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Reaction time (RT) is a critical element of return to participation (RTP), and impairments have been linked to subsequent injury after a concussion. Current RT assessments have limitations in clinical feasibility and in the identification of subtle deficits after concussion symptom resolution. 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 individuals at initial assessment and RTP. Prospective cohort study. A pediatric sports medicine center associated with a regional tertiary care hospital. Twenty-seven adolescents with a concussion (mean age = 14.8 ± 2.1 years; 52% female; tested 7.0 ± 3.3 days postconcussion) and 21 uninjured control individuals (mean age = 15.5 ± 1.6 years; 48% female). Participants completed the Post-Concussion Symptoms Inventory (PCSI) and a battery of RT tests: clinical drop stick, simple stimulus-response, single-task Stroop, and dual-task Stroop. The concussion group demonstrated slower clinical drop stick (β = 58.8; 95% CI = 29.2, 88.3; P <.001) and dual-task Stroop (β = 464.2; 95% CI = 318.4, 610.0; P <.001) RT measures at the initial assessment than the uninjured control group. At 1-month follow up, the concussion group displayed slower clinical drop stick (238.9 ± 25.9 versus 188.1 ± 21.7 milliseconds; P <.001; d = 2.10), single-task Stroop (1527.8 ± 204.5 versus 1319.8 ± 133.5 milliseconds; P =.001; d = 1.20), and dual-task Stroop (1549.9 ± 264.7 versus 1341.5 ± 114.7 milliseconds; P =.002; d = 1.04) RT than the control group, respectively, while symptom severity was similar between groups (7.4 ± 11.2 versus 5.3 ± 6.5; P =.44; d = 0.24). Classification accuracy and area under the curve (AUC) values were highest for the clinical drop stick (85.1% accuracy, AUC = 0.86, P <.001) and dual-task Stroop (87.2% accuracy, AUC = 0.92, P <.002) RT variables at initial evaluation. Adolescents recovering from concussion may have initial RT deficits that persist despite symptom recovery. The clinical drop stick and dual-task Stroop RT measures demonstrated high clinical utility given high classification accuracy, sensitivity, and specificity to detect postconcussion RT deficits and may be considered for initial and RTP assessment. [ABSTRACT FROM AUTHOR]

The abrupt cessation of school and sport participation during the COVID-19 pandemic may have negative implications for adolescent mental health. To (1) compare mental, physical, and social health and behaviors during pandemic-related stay-at-home mandates with the same measures collected 1 to 2 years earlier and (2) evaluate the relationships between physical activity and sleep during the pandemic and changes in anxiety, fatigue, and peer relationships between assessment times. Cohort study. Pediatric sports medicine center. A total of 39 high school athletes (25 adolescent girls, 14 adolescent boys; age = 16.2 ± 0.9 years). Patient-Reported Outcome Measurement System anxiety, fatigue, and peer relationships short forms and the Pittsburgh Sleep Quality Index were completed twice (initial assessment in May 2018 or 2019, follow-up assessment in May or June 2020). Frequency and duration of physical activity and frequency of interaction with other individuals (family, peers, sport coaches, etc) were self-reported at follow-up assessment for the 2 weeks before school or sport closure and the 2 weeks before questionnaire completion. Higher levels of anxiety (5.5 ± 4.0 versus 3.6 ± 3.4 points; P =.003) and fatigue (5.4 ± 3.7 versus 2.3 ± 2.5 points; P <.001) and worse sleep quality (6.6 ± 2.9 versus 4.3 ± 2.3 points; P <.001) were observed during the pandemic compared with previous assessments. Reductions in physical activity were noted between assessments (exercise duration: 86.4 ± 41.0 versus 53.8 ± 30.0 minutes; P <.001). Sleep quality but not physical activity during the pandemic predicted changes in fatigue (P =.03, β = 0.44 [95% CI = 0.06, 0.83]) and peer relationships (P =.01, β = −0.65 [95% CI = −1.16, −0.15]) from initial to follow-up assessment. Mental and physical health declined during stay-at-home mandates compared with assessments 1 to 2 years earlier. Physical activity behaviors and sources of social interaction underwent changes after school and sport cessation. Sleep quality may have provided some protection against declining adolescent mental health during the pandemic, although this relationship requires further investigation. [ABSTRACT FROM AUTHOR]

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. To compare the efficacy of 2 braces used by barefoot athletes with Sever's disease. Randomized controlled clinical trial. Pediatric sports medicine clinic. 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). 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. 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. 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). 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. [ABSTRACT FROM AUTHOR]

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. 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. Prospective, cross-sectional study. Clinical medicine facilities. 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%]). 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. 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). 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. [ABSTRACT FROM AUTHOR]

Clinical management of sport-related concussion requires the assessment of various factors, including motor performance. The tandem gait test, a measure of postinjury motor performance, has demonstrated clinical utility but is limited by time availability and test uniformity. To assess intrasession reliability between tandem gait test trials and determine the number of trials necessary for optimal utility and feasibility in clinical decision-making after concussion. Cross-sectional study. Pediatric sport medicine clinic. Adolescent athletes who recently sustained a concussion (n = 44; age = 15.4 ± 1.8 years; 39% females) and were seen for care within 14 days (7.3 ± 3.2 days) of their injury as well as uninjured control participants (n = 73; age = 15.8 ± 1.3 years; 41% females). All individuals completed 3 single-task and 3 dual-task tandem gait trials. We collected test completion time and cognitive performance for each trial and calculated Pearson correlation coefficients between trials and intraclass correlation coefficients (ICCs) to determine intrasession reliability. We also compared performance between groups and calculated area under the curve (AUC) values to identify the ability of each trial to distinguish between groups. Both the concussion and control groups demonstrated high intrasession reliability between tandem gait trials under single- (R ≥ 0.82, ICC ≥ 0.93) and dual- (R ≥ 0.79, ICC ≥ 0.92) task conditions. The greatest group classification values were obtained from the second single-task trial (AUC = 0.89) and first dual-task trial (AUC = 0.83). Test completion time provided excellent between-groups discrimination in single- and dual-task conditions. However, cognitive performance during dual-task trials demonstrated only marginally significant clinical utility (AUC ≤ 0.67). Tandem gait assessments may only require 2 trials under single-task and 1 trial under dual-task conditions to effectively discriminate between concussion and control groups. This approach may improve the feasibility (ie, time requirement) of the test while maintaining excellent discriminatory ability. [ABSTRACT FROM AUTHOR]

Dizziness, poor sleep quality, and postural instability are all commonly reported postconcussion and individually relate to poor outcomes. To examine sleep quality and postural stability among adolescents who did and those who did not report dizziness within 2 weeks of concussion. Cross-sectional study. Research laboratory. 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). 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]). 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 = < 3). The dizzy and not-dizzy groups both reported worse sleep quality compared with the control group (Pittsburgh Sleep Quality Index score: dizzy = 9.6 ± 3.7 versus not dizzy = 7.2 ± 3.5 versus control = 4.3 ± 2.6; P <.001) via univariable comparison. Similarly, the dizzy group performed slowest, followed by the not-dizzy group, and then the control group on single-task tandem gait (dizzy = 27.2 ± 11.7 seconds versus not dizzy = 21.2 ± 6.3 seconds versus control = 14.7 ± 3.6 seconds, P <.001) and dual-task tandem gait (dizzy = 38.4 ± 16.2 seconds versus not dizzy = 29.9 ± 7.2 seconds versus control = 21.6 ± 7.5 seconds, P <.001). Both concussion groups demonstrated more errors than the control group on the mBESS (dizzy = 9.8 ± 5.1 versus not dizzy = 6.9 ± 5.8 versus control = 3.8 ± 3.5, P <.001). After controlling for total symptom severity in the multivariable model, we observed that tandem gait, but not mBESS score or sleep quality, was associated with dizziness. 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. [ABSTRACT FROM AUTHOR]

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. 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. Cross-sectional study. Preparticipation evaluations for a local high school district. Female athletes, 13–18 years old (n = 90). Health history, family affluence, and patient-reported quality of life measures. 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. 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. [ABSTRACT FROM AUTHOR]

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 limitedcontact 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 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 associcollision and contact sport participation and adjusted for sex; age; history of bone, muscle, ligament, ortendon injury; history 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 i 1.2 years). A higher proportion of collision and contact sport athletes reported 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 limitedcontact contact athletes. After adjusting for covariates, we found that collision and contact sport participation was significantly associated with lower state anxiety (B =- 1.072, 95% confidence interval =- 1.834, -0.310, P = . 006) and depressive (13 =-0. 807 % 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 orthopaerlic injury histories. Potential benefjts 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 associcollision ated with negative quality of life. [ABSTRACT FROM AUTHOR]

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-symptomfrequency inventory, the Health and Behavior Inventory (HBI), at the initial postinjury examination. Patients were followed until they no longer reported concussion symptoms (symptomresolution 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 [Cl] = 0.80, 0.95). Adolescents' symptom-frequency reports were also highly correlated with those of their parents (rs = 0.78; 95% Cl = 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% Cl = 0.007, 0.031; P= .002) and longer return-to-play times (coefficient = 0.012; 95% Cl = 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. [ABSTRACT FROM AUTHOR]

Context: The tandem gait test is a method for assessing dynamic postural control and part of the Sport Concussion Assessment Tool, versions 3 and 5. However, its reliability among child and adolescent athletes has yet to be established. Objective: To examine the test-retest reliability of the single-task and dual-task tandem gait test among healthy child and adolescent athletes. Design: Descriptive laboratory study. Setting: Sports injury-prevention center. Patients or Other Participants: Uninjured and healthy athletes between the ages of 9 and 18 years. Intervention(s): Tandem gait measures repeated 3 times across the period of approximately 1 month. Main Outcome Measure(s): Participants completed the tandem gait test under single-task and dual-task (ie, while simultaneously executing a cognitive task) conditions. Our primary outcome measure was completion time during the single-task and dual-task conditions. We also assessed cognitive accuracy and response rate while participants completed the dual-task tandem gait test. Results: Thirty-two child and adolescent athletes completed the study (mean age = 14.3 ± 2.4 years; females = 16). Single- task tandem gait times were similar across the 3 testing sessions (14.4 ± 4.8, 13.5 ± 4.2, and 13.8 ± 4.8 seconds; P = .45). Dual-task tandem gait times steadily improved across the test timeline (18.6 ± 6.9, 16.6 ± 4.5, and 15.8 ± 4.7 seconds; P = .02). Bivariate correlations indicated moderately high to high agreement from test 1 to test 2 (single-task r= .627; dual-task r= 0.655) and from test 2 to test 3 (single-task r = 0.852; dual-task r = 0.775). Both the single-task (intraclass correlation coefficient; ICC [3,1] = 0.86; 95% confidence interval [CI] = 0.73, 0.93) and dual-task (ICC [3,1] = 0.84; 95% CI = 0.69, 0.92) conditions demonstrated high reliability across testing sessions. Conclusions: Tandem gait outcome measures demonstrat¬ed high test-retest reliability in both the single- and dual-task conditions. The overall reliability was within the acceptable range for clinical practice, but improvements across tests suggested a moderate practice effect. Tandem gait represents a reliable, dynamic, postural-control test that requires minimal space, cost, and time. [ABSTRACT FROM AUTHOR]

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 ¼ 40%, high ¼ 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. [ABSTRACT FROM AUTHOR]

Context: Concussions affect a large number of US athletes each year. Returning an athlete to activity once selfreported symptoms have resolved can be problematic if unrecognized neurocognitive and balance deficits persist. Pairing cognitive and motor tasks or cognitive and quietstance 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 = 1±.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 (1.1± ± 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 singletask gait or objective quiet-stance alterations. Dual-task gait assessments may, therefore, be a useful component in monitoring concussion recovery after symptom resolution. [ABSTRACT FROM AUTHOR]