Clinical Utility and Validity of Exercise Vital Sign in Children.

ABSTRACT: We reviewed charts of 14,446 sports medicine patients, children aged 5 to 18 years, over a 3-year period to determine the discriminant validity of Exercise Vital Sign (EVS) questions. A logistic regression analyzed factors related to any moderate to vigorous physical activity (MVPA). A linear regression analyzed factors related to amount of MVPA for those who participated in any weekly MVPA. Overall, 48% of children reported meeting physical activity guidelines for 420 min·wk-1. Overall, children reported 400.36 ± 280.04 min·wk-1 of MVPA. Those with depression had significantly less MVPA than those without (95% confidence interval [CI], -96.65 to -26.31). Girls had significantly less MVPA than boys (95% CI, -59.15 to -40.31). Overweight and obese children reported less MVPA compared with normal weight children (95% CIs, -42.65 to -17.29 and -91.61 to -65.50, respectively). EVS demonstrates strong discriminant validity to detect differences between groups as a function of sex, body mass index, and depression.

Achilles Tendon Injuries Requiring Surgical Treatment in the Pediatric and Adolescent Population: A Case Series.

ABSTRACT: Pediatric Achilles tendon injuries requiring surgical treatment are considered rare and have not been well described. A retrospective chart review was conducted from 2010 to 2020 to identify cases of acute Achilles tendon rupture or laceration that required surgical repair in individuals 19 years or younger. A total of 24 individuals with acute Achilles tendon ruptures (n = 8) and lacerations (n = 16) were identified. All spontaneous ruptures occurred in skeletally mature individuals during sports. One subject was on minocycline at the time of injury, while two had a body mass index (BMI) ≥ 99% for age. Another had a history of clubfoot surgery on the injured side. Patients with lacerations were younger (9.9 ± 3.3 vs 16.3 ± 1.6 years) and had lower BMI (17.3 ± 3.8 vs. 28.0 ± 9.4) than those with spontaneous ruptures. The majority of cases had good outcomes with no postoperative complications.

Concussion clinic presentation and symptom duration for pediatric sports-related concussions following Ohio concussion law.

In 2013, Ohio enacted a law to mitigate consequences of pediatric sports-related concussions. This study aimed to describe changes in clinic visits and symptom duration for pediatric sports-related concussions before and after this law. 3,133 new visits by 2,861 unique patients (10-18 years) presenting between April 2012 and April 2015 for sports-related concussions within 30 days of injury were included. There were 937 (29.9%), 1,132 (36.1%) and 1,064 (34.0%) concussion visits for pre-law, immediate-post law, and post-law periods, respectively. A greater proportion of concussion visits was observed among females from pre-law to post-law (P < 0.0001). No differences were observed across the three periods in symptom scores at injury (P = 0.5028) or at first clinic visit (P = 0.5686). However, patients presented to concussion clinics significantly earlier (17.6 vs. 22.8 days, P < 0.0001) and had quicker recovery (26.5 vs. 40.6 days, P < 0.0001) post-law than pre-law.

Lightheadedness After Concussion: Not All Dizziness is Vertigo.

OBJECTIVE: To characterize the presence and degree of postconcussion lightheadedness in relation to postconcussion vertigo and dizziness, and to determine whether lightheadedness influences overall symptom duration. DESIGN: Prospective, cohort design. SETTING: Nationwide Children's Hospital, Sports Concussion Clinic. PARTICIPANTS: Five hundred ten patients (9-19 years of age) within 30 days of concussion injury. MAIN OUTCOME MEASURES: Patient ratings (scale 0-6) of multiple postconcussion symptoms including lightheadedness, vertigo, and dizziness, reported from the day of clinic evaluation and recalled from the day of concussion. RESULTS: Postconcussion lightheadedness occurred commonly relative to vertigo. Lightheadedness was recalled more than vertigo (70.8% vs 48.6%, P < 0.001) on concussion day and reported more than vertigo (47.1% vs 24.1%, P < 0.001) on the day of clinic evaluation. Principal component analysis demonstrated strong correlations among lightheadedness, vertigo, balance difficulties, difficulty concentrating, mental fogginess, and difficulty remembering, relative to other postconcussion symptoms. When present on the day of clinic evaluation, these highly correlated symptoms predicted prolonged concussion recovery [P = 0.028; Hazard Ratio (HR) = 1.2]. Female sex (P = 0.04; HR = 1.23), emotional symptoms recalled from the day of concussion (P = 0.007; HR = 1.23), and cephalalgic symptoms (P < 0.001; HR = 1.34) reported on the day of clinic evaluation also predicted prolonged concussion recovery. CONCLUSIONS: Not all postconcussion dizziness is vertigo. Postconcussion lightheadedness is common and, when present at the time of clinic evaluation, can influence concussion recovery. CLINICAL RELEVANCE: Distinguishing postconcussion lightheadedness from vertigo may help to inform clinical treatment and concussion research design. This study adds to the growing body of evidence that supports an association between concussion and autonomic dysfunction.

Length of Recovery From Sports-Related Concussions in Pediatric Patients Treated at Concussion Clinics.

OBJECTIVES: We quantified the length of recovery time by week in a cohort of pediatric sports-related concussion patients treated at concussion clinics, and examined patient and injury characteristics associated with prolonged recovery. DESIGN: A retrospective, cohort design. SETTING: Seven concussion clinics at a Midwest children's hospital. PATIENTS: Patients aged 10 to 17 years with a diagnosed sports-related concussion presenting to the clinic within 30 days of injury. MAIN OUTCOME MEASURES: Length of recovery by week. METHODS: Unadjusted and adjusted multinomial logistic regression analyses were used to model the effect of patient and injury characteristics on length of recovery by week. RESULTS: Median length of recovery was 17 days. Only 16.3% (299/1840) of patients recovered within one week, whereas 26.4% took longer than four weeks to recover. By 2 months postinjury, 6.7% of patients were still experiencing symptoms. Higher symptom scores at injury and initial visit were significantly associated with prolonged symptoms by week. Patients who presented to the clinic more than 2 weeks postinjury or who had 2 or more previous concussions showed increased risk for prolonged recovery. Females were at greater risk for prolonged recovery than males (odds ratio = 2.08, 95% confidence interval = 1.49-2.89). Age was not significantly associated with recovery length. CONCLUSIONS: High symptom scores at injury and initial visit, time to initial clinical presentation, presence of 2 or more previous concussions, and female sex are associated with prolonged concussion recovery. Further research should aim to establish objective measures of recovery, accounting for treatment received during the recovery. CLINICAL RELEVANCE: The median length of recovery is 17 days among pediatric sports-related concussion patients treated at concussion clinics. Only 16.3% of patients recovered within one week, whereas 26.4% took longer than 4 weeks to recover.

Utilization of conventional neuroimaging following youth concussion.

BACKGROUND/OBJECTIVE: Conventional neuroimaging is not recommended for the routine diagnosis of concussion, but some patients with concussion undergo computed tomography (CT) or magnetic resonance imaging (MRI). The objective of this study was to explore the clinical factors that predict neuroimaging utilization in concussion. METHODS: Concussion-related CT and MRI data were analysed from 1953 patients, aged 10-19 years, who presented to a sports concussion clinic within 30 days of injury. RESULTS: The majority of CT scans (n = 193) were obtained during the acute concussion period (mean = 2.7 days post-concussion), whereas MRI scans (n = 134) were ordered later during recovery (mean = 39.4 days post-concussion). Predictors of CT utilization included loss of consciousness, amnesia and vomiting (all p < 0.001). Prior concussion (p = 0.002) and continued participation in activity after injury (p = 0.03) predicted greater MRI utilization. Neuroimaging with either CT (p = 0.024, hazard ratio = 1.2) or MRI (p < 0.001, hazard ratio = 2.75) was associated with prolonged symptoms. Only 3.1% of CTs and 1.5% of MRIs demonstrated signs of traumatic brain injury. CONCLUSION: Several clinical factors predict neuroimaging utilization in patients with concussion. CT is generally used acutely, while MRI is used in the sub-acute and chronic post-concussion periods. In a sports concussion clinic, delayed neuroimaging has limited clinical yield.

Specific Factors Influence Postconcussion Symptom Duration among Youth Referred to a Sports Concussion Clinic.

OBJECTIVE: To identify the clinical factors that influence the duration of postconcussion symptoms among youth referred to a sports concussion clinic. STUDY DESIGN: A retrospective cohort study was conducted to evaluate several potential predictors of symptom duration via a Cox proportional hazards analyses. The individual postconcussion symptom scores were highly correlated, so these symptoms were analyzed in the statistical model as coefficients derived from principal component analyses. RESULTS: Among 1953 youth with concussion, 1755 (89.9%) had dates of reported symptom resolution. The remainder (10.1%) were lost to follow-up and censored. The median time to recovery was 18 days (range 1-353 days). By 30 days, 72.6% had recovered; by 60 days, 91.4% had recovered; and by 90 days, 96.8% had recovered. Several variables in a multivariate Cox model predicted postconcussion symptom duration: female sex (P < .001, hazard ratio [HR] = 1.28), continued activity participation (P = .02, HR = 1.13), loss of consciousness (P = .03, HR = 1.18), anterograde amnesia (P = .04, HR = 1.15), premorbid headaches (P = .03, HR = 1.15), symptom components from the day of concussion (emotion, P = .03, HR = 1.08), and the day of clinic evaluation (cognitive-fatigue, P < .001, HR = 1.22; cephalalgic, P < .001, HR = 1.27; emotional, P = .05, HR = 1.08; arousal-stimulation, P = .003, HR = 1.1). In univariate analyses, greater symptom scores generally predicted longer symptom durations. Worsening of symptoms from the day of concussion to the day of clinic evaluation also predicted longer recovery (P < .001, HR = 1.59). CONCLUSIONS: Several factors help to predict protracted postconcussion symptom durations among youth referred to a sports concussion clinic.

Post-traumatic headaches correlate with migraine symptoms in youth with concussion.

OBJECTIVE: The term "post-traumatic migraine" (PTM) has been used to describe post-traumatic headaches (PTHs) that have associated migraine features, but studies of this relationship are lacking. The objective of the present study was to determine whether PTH correlates strongly with migraine symptoms among youth with concussion. METHODS: Twenty-three symptoms were analyzed from a retrospective cohort of 1953 pediatric patients with concussion. A principal component analysis (PCA) with oblique Promax rotation was conducted to explore underlying symptom relationships in the full cohort and in subcohorts stratified by the presence (n = 414) or absence (n = 1526) of premorbid headache. RESULTS: The mean patient age was 14.1 years; 63% were male. Headache was the most common postconcussion symptom, acknowledged by 69.4% of patients. When considering the full cohort, the PCA demonstrated clustering of headache with photophobia, phonophobia, nausea, dizziness, and neck pain. Similar clustering was present among patients without premorbid headaches. Repeating the analysis in the patients with preconcussion headaches led to elimination of neck pain from the cluster. CONCLUSIONS: PTH correlates strongly with other migraine symptoms among youth with concussion, regardless of premorbid headaches. This clustering of migraine symptoms supports the existence of PTM as a distinct clinical entity in some patients.

Increasing Primary Care Follow-up after Preparticipation Physical Evaluations.

Preparticipation physical evaluations (PPEs) strive to prevent injuries and sudden death in athletes. Ideally, the medical home is the best setting for completion. However, many school systems request large PPE screenings for their student-athletes. This quality-improvement project aimed to increase primary care provider (PCP) follow-up for athletes "cleared with recommendation" (CR) or "disqualified" (DQ) during our mass PPEs. METHODS: Our team evaluated prior PPE data for athlete clearance and PCP follow-up for CR or DQ athletes. The prominent gaps in our PPEs were resident education, PCP or medical home identification, and communication. Our team implemented interventions during the 2018 PPEs to increase both CR and DQ athlete follow-up at the medical home. RESULTS: Retrospective baseline data revealed that physicians categorized 11% (67/582) of athletes at our PPEs as CR or DQ. Of these athletes, the PCP and specialist follow-up rate was 13% (9/67). Our process changed to enhance athlete follow-up, but the rate only increased slightly to 15% (18/120). Medical home identification improved. Successful interventions included resident education, medical home identification, and increased communication. CONCLUSIONS: Despite our interventions, this quality-improvement initiative was unsuccessful in reaching the aim. This project found small achievements in educational opportunities, improved documentation, medial home identification for student-athletes, and lead to local changes in our standard operating procedures. Although our aim was ambitious, 100% athlete follow-up with the PCP or medical home ensures athletic safety and decreases liability for all.

Age and Sex Differences in Overuse Injuries Presenting to Pediatric Sports Medicine Clinics.

Pediatric overuse injuries present with a gradual mechanism of onset and an underlying pathogenesis of microtrauma. We evaluated the clinical presentation of pediatric sports injuries to determine if differences exist between age and sex. A retrospective chart review was performed over a 6-year period; 6593 overuse injuries were included with the mean age of 13.4 years. Males presented with a greater proportion of apophysis, physis, and articular cartilage injuries ( P < .01). Females presented with greater bone, tendon, and "other" injuries ( P < .01). Children <9 years of age demonstrated apophysis and physis injuries. Conversely, children older than 15 years of age presented with tendon, bone, bursa, and other ( P < .01) overuse injuries. A significant number of pediatric athletes in this cohort reported playing through pain prior to clinical evaluation. Injury prevention programs need to educate children, and a red flag should be raised when pediatric athletes are participating with pain.