Aaron J. Provance

Implications of Parental Influence on Child/Adolescent Helmet Use in Snow Sports

Objective:The main objective of this study was to assess the influencing factors in participants who do not use a helmet while skiing or snowboarding in the youth population. Design:Cross-sectional survey. Setting:The 2006-2007 and 2007-2008 ski seasons at the Crested Butte Mountain Resort. Participants:Children and adolescents between the ages of 6 to 17 years and their parents were enrolled in the study. Two hundred six children/adolescents participated. Independent Variables:Independent variables included age, gender, parental helmet use, ski/snowboard helmet past protection, and child/adolescent reason for wearing/not wearing helmet. Main Outcome Measures:Dependent variables included child/adolescent helmet use. Results:Fifty-one percent were male and 49% were female. One hundred seventy-one (83%) reported that they wear a ski/snowboard helmet, and 35 (17%) reported that they did not wear a ski/snowboard helmet. There was a significant relationship between parental helmet use and child helmet use (P ⩽ 0.0001). Of the 171 children/adolescents who reported wearing a helmet, 124 (72.5%) reported that wearing a helmet protected them in an accident. Of the 171 children/adolescents who reported wearing a helmet, 87.7% said that safety was the reason for wearing a helmet. The most common reason for not wearing a ski/snowboard helmet was comfort. Conclusions:Parents helmet-wearing behavior was strongly associated with the child/adolescents helmet-wearing behavior. The results demonstrate the overwhelming influence parental helmet use has on their child/adolescents decision to wear a helmet.

Management of sport-related concussion in the pediatric and adolescent population

Concussions make up nearly 10% of all high school athletic injuries. Recent changes in concussion management guidelines and legislation aim to make concussion care more standardized and safe but simultaneously pose a challenge for the primary care and sports medicine physician. Pediatric and adolescent concussions may cause anxiety for the treating physician due to concerns over return-to-play decisions, academic issues, and the potential for second impact syndrome. Determining when to refer a patient to an emergency department acutely, to an outpatient concussion clinic, or to other subspecialists may be a difficult decision for the primary care physician. The aim of this article is to review current evidence regarding concussion treatment and return-to-school and return-to-play recommendations to provide the primary care and sports medicine physician with practical guidelines for managing concussions.

Serum creatine kinase elevations in ultramarathon runners at high altitude

ABSTRACT Objectives: Creatine kinase (CK) is a sensitive enzyme marker for muscle damage in athletes. Elevated CK levels have been reported in many endurance physical activities. The consequence and possible long-term sequela of the CK elevation in athletes is unknown. There is a paucity of literature stating actual numerical values of CK associated with competing in an ultramarathon with extreme environmental conditions. Our hypothesis was that the serum CK levels increase significantly as a result of running a 161 km ultramarathon at high altitude. Methods: This was a prospective observational study of participants of the Leadville 100 ultramarathon race in Leadville, Colorado at high altitude (2800–3840 m) in August 2014. We collected blood samples from sixty-four volunteer runners before and eighty-three runners immediately after the race. Results: Out of 669 athletes who started the race, 352 successfully completed the race in less than the 30-hour cut-off time (52%). The majority of runners were male (84%). We were able to collect both pre- and post-race blood samples from 36 runners. Out of these 36 runners, the mean pre-race CK was increased from 126 ± 64 U/L to 14,569 ± 14,729 U/L (p < 0.001). There was a weak linear correlation between lower sodium levels and higher CK levels post-race (p = 0.003; R2 = 0.10). Using a multiple regression model, other than a negative correlation between sodium and CK levels (p = 0.001), there were no statistically significant correlations between post-race CK levels and athletes’ age, BMI, or finishing time. Conclusions: Significant elevation of CK level occurs as a result of running ultramarathons. The majority of athletes with significantly elevated CK levels were asymptomatic and required no major medical attention.

Pediatric and adolescent injury in adventure and extreme sports

Participation in children’s and youth sports and recreational activities is increasingly popular and widespread in Western culture. Trends over recent decades include increased numbers of participants, increased duration and intensity of training, earlier specialization and year-round training, and increased difficulty of skills practiced beginning at an early age. In addition to traditional sports, children and adolescents are increasingly visiting wilderness recreational destinations and participating in a growing number of adventure and extreme sports (AES) (Phit America, 2018; Outdoor Foundation, 2017; Heggie & Caine, 2012). AES are broadly defined as individualistic sports containing structural components of real or perceived danger (Ewert & Hollenhorst, 1997). These activities often involve speed, height, a high level of physical exertion and highly specialized gear or spectacular stunts. Moreover, participants in these activities often train and compete in variable environmental conditions such as those that are weatherand terrain-related, including wind, snow, water and mountains. Some AES are practiced and performed in populated urban areas including streets, parking lots or designated locations such as skateboard parks, climbing walls and dirt tracks. Examples of popular youth AES include indoor and outdoor rock climbing, scuba diving, surfing, personal water craft (PWC), whitewater canoeing, kayaking, rafting, extreme hiking, parkour, rodeo, skateboarding, mountain biking, bicycle motocross (BMX), in-line skating, alpine skiing, snowboarding, all-terrain vehicle (ATV) and motocross sports (Caine & Mei-Dan, 2016). Unlike many schooland club-related sports, participants in AES often have little or no access to immediate medical care (Mei-Dan & Carmont, 2013; Heggie & Heggie, 2012). Even if medical care is available, it may face challenges related to longer response and transport times, access to few resources, limited provider experience due to low patient volume and more extreme geographical and environmental challenges (Heggie & Heggie, 2009). Mass media showcasing breathtaking stunts at the X-Games and the inclusion of skateboarding, in-line sports, mountain biking and rock climbing in the Youth Olympic Games are all helping to drive the popularity of AES among youth. In the United States in 2016, there were 33.4 million youth outdoor participants, aged 6–17 years, an increase from 31.4 million in 2015 (Outdoor Foundation, 2017). During 2016, youth participants, aged 6–17 years, recorded 2.2 billion annual outdoor recreation outings, or 66 average outings per participant (Outdoor Foundation, 2017). The most popular outdoor and favourite outdoor activities are shown in Table 1 (Outdoor Foundation, 2017). RESEARCH IN SPORTS MEDICINE, 2018 VOL. 26, NO. S1, 5–19 https://doi.org/10.1080/15438627.2018.1434041

The relationship between initial physical examination findings and failure on objective validity testing during neuropsychological evaluation after pediatric mild traumatic brain injury

Background: The symptomatology after mild traumatic brain injury (mTBI) is complex as symptoms are subjective and nonspecific. It is important to differentiate symptoms as neurologically based or caused by noninjury factors. Symptom exaggeration has been found to influence postinjury presentation, and objective validity tests are used to help differentiate these cases. This study examines how concussed patients seen for initial medical workup may present with noncredible effort during follow-up neuropsychological examination and identifies physical findings during evaluation that best predict noncredible performance. Hypothesis: A portion of pediatric patients will demonstrate noncredible effort during neuropsychological testing after mTBI, predicted by failure of certain vestibular and cognitive tests during initial examination. Study Design: Retrospective cohort. Level of Evidence: Level 4. Methods: Participants (n = 80) underwent evaluation by a sports medicine physician ≤3 months from injury, were subsequently seen for a neuropsychological examination, and completed the Medical Symptom Validity Test (MSVT). Variables included results of a mental status examination (orientation), serial 7s examination, Romberg test, and heel-to-toe walking test. The primary outcome variable of interest was pass/fail of the MSVT. Results: Of the participants, 51% were male and 49% were female. Eighteen of 80 (23%) failed the MSVT. Based on univariable logistic regression analysis, the outcomes of the Romberg test (P = 0.0037) and heel-to-toe walking test(P = 0.0066) were identified as significant independent predictors of MSVT failure. In a multivariable model, outcome of Romberg test was the only significant predictor of MSVT failure. The probability of MSVT failure was 66.7% (95% CI, 33.3% to 88.9%) when a subject failed the Romberg test. Conclusion: A meaningful percentage of pediatric subjects present evidence of noncredible performance during neuropsychological examination after mTBI. Initial examination findings in some cases may represent symptom exaggeration.

Pediatric and adolescent injury in mountain biking

ABSTRACT Mountain-biking has become a popular competitive and recreational activity but also involves risk of injury. This article provides an overview of what is known about the scope of the injury problem affecting children and adolescent mountain bikers, the risk factors involved and injury prevention strategies. The proportion of injured child and adolescent mountain bikers ranges from 10.6% to 64.0%, but few studies provide separate analysis of youth injuries. Upper extremity injuries appear most common except among adolescents where the risk of head injury and traumatic brain injuries are greater. Concern is raised regarding the reported frequency of spine fractures and spinal cord injuries. Multi-faceted, longitudinal injury research focusing on youth mountain bikers is required to provide a reliable basis for testing risk factors and evaluating preventive measures. Reducing mountain biking-related injuries will require multiple strategies that integrate approaches from education, engineering, and evidence-based safety measures and their enforcement.

The Current State of Pediatric Sports Medicine: A Workforce Analysis

ABSTRACT Objective: Pediatric sports medicine is an evolving pediatric subspecialty. No workforce data currently exists describing the current state of pediatric sports medicine. The goal of this survey is to contribute information to the practicing pediatric sports medicine specialist, employers and other stakeholders regarding the current state of pediatric sports medicine. Methods: The Workforce Survey was conducted by the American Academy of Pediatrics (AAP) Division of Workforce and Medical Education Policy (WMEP) and included a 44-item standard questionnaire online addressing training, clinical practice and demographic characteristics as well as the 24-item AAP Council on Sports Medicine and Fitness (COSMF) questionnaire. Descriptive statistics were used to summarize all survey responses. Bivariate relationships were tested for statistical significance using Chi square. Results: 145 surveys were returned, which represented a 52.7% response rate for eligible COSMF members and board certified non-council responders. The most common site of employment among respondents was university-based clinics. The respondents board certified in sports medicine were significantly more likely to perform fracture management, casting and splinting, neuropsychological testing and injections compared to those not board certified in sports medicine. A large proportion of respondents held an academic/medical school appointment. Increases were noted in both patient volume and the complexity of the injuries the specialists were treating. Conclusion: This pediatric sports medicine workforce study provides previously unappreciated insight into practice arrangements, weekly duties, procedures, number of patients seen, referral patterns, and potential future trends of the pediatric sports medicine specialist.

Functional, Kinematic, and Isokinetic Strength outcomes of a Hip Strengthening Program among Adolescent Females with Idiopathic Patellofemoral Pain: A Pilot Study

Functional, Kinematic, and Isokinetic Strength outcomes of a Hip Strengthening Program among Adolescent Females with Idiopathic Patellofemoral Pain: A Pilot Study Based on the hypothetical association between decreased hip strength and patellofemoral pain (PFP) symptom severity, selective hip and core strengthening rehabilitation programs are frequently utilized to treat affected individuals. The purpose of this study was to compare the hip strength, hip kinematics, symptom severity and function of subjects affected by patellofemoral pain (PFP) before and after a hip strengthening intervention.

Pediatric and adolescent injury in skiing

ABSTRACT This review examines risks that accompany child and adolescent participation in downhill skiing. Falls and non-collision events were the most common mechanism of injury, but significant data implicate head injuries, blunt abdominal trauma, and spinal trauma as the leading causes of morbidity and mortality in this population. School-aged children and youth (7–14 years) are more likely to sustain an injury, compared to children (0–6 years) and older teenagers (15–17 years). Knee injuries were the most common injury, reported as 10.3%-47.7% of all lower limb injuries. The literature supports helmet use as protective against injury with a reduced risk of head, neck, or face injury in children under 13 years. Future studies are necessary to evaluate injury and risks in the backcountry given the rapid increase of adolescents traveling outside ski areas. Research examining risk factors and preventive measures in youth skiing is also warranted.

Using concurrent gait and cognitive assessments to identify impairments after concussion: a narrative review

Understanding how a concussion affects an individual is oftentimes difficult for clinicians due to the varying symptom profiles reported by the patient and the multifaceted and heterogeneous nature of the injury. Accordingly, the interpretation of postconcussion performance can be challenging, because many different testing paradigms have been reported as potentially useful in the literature. Among the types of tests clinicians use to understand how concussion affects an individual, both gait and neurocognitive evaluations have demonstrated utility. Our purpose is to describe how combined gait and cognitive (i.e., dual task), as well as single-task gait and computerized neurocognitive examinations can assist clinical decision-making.