The Tele-Exercise and Multiple Sclerosis (TEAMS) Study: Evaluating Predictors of Physical Activity Outcomes in the Deep South

Primary Author/Presenter: Irfan M. Asif, MD

Affiliation: University of Alabama at Birmingham, Birmingham, AL.

Coauthors: Tapan Mehta, PhD, Salma Aly, MD, Hui-Ju Young, PhD, Tracy Tracy, OT/L MSCS, Jim Rimmer, PhD

Topic: Rehabilitation.

Study: RCT.

Purpose: To evaluate physical activity (PA) outcomes in multiple sclerosis (MS) patients receiving a home-based tele-exercise program with prerecorded videos on an app (TeleCAM) versus in-clinic exercise program by a PT (DirectCAM).

Objective PA measures: Timed up and go (TUG), 6-min walking test (6MWT), and timed 25-foot walk (T25WT).

Methods: Patients with MS enrolled in a 12-week, 20-session exercise program with asynchronous TeleCAM or in-person DirectCAM. TeleCAM received monthly interactive voice response (IVR) calls with behavioral support. PA measures recorded at 3 and 12 months. Moderators included age, type of MS, residence location (metropolitan vs. micropolitan vs. small town), and disease severity. Statistical analysis used linear mixed models and ML.

Results: Seven hundred fifty-nine MS patients (377 = TeleCAM, 382 = DirectCAM; 89.1% women, 23.7% black, age = 50.0) from 43 OP PT clinics in AL/MS/TN participated. Residential area and functional disability were significant effect modifiers at 3 months. TeleCAM was superior to DirectCAM at 3 months in people residing in small towns, with improvement of 2.83 m in the 6MWT (95% CI: 1.3, 4.3), whereas no differences was observed in patients living in micropolitan and metropolitan areas. For patients with moderate disability, 3-month TUG scores were superior in DirectCAM compared with TeleCAM by 1.26 secs (95% CI: 0.16, 2.35), but differences for TUG scores were not found between TeleCAM and DirectCAM in mild or severe disability. Machine learning ridge shrinkage model identified health coaching with IVR for self-efficacy to be an important predictor of T25FW scores in TeleCAM at 3 and 12 months. Patients with MS who engaged with health coaching through IVR had better 6MWT scores at 12 months if using self-efficacy, social support, and exercise goal-setting tools.

Conclusions: Residential location and level of functional disability are critical modifiers for physical activity outcome measures, and they may determine who can benefit from a low-cost, asynchronous tele-exercise program versus a program with in-person support. Monthly psychosocial assessments with IVR are important predictors of PA outcomes and could be used to develop tailored adaptive tele-exercise programs.

Significance: SDH, psychosocial factors, and disease severity are vital when designing exercise programming to improve PA outcomes, particularly in those with limited access to care. Using IVR technology for health coaching is a unique modality to improve PA outcomes.

Gender Differences in Hip and Thigh Muscle Strength in NCAA Soccer Players

Primary Author/Presenter: David Bakal, MD

Affiliation: Emory University Department of Sports Medicine, Atlanta, GA.

Coauthors: Farah Hussain, MD, Justin Dzierzawski, MD, Holli Dawson, MS, ATC, Daniel Meyer, MS, ATC, Oluseun Olufade, MD

Topic: NCAA.

Study: Case–control.

Purpose: There are different injury patterns in NCAA men's and women's soccer players. Strength imbalances of the hip and thigh are known risk factors for many of these injuries. We performed hip and thigh strength assessments in NCAA soccer players to evaluate for differences between the genders.

Methods: Using a handheld dynamometer, we calculated weight-normalized isometric strength of 6 muscle groups (hip flexors, extensors, abductors and adductors, knee flexors and extensors) in NCAA soccer players. The strength ratio of each agonist/antagonist muscle was also calculated (hip flexors/extensors, hip abductors/adductors, knee extensors/flexors). Data were compared between the genders using t-tests.

Results: Thirty-six NCAA soccer players (18 men and 18 women) from a single institution were enrolled. Men were taller (178.2 vs 166.4 cm, P = 0.001) and heavier (74.1 vs 63.0 kg, P = 0.001) than women, although both the groups were similar in age (mean 20.4 years). Compared with men's players, women's players had decreased weight-normalized strength for hip extension in both the dominant (0.172 vs 0.215, P = 0.029) and nondominant (0.172 vs 0.207, P = 0.029) limbs, as well as for hip abduction in the dominant (0.178 vs 0.205, P = 0.047) and nondominant (0.162 vs 0.202, P = 0.005) limbs. There were no significant differences in strength between the genders for hip flexion, hip adduction, knee flexion, or knee extension. When comparing agonist/antagonist strength ratios, there were significant differences between women's and men's players for hip flexion/extension in the nondominant limb (1.730 vs 1.289, P = 0.003) and hip abduction/adduction in the nondominant limb (1.361 vs 1.577, P = 0.029).

Conclusions: Compared with men's players, women's players had decreased weight-normalized strength with hip extension and abduction in both the dominant and nondominant limbs. Consequently, the agonist/antagonist strength ratios for hip flexion/extension and hip abduction/adduction were different between the genders, although these differences were only significant in the nondominant limb. Otherwise, strength profiles were similar between the genders.

Significance: NCAA women's soccer players were deficient in hip extension and abduction. Future research can evaluate whether these disparities contribute to the different injury patterns seen in women's soccer, including the higher incidence of knee ligament injuries.

Acknowledgments: The authors acknowledge the Emory University intercollegiate soccer teams and sports medicine department for their contributions to this research.

Primary Author/Presenter: Joshua A. Beitchman, MD, MBS

Affiliation: Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas; Pediatric Residency Program, Children's Health, Dallas, Texas.

Endophenotype Presentation of Athletes With Concussion Contingent Upon Sex and Time Since Injury

Coauthors: Jacob Jones, MD, Nyaz Didehbani, PhD, Jane Chung, MD, Shane Miller, MD, Mathew Stokes, MD, Munro Cullum, PhD

Topic: Concussion.

Study: Other.

Purpose: Concussed athletes present with heterogeneous symptoms and clinical trajectories. Identifying endophenotypes helps improve prognostication and focused treatments. We evaluated how endophenotypes differ among athletes based on sex and injury time line.

Methods: Athletes aged 12-18 years in the North Texas Concussion Network Registry (ConTex) were divided based on days since injury. Results of KD, BESS, Concussion Symptom Log, GAD-7, PHQ-8, and Pittsburgh Sleep Quality Index were grouped into endophenotypes based on established data elements outlined by the Concussion Subtype Workgroup, and correlations were examined regarding days post injury (DPI) and sex.

Results: Distinct clusters in endophenotype matrices identified time points of maximum symptom correlations in 1385 athletes (M:51%; F:49%). Acutely (0-3DPI), male athletes demonstrated cognitive (r = 0.2-0.68) and headache (r = 0.59-0.74) endophenotypes, whereas female athletes had no predominant endophenotype. Subacutely (4-7DPI), female athletes demonstrated headache (r = 0.58-0.84), cognitive (r = 0.42-0.72), and vestibular (r = 0.15-0.76) endophenotypes, whereas male athletes had no predominant endophenotype. In the 8-28 DPI group, female athletes had a cognitive endophenotype (r = 0.43-0.7), whereas male athletes showed cognitive (r = 0.35-0.72) and vestibular (r = 0.13-0.72) endophenotypes. Chronically (29+DPI), female athletes had a mood (r = 0.130-0.8), sleep (r = -.42-.71), and cognitive (r = 0.41-0.71) endophenotypes, whereas male athletes had a mood (r = 0.16-0.8), sleep (r = -0.45-0.77), and headache (r = 0.49-0.76) endophenotypes. Correlation matrices in the chronic stage indicated mood and sleep symptoms were moderately correlated (r > 0.5) with cognitive, vestibular, and headache endophenotypes.

Conclusions: Concussed athletes experience symptoms differently based on sex and time since injury. This influences symptom clusters, with implications for concussion endophenotypes related to sex and injury time line. Chronically, endophenotypes appear most interrelated with dysregulated mood and sleep. These interactions may contribute to the multifactorial etiology of persistent postconcussion symptoms.

Significance: Proper characterization of sports-related concussion into endophenotypes requires consideration of gender and injury time line. Improved identification of clinical trajectories may allow for a targeted clinical approach of concussed athletes.

Fibula Stress Fractures Correlation to Pes Planus and Hindfoot Valgus Deformity

Primary Author/Presenter: Greta Bires, MD

Affiliation: Thomas Jefferson University Hospital, Philadelphia, PA.

Coauthors: Marya Ghazzi, Imana Rhoden, MD, Christopher Mehallo, DO, Marc Harwood, MD

Topic: Musculoskeletal.

Study: Cohort

.Purpose: Approximately 10% of stress fractures occur in the fibula. The pathogenesis and predisposing characteristics are not completely understood as the largest study is an n = 12 case series. Our hypothesis is that pes planus and hindfoot valgus are significantly associated with fibula stress fractures.

Methods: A retrospective study analyzed fibula stress fracture patients with visits in 2015-2020. χ2 and T-test for categorical and continuous variables, respectively, assessed pes planus and hindfoot valgus rates using Meary angle (MA), calcaneal pitch, and tibiotalar angle (TTA). Logistic regressions assessed rates of pes planus, MA > 4, and hindfoot valgus, TTA < 90, controlling for covariates.

Results: Sixty-two patients were analyzed. Baseline demographics showed female preponderance (74.2% female vs 25.8% male), average age = 42.2 years (SD 19.4), average BMI = 25.0 (SD 5.47), more nonsmokers (59 to 1), and a higher rate of sports injuries than not (40 patients or 64.5% vs. 22 patients or 35.5%). Thirty-one patients (50%) had a Meary angle < -4 (pes planus), 23 (37.1%) ranged 4 to -4, and 8 (12.9%) ranged > 4 (pes cavus) (P< 0.001). Of the 31 patients with pes planus, 27 (43.5%) ranged -4 to -15 (mild deformity) and 4 (6.45%) ranged -15 to -30 (moderate deformity). Twenty-six patients (41.9%) had calcaneal pitch 10-20 (pes planus), 35 (56.5%) had 20-30, and 1 (1.61%) had 30+ (pes cavus) (P value < 0.001). Thirty-nine (62.9%) had tibiotalar angle < 90 degrees compared with 23 (37.1%) with tibiotalar angle > 90 degrees (P = 0.004). There was continued significance of pes planus (P < 0.001) and hindfoot valgus (P = 0.004) rates when controlling for age, sex, BMI, and sports injury.

Conclusions: Baseline demographics showed higher rate of fibula stress fractures in women and through sports injuries. There was a higher rate of pes planus and hindfoot valgus among the population. These relationships remained significant when controlling for covariates such as age, sex, BMI, and sport injuries, supporting our hypothesis.

Significance: The results suggest the importance of pes planus and hindfoot valgus in those with fibula stress fractures. This study presents the largest study to date with a comprehensive analysis of characteristics and pes planus rates in this population.

Acknowledgments: Statistics were done by statistician Matthew Sherman.

Sleep Extension and Consistency Improve Athletic Performance in NCAA Division I Collegiate Athletes

Primary Author/Presenter: Nelson Boland, MD

Affiliation: University of California, Los Angeles—Division of Sports Medicine, Santa Monica, CA.

Coauthors: Brian Donohoe, MD, Calvin Duffaut, MD, Joshua Goldman, MD, MBA

Topic: NCAA.

Study: RCT.

Purpose: To determine the effects of sleep extension and sleep consistency interventions on athletic performance metrics, including sprint speed, reaction time, and sport-specific accuracy measurements, in NCAA Division I men's soccer, women's soccer, and men's water polo players.

Methods: This is a randomized, controlled, crossover study. Forty-six NCAA Division I athletes wore a validated device to quantify sleep time and consistency during a 2-week sleep consistency intervention, then a 2-week washout phase, followed by a 2-week sleep extension intervention. Baseline performance data were obtained at the beginning of the study and was repeated after each sleep intervention.

Results: The soccer cohort was 38% male (N = 8) and 62% female (N = 13; age 18-22 years). The water polo cohort was 100% male (N = 25; age 18-22 years). In soccer players, there was a significant improvement in 40-yard sprint time from baseline with sleep extension (5.64 s vs 5.49 s, P = 0.05) and sleep consistency interventions (5.64 s vs 5.38 s, P < 0.01). There was a significant improvement in shooting accuracy with sleep extension (44.7% vs 51.8%, P = 0.04) and sleep consistency interventions (44.7% vs 57.7%, P < 0.01). There was a significant improvement in reaction time with sleep extension (203 ms vs 184 ms, P < 0.01) and sleep consistency interventions (203 ms vs 193 ms, P = 0.04). In water polo players, there was a significant improvement in 50-yard swim time (24.7 s v 23.9 s, P < 0.01) and reaction time (192 ms vs 167 ms, P = 0.04) with the sleep consistency intervention. In all athletes, there was no change in mood state with any intervention (baseline POMS = -10.8, extension POMS = -6.3, P = 0.21; consistency POMS = -4.8, P = 0.10).

Conclusions: NCAA Division I soccer and water polo players showed significant improvement in athletic performance metrics after sleep extension and sleep consistency interventions. There was no difference in mood as assessed by the abbreviated profile of mood survey. These findings suggest that sleep extension and consistency interventions are effective tools for enhancing athletic performance but do not necessarily improve mood.

Significance: This is the first study to evaluate the effects of sleep extension on athletic performance in collegiate soccer and water polo players and the first to evaluate the effects of sleep consistency on athletic performance in any sport or athletic cohort.

Acknowledgments: The investigators acknowledge the UCLA athletic trainers and students who assisted with data collection. The team also thank WHOOP Inc. for their donation of activity tracking devices and statistical support.

Sport Specialization Is Associated With Increased Return-to-Play Time Periods in Youth Athletes

Primary Author/Presenter: Anna Buser, BS

Affiliation: Emory Sports Medicine Center & Emory University School of Medicine.

Coauthors: Ally Render, BS, Stacey Schley, MD, Mario Ramirez, BS, Caleb Truong, Stephanie Logterman, MD, Jeffery Webb, MD, Neeru Jayanthi, MD

Topic: Pediatrics.

Study: Cohort.

Purpose: To evaluate the effect of the degree of sport specialization in relation to return-to-play time periods (short (<10), intermediate (10-30), or long (>30 days)) in youth athletes. To evaluate the association of sport specialization with injury type and stage of biologic maturation.

Methods: Injured athletes aged 10 to 23 years who presented to sport medicine clinic reported their degree of sport specialization. Biologic maturation was measured by the Khamis–Roche method for the percentage of predicted adult height (PPAH). Injury type and return-to-sport (RTS) time frames were categorized from physician documentation. Multiple χ2 tests assessed potential associations between the variables.

Results: At submission, there were 359 subjects enrolled, and at analysis, 329 subjects (mean age = 15.5 years) had data on the degree of specialization, RTS, injury type, and PPAH. There is a strong association between the degree of sport specialization and return-to-play time periods (P = 0.034) with highly specialized athletes more likely to have longer return-to-play time periods. In addition, the degree of sport specialization was strongly associated with injury type (P = 0.0005), showing a higher incident of overuse and serious overuse injuries among highly specialized athletes. There is no association between the degree of specialization (categorized as low, middle, or high) and PPAH.

Conclusions: (1) There is a significant association between the degree of sport specialization and longer return-to-play time periods. (2) There is a significant association between the degree of sport specialization and overuse injury type. (3) There is no association between sport specialization and biologic maturation, nor individual specialization parameters and PPAH.

Significance: Highly specialized athletes may be more likely to have overuse injuries and longer return-to-play time periods. Anticipatory guidance of highly specialized athletes is recommended. The optimal stage of development for specialization is still unknown.

Acknowledgments: Funding Source: Emory University Department of Orthopedics intramural seed grant.

Longitudinal Patient-Reported Outcomes Among Osteoarthritis Patients Injected With Zilretta or Triamcinolone Acetate

Primary Author/Presenter: Cher Chang, MD

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

Coauthors: Mohammad N. Haider, MD, PhD, Nomi Weiss-Laxer, PhD, MPH, MA, Jesse M. Galina, BS, Sibtain Mustafa, BS, Sophia Bisson, Leslie J. Bisson, MD

Topic: Musculoskeletal.

Study: Other.

Purpose: Triamcinolone acetate (TA) and the newer extended-release Zilretta (ZA) are effective when compared with other corticosteroids with limited research comparing them. We compared patient-reported outcomes (Knee injury and Osteoarthritis Outcome Scores [KOOS]) in patients who received either injection.

Methods: Retrospective chart review of patients diagnosed with knee osteoarthritis (OA) who had TA (n = 522, 61.6 ± 10.9 years, 61% F, 33.6 ± 8.3 kg/m2) or ZA (n = 273, 58.3 ± 11.8 y/o, 58% female, 34.1 ± 6.5 kg/m2) injections from January 1, /2021, to December 31, 2021. KOOS data were collected at the initial visit and monthly for 6 months and analyzed using mixed-model linear regression.

Results: TA began with higher (better) KOOS pain scores than ZA (47.7 vs 43.9, P = 0.003). On mixed model regression, pain score changed over time (F = 6.1, P = 0.014) and was associated with preinjection score (F = 576.3, P < 0.001), but there was no significant effect of injection (F = 0.4, P = 0.545) or the interaction of injection with time (F = 0.3.3, P = 0.069).However, TA had a mean improvement from baseline at 1 month (12.0 [9.8, 14.3]), 2 months (8.9 [6.4, 11.3]), and 3 months (4.7 [2.4, 7.0]), whereas ZA had a mean improvement from baseline at 1 month (14.0 [10.4, 17.5]) and 2 months (7.6 [3.9, 11.4]) but not at 3 months (0.7, [-2.9, 4.5]). No differences from baseline were seen beyond 4 months for either injection. The same pattern existed for activities of daily living (ADL), sports and recreational activity, and symptom scores. Quality of life was better than baseline for both injections only at 1, 2, and 3 months.

Conclusions: We found that patient-reported outcomes over the first 6 months following an injection depended on the degree of patient-reported symptoms/activities at the time of injection. There was no difference in pain or outcomes between ZA or TA over time. It is even possible that TA offers symptom relief for a longer period than ZA, but future randomized controlled trials testing comparing the 2 drugs are warranted.

Significance: Our results are important for doctors and patients when deciding which injection to use. We found no evidence that ZA ($652.32) was better than TA ($17.75) for self-reported pain or other symptoms, ability to perform ADL, or sport participation.

Visual Perception Training for Basketball Affects Lower Extremity Motion and Loading

Primary Author/Presenter: Jaineet Chhabra, MS

Affiliation: Marshall University Joan C. Edwards School of Medicine, Huntington, WV.

Coauthors: Kassandra Flores, MS, Kasey Stickler, MD, David Rupp, MD, Steven Leigh, PhD

Topic: Training.

Study: RCT.

Purpose: We aimed to determine the short-term effects of four-weeks of visual perception training on lower extremity limb movement precision and joint forces of recreational basketball players performing common basketball skills.

Methods: Healthy, experienced, youth, basketball players were tested in basketball drills as their movements were recorded by a 3-D motion capture system and force plates. Players completed 4 weeks of randomly assigned general play or visual perception training and were then retested. Movement precision measures and joint forces were calculated from the motion analysis and force plate data using MatLab.

Results: Lower extremity position at impact was calculated as the combined, instantaneous hip, knee, and ankle angles at maximum ground reaction force. The precision (reproducibility) of this position was assessed with the coefficient of multiple correlation and was greater for the post test of the visual perception training group than for the general training group for the layup skill (0.860 vs 0.790) and the rebound skill (0.860 vs 0.648). Knee joint resultant force was similar for both the groups for the posttest of the layup and rebound skills. Ankle joint lateral shear force was significantly lower for the post test of the visual perception training group than for the general training group for the reactive defensive slide skill (21 ± 2 N/kg vs 25 ± 2 N/kg, t = 2.62, P < 0.05).

Conclusions: The greater joint position reproducibility for the visual perception training group suggests that these players' movements became more precise as they improved their proprioception. Because injuries tend to occur with inconsistent/unpredictable motion, greater movement precision is beneficial. The lower ankle lateral shear force for the visual perception training group indicates that they are at a lower risk of a lateral ankle sprain after the training.

Significance: These findings draw attention to potentially risky movement patterns that increase joint loading and suggest that perception and visualization techniques can be added to effective injury prevention interventions without adding an additional time burden.

Acknowledgments: The authors thank the participants for volunteering their valuable time with us.

Screening College Athletes for Sexual Violence: Current Trends and Athletes' Opinions on Best Practices

Primary Author/Presenter: Sherilyn DeStefano, MD

Affiliation: Oregon Health and Science University, Portland, OR.

Coauthors: Emily Peterson, MD, Derek C. Pham, Nicholas J. Jackson, PhD, MPH, Derjung M. Tarn, MD, PhD, Dena Florczyk, MD, Aurelia Nattiv, MD

Topic: NCAA.

Study: Other.

Purpose: Twenty-nine percent of student-athletes experience sexual violence during college, but only 9% formally report it. There is little data assessing screening for sexual violence among this population. This study examined past screening among athletes and athletes' opinions on best screening methods.

Methods: This was a cross-sectional survey study of intercollegiate and club athletes at a Division I university. Outcomes included the number of participants previously screened, personnel conducting screening, and timing of screening. Survey participants were invited to partake in follow-up group interviews on best screening practices. Interviews were transcribed then coded using thematic analysis.

Results: One hundred sixty-five participants (62% female and 38% male) completed the survey. One hundred twenty-four (75%) responded that they had not received previous screening. Of those who had been previously screened, this was most frequently completed by a health care provider (54%), and for 83%, it occurred within the past 2 years. Twelve student-athletes (8 female athletes and 4 male athletes) from a range of different sports participated in the group interviews. Areas of needed focus around sexual violence screening were identified: population-wide education, normalizing the conversation, emphasizing mental health, and decreasing stigma. Participants suggested that knowledge on the subject, shared experience, and a sense of caring/compassion are important components in the person conducting screening. They also identified several best practices for screening, including priming individuals for sensitive questions, creating a comfortable and private environment, being transparent about how the information will be used, and screening at regular intervals.

Conclusions: These results suggest that college athletes are not routinely being screened for sexual violence. Components such as regular screening, importance of a comfortable and private environment, building trust, decreasing stigma, transparency, and increasing population-wide knowledge on the subject were identified as important practices when developing and implementing screening protocols.

Significance: This study is the first to gather data directly from college athletes about their opinions on how health care teams can most effectively and sensitively screen this at-risk population to allow early intervention.

Acknowledgments: Funded in part by a grant from the American Medical Society for Sports Medicine (AMSSM) Foundation and supported by NIH/National Center for Advancing Translational Science (NCATS) UCLA CTSI Grant Number UL1TR001881. The opinions expressed herein are those of the authors.

Primary Author/Presenter: Bianca Edison, MD, MS

Affiliation: Children's Hospital Los Angeles, University Southern California.

Changes in Sports Participation, Specialization, and Burnout From 7th to 12th Grade: Final Results

Coauthors: Jacquelyn Valenzuela-Moss, BA, Milo Sini, MPA, Tishya Wren, PhD

Topic: Pediatrics.

Study: Cohort.

Purpose: This study examined changes in sports participation, specialization, and burnout in students followed longitudinally from 7th through 12th grade. We have now collected data through the participants' final year of high school and report results for the entire middle and high school period.

Methods: The same class (graduating class of 2023) was surveyed longitudinally in the fall of each school year from 7th to 12th grade (n = 35-77, depending on the year). Survey questions asked about sports participation, specialization, and burnout. Responses were analyzed by grade level using mixed-effects linear and logistic regression accounting for repeated measures.

Results: The number of days/week in which students engaged in at least 60 minutes of strenuous exercise progressively decreased from 7th through 12th grade from 4.0 to 2.3 days/week (P< 0.001). The percentage of students participating in sports also decreased from 7th to 12th grade from 82% to 41% (P< 0.001). More students stopped participating in a sport (38% vs. 21-29%, P = 0.046), quit a sport to focus on a single sport (60% vs. 46-49%, P = 0.02), or reported that one sport was most important to them (71% vs. 54-67%, P = 0.06) in 9th grade, although the percentage of athletes spending at least 75% of their time in a single sport did not differ significantly across grade level (59-75%, P> 0.09). Burnout in sports did not differ significantly by grade level (9-29%, P = 1.00). By contrast, burnout in school was significantly more common in high school (15-36%) compared with middle school (17%, P = 0.001) because homework load increased from an average 2.4 of hours to 3.4 per school night (P< 0.001).

Conclusions: Organized sports participation and exercise activity decreased throughout middle and high school, with the entry into high school at 9th grade being a time at which a significant number of students dropped other sports to specialize in a single sport or stopped participating. Burnout in sports did not appear to increase with age; however, there was an increase in school-related burnout as students transitioned from middle to high school.

Significance: Research ascertaining whether burnout from school and mental health challenges affect decreased physical activity or if decreased physical activity in turn affects school-related burnout would be important to develop impactful interventions and resources.

Acknowledgments: The authors thank the HW Institute of Scholastic Sports Science and Medicine for their help with project planning and implementation.

Primary Author/Presenter: Georgia Griffin, MD

Affiliation: University of Washington, Seattle, WA.

Project Nature: A Pilot to Promote Childhood Outdoor Physical Activity Through Primary Care

Coauthors: Carolina Nieto, PhD, Kirsten Senturia, PhD, Marshall Brown, MS, Kim Garrett, MPH, Elizabeth Nguyen, MD, Pooja Tandon, MD

Topic: Pediatrics.

Study: Other.

Purpose: We aimed to develop a family-centered and easily disseminated tool to promote active outdoor play during well-child visits and to meet the needs of diverse families living in areas where opportunities for outdoor recreation may be limited.

Methods: We adapted Project Nature, a tool consisting of a brochure and toy used by pediatric providers to encourage outdoor play. We conducted a mixed-methods pilot study (before/after surveys and qualitative interviews) of 20 families with children aged 4 to 10 years being seen for well-child visits at an urban clinic serving families from diverse backgrounds. We conducted quantitative and qualitative analyses.

Results: All parents surveyed felt that time in nature and daily physical activity were important. Parents recalled their child's medical provider encouraging daily outdoor time during a well-child visit in the past year: 67% of the time preintervention and 100% of the time postintervention. Children were reported to be physically active for at least 20 minutes for a median of 5 days per week preintervention (vs 6 days per week postintervention) and play outside for a median of 4 days per week preintervention (vs 5 days per week post-intervention). The most popular toys chosen were seed packets and shovel, chalk, magnifying glass, frisbee, and kite. Most (80%) parents liked the Project Nature kit, and they found the toy helpful because it provided a tangible activity to help their children be more active, and even helped parents be more active as well. Parents wished the nature kit had more emphasis on how to help their kids be more active during cold and wet times of the year.

Conclusions: The Project Nature kit was a practical intervention to employ during well-child visits, and it was acceptable and welcomed by families. This study shows that well-child visits are a feasible and potentially effective setting to promote active outdoor play.

Significance: Providing a nature toy as part of an intervention to promote outdoor activity during well-child visits may be one strategy to reduce disparities in children's physical activity and time in nature.

Primary Author/Presenter: Kimberly Harmon, MD, FAMSSM

Affiliation: University of Washington.

How Accurate Are the SCAT 5 and King–Devick for the Acute Diagnosis of Concussion?

Coauthors: Bridget Whelan, MPH, Heather Elkington, MS, ATC, Gabrielle Garruppo, MHS, Marissa Holliday, MEd, ATC, Calvin Hwang, MD, Sourav Poddar, MD, Douglas Aukerman, MD

Topic: Concussion.

Study: Case–control.

Purpose: The purpose of this study was to determine the diagnostic accuracy of components of the SCAT 5 (Symptom Score (SS), Symptom Severity Score (SEV), the 10-word Standardized Assessment of Concussion (SAC), and the modified-Balance Error Scoring System (m-BESS)) and of the King–Devick Test (KD).

Methods: NCAA Division I college athletes from four schools completed baseline testing including the SCAT-5 and KD. When an athlete presented acutely with suspected concussion from February 2020 to December 2022 (sideline/within 24 hours), the tests were repeated. If a concussion was diagnosed, a control was identified to test, matched on comorbid conditions, gender, team, season, and baseline scores.

Results: Baseline and postinjury data were collected on 147 concussed and 147 matched control athletes. Athletes were predominantly male (n = 152, 52%), with the most concussions among football (n = 56, 38%), volleyball (n = 21, 14%), softball (n = 15, 10%), and women's soccer (n = 9, 6%) and other sports (n = 46, (31%). SS and SEV were the most sensitive and specific measures with sensitivities of 84% and 88% (3-point increase in scores) and AUC of 0.93 (0.90-0.96) and 0.94 (0.91-0.96), respectively. The 10-word SAC had poor test–retest reliability with ICC of 0.56 (0.38-0.69), poor sensitivity (53% with 1-point decrease), and fair AUC at 0.70 (0.64-0.76). m-BESS also had poor test–retest reliability ICC of 0.43 (0.28-0.56), poor sensitivity (37% with 3-point increase), and poor AUC at 0.61 (0.55-0.68). The KD had fair test–retest reliability of 0.71 (0.62-0.79), the best sensitivity of the objective tests at 84% (with any increase in time), but only fair AUC of 0.74 (0.69-0.80).

Conclusions: Symptoms are the most accurate indicator of concussion but are subjective and require the athlete to accurately recognize and report them. Of the objective measures, the KD had the best test–retest reliability, was the most sensitive indicator of concussion, and had the best AUC. The 10-word SAC and m-BESS were not reliable or sensitive indicators of concussion but were more specific as errors increased.

Significance: Understanding the psychometric properties of recommended concussion tests is critically important in their accurate interpretation. Although the SAC and the m-BESS are not sensitive, they become specific with increasing errors.

Acknowledgments: The authors acknowledge funding support from generous donations from the University of Washington alumni Jack and Luellen Charneski and the Chisholm Foundation.

Primary Author/Presenter: Brian S Harvey, DO

Affiliation: Children's Mercy Hospital, Kansas City 2401 Gillham Road Kansas City, MO.

Injury Patterns in Elite US Youth Soccer Players

Coauthors: Jonathan Warren, MD, Shannon Margherio, PT, OCS, Thomas Munro, MD, James Roberson, MD, Kevin Latz, MD

Topic: Epidemiology.

Study: Cohort.

Purpose: Reducing the incidence and severity of injury is one of the primary goals of health care in sports medicine. However, to prevent injury overall injury patterns and epidemiological factors of the injuries must be understood.

Methods: The soccer database for local developmental academy teams U12 (12 years and under) to U19 (19 years and under) was reviewed. We analyzed data from the 2019-2020, 2020-2021, and 2021-2022 seasons, including injury frequency, hours played, type, and location of injury were then compared between the teams.

Results: Over three seasons, there were 94,400 total hours played with an injury rate of 3.7/1,000 hours. Older teams had higher injury rates than younger teams with the U15s, U17s, and U19s having injury rates of 4.6 per 1000 hours and the U14s, 13s, and 12s having injury rates of 3 per 1000 hours. Among injury types, 38.2% were muscle injuries and 18.6% were ligament injuries. The thigh was the most commonly injured location (20.9%). The hip/groin (15.9%), knee (14.1%), and ankle (13.5%) were also common injury locations. The most frequent (40.5%) injury severity was classified as “moderate” requiring 8 to 28 days of recovery. The U13s (24%) had the highest frequency of bone injury compared with all other groups. Among injury types, the U19s (P equals 0.046) and U17s (P equals 0.012) had significantly more muscle and ligament injuries and fewer concussions compared with the U12s. There were no other significant differences in injury type or location between the teams.

Conclusions: Among elite youth soccer athletes in the United States, muscle and ligament injuries are the most common types of injury. The hip, groin, knee, and ankle are the most common injury locations. Athletes experience significantly more muscle and ligament injuries as well as fewer head injuries as they get older. Bone injury (most commonly apophysitis) had the highest frequency in the U13 team, indicating an age component to this injury type.

Significance: There is very little data on injury patterns for elite youth soccer athletes. These data suggest that certain age groups may be more likely to sustain specific injuries, allowing providers to create preventive, age-based strategies.

Acknowledgments: Kurt Andrews.

Primary Author/Presenter: Marc Heronemus, MD

Affiliation: University of Colorado.

Concussion History Does Not Affect Smartphone-Based Dual-Task Performance in Adolescents

Coauthors: Matthew Wingerson, MS, Samantha Magliato, BS, Katherine Smulligan, PT, DPT, Julie Wilson, MD, Vipul Lugade, PhD, David Howell, PhD, ATC

Topic: Concussion.

Study: Cohort.

Purpose: Impairments in dual-task function (concurrent motor/cognitive task) emerge following concussion in adolescents. The cumulative effect of prior lifetime concussions on dual-task performance in patients within 14 days of current concussion requires further investigation.

Methods: We tested 3 groups of participants: uninjured controls with no concussion history, patients seen within 14 days after their first lifetime concussion, and patients seen within 14 days after their second or greater concussion. Outcomes assessed under single- and dual-task conditions were gait velocity, auditory Stroop accuracy, and response time. We compared performance using 1-way ANOVAs.

Results: Forty-eight participants were included, n = 15 (31%) following their first lifetime concussion, n = 12 (25%) following their second or greater lifetime concussion, and n = 21 (43%) with no concussion history. There were no significant demographic or injury characteristic differences among the groups. No between-group differences for single-task (0.91 ± 0.13 vs. 0.94 ± 0.21 vs. 0.92 ± 0.16 m/s; P = 0.91) or dual-task (0.84 ± 0.13 vs. 0.92 ± 0.21 vs. 0.89 ± 0.13 m/s; P = 0.38) gait velocity or single-task (79 ± 24% vs. 84 ± 16% vs. 75 ± 15% correct; P = 0.41) or dual-task (79 ± 25% vs. 86 ± 19% vs. 75.0 ± 18.3% correct; P = 0.29) Stroop accuracy were identified. The first lifetime concussion group had significantly slower single-task Stroop response times (1707 ± 148 ms) than the other groups (1442 ± 193 and 1499 ± 197 ms; P = 0.001). The control group demonstrated significantly faster dual-task Stroop response times (1283 ± 117 ms) than the 2 concussion groups (1593 ± 174 and 1566 ± 324 ms; P< 0.001).

Conclusions: Smartphone-assessed dual-task response time, but not response accuracy or single-task or dual-task gait velocity, is negatively impacted by concussion within 14 days of injury. There does not appear to be a cumulative effect of multiple lifetime concussions on postconcussion single-task or dual-task gait velocity, response time, or accuracy as participants with prior concussions did not have worse outcomes than the first lifetime concussion group.

Significance: Assessing dual-task performance may be useful as an additional tool for concussion evaluation. The effect of multiple concussions on dual-task function in adolescents warrants further research given our small sample size.

Acknowledgments: This study was funded by the National Institute of Neurological Disorders and Stroke (R43NS108823) and the Tai Foundation.

Primary Author/Presenter: Rajiv Jain, MD

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

The Effect of Exertion on Common Sideline Assessments Of Concussion In Healthy Adolescent Athletes—Randomized Controlled Trial

Coauthors: Kendall Marshal, ATC, Mohammad Haider, MD, PhD, Antony Surace, ATC, Griffen Spatorico, ATC, Nomi Weiss-Laxer, MPH, PhD, Jason Matuszak, MD, John Leddy, MD

Topic: Concussion.

Study: RCT.

Purpose: Common sideline concussion assessments, i.e., Sport Concussion Assessment Tool 5 (SCAT5) and Vestibular Ocular Motor Screen (VOMS), are sensitive in identifying deficits immediately after head injury. This study's purpose is to see how level of exertion affects these assessments in healthy athletes.

Methods: Athletic adolescents with no concussion within past 1 month performed concussion assessments at rest and then were randomized to perform (1) no exertion (15 minute seated rest); (2) minimal exertion (15-minute walking at 50-55% of heart rate [HR] max); and (3) moderate exertion (15-minute jogging at 70-75% HR max). Participants performed assessments again after exertion and were compared.

Results: No demographic differences were seen between no (n = 16, 15.6 ± 1.1 y/o, 56% male, 38% history of concussion), minimal (n = 16, 15.9 ± 1.1 y/o, 56% male, 44% history of concussion), or moderate (n = 15, 15.7 ± 1.1 y/o, 60% male, 13% history of concussion) exertion groups. Before exertion, groups did not differ in symptoms (1.4 ± 1.5, 2.7 ± 4.7, 2.2 ± 4.7, P = 0.789), orientation (4.9 ± 0.3, 4.9 ± 0.3, 4.8 ± 0.4, P = 0.370), immediate memory (14.8 ± 0.4, 14.5 ± 1.0, 14.5 ± 0.5, P = 0.468), mBESS (3.1 ± 2.8, 3.9 ± 2.2, 3.5 ± 3.2, P = 0.578), or VOMS (0.1 ± 0.3, 0.1 ± 0.3, 0.1 ± 0.3, P = 0.836). Groups reached different HR during exertion (84.1 ± 14.3, 133.9 ± 15.9, 155.1 ± 19.0, P < 0.001). After exertion, groups did not differ in symptoms (0.7 ± 1.2, 1.8 ± 3.4, 1.7 ± 5.1, P = 0.872), orientation (4.9 ± 0.3, 4.9 ± 0.3, 4.9 ± 0.4, P = 0.725), immediate memory (14.6 ± 0.7, 14.1 ± 1.3, 14.2 ± 1.1, P = 0.305), mBESS (3.4 ± 3.0, 4.0 ± 3.0, 3.5 ± 2.8, P = 0.801), or VOMS (0.1 ± 0.5, 0.1 ± 0.3, 0.1 ± 0.3, P = 0.810).

Conclusions: This study did not find any groupwise differences in concussion assessment performance after different levels of exertion (none, minimal, or moderate). The effects of maximal exertion cannot be commented on because they were not assessed in this study. In addition, no obvious learning effect was observed in participants who were randomized to the no exertion group, which may be attributed to the ceiling effect.

Significance: This randomized controlled trial did not find any differences in concussion assessment after healthy adolescents had performed no exertion, minimal exertion, or moderate exertion, suggesting that these tests are appropriate for sideline assessment.

Acknowledgments: Galen Argyle.

Primary Author/Presenter: James Jastifer, MD

Affiliation: Western Michigan University Homer Stryker M.D. School of Medicine Department of Orthopaedic Surgery, Ascension Borgess Hospital, Kalamazoo, MI.

COVID-19 in Ultramarathon Runners: Findings of The Ultrarunner Longitudinal TRAcking Study

Topic: COVID.

Study: Cohort.

Purpose: Ultramarathon runners are a unique patient population who have been shown to be free of nearly all severe chronic medical conditions. The effect that COVID-19 infection has on this population and their running behavior is unknown.

Methods: The Ultrarunner Longitudinal TRACking Study (ULTRA Study) is the largest known longitudinal study of ultramarathon runners. Questions on general health status, running behavior, performance, and COVID-19 infection were included.

Results: Six hundred sixty-two ultramarathon runners participated in the study. This group exercised an average of 10.0 hours per week, including running an average of 26.8 miles per week; 52.1% of ultramarathon runners reported ever being symptomatic from a COVID-19 infection with 6.3% testing positive multiple times. Severe infection occurred in 0.3% (2 patients) requiring a total of 3 days of hospitalization. Of those who were infected, 84% were fully vaccinated at the time of their infection; 67% of infections effected running for a mean of 33.1 days. The most common other symptoms included fever (73.3%), fatigue (68.7%), sore throat (67.5%), runny nose (67.0%), and cough (66.7%). Cardiovascular symptoms, which are of particular interest in the running population, included shortness of breath (46.4%), increased heart rate (45.2%), chest pain (34.2%), and wheezing (32.5%). Of 662, 48 (7.3%) of ultrarunners reported Long COVID (symptoms lasting more than 12 weeks).

Conclusions: Severe COVID-19 infection is rare in ultramarathon runners, although symptomatic infection that affects running is common. These rates, along with Long COVID, are lower than is reported in the literature for the population on average.

Significance: Ultrarunners are at very low risk of COVID-19 symptoms requiring hospital care but significant risk of infection that effects running. Cardiovascular symptoms are common, and the long-term significance of these symptoms in runners is unknown.

Primary Author/Presenter: Jacob Jones, MD

Affiliation: Scottish Rite for Children, Dallas, TX.

Increased Ultrasonographic Humeral Retrotorsion in Young Overhead Athletes With Little League Shoulder or Elbow

Coauthors: Cassidy Schultz, BS, Joseph Chang, MD, Hamza Alizai, MD, Jane Chung, MD, Shane Mill