Sports Related Concussion.

Sports-related concussions (SRC) have been a topic of interest for decades and are a prevalent risk of sports participation. The definition of SRC continues to evolve but includes a plausible mechanism and associated symptoms of injury. Rates of concussion vary among sports, and many sports have adopted rule changes to limit this risk for its athletes. There has been a considerable effort to prevent the occurrence of SRC, as well as a focus on safe return to learn and sport alike. There is growing concern about the ramifications of concussions, which will continue to warrant further investigation.

Assessment of the Current State of Sports Coverage Participation, Training, and Confidence Ratings among Physical Medicine and Rehabilitation Residents and Residency Programs.

ABSTRACT: A significant proportion of physical medicine and rehabilitation residents are pursuing sports medicine-related fellowships and are recommended to participate in sports coverage during residency training. The purpose of this article is to assess the current state of sports coverage participation, training, and confidence ratings among physical medicine and rehabilitation residents and residency programs. Physical medicine and rehabilitation residents from Accreditation Council for Graduate Medical Education-accredited programs were invited to participate in a nationwide cross-sectional survey. A total of 90 resident responses from 43 programs were included. Residents from 91% of represented programs indicated that sports coverage opportunities were available. At least one resident from 63% of represented programs and 50% of responding residents reported sports coverage training during residency. Sports coverage confidence ratings were higher in 91% of topics among residents who received training. The results of this study indicate that sports coverage opportunities are common among physical medicine and rehabilitation residencies, and while sports coverage training is variable, a positive correlation with confidence ratings was identified.

Collision and Contact Sport Participation and Quality of Life Among Adolescent Athletes.

CONTEXT: Researchers investigating collision and contact sport participation during high school have found mixed results. Understanding the association between current contact and collision sport participation and quality-of-life outcomes can enhance our knowledge about the risks and benefits of sport participation. OBJECTIVE: To examine quality-of-life outcomes among high school athletes who reported participation in collision and contact sports in the year preceding assessment compared with no- or limited-contact sport athletes. DESIGN: Cross-sectional study. SETTING: Preparticipation physical examination. PATIENTS OR OTHER PARTICIPANTS: High school athletes 13 to 18 years of age. MAIN OUTCOME MEASURE(S): We obtained sport participation and Patient-Reported Outcomes Measurement Information System (PROMIS) Pediatric-25 outcomes, which assess self-reported, quality-of-life domains in the preceding 7 days (ie, state assessment). Our grouping variable was collision and contact versus no- or limited-contact sport participation during the year preceding assessment. We used multivariable linear regression models to identify the associations between PROMIS scores and collision and contact sport participation and adjusted for sex; age; history of bone, muscle, ligament, or tendon injury; history of acute fracture or dislocation; and history of concussion. RESULTS: A total of 143 (51%) athletes reported collision and contact sport participation (24% female, mean age = 15.1 ± 1.7 years) and 138 (49%) reported no- or limited-contact sport participation (66% female, mean age = 15.4 ± 1.2 years). A higher proportion of collision and contact sport athletes reported a history of time loss for bone, muscle, ligament, and tendon injuries (51% versus 29%, P < .001) and for acute fracture or dislocation (46% versus 26%, P < .001) than did no- or limited-contact athletes. After adjusting for covariates, we found that collision and contact sport participation was significantly associated with lower state anxiety (ß = -1.072, 95% confidence interval = -1.834, -0.310, P = .006) and depressive (ß = -0.807, 95% confidence interval = -1.484, -0.130, P = .020) symptom scores. CONCLUSIONS: Collision and contact sport athletes reported fewer anxiety and depressive symptoms in the week preceding evaluation than did no- or limited-contact sport athletes, but they had more extensive orthopaedic injury histories. Potential benefits and risks are associated with collision and contact sport participation. These data reinforce the need to examine the assumption that youth collision and contact sports are associated with negative quality of life.

Pain Management Best Practices from Multispecialty Organizations During the COVID-19 Pandemic and Public Health Crises.

BACKGROUND: It is nearly impossible to overestimate the burden of chronic pain, which is associated with enormous personal and socioeconomic costs. Chronic pain is the leading cause of disability in the world, is associated with multiple psychiatric comorbidities, and has been causally linked to the opioid crisis. Access to pain treatment has been called a fundamental human right by numerous organizations. The current COVID-19 pandemic has strained medical resources, creating a dilemma for physicians charged with the responsibility to limit spread of the contagion and to treat the patients they are entrusted to care for. METHODS: To address these issues, an expert panel was convened that included pain management experts from the military, Veterans Health Administration, and academia. Endorsement from stakeholder societies was sought upon completion of the document within a one-week period. RESULTS: In these guidelines, we provide a framework for pain practitioners and institutions to balance the often-conflicting goals of risk mitigation for health care providers, risk mitigation for patients, conservation of resources, and access to pain management services. Specific issues discussed include general and intervention-specific risk mitigation, patient flow issues and staffing plans, telemedicine options, triaging recommendations, strategies to reduce psychological sequelae in health care providers, and resource utilization. CONCLUSIONS: The COVID-19 public health crisis has strained health care systems, creating a conundrum for patients, pain medicine practitioners, hospital leaders, and regulatory officials. Although this document provides a framework for pain management services, systems-wide and individual decisions must take into account clinical considerations, regional health conditions, government and hospital directives, resource availability, and the welfare of health care providers.

Relationship of Overuse Injuries and Extrascholastic Sport Participation in High School Athletes 2009-2010 through 2015-2016.

INTRODUCTION: Overuse injuries (injuries due to repetitive loads with inadequate rest) can negatively affect high school athletes, but limited data exist on the effect of sports participation outside of the school-sanctioned season on the development of overuse injuries. OBJECTIVE: Compare overuse injury patterns among high school athletes who participate in extrascholastic athletics to those participating only in scholastic sports. DESIGN: Descriptive cross-sectional, secondary analysis of injury data collected on high school athletes across 22 sports over the 2009-2010 through 2015-2016 academic years. SETTING: Deidentified data collected as part of the High School Reporting Information Online study (HS RIO). PARTICIPANTS: High school athletes from a large convenience sample of U.S. high schools. MAIN OUTCOME MEASUREMENTS: Injury proportion ratios (IPRs) were computed overall and for individual sports to compare the proportion of overuse injuries in athletes competing in extrascholastic sports to athletes participating only in scholastic athletics. RESULTS: Overall, extrascholastic athletes experienced a higher proportion of overuse injuries compared to scholastic-only athletes (IPR = 1.21, 95% confidence interval [CI] 1.13-1.30), but this association varied by sport. Among extrascholastic athletes, a higher proportion of overuse injuries occurred in those simultaneously playing the same sport outside the school setting (IPR = 1.32, 95% CI 1.11-1.57) as well as having experienced an injury within the past year (IPR = 1.63, 95% CI 1.36-1.95) compared to those sustaining non-overuse injuries. CONCLUSIONS: Overuse injuries were associated with extrascholastic athletics and occurred in higher proportion in extrascholastic athletes who were playing the same sport in more than one league.

The utility of magnetic resonance imaging results in physician decision-making before initial lumbar spinal injection.

BACKGROUND CONTEXT: The need for advanced imaging before spinal intervention is an area of ongoing debate. Many studies have demonstrated the accuracy of magnetic resonance imaging (MRI) results in evaluating structural pathology in the lumbar spine, but few have addressed how frequently MRI findings change clinical management. A randomized controlled trial showed that viewing MRI results did not impact outcomes in patients with radiculopathy undergoing epidural steroid injection (ESI). The results suggested ESIs that correlated with both imaging and clinical findings experienced slightly more benefit than the blinded cohort, although statistically insignificantly. PURPOSE: Three related studies were conducted to (1) increase understanding of the opinions of interventional spine physicians regarding the utility of viewing imaging before injection and (2) evaluate the impact of viewing MRI results on injection planning (retrospective and prospective analyses). STUDY DESIGN: Survey, prospective, and retrospective analysis. PATIENT SAMPLE: Patients presenting to a university-based spine center for initial evaluation of back or leg pain who were candidates for spinal intervention. OUTCOME MEASURES: Self-reported measures from a clinical practice questionnaire distributed to interventional spine physicians to determine rates and rationale for utilization of MRI before spine injection, physiologic measures including MRI results, functional measures including physician decision-making regarding type and location of injection performed. METHODS: This study was funded by the University of Colorado Health and Welfare Trust. A survey was sent to interventional spine physicians to assess their utilization of MRI results before spine procedures. A retrospective analysis of patients who were candidates for ESI was conducted to evaluate how initial injection plan compared with the postviewing of MRI results on injection performed. In a prospective analysis, injection plans pre- and post-MRI were compared among patients presenting for initial evaluation of low back or leg pain. RESULTS: Survey responses showed that specialists order MRI studies to correlate with physical exam (91%) and to detect the presence of synovial cysts (68%), whereas tumor/infection (93%) was most likely to cause a change in their approach. In the retrospective review, the physician's planned approach before viewing the MRI was concordant with the actual procedure 49% of the time. A different type of procedure was performed in 15% of planned injections. In such cases, the initial treatment plan was altered (ie, same procedure at a different or additional level or side) in 35% of planned injections. In the prospective data collection, 43% of injections were different from the initial physician decision. The most common reasons for altering the injection was different level affected (36%), facet pathology (22%), and different nerve root affected (16%). CONCLUSIONS: In clinical practice, MRI before injection frequently changes management decisions in the planning and delivery of lumbar spine injections.

The Natural History of Postconcussion Recovery Among High School Athletes.

OBJECTIVE: Evaluate postconcussive symptom reporting and recovery. SETTING: Public high school. PARTICIPANTS: Unmatched controls (n = 760); students who sustained a sports-related concussion (n = 77); matched controls (gender, grade, sport) (n = 77). DESIGN: Prospective longitudinal cohort study. OUTCOME MEASURE: Immediate Postconcussion Assessment and Cognitive Testing. RESULTS: At baseline, athletes who went on to sustain concussions were more likely than unmatched controls to be younger (P = .02), male (P = .001), and participate in different sports (P < .0001) such as football (concussed = 52%, unmatched controls = 20%). Differences were also noted regarding a previous history of concussion (P = .045; concussed athletes = 26%; unmatched control athletes = 16%) and lifetime number of concussions (P = .05). At baseline, those whose sustained concussions during the study period were more likely than matched controls to report numbness (P = .01) and concentration problems (P = .01) and more likely than unmatched controls to report dizziness (P = .02), sensitivity to light (P = .01), sensitivity to noise (P = .002), and numbness (P = .02). However, when data were reanalyzed and those with a previous history of concussion were removed, differences between those who sustained concussions during the study period and matched controls were no longer significant; when compared to unmatched controls, sensitivity to light (P = .01) and vision problems (P = .04) remained significant. Among those who sustained concussions, median time to recovery was 6 days (95% confidence interval: 4-9), and 71 out of 77 (92%) recovered by the fourth postinjury evaluation (median: 20 days postinjury). CONCLUSIONS: Course and time frame of recovery were variable. Data also suggest that a previous history of concussion may be contributing to baseline symptom reporting and highlight the potential enduring impact of history of concussion on sensorimotor function. However, further research as to whether preinjury measures of sensorimotor function may increase understanding regarding concussion risk is warranted.

Epidemiology of Cervical Spine Injuries in High School Athletes Over a Ten-Year Period.

BACKGROUND: More than 7 million athletes participate in high school sports annually, with both the benefits of physical activity and risks of injury. Although catastrophic cervical spine injuries have been studied, limited data are available that characterize less-severe cervical spine injuries in high school athletes. OBJECTIVE: To describe and compare cervical spine injury rates and patterns among U.S. high school athletes across 24 sports over a 10-year period. DESIGN: Descriptive epidemiology study. SETTING: National sample of high schools participating in the High School Reporting Information Online injury surveillance system. PARTICIPANTS: Athletes from participating schools injured in a school sanctioned practice, competition, or performance during the 2005-2006 through 2014-2015 academic years. METHODS: Cervical spine injury data captured by the High School Reporting Information Online system during the 10-year study period were examined. Cervical spine injury was defined as any injury to the cervical spinal cord, bones, nerves, or supporting structures of the cervical spine including muscles, ligaments, and tendons. MAIN OUTCOME MEASUREMENTS: Cervical spine injury rates, diagnoses, mechanisms, and severities. RESULTS: During the study period, 1080 cervical spine injuries were reported during 35,581,036 athlete exposures for an injury rate of 3.04 per 100,000 athlete exposures. Injury rates were highest in football (10.10), wrestling (7.42), and girls' gymnastics (4.95). Muscle injuries were most common (63.1%), followed by nerve injuries (20.5%). A larger proportion of football injuries were nerve injuries compared with all other sports (injury proportion ratio 3.31; confidence interval 2.33-4.72), whereas in boys' ice hockey fractures represented a greater proportion of injuries compared with all other sports (injury proportion ratio 7.64; confidence interval 2.10-27.83). Overall, the most common mechanisms of injury were contact with another player (70.7%) and contact with playing surface (16.1%). CONCLUSIONS: Cervical spine injury rates and patterns vary by sport and gender. Characterizing these differences is the first step in developing effective, evidence-based prevention guidelines. LEVEL OF EVIDENCE: IV.

Robot-Assisted Laparoscopic Repair of Extraperitoneal Ureteral Inguinal Hernia with Mesh Placement.

Background: Ureter involvement within indirect hernias is a rare phenomenon usually identified incidentally during herniorrhaphy. Even more rare are extraperitoneal ureteral inguinal hernias, which represent about 20% of these cases and are characterized by a substantial amount of extraperitoneal fat in the hernia defect, the absence of a peritoneal sac, and associated with hydroureteronephrosis and nephroptosis. To date, repair of ureteral inguinal hernias has been performed exclusively using open surgical techniques. We report the first case of successful robot-assisted laparoscopic repair of this rare presentation. Case Presentation: A morbidly obese 70-year-old male with an unremarkable surgical and urological history presents with a 15-year history of nonpainful, enlarging right scrotal swelling measuring 25 cm in diameter. CT imaging revealed right nephroptosis and a hernia defect containing a dilated right ureter looping into the scrotum surrounded by significant extraperitoneal fat. Retrograde pyelography and ureteral catheter placement confirmed a >100 cm ureter. The patient underwent a robot-assisted laparoscopic repair. The inferior epigastric artery, spermatic cord vessels, vas deferens, and ureter were identified. The defect was reduced using external scrotal pressure and reinforced with ProGrip™ self-fixating laparoscopic mesh. The patient was discharged 2 days later following an uneventful postoperative course. Conclusion: Although rare and usually incidentally discovered, extraperitoneal ureteral inguinal hernias can be identified preoperatively by the astute clinician. Preoperative identification allows for improved surgical planning, including a minimally invasive approach. Robot-assisted laparoscopic repair with mesh placement is a feasible alternative to traditional open techniques.

Retirement and Activity Restrictions Following Concussion.

Sport-related concussion is prevalent at all levels of play. Increased attention from sports media and scientific and medical communities has prompted players and physicians to explore the long-term effects of concussion and ask the questions of when and how players should begin to mitigate their concussion risk. The authors evaluate their risks from the perspective of epidemiology, symptomatology, neuropsychological performance, and biomechanics. The authors propose that there is not a set number of concussions that necessitates retirement in athletes and, aside from a few absolute contraindications to return to collision sport, return to play should be an individualized process.

Sports-Related Concussion.

Sports-related concussions (SRC) are common in all ages and occur in all sports. The diagnosis based on clinical suspicion after more serious injury is ruled out. Symptoms of concussion are due to a temporary and reversible neurometabolic cascade resulting in blood flow changes, neuronal excitotoxicity, ionic shifts, and mitochondrial changes. Symptoms are nonspecific, and commonly include headache, cognitive complaints, photophobia, and phonophobia. Loss of consciousness is rare in SRC and has limited influence on recovery and prognosis. Imaging has a limited role in the management of concussion and should be used to evaluate for more serious intracranial pathology. Treatment is based on symptoms and an understanding of the typical, rapid (7-10 days) recovery. No athlete should return to play until their symptoms have resolved and they have completed a supervised, step-wise return to play protocol. The article covers the most recent literature on the diagnosis and management of SRC, including evidence-based recommendations and expert-based consensus opinion. The article will also discuss issues regarding medical retirement, legislation, and future concepts in concussion diagnosis and management.

Failure to obtain microbiological culture and its consequence in a mesh-related infection.

This report describes a case of a delayed diagnosis of a late-onset mesh infection due to an unexpected enteric pathogen, Enterobacter cloacae. A 62-year-old woman with a history of prior incisional hernia repair with a prosthetic mesh presented to the emergency room with signs of an abscess with surrounding cellulitis of her abdomen over a year after her hernia repair. The patient manifested minimal response to 1 month of oral antibiotics. She underwent a complicated yet successful treatment course including surgical mesh removal (with a peri-operative complication), implantation of a biological mesh for the ventral hernia defect and ultimately, antibiotics tailored to the offending pathogen identified by postoperative culture of the infected mesh.