Positive Deviance and Exploring the Role of Mental Health on Early Postoperative Recovery After Total Hip Arthroplasty: A Retrospective Analysis Using the PROMIS-10 Global Health.

INTRODUCTION: Mental illnesses are well-known factors that contribute to poor outcomes among total hip arthroplasty (THA) patients. However, a dichotomized mental illness diagnosis may not reflect the complex biopsychosocial factors contributing to a patient's health. Investigating patients who achieve positive outcomes despite having risk factors, known as positive deviants, may help identify protective characteristics and decrease health disparities among this growing population of patients. Using preoperative Mental Health T-scores (MHT) from the PROMIS-10 Global Health questionnaire among patients with a mental illness diagnosis, the purpose of this study was to explore whether patients with above-average MHT, or positive deviants, experienced a different immediate postoperative recovery path compared with patients with below-average MHT. METHODS: This was a retrospective chart review of patients undergoing elective primary THA. Patients with a formal diagnosis of a mental health condition were divided based on their MHT (above average [AA] >50, average [A] 40 to 50, below average [BA] <40). Postsurgical parameters included total opioid consumption, self-reported pain scores, and discharge disposition. RESULTS: A total of 299 patients were analyzed. After controlling for length of stay and type of mental illness, patients in the AA-MHT and A-MHT groups used 33.8 and 29.8 morphine milligram equivalents less than patients in the BA-MHT group during the inpatient stay, respectively. Patients in the AA-MHT group reported a 1.0 lower pain with activity score at discharge compared with patients in the BA-MHT group. DISCUSSION: The intersection between patients with a mental illness in need of a THA is becoming more commonplace. Data suggest that patients with a mental illness who report AA-MHT on the PROMIS-10 Global Health questionnaire may represent positive deviants or those with a more positive in-hospital recovery path compared with those patients with BA-MHT. LEVEL OF EVIDENCE: Diagnostic study-retrospective cohort study.

Low Body Mass Index Patients Undergoing an Anterior Lumbar Fusion May Have an Increased Risk of Perioperative Complications.

BACKGROUND: Previous research has shown that underweight patients may be at a greater risk of experiencing postsurgical complications. The purpose of this study was to investigate the association between body mass index (BMI) and postoperative complications following single-level anterior lumbar fusion (ALF). METHODS: All single-level elective ALF procedures performed between 2010 and 2020 were identified in the PearlDiver Mariner Database. Patients were separated into 6 groups based on the World Health Organization BMI classifications. Differences in postsurgical complications (ie, deep vein thrombosis, pulmonary embolism, surgical site infection, hardware malfunction, wound dehiscence, and blood transfusion) among BMI categories were assessed using a χ2 contingency test. RESULTS: Results indicated that underweight patients (BMI <20) were at a significantly greater risk of developing deep vein thromboses, experiencing hardware malfunction, and requiring blood transfusion compared with any other BMI classification (P < 0.001). Results also demonstrated that underweight individuals had similar risks of developing surgical site infection and wound dehiscence compared with patients classified as having obesity class III. CONCLUSION: Underweight patients may be at a greater risk than currently believed of experiencing postoperative complications following single-level ALF procedures. CLINICAL RELEVANCE: Patients with a BMI of 20 or less should be carefully evaluated prior to surgical intervention to ensure they are optimized for surgery.

The effect of cannabis use on postoperative complications in patients undergoing spine surgery: A national database study.

Background: With the increased use of cannabis in the US, there is a significant need to understand the medical complications associated with its use in relationship to a surgical population. Cannabis has mainly been studied with respect to its qualities of pain treatment, yet few studies have investigated post-surgical complications associated with its use. Therefore, the purpose of this study was to explore the effect of cannabis use on complications in spine surgery, and compare these complications rates to opioid-related complications. Methods: This was a retrospective study conducted using the PearlDiver Database. Using ICD codes 40,989 patients that underwent lumbar spine fusion between January 2010 and October 2020 were identified and divided into 3 study groups (i.e., control, patients with known opioid use disorder, and patients identified as cannabis users). Differences in the incidence of complications within 30 days of the index procedure and pseudarthrosis rates at 18 months postindex procedure were assessed among study groups using a multivariate logistic regression. Results: Of 12.4% study population used cannabis and 38.8% had a known opioid use disorder. Results indicated increased odds of experiencing a VTE, hypoxia, myocardial infarction, and arrhythmia for both opioid and cannabis users compared to controls; however, when controlling for tobacco use there were no increased odds of complications within the cannabis group. The pseudarthrosis rate was greater in cannabis users (2.4%) than in controls (1.1%). Conclusions: The pseudarthrosis rate was significantly greater in patients using cannabis and opioids compared to the control group. However, when controlling for tobacco use, results suggested a possible negative synergistic between cannabis use and concomitant tobacco use that may influence bone fusion.

Descriptive Epidemiology From the Research in Osteochondritis Dissecans of the Knee (ROCK) Prospective Cohort.

BACKGROUND: Osteochondritis dissecans (OCD) occurs most commonly in the knees of young individuals. This condition is known to cause pain and discomfort in the knee and can lead to disability and early knee osteoarthritis. The cause is not well understood, and treatment plans are not well delineated. The Research in Osteochondritis Dissecans of the Knee (ROCK) group established a multicenter, prospective cohort to better understand this disease. PURPOSE: To provide a baseline report of the ROCK multicenter prospective cohort and present a descriptive analysis of baseline data for patient characteristics, lesion characteristics, and clinical findings of the first 1000 cases enrolled into the prospective cohort. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: Patients were recruited from centers throughout the United States. Baseline data were obtained for patient characteristics, sports participation, patient-reported measures of functional capabilities and limitations, physical examination, diagnostic imaging results, and initial treatment plan. Descriptive statistics were completed for all outcomes of interest. RESULTS: As of November 2020, a total of 27 orthopaedic surgeons from 17 institutions had enrolled 1004 knees with OCD, representing 903 patients (68.9% males; median age, 13.1 years; range, 6.3-25.4 years), into the prospective cohort. Lesions were located on the medial femoral condyle (66.2%), lateral femoral condyle (18.1%), trochlea (9.5%), patella (6.0%), and tibial plateau (0.2%). Most cases involved multisport athletes (68.1%), with the most common primary sport being basketball for males (27.3% of cases) and soccer for females (27.6% of cases). The median Pediatric International Knee Documentation Committee (Pedi-IKCD) score was 59.9 (IQR, 45.6-73.9), and the median Pediatric Functional Activity Brief Scale (Pedi-FABS) score was 21.0 (IQR, 5.0-28.0). Initial treatments were surgical intervention (55.4%) and activity restriction (44.0%). When surgery was performed, surgeons deemed the lesion to be stable at intraoperative assessment in 48.1% of cases. CONCLUSION: The multicenter ROCK group has been able to enroll the largest knee OCD cohort to date. This information is being used to further understand the pathology of OCD, including its cause, associated comorbidities, and initial presentation and symptoms. The cohort having been established is now being followed longitudinally to better define and elucidate the best treatment algorithms based on these presenting signs and symptoms.

Male and Female Adolescent Athletes' Readiness to Return to Sport After Anterior Cruciate Ligament Injury and Reconstruction.

OBJECTIVE: The purpose of this study was to examine whether readiness to return to sport (RTS) differed between adolescent male and female athletes after anterior cruciate ligament reconstruction (ACLR). DESIGN: Longitudinal, prospective cohort. SETTING: Outpatient office associated with tertiary-care hospital. PATIENTS: A total of 93 adolescent athletes, 17 years of age and younger, who underwent ACLR surgery with a hamstring autograft were included. INDEPENDENT VARIABLES: Male and female athletes. MAIN OUTCOME MEASURES: Anterior cruciate ligament-return to sport after injury (ACL-RSI) completed at 3 time points: (1) preoperatively (Pre-op), (2) approximately 3 months into rehabilitation (Post-op 1), and (3) during RTS phases of recovery (Post-op 2). RESULTS: There was a significant main effect for both sex (P < 0.010) and time (P < 0.0001) with male athletes having higher ACL-RSI scores than female athletes at all 3 time points; however, there was no significant time by sex interaction. All ACL-RSI scores increased significantly across time, regardless of sex. There were no statistically significant differences between ACL-RSI scores at all 3 time points between individuals who did and did not receive physician clearance. CONCLUSIONS: This study provides a longitudinal depiction of adolescent athletes' readiness to RTS after ACL injury throughout recovery. Both male and female athletes demonstrated diminished ACL-RSI scores before undergoing surgery, with increasing scores at both postoperative time points for both sexes. Overall, female athletes reported lower readiness to RTS at all 3 time points compared with male athletes.

Patient-Reported Outcomes, Return-to-Sport Status, and Reinjury Rates After Anterior Cruciate Ligament Reconstruction in Adolescent Athletes: Minimum 2-Year Follow-up.

BACKGROUND: Significant variation exists in the published rates of return to sport after anterior cruciate ligament (ACL) reconstruction (ACLR). Functional outcomes and psychological response to injury have been implicated as factors that influence return to sport. Most studies focus on patients aged in the mid-20s, and less is known about this topic in adolescents. PURPOSE: To report midterm ACLR results for adolescent patients with regard to return to primary sport, patient-reported outcomes, and reinjury rate. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: Adolescent athletes were contacted at a minimum of 2 years after ACLR. Patients completed 2 patient-reported outcome measures, the ACL--Return to Sport After Injury (ACL-RSI) and the International Knee Documentation Committee (IKDC) subjective form, and responded to questions regarding preinjury primary sport and level of competition, post-ACLR return to primary sport status, and reinjury. RESULTS: A total of 74 patients (mean ± SD surgical age, 15.9 ± 1.5 years; follow-up age, 19.9 ± 2.0 years; response rate, 24.5%) completed the surveys at a mean of 4.0 ± 2.0 years after primary ACLR. Outcome scores averaged 90.3 ± 12.3 for IKDC and 81.6 ± 20.4 for ACL-RSI. Questionnaire responses indicated that 27.0% of patients did not return to or sustain primary sport participation after ACLR; the principal reasons were poor knee function, team/training change, and fear of another injury. Both IKDC and ACL-RSI scores were statistically lower in patients who did not successfully return to their primary sport in contrast to patients who successfully resumed their primary sport (IKDC, P = .026; ACL-RSI, P < .001). IKDC and ACL-RSI scores were moderately positively correlated with one another (r Spearman = 0.60). There were 18 patients (reinjury rate, 24.3%) who suffered another ACL injury; 8 of these injuries included ipsilateral ACL graft tear (retear rate, 10.8%). CONCLUSION: In our cohort, 73% of adolescent patients successfully returned to their primary preinjury sport at a minimum of 2 years after ACLR. Both knee function and psychological responses to injury were important in determining an adolescent athlete's return to sport. The findings support the use of the IKDC and ACL-RSI at midterm follow-up, with higher scores associated with a greater likelihood of adolescent patients returning to sport after ACLR.

Osteochondritis Dissecans of the Knee: An Interrater Reliability Study of Magnetic Resonance Imaging Characteristics.

BACKGROUND: Imaging characteristics of osteochondritis dissecans (OCD) lesions quantified by magnetic resonance imaging (MRI) are often used to inform treatment and prognosis. However, the interrater reliability of clinician-driven MRI-based assessment of OCD lesions is not well documented. PURPOSE: To determine the interrater reliability of several historical and novel MRI-derived characteristics of OCD of the knee in children. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 3. METHODS: A total of 42 OCD lesions were evaluated by 10 fellowship-trained orthopaedic surgeons using 31 different MRI characteristics, characterizing lesion size and location, condylar size, cartilage status, the interface between parent and progeny bone, and features of both the parent and the progeny bone. Interrater reliability was determined via intraclass correlation coefficients (ICCs) with 2-way random modeling, Fleiss kappa, or Krippendorff alpha as appropriate for each variable. RESULTS: Raters were reliable when the lesion was measured in the coronal plane (ICC, 0.77). Almost perfect agreement was achieved for condylar size (ICC, 0.93), substantial agreement for physeal patency (ICC, 0.79), and moderate agreement for joint effusion (ICC, 0.56) and cartilage status (ICC, 0.50). Overall, raters showed significant variability regarding interface characteristics (ICC, 0.25), progeny (ICC range, 0.03 to 0.62), and parent bone measurements and qualities (ICC range, -0.02 to 0.65), with reliability being moderate at best for these measurements. CONCLUSION: This multicenter study determined the interrater reliability of MRI characteristics of OCD lesions in children. Although several measurements provided acceptable reliability, many MRI features of OCD that inform treatment decisions were unreliable. Further work will be needed to refine the unreliable characteristics and to assess the ability of those reliable characteristics to predict clinical lesion instability and prognosis.

Motion analysis evaluation of adolescent athletes during dual-task walking following a concussion: A multicenter study.

BACKGROUND: Research suggests that dynamic balance in adolescents is compromised following concussion and may worsen if patients return to sport (RTS) too soon. Understanding if there are ongoing dynamic balance deficits in adolescents at the time of RTS clearance would determine if more complex motor tasks are necessary to facilitate safe RTS decisions. RESEARCH QUESTION: The purpose of this study was to determine if there were remaining dynamic balance deficits in concussed adolescents at the time of clearance for RTS. METHODS: Sixteen concussed adolescent athletes (age 14.6 ±â€¯1.8 years; 9 males; 57 ±â€¯46 days post injury) performed a simple walking task as well as two split attention gait tasks (reciting months backwards and audio Stroop). The center of mass (COM) movement and walking velocity during these tasks was compared to a control group of 15 healthy non-concussed adolescent athletes (age 13.8 ±â€¯1.4 years; 9 male). RESULTS: The results indicated that there were no statistically significant differences between the two groups for any of the tasks. Height-normalized walking speed did not differ between groups during walking alone (control: 0.757 ±â€¯0.119, concussed: 0.739 ±â€¯0.108, p = 0.34), with the recitation task (control: 0.555 ±â€¯0.095, concussed: 0.557 ±â€¯0.143, p = 0.72), or with the Stroop task (control: 0.589 ±â€¯0.129, concussed: 0.567 ±â€¯0.141, p = 0.43). Similarly, height-normalized medial-lateral COM displacement did not differ between groups during walking alone (control: 0.027 ±â€¯0.007, concussed: 0.028 ±â€¯0.007, p = 0.98, with the recitation task (control: 0.037 ±â€¯0.012, concussed: 0.0.037 ±â€¯0.016, p = 0.82), or with the Stroop task (control: 0.032 ±â€¯0.014, concussed: 0.033 ±â€¯0.009, p = 0.891). SIGNIFICANCE: These findings indicate that the patients were returned to sport when their dynamic balance was similar to controls suggesting that this cohort had recovered from their concussion. However, large variability in dynamic balance measures in both the patient and control groups may reflect ongoing neuromuscular development and requires further exploration.

Clinical Outcome Measures and Return-to-Sport Timing in Adolescent Athletes After Anterior Cruciate Ligament Reconstruction.

CONTEXT: Multiple factors are likely associated with an adolescent athlete's ability to return to play after anterior cruciate ligament (ACL) reconstruction (ACLR). OBJECTIVE: To investigate the relationship between self-reported and functional outcome measures on return-to-play timing in an adolescent population, in athletes who returned and those who did not return to sport, and to identify a cutoff value for isometric quadriceps strength that could serve as a clinical target for maximizing the odds of returning to play after ACLR. DESIGN: Cross-sectional study. SETTING: Outpatient clinic. PATIENTS OR OTHER PARTICIPANTS: Adolescent athletes who underwent ACLR and completed clinical measures at their 3- and 6-month follow-up appointments were included. MAIN OUTCOME MEASURE(S): Clinical measures included functional outcomes of isometric and isokinetic strength tests and the Anterior Cruciate Ligament Return to Sport After Injury scale and the pediatric version of the International Knee Documentation Committee subjective form. Physician clearance dates for return to play were obtained from patient records. RESULTS: Higher strength measures were associated with better scores on the Anterior Cruciate Ligament Return to Sport After Injury and the pediatric version of the International Knee Documentation Committee instruments at each follow-up. Differences were found in isometric extension strength ( P = .001) and isokinetic extension strength at 180°/s ( P = .03) and 300°/s ( P = .002) between patients who returned to sports and those who did not. A 6-month isometric extension deficit (mean Limb Symmetry Index = 85.48 ± 23.15) displayed high accuracy (area under the curve = 0.82, 95% confidence interval = 0.68, 0.95) for identifying patients who returned to play after ACLR. CONCLUSIONS: Higher strength measures at both 3 and 6 months after ACLR were associated with greater self-reported knee function and greater readiness to return to functional activities at 6 months and ultimately earlier return to sport in adolescent athletes. These results provide evidence that self-reported outcome scores should be used as an additional screening tool in conjunction with quadriceps strength testing to help provide realistic recovery timeframes for adolescent patients.

Do Age and Weightbearing Radiographs Affect Lateral Joint Space and Fibular Height Measurements in Patients With Discoid Lateral Meniscus?

BACKGROUND: Several radiographic parameters have been associated with a discoid lateral meniscus. However, limited information is available regarding the radiographic findings of a discoid meniscus in the pediatric population. PURPOSE: To determine the effect of age and weightbearing (WB) on radiographic parameters associated with discoid lateral menisci in pediatric patients. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 3. METHODS: Radiographs of pediatric patients with arthroscopically confirmed lateral discoid menisci were compared with age-, side-, and sex-matched individuals with confirmed normal menisci. Radiographic parameters of lateral joint space width (LJSW) and fibular head height (FHH) were measured by 3 physicians. RESULTS: Significant differences were found between the discoid and control groups when LJSW (P = .002) and FHH (P < .001) were compared. Interrater reliability was good for LJSW (intraclass correlation coefficient [ICC], 0.635) and excellent for FHH (ICC, 0.759). WB radiographs were noted to have better interrater reliability compared with non-WB radiographs for LJSW (ICC, 0.729 vs 0.514, respectively) but had reduced interrater reliability for FHH (ICC, 0.625 vs 0.868, respectively). Subgroup analysis with age stratification indicated that FHH was significantly decreased (indicative of a high fibular head) in the discoid group for all age groups (P < .001 for <10 years and 10-14 years; P = .030 for >14 years); however, LJSW was significantly different only in patients older than 14 years. CONCLUSION: Increased LJSW and FHH were associated with discoid lateral menisci and showed satisfactory interrater reliability. Radiographic evaluation for potential discoid meniscus in pediatric and adolescent patients may be improved by use of fibular height to indicate the presence of a discoid lateral meniscus across age groups, while lateral joint space may be more reliable for older patients.

Anterior Cruciate Ligament Reconstruction in Skeletally Immature Patients: Early Results Using a Hybrid Physeal-Sparing Technique.

BACKGROUND: Reconstruction of the anterior cruciate ligament (ACL) in the skeletally immature patient is frequently performed in hopes of preventing new or additional chondral damage and meniscal injuries. Patients within a few years of skeletal maturity are more at risk for ACL injuries than prepubescent patients, about whom several physeal-sparing techniques have been described. Reconstruction techniques in the former higher risk group need to be better understood. PURPOSE: To review a series of adolescent patients with ACL injuries surgically treated with the hybrid physeal-sparing technique. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Surgical logs of ACL reconstructions (ACLRs) performed at a single pediatric/adolescent sports medicine center over a 6-year period were reviewed. Patients with open physes who had undergone ACLR with a femoral physeal-sparing tunnel and transphyseal tibial tunnel were identified. Their demographics, operative reports, rehabilitative course, time to return to play, outcome scores, and postoperative radiographs were collected and analyzed. RESULTS: Twenty-three patients with a mean chronological age and bone age of 13.0 and 13.6 years, respectively, were identified. Examination and subjective outcome scores were obtained at a mean of 19 months and overall demonstrated positive results, with a mean Pediatric International Knee Documentation Committee (Pedi-IKDC) score of 96.0 and a mean Anterior Cruciate Ligament-Return to Sport after Injury (ACL-RSI) score of 89.1. Full-length mechanical axis films obtained at a mean 21 months postoperatively demonstrated no leg-length discrepancies or angular deformities in 21 of 23 patients. Two patients had an identified growth disturbance in the form of femoral and tibial growth acceleration on the ACL-reconstructed limb. CONCLUSION: The femoral physeal-sparing with transphyseal tibial drilling "hybrid" technique in skeletally maturing patients appears to have a high rate of success with low morbidity. However, the possibility of physeal abnormalities does exist, which demonstrates the importance of a close postoperative follow-up and evaluation until skeletal maturity is achieved. ACLR in skeletally immature patients is performed on an increasingly regular basis. Establishing the best and safest technique to do so is therefore important.

The Biomechanics of Cranial Forces During Figure Skating Spinning Elements.

Several facets of figure skating, such as the forces associated with jumping and landing, have been evaluated, but a comprehensive biomechanical understanding of the cranial forces associated with spinning has yet to be explored. The purpose of this case study was to quantify the cranial rotational acceleration forces generated during spinning elements. This case report was an observational, biomechanical analysis of a healthy, senior-level, female figure skating athlete who is part of an on-going study. A triaxial accelerometer recorded the gravitational forces (G) during seven different spinning elements. Our results found that the layback spin generated significant cranial force and these forces were greater than any of the other spin elements recorded. These forces led to physical findings of ruptured capillaries, dizziness, and headaches in our participant.

Protracted recovery from a concussion: a focus on gender and treatment interventions in an adolescent population.

BACKGROUND: Several studies have demonstrated that age and sex may influence concussion recovery time frames, with female athletes and adolescents being potentially more susceptible to a protracted recovery course. Currently, limited work has examined the influence sex may have on concussion management strategies and treatment interventions, especially for younger individuals suffering persistent concussion symptoms and cognitive dysfunctions. HYPOTHESIS: Female athletes are prescribed more treatment interventions than male athletes during a protracted recovery from a concussion. STUDY DESIGN: Descriptive epidemiology study. LEVEL OF EVIDENCE: Level 4. METHODS: Data were retrospectively collected for adolescent athletes presenting to a sports medicine concussion clinic between September 2010 and September 2011. RESULTS: A total of 266 adolescent athletes were evaluated and treated for concussion. Female athletes had a longer recovery course (P = 0.002) and required more treatment interventions (P < 0.001) for their symptoms and dysfunction. Female athletes were more likely to require academic accommodations (P < 0.001), vestibular therapy (P < 0.001), or medication (P < 0.001). CONCLUSION: Medical providers should be aware that during the recovery course, adolescent female athletes may require a management plan that will most likely include additional treatment interventions beyond the standard cognitive and physical rest. CLINICAL RELEVANCE: Treatment interventions are more commonly prescribed for adolescent female athletes than for adolescent male athletes during a protracted recovery from a concussion. This highlights the need for identifying evidence-based clinical management guidelines that focus on sex, especially when dealing with persistent concussion symptoms and cognitive dysfunctions.

Sleep disturbance and neurocognitive function during the recovery from a sport-related concussion in adolescents.

BACKGROUND: Sleep disturbances are a hallmark sign after a sport-related concussion (SRC). Poor sleep has been shown to adversely affect baseline neurocognitive test scores, but it is not comprehensively understood how neurocognitive function is affected by disrupted sleep during recovery from a concussion. PURPOSE: To identify the correlation between adolescent athletes' neurocognitive function and their self-reported sleep quantity and sleep disturbance symptoms during recovery from SRC. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: Immediate Post-Concussion Assessment and Cognition Testing (ImPACT) data were retrospectively collected for 545 adolescent athletes treated for SRC at a sports medicine concussion clinic. Patients were stratified into groups based on 2 criteria: self-reported sleep duration and self-reported sleep disturbance symptoms during postinjury ImPACT testing. Sleep duration was classified as short (<7 hours), intermediate (7-9 hours), and long (>9 hours). Sleep disturbance symptoms were self-reported as part of the Post-Concussion Symptom Scale (PCSS) as either sleeping less than normal, sleeping more than normal, or having trouble falling asleep. One-way analyses of variance were conducted to examine the effects that sleep duration as well as self-reported sleep disturbance symptoms had on composite scores. A total of 1067 ImPACT tests were analyzed: test 1, 545; test 2, 380; and test 3, 142. RESULTS: Sleeping fewer than 7 hours the night before testing correlated with higher PCSS scores (P < .001), whereas sleeping longer than 9 hours correlated with worse visual memory (P = .01), visual motor speed (P <.001), and reaction time (P = .04) composite scores. With regard to self-reported sleep disturbance symptoms, patients demonstrated worse composite scores during ImPACT testing when they self-reported sleeping more than normal (ImPACT test 1: verbal memory, P < .001; visual motor speed, P = .05; reaction time, P = .01; ImPACT test 2: verbal memory, P < .001; visual memory, P < .001; visual motor speed, P < .001; reaction time, P = .01). Adolescent patients recovering from SRC demonstrated higher (worse) PCSS scores (P < .001) when they sensed that their sleep had been disrupted. CONCLUSION: Adolescent patients who perceive that their sleep is somehow disrupted after SRC may report a greater number of concussion symptoms during their recovery. In addition, the study results suggest that sleeping more than normal may identify an individual who continues to be actively recovering from concussion, given the correlation between lower neurocognitive function and this self-reported symptom.

Concussion management for the adolescent patient: an algorithm for primary-care providers.

A sharp increase in the number of diagnosed concussions has been observed for the traditional adultathlete, as well as the young recreational athlete. An enhancing awareness and growing concern has been noted for the potentially larger number of concussions that go undiagnosed and the unknown capability for long-term complications associated with this injury. This increase in concussion awareness has appropriately led to an enhanced utilization of the health-care system for concussion evaluation and management. As is always the case in the practice of medicine, it is important for healthcare providers, from all points of entry in the healthcare system, to provide consistent management for the best outcomes for any disease process. Millions of sport-related concussions occur each year in the United States, placing a large demand on the healthcare system. Utilization of appropriate and congruent treatment plans during the medical discourse when transferring care of patients between providers is paramount. In the co-management model of care, subspecialists lend expertise to assist primary-care providers (PCPs) in gaining the core competencies necessary to provide appropriate levels of care for certain conditions. Increased use of co-management could make the health-care system more efficient and collaborative, leading to: increased access for patients, lower overall costs, and improved quality of care and health outcomes. Co-management allows patients and families to have access to the expert knowledge of subspecialist while receiving more of their care from their PCP, increasing their comfort and making treatment more convenient. The intent of this paper is to distribute an algorithm created by a multidisciplinary group of medical providers to provide a rational approach, congruent with the standard of care, for the primary-care provider to institute an individualized stepwise progression.