Purpose The purpose of the study was to evaluate the reliability, review differences and assess patient satisfaction of electronic patient-reported outcome measures (PROMs) compared with paper PROMs. Methods Participants between 12 and 19 years of age with a knee-related primary complaint were randomized into two groups. Group 1 completed paper PROMs followed by electronic, while Group 2 received the electronic followed by paper. PROMs included the Pediatric International Knee Documentation Committee (Pedi-IKDC), Hospital for Special Surgery (HSS) Pediatric Functional Activity Brief Scale (HSS Pedi-FABS), Tegner Activity Level Scale, Visual Analogue Scale (VAS), PedsQL Teen and a satisfaction survey. Results In all, 87 participants were enrolled with one excluded due to incomplete PROMs. Of the 86 participants, 54 were female and 32 were male with an average age of 14.3 years (12 to 18). A high degree of reliability was found when comparing the paper and electronic versions of the Pedi-IKDC (0.946; p < 0.001), HSS Pedi-FABS (0.923; p < 0.001), PedsQL Teen (0.894; p < 0.001), Tegner Activity Level Scale before injury (0.848; p < 0.001) and the Tegner Activity Level Scale after (0.930; p < 0.001). Differences were noted between the VAS scores, with paper scores being significantly higher than electronic (5.3 versus 4.6; p < 0.001). While not significant, a trend was noted in which electronic PROMs took, overall, less time than paper (10.0 mins versus 11.2 mins; p = 0.096). Of all participants, 69.8% preferred the electronic PROMs, 67.4% felt they were faster, 93.0% stated they would complete forms at home prior to appointments and 91.8% were not concerned about the safety/privacy of electronic forms. Conclusion PROMs captured electronically were reliable when compared with paper. Electronic PROMs may be quicker, will not require manual scoring and are preferred by patients. Level of Evidence II

Our objective was to determine the association between sleep quality, symptom severity, and recovery following sport-related concussion in pediatric athletes. A review of data from the North Texas Concussion Network Prospective Registry (ConTex) was performed. Participants were diagnosed with a sport-related concussion and were ≤18 years old. Participants were categorized based on their initial clinic visit Pittsburgh Sleep Quality Index composite score (0-21) into good sleep quality (GS≤5) and poor sleep quality (PS>5) groups. The PS group reported higher median total symptom scores at 3-month follow-up (3.0 vs 0.0, P < .01) and took more than a median of 2 weeks longer to recover compared to the GS group (35.0 days vs 20.0 days, P < .01). Poor sleep quality was strongly associated with greater symptom severity and longer time to recovery following sport-related concussion. Early recognition of concussed athletes with poor sleep quality at initial clinic visit may help predict prolonged recovery.

Introduction: The rate of sport-related concussion (SRC) has increased steadily over the past two decades in the pediatric population. Docosahexaenoic acid (DHA), an Omega-3 fatty acid important for brain development in children, may aid in recovery following SRC. The purpose of this study was to determine the feasibility, outcomes, and safety of DHA as early treatment for SRC in pediatrics. Methods: A double-blind, randomized, placebo-controlled feasibility trial was conducted. Inclusion criteria were ages 14-18 and SRC within 4 days of enrollment. Exclusion criteria included taking DHA, radiographic evidence of TBI, participation in motorized sports, or previous concussion within past 6 months. Following diagnosis of concussion and initiation of standard treatment, subjects were randomized in a 1:1 fashion to DHA or a placebo and were instructed to take 2 capsules twice daily for 12 weeks. DHA capsules contained a total of 2000 mg of DHA/day and PLACEBO capsules contained corn and soy oil. Both were flavored with masking agents. Subjects were followed prospectively. Standard clinical assessments, SCAT-3 symptoms, ImPACT scores, BESS scores, adverse effects, and drug compliance was collected at enrollment, 1-week, 2-weeks, 4-weeks and 12-weeks. Demographics, day of injury symptoms, injury characteristics, and sport played were also collected. Subjects who demonstrated normal neurocognitive testing, complete symptom resolution and were cleared to begin a return to play (RTP) progression prior to the 4-week follow-up visit were permitted to forgo additional study visits, but requested to return for the 12-week visit. Groups were compared using Mann-Whitney tests for continuous variables and chi-square tests for categorical variables. Results: 40 subjects were enrolled; 20 in the DHA group (mean age: 16.02 years; 65% male) and 20 in the PLACEBO group (mean age: 15.97 years; 70% male). No significant differences in demographics, sport, symptoms, ImPACT scores, or BESS scores at enrollment were noted between groups. 25 (62.5%) subjects completed the 12-week visit. Overall drug compliance was 61.57% in the DHA group compared to 66.34% in the PLACEBO group (p=0.727). Subjects in the DHA group were symptom-free 4 days earlier than the PLACEBO group (16.1 vs. 20.9 days, p=0.082), demonstrated normal ImPACT neurocognitive testing (12.2 vs. 16.8 days, p=0.382), and were cleared to begin a RTP progression (21.4 vs. 23.4 days, p=0.115) sooner than those in the PLACEBO group. Two adverse effects were noted in the DHA group. One event was determined to be unrelated to the study. The second event was drug-related eructation and considered minor. No adverse effects were reported in the PLACEBO group. Conclusion: This study demonstrated that use of high-dose DHA for treatment of SRC in pediatrics is feasible and safe. DHA may allow for a faster symptom-free state and for an earlier return to play, but a large-scale trial is needed.

Context: Return-to-play following sport-related concussion(SRC) requires authorized clearance from a healthcare provider(HCP). Variability in HCPs and facilities where athletes seek care may influence return time. Objective: Determine the initial examiner, HCPs that authorize clearance, and medical facilities authorizing clearance among high school student-athletes following SRC, and compare authorized clearance time by HCPs and medical facilities. Design: Prospective Cohort Study. Setting: High school. Patients or Other Participants: Student-athletes(n=16,001) with SRC participating in STATE-XXX High School Athletic Association(XHSAA)-sponsored athletics. Main Outcome Measure(s): Frequencies of initial examiner and authorized clearance for each HCP(Doctor of Osteopathic Medicine(DO), Doctor of Medicine(MD), Nurse Practitioner(NP), Physician Assistant(PA)) and medical facility (Neurologist's Office, Team Physician, Primary Care Physician or Pediatrician's Office(PCP), Hospital, Urgent/Ready Care) for each SRC case. Kaplan–Meier curves and Peto tests evaluated differences in median time to authorized clearance between HCPs and facilities. Only cases with a follow-up authorized clearance date(80.3%, n=12,856) were included in authorized clearance and time to return analyses. Results: An athletic trainer was at least one of the initial examiners for 71.3%(n=11,404) of cases; 80.2%(n=12,990) had only one initial examiner. There was an association between initial examiner and medical facility providing clearance for athletic director(χ2=52.6, p≤.001, V=.06), athletic trainer(χ2=172.0, p≤.001, V=.12), coach(χ2=161.5, p≤.001, V=.11), DO(χ2=59.4, p≤.001, V= 07), and NP(χ2=10.0, p .03, V=.12). The majority(n=8,218, 63.9%) received clearance by an MD; 70.8%(n=9,099) were cleared at a PCP. Median time to authorized clearance varied by facility(Urgent/Ready Care: 7 days[4,11], Hospital: 9 days[6,14], PCP: 10 days[6,14], Team Physician: 12 days[8,16], Neurologist Office: 13 days[9,20]; p ≤ .001). Conclusions: Clearance was frequently provided by an MD and at a PCP. Median time to return to unrestricted participation following SRC varied by HCP and medical facility. Future research should elucidate why differences exist and determine why athletes seek care at different medical facilities.

Background: In young athletes, patient-reported activity level is frequently used to determine return to the same level of sport after treatment. Purpose: To evaluate the validity and score distributions of the Hospital for Special Surgery Pediatric Functional Activity Brief Scale (HSS Pedi-FABS) compared with the Tegner Activity Level Scale (Tegner) in pediatric athletes. Study Design: Cohort study (Diagnosis); Level of evidence, 2. Methods: A retrospective review of 517 consecutive youth athletes who came to a sports medicine specialty clinic for a knee evaluation was performed. Patients completed the HSS Pedi-FABS, Tegner, and a sports participation survey before evaluation. Scores were compared with reported hours, days, and weeks of participation in sports as well as level of competition. Floor or ceiling effects were identified, and finally, the means and distributions of scores in the 8 most common primary sports were analyzed. Results: A total of 398 participants (54.0% female) with an average age of 14.5 years (range, 10.0-18.8 years) were included in the study. The HSS Pedi-FABS demonstrated correlations with hours per week ( r = 0.302; P < .001), days per week ( r = 0.278; P < .001), and weeks per year ( r = 0.136; P = .014) playing a primary sport. The Tegner only demonstrated a correlation with days per week ( r = 0.211; P = .001). Additionally, club/select-level athletes scored higher than junior high/high school–level athletes on the HSS Pedi-FABS (23.8 vs 21.0; P = .004), but no difference was observed with the Tegner. No floor or ceiling effect was observed for the HSS Pedi-FABS, but a ceiling effect was present for the Tegner (32.8%). The HSS Pedi-FABS demonstrated a varied score distribution between the 8 most common primary sports ( P < .001), with soccer players scoring the highest, on average (23.5). Conclusion: The HSS Pedi-FABS, compared with the Tegner, demonstrated more correlations with an athlete’s participation in sport with no floor or ceiling effect and had a wide distribution of scores even among same-sport athletes. The HSS Pedi-FABS may be a more valuable activity measure than the Tegner in pediatric athletes.