Changes in Physician Recommendations for Early Physical Activity After Pediatric Concussion: A Retrospective Study.

OBJECTIVES: This study aimed to analyze changes in physical activity (PA) recommendations after pediatric concussions and examine the associations of patient and injury characteristics with physicians' PA recommendations. DESIGN: Retrospective observational study. SETTING: Concussion clinics associated with a pediatric hospital. PATIENTS: Patients aged 10 to 18 years with a concussion diagnosis, presenting to the concussion clinic within 14 days of the injury were included. A total of 4727 pediatric concussions and corresponding 4727 discharge instructions were analyzed. INDEPENDENT VARIABLES: The independent variables for our study were time, injury characteristics (eg, mechanism and symptom scores), and patient characteristics (eg, demographics and comorbidities). MAIN OUTCOME MEASURES: Physician PA recommendations. RESULTS: From 2012 to 2019, the proportion of physicians recommending light activity at an initial visit increased from 11.1% to 52.6% ( P < 0.05) within 1-week postinjury and from 16.9% to 64.0% during the second week postinjury ( P < 0.05). A significantly increased odds of recommending "light activity" (odds ratio [OR] = 1.82, 95% confidence interval [CI], 1.39-2.40) and "noncontact PA" (OR = 2.21, 95% CI, 1.28-2.05), compared with "no activity" within 1-week postinjury, was observed in each consecutive year. In addition, higher symptom scores at the initial visit were associated with lower likelihood of recommending "light activity" or "noncontact PA." CONCLUSIONS: Physician recommendation of early, symptom-limited PA after a pediatric concussion has increased since 2012, which mirrors a shift in acute concussion management. Further research assessing how these PA recommendations may facilitate pediatric concussion recovery is warranted.

An Unusual Case of Arm Pain in a Young Soccer Player: Herpes Zoster in the Pediatric Athlete.

ABSTRACT: Herpes zoster (HZ), shingles, is caused by the varicella-zoster virus (VZV). HZ develops as a reactivation of latent VZV and is characterized by a painful, vesicular rash typically manifesting in a dermatomal distribution on the arms, trunk or face. HZ occurs in individuals who had primary VZV disease (chickenpox) as a child or in those who have received live, attenuated VZV vaccine. HZ is common in the elderly and the immunocompromised, with age being the single greatest risk factor. The incidence of HZ in children is 74/100,000 person years for the unvaccinated and 38/100,000 person years for the vaccinated. We discuss the case of a 12-year-old soccer player with HZ who presented with right arm pain after a putative traumatic event. Diagnosis was made after two emergency department visits where the condition was not identified. HZ should be considered in the clinician's differential even in immunocompetent, vaccinated children.

Risk factors for prolonged recovery from concussion in young patients.

OBJECTIVES: For young patients sustaining concussion, assessing recovery is vital in determining safe return to play. Identifying risk factors may aid clinicians in recognising patients at risk for prolonged recovery. The study objective is to identify risk factors for prolonged (>28 days) and extended (>90 days) recovery (defined as symptom duration) and analyse how these risk factors differ between the two groups. METHODS: We retrospectively analysed electronic health record data (n=4937) among patients aged 10-18 years collected at Nationwide Children's Hospital Sports Medicine concussion clinics between 1 July 2012 and 30 June 2019. Data collected included patient demographics, comorbidities (eg, prior psychiatric diagnoses, prior concussions) and injury characteristics (eg, loss of consciousness, injury setting). We examined patient risk factors for prolonged (>28 days) and/or extended (>90 days) recovery using modified Poisson regression models. RESULTS: Factors associated with increased risk of prolonged recovery from concussion included prior concussions (adjusted risk ratio (ARR) 1.19, 95% CI 1.02 to 1.38) for two concussions (ARR 1.36, 95% CI 1.14 to 1.61), for >3, and higher initial symptom score (ARR 2.57, 95% CI 2.34 to 2.83) for postconcussion symptom (PCS) scores 21-60 (ARR 2.89, 95% CI 2.54 to 3.29), for PCS>60. Risk factors for extended recovery included history of concussion (ARR 1.50, 95% CI 1.09 to 2.06) for two concussions (ARR 1.75, 95% CI 1.17 to 2.62), for >3 and older age (15-18 years, ARR 1.11, 95% CI 1.05 to 1.18). Additionally, comorbid attention deficit hyperactivity disorder increased risk of prolonged recovery (ARR 1.14, 95% CI 1.01 to 1.29) while anxiety increased risk for extended recovery (ARR 1.47, 95% CI 1.10 to 1.95). CONCLUSION: Overall, risk factors for prolonged recovery differ somewhat from risk factors for extended recovery. For patients who present to clinic with concussion, mental health is an important consideration which may impact the timeline for symptom recovery.

Musculoskeletal and Sports Medicine Curriculum Guidelines for Pediatric Residents.

ABSTRACT: Musculoskeletal (MSK) and sports-related conditions are relatively common in the pediatric population. Pediatric residencies should provide residents with the knowledge and skills to assess and manage both acute and chronic MSK and sports injuries and complaints. Residents should develop the competencies and attitudes to safeguard and promote a healthy and active lifestyle for youth. Programs can use a variety of educational tools, both in the clinic and on the field, to provide a well-rounded MSK curriculum throughout the residency years. This article provides a review of general pediatric sports medicine curriculum guidelines and suggested implementation strategies.

Organized Sports for Children, Preadolescents, and Adolescents.

Interest and participation in organized sports for children, preadolescents, and adolescents continue to grow. Because of increased participation, and younger entry age, in organized sports, appropriate practice, game schedules, and content become more important, taking into account athlete developmental stage and skills. Parental support for organized sports in general, with focus on development and fun instead of winning, has emerged as a key factor in the athlete's enjoyment of sports. Schools and community sports organizations who support multiple levels of sport (eg, recreational, competitive, elite) can include more youth who want to play sports and combat sport dropout. This report reviews the benefits and risks of organized sports as well as the roles of schools, community organizations, parents, and coaches in organized sports. It is designed to complement the American Academy of Pediatrics clinical reports "Physical Activity Assessment and Counseling in Pediatric Clinical Settings" and "Sports Specialization and Intensive Training in Young Athletes" by reviewing relevant literature on healthy organized sports for youth and providing guidance on organized sport readiness and entry. The report also provides guidance for pediatricians on counseling parents and advocating for healthy organized sports participation.

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

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

Orthostatic Intolerance and Autonomic Dysfunction in Youth With Persistent Postconcussion Symptoms: A Head-Upright Tilt Table Study.

OBJECTIVE: To explore head-upright tilt table (HUT) signs of autonomic dysfunction in a cohort of youth with persistent postconcussion symptoms (PCSs) that include light-headedness and to correlate repeat tilt table results with symptom improvements for those patients found to have postural tachycardia syndrome (POTS) on initial testing. DESIGN: Prospective cohort design. SETTING: Nationwide Children's Hospital, Neurology Clinic. PARTICIPANTS: Thirty-four patients (13-18 years of age) with persistent PCSs. MAIN OUTCOME MEASURES: All patients underwent at least 1 tilt table test. The PCS Interview (PCS-I) and patient ratings of light-headedness and vertigo were used to measure symptom burden. Patients found to have POTS were asked to repeat tilt table testing when PCSs improved or 3 to 6 months after the initial test if symptoms persisted. RESULTS: Twenty-four of the 34 (70.6%) patients had abnormal tilt table results with patients categorized as normal (n = 10), isolated syncope (n = 10), and POTS (n = 14). Patients with POTS had higher PCS-I scores than normal patients (P < 0.001) and higher ratings of light-headedness than both normal patients (P = 0.015) and syncope patients (P = 0.04). Twelve POTS patients underwent repeat tilt table testing, and 9 of 12 (75%) no longer met POTS diagnostic criteria. All patients with resolution of POTS had corresponding improvements in PCSs, including light-headedness and vertigo. CONCLUSIONS: Our study demonstrates a high rate of tilt table abnormalities among youth with persistent PCSs. Several patients with POTS had normalization of tilt table testing when PCSs improved. These findings warrant further research of autonomic dysfunction related to concussion. CLINICAL RELEVANCE: Our study is the first to prospectively characterize autonomic dysfunction in patients with persistent PCSs using HUT testing and to show that the tilt test abnormalities normalize in some patients as PCSs improve.

Overuse injuries in high school athletes.

PURPOSE: To evaluate relationships between seasonal patterns of athletic participation and overuse injuries in high school athletes. METHODS: Self-reported survey of sports played and injuries sustained during the preceding 12 months administered anonymously to 9th-12th graders in school. RESULTS: Females suffered more overuse injuries than males. Overuse injuries increased slightly with age and with seasons of sports played per calendar year. Students who played sports all year long had 42% increased risk of overuse injury compared to those who played fewer than 4 seasons. CONCLUSIONS: Reducing the number of sport seasons played by high school athletes could decrease their rate of overuse injuries, with the greatest gains potentially achieved by taking at least one season off from sports entirely each calendar year.