCHL; Ritschl\u0026rsquo;s classification stage\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable. 4. Size of lesions and age according to Ritschl classificiation\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"593\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.794612794612794%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"14.30976430976431%\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of Lesion\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.50841750841751%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSize(cm\u003c/strong\u003e\u003cstrong\u003e\u003csup\u003e3\u003c/sup\u003e\u003c/strong\u003e\u003cstrong\u003e)\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;Mean(\u003c/strong\u003e\u003cstrong\u003e\u0026plusmn;\u003c/strong\u003e\u003cstrong\u003eSD)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eMin-Max\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.468013468013469%\"\u003e\n \u003cp\u003e\u003cstrong\u003eP\u003csup\u003e#\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.925925925925927%\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean(\u003c/strong\u003e\u003cstrong\u003e\u0026plusmn;\u003c/strong\u003e\u003cstrong\u003eSD)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eMin-Max\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.993265993265993%\"\u003e\n \u003cp\u003e\u003cstrong\u003ep\u003csup\u003e\u0026amp;\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.794612794612794%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eStage A\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.30976430976431%\" valign=\"top\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.50841750841751%\" valign=\"top\"\u003e\n \u003cp\u003e1.63(\u0026plusmn;0.30)\u003c/p\u003e\n \u003cp\u003e0.32-3.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.468013468013469%\"\u003e\n \u003cp\u003e0.022\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.925925925925927%\" valign=\"top\"\u003e\n \u003cp\u003e14.2 (\u0026plusmn;2.17)\u003c/p\u003e\n \u003cp\u003e10-17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.993265993265993%\" rowspan=\"4\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.13\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"15.230460921843687%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eStage B\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.034068136272545%\" valign=\"top\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.841683366733466%\" valign=\"top\"\u003e\n \u003cp\u003e5.96(\u0026plusmn;1.67)\u003c/p\u003e\n \u003cp\u003e0.39-15.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.03206412825651%\"\u003e\n \u003cp\u003e0.022\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.861723446893787%\" valign=\"top\"\u003e\n \u003cp\u003e14.6(\u0026plusmn;1.6)\u003c/p\u003e\n \u003cp\u003e11-16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"15.230460921843687%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eStage C\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.034068136272545%\" valign=\"top\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.841683366733466%\" valign=\"top\"\u003e\n \u003cp\u003e6.22(\u0026plusmn;7.56)\u003c/p\u003e\n \u003cp\u003e0.35-21.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.03206412825651%\"\u003e\n \u003cp\u003e0.026\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.861723446893787%\" valign=\"top\"\u003e\n \u003cp\u003e15.8(\u0026plusmn;1.6)\u003c/p\u003e\n \u003cp\u003e13-18\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"15.230460921843687%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.034068136272545%\" valign=\"top\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.841683366733466%\" valign=\"top\"\u003e\n \u003cp\u003e3.68(\u0026plusmn;4.75)\u003c/p\u003e\n \u003cp\u003e0.12-21.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.03206412825651%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.861723446893787%\" valign=\"top\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eP\u003csup\u003e#\u0026nbsp;\u003c/sup\u003evalue is the result of comparison of three group(Stage A,B,C), post hoc results for comparison;1:Stage B-C, 2:Stage A-C, 3:Stage A-B,\u0026nbsp;p\u003csup\u003e\u0026amp;\u003c/sup\u003e value is the result of comparison of three group(Stage A,B,C), One way ANOVA was used\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"fibrous cortical defect (FCD), non-ossifying fibroma (NOF), clinical findings, physical activity, children, adolescents, 21-numbered circle activity scale, IPAQ, 21-numbered circle VAS","lastPublishedDoi":"10.21203/rs.3.rs-4817840/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4817840/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eFibrous cortical defect (FCD) and non-ossifying fibroma (NOF) are incidentally recognised and benign developmental lesions. The objective of this study was to ascertain the clinical manifestations and symptoms of FCD/NOF in children and adolescent patients, to characterise the lesions radiologically using X-ray and MRI techniques, and to determine the relationship between physical activity and the condition.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMaterials and Methods:\u003c/strong\u003e The study included patients under the age of 18 with radiological lesions on their extremities. The lesions were classified as FKD or NOF in accordance with the distinctive imaging features. For each lesion, the bone involved, the site involved, the size of the lesion, and the type of lesion according to the Ritschl classification were recorded. In the anamnesis, the patient's presenting complaint, the character of the pain, if any, and the level of activity were investigated. Pain was quantified using the visual analogue scale (VAS) and the 21-Numbered Circle VAS.(21-NCVAS) The 21-Numbered Circle Activity Scale(21-NCAS) \u0026nbsp;and the International Physical Activity Questionnaire (IPAQ) were employed for the assessment of physical activity.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e 34 lesions in 28 children (14 girls/14 boys) were included in the study. Age was not different between girls and boys (p = 0.45). According to Ritschl classification, 18 (52.9%) lesions were stage A, 9 (26.5%) were stage B and 7 (20.6%) were stage C. The lesion size increased with increasing Ritschl stage (p\u0026lt;0.02). The main presenting complaint was pain (n = 13, 49.9%). In 21.4% of the children (n=6), lesions were detected incidentally on radiographs. According to IPAQ, 39.3% of the children were physically inactive. There was a significant negative correlation between 21-NCAS and Ritschls stage (r= -.51, p\u0026lt;.05). Activity decreased as the Ritschl stage increased. There was a significant negative correlation between 21-NCAS and VAS (r=-.69, p\u0026lt;.05).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eSpontaneous pain was observed in 49.9% of patients diagnosed with FCD/NOF. No correlation was identified between lesion size and the presence or severity of pain. As the severity of pain and Ritschl stage increased, there was a corresponding decrease in physical activity.\u003c/p\u003e","manuscriptTitle":"Are fibrous cortical defect (FCD) and non-ossifying fibroma (NOF) only a radiological finding? Relationship between radiological/clinical findings and physical activity in children and adolescents: A cross-sectional study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-09-12 12:24:32","doi":"10.21203/rs.3.rs-4817840/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"60a40ba6-84e0-4e0b-b6bd-864ec967f015","owner":[],"postedDate":"September 12th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":36912771,"name":"Health sciences/Medical research"},{"id":36912772,"name":"Health sciences/Medical research/Paediatric research"},{"id":36912773,"name":"Health sciences/Rheumatology/Musculoskeletal system/Bone"}],"tags":[],"updatedAt":"2024-10-03T18:53:25+00:00","versionOfRecord":[],"versionCreatedAt":"2024-09-12 12:24:32","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4817840","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4817840","identity":"rs-4817840","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}