Link Between the Female Athlete Triad and Gymnastics-Related Injury in Retired Collegiate Gymnasts.

OBJECTIVES: To compare gymnastics-related injuries between former collegiate gymnasts who did and did not report components of the female athlete triad (Triad) during college, including disordered eating or menstrual irregularity. We hypothesized that athletes reporting these 2 triad symptoms would have higher rates of time loss injury and injuries requiring surgery. DESIGN: Retrospective case-control. SETTING: Online survey. PATIENTS: Four hundred seventy former collegiate gymnasts. INTERVENTIONS: Athletes completed online survey distributed through social media. MAIN OUTCOME MEASURES: Participants were grouped based on self-reported menstrual irregularity and disordered eating during college. We compared time loss injuries, injuries resulting in surgery, and injury locations between the groups using χ2 analyses. RESULTS: Seventy percent (n = 328) of participants in this study reported a time loss college injury without surgery, and 42% (n = 199) reported an injury during college that required surgical treatment. A significantly greater proportion of gymnasts with only disordered eating reported a time loss gymnastics injury (without surgery) compared with those who reported only menstrual irregularity during college (79% vs 64%; P =0 .03). A significantly greater proportion of the disordered eating-only group reported a spine injury compared with the menstrual irregularity-only group (P = 0.007) and the group who reported neither menstrual irregularity nor disordered eating (P = 0.006). CONCLUSIONS: College gymnasts who experienced disordered eating were more likely to experience a nonsurgical time loss injury while in college, as well as spine injury compared with those with menstrual irregularity. Sports medicine providers should be aware of the association between injuries and individual components of Triad in gymnasts beyond bone stress injuries.

Sleep Problems After Concussion Are Associated With Poor Balance and Persistent Postconcussion Symptoms.

We examined the association of self-reported sleep problems with clinical measures of postural stability, memory performance, symptom burden, and symptom duration following youth concussion. Patients 6-18 years of age presenting ≤21 days postconcussion underwent a clinical evaluation including modified Balance Error Scoring System, single- and dual-task tandem gait, immediate and delayed recall, and symptom severity. We calculated time from injury until symptom resolution and determined the proportion of patients who developed persistent postconcussion symptoms, defined as a symptom duration >28 days postconcussion. We grouped patients based on whether they reported sleep problems at their postconcussion clinical evaluation and compared symptom-based and functional outcomes between groups. Of the 207 patients included, n = 97 (14.3 ± 2.9 years; 49% female; initial visit 10.2 ± 5.8 days postconcussion) reported sleep problems postconcussion and n = 110 (14.3 ± 2.4 years; 46% female; initial visit 9.3 ± 5.4 days postinjury) did not. Those reporting sleep problems postconcussion had significantly more modified Balance Error Scoring System errors than those without (8.4 ± 5.5 vs 6.7 ± 4.7; P = .01), but similar tandem gait and memory performance. A significantly greater proportion of those who reported sleep problems postconcussion experienced persistent postconcussion symptoms than those who did not (53% vs 31%; P = .004). After adjusting for time from concussion to clinical visit and preconcussion sleep problems, postconcussion sleep problems were associated with a 2 times greater odds of developing persistent postconcussion symptoms (adjusted odds ratio = 2.02, 95% CI = 1.01, 4.06; P = .049). Identifying sleep problems early following concussion may allow clinicians to implement targeted treatment recommendations to improve sleep and provide an optimal recovery environment.

Athlete Burnout Is Associated With Perceived Likelihood of Future Injury Among Healthy Adolescent Athletes.

We examined perceived risk of future sports injury and athlete burnout among uninjured adolescent athletes. Uninjured high school athlete participants completed the Athlete Burnout Questionnaire (ABQ) and a questionnaire assessing attitudes toward likelihood of sustaining a future sport-related injury. We compared ABQ responses between injury risk perception groups: those who expected injury versus those who did not. Half of the participants reported a somewhat/very high likelihood of future sport-related injury (n = 98; 52% female; age = 15.3 ± 1.9 years), while the other half reported it was unlikely/not possible (n = 98; 45% female; age = 15.3 ± 1.3 years). A significantly greater proportion of those in the expected injury group reported a history of bone/muscle/ligament/tendon injury (56% vs 24%; P < .001). Those in the expected injury group reported higher athlete burnout scores (median = 28 [interquartile range = 25-34] vs 25 [23-30]; P = .002). Adolescent athletes who reported they were likely to experience a future injury in their sport also reported greater levels of burnout.

Differences in Training and Health Characteristics Between Trail Ultrarunners and Shorter Distance Runners.

INTRODUCTION: The primary aim of the study was to compare select training and health characteristics between ultramarathon and shorter distance runners participating in a trail race series. METHODS: A questionnaire was sent to all participants who signed up for a trail race series, including distances of 10 km, half marathon, 50 km, 80.5 km (50 mi), and 100 km. There were 59 participants (27 ultramarathoners and 32 half marathon/10-km runners) who completed the questionnaire. We compared the training and health characteristics between groups using t tests and Fisher exact tests. RESULTS: There were no significant differences in reported history of stress fracture (15% vs 9%; P=0.70) or sleep quality scores (4.4 vs 5.5; P=0.15) between the ultramarathon and half marathon/10-km groups. Over half of both groups reported trying to change body weight to improve performance, without significant differences between groups (65% vs 53%; P=0.42). A significantly greater proportion of the ultramarathoners reported an episode of binge eating in the 4 wk preceding the race (38% vs 3%; P=0.001). CONCLUSIONS: Despite differences in training volume, we did not find different injury, sleep, and nutrition data between the ultramarathoners and half marathon/10-km runners, with the exception of more ultramarathoners reporting binging behaviors in the 4 wk leading up to the race. Screening for eating disorder behaviors should be considered in distance runners, particularly ultrarunners.

The association between sleep and physical activity with persisting postconcussion symptoms among adolescent athletes.

BACKGROUND: Both sleep duration and physical activity following concussion may influence subsequent recovery. Objective measurement of sleep and physical activity behavior via wearable technology may provide insights into their association with concussion recovery. OBJECTIVE: To determine whether sleep behavior (eg, duration, timing) and/or physical activity (steps/day, or exercise frequency, duration, intensity) in the first month after adolescent sports-related concussion are associated with developing persisting postconcussion symptoms (PPCS). DESIGN: Case-control. SETTING: Outpatient sports medicine clinic. PARTICIPANTS: The study prospectively enrolled adolescent athletes who sustained a concussion (N = 49, age = 14.8 ± 1.8 years; 51% female) who were evaluated within 14 days of concussion (mean = 6.7 ± 2.7 days) and followed uvia sleep/physical activity monitoring for the subsequent 2 weeks. MAIN OUTCOME MEASURES: Participants wore a monitor to track sleep (sleep time, wake time, and time spent awake in bed at night) and physical activity (average steps/day, exercise frequency, exercise duration) behavior for 2 weeks after initial assessment. Participants were followed until symptom resolution, and the main outcome of interest was development of PPCS (symptom duration >28 days). A multivariable logistic regression model was used to examine associations between physical activity and sleep behavior with PPCS. RESULTS: Of the 49 participants, 47% (n = 23, mean symptom resolution = 57 ± 23 days post injury) developed PPCS and 53% (n = 26, mean symptom resolution = 15 ± 7 days post injury) did not. Univariable analysis showed that the PPCS group took fewer steps/day (7526 ± 2975 vs. 9803 ± 3786 steps/day; p = .02), exercised less frequently (2.5 ± 2.2 vs. 4.4 ± 2.1 days/week; p = .005), and spent more time in bed awake (1.2 ± 0.3 vs. 0.8 ± 0.3 h/night; p = .03) than the no PPCS group. Multivariable results indicated the odds of developing PPCS significantly increased with fewer exercise session/week (adjusted odds ratio = 1.96, 95% confidence interval = 1.09, 3.51, p = .024). CONCLUSIONS: More exercise sessions that were longer than 15 minutes during concussion recovery was associated with a lower risk of developing PPCS, whereas sleep and other physical activity measures were not. Further studies regarding exercise duration and intensity are needed. Clinicians may consider advising patients to optimize sleep and physical activity during concussion recovery.

More Physical Activity Is Correlated With Reduction in Kinesiophobia for Adolescents With Persistent Symptoms After Concussion.

CONTEXT: The relationship between physical activity (PA) and fear of pain with movement (ie, kinesiophobia) during concussion recovery is unknown. Kinesiophobia may limit PA, while PA after concussion may reduce kinesiophobia. Our purpose was to examine the correlation between PA and self-reported kinesiophobia during concussion recovery for adolescents with and without persistent symptoms. DESIGN: Prospective cohort study of children ages 10-18 years within 14 days of concussion. METHODS: Participants rated kinesiophobia using the Tampa Scale of Kinesiophobia (TSK) at initial (≤14 d postconcussion) and return to play (RTP) assessments, and wore activity monitors between assessments. Our primary outcome was TSK score change from initial to RTP assessments. We grouped participants based on whether they experienced persistent symptoms (symptoms ≥28 days) or not (symptoms <28 days) and calculated correlation coefficients (Pearson r for normally distributed and Spearman rho for nonnormally distributed variables) between PA variables and TSK change scores. RESULTS: Among the 41 participants enrolled, 44% developed persistent symptoms (n = 18; age = 14.5 [2.0] y; 50% female; symptom duration = 57.3 [6.2] d; RTP = 66.8 [6.4] d) and 56% did not (n = 23; age = 14.9 [1.8] y; 48% female; symptom duration = 15.2 [1.5] d; RTP = 21.7 [1.9] d). For the persistent symptoms group, greater TSK change scores (mean = -2.5 [5.7] point change) were significantly and moderately correlated with higher daily step count (r = -.60, P = .008) and exercise frequency (r = -.63, P = .005), but were not correlated with exercise duration (ρ = -.12, P = .65). Among the no persistent symptoms group, TSK change scores (mean = -6.0 [5.0] point change) were not correlated with step count (r = -.18, P = .41) or exercise duration (ρ = .10, P = .67), and the correlation with frequency was low and not significant (r = -.34, P = .12). CONCLUSIONS: Regular PA during concussion recovery, regardless of duration or intensity, may help reduce kinesiophobia for those experiencing persistent symptoms.

Comparison of Braces for Treatment of Sever's Disease (Calcaneal Apophysitis) in Barefoot Athletes: A Randomized Clinical Trial.

CONTEXT: Sever's disease (calcaneal apophysitis) is a common condition in youth athletes, including those who participate in barefoot sports. Health care professionals often recommend that young athletes with Sever's disease wear heel cups in their shoes while active, but barefoot athletes are unable to use heel cups. OBJECTIVE: To compare the efficacy of 2 braces used by barefoot athletes with Sever's disease. DESIGN: Randomized controlled clinical trial. SETTING: Pediatric sports medicine clinic. PATIENTS OR OTHER PARTICIPANTS: A total of 43 barefoot athletes aged 7 to 14 years were enrolled, and 32 completed the study (age = 10.3 ± 1.6 years; 29 girls, 3 boys). INTERVENTION(S): Participants were randomized to the Tuli's Cheetah heel cup (n = 16) or Tuli's The X Brace (n = 16) group for use during barefoot sports over the 3-month study period. MAIN OUTCOME MEASURE(S): Participants completed self-reported assessments after diagnosis (baseline) and 1, 2, and 3 months later. The primary outcome was the Oxford Ankle Foot Questionnaire for Children (OxAFQ-C) physical score (3 months postenrollment). The secondary outcomes were OxAFQ-C school or play and emotional scores and the visual analog scale pain score. RESULTS: The percentage of time wearing the brace during barefoot sports was not different between the Cheetah heel cup and The X Brace groups (82% versus 64% of the time in sports; P = .08). At 3 months, we observed no differences for the OxAFQ-C physical (0.79 versus 0.71; P = .80; Hedges g = 0.06), school or play (0.94 versus 1.00; P = .58; Hedges g = 0.26), or emotional (1.00 versus 1.00; P = .85; Hedges g = 0.21) score. Visual analog scale pain scores during activities of daily living and sports were lower (better) at the 2- and 3-month time points than at baseline (P < .001). CONCLUSIONS: Both groups demonstrated improvements in ankle and foot function across time, but no between-groups differences were seen at 3 months. Given these results, barefoot athletes with Sever's disease may consider using either brace with barefoot activity to help improve pain and functional status.

Patient Characteristics Predictive of Immediate and Delayed Word Recall Performance Following Adolescent Concussion.

Clinicians rely on objective concussion assessments that may be influenced by patient characteristics, creating difficulties in isolating the effect of concussion on patient function. The purpose of our study was to identify characteristics associated with performance on the Sport Concussion Assessment Tool 5th edition (SCAT5) 10-word recall test following adolescent concussion. We evaluated patients seen for care within 14 days of concussion (n=125; 15.2±1.6 years of age, range=11-18 years; 46% female; 6.9±3.4 days post-concussion). Patient demographic (age, sex, medical and concussion history, etc.), injury (timing of presentation, symptom severity, sport-type, etc.), and clinical test (Modified Balance Error Scoring System [mBESS], tandem gait) characteristics were assessed, in addition to SCAT5 immediate and delayed memory testing using the 10-word recall list. Immediate and delayed recall performance was significantly associated with concussion symptom burden and cognitive accuracy during tandem gait, although effect sizes were notably small. Specific variables such as age, sex, diagnosis of ADD/ADHD, and performance on other clinical assessments were not significantly associated with recall performance after controlling for covariates. Further, the 10-word recall list demonstrates specific advantages over previously used 5-word lists by way of decreased ceiling effects and reduced interference of inherent patient characteristics.

Dizziness Is Associated With Neck/Shoulder Pain Following Pediatric Concussion.

OBJECTIVE: To examine the association between dizziness and neck/shoulder pain after concussion and if differences in postural stability and oculomotor function exist among patients reporting dizziness with or without concurrent neck/shoulder pain. DESIGN: Cross sectional. SETTING: Sports medicine clinic. PATIENTS: Pediatric patients ≤14 days post concussion. INTERVENTIONS: N/A. OUTCOME MEASURES: Patients completed the Health and Behavior Inventory (HBI) symptom rating and separately rated neck/shoulder pain (scale 0-3; 0 = no pain). We grouped patients by HBI dizziness rating (0 = not-dizzy; 1-3 = dizzy) and compared neck/shoulder pain ratings between the groups. We then compared oculomotor and postural stability outcomes between dizzy patients with and without neck/shoulder pain. RESULTS: We included 153 patients: dizzy (n = 100; age = 14.6 ± 2.2 years; 48% female) and not-dizzy (n = 53, age = 14.4 ± 3.1 years; 38% female). The dizzy group reported significantly higher neck/shoulder pain (1.4 ± 1.1 vs 0.5 ± 0.9 points, P < 0.001) and total symptom score (25.7 ± 11.2 vs 11.7 ± 9.3 points, P < 0.001) than the not-dizzy group. After adjusting for total symptom score and preinjury anxiety, depression, and migraines, dizziness was associated with higher odds of neck/shoulder pain (odds ratio = 1.9, 95% CI, 1.2-3.0; P = 0.004). No differences were observed between dizzy patients with and without neck/shoulder pain for near point of convergence (10.0 ± 7.5 vs 8.5 ± 6.7 cm, P = 0.43), modified Balance Error Scoring System (8.9 ± 5.5 vs 6.8 ± 4.7 errors, P = 0.09), or tandem gait (single-task: 26.0 ± 12.3 vs 24.2 ± 11.9 seconds, P = 0.56; dual-task: 35.1 ± 14.3 vs 35.6 ± 18.6 seconds, P = 0.90). CONCLUSIONS: In concussion patients experiencing dizziness, evaluating neck/shoulder pain may help identify individuals who would benefit from cervical spine rehabilitation. However, other potential causes of dizziness should also be evaluated to facilitate timely recovery.

Examining initial post-concussion dizziness and postural stability as predictors of time to symptom resolution.

OBJECTIVES: To examine the utility of a multimodal assessment battery of self-reported dizziness, clinician obtained postural stability, and symptom severity ratings within 14 days of concussion to predict symptom resolution time among children and adolescents. DESIGN: Prospective cohort. METHODS: Patients ages 6-18 years completed evaluation ≤14 days post-concussion, including self-reported symptom severity using the Post-Concussion Symptom Inventory (PCSI) and postural stability assessments. We grouped patients as dizzy or not dizzy based on the difference in current and pre-injury PSCI dizziness ratings: difference between current and pre-injury dizziness ≥3 = dizzy; difference <3 = not dizzy. We evaluated postural stability using modified Balance Error Scoring System (mBESS) and tandem gait (TG). Our primary outcome was time from concussion to symptom resolution. Using a univariable Cox proportional hazard model, we examined the association between dizziness and symptom resolution time. We then used a multivariable Cox proportional hazard model to adjust for potential confounding variables. RESULTS: We examined 89 patients and grouped each as dizzy (n = 34; age = 14.7 ±â€¯2.7 years; 7.1 ±â€¯3.4 days post-injury; symptom resolution time = 40.8 ±â€¯5.7 days) or not dizzy (n = 55; age = 14.4 ±â€¯2.3 years; 7.2 ±â€¯3.1 days post-injury; symptom resolution time = 23.3 ±â€¯3.2 days). Upon univariable examination, dizziness was independently associated with increased symptom resolution time (Hazard Ratio [HR] = 0.49; 95%CI: 0.28, 0.83; p = 0.009). After adjusting for potential confounders (total symptom severity, mBESS tandem stance errors, TG time, loss of consciousness), only symptom severity change was associated with symptom resolution time (HR = 0.98; 95%CI: 0.96, 0.997; p = 0.025). CONCLUSIONS: Total symptom severity assessed within 14 days of concussion, but not dizziness or postural stability, was significantly associated with symptom resolution time among children and adolescents following concussion.

An 8-Week Neuromuscular Training Program After Concussion Reduces 1-Year Subsequent Injury Risk: A Randomized Clinical Trial.

BACKGROUND: Existing data suggest that after concussion, athletes experience an increased risk of subsequent injury. Exploring methods that may reduce injury risk after successful postconcussion return to play may lead to new treatment approaches. PURPOSE: To examine the efficacy of a neuromuscular training (NMT) intervention on acute sports-related time-loss injury over the subsequent year relative to standard of care. STUDY DESIGN: Randomized clinical trial; Level of evidence, 1. METHODS: A total of 27 youth athletes were assessed initially postconcussion (median, 7 days postconcussion; interquartile range [IQR], 5-10) and after return-to-play clearance (median, 40 days postconcussion; IQR, 15-52). After return-to-play clearance, they were randomly assigned to NMT intervention (n = 11; mean ± SD age, 14.7 ± 1.7 years; 36% female) or standard of care (n = 16; mean ± SD age, 15.3 ± 1.8 years; 44% female). The intervention (duration, 8 weeks; frequency, 2 times per week) included guided strength exercises with landing stabilization focus. Standard of care received no recommendations. For the subsequent year, athletes prospectively completed a monthly log of sports-related injuries and organized sports competitions. RESULTS: During the first year after postconcussion return-to-play clearance, sports-related time-loss injuries were more common among standard of care relative to NMT intervention (75% [95% CI, 48%-93%] vs 36% [95% CI, 11%-69%]). After adjusting for age and sex, the hazard of subsequent injury in the standard-of-care group was 3.56 times (95% CI, 1.11-11.49; P = .0334) that of the NMT intervention group. Sports participation was similar between NMT intervention and standard of care during the year-long monitoring period (hours of organized sports per month; median, 12 [IQR, 2.6-32.1] vs 15.6 [IQR, 3.5-105.9]; P = .55). The age- and sex-adjusted incidence of injuries was 10.2 per 1000 competitive exposures (95% CI, 3.7-28.4) in the standard-of-care group as opposed to 3.4 per 1000 (95% CI, 0.9-13.4) in the NMT intervention group. After adjusting for age and sex, incidence of injuries was higher for standard of care vs NMT intervention (rate ratio, 2.96 [95% CI, 0.89-9.85]; P = .076). CONCLUSION: Although preliminary, our findings suggest that an NMT intervention initiated after return-to-play clearance may significantly reduce sports-related time-loss injuries over the subsequent year. REGISTRATION: NCT03917290 (ClinicalTrials.gov identifier).

Postconcussion Dizziness Severity Predicts Daily Step Count during Recovery among Adolescent Athletes.

PURPOSE: Physical activity (PA) after concussion is an important aspect of appropriate clinical management. However, symptoms or functional deficits may reduce patient propensity toward PA, thereby negatively affecting recovery. Our purpose was to examine whether postconcussion dizziness, total symptom severity, or postural stability predicts PA level in the 2 wk after initial evaluation. METHODS: We evaluated adolescent athletes within 14 d of concussion on assessments of symptoms, dizziness, and postural stability. Athletes were provided an activity monitor to track PA for 2 wk after the evaluation. Our primary outcome was step count (mean steps per day). Potential predictor variables included sex, Post-Concussion Symptom Inventory (PCSI) total symptom severity, individual PCSI ratings of dizziness and balance impairment, and postural stability assessments (single- and dual-task tandem gait, modified Balance Error Scoring System). To examine predictors of PA, we calculated correlation coefficients between steps per day and each potential predictor and included significantly correlated variables in a multivariable regression model. RESULTS: Participants were ages 12-18 yr (n = 35, 15.2 ± 1.7 yr, 49% female) and initially evaluated 7.3 ± 3.0 d after concussion. Upon univariable evaluation, PCSI dizziness rating (Pearson R = -0.49, P = 0.003) and sex (mean difference, 2449 steps per day; P = 0.05) were associated with steps per day. Within the multivariable regression analysis, PCSI dizziness rating (ß = -1035; 95% confidence interval, -191 to -1880; P = 0.018), but not sex, predicted average steps per day in the 2 wk after initial evaluation. CONCLUSIONS: Self-reported dizziness, but not overall symptom severity or postural stability, assessed within 14 d of concussion predicted daily step count in the subsequent 2 wk. Given the importance of PA for concussion recovery, treating acute postconcussion dizziness can potentially reduce a barrier to PA and improve recovery trajectories.

Intersection of surgical injuries and pain interference among former female collegiate gymnasts.

BACKGROUND: Gymnastics is a competitive sport with numerous health benefits. However, few data exist that examine the lasting effects of injuries in retired gymnasts. OBJECTIVE: To examine pain interference among former collegiate gymnasts. Specifically, we focused on the relationship between gymnastics-related injuries sustained during middle/high school or college that required surgery and former collegiate gymnasts' current pain. We hypothesized that injuries requiring surgery would be associated with increased pain and reduced function after retirement. DESIGN: Cross-sectional survey. SETTING: An online questionnaire was distributed to former female collegiate gymnasts via social media. PARTICIPANTS: A total of 447 former female collegiate gymnasts completed the survey and were grouped according to whether they indicated an injury during their middle/high school or collegiate gymnastics career that required surgery. MAIN OUTCOME MEASURES: The association between current pain interference (Patient-Reported Outcomes Measurement Information System [PROMIS] scale) and injuries in middle/high school or college that resulted in surgery. Pain interference elements included current enjoyment of life, ability to concentrate, participation in day-to-day activities, enjoyment of recreational activities, ability to perform errands, and ability to socialize with others. RESULTS: Those who reported an injury that resulted in surgery (n = 260; mean current age ± SD = 32.8 ± 9.5 years) were younger than those who did not at the time of survey completion (n = 187; current age: 37.0 ± 11.0 years) and reported beginning gymnastics at an earlier age (4.4 ± 2.0 years vs. 5.1 ± 2.5 years; p = .001). There were no statistically significant differences between the groups on any PROMIS questions. In secondary analyses, we found a small but significant association between beginning gymnastics at an earlier age and the odds of requiring surgery (odds ratio = 1.11, 95% confidence interval [CI] = 1.02-1.21; p = .02). CONCLUSIONS: Most retired gymnasts reported a gymnastics-related injury that required surgery. Gymnasts who start gymnastics at a younger age were more likely to sustain an injury that required surgery, but surgery was not associated with higher levels of pain interference.

Transitory kinesiophobia after sport-related concussion and its correlation with reaction time.

OBJECTIVES: To examine kinesiophobia (i.e. fear of movement) among adolescent athletes with concussion compared to controls, and correlations of kinesiophobia with symptoms and reaction time. DESIGN: Prospective cohort study. METHODS: We evaluated 49 adolescent athletes twice. The concussion group was assessed within 14 days of injury and at return-to-play clearance. The control group was tested initially and approximately 28 days later. Participants completed Tampa Scale of Kinesiophobia, Post-Concussion Symptom Inventory, and clinical reaction time assessments. RESULTS: We included 32 concussion participants (15 ± 2 years; 50% female) and 17 controls (16 ± 1 years; 47% female). Acutely (<14 days post-injury), the concussion group reported greater Tampa Scale of Kinesiophobia scores (38.5 ± 5.4 vs. 29.4 ± 6.7; p < 0.001; Cohen's d = 1.54), and a greater proportion of "high" (≥37) scores than controls (69% vs. 6%; p < 0.001). At return-to-play, there were no significant between-group differences (33.3 ± 6.5 vs. 30.8 ± 7.4; p = 0.23; Cohen's d = 0.36); 28% of the concussion group reported "high" Tampa Scale of Kinesiophobia scores. At return-to-play, kinesiophobia was significantly/moderately correlated with clinical reaction time for the concussion group (r = 0.50; p = 0.01). CONCLUSIONS: Adolescents recovering from concussion commonly reported high kinesiophobia initially postconcussion, while 28% continued to report high kinesiophobia at return-to-play clearance. Additionally, a correlation between Tampa Scale of Kinesiophobia scores and clinical reaction time was observed for the concussion group. This finding would benefit from further study to determine potential perception-behavior relationships following concussion.

Sport specialization, sleep, fatigue, and psychosocial ratings: do highly specialized athletes differ from their less specialized peers?

OBJECTIVES: To determine if sleep quality, fatigue, anxiety, depressive symptoms, or perceptions of sport participation differ between high-, moderate-, and low-specialized high school athletes with or without prior injuries. METHODS: During pre-participation physical examinations (PPE), high school athletes completed questionnaires on sport specialization level, history of time-loss orthopedic injury, perceptions of sport participation, as well as sleep quality (Pittsburgh Sleep Quality Index (PSQI)), fatigue, anxiety, and depressive symptoms (Patient-Reported Outcomes Measurement Information System (PROMIS®)). Athletes were grouped according to sport specialization level and history of prior time-loss orthopedic injury. RESULTS: A total of 186 athletes completed the study: 49% (n = 92; mean age = 15.3 ± 2.0 yrs; 50% female) were low specialized, 34% (n = 64; mean age = 15.3 ± 1.3 yrs; 47% female) were moderately specialized, and 16% (n = 30; mean age = 15.7 ± 1.1 yrs; 57% female) were highly specialized. Groups were similar for demographics, training volume, and injury history. Compared to the moderate-specialization group, highly specialized athletes reported higher levels of fatigue (3.1 ± 3.7 vs. 1.5 ± 2.2; p = 0.02), anxiety (3.6 ± 4.1 vs. 1.8 ± 2.6; p = 0.02), and depressive symptoms (2.4 ± 4.0 vs. 0.8 ± 2.0; p = 0.02). No differences in psychometric ratings, sleep quality, or perceptions of sport participation were observed between the low/moderate- or low/high-specialization groups. We did not observe any significant differences between groups who did and did not report a history of prior time-loss orthopedic injury. CONCLUSIONS: Highly specialized high school athletes report higher levels of fatigue, more anxiety symptoms, and more depressive symptoms than their moderately specialized peers, despite no differences in training volume or injury history. Low specialized athletes did not differ from moderately specialized or highly specialized athletes in the aforementioned domains, and there were no differences in sleep quality across specialization groups. These findings add to the current body of literature on early sport specialization by illustrating the distinctive psychosocial implications of sport specialization and demonstrating the need for further prospective research.

Post-Concussion Dizziness, Sleep Quality, and Postural Instability: A Cross-Sectional Investigation.

CONTEXT: Dizziness, postural instability, and poor sleep quality are all commonly reported post-concussion and individually relate to poor outcomes. OBJECTIVE: To examine sleep quality and postural stability among adolescents who did and did not report dizziness within two weeks of concussion. DESIGN: Cross-sectional study. SETTING: Research laboratory. PATIENTS OR OTHER PARTICIPANTS: Participants ages 12-18 years within 14 days of concussion (n=58, 15.2±1.8 years; 50% female; 7.1±3.1 days post-injury) and uninjured controls (n=73; 15.8±1.3 years; 42% female). MAIN OUTCOME MEASURES: Participants completed pre-injury and current dizziness ratings on the Post-Concussion Symptom Inventory (PCSI) and current sleep quality on the Pittsburgh Sleep Quality Index (PSQI). Participants also completed postural stability assessments (single/dual-task tandem gait and modified Balance Error Scoring System [mBESS]). RESULTS: We grouped concussion patients into dizzy (n=21) or not dizzy (n=37) groups based on PCSI dizziness ratings: difference between current and pre-injury dizziness rating >3=dizzy; difference <3=not dizzy. The dizzy and not dizzy groups both reported significantly worse sleep quality than the control group (PSQI score: mean=9.6±3.7 vs 7.2±3.5 vs 4.3±2.6; p<0.001) upon univariable comparison. Similarly, the dizzy group performed slowest on single and dual-task tandem gait, followed by the not dizzy group, then the control group (single-task TG: mean= 27.2±11.7 sec vs 21.2±6.3 vs 14.7±3.6; p<0.001); (dual-task TG: mean=38.4±16.2 sec vs 29.9±7.2 vs 21.6±7.5; p<0.001). Both concussion groups demonstrated significantly more errors than the control group on the mBESS (mean=9.8±5.1 vs 6.9±5.8 vs 3.8±3.5; p<0.001). After controlling for total symptom severity in the multivariable model, tandem gait, but not mBESS or sleep quality, was associated with dizziness. CONCLUSION: Individuals with post-concussion dizziness also demonstrated impaired tandem gait performance, while poor sleep quality was associated with total symptom severity. Identifying and treating the underlying dysfunction contributing to dizziness and postural instability may guide individualized rehabilitation strategies and facilitate recovery.

Patient perception of dizziness and imbalance does not correlate with gait measures in adolescent athletes post-concussion.

BACKGROUND: Dizziness and gait impairments are commonly observed following a concussion, and both are associated with prolonged concussion recovery. RESEARCH QUESTION: Is there a correlation between combined self-reported dizziness and balance impairment severity with objective gait impairments after concussion? METHODS: Participants (n = 51; 15.4 ± 1.6 years; 51 % female; 7.3 ± 3.2 days post-injury) age 12-18 years self-reported ratings of dizziness and balance impairment using the Post-Concussion Symptom Inventory (PCSI) within 14 days of injury. Individual ratings of dizziness, balance impairment, and moving clumsily on the PCSI were combined to create a comprehensive dizziness and imbalance score. Participants also completed a smartphone-based gait evaluation under single-task and dual-task conditions. Correlation coefficients (Pearson r for normally distributed and Spearman rho for non-normally distributed variables) were calculated between self-reported symptoms and single and dual-task spatiotemporal gait parameters, specifically step velocity, step time, and step length. RESULTS: Correlation coefficients indicated that there was low to no correlation between self-reported dizziness and imbalance impairment severity and smartphone-obtained gait parameters under single- or dual-task conditions, including step velocity (single-task: r=-0.22, p = 0.13; dual-task: r=-0.05, p = 0.72), step time (single-task: rho = 0.16, p = 0.27; dual-task: rho = 0.14, p = 0.33), and step length (single-task: r=-0.15, p = 0.30; dual-task: r = 0.03, p = 0.84). SIGNIFICANCE: Self-reported dizziness and balance impairment severity within the first two weeks of concussion may not reflect objectively measured gait performance, given the lack of association between subjective symptom ratings and functional measures. Further, smartphone collected gait parameters may not provide the necessary sensitivity to detect an association with dizziness. The lack of significant correlation between self-reported symptoms and objective gait performance highlights the importance of using both objective and subjective measures to obtain a more complete picture of concussion deficits.

Symptom and clinical recovery outcomes for pediatric concussion following early physical activity.

OBJECTIVE: Recent research supports initiating physical activity as soon as 24 to 48 hours after concussion to reduce persistent postconcussive symptoms. However, this practice has not been widely adopted. The objective of this study was to evaluate the association of early physical activity with patient-reported and functional outcomes for pediatric patients following a concussion. METHODS: A retrospective cohort of patients who presented to a pediatric sports medicine clinic (48% female, mean age14.3 ± 2.6 years, and mean 9.8 ± 5.7 days postconcussion) were evaluated. Patients were grouped based on whether they reported engaging in physical activity prior to presenting to the clinic. Patient- and parent-reported symptom frequency (Health and Behavior Inventory), 11 different clinical outcomes (including missed school, memory recall, and balance assessments), the presence of symptoms persisting beyond 28 days, and a subgroup analysis of those patients receiving exercise versus symptom-limiting activity prescriptions were examined. Outcomes were compared between physical activity groups using the Mann-Whitney U-test and the chi-square test. To adjust for the effect of potential confounders, a logistic binary regression model was constructed. RESULTS: In total, 211 pediatric patients were included, 35 (17%) of whom reported early physical activity. A greater proportion of the no physical activity group reported a headache (85% vs 60%, p = 0.001). The no physical activity group also reported higher patient-reported (23.1 ± 13.4 vs 15.0 ± 13.4, p < 0.001) and parent-reported (19.4 ± 12.7 vs 11.2 ± 10.3, p = 0.001) symptom frequency at the initial visit. The early physical activity group had a lower proportion of patients with persistent symptoms (44% vs 22%, p = 0.02) and a shorter time to symptom resolution (15.6 ± 12.4 days vs 27.2 ± 24.2 days, p = 0.02). After adjusting for potential confounders, early physical activity was associated with 5.8 lower odds of experiencing persistent symptoms (adjusted OR 5.83, 95% CI 2.05-16.61; p = 0.001). CONCLUSIONS: A significant association between early physical activity and decreased symptom burden was observed. A lower proportion of those patients who engaged in early physical activity experienced persistent symptoms 28 days postinjury. However, low rates of early physical activity prior to the initial clinic visit were also observed, indicating that this approach may not be well known by acute care or primary care providers, or is not widely adopted by patients and families.

Neuromuscular training after concussion to improve motor and psychosocial outcomes: A feasibility trial.

OBJECTIVE: To determine the feasibility of an 8-week neuromuscular training program initiated upon return-to-play clearance following concussion. DESIGN: Feasibility trial. SETTING: A single sports medicine center. PARTICIPANTS: We approached n = 54 patients; n = 32 agreed to participate (59%). N = 27 participants returned for their second visit at return-to-play clearance (84%) and were randomized to neuromuscular training (n = 13) or standard-of-care (n = 14). MAIN OUTCOME MEASURES: Participants completed three assessments: within 14 days post-concussion, immediately after return-to-play clearance, and 8-weeks following return-to-play clearance. The intervention aimed to achieve positive neuromuscular adaptations and occurred 2x/week for 8 weeks under supervision. RESULTS: N = 2 participants randomized to the intervention elected not to participate, both due to schedule conflicts (e.g., time required to meet with the study team). Participants began the intervention an average of 11 days after return-to-play clearance, the majority (91%) completed >75% of training sessions, and training sessions lasted an average of 18.2 ± 4.8 min. One participant stopped the intervention after 7 training sessions due to time availability. CONCLUSION: It is feasible to initiate a neuromuscular training program for most athletes shortly after returning to play following concussion. Clinicians and researchers may consider this approach to mitigate the increased musculoskeletal injury risk for concussion patients returning to sports.

More Physical Activity after Concussion Is Associated with Faster Return to Play among Adolescents.

Concussion management has evolved to de-emphasize rest in favor of early introduction of post-injury physical activity. However, the optimal quantity, frequency and intensity of physical activity are unclear. Our objective was to examine the association between objective physical activity metrics and clinical recovery after concussion. We prospectively enrolled a cohort of 32 youth athletes with concussion, evaluated within 14 days of injury and after return-to-play (RTP) clearance. For two weeks after enrollment, we quantified steps/day and exercise frequency, duration, and intensity via wrist-worn actigraphy. We grouped participants by RTP clearance timing (<28 days vs. ≥28 days). Seventeen (53%) participants required ≥28 days post-concussion for RTP clearance. Groups were similar in age (14.9 ± 1.9 vs. 15.4 ± 1.5 years; p = 0.38), proportion of females (47% vs. 40%; p = 0.69), and concussion history (59% vs. 47%; p = 0.49). During the study period, the RTP ≥ 28 days group took fewer steps/day (8158 ± 651 vs. 11,147 ± 4013; p = 0.02), exercised fewer days/week (2.9 ± 2.4 vs. 5.0 ± 1.9 days/week; p = 0.01), and exercised fewer total minutes/week (117 ± 122 vs. 261 ± 219 min/week; p = 0.03). Furthermore, we observed ≥10,251 average steps/day, ≥4 exercise sessions/week, and exercising ≥134 total minutes/week were optimal cutpoints to distinguish between groups. These findings support the benefit of physical activity during concussion recovery.