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Clinical Scenario: Youth athletes may specialize in a sport of their choosing, or based on external pressures, to pursue elite status in that sport. Current evidence shows an association between highly specialized athletes and an increase in injuries as well as a connection between injury and lower health-related quality of life (HRQOL). Clinical Question: In college athletes, do early sport specialization characteristics (ie, age at specialization and degree of specialization) impact current HRQOL? Summary of Key Findings: The literature was searched for studies that investigated the age of specialization (early vs late) or degree of specialization (high, moderate, and low) and the impact on HRQOL. (1) The search returned 6 possible studies related to the clinical question. Three of the studies met the inclusion criteria and were used for this appraisal. (2) Two of the 3 included studies reported that highly specialized athletes noted lower HRQOL. (3) One study found there to be no significant difference in HRQOL between athletes who specialized early versus late but did find those who specialized early to have a greater incidence of injuries that required surgery. Clinical Bottom Line: There is moderate evidence that early sport specialization is associated with lower HRQOL compared with late sport specialization. It is important to educate athletes, parents, and coaches on the potential detriments that are associated with early sport specialization to allow stakeholders to make informed decisions regarding participation. Strength of Recommendation: Grade B evidence exists to support the idea that early, intensive sport specialization may be associated with decreased HRQOL in current college athletes. [ABSTRACT FROM AUTHOR]

Background: A validated clinical risk tool has been developed to identify pediatric and adolescent patients at risk of developing persisting symptoms after concussion, but has not been prospectively investigated within a sample of athletes seen after concussion by primary care sports medicine physicians and/or athletic trainers. Purpose: To determine whether a validated clinical risk prediction tool for persistent postconcussive symptoms (PPCSs) predicted which patients would develop PPCSs when obtained within 14 days of concussion among a multicenter sample of adolescent athletes. Study Design: Cohort study; Level of evidence, 2. Methods: Pediatric and adolescent patients (8-18 years of age) from 7 pediatric medical centers and 6 secondary school athletic training facilities who were diagnosed with a concussion and presented ≤14 days after concussion were enrolled as part of the Sport Concussion Outcomes in Pediatrics (SCOPE) study during their initial visit and were followed until symptom resolution. Clinical risk scores (Predicting and Preventing Post-concussive Problems in Pediatrics [5P]) and total symptom severity were obtained using the Post-Concussion Symptom Inventory at the initial visit (mean, 4.9 ± 2.9 days after concussion). Participants were then compared based on symptom resolution time: PPCS group (≥28 days to symptom resolution) and no-PPCS group (<28 days). The authors assessed the odds of developing PPCSs based on the 5P risk score using a binary logistic regression model and the utility of the clinical risk prediction tool to identify total time to symptom resolution using a Cox proportional hazards model. Results: A total of 184 participants enrolled, underwent initial evaluation, and were followed until symptom resolution (mean age, 15.2 ± 2.1 years; 35% female). The mean time to symptom resolution across the entire sample was 17.6 ± 3.7 days; 16% (n = 30) of participants developed PPCS. Those in the PPCS group had significantly greater mean initial total 5P risk scores than those in the no-PPCS group (7.9 ± 1.7 vs 5.9 ± 2.3, respectively; P <.001). After adjustment for initial symptom severity, time to assessment, and assessment setting, a higher initial total 5P risk score was associated with a significantly greater odds of developing PPCSs (adjusted odds ratio, 1.49; 95% CI, 1.07-2.08; P =.019). Furthermore, a higher 5P risk score was significantly associated with longer total symptom resolution time (hazard ratio, 0.80; 95% CI, 0.74-0.88; P <.001). Conclusion: In a multicenter sample of youth athletes seen in different outpatient health care settings, the 5P risk score accurately predicted which athletes may be at risk for developing PPCSs. [ABSTRACT FROM AUTHOR]

Injury or illness can affect individual perceptions of health status and health-related quality of life (HRQOL). Concussion can result in different symptoms, impairments, and functional limitations that have been found to lower HRQOL. Furthermore, concussion is known to influence the emotional and behavioral dyscontrol domains of HRQOL in pediatric populations; however, this has yet to be explored in other populations. To compare individuals with and those without a concussion history and (1) HRQOL and (2) the emotional and behavioral dyscontrol domains of HRQOL in college students. Cross-sectional study. University laboratory setting. Of a total of 252 participants (155 women; age = 19.95 ± 1.53 years), 76 (30.2%) had a history of concussion and 176 (69.8%) did not. For participants with a history of concussion, the mean time since injury was 5.29 ± 2.77 years. The Patient-Reported Outcome Measures Information System (PROMIS) Global Health, version 1.1, and Quality of Life in Neurological Disorders Emotional and Behavioral Dyscontrol Short Form (Neuro-QOL). No differences were seen between median scores in individuals with and those without a history of concussion in the PROMIS Physical Health (13.0 versus 14.0; P =.24), PROMIS Mental Health (12.0 versus 12.0; P =.99), and Neuro-QOL (16.0 versus 16.0; P =.47) scores. Additionally, when gender was controlled, the associations between a history of concussion and PROMIS Physical Health score (odds ratio [OR] = 1.04; 95% CI = 0.43, 2.52), PROMIS Mental Health score (OR = 0.66; 95% CI = 0.13, 3.25), and Neuro-QOL score (OR = 1.16; 95% CI = 0.66, 2.04) were not significant. Preliminary findings suggested that the emotional and behavioral dyscontrol domains were not influenced by a concussion history of > 1 year in college-aged participants. Future researchers should continue to explore specific HRQOL domains affected by concussion as well as the influences of prior mental health conditions and behavioral dysfunction after a subsequent injury. [ABSTRACT FROM AUTHOR]

Context: Concussions are shown to hinder multiple health dimensions, including health-related quality of life (HRQOL), suggesting a need for a whole-person approach to assessment and treatment. Patient-reported outcome measures are one method to gather the patient's perspective regarding their HRQOL. Objective: To evaluate perceived HRQOL using the Patient-Reported Outcomes Measurement Information System Pediatric-25 subscale in patients throughout concussion recovery. Design: Prospective cohort, descriptive survey. Setting: There were 9 high school athletic training facilities. Participants: A total of 70 patients with diagnosed concussions (51 males, 7 females, 12 unreported; age = 15.7 [0.9] y, height = 174.6 [8.4] cm, mass = 72.8 [14.8] kg, grade = 10.0 [0.9] level). Interventions: Patient-Reported Outcomes Measurement Information System Pediatric-25 was administered at 3 days, 10 days postconcussion, and return to play (RTP). Main Outcome Measures: Patient-Reported Outcomes Measurement Information System Pediatric-25 subscale T scores and self-reported concussion history (yes/no). Results: A total of 70 patients completed the study. For the Pediatric-25 subscales, the severity of problems associated with Physical Function Mobility, Anxiety, Depression, Fatigue, and Pain Interference were highest 3 days postconcussion, decreasing at 10 days and RTP (all p <.05). No differences were found between days 3 and 10 for Peer Relationship scores, but improvements were identified at RTP (p <.05). Pediatric-25 subscale scores at the 3 measurements were not statistically associated with concussion history (all p >.05). Ceiling and floor effects were present in all subscales throughout each timepoint, except for Physical Function Mobility (14.7%), and pain interference (11.8%) at day 3 postinjury. Conclusions: Patients who had suffered a concussion improved from day 3 through RTP on multiple health domains as demonstrated through the Pediatric-25 subscales. These findings highlight the need for health care professionals to serially monitor HRQOL and social factors that may affect the patient postconcussion as part of a multifactorial assessment. Ceiling effects in high functioning adolescent athletes were present; thus, efforts should be made to identify appropriate scales for use in managing recovery in athletic populations. [ABSTRACT FROM AUTHOR]

Sport specialization, or focused participation in a single sport, is associated with an increased rate of overuse injury and burnout. Medical associations and sport organizations have published recommendations for sport specialization aimed at reducing its negative consequences. Health care providers (HCPs) are often identified as individuals who can educate athletes and parents about these important recommendations. To compare knowledge, perceptions, awareness, confidence in knowledge, and use of sport specialization recommendations among HCPs who work with pediatric athletes. Cross-sectional study. An online web-based survey was developed to assess HCPs' knowledge, perceptions, awareness, confidence in knowledge, and clinical use of sport specialization recommendations. Participants were recruited from the research survey services of 4 professional organizations. Dependent variables were responses for awareness, perceptions, confidence in knowledge, use, and barriers sections of the survey. Data were analyzed with descriptive statistics; comparisons among HCPs were made through χ2 and Kruskal-Wallis tests. The survey was completed by 770 HCPs (completion rate = 95.1%). Respondents lacked awareness specific to recommendations surrounding the maximum number of sport participation months per year (39.5%), maximum hours per week (40.7%), and maximum number of teams on which youth athletes should participate concurrently (43.9%). Physicians were the most aware of medical organization recommendations generally (48%–68.8%) and confident in their knowledge (41.5%–75.1%). All HCPs were less aware and confident in their knowledge of sport organization recommendations, with no differences among HCPs. Physicians did not perceive many barriers to the use of the recommendations, whereas athletic trainers felt that patient (39.9%) and parent (45.3%) behaviors were the greatest barriers to usage. Awareness, perceptions, and use of sport specialization recommendations varied by discipline, but most respondents believed they were associated with a decreased risk of injury. Future researchers should focus on improved education and implementation of recommendations across all roles. [ABSTRACT FROM AUTHOR]

Clinical Scenario: Low back pain is widely prevalent in the general population as well as in athletes. Therapeutic exercise is a low-risk and effective treatment option for chronic pain that can be utilized by all rehabilitation clinicians. However, therapeutic exercise alone does not address the psychosocial aspects that are associated with chronic low back pain. Pain education is the umbrella term utilized to encompass any type of education to the patient about their chronic pain. Therapeutic exercise in combination with pain education may allow for more well-rounded and effective treatment for patients with chronic nonspecific low back pain (NS-LBP). Clinical Question: Does pain education combined with therapeutic exercise, compared with therapeutic exercise alone, improve patient pain in adults with chronic NS-LBP over a 2- to 3-month treatment period? Summary of Key Findings: A thorough literature review yielded 8 studies potentially relevant to the clinical question, and 3 studies that met the inclusion criteria were included. The 3 studies included reports that exercise therapy reduced symptoms. Two of the 3 included studies support the claim that exercise therapy reduces the symptoms of chronic NS-LBP when combined with pain education, whereas one study found no difference between pain education with therapeutic exercise. Clinical Bottom Line: There is moderate evidence to support the use of pain education along with therapeutic exercise when attempting to reduce symptoms of pain and disability in patients with chronic NS-LBP. Educational interventions should be created to educate patients about the foundation of pain, and pain education should be implemented as a part of the clinician's strategy for the rehabilitation of patients with chronic NS-LBP. Strength of Recommendation: Grade B evidence exists to support the use of patient education with therapeutic exercise for decreasing pain in patients with chronic NS-LBP. [ABSTRACT FROM AUTHOR]

Clinical Scenario: Recent systematic reviews have shown that extended rest may not be beneficial to patients following concussion. Furthermore, recent evidence has shown that patient with postconcussion syndrome benefit from an active rehabilitation program. There is currently a gap between the ability to draw conclusions to the use of aerobic exercise during the early stages of recovery along with the safety of these programs. Clinical Question: Following a concussion, does early controlled aerobic exercise, compared with either usual care or delayed exercise, improve recovery as defined by symptom duration and severity? Summary of Key Findings: After a thorough literature search, 5 studies relevant to the clinical question were selected. Of the 5 studies, 1 study was a randomized control trial, 2 studies were pilot randomized controlled trials, and 2 studies were retrospective. All 5 studies showed that implementing controlled aerobic exercise did not have an adverse effect on recovery. One study showed early aerobic exercise had a quicker return to school, and another showed a 2-day decrease in symptom duration. Clinical Bottom Line: There is sufficient evidence to suggest that early controlled aerobic exercise is safe following a concussion. Although early aerobic exercise may not always result in a decrease in symptom intensity and duration, it may help to improve the psychological state resulting from the social isolation of missing practices and school along with the cessation of exercise. Although treatments continue to be a major area of research following concussion, management should still consist of an interdisciplinary approach to individualized patient care. Strength of Recommendation: There is grade B evidence to support early controlled aerobic exercise may reduce the duration of symptoms following recovery while having little to no adverse events. [ABSTRACT FROM AUTHOR]

The school nurse plays a dynamic role in the care and treatment of a concussed athlete. Concussions in the adolescent populations are of special concern due to their potential impact on mental development and cognitive function, as well as an increased risk of serious complications including second impact syndrome. The complexity of a concussion requires collaboration between of a variety of health care and school personnel to create an optimal situation for the student-athlete and their family. As the primary health care provider for students during the school day, school nurses can help ensure all necessary steps are taken to aid the recovery of an injured student-athlete. It is important that school nurses are up-to-date on current concussion information to allow for optimal care following injury and during the recovery process. (Contains 3 tables and 2 figures.)

Clinical Scenario: Patients who experience prolonged concussion symptoms can be diagnosed with postconcussion syndrome (PCS) when those symptoms persist longer than 4 weeks. Aerobic exercise protocols have been shown to be effective in improving physical and mental aspects of health. Emerging research suggests that aerobic exercise may be useful as a treatment for PCS, where exercise allows patients to feel less isolated and more active during the recovery process. Clinical Question: Is aerobic exercise more beneficial in reducing symptoms than current standard care in patients with prolonged symptoms or PCS lasting longer than 4 weeks? Summary of Key Findings: After a thorough literature search, 4 studies relevant to the clinical question were selected. Of the 4 studies, 1 study was a randomized control trial and 3 studies were case series. All 4 studies investigated aerobic exercise protocol as treatment for PCS. Three studies demonstrated a greater rate of symptom improvement from baseline assessment to follow-up after a controlled subsymptomatic aerobic exercise program. One study showed a decrease in symptoms in the aerobic exercise group compared with the full-body stretching group. Clinical Bottom Line: There is moderate evidence to support subsymptomatic aerobic exercise as a treatment of PCS; therefore, it should be considered as a clinical option for reducing PCS and prolonged concussion symptoms. A previously validated protocol, such as the Buffalo Concussion Treadmill test, Balke protocol, or rating of perceived exertion, as mentioned in this critically appraised topic, should be used to measure baseline values and treatment progression. Strength of Recommendation: Level C evidence exists that the aerobic exercise protocol is more effective than the current standard of care in treating PCS. [ABSTRACT FROM AUTHOR]

Clinical Scenario: Shoulder range of motion (ROM) in throwing athletes relies on a balance of mobility and stability to maintain proper function and health that, if disrupted, can lead to shoulder injury. There have been several studies that address the relationship between ROM deficits and overhead injuries; however, it may be unclear to clinicians which interventions are most effective for increasing ROM in the glenohumeral joints of overhead athletes. Clinical Question: In overhead athletes who have deficient shoulder ROM, is instrument-assisted soft tissue mobilization (IASTM) more effective at acutely increasing ROM over the course of a patient’s treatment when compared with self-stretching? Summary of Key Findings: A thorough literature review yielded 3 studies relevant to the clinical question, and all 3 studies were included. Two articles found a significant increase in acute ROM when compared with a self-stretch measure. All 3 articles showed increases in internal rotation and horizontal adduction, and 1 study reported an increase in total arc of shoulder ROM. Clinical Bottom Line: There is moderate evidence to support the use of IASTM to acutely increase ROM in the glenohumeral joint of overhead athletes. Clinicians should be aware of the variability with recommended treatment times; however, positive results have been seen with treatments lasting 5 to 6 minutes per treatment region. There is no consensus for treatment intensity, and certain IASTM tools require certification. Strength of Recommendation: Grade B evidence exists that IASTM is more effective at increasing shoulder ROM (ie, internal rotation, horizontal adduction, external rotation, total arc of motion) in overhead athletes than self-stretching measures. [ABSTRACT FROM AUTHOR]

Clinical Scenario: Mild traumatic brain injury, or concussion, has been associated with physical, cognitive, and emotional sequelae. Little is understood in regard to many characteristics, such as anxiety, and their effect on post-concussion symptoms. Clinical Question: Is state anxiety, trait anxiety, or anxiety sensitivity a clinical predictor of symptoms in those presenting with mild traumatic brain injury or concussion? Summary of Key Findings: A literature search returned 3 possible studies; 3 studies met inclusion criteria and included. One study reported in athletes that greater social support was associated with decreased state-anxiety, lower state anxiety post-concussion was associated with increased social support, and that those with greater social support may experience reduced anxiety, regardless of injury type sustained. One study reported baseline trait anxiety in athletes was not significantly associated with post-concussion state anxiety, but that symptoms of depression at baseline was the strongest predictor for post-concussion state anxiety. Three studies reported that state and trait anxiety are not related to increased post-concussion symptom scores. One study reported that greater anxiety sensitivity is related to higher reported post-concussion symptom scores, which may manifest as somatic symptoms following concussion, and revealed that anxiety sensitivity may be a risk factor symptom development. Clinical Bottom Line: There is low-level to moderate evidence to support that anxiety sensitivity is linked to post-concussion symptoms. State and trait anxiety do not appear to be related to post-concussion symptoms alone. Post-concussion state anxiety may occur if post-concussion symptoms of depression are present or if baseline symptoms of depression are present. Better social support may improve state anxiety post-concussion. Strength of Recommendation: There is grade B evidence to support that state and trait anxiety are not risk factors for post-concussion symptom development. There is grade C evidence to support anxiety sensitivity as a risk factor for developing post-concussion symptoms. [ABSTRACT FROM AUTHOR]

Clinical Scenario: Thoracic outlet syndrome is quite challenging to diagnose. Currently, there are myriad diagnostic procedures used in the diagnosis of all types of thoracic outlet syndrome. However, controversy exists over which diagnostic procedures produce accurate findings. Clinical Question: Can clinical diagnostic tests accurately diagnose patients presenting with symptoms of thoracic outlet syndrome? Summary of Key Findings: A thorough literature search returned 6 possible studies; 3 studies met the inclusion criteria and were included. Two studies supported the use of clinical diagnostic tests for the diagnosis of thoracic outlet syndrome. One study reported high false-positive rates among clinical diagnostic tests for thoracic outlet syndrome. One study reported that clinical diagnostic test findings correlate to provocative positioned magnetic resonance imaging findings. Clinical Bottom Line: There is moderate evidence to support the use of the Halstead maneuver (also known as the costoclavicular maneuver or exaggerated military brace test), Wright's test, Cyriax Release test, and supraclavicular pressure test to have good diagnostic accuracy for the provocation of symptoms in patients presenting with upper extremity pathology. However, these clinical diagnostic tests do not appear to allow for the differential diagnosis of thoracic outlet syndrome exclusively. The use of the Adson's test and Roos test should be discontinued for the differential diagnosis of thoracic outlet syndrome. Strength of Recommendation: Grade B evidence exists to support the accuracy of the Halstead maneuver, Wright's test, Cyriax Release test, and supraclavicular pressure test for the diagnosis of upper extremity pathology in general. Grade C evidence exists for the use of these clinical diagnostic tests to exclusively diagnose thoracic outlet syndrome. [ABSTRACT FROM AUTHOR]

Clinical Scenario: It is hypothesized that cognitive activity following a concussion may potentially hinder patient recovery. While the recommendation of cognitive rest is often maintained and rationalized, a causal relationship between cognitive activity and symptom duration has yet to be established. Clinical Question: Does the implementation of cognitive rest as part of the postconcussion management plan reduce the number of days until the concussed adolescent patient is symptom free compared to a postconcussion management plan that does not incorporate cognitive rest? Summary of Key Findings: A thorough literature search returned 7 possible studies; 5 studies met the inclusion criteria and were included. Three studies indicated that increased cognitive activity is associated with longer recovery from a concussion, and, therefore, supported the use of cognitive rest. One study indicated that the recommendation for cognitive rest was not significantly associated with time to concussion symptom resolution. One study indicated that strict rest, defined as 5 days of no school, work, or physical activity; might prolong symptom duration. Clinical Bottom Line: There is moderate evidence to support the prescription of moderate cognitive rest for concussed patients. Clinicians who intend on implementing cognitive rest in their concussion protocols should be aware of inconsistencies and be open-minded to alternative treatment progressions while taking into consideration each individual patient and maintaining adequate patient-centered care principles. Strength of Recommendation: Grade B evidence exists that prescription of moderate cognitive rest for concussed patients may be beneficial as a supplement to physical rest as treatment for symptom reduction in adolescents. [ABSTRACT FROM AUTHOR]

Despite a call to incorporate patient-reported outcome measures (PROMs) into all aspects of health care, little is known about which instruments are best suited for a pediatric patient population with sport-related injury. The objective of this article was to perform a systematic review of the currently available evidence to determine which PROMs were used for pediatric patients with sport-related injuries and identify the associated psychometric properties and considerations for clinical utility. We conducted a literature search for articles on PROMs used in the pediatric population through electronic databases and a manual search of reference lists and authors between from inception to 2020. Articles were grouped based on the PROM(s) included, and considerations for clinical utility and psychometric properties were extracted from each article. Thirty-nine articles were included in this review, from which 22 PROMs were identified: 12 PROMs were developed specifically for the pediatric population, 4 were modified versions of an adult scale, and 6 were adult measures used in a pediatric population. Of the PROMs included in this review, the Oxford Ankle Foot Questionnaire for Children and the Pediatric Quality of Life Inventory were the most comprehensive in their development and assessment. Several outcome measures used for pediatric patients had missing or inadequate measurement properties and considerations for clinical utility, particularly in regard to readability, responsiveness, and interpretability. Clinicians and researchers should consider a measure's feasibility, acceptability, appropriateness, and psychometric properties when selecting a PROM for use with the pediatric population. [ABSTRACT FROM AUTHOR]