Exploring the association between cognitive activity and symptom resolution following concussion in adolescents aged 11-17 years.

OBJECTIVE: As opposed to postconcussion physical activity, the potential influence of cognitive activity on concussion recovery is not well characterised. This study evaluated the intensity and duration of daily cognitive activity reported by adolescents following concussion and examined the associations between these daily cognitive activities and postconcussion symptom duration. METHODS: This study prospectively enrolled adolescents aged 11-17 years with a physician-confirmed concussion diagnosis within 72 hours of injury from the emergency department and affiliated concussion clinics. Participants were followed daily until symptom resolution or a maximum of 45 days postinjury to record their daily cognitive activity (intensity and duration) and postconcussion symptom scores. RESULTS: Participants (n=83) sustained their concussion mostly during sports (84%), had a mean age of 14.2 years, and were primarily male (65%) and white (72%). Participants reported an average of 191 (SD=148), 166 (SD=151) and 38 (SD=61) minutes of low-intensity, moderate-intensity and high-intensity daily cognitive activity postconcussion while still being symptomatic. Every 10 standardised minutes per hour increase in moderate-intensity or high-intensity cognitive activities postconcussion was associated with a 22% greater rate of symptom resolution (adjusted hazard ratio (aHR) 1.22, 95% CI 1.01 to 1.47). Additionally, each extra day's delay in returning to school postconcussion was associated with an 8% lower rate of symptom resolution (aHR 0.92, 95% CI 0.85 to 0.99). CONCLUSION: In adolescents with concussion, more moderate-high intensity cognitive activity is associated with faster symptom resolution, and a delayed return to school is associated with slower symptom resolution. However, these relationships may be bidirectional and do not necessarily imply causality. Randomised controlled trials are needed to determine if exposure to early cognitive activity can promote concussion recovery in adolescents.

Shared Decision-Making About Returning to Sport After Recovery From Pediatric Concussion: Clinician Perspectives.

OBJECTIVE: Describe how sports medicine clinicians support decision making about sport participation after concussion recovery with adolescent patients and their parents. Specific areas of inquiry related to how clinicians framed the decision, what factors they considered in how they approached the decision process, and how they navigated discordance within families. DESIGN: Qualitative study. SETTING: Tertiary care sports medicine clinics at 4 children's hospitals in the United States. PARTICIPANTS: Individual interviews were conducted with 17 clinicians practicing in sports medicine settings. INTERVENTIONS: N/A. MAIN OUTCOME MEASURES: Semi-structured interviews explored clinician approaches to supporting decision making, with the question guide informed by components of the Ottawa Decision Support Framework. RESULTS: Clinicians routinely incorporated aspects of shared decision making (SDM) into their conversations with families. This included ensuring all parties were informed about risk and aligned behind a shared value of adolescent well-being. Mediation strategies were used to manage discordance between adolescents and their parents, and between parents. These strategies aimed to facilitate a decision that was adolescent centered. When clinicians believed that there was a medical benefit to modifying the adolescent's sport participation practices, or when they did not believe the athlete was psychologically ready to return to the sport in which they were injured, they initiated conversations about alternative activities. In such situations, they used persuasive communication practices to encourage families to strongly consider this option. CONCLUSION: The strengths and strategies used by sports medicine clinicians in this study provide a foundation for guidance or intervention development aimed at supporting SDM after concussion with adolescents and their families.

Clinical Practice Patterns of Isthmic Spondylolysis in Young Athletes: A Survey of Pediatric Research in Sports Medicine Members.

ABSTRACT: Isthmic spondylolysis is a common cause of back pain in young athletes. The condition presents to numerous medical providers who employ a variety of different practices in diagnosis and management. The purpose of this study was twofold: to review the literature of diagnosis and management of the young athlete with isthmic spondylolysis and to survey Pediatric Research in Sports Medicine (PRiSM) members during the 2021 PRiSM Annual Meeting on practice patterns of diagnosis and management of the young athlete with isthmic spondylolysis. The response rate was 27%. Per respondents: 24% obtain oblique radiographs; 90% use magnetic resonance imaging as the advanced imaging modality; 60% treat with bracing; 57% recommend rest prior to physical therapy (PT); 53% prescribe return to sport activity restrictions. Although there are similarities in the diagnosis of isthmic spondylolysis in young athletes, this survey confirmed variability in management, especially bracing, timing of PT and return to sport activity restrictions.

MRI of tibial stress fractures: relationship between Fredericson classification and time to recovery in pediatric athletes.

BACKGROUND: Tibial stress fractures are not uncommon in pediatric athletes. The severity of injury may be graded using magnetic resonance imaging (MRI). OBJECTIVE: To determine whether Fredericson MRI grading of tibial stress fractures can differentiate times to recovery across different grades in pediatric athletes. MATERIALS AND METHODS: A medical record search identified all athletes younger than 19 years old who had tibial stress fractures confirmed by MRI and were treated by sports medicine specialists in our clinic system over a 5-year period. Two pediatric radiologists graded MRI exams using the Fredericson system. Time to recovery (in days) was defined in four ways: pain onset to full participation, pain onset to zero pain, first treatment to full sport participation and first treatment to zero pain. Recovery times were compared to tibial stress fracture Fredericson MRI grade and to the use of a recovery device. RESULTS: Thirty-eight pediatric athletes (age range: 7-18 years, mean: 15.4±2.2 years) had 42 tibial stress fractures while participating in 12 different sports. About half (55%) were track and/or cross-country athletes. The mean time from diagnosis to report of no pain for all patients was 55.6±5.0 days. We found no significant difference in time to recovery across stress fracture grade or with the use of a recovery device. CONCLUSION: No differences were noted between Fredericson stress fracture grades and different time periods to recovery or between differences in recovery time and the return to full participation in sports, regardless of the use of assistive devices.

Making a Strong Case for Prioritizing Muscular Fitness in Youth Physical Activity Guidelines.

Although evidence indicates that muscular fitness is foundational for ongoing participation in active play, exercise and sport, current national and international youth physical activity guidelines underplay the critical importance of strength-building activities during this developmental phase of life. In view of troubling trends in muscular fitness in today's youth, specific recommendations to address neuromuscular deficiencies are required. An understanding of the multidimensional development of youth physical inactivity and the importance of muscular fitness are needed to have the most significant impact on youth physical activity at the population level. The mounting evidence of the detrimental effects of physical inactivity on youth warrant a review of existing physical activity recommendations and guidelines. The proposed pediatric activity pyramid recognizes the shared importance of strength, skill, and aerobic activities required for the successful implementation of sustainable youth physical activity interventions.

The Reliability and Validity of a Pediatric Back Outcome Measure.

OBJECTIVE: Young athletes not uncommonly complain of back pain. Many patient-reported outcome measures are used to evaluate back pain, but none have been designed specifically to assess young, athletic patients. The Micheli Functional Scale (MFS) was developed to measure impairment due to back pain in this population. This study examined the reliability, validity, and responsiveness of the MFS used in routine clinical assessments. DESIGN: Retrospective Cohort Study. SETTING: Pediatric sports medicine specialty clinic. INTERVENTIONS: Patients presenting with a chief concern of back pain over 1 year (n = 93) were enrolled in the study. Study subjects were administered the MFS and the revised Oswestry Disability Index (ODI) at each visit as part of routine clinical care. MAIN OUTCOME MEASURES: Reliability of the MFS was assessed by calculating Cronbach alpha (α). Concurrent validity was determined by measuring Spearman coefficient (rs) for the correlations between the MFS and ODI. RESULTS: Ninety-three patients (50 female, 43 male), mean age 14.1 ± 2.3 years were enrolled and 242 clinic encounters (71 initial/171 follow-up visits) analyzed. The MFS had acceptable item reliability (α = 0.786) and concurrent validity: the MFS and ODI were strongly and positively correlated [rs = 0.824 (P < 0.001)]. The MFS was comparatively more reliable and valid when used in follow-up versus initial visits. CONCLUSIONS: The MFS is a reliable and valid instrument in assessing young athletes with back pain, although the instrument has different performance characteristics on initial versus follow-up assessments. Further work is needed to refine the MFS to enhance the instrument's reliability, validity, and responsiveness. CLINICAL RELEVANCE: This study provides further insight into an outcome measure of clinical use in evaluating young athletes with back pain.

Athletes Doing Arabesques: Important Considerations in the Care of Young Dancers.

Dance is as much a sport as an art form. Sports medicine clinicians seeing dancers in their practice will need to be familiar with the unique characteristics of dance in order to provide proper care. Dance encompasses different forms, which vary in equipment and terminology. The epidemiology of dance injuries has historically focused on ballet, but there is increasing research on other dance forms. Lower extremity and back injuries predominate. Injury prevention, both primary and secondary, is at the heart of dance medicine. Primary prevention includes preseason conditioning, identifying risk factors for injury, and recognizing the female athlete triad. Secondary prevention includes a comprehensive approach to injury rehabilitation, an appreciation for the unique demands of dance, and an understanding of the particulars of the injury being treated. Dancers may have difficulty accessing medical care or following prescribed advice; the proactive clinician will anticipate these situations.

Tibial Spine Fractures in the Child and Adolescent Athlete: A Systematic Review and Meta-analysis.

BACKGROUND: Tibial spine fractures (TSFs) are uncommon injuries that may result in substantial morbidity in children. A variety of open and arthroscopic techniques are used to treat these fractures, but no single standardized operative method has been identified. PURPOSE: To systematically review the literature on pediatric TSFs to determine the current treatment approaches, outcomes, and complications. STUDY DESIGN: Meta-analysis; Level of evidence, 4. METHODS: A systematic review of the literature was performed in accordance with the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analyses) guidelines using PubMed, Embase, and Cochrane databases. Studies evaluating treatment and outcomes of patients <18 years old were included. Patient demographic characteristics, fracture characteristics, treatments, and outcomes were abstracted. Descriptive statistics were used to summarize categorical and quantitative variables, and a meta-analytic technique was used to compare observational studies with sufficient data. RESULTS: A total of 47 studies were included, totaling 1922 TSFs in patients (66.4% male) with a mean age of 12 years (range, 3-18 years). The operative approach was open reduction and internal fixation in 291 cases and arthroscopic reduction and internal fixation in 1236 cases; screw fixation was used in 411 cases and suture fixation, in 586 cases. A total of 13 nonunions were reported, occurring most frequently in Meyers and McKeever type III fractures (n = 6) and in fractures that were treated nonoperatively (n = 10). Arthrofibrosis rates were reported in 33 studies (n = 1700), and arthrofibrosis was present in 190 patients (11.2%). Range of motion loss occurred significantly more frequently in patients with type III and IV fractures (P < .001), and secondary anterior cruciate ligament (ACL) injury occurred most frequently in patients with type I and II fractures (P = .008). No statistically significant differences were found with regard to rates of nonunion, arthrofibrosis, range of motion loss, laxity, or secondary ACL injury between fixation methods (screw vs suture). CONCLUSION: Despite variation in TSF treatment, good overall outcomes have been reported with low complication rates in both open and arthroscopic treatment and with both screw and suture fixation. Arthrofibrosis remains a concern after surgical treatment for TSF, but no significant difference in incidence was found between the analysis groups. Larger studies are necessary to compare outcomes and form a consensus on how to treat and manage patients with TSFs.

Evaluation of Tibial Slope on Radiographs in Pediatric Patients With Tibial Spine Fractures: An Age- and Sex-Matched Study.

Background: A recent study has reported that the radiographic measurement of posterior tibial slope (PTS) is larger in male pediatric patients with tibial spine fractures (TSF) than in controls. However, they found no difference in PTS between female patients and controls. Purpose: (1) To identify whether PTS is larger in female pediatric patients with TSF than in female controls and (2) to validate the relationship between PTS and pediatric TSF in male patients. Study Design: Cross-sectional study; Level of evidence, 3. Methods: After an a priori power analysis, 84 pediatric patients with TSF (50 female patients and 34 male patients) and 84 age- and sex-matched controls were enrolled in this study. Demographic information, including sex, age, and race, was recorded. Skeletal maturity was determined based on the stage of epiphyseal union on knee radiographs. PTS was defined as the angle between a line perpendicular to the longitudinal axis of the tibia and the posterior inclination of the medial tibial plateau on standard knee lateral radiographs. Results: The mean age when the TSF occurred was 11.2 ± 2.7 years for female patients and 12.9 ± 2.5 years for male patients. There was no significant difference in skeletal maturity between female patients and female controls or between male patients and male controls. The mean PTS was not significantly different between female patients (8.8°± 2.8°) and female controls (8.3°± 3.1°) (P = .366) or between male patients (9.0°± 2.8°) and male controls (9.3°± 2.6°) (P = .675). Those with a PTS >1 SD (2.9°) above the mean (8.8°) had no greater odds (1.0 [95% CI, 0.4-2.5]; P≥ .999) of having a TSF than others. Conclusion: PTS was not found to be a risk factor for pediatric TSF in female or male patients in this study.

Salivary miRNA Expression in Children With Persistent Post-concussive Symptoms.

Background: Up to one-third of concussed children develop persistent post-concussive symptoms (PPCS). The identification of biomarkers such as salivary miRNAs that detect concussed children at increased risk of PPCS has received growing attention in recent years. However, whether and how salivary miRNA expression levels differ over time between concussed children with and without PPCS is unknown. Aim: To identify salivary MicroRNAs (miRNAs) whose expression levels differ over time post-concussion in children with vs. without PPCS. Methods: We conducted a prospective cohort study with saliva collection at up to three timepoints: (1) within one week of injury; (2) one to two weeks post-injury; and (3) 4-weeks post-injury. Participants were children (ages 11 to 17 years) with a physician-diagnosed concussion from a single hospital center. We collected participants' daily post-concussion symptom ratings throughout their enrollment using the Post-concussion Symptom Scale, and defined PPCS as a total symptom score of ≥ 5 at 28 days post-concussion. We extracted salivary RNA from the saliva samples and measured expression levels of 827 salivary miRNAs. We then compared the longitudinal expression levels of salivary miRNAs in children with vs. without PPCS using linear models with repeated measures. Results: A total of 135 saliva samples were collected from 60 children. Of the 827 miRNAs analyzed, 91 had expression levels above the calculated background threshold and were included in the differential gene expression analyses. Of these 91 miRNAs, 13 had expression levels that differed significantly across the three timepoints post-concussion between children with and without PPCS (i.e., hsa-miR-95-3p, hsa-miR-301a-5p, hsa-miR-626, hsa-miR-548y, hsa-miR-203a-5p, hsa-miR-548e-5p, hsa-miR-585-3p, hsa-miR-378h, hsa-miR-1323, hsa-miR-183-5p, hsa-miR-200a-3p, hsa-miR-888-5p, hsa-miR-199a-3p+hsa-miR-199b-3p). Among these 13 miRNAs, one (i.e., hsa-miR-203a-5p) was also identified in a prior study, with significantly different expression levels between children with and without PPCS. Conclusion: Our results from the longitudinal assessment of miRNAs indicate that the expression levels of 13 salivary miRNAs differ over time post-injury in concussed children with vs. without PPCS. Salivary miRNAs may be a promising biomarker for PPCS in children, although replication studies are needed.