TOPIC: Pre-Game Timeout Checklist

STUDY TYPE: Survey

The Pre-Game Medical Timeout in Florida High School Athletics

Submitting Author/Presenter: Nicholas Pekmezian, BS

Bradley Richey, MD, Daryl Osbahr, MD, Ibrahim Zeini, PhD, Robert Sefcik, MS, and Jason Epstein, MD

Affiliation: UCF College of Medicine, Orlando, FL.

Purpose: To understand how commonplace pre-game timeouts are in high school athletics, the perception that athletic medical providers have regarding the utility of such timeouts, and to report how often pre-game timeouts are conducted that address the guideline-recommended checklist action items.

Methods and Study Design: This study was an electronically distributed cross-sectional survey of athletic trainers tasked with the care of high school athletes at Florida High School Athletic Association (FHSAA) member organizations. The survey was designed based on the guideline-recommended pre-game timeout checklist items as proposed by the NATA. The survey contained 17 questions, of which 3 screened for eligibility.

Results: For the athletic trainers surveyed in this study, it appeared that a medical timeout was much more common prior to competition/games (44.8% of athletic trainers always complete a timeout, 6.3% never complete a timeout) when compared to a practice (7.2% always complete a timeout, 48.5% never conduct a timeout). With regards to communication, 43.8% of trainers always review their primary method prior to competition and only 22.9% always review their secondary method of communication. Emergency equipment was always checked to be in full working order in 50.5% of participants. 23.7% of athletic trainers never reviewed a plan for crowd control prior to a sporting event. The vast majority of the schools had their own athletic training staff (94.6%) rather than having to share staff with other schools (5.4%). 83.9% of athletic trainers strongly agreed with the perception that medical timeouts are a critical part of emergency preparedness while only 4.3% were neutral and no trainers disagreed with the concept.

Conclusions: The primary hypothesis was supported as many athletic trainers do not routinely conduct a medical timeout prior to sporting events. Less than half (44.8%) of the athletic trainers always conducted a medical timeout prior to competition with only 7.2% prior to practice. Secondary hypothesis was supported as 80.4% (37/46) of trainers never completing timeouts pre-practice strongly agreed that medical timeouts are critical to athletic preparedness.

Significance: This project displays the current perception and implementation of medical timeouts prior to athletic events. The project provides a foundation by which further education and awareness can be brought to improve the care of high school athletes.

Acknowledgements: I would like to extend a special thank you to Dr. Brad Richey, Dr. Daryl Osbahr, Dr. Jason Epstien, and Dr. Ibrahim Zeini for their continuous support and diligence in always looking out for my success/future!

TOPIC: PRP

STUDY TYPE: Other

Assessment of Complications With IA PRP for Treatment of Knee OA

Submitting Author/Presenter: Hirotaka Nakagawa, MD

James Kim, BA, Joseph Rinaldi, MD, and Walter Sussman, DO

Affiliation: Tufts Medical Center.

Purpose: The purpose was to assess complications associated with intra-articular (IA) platelet rich plasma (PRP) injections for the treatment of knee osteoarthritis (KOA) and to compare the rates of complications to those of IA corticosteroid (CS), hyaluronic acid (HA), and normal saline (NS) injections.

Methods and Study Design: A systematic review was performed of randomized controlled trials (RCTs) reporting on KOA treatment with IA-PRP injections. Data on complications were extracted from each study. A random-effects meta-analysis was conducted to compare the rates of complications among the PRP, CS, HA, and NS groups, with a 95% confidence interval for the odds ratio (OR).

Results: Eighty-seven studies met the inclusion criteria. Out of these, 66 studies (76%) provided data on adverse events. Among the 3,851 subjects who underwent IA-PRP injections, complications were reported by 402 subjects (10%). The most common complications included “mild” knee pain and swelling (7.6%) and “severe” knee pain (0.08%). No severe complications were reported (ie, infection, septic arthritis, osteonecrosis). There was a significant difference in mild pain and swelling between the PRP group and the HA group (OR 0.42, [95% CI 0.21, 0.83], P = 0.02) and NS group (OR 0.62, [95% CI 0.40, 0.96], P = 0.04), but there was no significant difference when compared to CS group (OR 1.25, [95% CI 0.78, 1.98], P = 0.23). There was a significant difference in severe pain between the PRP group and HA group (OR 1.51, [95% CI 1.11, 2.04], P = 0.01), but there was no significant difference when compared to CS group (OR 1.25, [95% CI 0.78, 1.98], P = 0.23) or NS group (OR 1.11, [95% CI 0.87, 1.41], P = 0.33).

Conclusions: The overall reported complication rate for IA-PRP injections is approximately 10%, with the most common complication being mild pain and swelling resulting from the injection. The rate of mild pain and swelling was higher for IA-PRP compared to IA-NS and IA-HA injections, but no significant difference was observed when compared to IA-CS injections. The rate of severe pain was higher for IA-HA injections when compared to IA-PRP injections.

Significance: IA-PRP is associated with mild pain and swelling, which is expected due to its mechanism of action. Severe complications are rare, and their rate is may be lower than that of IA-HA. Overall, IA-PRP is considered a safe treatment option for Knee OA.

TOPIC: Concussion

STUDY TYPE: Other

Concussion Characteristics for Pediatric Patients Differ Based on Age

Submitting Author/Presenter: Jonathan Santana, DO

Keila Hirokawa, BA, Tishya Wren, PhD, Yeng Vue, MA, and Anita Hamilton, PhD, ABPP-CN

Affiliation: Children’s Hospital Los Angeles, Los Angeles, CA.

Purpose: Pediatric concussions pose a unique challenge in diagnoses and management due to symptoms presenting differently across developmental stages. The purpose of this study was to determine differences in the mechanism of injury and initial presentation of pediatric concussions over different age ranges.

Methods and Study Design: Information was collected on concussion patients presenting to sports medicine clinics in a large tertiary children's hospital system including the mechanism of injury, initial and current symptoms, and other demographic information. Patients were grouped by age: 0 to 8, 9 to 12 and ≥13 years and compared using Kruskall-Wallis for continuous variables and Fisher's exact test for categorical variables.

Results: Two hundred ninety-three patients (341 concussions) were included in the study. The proportion of males decreased in older age groups (88%, 62%, 51%, P = 0.001). More patients were injured through non-sports mechanisms at younger ages (74%, 41%, 26%, P < 0.001) with falls being the most common cause in patients under 9 years old. Older age groups had more concussion symptoms at time of presentation compared to the younger age group (median symptom score 5,10,12 out of 74, P = 0.007) with the older group endorsing significantly more headache (25%, 64%, 71%, P < 0.001), pressure (25%, 43%, 50%, P = 0.04), neck pain (17%, 17%, 30%, P = 0.04), light sensitivity (17%, 38%, 44%, P = 0.03), sound sensitivity (17%, 36%, 42%, P = 0.05), not feeling right (17%, 40%, 45%, P = 0.02), slowness (13%, 31%, 45%, P = 0.001), fogginess (8%, 17%, 30%, P = 0.009), difficulty remembering (8%, 26%, 31%, P = 0.05), difficulty concentrating (21%, 44%, 52%, P = 0.01), low energy (13%, 48%, 48%, P = 0.002), and sleep changes (17%, 39%, 42%, P = 0.04).

Conclusions: Our results build on previous studies showing that younger pediatric patients sustain concussions mostly from non-sports mechanisms and endorse fewer symptoms which could be due to lower severity of injury and/or primarily relying on parent reporting of observable concussion symptoms. It is important to take into account how younger patients describe their specific symptoms and may require closer follow up.

Significance: Pediatric concussion mechanism and presentation differ across ages, emphasizing the importance of age-appropriate symptom checklists and assessing for non-observable symptoms to ensure accurate diagnosis and management in pediatric populations.

TOPIC: Pediatrics

STUDY TYPE: Survey

Diving into Sports Specialization: Association of Early Specialization on Injury Risk in Youth Divers

Submitting Author/Presenter: Annika Lenz, MD

Aaron Provance, CAQSM, FAAP, MD, Luke Johnson, BS, and Masaru Teramoto, PhD, MPH, PStat

Affiliation: University of Utah, Salt Lake City, Utah.

Purpose: Early sports specialization is associated with overuse injuries, burnout, and psychological fatigue. Despite consensus against early specialization, a literature gap exists. This study tests the hypothesis that early-specialized divers face increased injury risk compared to those specializing later.

Methods and Study Design: This cross-sectional study utilized a 29-question survey, distributed to USA Diving and college athletes. Participants, aged 8 to 25, provided demographic data, diving specifics, training habits, injury history, and preventive measures. Statistical analyses, including contingency tables and logistic regression, were conducted to explore associations between variables and diving injuries.

Results: One hundred eighty-two divers completed the survey; 70% female. There was no significant association between gender and diving injuries (P > 0.05). Age to start diving and age to switch to solely diving were significantly associated with certain injuries (P < 0.05). Starting diving before or by 12 years of age was significantly associated with lower odds of injuries in the shoulder and wrist (P = 0.013 and 0.018, respectively), after adjusting for select covariates. Age to switch to solely diving was not significantly associated with injuries in any body part (P > 0.05), after adjusting for covariates. Longer diving experience was significantly associated with diving injuries in all 11 body parts (P < 0.05). Lastly, amount of training was significantly associated with diving injuries in 7 out of 11 body parts (P < 0.05).

Conclusions: Early sports specialization correlates with lower injury risk in youth divers starting before age 13. Notable findings include reduced risks for head/neck, shoulder, and wrist injuries. A positive correlation with experience and injury risk was observed. However, the study did not differentiate between acute and overuse injuries, crucial for understanding the impact on overuse injuries, a recognized concern in various sports.

Significance: The information gathered from this study provides a foundation to ask additional questions that may help to implement rules to mitigate diving injuries and protect athletes from long term complications.

Acknowledgements: I would like to express my special thanks to my mentor Dr. Provance for his time and efforts he provided. I would like to thank Mr. Johnson and Dr. Teramoto for all their help, as well as the University of Utah for allowing me this opportunity.

TOPIC: Pediatrics

STUDY TYPE: Cohort

Efficacy of Eccentric Exercises in the Treatment of Sever's Disease

Submitting Author/Presenter: Noelle Terrero, BA

Daniel Herman, MD, PhD and Marko Bodor, MD

Affiliation: University of California, Davis School of Medicine, Sacramento, CA.

Purpose: Sever's Disease is a common etiology of heel pain in pediatric patients; however, evidence-based treatment options are limited. The purpose of this single-cohort study was to investigate eccentric exercises as a conservative intervention for providers treating patients with Sever's Disease.

Methods and Study Design: Subjects completed daily eccentric exercises targeting the Achilles tendon for twelve weeks and questionnaires on their pain (Numeric Pain Rating Scale, NPRS), function (Pain, Enjoyment, and General Activity, PEG), and sports activity at baseline, two, and twelve weeks. Paired Samples and McNemar's tests were used for timepoint comparisons (alpha = 0.05) and Cohen's d was used for effect sizes.

Results: N = 52 subjects (M = 32, F = 20; Age = 11.5 ± 1.9 years; BMI = 19.2 ± 3.8 kg/m2) with a mean symptom duration of 16.2 ± 15.9 weeks completed the protocol. 90.4% of subjects had failed a trial of rest, heat/ice, medications, physical therapy, massage/manipulation, and/or orthotics, and 63.5% had previously been evaluated by other medical providers. Common self-reported activities that caused pain included sports where running is a major component, including soccer, basketball, track, baseball/softball, tennis, and football. There were significant improvements in NPRS from baseline (7.5 ± 1.3) to two weeks (2.8 ± 1.8, P < 0.001, d = 2.27) and from two weeks to twelve weeks (0.8 ± 1.6, P < 0.001, d = 0.93). Total PEG scores also significantly improved from baseline (21.2 ± 3.4) to two weeks (7.2 ± 1.6, P < 0.001, d = 1.90) and from two weeks to twelve weeks (2.3 ± 1.7, P < 0.001, d = 0.75). 78.0% of patients had fully returned to sport at two weeks, which then improved to 96.2% by twelve weeks (P = 0.004).

Conclusions: Eccentric exercises resulted in very large gains in pain, function, and sports participation in patients with Sever's Disease. Although this study lacked a control group, many subjects had a long symptom duration and a high rate of failure with other treatments. Improvements were particularly prominent with very large effect sizes within the first two weeks, with continued improvements over the remaining ten weeks of the intervention.

Significance: This is the first study showing eccentric exercises may be a treatment option for Sever's Disease. This may be particularly useful in recalcitrant cases or in those who lack orthotic options for use in their sport such as gymnasts and dancers.

TOPIC: NCAA

STUDY TYPE: Cohort

Does Practice Type and Gear Worn Mitigate Head Impact Exposure in College Football Players

Submitting Author/Presenter: Beatrice Caballero, MD

Bridget M. Whelan, MPH, Anna DeLeo, ATC, Tiger Wong, ATC, and Kimberly G. Harmon, MD

Affiliation: University of Washington, Seattle, WA.

Purpose: In 2021, NCAA football practice rule changes were made to limit Head Impact Exposures (HIE), a proposed risk factor for long-term neurologic problems. The objective of this study is to determine if rule changes limiting full pad practices are supported by HIE data using research-grade mouthguards.

Methods and Study Design: Division I football players were fit with custom mouthguards, which recorded head impacts and linear and angular acceleration for the 2022 football season. Data were collected from 40 players along with contextual data including pre-season or in-season, game or practice, and equipment (full pads/shells/helmets). Impacts, significant impacts, and player-days were recorded.

Results: There was a total of 4613 impacts over 574 player-days with 805 (17%) meeting criteria for significant impacts (SI). This equated to 8.04 impacts and 1.40 SI per player-day. Games had 14.80 impacts per player-day and 2.90 SI, while practices had 6.84 impacts and 1.14 SI per player-day. Regular season practices had slightly more total impacts per player-day (6.90) than pre-season (6.40), but there were more SI (1.30) in pre-season practices compared to regular season practices (1.12). Impacts were more frequent and there were more SI per player day when practicing in full pads (1.30), compared to shells (1.07) and helmets (0.94). 74% of total impacts during the season occurred during practice and accounted for 70% of the significant impacts.

Conclusions: Head impacts among college football players are more frequent and more severe during games compared to practices, however, practices account for 74% of total impacts during the season and 70% of significant impacts. Impacts were also more frequent and severe with full pads compared to shells or helmets alone.

Significance: Research exploring HIE by drill type and position should inform future efforts to monitor athlete exposure and inform rule changes. Continuing to explore ways to decrease contact in practice represents an opportunity to decrease HIE in football.

Acknowledgements: This project was funded by Football Research, Inc.

TOPIC: Concussion

STUDY TYPE: Cohort

Stimulated Blink Reflex Abnormalities Before and After Sport-Related Concussion

Submitting Author/Presenter: Michael Freitas, MD, MS

John Leddy, MD, Mohammed Haider, MD, PhD, and Dena Garner, PhD

Affiliation: UBMD Orthopaedics and Sports Medicine, University at Buffalo, Buffalo, NY.

Purpose: Athletes with sport-related concussion (SRC) have blink reflex abnormalities, and can report combinations of physical, cognitive, fatigue or mood-related symptoms after injury. This study compares blink reflex before and after injury and identifies associations with self-reported symptoms.

Methods and Study Design: Blink reflex (EyeStat, BlinkCNS) and Post-Concussion Symptom Scale (max = 126) were assessed preseason and within 2 days of SRC. Clustering identified High (HS) and Low (LS) symptom groups. Blink reflex parameters: time to ipsilateral blink (latency), contralateral blink (differential latency), initial velocity, time to open, time to close, number of oscillations, and distance traveled (excursion).

Results: Differential latency increased (baseline: 4.28 ± 1.8 vs post-injury: 5.33 ± 3.0 ms, P = 0.047) and time to close decreased (34.30 ± 5.6 vs 32.38 ± 4.3 ms, P = 0.022) post-injury on paired t-test; there was a trend for significance for latency (P = 0.094) and oscillations (P = 0.074). HS (n = 15, 87% male, 20.8 ± 1.5 years, symptoms=43.3 ± 11.4) had slower initial velocity (4.23 ± 0.7 vs 5.16 ± 1.0 pixel/s, P = 0.002) than LS (n = 23, 74% male, 20.1 ± 1.4 years, symptoms = 13.0 ± 6.3), and there was a trend for significance for excursions (P = 0.081). Physical symptoms correlated with latency (rho = −0.28, P = 0.026) and oscillations (rho = 0.37, P = 0.003); cognitive correlated with initial velocity (rho = −0.36, P = 0.003) and exclusions (rho = −0.38, P = 0.002); fatigue correlated with initial velocity (rho = −0.48, P < 0.001), time to close (rho = −0.26, P = 0.034) and excursion (rho = −0.49, P < 0.001). Mood correlated with differential latency (rho = 0.49, P < 0.001) and initial velocity (rho = −0.30, P = 0.014).

Conclusions: The stimulated blink reflex is abnormal acutely after SRC. Increase in differential latency is suggestive that the contralateral blink reflex arch is less efficient. Decreased time to close with a trend that latency is also faster is suggestive that the blink reflex is excited. The strongest correlations were between increasing differential latency and increasing mood symptoms and decreasing excursions and increasing fatigue.

Significance: The corneal blink reflex is a primitive brainstem response initiated by light, touch or sound. Technology-assisted objective assessment using a portable blink reflexometer has the potential to aid in SRC diagnosis and validate self-reported symptoms

Acknowledgements: Big thank you to Dr Garner at the Department of Health and Human Performance, The Citadel, Charleston, SC.

TOPIC: NCAA

STUDY TYPE: Other

Does Equestrian Helmet Type Have an Effect on Head Injury among Collegiate Athletes

Submitting Author/Presenter: Sara Gould, MD, MPH

Devon Serrano, Fernanda Dib, Gerald Mcwin, PhD, Kevin Schrum, PhD, and Avinash Chandran, PhD, MS

Affiliation: University of Alabama, Department of Orthopedics, Division of Sports Medicine Birmingham, AL; Birmingham VA Health Care System, Birmingham, AL.

Purpose: Risk of head injury associated with equestrian sports is high, with a comparable risk of severe head injury similar to off-road vehicular sports. We sought to characterize helmet use, head injury risk, and to examine factors that influence these variables in collegiate equestrians.

Methods and Study Design: Design: Cross-sectional study Setting: Collegiate level equestrian teams within the United States Participants: A survey was administered via email to members of the National Collegiate Equestrian Association and the Intercollegiate Horse Shows Association. Assessment of Risk Factors: Demographics, riding and helmet use characteristics. Main Outcome Measurements: Self-reported head injury.

Results: Over 50% reported falling off a horse in the last year (n = 207, 58%). Head injury occurred with high frequency (n = 37, 18% of falls). Concussion was the most frequently reported type (n = 30, 81% of head injuries). Over 50% of athletes with self-reported concussion did not report receiving medical treatment (n = 18, 60%) The risk of head injury was similar across helmet brands, as well as between helmets with Multi-Directional Impact Protection System (MIPS) and those without. Riders with the most experience were less likely to report a head injury than those with less experience (6.7%, vs 12.3%). 78% of equestrians said that they would not replace their helmet after every fall.

Conclusions: Collegiate equestrians do not adhere to recommendations for replacing helmets. Fall-related head injury risk among collegiate equestrians is high. Neither helmet brand nor helmet liner type were associated with lower rate of reported head injury.

Significance: The lack of epidemiological literature on this topic points to an urgent need for large-scaled injury and illness monitoring efforts in equestrian sports. These efforts may be most successful when customized for the nuances of equestrian sports.

Acknowledgements: The views expressed in this material are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the U.S. Government.

TOPIC: PPE

STUDY TYPE: Survey

Concussion Reporting Screening in Pre-Participation Physical Exams

Submitting Author/Presenter: Alexandra Abbott, MD

Alexandra Klomhaus, PhD, Joshua Goldman, MD, MBA, and Aurelia Nattiv, MD

Affiliation: University of California, Los Angeles.

Purpose: This study aims to determine if application of a brief and validated scale for concussion reporting expectation (CR-E) results in a significant proportion of collegiate athletes receiving counseling, education, or other interventions that would not have received it without positive screening.

Methods and Study Design: NCAA Division I athletes presenting to providers for PPE were additionally queried with the CR-E. Providers recorded whether a patient demonstrated need for additional counseling/education or other interventions based on this screening. Time to complete and interpret the CR-E was recorded to provide additional data regarding screening utility.

Results: Of 627 athletes available for survey completion, 358 completed the survey at our D1 NCAA institution (57%). 62% of participants were women and 38% were men. The average completion time of the survey was 2 minutes, and 66% of athletes warranted additional counseling, education, or other intervention by their determining provider. Our internal validity scores were high for each survey item, suggesting strength in the survey applied to collegiate athletes in different sports. 18% of athletes endorsed a history of not reporting or of continuing to play with known symptoms of concussion. On average, athletes felt “neutral” about agreement to report concussion symptoms if the “team was counting on me” (3.5/5), they “wanted to keep playing” (3.5/5), it was a “close game,” (3.4/5), and if they were “down a player” (3.3/5). Athletes who more frequently endorsed nonreporting in the past were representing water polo (44%), football (40%), and gymnastics (40%). Sports with above average counseling rates based on this survey were volleyball (79%), softball (76%), and water polo (75%).

Conclusions: Our study demonstrates utility in screening collegiate athletes for concussion reporting expectation, given the brevity, high internal validity, and high rate of counseling or interventional need determined by examiners. Sports with high rates of concussion are well described; our study contributes evidence to risk stratify sports with high rates of nonreporting, reluctance to discuss concussion, and concussion education or counseling needs.

Significance: Risk stratification for concussion nonreporting may help providers identify opportunities for counseling and address barriers to reporting. Open discussions regarding symptom reporting may improve outcomes directly as well.

TOPIC: Pediatrics

STUDY TYPE: Other

The Association of Self-Reported Pain on Movement Patterns in Adolescent Female Ballet Dancers

Submitting Author/Presenter: Jane S. Chung, MD

Ashley Erdman, BS, MBA, Sophia Ulman, PhD, Shane Miller, MD, Jacob Jones, MD, Jessica Dabis, DPT, and Henry Ellis, MD

Affiliation: Scottish Rite for Children Orthopedic and Sports Medicine Center, Frisco, TX; University of Texas Southwestern Medical Center, Dallas, TX.

Purpose: Across all genres of dance, studies have reported history of musculoskeletal pain in 95% of dancers. The purpose of this study was to evaluate the association of self-reported pain level on ballet-specific movement patterns in pre-professional pediatric female ballets dancers training en pointe.

Methods and Study Design: Pre-professional pediatric ballet dancers (age 10-18) who train en pointe were enrolled in an AMSSM funded study. The PROMIS Pediatric Numeric Rating Scale was administered to assess the presence and level of pain. Trunk and lower extremity joint motion was captured during static (5 classical positions) and dynamic (developpe, arabesque, grand jete) movements using inertial measurement sensors.

Results: Data was collected on 55 dancers, with 34 dancers (62%) reporting pain in the past 7 days. Pain level was rated from 0 to 10 (0, No pain up to 10, Worst pain), with an average rating of 3.4 (range 1-8). Location of pain was indicated in the hip (25%), followed by low back (21%) and ankle (20%). Higher levels of reported pain were associated with greater trunk lean toward the right non-barre leg while standing in third (r = 0.45, P = 0.01), fourth (r = 0.35, P = 0.04), and fifth (r = 0.43, P = 0.01) positions. No correlations were found with pain level in first or second positions. When performing the developpe en pointe, a moderate correlation was found showing less external knee rotation on the working leg with higher pain levels (r = 0.38, P = 0.03). During the grande jete, higher pain level was associated with increased trunk rotation (r = 0.50, P < 0.01) and hip abd/adduction (r = 0.36, P = 0.04) with reduced ankle plantarflexion (r = 0.39, P = 0.02). There were no significant correlations with the arabesque.

Conclusions: Adolescent ballet dancers with pain exhibited differences in movement patterns during certain ballet tasks. Less tibial rotation on the developpe working leg increased trunk rotation and coronal hip motion with the jete, may indicate altered movement patterns associated with higher levels of pain, hence more difficulty maintaining pelvic/hip alignment and stability.

Significance: This study shows the association between pain and altered movement patterns in ballet dancers, which potentially may lead to higher injury risk. These findings may provide the dance community information in reducing injury risk for this population.

Acknowledgements: This study is supported by the AMSSM Foundation grant.

TOPIC: Epidemiology

STUDY TYPE: Survey

Sports Bra Preferences in Young Japanese Women Compared to American Women: A Cross-sectional Study

Submitting Author/Presenter: Yuka Tsukahara (Kodama), MD, PhD

Seira Takei, MD, PhD, Akiko Hatsukari, MD, MPH, Mikako Sunaga, Nodoka Ikegami, Courtney Jones Jones, MPH, PhD, and Katherine Rizzone, MD, MPH

Affiliation: Tokyo Women’s College of Physical Education.

Purpose: A previous study on women in the United States (US) showed that more than 25% reported that lack of breast support was a barrier to exercise. Our purpose was to evaluate sports bra preferences in active Japanese women and compare this data to the American cohort.

Methods and Study Design: The cohort consisted of college students from three universities in two different Japanese prefectures. A questionnaire previously utilized in the US cohort was translated into Japanese and assessed for test-retest reliability using intraclass correlation coefficient. Chi-square tests and Fisher's exact tests were employed to assess for differences between the Japanese and US cohorts.

Results: The cohort was composed of 620 collegiate women (19.3 ± 1.3 years old). Test-retest reliability was examined in 294 participants with intraclass correlation coefficients for each item ranging from 0.6 to 0.9, indicating high reliability. The percentage of women who reported they do not wear a sports bra during activity was significantly higher in Japanese compared to US women (14.4% vs 0%, P < 0.001), especially in women with larger cup size (C-G). Japanese women reported that lack of breast support prevented them from being active with greater frequencies than US women (P = 0.002). Respondents in both countries identified that the most important factor they considered in a sports bra purchase was “amount of support,” but higher responses were reported for “fabric” in Japanese compared to US women (22.1% vs 7.5%, p < 0.001). Japanese women responded significantly higher rates of “no preference” for type of sports bra (44.6% vs 2.5%) while US women preferred compression type (P < 0.001).

Conclusions: Women in both countries with larger cup size (C-G) were significantly more likely to report breast support barriers that prevented them from exercising. Japanese women reported a higher frequency of discomfort due to lack of breast support, but they had less preference for type of sports bras. Selecting an appropriate sports bra that accurately matches cup size and preference may help reduce obstacles to physical activity for Japanese women.

Significance: Lack of breast support may prevent Japanese women from being more physically active. Improving our understanding of appropriate bra fit and preferences may help women to exercise more comfortably, especially those with larger cup size.

Acknowledgements: This collaboration was made possible by the AMSSM global exchange program.

TOPIC: Concussion

STUDY TYPE: Case-Control

Review of Validity Indicators for Home-based ImPACT Computerized Neurocognitive Testing

Submitting Author/Presenter: Maheep Vikram, MD

Britney Niles-Schoeller, DO, Viraj Patel, DO, William McCafferty, DO, Vikram Padala, Medical Student, and Christopher Kustera, MD

Affiliation: St. Luke's University Health Network, Bethlehem, PA.

Purpose: FDA clearance is now available for self-adminstered ImPACT neurocognitive testing. This study aims to see if there is a statistical difference in test scores between home based unproctored vs school based proctored test environment.

Methods and Study Design: Retrospective case control study with comparison between home(unproctored) vs. school based (proctored) groups. Student athletes between 12 and 19 years of age. Fifty athletes took the home based test vs 32 athletes who took it at school. All genders and sports were represented. Statistical analysis of the variables was done via χ2 tests.

Results: Eighty-two athletes met inclusion criteria. Average age at baseline testing was 15.26 years. Of all baseline tests, only 1 (school testing group) was invalidated by ImPACT's built-in invalidity indicators. In home testing group, 72% reported symptom score > 1 at baseline, 14% had history of neurocognitive disorder and 62.5% slept < 8 hours before taking test. In school group, 43.8% reported symptom score > 1 at baseline, 6.3% had history of neurocognitive disorder and 44% reported sleeping < 8 hours before taking test. No statistical difference was noted in test location vs. hours of sleep (P = 0.102). Statistically significant difference was noted in test location vs. symptom categories (P = 0.011). No statistical difference was noted in test location vs. history of neurocognitive disorder (P = 0.273)

Conclusions: No significant difference between home based unproctored ImPACT baseline test results vs. test administered in proctored school environment. Future studies need to determine the concern for “sandbagging” and “horseplay” for students taking unproctored testing. Further evaluation of baseline symptom scores reporting will be useful.

Significance: Home based ImPACT neurocognitive testing has become very popular for mass-administration of baseline testing. This study confirms that home based administration does not have any statistically significant impact on test scores.

Acknowledgements: Dr. Jill Stoltzfus PhD. Senior Network Director, GME Data Measurement and Outcomes Assessment St. Luke's Univeristy Health Network.

TOPIC: Musculoskeletal

STUDY TYPE: Cohort

Energy Absorption in Single Leg Vertical and Horizontal Hops in Adolescents Post-ACL Reconstruction

Submitting Author/Presenter: Ryan Kelln, DO

Eva Ciccodicola, DPT, Veronica Beltran, BS, Alison Hanson, MSPT, and Tishya Wren, PhD

Affiliation: Children's Hospital Los Angeles, Children's Orthopaedic Center, Los Angeles, CA 90027.

Purpose: To examine the difference in intralimb contributions to energy absorption during landing of single leg horizontal (SLHH) and vertical (SLVH) hop in pediatric athletes post-anterior cruciate ligament reconstruction (ACLR). This has only been studied in older populations, and not in adolescents.

Methods and Study Design: Nine athletes (3 female; median age 16.1 years, range 14-18; 8.3 months post-ACLR, range 6-13) completed the SLVH and SLHH while kinematics/kinetics were collected. Hop height/distance and energy absorption were averaged across 3 trials during landing. Performance, total energy absorption, and percent energy absorption at each joint were compared between tasks and limbs using linear mixed models.

Results: SLHH (1.45 vs. 1.55 leg lengths, P = 0.14) and SLVH (0.31 vs. 0.34 leg lengths, P = 0.047) distance tended to be shorter for ACLR compared to contralateral limbs. Total energy absorption was lower on the ACLR side for both SLHH (3.3 vs. 4.1 W/kg, P = 0.0008) and SLVH (3.2 vs. 3.9, P = 0.004). Distribution of energy absorption differed between tasks with SLVH having greater ankle contribution (P < 0.0001) and lower contributions of the hip (P = 0.0008) and knee (P = 0.0002). A lower percentage of energy was absorbed by the ACLR compared with contralateral knees in both tasks (P < 0.04). This was compensated by a trend toward increased energy absorption at the hip in ACLR limbs (significant for the SLHH, P = 0.02).

Conclusions: While intralimb contributions to energy absorption differ between the SLVH and SLHH, energy absorption was lower and there was offloading of the surgical knee in both tasks.

Significance: Monitoring joint contributions to energy absorption is important in progressing athletes towards their return to sport or performance goals, particularly during landing when the majority of injuries occur.

TOPIC: Concussion

STUDY TYPE: Other

NFL Concussion Rates across Helmet Types

Submitting Author/Presenter: Jack Keeley, MD

Zachary Sitton, MD, Jeremy Swisher, MD, Paul Kang, MPH, and Laura Lintner, DO

Affiliation: Advocate Health- Wake Forest School of Medicine, Winston-Salem, North Carolina.

Purpose: The purpose of this study is to examine the relationship between National Football League (NFL) concussions during the 2022 regular season and type of helmet worn.

Methods and Study Design: Data obtained from publicly available resources including Pro-Football-Reference.com, NFL.com, and from in-game photos and footage from the 2022 NFL regular season. Multivariate logistic regression was used to analyze concussions by helmet type, controlling for position, snaps played, and years played in the NFL. Statistical significance was defined as a P-value < 0.05.

Results: A total of 543 players were included for analysis, including two quarterbacks, two running backs, two wide receivers, two tight ends, two linebackers, two cornerbacks, two safeties, and three special teams players from all 32 NFL teams. 56/543 (10.3%) players sustained a concussion during the 2022 NFL regular season. The two most common helmet types worn by players were the Riddell Speedflex (67.8%) and Schutt F7 (17.3%). Vicis, Riddell Axiom, Riddell Speed, Schutt Air, Schutt Vengeance, and Xenith helmets types were each worn by less than 10% of players. Adjusting for position and snaps played, players that wore the Schutt F7 helmet had 2.61 times the odds of sustaining a concussion compared to all other helmet types worn (OR, 2.61 [95% CI, 1.39-4.91); P = 0.003). Safeties had 2.26 times the odds of all other positions of having a concussion (OR, 2.26 [95% CI, 1.11-4.59); P = 0.024.

Conclusions: NFL players that wore the Schutt F7 helmet had significantly higher odds of experiencing a concussion during the 2022 regular season than players that wore another helmet type. Safeties had higher odds of concussion compared to other position types.

Significance: NFL players wearing Schutt F7 helmets may be at higher risk of experiencing concussions. Further studies examining concussions during play are necessary to compare with initial laboratory safety results as new helmets are introduced.

Acknowledgements: The authors thank Stephen Davis, MA, for advice on experimental design and statistical analysis.

TOPIC: Epidemiology

STUDY TYPE: Other

Descriptive Epidemiology and Time Lost Analysis of Forearm and Elbow Injury in NBA Players

Submitting Author/Presenter: Emilio Arellano, BS

Jenny Nguyen, BS, James Gardner, MD, and Robert Bowers, DO, PhD

Affiliation: Emory University, Atlanta, GA.

Purpose: The purpose of this study is to characterize the epidemiology of forearm and elbow injuries in the NBA and to evaluate the impact of these injuries on games missed and return to play time, looking at different pathologies, injury mechanisms, and player positions.

Methods and Study Design: NBA injury database was queried for all upper extremity injuries reported from 2013 to 2022. Injury data was characterized by injury type, mechanism, player demographics, games missed, and return to play (RTP) interval. ANOVA was used to analyze RTP and games missed between the elbow and forearm injury groups followed by Tukey-Kramer's post-hoc test with significance level Α = 0.05.

Results: There were 421 elbow and 43 forearm injuries. The most common elbow injuries were contusions (33.4%) and ligament sprains (23.8%). The most common forearm injuries were contusions (60.5%) and muscle strains (16.3%). Injuries were more likely to happen in-game (75%). The most common elbow injury mechanism was contact with another player (30.9%) and fall to floor (30.6%) and for forearm injuries was contact with another player (46.5%). 51.07% of elbow injuries led to at least one missed game, compared to 13.95% in forearm injuries. In-game elbow injuries had longer RTP. Post-hoc testing showed fall to floor and elbow hyperextension associated with more games missed. Forearm injuries in-game showed longer RTP, but mechanism did not affect RTP nor games missed. Guards and forwards were more likely to sustain elbow injuries than centers. Ligament sprains were the most common injury in guards, compared to contusions in other positions. No difference was seen in RTP or games missed by position.

Conclusions: Elbow injuries are more common than forearm injuries in NBA players. Over half of elbow injuries led to missed games compared to less than 14% of forearm injuries. Elbow ligament injuries led to the most time lost. In-game elbow and forearm injuries led to longer RTP. For injury mechanism, fall to the floor and hyperextension of the elbow led to significant time lost. Player position had no effect in RTP or games missed for these injuries.

Significance: This study identifies elbow ligament injuries, in-game injuries, and different mechanisms as causes of lengthier RTP in NBA players. This provides significant granularity to inform the discussion on injury prevention strategies.

Acknowledgements: This abstract contains material created, compiled, or produced by IQVIA and the NBA. Access to data was approved by NBA and NBPA. The content of this article is solely the responsibility of the authors and does not necessarily represent the official views

TOPIC: Musculoskeletal

STUDY TYPE: Cohort

Effect of Insurance Type on Physical Therapy Referral Rates for Knee Osteoarthritis Patients

Submitting Author/Presenter: Erika Yasuda, BS

Shannon Alsobrooks, MS, Pooja Rangan, MPH, MBBS, Ramesses Ramirez, BS, and Leah Hillier, MD

Affiliation: University of Arizona College of Medicine—Phoenix.

Purpose: To explore potential disparities in physical therapy referral rates for patients at diagnosis of knee osteoarthritis based on insurance type, sex, age, and race.

Methods and Study Design: Retrospective cohort study using data collected from 58,383 patients at outpatient clinics within Banner Health Facilities in Arizona. Patient demographics including insurance type, sex, age, and race were collected. Primary outcome measure was referral rate to physical therapy at the time of initial knee osteoarthritis diagnosis. Chi-square analysis was performed.

Results: Physical therapy referral rates were alarmingly low across all insurance types: Medicare (6.85%), Medicaid (12.29%), Commercial (10.35%), and Other (8.52%). No significant differences in referral rates were found between groups based on insurance type. Women received more physical therapy referrals than men (10.94% vs. 9.46%). Mean age of patients was higher for those who did not receive a referral compared to those who did receive a referral (66.22 years vs. 64.00 years). Physical therapy referral rate was lowest among White patients (9.64%), followed by Hispanic (11.83%), Native American/Alaskan (12.34%), Black (13.02%), Asian/Pacific Islander (13.21%), Other/Multiple (13.6%), and Unknown (14.68%).

Conclusions: Among the various treatments offered for knee osteoarthritis, physical therapy remains a key evidence-based intervention. This study demonstrates that physical therapy referrals have been underprovided for patients with knee osteoarthritis, contributing to challenges in access to effective treatment regardless of insurance type. Specifically, it raises concern for Medicaid patients who rely on a referral for physical therapy coverage.

Significance: Though providers may offer verbal referrals to physical therapy, we theorize that improved rates of written referrals would improve access to evidence-based care for knee osteoarthritis, particularly for those with limited financial resources.

TOPIC: Rehabilitation

STUDY TYPE: RCT

A Randomized Controlled Trial of Blood Flow Restriction Plus Conventional Physical Therapy vs. Conventional Physical Therapy

Submitting Author/Presenter: Aaron Lear, MD

Phillip Toal, DPT, Daniel Hass, DPT, Art McCreary, MS, ATC, Huijun Xiao, MS, and Chanda Mullen, PhD

Affiliation: Cleveland Clinic Akron General, Akron, OH.

Purpose: The primary objective of this study was to evaluate if a blood flow restriction (BFR) rehabilitation program results in superior self-reported function and pain compared to a standard physical therapy (PT) program in the treatment of lateral epicondylitis.

Methods and Study Design: We performed a randomized controlled trial (RCT) comparing PT with addition of BFR to a standard PT program. The primary outcome was the change in the baseline point patient rated tennis elbow evaluation (PRTEE) score, and the score at 12 months. Secondary outcomes included change in numeric pain rating scale (NPRS) and maximum grip strength.

Results: A total of 40 patients were enrolled and randomized. Subjects were 53% female, with a median age of 53 years. The median duration of symptoms was 120 (IQR: 82.5, 293.75) days prior to enrollment with a median of 6 (IQR: 4, 7) PT visits attended during the study period. PRTEE change from baseline to 12 months in the BFR group was −33.14 (95% CI: −41.95, −24.33), and in the standard PT group was −25.18 (95% CI: −33.47, −16.88). Linear mixed effect model was used for comparison controlling for age, number of PT visits, and duration of symptoms at the time of enrollment. The difference at 12 months was −7.96 (95% CI: −20.39, 4.46) and was found to be non-significant (P = 0.10). Secondary outcomes were also found to be non-significant between treatment groups including difference NPRS change at 12 months (0.24; 95% CI: 1.63-2.11; P = 0.80), and difference in maximum grip strength change (−4.95; 95% CI: −28.61, 18.71; P = 0.66).