H1020- Council on Sports Medicine and Fitness Program

Promoting Physical Literacy in American Youth

Topic: Sports Medicine

Sponsors: Council on Sports Medicine & Fitness (COSMF)

Saturday, October 22
8:00AM - 5:00PM
Moscone West, 2008

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This case-based discussion will cover the latest issues regarding physical literacy in American youth: What is physical literacy, why is it important, and how do we assess and promote it? Additional presentations include the Vito Perriello Jr., MD Lecture Series focusing on youth athletic development and the American College of Sports Medicine (ACSM) Exchange Lecture focusing on sports medicine care in underserved and minority populations. The Top 10 Orthopedics and Sports Medicine Articles of 2016 along with Hot Topics for the Sports Medicine Providers will encourage timely discussions. The Thomas Shaffer, MD Award and the council business meeting will occur at lunchtime. Rounding out the program are research and clinical case poster sessions, oral research presentations, and the Oded Bar-Or Presentation for the best research presentation.

8:00AM Media and Technology: Using It To Promote Physical Literacy
Thomas Farrey
8:45AM Health Care Providers: Tools To Assess Physical Literacy
Shale Wong, MD, MSPH, FAAP
9:20AM Leading the Way: Physical Literacy Programs at Work in Communities
Stephen McDonough, MD, FAAP
9:55AM Fostering the Youth Sport Ethos in Organized Sports
Amanda Visek, PhD
10:30AM Roundtable Discussion
11:00AM Break
11:15AM Vito Periello Jr., MD Lecture Series, Youth Athletic Development
Suzanne McNulty, MD, FAAP
12:00PM Thomas Shaffer, MD Award, Council Annual Meeting, and Lunch
Award Recipient: Thomas Rowland, MD
1:00PM ACSM Exchange Lecture, Providing Quality Sports Medicine Care for Underserved and Minority Athletes: Is There a Level Playing Field?
Lisa Barkley, MD
2:00PM Hot Topics for the Sports Medicine Provider
Tracy Zaslow, MD, FAAP
2:30PM Break
2:45PM Research Abstract Presentations
4:15PM Top 10 Best Sports Medicine and Orthopaedic Articles of 2016
Rebecca Demorest, MD, FAAP; J. Todd Lawrence, MD, PhD, FAAP 
5:00PM Oded Bar-Or Award Presentation and Closing Remarks

Abstracts

11:00AM - 11:15AM
11:00AM - 11:15AM
3:25PM - 3:35PM
Moscone West, 2008

Lisa Barkley, MD

Assistant Dean for Diversity & Inclusion
University of Central Florida College of Medicine
Orlando, Florida

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Rebecca Demorest, MD, FAAP

Pediatric and Young Adult Sports Medicine Specialist
Webster Orthopedics
Dublin, California

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Thomas Farrey

Executive Director
Aspen Institute Sports & Society Program
Burlington, Connecticut

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J. Todd Lawrence, MD, PhD, FAAP

Pediatric Orthopaedic Surgeon
The Children's Hospital of Philadelphia
Philadelphia, Pennsylvania

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Stephen McDonough, MD, FAAP

Retired Pediatrician
Medcenter One Bismarck North Dakota
Bismarck, North Dakota

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Suzanne McNulty, MD, FAAP

Owner/Pediatrician
Mia Bella Pediatrics
Mission Viejo, California

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Amanda Visek, PhD

Associate Professor
The George Washington University
Washington, District of Columbia

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Shale Wong, MD, MSPH, FAAP

Professor of Pediatrics
University of Colorado School of Medicine
Denver, Colorado

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Tracy Zaslow, MD, FAAP

Director, Sports Concussion Program Medical Director, Sports Medicine Program
Children's Orthpaedic Center at Children's Hospital Los Angeles

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Faculty

Thomas Farrey

Executive Director
Aspen Institute Sports & Society Program
Burlington, Connecticut

Stephen McDonough, MD, FAAP

Retired Pediatrician
Medcenter One Bismarck North Dakota
Bismarck, North Dakota

Suzanne McNulty, MD, FAAP

Owner/Pediatrician
Mia Bella Pediatrics
Mission Viejo, California

Amanda Visek, PhD

Associate Professor
The George Washington University
Washington, District of Columbia

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1- In-season Changes in Ventricular Morphology and Function in Female Youth Athletes Is Not Related to Physical Maturity

Saturday, October 22
11:00AM - 11:15AM
Moscone West, 2008

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The ventricular adaptations to exercise in children are poorly defined, and whether these adaptations are influenced by physical maturity is unknown. Therefore, the purpose of this study was to evaluate the changes in ventricular morphology and function with exercise training in youth athletes, and whether these adaptations were influenced by height velocity.

30 female youth athletes (age 13-18 years) underwent height measurement, Tanner stage determination, and resting 2-D echocardiography immediately prior to, and following, a 20-week outdoor soccer season for left ventricular end-diastolic diameter (LVEDD), end-diastolic volume (LVEDV), ejection fraction (LVEF), stroke volume (LVSV), mass (LVM), and posterior wall thickness (LVPWT), right ventricular end-diastolic diameter (RVEDD), area (RVEDA), and fractional area change (RVFAC), and interventricular septal thickness (IVST). In-season training load was quantified individually using session-rating of perceived exertion for all physical activity during the study period. Pre- and post-season echocardiographic variables were compared using paired Wilcoxon tests and height velocity, LVEDV, LVM, and RVEDA were compared across Tanner stage using Kruskal-Wallis tests. Multivariable linear regression was used to evaluate the relationship between height velocity and in-season changes in LVEDV, LVM, and RVEDA while controlling for cumulative training load.

From pre- to post-season, significant increases were identified in LVEDV (82.3±20.9 v 91.4±19.4 cm3, p=0.001), LVM (106.7±23.0 v 113.1±23.4 g, p=0.047), and RVEDA (16.7±3.2 v 18.2±4.2 cm2, p=0.040). Differences in LVEDD (4.56±0.3 v 4.61±0.4 cm, p=0.29), LVPWT (0.44±0.1 v 0.44±0.1 cm, p=0.92), RVEDD (2.58±0.6 v 2.67±0.4 cm, p=0.25), LVSV (50.2±13.7 v 52.2±13.0 cm3, p=0.39), RVFAC (42.4±9.9 v 38.5±10.9 %, p=0.15), and IVST (0.74±0.1 v 0.78±0.1 cm, p=0.17) were not statistically significant. LVEF was found to decrease significantly (60.9±5.2 v 57.0±5.8 cm3, p=0.019), as a result of greater increases in LVEDV relative to LVSV. Height velocity was significantly different between Tanner stage 3, 4, and 5 (8.25±5.1 v 6.11±5.0 v 3.05±1.8 cm/year, respectively, p=0.015), but in-season changes in LVEDV, LVM, LVPWT, IVST, LVEF, RVEDA, and RVFAC did not differ between Tanner stages (p>0.05 for all). After controlling for individual in-season training load, height velocity was not significantly related to changes in LVEDV (b=-0.39, p=0.50), LVM (b=-0.21, p=0.75), or RVEDA (b=0.17, p=0.29).

Among female youth athletes, in-season training elicits changes in resting LV and RV size, but not function or wall thickness. These adaptations to exercise training are unrelated to Tanner stage or height velocity, suggesting that cardiovascular adaptations to exercise are not influenced by level of physical maturity in older adolescents.

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2- Vestibular and Oculomotor Findings Neurologically-normal, Non-concussed Children

Saturday, October 22
11:00AM - 11:15AM
Moscone West, 2008

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Purpose
Balance and vestibulo-ocular deficits, secondary to abnormalities of the vestibular system, have been recognized as objective measures of dysfunction and markers of morbidity and recovery from concussions. In order to understand how to interpret these deficits in concussed youth, it is important to quantify the performance of normal controls on vestibulo-ocular testing. Limited data exist describing the distribution of findings in a control population, or at what age the examination can be reliably completed. The objective of this study was to determine the proportion of non-concussed, neurologically normal children who exhibit vestibulo-ocular deficits on examination in a population of those seeking care in the emergency department (ED); secondary objectives included determining at what age the vestibulo-ocular examination can be reliably completed, and the vestibulo-ocular deficit distribution across age groups.

Methods
This was a cross-sectional study of patients age 6-18 years old presenting to a pediatric ED in a tertiary care children’s hospital with non-neurologic chief complaints (including, but not limited to, abdominal pain, chest pain, rash, mild respiratory distress, and upper extremity trauma). Patients with underlying neurologic conditions, recent head injury, or use of psychoactive medications were excluded. The vestibulo-ocular examination for concussion includes assessments of (1) dysmetria, (2) nystagmus, (3) smooth pursuits, (4) fast saccades, (5) gaze stability (both the horizontal and vertical vestibulo-ocular reflex), (6) near-point convergence, and (7) gait/balance (tandem gait forwards and backwards eyes open and closed). This previously standardized examination was performed by one physician. Baseline and demographic characteristics were summarized using standard descriptive statistics.

Results
A total of 170 patients were enrolled in the study. 44 patients (26%) had at least one abnormality on the vestibulo-ocular examination. Of those, 16 (36%) reported feeling mild dizziness after completing at least 20 horizontal or vertical saccades, but had an otherwise normal examination. 23 patients (14%) had >1 abnormality on the exam. 32% of females and 21% of males had abnormal examinations. By age, 16% of patients age 6-8 years old, 30% age 9-11, 32% age 12-14, and 22% age 15-18 had abnormal examinations. Overall, 16 (9%) were unable to complete the exam due to developmental age; all were age 6-9 (27% of those ages 6-9 years).

Conclusion
26% of neurologically-normal pediatric patients had a deficit on the vestibulo-ocular examination for concussion, though a significant proportion of those patients had either one isolated abnormality, or only reported mild symptoms when completing fast saccades. The exam can be reliably completed in all patients age 10 and older, and can be attempted on patients as young as 6 years old. These data should allow clinicians to effectively implement the use of the vestibulo-ocular examination as a diagnostic and prognosticative measure for those presenting to the ED with concussion.

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3- Emergency Action Plans in Illinois High Schools

Saturday, October 22
11:00AM - 11:15AM
Moscone West, 2008

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Purpose: To investigate the composition of Emergency Action Plans (EAPs) in Illinois high schools. In recent years, there has been a trend towards improving secondary prevention strategies following catastrophic injuries in the high school setting. In Illinois, the Youth Sports Concussion Safety Act (SB 07) will require all schools to develop school-specific EAPs effective for the 2016-2017 school year; these plans must be posted at all schools and reviewed annually. This study compares current Illinois high school EAP practices to both planned Illinois legislation and current Inter-Association Task Force recommendations on Emergency Preparedness in order to understand how to improve responses to emergencies in Illinois high schools.

Methods: Invitation to participate in an online survey was distributed to all athletic directors at high schools in the Illinois High School Association. Contacts were obtained from a database created at the start of the 2015-2016 school year based on emails available on schools’ websites. Athletic directors were asked to either complete the survey or refer the survey to the most knowledgeable about details of the school’s EAP. The survey was conducted through REDCap, a Secure Sockets Layer encrypted web-based survey platform, and included 24 questions addressing school demographics, details of EAP, presence of athletic trainer, and utilization of automated external defibrillator (AED). Reminder emails with links to the survey were sent at 2,4, and 8 weeks intervals following initial invitation.

Results: Of the 831 survey invitations distributed, 792 (95.3%) were indicated as being successfully delivered; of these, 228 (28.8%) were completed and eligible for analysis. Seventy-five percent of high schools have an existing EAP for sudden collapse at a sporting event. Of those schools with an EAP, 73% have a venue-specific EAP, 76% review their EAP at least annually, 38% rehearse their EAP annually, 68% have their EAP posted, and 45% had their EAP established in consultation with EMS. Sixty-six percent of responding high schools have an athletic trainer and athletic trainers were identified as the usual primary responders to injury or collapse (51%) followed by sports coaches (43%). Ninety-eight percent of schools have an AED on campus with 94% reporting maintenance of AED at least once per year, and 62% reporting that someone checks the AED works properly prior to each athletic event.

Conclusion: Although the majority of Illinois high schools are currently compliant with forthcoming legislation regarding EAPs, there are several areas for improving response to emergencies. Specific Inter-Association Task Force recommendations that should be targeted include increasing utilization of venue-specific EAPs, rehearsing EAPs annually, and checking function of AED prior to each athletic event. Athletic trainers additionally play key roles in responding to emergencies and efforts to increase their presence at high schools should be pursued.

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4- Return to School After Sports-related Concussion

Saturday, October 22
11:00AM - 11:15AM
Moscone West, 2008

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The purpose of this study was to describe return to school after sports-related concussion, including absences, academic performance, receipt of accommodations, and satisfaction of the parent/child with classroom accommodations and the return-to-school experience. We conducted telephone surveys of 83 families (78 parent-child dyads, 5 parents) a median of 276 days following concussion.
Students missed a median of 2 days of school following concussion. There was a positive relationship between number of reported school-related problems and absences in the child-reported data only. There was a positive relationship between number of absences and symptom severity in both the parent and child-reported data. Return to academic baseline was reported by 86.7% of parents and 92.3% of children. Return to academic baseline was more likely in children with fewer school-related problems per parent report, and more likely in younger students and those with a lower symptom severity score per child report.
Academic accommodations were provided to 73.5% of children per parent report and 76.9% of children per child report. Receipt of accommodations was related to parent communication with the school, physician recommendation for accommodations, number of post-concussion school-related problems, and increased absences per parent report. No relationships were found between receipt of accommodations and investigated variables in the child-reported data.
The majority of parents (81.9%) and children (82.1%) reported being satisfied with the school’s response to accommodating the child’s needs following concussion. Satisfaction with receipt of accommodations was higher for children who received accommodations and/or who returned to academic baseline, according to both parent and child-reported data. Parent income was positively associated with satisfaction with accommodations in the parent-reported data only. Similarly, 89.2% of parents and 85.9% of children reported being satisfied with the overall return-to-school experience. Satisfaction with the overall return-to-school experience was related to receipt of accommodations in both the parent and child-reported data, but was related to return to academic baseline only in the child-reported data. There was no significant relationship between other investigated variables and satisfaction outcomes.
Findings highlight the continued need for policies and education of stakeholders to insure appropriate academic management of concussions in students, as well as the need for the identification of prognostic indicators of poor school outcomes following concussion so that schools can target the minority of children who are at risk for an unsatisfactory outcome. Additionally, the fair to moderate agreement between parents and children on outcomes including change in academic performance, receipt of accommodations, and satisfaction with classroom accommodations and the return-to-school experience suggest that parents and children have different perspectives on school outcomes, and that future research and interventions should include both of those perspectives when determining how to successfully manage return to school following concussion.

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5- Eleven Year Old Wrestler with a Traumatic Pectoralis Hematoma

Saturday, October 22
11:00AM - 11:15AM
Moscone West, 2008

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Introduction: Rupture of the pectoralis major muscle is a rare occurrence. In the past twenty years the incidence of rupture has increased in young adult athletes mostly with weight lifting and high impact sports. It is extremely uncommon in athletes under twenty years old. This case highlights the clinical features, diagnosis and management of a pectoralis major rupture in a child.
Case Report: An 11 year old wrestler presents to the sports medicine clinic with 3 weeks of left sided chest pain and swelling. Symptoms began after a wrestling meet without a specific injury. Evaluation in the ED showed left pectoral swelling, normal Xray but an ultrasound showed possible hematoma in the left pectoral muscle. On clinic evaluation he has severe swelling and pain of his left anterior chest with reduced range of motion. Repeat ultrasound showed mildly enlarged fluid collection in the pectoralis muscle. An MRI without contrast was done the next day which showed a 7x2x6cm fluid collection within the left pectoralis major muscle sternal head, with a defect in the sternal insertion and edema in the 2nd rib. The pectoralis major musculotendinous junction and humeral origin were intact. The patient was still in significant pain after the MRI; he was referred to interventional radiology for aspiration of the fluid; the procedure was unsuccessful, due to the complexity of the fluid collection and patient tolerance to the procedure. He was treated with high dose NSAID’s. One week after his initial visit, his pain had improved, and exam showed his swelling had greatly improved, with mild pain over his left pectoral muscle. The patient was referred to physical therapy and allowed to slowly return to activities as tolerated.
Discussion: The pectoralis major muscle is an important adductor, flexor, and internal rotator of the humerus. Its two heads (clavicular and sternal) converge on the lateral proximal humerus. It is most commonly injured during eccentric exercises in the “bench press” position. While originally reported in weight lifters, it has been seen in wrestlers, rugby athletes, and wind surfers. Patients usually complain of a pop or a snap during a traumatic event. Swelling and ecchymosis are usually found on exam. The differential diagnosis may include avulsion fracture, biceps tendon injury, rotator cuff injury, or abscess. Xrays are important to rule out bony abnormalities, but MRI should be done to evaluate the soft tissue structures. Partial tears can be managed nonoperatively with a sling, where complete ruptures usually require surgical repair.
Conclusion: This is an extremely rare report of a sternal head rupture in an athlete this young. This case highlights hematoma symptoms and resolution in an unusual anatomic area.

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6- Simple Clavicle Fractures, a Primary Care Musculoskeletal Injury

Saturday, October 22
11:00AM - 11:15AM
Moscone West, 2008

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Background: The clavicle is the most commonly fractured bone and accounts for 10-15% of pediatric fractures. Simple clavicle fractures include middle third minimally displaced, greenstick and angulated fractures. Children with simple fractures are treated with conservative measures such as a sling but are are often referred to orthopedic surgeons by their primary care physician for fracture care.
Objective: The objective of this study was to demonstrate that simple clavicle fractures have excellent outcomes when treated with a sling and therefore recommend that simple clavicle fractures represent a primary care musculoskeletal injury that can be managed exclusively by a primary care physician.
Methods: We performed a retrospective chart review, consisting of children ages 12-17 with simple clavicle fractures and at least one follow up visit. Primary outcomes were bony union, remodeling angulation and pain. Secondary outcomes included activities of daily living and household chores. We reviewed 16 patients with a mean follow up of 80 days following conservative management with a sling.
Results: All 16 patients had excellent outcomes with conservative management. (Figure 2) Treatment included a sling for 4 weeks and increased activities as tolerated. No case of nonunion or malunion occurred. Angulation did not affect the clinical decision-making and all patients with angulation healed and remodeled without complication. At final follow up, all patients were pain free with return to normal function. No restrictions of activities of daily living or problems with household chores were reported.
Conclusion: Pediatric patients with simple clavicle fractures have excellent outcomes with conservative management. Treatment includes a sling for 4 weeks and a gradual return to activities. The outcomes would be identical whether treated by an orthopedic surgeon or a primary care physician. The cost to the patient and to society is potentially less when the primary care physician manages the fracture. By decreasing cost and maintaining the same outcomes the value of the care is increased (Value=Outcomes/Cost). Simple clavicle fractures represent a primary care musculoskeletal injury that can be managed exclusively by a primary care physician. The diagnostic tree presented below can be utilized by primary care physicians who treat clavicle fractures. (Figure 1)

Figure 1
Suggested diagram to use for management of clavicle fractures.
Figure 2
Depicted a simple clavicle fracture radiographs before and after healing process.

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7- Neuromuscular Training Availability and Efficacy in Preventing Anterior Cruciate Ligament Injury in High School Sports: A Retrospective Cohort Study

Saturday, October 22
11:00AM - 11:15AM
Moscone West, 2008

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Purpose: Anterior cruciate ligament (ACL) injury presents both acute and chronic consequences to injured high school athletes. Young females are especially at risk of this injury for anatomic, hormonal and mechanistic reasons. Neuromuscular training (NMT) has been shown to prevent ACL injuries among youth in both genders. Proven regimens include plyometric exercises, education and feedback regarding proper body mechanics as well as proximal/core muscle strengthening. This is the first study to investigate NMT availability and its impact on ACL injuries in four major high school sports by gender, sport and rural/urban geography.
Methods: Athletic directors (AD) of 489 high schools were invited to complete a paper and pencil survey regarding their school’s Fall 2014 sports seasons. Questions were asked about pre-season and in-season training activities and ACL injuries for boys football and soccer, and for girls volleyball and soccer seasons.
Results: 235 of 439 ADs (53.5%) responded documenting the Fall 2014 high school sports experiences of 27,335 student athletes. 12,799 (46.8%) male athletes played football (FB) and 3,753 (13.7%) played soccer (BS). Female athletes were 7,672 (28.1%) volleyball (VB) players and 3,111 (11.4%) girls soccer (GS) players. ADs reported a total of 167 (0.6%) ACL injuries among student athletes. The largest proportions of these injuries were in GS (n = 29, 0.9% of GS athletes), and FB (n = 96, 0.8% of FB athletes), consistent with previous reports.
Overall, more than 2/3 of teams incorporated facets of NMT into their sport. Male athletes exposed to NMT experienced fewer ACL injuries than those who were not. In BS, significant injury reduction resulted from three different activities: plyometric exercises (RR = 0.574, 95% CI 0.369-0.893), even when only engaged as an in-season exercise (RR = 0.668, CI 0.489-0.912) and having a licensed trainer (RR = 0.683, CI 0.556-0.839). In FB, strength training reduced ACLs (RR = 0.088, CI 0.013-0.608). Female athletes did not benefit similarly; among VB players, pre-season NMT actually increased the number of ACL injuries whether any (RR = 1.460, CI 1.249-1.706) or all (RR = 1.504, CI 1.268-1.784) of the training modalities were reported. In GS, none of the training activities related statistically to the number of reported ACLs. However, rural GS teams experienced significantly fewer ACL injuries compared to metro teams (RR = 0.358, CI 0.215-0.596).
Conclusions: Most fall sport high school student athletes have access to NMT, which was associated with fewer male, but not fewer female ACL injuries. With the many costs associated with ACL injury, improved gender and sport-specific preventative training programs are indicated. Possible reasons for geographic differences require further investigation.

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8- Prevalence of Vestibular and Vision Problems Following Concussion in Children Under 12

Saturday, October 22
11:00AM - 11:15AM
Moscone West, 2008

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Purpose: Concussion is a common injury among children and adolescents. Most studies of pediatric concussion focus on adolescents, while less is known about concussion in children under age 12. This study aims to describe the prevalence of vestibular, balance and binocular vision problems seen following concussion in patients under the age of 12.

Methods: This is a retrospective cohort study of patients under 12 years of age referred to the Minds Matter Concussion Program at The Children’s Hospital of Philadelphia CHOP Sports Medicine Clinic with concussion from 2010 to 2015. Eligible patients were those with a diagnosis of concussion confirmed by the sports medicine physician at the initial visit. Data recorded from the initial visit included demographics, date and mechanism of the injury, symptoms experienced at the time of injury, and findings on physical examination. The recovery outcomes were time to return to school, time to return to exercise, and time to return to sport.

Results: 132 patients were included. The median age was 11 years (range 9.08-11.79). 55.3% percent of injuries were sports-related; of these the most common sports involved were soccer (21.9%) and football (17.8%). Common symptoms on presentation were headache (73.5%), dizziness (45.5%), fatigue (44.7%), and difficulty concentrating (41.7%). On physical examiation, 65.9% had balance abnormalities, 56.6% had saccadic dysfunction, 55.3% convergence insufficiency.

Conclusion:  There is a high prevalence of balance, vestibular, and binocular vision problems following concussion in children under age 12. Improved recognition of the deficits following concussion in young children is necessary to guide timely diagnosis and appropriate management, including appropriate school accommodations for binocular vision problems and vestibular therapy for balance and dizziness issues.

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9- Parents Take on Concussion: advances in Sideline Research and Culture in Youth Sports

Saturday, October 22
11:00AM - 11:15AM
Moscone West, 2008

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Background: Identifying concussion and initiating removal from play can be challenging for even the most diligent youth sports organizations. Empowering parents to implement removal from play and sideline testing may be the most practical plan at community levels to protect young athletes.

Aims/Objectives: We present methodologies from community-based youth sports organizations that incorporated research studies of sideline testing. These investigations involved parents as team testers and developed infrastructures for concussion management protocols for the organization.

Methods: Investigators developed research protocols to determine how sideline tests of vision (rapid number naming), cognition (standardized assessment of concussion) and balance (timed tandem gait) could augment the capacity for responsible adults to identify youth athletes with concussion in ice hockey, football, lacrosse and cheerleading. Through outreach efforts, teams were organized to participate in the research studies, incorporating concussion education on early recognition and training of volunteer students and youth sports parents as test administrators. Research sideline tests were performed as a pre-season baseline and during the season on the sideline at time of injury, or as soon as symptoms were recognized. Concussion was determined using standard definitions: any blow to the head or body with new neurological signs or symptoms.

Results: The research studies enrolled 408 athletes, aged 5-17 years, over 2.5 years through 5 athletic seasons. Over 80 students and parents were educated and trained on early concussion recognition and sideline test administration. Over 80% of the head injuries and suspected concussions were physician-diagnosed concussions. Concussion sideline tests were administered within 24 hours of injury in over two-thirds of the cases, and the rest within an average of three days post-injury as symptoms developed over time. Existing concussion protocols were successfully maintained in the context of the research studies, with immediate removal from play and evaluation by medical professionals for definitive diagnosis.

Conclusions: Parents of youth athletes can be successfully empowered to perform rapid sideline tests of vision, cognition and balance in the context of existing concussion protocols. Implementation of objective testing may improve concussion identification while also shifting the culture of advocacy and responsibility towards parent groups to promote safety of young athletes.

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Anterior Cruciate Ligament Reconstruction Using Quadriceps Tendon Autograft in Adolescent Athletes

Saturday, October 22
2:45PM - 2:55PM
Moscone West, 2008

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Purpose: The ideal graft material for pediatric anterior cruciate ligament (ACL) reconstruction is controversial with many options available. Use of hamstrings tendon can compromise dynamic stability in an ACL-reconstructed knee, and patellar tendon harvest can lead to anterior knee pain and numbness. Allografts avoid donor-site morbidity, but have been associated with infection and rejection. To date, there have been no studies reporting the use of quadriceps tendon autograft for ACL reconstruction in adolescent athletes in the United States. The purpose of this study is to report the outcomes of quadriceps tendon autograft with a single bone block for ACL reconstruction in adolescent athletes.
Methods: 24 consecutive patients (25 knees) that underwent ACL reconstruction using quadriceps tendon autograft were studied. Data collected included demographics, injury characteristics, imaging findings, physical exam findings, intraoperative findings, follow-up Lysholm scores, growth disturbances, and post-operative return-to-sport outcomes. The typical graft size was 9 mm x 9 mm x 75 mm.
Results: From June 2010 to March 2015, 25 ACL reconstructions using quadriceps tendon autografts were performed by the senior author. The average age at the time of surgery was 16 years. 14 males and 10 females were studied. 15 patients had open growth plates; 9 patients had closed growth plates. The ACL tear occurred most commonly during basketball (9), soccer (5), and football (5). 19 of the 24 patients were multi-season or multi-sport athletes. 5 patients were initially treated non-operatively, but ultimately elected to undergo ACL reconstruction due to episodes of instability. The average duration from the time of injury to the time of surgery was 64 days. 24 of the 25 knees had concomitant injuries, including meniscal tears and chondromalacia. Follow-up data was available for all patients (average of 490 days). No patients had angular deformities or leg length discrepancies noted at follow-up. The average quadriceps atrophy at 1 year post-op was 8 mm. The average Lysholm score at 1 year post–op was 98. One patient had a re-injury at 2-year follow-up: a meniscal tear sustained during college basketball practice. Her ACL was intact. 7 patients returned to all pre-injury sports, 11 to at least one pre-injury sport, 3 to another sport, and 2 did not return to sport but reported no functional limitations. No infections, numbness, re-tears, or reports of anterior knee pain occurred.
Conclusion: Quadriceps tendon autograft for ACL reconstruction in adolescent athletes resulted in excellent outcomes and Lysholm scores with no cases of growth disturbances. Although underutilized in the literature, quadriceps tendon autograft is an attractive graft choice for adolescent athletes due to the preservation of dynamic stability of the knee, a large graft size, and minimal risks for growth injury, anterior knee pain, rejection, and infection.

Figure 1: Graft size
The graft contains a single bone block with an average length of 20 mm and thickness of 9 mm.

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Graded Exercise Testing for Risk Stratification of Children and Adolescent Concussion

Saturday, October 22
2:55PM - 3:05PM
Moscone West, 2008

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Hypothesis-
Concussion is a physiologic brain injury that produces systemic and cognitive symptoms. Following a concussion patients are in a hypermetabolic state characterized by altered cerebral blood flow (CBF). Normalization of altered CBF has been shown to be a useful marker for recovery from concussion. Graded exercise testing may be a convenient clinical measure for assessing concussion-related physiological dysfunction due to altered cerebral blood flow and for monitoring recovery.

Purpose-
To determine if a graded exercise test can be used to monitor patient recovery and predict patient outcome following a concussion injury.

Methods-
Prospective study conducted at Children’s Hospital at Westmead, Children’s Hospital Institute of Sports Medicine (CHISM) a tertiary referral concussion service in Sydney Australia over a 5 year period. CHISM is a designated center established to provide high quality treatment and management of sports-related injuries, including head injury in children and adolescents. Concussion was confirmed in all cases by a concussion specialist using a standard concussion test battery, and this test battery used at each successive visit. In addition, all patients underwent a graded exercise test to determine physiologic recovery from concussion. Time to symptom onset and symptom severity using a liner analogue scale were reported.

Results-
There were 140 episodes of concussion during the study period, have a mean age of 12.4 years, with the majority, (73%) being males. Emergency Department referral accounted for 76%, with 40% reporting loss of consciousness and 35% retrograde amnesia. In 25%, concomitant injuries or signs and in 26% pre-morbidities were recorded, with one-third had previous episodes of concussion. Organised sport accounted for 62% of injuries. 83% of patients reported headache, 72% balance dysfunction, 64% behavioural issues, 43% vestibular or ocular problems and 12% cervicogenic pain, these findings confirmed on clinical evaluation. The most significant predictors of recovery were headache, balance and vestibular dysfunction exacerbation by exercise. In 61% of patients no symptom exacerbation was reported during an average of 9.8 minutes of exercise. This group returning uneventfully to normal activity within 10 days. Where exercise limited by exacerbation of symptoms, recovery was prolonged. Of these patients, 24% exercised for less than 9 minutes (average 6.2 minutes) and 12% for less than 3 minutes (average 2.8 minutes). respectively. Symptom severity was directly related to exercise time and hence recovery, with patients recovering in 24.6 days and 86.5 days respectively. In addition, females accounted for 72% of the prolonged recovery group, the remainder being children less than 10 years of age.

Conclusion-
A graded exercise testing can risk stratify patients to high or low risk for prolonged recovery following a concussion. Clinicians can therefore effectively monitor recovery from concussion and give more informed return to activity decision.

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Oral (Podium)

Vestibular and Visual Dysfunction as Predictors of Prolonged Recovery Following Pediatric Concussion

Saturday, October 22
3:05PM - 3:15PM
Moscone West, 2008

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Purpose: Visual complaints are common following concussion and include blurry or double vision, difficulty with near visual work, or eye fatigue. However, these deficits are not always detected with routine neurologic or visual acuity assessments. Directed examination of balance, smooth pursuits, saccadic function, vestibulo-oculomotor reflex (VOR), and convergence are not always performed on a routine basis in children with concussion, and as such, these deficits may sometimes be missed. Yet they may be valuable for both diagnostic and prognostic purposes. The purpose of this study was to examine whether vestibular and visual dysfunction following pediatric concussion as identified by specific clinical assessment contribute to our ability to predict prolonged recovery.
Methods: Retrospective cohort study of pediatric patients with a diagnosis of concussion seen in The Children’s Hospital of Philadelphia Minds Matter Concussion Program between July 1, 2014 and June 30, 2015. 274 consecutive patient records were abstracted for clinical data including specific assessments of the vestibular and oculomotor/visual systems. Variables were entered sequentially into logistic regression models in blocks – demographics, total symptoms (Post Concussion Symptom Scale), mental health, medical history (previous concussion; motion sickness), and vestibular function to predict the outcome of being symptom free within 28 days post injury. The area under the receiver operating characteristic curve (AUC) was calculated after each block entry to estimate its relative contribution to prediction. Multicolinearity was avoided using conventional diagnostics.
Results: Study subjects ranged from 3-18 years (median=14), 52% female, 58% with a sports-related mechanism of injury, presenting a median of 14 days from injury. All (100%) patients presented with one or more of the following visual deficits: nystagmus (14%), abnormality in smooth pursuits (95%), saccades (79%), symptoms with gaze stability (61%), tandem walk (58.4%). 39% of patients had recovered by 28 days. The AUC predicting recovery from measures of vestibular oculomotor function alone – saccades, gaze, and tandem walk – was 0.75. The AUC predicting recovery from all demographic and clinical variables other than vestibular function was 0.78 (Fig 1. orig ROC area). Adding the measures of vestibular function into that comprehensive logistic regression model improved prediction (p < 0.05), yielding an AUC of 0.81 (Fig 1. withvest ROC area).
Conclusion: Vestibular oculomotor deficits are highly prevalent following concussion in children and contribute significantly to our ability to predict prolonged recovery, both on their own and when used in addition to variables including patient demographics and clinical characteristics. Deficits in these vestibular and visual systems can be detected using directed clinical assessments that screen for vestibular deficits, saccadic function, as well as convergence. These may represent important prognostic factors in predicting which children may go on to have longer than usual recovery times from concussion.

Figure 1.
Receiver operating characteristic (ROC) curves with corresponding area under curve (AUC) statistics for risk of symptoms of concussion at 28 days

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Oral (Podium)

The Use of Functional Near-infrared Spectroscopy (fnirs) for the Assessment of Vestibular Oculomotor Task-related Brain Activity in Concussion

Saturday, October 22
3:15PM - 3:25PM
Moscone West, 2008

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Purpose
Given the fact that neuroimaging studies are currently not used routinely in the evaluation of concussions in the clinical setting, the diagnosis and management of concussion has centered around subjective symptom reports, clinical and neurocognitive examinations. Functional near-infrared spectroscopy (fNIRS), a noninvasive and portable neuroimaging modality that detects changes in blood oxygenation related to human brain function, is a promising tool to address this gap in the clinical evaluation of concussion. While fNIRS has recently demonstrated that adults with a concussion show reduced brain activation on neurocognitive tests compared to healthy age-matched controls, it has not yet been assessed with other clinical tasks or in the pediatric setting. Thus, we sought to determine the utility of fNIRS to detect and differentiate cortical brain activity among the suite of vestibular oculomotor tests used in a standard clinical evaluation of pediatric concussion.

Methods
We conducted baseline testing of nine athletes, ages 11-17, who performed a series of tasks commonly used in the clinical evaluation of concussion while wearing an fNIRS headband that recorded anterior prefrontal cortex oxygenation changes with 12 channels/4 optodes at 4Hz sampling rate. The fNIRS sensor used in the study is a portable system miniaturized to the size of a smartphone that can wirelessly transfer data in real-time. The tasks that participants performed with the fNIRS system included a modified version of the vestibulo-ocular motor screen (VOMS), the King-Devick test, and tandem walk assessment.

Results
Cortical oxygenation changes confirmed prefrontal cortex involvement in oculomotor task engagement as reported in the literature. With controlled task load changes throughout the oculomotor tasks, there were significant differences across increasing difficulty of King-Devick test conditions (F3,32=4.65, p < 0.01) and for horizontal and vertical saccades (F3,14=3.35, p < 0.01). Moreover, for tandem walk, there was a significant interaction with direction (forward and backward) with eyes open and closed (F1,20=7.33, p < 0.014) highlighting that more prefrontal coordination is required specifically for backward eyes closed movement.

Conclusion
Our preliminary experimental results demonstrate that fNIRS can reliably detect changes in cerebral blood oxygenation that reflect the cognitive workload associated with a given task. The fNIRS’ portability and sensitivity to discriminate based on task difficulty makes it a promising clinical tool for quantifying cortical oxygenation changes after concussion. Further investigation into the utility of this neuroimaging modality in detecting and quantifying changes in the cognitive workload demands of these clinical tasks after injury and over the course of recovery is warranted.

Oxygenation changes with varying conditions of King-Devick test
Cortical oxygenation changes differed significantly across increasingly difficult King-Devick test conditions (F3,32=4.65, p<0.01).
A comparison of oxygenation changes with horizontal and vertical saccades
Significant cortical oxygenation changes were observed during the horizontal and vertical saccade components of the oculomotor exam (F3,14=3.35, p<0.01).

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Abnormal Gait in Healthy Teen

Saturday, October 22
3:25PM - 3:35PM
Moscone West, 2008

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Introduction
HNPP is a slowly progressive, hereditary, neuromuscular disorder, which makes an individual susceptible to nerve injury from pressure, stretch or repetitive use. It is an autosomal dominant disease caused deletion of chromosome 17p11.2. This segment is responsible for peripheral myelin protein 22 (PMP22). It often presents in second or third decade of life , with pressure palsy often being reason for presentation. Males and females are equally affected.
Case Report
13 yo female referred to sports medicine by PCP for evaluation of left foot problem. 3 weeks prior to presentation she was at home sitting on hardwood floor with left flexed and leg tucked under right, directly in contact with floor. After about 20 minutes of sitting, she noticed the lateral border of her foot and bottom of 5th toe were numb when she rose to walk. This caused her to walk clumsily and trip. Numbness resolved after about 15 minutes but she did not regain ability to lift foot to walk normally by time of presentation. No history of back pain or numbness/tingling in back, thighs or legs. No recent illness.
Exam:
DTR 2+ at knees bilaterally, 0 at achilles bilaterally
Foot/Ankle: unable to actively dorsiflex, passive dorsiflexion to neutral +achilles tightness
Strength: Dorsiflexion 1/5, Eversion 1/5 otherwise grossly 5/5
Steppage gait

Studies:
Electrodiagnostic evidence consistent with acute left peroneal nerve injury and generalized nerve insult. Ongoing denervation in the two muscles tested with common peroneal nerve innervation (PL, AT). Nerve conduction showed demyelination injury or defect of most nerves tested at distal nerve segments, except left ulnar motor and sural sensory nerves.

Discussion
Supporting findings for HNPP include absent ankle reflexes , diffusely reduced tendon reflexes and focal weakness or atrophy on exam. EMG and nerve conduction can help establish this diagnosis. Findings of slowed conduction velocity and prolongation of distal motor latencies are often found at the common entrapment sites of elbows, wrists and knees. Motor amplitudes can be compared to the uninvolved side to estimate the extent of injury. However, electrodiagnostic studies may lag behind clinical recovery, therefore in regards to sports, they should not be determining factor for return to play decisions. PMP22 is the only gene in which mutation is known to be associated with HNPP, and genetic testing is available. If done, nerve biopsies show demyelination and ‘sausage like’ enlargements of myelin sheaths, called tomacula.
Conclusion
Recovery is often complete, however, those with incomplete recovery rarely have severe residual symptoms. Bracing with wrist splint or AFO may be helpful during recovery. Individuals are advised to avoid prolonged cross-legged sitting, prolonged leaning on elbows or occupations requiring repetitive wrist movements.

EMG
EMG study
NCS
Motor study

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Oral (Podium)

Same-day Return to Play After Pediatric Athletes Sustain Concussions

Saturday, October 22
3:35PM - 3:45PM
Moscone West, 2008

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Background:
A rigid return to play criteria for athletes suffering from a concussion has been widely established for the pediatric population. Based on concussion guidelines released over the last decade and laws that have been established in most states, athletes are prohibited from returning to play if they display any signs or symptoms of concussion after an injury.

Purpose:
To identify how many pediatric athletes have returned to play on the same day as the initial injury.

Methods:
A retrospective review of 187 consecutive patients treated for concussion at a single pediatric sports medicine center over a 10 month period was completed. Two patients were excluded because they were missing day-of-injury information. All other sports-related concussions identified through the scheduling system were reviewed for a total of 185 subjects. Medical records were reviewed for patient reported symptoms, as identified on the SCAT-3, and patient reported return to play on the same day as initial injury. Demographics, symptoms on day of injury, mechanism of injury, location of head impact, sport, and previous history of concussion were also reviewed when available.

Results:
Of 185 patients treated, 133 were males and 52 were females, with a mean age of 14.1 (range 7-18). 86 of the 185 athletes (46.5%) sustained a concussion while playing football, with the second highest reported sport being soccer (16.2%). 71 (38 %) patients reported returning to play on the same day as initial injury. 52 of the 133 males (39.1%) reported returning to sport after initial injury as compared to 19 out of 52 females (36.5%).

No differences were noted in age, gender, presence of concussion symptoms on day of injury, sport, mechanism of injury, or impact location between those that returned to play on the same day and those who did not. Patients who immediately returned to play reported less severe symptoms of dizziness (p=.04) and balance problems (p=.01) on the day of initial injury. However, at initial clinic visit, these patients were statistically more likely to report the presence and increased severity of nausea, dizziness, balance problems, sensitivity to light, sensitivity to noise, trouble concentrating, pressure in the head, feeling slowed down, and confusion (p < .05). Trouble falling asleep was also reported to be more severe at initial clinic visit (p=0.049).

Conclusions:
Despite guidelines recommending immediate removal from play and no same day return to play following a concussion, a significant number (38%) of athletes returned to play following their initial injury. Patients who immediately return to play are more likely to report the presence and worsening of concussion symptoms at initial clinic visit.

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Oral (Podium)

Subjective Well-being and Training Load Predict In-season Injury and Illness in Youth Soccer Players

Saturday, October 22
3:45PM - 3:55PM
Moscone West, 2008

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It has been suggested that training load (TL) and subjective well-being influence injury and illness risk in adults. The purpose of this study was to evaluate the effects of TL and well-being on illness and injury risk in youth soccer players.

75 female youth soccer players (ages 13-18) reported subjective well-being each morning (mood, fatigue, stress, soreness, sleep quality, and sleep hours), TL after all activities (session-rating of perceived exertion), and all illnesses and injuries throughout a 19-week season. Except for sleep quantity (hours), well-being measures were reported as -3 (worst) to +3 (best) and calculated as a daily average as well as weekly and monthly rolling averages. Total TL was calculated daily and expressed as weekly and monthly rolling averages as well as acute:chronic (ratio of weekly over monthly). TL and well-being measures were compared between days without and without an injury. TL and well-being measures from the preceding day were compared between days with or without a reported illness. The influence of TL on well-being was evaluated using generalized linear regression, and Poisson regression models were developed to predict number of injuries and illnesses per day using well-being and TL as covariates.

36 injuries and 52 illnesses were recorded during the season. Compared to days without an injury, days with an injury had lower daily ratings of mood (1.24±0.2 v 1.16±0.1, p=0.012), as well as higher daily TL (13809±10691 v 20865±11261, p=0.003). No differences were noted with respect to other measures of well-being or weekly, monthly, or acute:chronic TL (p>0.05 for all). Average monthly TL was higher immediately preceding days with a reported illness (15890±2291 v 14775±2827, p=0.027), while no differences were found with respect to daily, weekly, or acute:chronic TL or any measures of well-being (p>0.05 for all). Daily measures of well-being were significantly and inversely associated with prior daily, weekly, and acute:chronic TL (r=-0.20 to -0.71, p < 0.05), but not monthly TL (r=0.01 to 0.16, p>0.05). After inclusion in the multivariable model, only daily mood (p=0.008, OR=0.085) and daily TL (p < 0.001, OR=1.0001) persisted as significant, independent predictors of injury. No other well-being or TL variables were associated with injury. On the other hand, average weekly (p=0.007, OR=1.0001) and monthly TL (p=0.009, OR=1.0002) were significant predictors of illness, while well-being, daily TL and acute:chronic TL were not.

Among female youth soccer players, subjective well-being is influenced by acute, but not chronic, TL. Mood and acute TL are independent predictors of injury risk, while higher chronic TL appears to increase the risk of illness. Prospective monitoring of well-being and TL may help identify individual players at risk and allow for interventions to reduce in-season injury and illness. .

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Oral (Podium)

Using Actigraphy to Assess the Effects of Sleep on Neurocognitive Performance and Injury Rate in Adolescent Athletes

Saturday, October 22
3:55PM - 4:05PM
Moscone West, 2008

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Purpose: Insufficient sleep has been associated with cognitive dysfunction, decreased reaction time, and poorer athletic performance. The National Sleep Foundation’s recommendation for adolescent sleep duration (Ages 14-17) is 8 and 10 hours per night. Our previous research has demonstrated that lack of sleep is a possible contributor to injury in pediatric athletes. This study seeks to evaluate effects of sleep on sports injury rate, academic and cognitive performance. We hypothesized that participants who slept less than expert recommendation were more likely to a) have more injuries b) demonstrate poorer academic performance and c) have lower scores on neurocognitive testing.

Methods: 19 high school track and field athletes (7M, 12F, mean age 15.8 years old) wore an ActiGraph watch for 10 weeks (at time of abstract submission, 7 weeks and 2 days of data collection have elapsed). Subjects also completed a sleep and activity survey and performed a computerized neurocognitive assessment with the NIH toolbox for cognitive function. Injury data were collected from the school’s injury tracking system. Academic information is pending. Athletic performance is pending completion of the competitive athletic season.

Results: During the study period, 865 nights of nocturnal sleep data were analyzed. Total Minutes in Bed averaged 482 minutes (8 hours and 1 minute), Total Sleep Time (TST) averaged 381 minutes (6 hours and 21 minutes), and Wake After Sleep Onset (WASO) averaged 94 minutes (1 hour and 34 minutes). Average sleep efficiency (the percentage of sleep time divided by the total minutes in bed) was 79.3%. There was a statistically significant correlation observed between average sleep hours versus age adjusted scores for the neurocognitive sequence subset of the NIH Toolbox, which tests executive function and memory, specifically acquisition, storage, and effortful recall of new information (r= 0.62, p= 0.007). Those who had an injury actually had more average sleep in comparison to their peers (p=0.0146 and 0.0196, for sports season and school year, respectively). This is in contrast to earlier pilot data (N = 16 for 2 weeks time) showing the three athletes who had injuries during the time period window were within the bottom four participants with the lowest average sleep time.
Our group plans to analyze how sleep relates to academic and athletic performance in our athletes; however due to the academic schedule as well as the completion of the competitive sports season, this data will be available 6/2016. We also plan to further evaluate injury rate in relation to sleep.

Conclusion: In high school track and field athletes, decreased sleep is associated with decreased neurocognitive performance in episodic memory, which includes acquisition, storage, and effortful recall of new information. To date of the study, those athletes with more average sleep tended to have injuries.

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Oral (Podium)

Geographic and Socioeconomic Patterns of Sports Specialization

Saturday, October 22
4:05PM - 4:15PM
Moscone West, 2008

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Purpose: Sports specialization, training in a single sport, has become a recent trend in youth athletics. To date, little is known as to whether specific geographic regions or socioeconomic characteristics are associated with younger ages of sports specialization or sports-related injuries.
It has been well established that health and health disparities can differ by geographical region in the United States (CDC Health Disparities and Inequalities Report 2013). Sports participation and sports specialization may also have geographic differences. The ability, or inability, to move outdoor sports indoors, as determined by climate might influence activity exposure and specialization and thereby risk of injury.
Particular sports involve a significant financial investment (e.g. football, hockey, lacrosse). Household income may impact specialization by determining the type and number of sports that a child may play, therefore influencing athletic exposures. Thus, median household income may indirectly affect sports-related injury risk and the type of injuries experienced. Awareness of the possible relationships between age of specialization, type and seasonality of sport, socioeconomic and regional/geographic differences, and sports-related injuries will allow for targeting of prevention and awareness programs and help clinicians become better informed about their patients, and enhance their ability to advise patients on the risks and benefits of youth activity. The public health implication could be large in light of the number of children participating in youth sports.
Our objective was to analyze geographic and socioeconomic patterns related to age of sports specialization and sports-related injuries in a cohort of Division I collegiate athletes.

Methods: Data from a retrospective cohort of 252 Division I college athletes were grouped and analyzed by nine geographic regions. T-tests and ANOVA tests and multiple comparisons were performed between regions.

Results: The majority of the athletes (n= 67; 53%) were from the Southeast region (KY, TN, MS, AL). There was a statistically significant difference in age of specialization by region of the country (p < 0.01). No differences in total number of injuries (p=0.17), acute injuries (p=0.20), overuse injuries (p=0.24), or surgeries (p=0.08) was found between regions. There was a difference in median income by region (p < 0.01) but no difference was found in age of specialization by median household income (p=0.07) nor total number of injuries (p=0.55), acute injuries (p=0.62), overuse injuries (p=0.17), or surgeries (p=0.11).

Conclusions: Age of sports specialization of collegiate athletes differed regionally with individuals from the eastern United States reporting a younger age of specialization. There were no statistical differences in sports-related injuries in collegiate athletes based on region or median household income.

Median Household Income of Study Cohort
Data by Geographic Region

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Gary Browne, MD, MBBS, MSpMed, FRACP, FACEM

Senior Staff Specialist
Sydney Children's Hospital Network
Sydney, Australia

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Daniel Corwin, MD

Division of Emergency Medicine, The Children's Hospital of Philadelphia
Philadlephia, PA

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Angie Curtis, MD, MPT

Sports Medicine Fellow
Cincinnati Childrens Hospital
Houston, TX

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Kathleen Linzmeier, MD

Primary Care Sports Medicine Fellow
Ann & Robert H. Lurie Children's Hospital of Chicago
Pasadena, CA

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Kelsey Logan, MD

Physician
Cincinnati Children's Hospital
Cincinnati, Ohio

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Christina Master, MD, CAQSM

Associate Program Director, Pediatric Primary Care Sports Medicine Fellowship Program
The Childrens Hospital of Philadephia
Perelman School of Medicine at The University of Pennsylvania
Philadelphia, Pennsylvania

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Jared Murray, B.A.

University of Minnesota Medical School
Hermantown, MN

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Akash Patel, B.S.

Research Assistant
Children's Hospital Los Angeles, University of Southern California
Los Angeles, California

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Katherine Rizzone, MDMPHFAAP

Assistant Professor
University of Rochester Medical Center
University of Rochester Medical Center
Rochester, NY

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Meagan Sabatino, B.A., CCRP

Research Coordinator
Texas Scottish Rite Hospital for Children
Plano, Texas

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Arlene Silverio, MD

Adjunct Asst Professor
New York University School of Medicine
New York University School of Medicine
Pelham Manor, NY

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Hayk Stepanyan

Medical Student
Penn State College of Medicine
Los Angeles, CA

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Eileen Storey, B.A.

Clinical Research Coordinator
The Children's Hospital of Philadelphia
Philadelphia, Pennsylvania

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Natalie Vaughn, MD

Penn State Health
Hershey, PA

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Drew Watson, MD, MS

Assistant Professor
University of Wisconsin - Madison
Madison, Wisconsin

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Drew Watson, MD, MS

Assistant Professor
University of Wisconsin - Madison
Madison, Wisconsin

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Laura Wilson, PhD, CCC-SLP, CBIST

Assistant Professor
University of Tulsa
University of Tulsa
Tulsa, OK

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Stacey Brickson, PhD

Researcher
University of Wisconsin - Madison
Madison, Wisconsin

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Stacey Brickson, PhD

Researcher
University of Wisconsin - Madison
Madison, Wisconsin

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Charlotte Cherry, MS MPH

program coordinator
Vanderbilt Institute for Global Health, Vanderbilt University Medical Center
Nashville, TN

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Emily Cross, A.B.

University of Pennsylvania
Philadelphia, PA

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Alex Diamond, DO, MPH

Vanderbilt University
Nashville, Tennessee

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Barbara Elliott, PhD

University of Minnesota Medical School
Duluth, MN

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David Gendelberg, MD

Orthopedics Resident
Penn State College of Medicine, Department of Orthopedics
Hershey, PA

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Matthew Grady, MD, CAQSM

Assistant Professor of Clinical Pediatrics
Perelman School of Medicine at The University of Pennsylvania
Philadelphia, Pennsylvania

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Lisena Hasanaj, BA

New York University
New York, NY

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Angela Hsu, BA

Medical Student Research Fellow
Children's Hospital Los Angeles
Los Angeles, CA

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Trevor Jackson, M.D.

Penn State Health
Hershey, PA

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Lawrence Lam

Professor of Public Health
Sydney Children's Hospital Network
Sydney, Australia

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Anthony Okamura, MD

Physician
Cincinnati Children's Hospital
Los Angeles, CA

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Lei Wang, MS

Drexel University School of Biomedical Engineering
Philadelphia, Pennsylvania

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Mark Zonfrillo, MD, MSCE

Department of Emergency Medicine, Alpert Medical School of Brown University and Hasbro Children's Hospital
Providence, Rhode Island

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Aaron Zynda, BS

Research Coordinator
Texas Scottish Rite Hospital for Children
Plano, Texas

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Kristy Arbogast, PhD

Research Professor
Division of Emergency Medicine and Center for Injury Research and Prevention, The Children's Hospital of Philadelphia
Philadelphia, Pennsylvania

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Hasan Ayaz, PhD

Drexel University School of Biomedical Engineering
Philadelphia, Pennsylvania

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Tina Bogg

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Michael de Riesthal, PhD, CCC-SLP

Vanderbilt University
Nashville, TN

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Warren Dunn, MD

Associate Professor
University of Wisconsin - Madison
Madison, WI

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Warren Dunn, MD

Associate Professor
University of Wisconsin - Madison
Madison, WI

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Jeffrey Hurd

Cornell University
Pelham Manor, NY

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Julia Lockyer, MS

Division of Orthopedics, The Children's Hospital of Philadelphia
Philadelphia, PA

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Julia Lockyer, MS

Division of Orthopedics, The Children's Hospital of Philadelphia
Philadelphia, PA

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Shane Miller, MD, FAAP

Assistant Professor of Orthopaedics and Pediatrics
Texas Scottish Rite Hospital Sports Medicine Center, UT Southwestern Medical Center
Plano, Texas

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Iris Perez, MD

Associate Professor of Clinical Pediatrics
Children's Hospital Los Angeles, University of Southern California
Los Angeles, CA

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Daniel Corwin, MD

Division of Emergency Medicine, The Children's Hospital of Philadelphia
Philadlephia, PA

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Kristin Haraldsdottir, MS

University of Wisconsin - Madison
Madison, WI

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Max Lahn

Brown University
Pelham Manor, NY

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Eileen Storey, B.A.

Clinical Research Coordinator
The Children's Hospital of Philadelphia
Philadelphia, Pennsylvania

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Tishya Wren, PhD

Director of Research
Children's Hospital Los Angeles, University of Southern California
Los Angeles, California

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Bianca Edison, MD, FAAP

Attending Physician, COC Sports Medicine and Concussion Program
Children's Hospital Los Angeles, University of Southern California
Los Angeles, CA

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Marlowe Eldridge, MD

University of Wisconsin - Madison
Madison, WI

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Matthew Grady, MD, CAQSM

Assistant Professor of Clinical Pediatrics
Perelman School of Medicine at The University of Pennsylvania
Philadelphia, Pennsylvania

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Liliana Serrano

New York University
New York, NY

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Eileen Storey, B.A.

Clinical Research Coordinator
The Children's Hospital of Philadelphia
Philadelphia, Pennsylvania

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Dennis Cardone, DO

New York University
New York, NY

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Matthew Grady, MD, CAQSM

Assistant Professor of Clinical Pediatrics
Perelman School of Medicine at The University of Pennsylvania
Philadelphia, Pennsylvania

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Christina Master, MD, CAQSM

Associate Program Director, Pediatric Primary Care Sports Medicine Fellowship Program
The Childrens Hospital of Philadephia
Perelman School of Medicine at The University of Pennsylvania
Philadelphia, Pennsylvania

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Douglas Wiebe, PhD

Associate Professor of Epidemiology
Perelman School of Medicine at The University of Pennsylvania
Philadelphia, PA

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Steven Galetta, MD

NYU
New York, NY

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Christina Master, MD, CAQSM

Associate Program Director, Pediatric Primary Care Sports Medicine Fellowship Program
The Childrens Hospital of Philadephia
Perelman School of Medicine at The University of Pennsylvania
Philadelphia, Pennsylvania

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Laura Balcer, MDMSCE

New York University
New York, NY

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