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Context The abrupt cessation of school and sport participation during the COVID-19 pandemic may have negative implications for adolescent mental health. Objective (1) To compare mental, physical, and social health and behaviors during pandemic-related stay-at-home mandates with the same measures collected 1–2 years prior. (2) To assess the relationship of physical activity and sleep during the pandemic with anxiety, fatigue, and peer relationship changes between assessment timepoints. Design Prospective cohort study, repeated-measures Setting Pediatric sports medicine center Participants High school athletes (n=39; 16.2±0.9 years of age; 64% female) Main Outcome Measures Patient Reported Outcome Measurement System (PROMIS) anxiety, fatigue, and peer relationships short forms and the Pittsburgh Sleep Quality Index (PSQI) were completed at two timepoints (initial assessment: May 2018 or 2019; follow-up assessment: May/June 2020). Physical activity frequency and duration, and frequency of interaction with other individuals (family, peers, sport coaches, etc.), were self-reported at follow-up assessment for the two weeks prior to school/sport closure and the two weeks prior to questionnaire completion. Results Higher levels of anxiety (5.5±4.0 vs. 3.6±3.4; p=0.003) and fatigue (5.4±3.7 vs. 2.3±2.5; p Conclusions Mental and physical health declined during stay-at-home mandates, compared to assessments 1–2 years earlier. Physical activity behaviors and sources of social interaction underwent significant changes following school and sport cessation. Quality sleep may provide some protection against declining adolescent mental health during the pandemic, although this relationship requires further investigation.

Context Dizziness, poor sleep quality, and postural instability are all commonly reported postconcussion and individually relate to poor outcomes. Objective To examine sleep quality and postural stability among adolescents who did and those who did not report dizziness within 2 weeks of concussion. Design Cross-sectional study. Setting Research laboratory. Patients or Other Participants Participants were individuals 12 to 18 years old and either within 14 days of concussion (n = 58; girls = 29, boys = 29, age = 15.2 ± 1.8 years, time postinjury = 7.1 ± 3.1 days) or uninjured control recruits (n = 73, girls = 31, boys = 42, age = 15.8 ± 1.3 years). Main Outcome Measure(s) Participants rated preinjury and current dizziness using the Post-Concussion Symptom Inventory (PCSI) and current sleep quality using the Pittsburgh Sleep Quality Index. They also completed postural stability assessments (single-task and dual-task tandem gait and modified Balance Error Scoring System[mBESS]). Results We divided patients with concussion into dizzy (n = 21) or not-dizzy (n = 37) groups based on PCSI dizziness ratings (difference between current and preinjury dizziness rating: dizzy = >3, not dizzy = Conclusions Individuals with postconcussion dizziness demonstrated impaired tandem-gait performance, whereas poor sleep quality was associated with total symptom severity. Identifying and treating the underlying dysfunction contributing to dizziness and postural instability may guide customized rehabilitation strategies and facilitate recovery.

Context Reaction time (RT) is a critical element of return to participation (RTP), and impairments have been linked to subsequent injury following a concussion. Current RT assessments have limitations in clinical feasibility, and identification of subtle deficits after concussion symptom resolution. Objective To examine the utility of RT measurements (clinical drop stick, simple stimulus-response, single-task Stroop, and dual-task Stroop) to differentiate between adolescents with concussion and uninjured control at initial assessment and RTP. Design Prospective Cohort Study Setting Pediatric sports medicine center associated with a regional tertiary care hospital. Patients or Other Participants Twenty-seven adolescents with a concussion (mean age=14.8±2.1 years; 52% female; tested 7.0±3.3 days post-concussion) and twenty-one uninjured controls (mean age=15.5±1.6 years; 48% female). Main Outcome Measure(s) Participants completed the Post-Concussion Symptoms Inventory (PCSI) and battery of RT tests: clinical drop stick, simple stimulus-response, single-task Stroop, and dual-task Stroop. Results The concussion group demonstrated significantly slower clinical drop stick (β=58.8; 95% CI= 29.2, 88.3, p Conclusion Adolescents recovering from concussion may have initial RT deficits which persist despite symptom recovery. Clinical drop stick and dual-task Stroop RT demonstrate high clinical utility given high classification accuracy, sensitivity, and specificity to detect post-concussion RT deficits, and may be considered for initial and RTP assessment.

Context Adolescent female athletes are at risk for menstrual dysfunction in the setting of exercise and low energy availability. Education regarding menstrual dysfunction and its associated consequences is important to promote athlete wellbeing. Objective The primary aim was to determine the prevalence and characteristics of female athletes who believed that losing their period was a normal response to high training demands. The secondary aim was to explore the relationship between menstrual dysfunction and patient-reported quality of life measures. Design Cross-sectional study. Setting Preparticipation evaluations for a local high school district. Patients or Other Participants Female athletes, 13–18 years old (n = 90). Main Outcome Measure(s) Health history, family affluence, and patient-reported quality of life measures. Results Forty four percent (n = 40) of 90 adolescent athletes answered that losing their period was a normal response to a high level of training, and this group had a lower body mass index, were less likely to report being worried about their current weight, and had a higher family affluence level than those who answered that losing their period was not a normal response to training. The overall prevalence of menstrual dysfunction was 28%. After adjusting for age and body mass index, we found that menstrual dysfunction was significantly associated with higher levels of anxiety, fatigue, and pain interference. Conclusions Nearly half of our sample of adolescent female athletes perceived losing their period was a normal response to high training demands. Females with menstrual dysfunction reported higher levels of anxiety, fatigue, and pain interference than those without menstrual dysfunction. Understanding adolescent perceptions of menstrual dysfunction and the characteristics of those with menstrual dysfunction can guide the development of future educational interventions aimed at athletes at risk for the female athlete triad.

Context Researchers investigating collision and contact sport participation during high school have found mixed results. Understanding the association between current contact and collision sport participation and quality-of-life outcomes can enhance our knowledge about the risks and benefits of sport participation. Objective To examine quality-of-life outcomes among high school athletes who reported participation in collision and contact sports in the year preceding assessment compared with no- or limited-contact sport athletes. Design Cross-sectional study. Setting Preparticipation physical examination. Patients or Other Participants High school athletes 13 to 18 years of age. Main Outcome Measure(s) We obtained sport participation and Patient-Reported Outcomes Measurement Information System (PROMIS) Pediatric-25 outcomes, which assess self-reported, quality-of-life domains in the preceding 7 days (ie, state assessment). Our grouping variable was collision and contact versus no- or limited-contact sport participation during the year preceding assessment. We used multivariable linear regression models to identify the associations between PROMIS scores and collision and contact sport participation and adjusted for sex; age; history of bone, muscle, ligament, or tendon injury; history of acute fracture or dislocation; and history of concussion. Results A total of 143 (51%) athletes reported collision and contact sport participation (24% female, mean age = 15.1 ± 1.7 years) and 138 (49%) reported no- or limited-contact sport participation (66% female, mean age = 15.4 ± 1.2 years). A higher proportion of collision and contact sport athletes reported a history of time loss for bone, muscle, ligament, and tendon injuries (51% versus 29%, P < .001) and for acute fracture or dislocation (46% versus 26%, P < .001) than did no- or limited-contact athletes. After adjusting for covariates, we found that collision and contact sport participation was significantly associated with lower state anxiety (β = −1.072, 95% confidence interval = −1.834, −0.310, P = .006) and depressive (β = −0.807, 95% confidence interval = −1.484, −0.130, P = .020) symptom scores. Conclusions Collision and contact sport athletes reported fewer anxiety and depressive symptoms in the week preceding evaluation than did no- or limited-contact sport athletes, but they had more extensive orthopaedic injury histories. Potential benefits and risks are associated with collision and contact sport participation. These data reinforce the need to examine the assumption that youth collision and contact sports are associated with negative quality of life.

Context Clinical reaction-time (RT) measures are frequently used when examining patients with concussion but do not correlate with functional movement RT. We developed the Standardized Assessment of RT (StART) to emulate the rapid cognitive demands and whole-body movement needed in sport. Objective To assess StART differences across 6 cognitive-motor combinations, examine potential demographic and health history confounders, and provide preliminary reference data for healthy collegiate student-athletes. Design Prospective, cross-sectional study. Setting Clinical medicine facilities. Patients or Other Participants A total of 89 student-athletes (56 [62.9%] men, 33 [37.1%] women; age = 19.5 ± 0.9 years, height = 178.2 ± 21.7 cm, mass = 80.4 ± 24 kg; no concussion history = 64 [71.9%]). Main Outcome Measure(s) Student-athletes completed health history questionnaires and StART during preseason testing. The StART consisted of 3 movements (standing, single-legged balance, and cutting) under 2 cognitive states (single task and dual task [subtracting by 6's or 7's]) for 3 trials under each condition. The StART trials were calculated as milliseconds between penlight illumination and initial movement. We used a 3 × 2 repeated-measures analysis of variance with post hoc t tests and 95% CIs to assess StART cognitive and movement differences, conducted univariable linear regressions to examine StART performance associations, and reported StART performance as percentiles. Results All StART conditions differed (P ≤ .03), except single-task standing versus single-task single-legged balance (P = .36). Every 1-year age increase was associated with an 18-millisecond (95% CI = 8, 27 milliseconds) slower single-task cutting RT (P < .001). Female athletes had slower single-task (15 milliseconds; 95% CI = 2, 28 milliseconds; P = .02) and dual-task (28 milliseconds; 95% CI = 2, 55 milliseconds; P = .03) standing RT than male athletes. No other demographic or health history factors were associated with any StART condition (P ≥ .056). Conclusions The StART outcomes were unique across each cognitive-motor combination, suggesting minimal subtest redundancy. Only age and sex were associated with select outcomes. The StART composite scores may minimize confounding factors, but future researchers should consider age and sex when providing normative data.

Context Many factors can affect the injury risk and quality of life among high school athletes. Early sport specialization and club sport participation may be components to consider when assessing the injury risk and quality of life. Objective To investigate patient-reported quality-of-life and injury-history measures among adolescent athletes at different sport-specialization levels and to compare these measures between those who did and those who did not report participating in club sports. Design Cross-sectional study. Setting High school athletic facility. Patients or Other Participants High school student athletes 13 to 18 years of age were recruited and tested during their annual preseason athletic physical examinations. Main Outcome Measure(s) Our primary grouping variables were sport-specialization level (classified as low, moderate, or high) and club sport participation (organized sport outside of traditional school athletics). Our outcome variables were the Patient-Reported Outcome Measurement Information System Pediatric Profile-37 rating, Severity Measure for Depression–Child score, and injury history. Results A total of 97 individuals participated (mean age = 15.2 ± 1.1 years; 38% female). Relatively similar proportions of individuals reported participating at each level of sport specialization (low = 34%, moderate = 40%, high = 26%). Forty-six (48%) participants stated they participated in club sports. No differences were evident in quality of life (P values = .15–.92 across domains), depression (P = .60), or injury history (P > .70) among the specialization groups. Those who described participating in club sports had a higher proportion of time-loss musculoskeletal injuries (63% versus 29%; P = .002) and of injuries requiring imaging, injection, a cast, a brace, or crutches (72% versus 46%; P = .013) than those who did not. Conclusions Although no injury-history differences were found among the sport-specialization groups, a higher proportion of club sport athletes than nonclub sport athletes reported a history of injury. Club sports are generally seen as more competitive, and the higher number of injuries seen in this setting could be related to a higher level of play among club sport athletes.

Context Understanding how parents and their children perceive concussion symptoms may provide insights into optimal concussion-management strategies. Objective To examine patient-parent correlations and agreement on concussion-symptom ratings, to identify differences in patient-parent symptom reporting between children (8–12 years of age) and adolescents (13–18 years of age), and to evaluate the correlation between patient and parent initial symptom-severity ratings with symptom duration and return-to-play time. Design Cross-sectional study. Setting Primary care sports medicine clinic. Patients or Other Participants A total of 267 patients aged 8 to 18 years seen for care within 21 days of sustaining a concussion. Patients were classified as children (n = 65; age = 11.3 ± 1.4 years; age range, 8–12 years) or adolescents (n = 202; age = 15.5 ± 1.4 years; age range, 13–18 years). Main Outcome Measure(s) Each patient and his or her parent (or legal guardian) completed a concussion-symptom–frequency inventory, the Health and Behavior Inventory (HBI), at the initial postinjury examination. Patients were followed until they no longer reported concussion symptoms (symptom-resolution time) and were allowed to return to unrestricted sport participation (return-to-play time). Results At the initial examination (8.9 ± 5.2 days postinjury), the symptom-frequency correlation between children and their parents was high (rs = 0.88; 95% confidence interval [CI] = 0.80, 0.95). Adolescents' symptom-frequency reports were also highly correlated with those of their parents (rs = 0.78; 95% CI = 0.71, 0.85). However, the child-parent correlation was higher than the adolescent-parent agreement (z = 2.21, P = .03). Greater patient (consolidated child and adolescent) HBI ratings were associated with longer symptom-resolution times (coefficient = 0.019; 95% CI = 0.007, 0.031; P = .002) and longer return-to-play times (coefficient = 0.012; 95% CI = 0.002, 0.022; P = .02), whereas parent HBI ratings were not. Conclusions Our findings may help to set expectations regarding concussion-symptom durations and return-to-play timing for pediatric patients and their families. Given the patient-parent correlations in our sample, substantial reporting discrepancies between patients and their parents may be a relevant factor for clinicians to investigate further during concussion evaluations.

Context: Concussions affect a large number of US athletes each year. Returning an athlete to activity once self-reported symptoms have resolved can be problematic if unrecognized neurocognitive and balance deficits persist. Pairing cognitive and motor tasks or cognitive and quiet-stance tasks may allow clinicians to detect and monitor these changes postconcussion. Objective: To prospectively examine adolescent athletes' gait and quiet-stance performance while concurrently completing a cognitive task acutely after concussion and after symptom resolution. Design: Case-control study. Setting: Sport concussion clinic. Patients or Other Participants: Thirty-seven athletes (age = 16.2 ± 3.1 years; 54% female) were diagnosed with a concussion, and their performance was compared with that of a group of 44 uninjured control participants (age = 15.0 ± 2.0 years; 57% female). Intervention: Participants diagnosed with a concussion completed a symptom inventory and single- and dual-task gait and quiet-stance evaluations within 21 days of injury and then again after symptom resolution. Gait and postural-control measurements were quantified using an inertial sensor system and analyzed using multivariate analyses of covariance. Main Outcome Measure(s): Post-Concussion Symptom Scale, single-task and dual-task gait measures, quiet-stance measures, and cognitive task performance. Results: At the initial postinjury examination, single-task gait stride length (1.16 ± 0.14 versus 1.25 ± 0.13 m, P = .003) and dual-task gait stride length (1.02 ± 0.13 m versus 1.10 ± 0.13 m, P = .011) for the concussion group compared with the control group, respectively, were shorter. After symptom resolution, no single-task gait differences were found, but the concussion group demonstrated slower gait velocity (0.78 ± 0.15 m/s versus 0.92 ± 0.14 m/s, P = .005), lower cadence (92.5 ± 12.2 steps/min versus 99.3 ± 7.8 steps/min, P < .001), and a shorter stride length (0.99 ± 0.15 m versus 1.10 ± 0.13 m, P = .003) during dual-task gait than the control group. No between-groups differences were detected during quiet stance at either time point. Conclusions: Acutely after concussion, single-task and dual-task stride-length alterations were present among youth athletes compared with a control group. Although single-task gait alterations were not detected after symptom resolution, dual-task gait differences persisted, suggesting that dual-task gait alterations may persist longer after concussion than single-task gait or objective quiet-stance alterations. Dual-task gait assessments may, therefore, be a useful component in monitoring concussion recovery after symptom resolution.