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Objective: To assess the risk of spondylolysis by sport in nonelite adolescent athletes with low back pain (LBP). Design: Retrospective case series. Setting: Hospital-based sports medicine clinic. Patients: The medical charts of 1025 adolescent athletes with LBP (age 15 +/- 1.8 years) were examined; 308 (30%) were diagnosed with a spondylolysis. Assessment of Risk: Risk of spondylolysis was assessed in 11 sports for males and 14 sports for females. Main Outcome Measure: Relative risk of diagnosis of spondylolysis injury. Results: The risk of spondylolysis differed by sex with baseball (54%), soccer (48%), and hockey (44%) having the highest prevalence in males and gymnastics (34%), marching band (31%), and softball (30%) for female athletes. Baseball was the only sport to demonstrate a significant increased risk of spondylolysis. Conclusions: The sports with the greatest risk of spondylolysis in adolescent athletes in this study were not consistent with published literature. Clinicians should be cautious generalizing high-risk sports to their practice, as geographic region and level of the athlete may significantly influence the incidence of spondylolysis in the population they are treating. [ABSTRACT FROM AUTHOR]

Objectives: The purposes of this study were (1) to determine whether the duration of rest before referral to physical therapy (PT) affects the time to make a full return to activity for patients with an acute spondylolysis, (2) to assess the safety of an early referral to PT in patients with an acute spondylolysis. Study Design: Retrospective chart review. Setting: Hospital-based sports medicine clinic. Patients: The medical charts of 196 adolescent athletes (mean age = 14.3 6 1.8 years) with an acute spondylolytic injury met the inclusion criteria and were reviewed. Independent Variable: Patients were subgrouped based on physician referral to PT. Patterns: An aggressive referral group (<10 weeks) and a conservative referral group (> 10 weeks). Main Outcome Measures: Duration of rest before clearance to a full return to activity and the frequency of adverse reactions during the course of treatment. Safety was assessed by calculating the risk of experiencing an adverse reaction in each group. Results: Median days to a full return to activity for aggressive referral group (115.5 days, interquartile range 98-150 days) and conservative referral group (140.0 days, interquartile range 114.5-168 days) were significantly different (P = 0.002). Eleven patients had adverse reactions during the course of treatment. The risk of adverse reaction was not statistically significant between groups (P = 0.509). Conclusions: Patients with acute spondylolysis in the aggressive referral group were able to make a full return activity almost 25 days sooner. No differences in the risk of adverse reactions were noted between aggressive and conservative referral groups. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

The article offers information on the syndrome of menstrual dysfunction, relative energy deficiency, and low bone mineral density in women athletes. Topics discussed include an increased risk of musculoskeletal injuries in teenagers with menstrual dysfunction (MD), risk factors for amenorrhea, eating disorders, or osteoporosis, and physical examination for sports for MD screening among female high school and middle school athletes.

Background/aim: A standard definition of Post-concussion Syndrome (PCS) does not exist. The objective was to determine consensus regarding the definition of PCS among physician members of the American College of Sports Medicine (ACSM). Methods: Physician members of the ACSM were sent an electronic survey to determine opinions regarding the PCS diagnosis. Results: Five hundred and ninety-seven physicians completed the survey. When asked the minimum duration of symptoms required to diagnose PCS, respondents answered: <2 weeks (26.6%), 2 weeks to 1 month (20.4%), 1-3 months (33%) and >3 months (11.1%). Physicians who see ≥10% concussion patients in their practise, as well as physicians whose concussion population consists of >50% paediatric patients, were more likely to require >1 month of symptoms ( p < 0.001). When asked the minimum number of symptoms required to diagnose PCS, responses varied: one symptom (55.9%), two symptoms (17.6%), three symptoms (14.6%) and four or more symptoms (3.2%). Respondents from the US were more likely than non-US respondents to require only one symptom for the PCS diagnosis ( p = 0.01). Conclusions: There is a lack of consensus regarding the definition of PCS among physician members of the ACSM. A standard definition would improve consistency in concussion research and in clinical practise. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Objective: To characterize the presence and degree of postconcussion lightheadedness in relation to postconcussion vertigo and dizziness, and to determine whether lightheadedness influences overall symptom duration. Design: Prospective, cohort design. Setting: Nationwide Children's Hospital, Sports Concussion Clinic. Participants: Five hundred ten patients (9-19 years of age) within 30 days of concussion injury. Main Outcome Measures: Patient ratings (scale 0-6) of multiple postconcussion symptoms including lightheadedness, vertigo, and dizziness, reported from the day of clinic evaluation and recalled from the day of concussion. Results: Postconcussion lightheadedness occurred commonly relative to vertigo. Lightheadedness was recalled more than vertigo (70.8% vs 48.6%, P < 0.001) on concussion day and reported more than vertigo (47.1% vs 24.1%, P < 0.001) on the day of clinic evaluation. Principal component analysis demonstrated strong correlations among lightheadedness, vertigo, balance difficulties, difficulty concentrating, mental fogginess, and difficulty remembering, relative to other postconcussion symptoms. When present on the day of clinic evaluation, these highly correlated symptoms predicted prolonged concussion recovery [P = 0.028; Hazard Ratio (HR) = 1.2]. Female sex (P = 0.04; HR = 1.23), emotional symptoms recalled from the day of concussion (P = 0.007; HR = 1.23), and cephalalgic symptoms (P < 0.001; HR = 1.34) reported on the day of clinic evaluation also predicted prolonged concussion recovery. Conclusions: Not all postconcussion dizziness is vertigo. Postconcussion lightheadedness is common and, when present at the time of clinic evaluation, can influence concussion recovery. Clinical Relevance: Distinguishing postconcussion lightheadedness from vertigo may help to inform clinical treatment and concussion research design. This study adds to the growing body of evidence that supports an association between concussion and autonomic dysfunction. [ABSTRACT FROM AUTHOR]

We examined the effect of a noncontact, subsymptom exacerbation early exercise recommendation on recovery from sports-related concussion. Retrospective analysis of adolescents, 10-17 years old, with symptomatic concussion, within 30 days of injury was performed. Time to recovery was measured between the early exercise group and a comparison group. A total of 187 patients studied—112 in the exercise group and 75 in the comparison group; 55% were male (n = 103). The exercise group had a significantly longer duration of concussion symptoms (18.5 days vs 14, P =.002), although both groups recovered within the expected time to recovery for concussion. When analyzed separately, males experienced longer time to recovery from injury (19 days vs 14, P =.003), than females, respectively (18 days vs 14.5, P =.18). Recommendation of early exercise resulted in significantly longer recovery from concussion in male adolescents but had no significant effect in female adolescents; both groups recovered within the expected time frame. [ABSTRACT FROM AUTHOR]

Background/objective: Conventional neuroimaging is not recommended for the routine diagnosis of concussion, but some patients with concussion undergo computed tomography (CT) or magnetic resonance imaging (MRI). The objective of this study was to explore the clinical factors that predict neuroimaging utilization in concussion. Methods: Concussion-related CT and MRI data were analysed from 1953 patients, aged 10–19 years, who presented to a sports concussion clinic within 30 days of injury. Results: The majority of CT scans (n= 193) were obtained during the acute concussion period (mean = 2.7 days post-concussion), whereas MRI scans (n= 134) were ordered later during recovery (mean = 39.4 days post-concussion). Predictors of CT utilization included loss of consciousness, amnesia and vomiting (allp< 0.001). Prior concussion (p= 0.002) and continued participation in activity after injury (p= 0.03) predicted greater MRI utilization. Neuroimaging with either CT (p= 0.024, hazard ratio = 1.2) or MRI (p< 0.001, hazard ratio = 2.75) was associated with prolonged symptoms. Only 3.1% of CTs and 1.5% of MRIs demonstrated signs of traumatic brain injury. Conclusion: Several clinical factors predict neuroimaging utilization in patients with concussion. CT is generally used acutely, while MRI is used in the sub-acute and chronic post-concussion periods. In a sports concussion clinic, delayed neuroimaging has limited clinical yield. [ABSTRACT FROM AUTHOR]

accounting for as much as 40% of all low back pain in this population. Currently, there is no evidence to guide physicians on when to make a safe referral to physical therapy [PT] for these patients. There were two primary objectives of this study: (1) to determine if the amount of time prior to referral to PT affects the time to make a full return to activity for patients with an acute spondylolysis (2) To assess the safety of an early referral to PT compared with a longer rest period prior to PT in patients with an acute spondylolysis. Methods: This was a retrospective study which consisted of the review of each patient's medical chart and lumbar imaging. Participants: One hundred and ninety-six patients with an acute spondylolysis injury met the inclusion criteria during the pre-selected review period. Patients were sub-grouped into 2 groups by physician referral patterns: an aggressive referral to PT group (< 10 weeks) and a conservative referral to PT group (> 10 weeks). Safety was assessed by calculating the number of adverse reactions experienced in each group during the course of treatment. Data Analysis: Mann-Whitney U tests were used to analyze the first study objective. Relative risk of an adverse reaction was calculated to assess the second study objective. Results: Median days to a full return to sport for aggressive PT referral group (115.5 days IQR 50.5) and conservative PT referral (140.0 days IQR 40.3) was significantly different (p = 0.003). A total of 11 patients had documented adverse reactions during the course of treatment for acute spondylolysis. Although there was a higher percentage of patients who experienced an adverse reaction in the conservative referral to PT group, this difference was not statistically significant (p = 0.509). Conclusions: The results of this retrospective study show that patients of physicians who referred to physical therapy sooner returned to sport more quickly without an increased risk of adverse reaction. [ABSTRACT FROM AUTHOR]

Objective: The term "post-traumatic migraine" (PTM) has been used to describe post-traumatic headaches (PTHs) that have associated migraine features, but studies of this relationship are lacking. The objective of the present study was to determine whether PTH correlates strongly with migraine symptoms among youth with concussion.Methods: Twenty-three symptoms were analyzed from a retrospective cohort of 1953 pediatric patients with concussion. A principal component analysis (PCA) with oblique Promax rotation was conducted to explore underlying symptom relationships in the full cohort and in subcohorts stratified by the presence (n = 414) or absence (n = 1526) of premorbid headache.Results: The mean patient age was 14.1 years; 63% were male. Headache was the most common postconcussion symptom, acknowledged by 69.4% of patients. When considering the full cohort, the PCA demonstrated clustering of headache with photophobia, phonophobia, nausea, dizziness, and neck pain. Similar clustering was present among patients without premorbid headaches. Repeating the analysis in the patients with preconcussion headaches led to elimination of neck pain from the cluster.Conclusions: PTH correlates strongly with other migraine symptoms among youth with concussion, regardless of premorbid headaches. This clustering of migraine symptoms supports the existence of PTM as a distinct clinical entity in some patients. [ABSTRACT FROM AUTHOR]

PURPOSE: Half of all adolescents report low back pain (LBP), with an even higher rate among athletes. Spondylolysis is the most common identifiable cause of LBP in adolescent athletes. Expert consensus recommends resting for up to 3 months before beginning rehabilitation. This recommendation may have negative consequences including 5-7 months out of sport, muscle atrophy, weight gain, and depression. The purpose of this pilot study was to assess the viability of using an immediate functional progression program to treat adolescent athletes with an active spondylolytic injury. METHODS: Adolescent athletes were referred to physical therapy (PT) without restrictive bracing immediately after diagnosis of the active spondylolysis. The PT program progressed participants based upon pain-free functional ability and the athletes returned to sport when they passed predetermined functional criteria. Clinical outcomes included time out of sport, Micheli Functional Scale (Function and Pain) and adverse reactions. Clinical outcomes were assessed at baseline, 1 month, 3 months and 6 months. MR imaging was performed at baseline and 3 months to confirm diagnosis and assess healing of lesion. Data Analysis: Descriptive statistics were calculated to assess viability of the program. RESULTS: Twelve participants (14.2 ± 2 years, 25% female) with active spondylolytic injuries completed the immediate functional progression program. Eleven participants (92%) were able to return to sport in a median time of 2.5 months (interquartile range 55 days, 85 days). All participants demonstrated marked improvements in pain and function (35.6 ± 22.1 on Micheli Functional Scale) by the end of the program. One participant (8%) had an adverse reaction during care with a significant recurrence of LBP and was unable to return to sport by 6 months. MR imaging demonstrated that only one participant had a progression of a lesion at 3 months. CONCLUSION: Athletes in the immediate functional progression program experienced similar clinical and imaging outcomes to previously published research and returned to sports two months sooner. Beginning PT immediately and progressing the young athlete based on functional ability appears to be a viable method for treating this population and warrants future research. [ABSTRACT FROM AUTHOR]