Reduced Concussion Symptom Burden in Early Adolescent Athletes Using a Head-Neck Cooling Device.

OBJECTIVE: To determine whether an investigational head-neck cooling device, Pro2cool, can better reduce symptom severity compared with standard postconcussion care in early adolescent athletes after a sports-related concussion. DESIGN: Prospective, longitudinal, randomized trial design conducted over a 28-day period. SETTING: Six pediatric medical centers in Ohio and Michigan. PARTICIPANTS: The study enrolled 167 male and female 12- to 19-year-old athletes who experienced a sports-related concussion within 8 days of study enrollment and registering a Sports Concussion Assessment Tool 5 (SCAT5) composite score >7. INTERVENTIONS: Pro2cool, an investigational head-neck cooling therapy device, was applied at 2 postinjury time points compared with postconcussion standard of care only. MAIN OUTCOME MEASURES: Baseline SCAT5 composite symptom severity scores were determined for all subjects. Sports Concussion Assessment Tool 5 scores for concussed athletes receiving cooling treatment were analyzed across 6 independent postenrollment time points compared with subjects who did not receive cooling therapy and only standard care. Adverse reactions and participate demographics were also compared. RESULTS: Athletes who received Pro2cool cooling therapy (n = 79) experienced a 14.4% greater reduction in SCAT5 symptom severity scores at the initial visit posttreatment, a 25.5% greater reduction at the 72-hour visit posttreatment, and a 3.4% greater reduction at the 10-day visit compared with subjects receiving only standard care (n = 88). Overall, 36 adverse events (increased blood pressure, decreased pulse, and dizziness) were reported, with 13 events associated with the device, of which 3 were classified as moderate in severity. CONCLUSIONS: This study demonstrates the efficacy and safety of head and neck cooling for the management of concussion symptoms in adolescent athletes of an age group for which little to no prior data are available.

Preliminary Safety and Efficacy of Head and Neck Cooling Therapy After Concussion in Adolescent Athletes: A Randomized Pilot Trial.

OBJECTIVE: To determine the safety and efficacy of head and neck cooling when applied up to 8 days after concussion among adolescent athletes. DESIGN: A randomized nonblinded pilot trial. SETTING: Sports Medicine Clinic in a tertiary hospital. PATIENTS: Adolescent athletes aged 12 to 17 years diagnosed with a concussion within 1 week of injury. INTERVENTIONS AND MAIN OUTCOME MEASURES: The control group (n = 27) received standard treatment (short term brain rest), whereas the treatment group (n = 28) received standard treatment and head and neck cooling. Head and neck cooling treatment was applied to patients at the postinjury assessment visit and at 72 hours post-injury. The SCAT5 (Sport Concussion Assessment Tool) total symptom severity score was collected at postinjury assessment visit, pre- and post-treatment at 72 hours, and at 10 days, and 4 weeks post-treatment. RESULTS: Athletes who received head and neck cooling had a faster symptom recovery ( P = 0.003) and experienced significant reduction in symptom severity scores after treatment ( P < 0.001). Sport type and gender did not influence the treatment outcome ( P = 0.447 and 0.940, respectively). CONCLUSIONS: This pilot study demonstrates feasibility of head and neck cooling for the management of acute concussion in adolescent athletes.

The relationship between adherence behaviors and recovery time in adolescents after a sports-related concussion: an observational study.

BACKGROUND: Adherence to rehabilitation is widely accepted as vital for recovery and return to play following sports injuries. Medical management of concussion is centered around physical and cognitive rest, a theory largely based on expert opinion, not empirical evidence. Current research on this topic focuses on factors that are predictive of adherence to rehabilitation, but fails to examine if patient adherence leads to a better outcome. The purpose of this study was to determine the adherence tendencies of adolescents to treatment recommendations provided by a sports-medicine physician after a concussion and to determine if adherence to each recommendation was a predictor of treatment duration. STUDY DESIGN: Observational. METHODS: Participants were enrolled in the study at their initial visit to the Sports-Medicine Center for medical care after a sports-related concussion. Individual treatment recommendations provided by a sports-medicine physician for concussion were recorded over the course of each participant's care. Once released from medical care, each participant was contacted to complete an online questionnaire to measure self-reported adherence tendencies to each treatment recommendation. Adherence was measured by two constructs: 1) the reported receptivity to the recommendation and 2) the frequency of following the recommendation. Exploratory univariate Poisson regression analyses were used to describe the relationship between adherence behaviors and the number of days of treatment required before the participant was returned to play. RESULTS: Fifty-six questionnaires were completed, by 30 male and 26 female adolescent athletes. The self-reported adherence tendencies were very high. None of the measures of adherence to the treatment recommendations were significant predictors of the number of days of treatment; however, there was a clear tendency in five of the six rest parameters (physical rest, cognitive rest with restrictions from electronics, and cognitive rest with restrictions from school), where high levels of adherence to rest resulted in an increased average number of days of treatment (slower recovery) and those who reported being less adherent recovered faster. CONCLUSIONS: Adolescents were generally adherent to the physician recommendations. Those participants who reported being less adherent to physical and cognitive rest generally recovered faster than those who reported higher levels of adherence to these recommendations. As time progresses after the initial injury, physical and mental rest may be less effective to hasten recovery than more active treatment recommendations. LEVEL OF EVIDENCE: Level 2.

Differential diagnosis of dizziness after a sports-related concussion based on descriptors and triggers: an observational study.

BACKGROUND: Dizziness is often reported after a sports-related concussion. Forces experienced at the time of the concussion can cause an injury to multiple anatomical areas, including the central nervous system, the vestibular system, and the cervical spine, each of which is sufficient to cause dizziness. Medical professionals routinely use the subjective history to develop hypotheses about what may be causing a patient's dizziness. No previous studies have attempted to differentiate the source of the dizziness through precise patient descriptors or the triggers of dizziness. METHODS: A structured symptom questionnaire was developed through purposive exploration of relevant literature for common dizziness quality descriptors and triggers. This questionnaire was used to interview a sample of 86 adolescent athletes (12-19 years of age) with a sports-related concussion between August 2013 and April 2014. Exploratory Latent Class Analysis was used to uncover latent constructs within the 15 dizziness descriptors and 11 dizziness triggers. The covariates sex, attention deficit hyperactivity disorder, and number of days between the concussion and the assessment were added to the model to estimate if these variables influenced class membership probabilities. RESULTS: Thirty-two (36 %) of the patients interviewed did not report a complaint of dizziness but did affirm one or more of the other descriptors. Three classes of dizziness based on dizziness quality descriptors and three classes based on dizziness triggers were identified by the analysis. Neither the classes of descriptors nor the classes of triggers enabled differentiation based on anatomical etiology of the dizziness. CONCLUSIONS: Patient description of dizziness is limited in its ability to assist in differential diagnosis based on anatomical location for athletes with concussion. This may be because more than one area is contributing to the dizziness or because concussed adolescents have difficulty describing the way that they feel. In this case, solely relying on the patient to provide a description of dizziness to develop the formation of hypotheses and lead the direction of objective tests is inappropriate. If the scope of the objective assessment is limited by the patient description of dizziness, it is likely that areas of dysfunction may be overlooked.

Baseball and softball.

Baseball and softball are among the most popular and safest sports in which children and adolescents participate. Nevertheless, traumatic and overuse injuries occur regularly, including occasional catastrophic injury and even death. Safety of the athlete is a constant focus of attention among those responsible for modifying rules. Understanding the stresses placed on the arm, especially while pitching, led to the institution of rules controlling the quantity of pitches thrown in youth baseball and established rest periods between pitching assignments. Similarly, field maintenance and awareness of environmental conditions as well as equipment maintenance and creative prevention strategies are critically important in minimizing the risk of injury. This statement serves as a basis for encouraging safe participation in baseball and softball. This statement has been endorsed by the Canadian Paediatric Society.

Management of the adolescent concussion victim.

Increasing awareness and understanding of the implications of concussion have shaped a more proactive management approach to this problem. Although the incidence of brain injuries in adolescent athletes is probably in the range of 1.6 to 3.8 million per year (Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Facts for physicians about mild traumatic brain injury. Available at: www.cdc.gov/ncipc/pubres/tbi_toolkit/physicians/mtbi/mtbi.pdf), difficulties in recognizing and diagnosing this condition mean that as many as 80% go unrecognized and have led to its being known as "the silent epidemic." Attempts to improve the evaluation on the sidelines, in the outpatient clinic, and in the home are helping to improve management. Better understanding of the prognosis and clinical course of concussion, as well as the importance of physical and mental rest, have also helped healthcare providers to make better decisions about allowing athletes to return to play.

Anabolic-androgenic steroids: use and abuse in pediatric patients.

The "win at all costs" mentality fuels athletes to seek performance-enhancing substances, such as anabolic-androgenic steroids, to gain an advantage over their opponents. Nonathletes espouse this same attitude to "win" the battle of attractiveness. An enhanced understanding of anabolic-androgenic steroids and the motivations behind their abuse will arm pediatricians with the ability to engage their patients in a balanced discussion of the benefits and costly risks of anabolic-androgenic steroids and successfully deter further use.

Testosterone precursors: use and abuse in pediatric athletes.

The dietary supplements androstenedione, dehydroepiandrosterone, and androstenediol are precursors in the endogenous production of testosterone. The efficacy and safety of these prohormones are not well established but are promoted to have the same androgenic effects on building muscle mass and strength as anabolic-androgenic steroids. Studies have demonstrated repeatedly that acute and long-term administration of these oral testosterone precursors does not effectively increase serum testosterone levels and fails to produce any significant changes in lean body mass, muscle strength, or performance improvement compared with placebo. The Anabolic Steroid Control Act of 2004 lists androstenedione as a schedule III controlled substance, and it is regulated by the U.S. Food and Drug Administration. Testosterone precursors are banned by most major sports organizations.

Current concepts in the diagnosis and treatment of spondylolysis in young athletes.

Spondylolysis is common among young athletes and should be suspected in any young athlete presenting with low back pain that persists for more than a few weeks. Diagnostic evaluation typically includes plain radiographs followed by more sensitive modalities, including single-photon emission CT, CT, or MRI. There is no consensus on the most appropriate protocol for diagnostic evaluation. Treatment usually consists of rest and/or bracing to allow healing to occur, followed by rehabilitation that includes core strengthening. More large-scale controlled studies need to be done in order to clarify the most effective diagnostic and therapeutic protocols.

Awareness of genital health in young male athletes.

OBJECTIVE: To assess young male athletes' understanding of the need for a genital examination during the sports physical, their knowledge of signs and symptoms of serious testicular pathology, and the type of genital protection they wear for specific sports. Additionally, to identify common sport-specific genital injuries requiring emergency department treatment. DESIGN: Descriptive survey. SETTING: Station-based mass screening preparticipation physical exams performed in northeastern Ohio. PARTICIPANTS: A total of 755 male athletes at the junior high school, high school, and collegiate levels (age 12-25 years). MAIN OUTCOME MEASUREMENTS: Participants' answers to a 5-question survey. Male genital injury occurring in common contact and collision sports identified from the National Electronic Injury Surveillance System. RESULTS: Fifty percent did not understand why the genital examination is done. Forty-seven percent did not wear genital protection during sports. Most were unaware of the risk of testicular cancer and did not appreciate the difference in urgency of seeking medical treatment of painless versus painful testicular swelling. Approximately 20% of emergency department visits for sports-related genital trauma had a risk of permanent injury, and up to 7% resulted in hospitalization or transfer. CONCLUSIONS: Young male athletes are unaware of testicular pathology that affects their age group, and many do not wear genital protection during sports. Better education of young males regarding genital health and protection is necessary.

Long-term functional and anatomical follow-up of early detected spondylolysis in young athletes.

BACKGROUND: Spondylolysis defects detected by nuclear scintigraphy but not by plain radiographs represent early lesions. Functional outcome and eventual bony union of these defects are unknown. HYPOTHESIS: Defects with greater degree of healing shortly after treatment will proceed to full bony union and better long-term functional outcome. STUDY DESIGN: Longitudinal cohort study. METHODS: Forty young athletes with early detected spondylolysis (radiograph negative, nuclear scintigraphy positive) were divided into 3 stages of healing by computed tomography scan. Functional outcome was assessed 7 to 11 years later using the low back outcome score and other factors. Degree of bony healing was assessed in volunteers. RESULTS: Thirty-two of 40 subjects (80%) completed the survey. Twenty-nine of 32 (91%) had good or excellent low back outcome scores. None required spinal fusion, but 1 required partial diskectomy. Functional outcome did not differ based on initial computed tomography results. Radiographic follow-up was obtained in 11 volunteers. None of the 7 bilateral defects healed, and 3 of these progressed to grade 1 spondylolisthesis. All 4 unilateral defects healed fully with bone. CONCLUSIONS: Most young athletes conservatively treated for early spondylolysis maintain good functional outcome up to 11 years later. Unilateral defects can undergo full bony healing but may take longer than 12 weeks. Bilateral defects may undergo further degeneration and slip with time.

Reports of head injury and symptom knowledge among college athletes: implications for assessment and educational intervention.

OBJECTIVE: To identify the prevalence of head injuries and related symptoms among college athletes and examine knowledge of head injury consequences and behavioral tendencies of athletes in the presence of symptoms. DESIGN: Retrospective survey. PARTICIPANTS: A total of 461 male and female athletes beginning competitive play at the University of Akron (Akron, OH) during the years 1995 to 2001. MAIN OUTCOME MEASURES: Responses to survey questions were analyzed to determine the frequency of concussions and injury-related symptoms (eg, dizziness, headache, nausea or vomiting) in addition to behavioral responses in the presence of certain symptoms (eg, playing with headache, failure to report symptoms while playing). Written responses to queries regarding symptom knowledge were analyzed for thematic content and were used to identify deficiencies in signs and symptoms of concussion. RESULTS: Nearly 32% of all athletes had experienced a blow to the head causing dizziness, with over 1/4 confirming various somatic symptoms following a blow to the head (eg, seeing stars, nausea or vomiting, head pain). Continuing to play despite symptom presence was noted (eg, dizziness, 28.2%; headache, 30.4%), with 19.5% reporting a concussion diagnosis. Knowledge of head injury consequences was found to be deficient, with 56% indicating no knowledge of the possible consequences following a head injury. Of those providing responses, the majority reflected awareness of cognitive (eg, memory problems) and physical (eg, brain damage) consequences. CONCLUSIONS: A sizable number of athletes may enter collegiate play with a previous concussion diagnosis, and many more are likely to have experienced symptoms suggestive of a mild head injury. Of considerable concern is the tendency to play while symptomatic (eg, headache, dizziness) and the failure to report symptoms while playing--especially among football players (25.2%). The apparent deficiency in athlete knowledge of head injury consequences raises concern regarding athlete recognition of potentially problematic symptoms and represents an important area for educational intervention.

Supplements and drugs used to enhance athletic performance.

The temptation of using drugs and supplements as shortcuts to improving athletic performance or even to enhance appearance is very seductive to adolescents. This age group is often characterized by a desire for quick results and a lack of concern for future consequences. Preventing the use of drugs to enhance athletic performance is difficult even when we have good medical and scientific evidence to prove a dangerous risk-benefit ratio, such as with AASs. The use of "nutritional supplements" is even more difficult to control. The protection of these substances by the Dietary Supplement Health and Education Act of 1994 removed control of these substances from the FDA. Therefore, release and widespread use of new supplements occurs before significant clinical study of benefit and adverse effects takes place. The distributors' financial interest, the products' promotional claims, and the athletes' and coaches' insatiable desire to win at all costs are a volatile combination. This spawns the production of a huge number of "natural" products, making it even more difficult to assess efficacy, safety, legality, and purity of these substances. Health care professionals need to rely on research when available, stay current on trends in athletes' drug and supplement use, and discuss the individual athlete's concerns when they arise. The preparticipation physical examination can be a good opportunity for discussion. Finally, physicians need to educate athletes, parents, coaches, trainers, and other physicians. A reasonable strength and conditioning program and a well-balanced diet must be presented as a sensible alternative to a riskier, shortcut mindset.