Anxiety is common in adolescents but short-term changes in anxiety have not been studied. The purpose of this observational study was to describe how anxiety changes in high school female athletes over 16 weeks. Participants completed the Generalized Anxiety Disorder-7 (GAD-7) every other week. We categorized participants as elevated if their GAD-7 score was >9 and a score change of ≥4 classified those with clinically meaningful anxiety change. Of the 28 participants, 30% reported elevated GAD-7 scores at least once and 80% reported anxiety changes ≥4. Athletic trainers are poised to monitor anxiety and can promote optimal mental health by referring those with elevated GAD-7 scores for timely intervention.

HISTORY: A 14-year-old healthy freshman high school basketball athlete contracted COVID-19 in the pre-season. He developed mild symptoms with fatigue, sore throat, cough, headache, nausea, vomiting, and a fever for 24 hours. Thirteen days after the onset of symptoms (10 days after positive test), he returned to basketball and reported mid-sternal chest pain with a sharp/stabbing quality. There was no radiation of pain. He also had palpitations and shortness of breath with these episodes. The pain lasted the entire practice (1.5 hours) and improved with rest. His school athletic trainer notified the family that he needed sports clearance before playing again and was referred to our clinic. PHYSICAL EXAMINATION: BP Right Arm: 134/60 BP Right Leg: 140/72 Pulse: 80, Resp: 18 Weight: 58.2 kg, Height: 180 cm. General Appearance: No acute distress but appears tired. Chest wall: symmetrical expansion with respiration Respiratory: breath sounds clear to auscultation and equal bilaterally. Cardiovascular: normal point of maximal impulse in the left mid-clavicular line, normal S1 & physiologically split S2, regular rate. No murmur. No clicks, gallop or rub. Pulses: 2+ pulses bilaterally in upper and lower extremities. Abdominal: bowel sounds present in all four quadrants, no bruits, soft, no rebound tenderness, no hepatosplenomegaly, no masses. Extremities: no rashes, swelling, color change, or cyanosis, no clubbing, capillary refill is brisk Neurological: alert, appropriate for age, no gross motor deficits DIFFERENTIAL DIAGNOSIS: 1. Arrhythmia 2. Myocarditis 3. Anomalous coronary. TEST AND RESULTS: Chest Radiograph: clear without infiltrates. ECG: normal. Echocardiogram: Mild aortic valve regurgitation, moderately diminished left ventricular systolic function. Cardiac MRI: focal area of delayed enhancement, moderately dilated left ventricle with mildly depressed global LV systolic function (EF52%) and moderately dilated right ventricle with low-normal global RV systolic function (EF 49%). FINAL WORKING DIAGNOSIS: Post-COVID-19 Myocarditis TREATMENT AND OUTCOMES: 1. Held from sports and exercise. 2. Holter monitor revealed no arrhythmias. 3. Awaiting repeat cardiac MRI and exercise stress test to reevaluate cardiac function in 3 months.

PURPOSE: Consistency in physical activity is crucial to acquire maximum health benefits. The current physical activity (PA) recommendation for adolescents is to accrue 420 minutes of PA a week. The purpose of this study was to examine proximal changes in adolescent physical activity. METHODS: Adolescents in a freshman high school health class answered Exercise Vital Sign (EVS) questions over the course of nine weeks. Minutes of PA per week was calculated by multiplying days of PA by minutes of PA. Participants were then categorized as meeting (≥420 minutes/week) or not meeting (<420 minutes per week) current PA guidelines. An alluvial diagram was created to perform exploratory visual analysis of the magnitude and variability in meeting and not meeting PA trajectories across the four time points. RESULTS: Of the twenty-five who participated, 21 had EVS data at four points in time. The average PA across all time points was 312 ± 272 minutes per week. PA between the time points ranged from 245-355 minutes per week. 14% of adolescents always met PA recommendations and 48% never met PA recommendations. 10% of adolescents missed the recommended PA only once, 24% missed twice, and 5% missed PA recommendations three times. From Time Point 1 to Time Point 4 the percentage of adolescents who did not meet PA recommendations were 57%, 71%, 71%, and 62%, respectfully. DISCUSSION: The benefits of regular, consistent exercise include improved mood, physical fitness and sleep quality as well as a decreased risk of chronic diseases. Adolescence is a key developmental stage because developed health behaviors often translate into adulthood. A large majority (86%) did not meet PA guidelines at least once during the study. There may be differences between those who never meet and those who sometimes meet the recommended PA levels. Individual Trajectories of Meeting and Not Meeting PA Guidelines over Four points in Time

Introduction: Musculoskeletal injuries are common among adolescents with roughly half reporting an injury in the last year. Injury impairs function, but it may impact psychological or behavioral well-being as well. Mental health concerns such as anxiety and depression can negatively affect an adolescent’s quality of life. As mental health disorders are being seen more frequently in the young population it is important to understand their relationship with injury. Athletes who are no longer able to participate in their normal activities due to injury may have elevated symptoms of anxiety and depression from this sudden lifestyle change. The purpose of this study was to determine if a musculoskeletal injury is associated with elevated anxiety and depression in adolescent athletes. Methods: Adolescents between the ages of 12-18 from sports medicine clinics presenting with musculoskeletal injuries were age and sex matched to non-injured adolescents from high school health and weight training classes as well as adolescent medicine clinics. The General Anxiety Disorder-7 and Patient Health Questionnaire-9 were used to assess for anxiety and depression symptoms, respectively. Scores of ≥5 on each questionnaire were considered elevated. Chi-Square analyses analyzed the differences in proportions of elevated anxiety and depression in the injured and uninjured participants. Results: Matched data was available for 108 participants, 54 in each group. Average age was 15.99± 1.58 and 83% were females. Overall, 41% reported elevated anxiety symptoms and 36% reported elevated depressive symptoms. There were no differences in the proportion of injured adolescents that had elevated anxiety or depression compared to uninjured adolescents (p=.386 and p=.071, respectively). Discussion: Elevated anxiety and depressive symptoms are common among injured and non-injured adolescents. High rates in our sample could be impacted by the predominance of female participants, as female are more likely to experience this symptomology than males. It is possible that the severity of the injury may influence anxiety and depression symptoms, which we did not assess. In addition, participants were enrolled during COVID-19, which may have influenced the rates of elevated anxiety and depression symptoms. Elevated anxiety and depressive symptoms are associated with high levels of functional impairment. Therefore, adolescents should be routinely assessed for anxiety and depression, regardless of injured status.

Introduction: Prevalence of menstrual dysfunction (MD) in high school athletes ranges from 7% to 54%. Early recognition and intervention are crucial to prevent future consequences. The purpose of this Quality Improvement project was to optimize the institution’s Epic Best Practice Advisory (BPA) screening tool and synthesize new patient questionnaires to diagnose MD in athletes greater than 12 years of age presenting to a pediatric sports medicine clinic. Methods: Using Quality Improvement methodology, we evaluated clinic flow, the Epic BPA tool, and actions by the physician following the appropriate triggering of the BPA. Diagnoses targeted were primary amenorrhea, oligomenorrhea, or irregular menstruation unspecified. Areas for intervention were global staff education, patient education, and provider alert fatigue. Our team implemented interventions using monthly Plan-Do-Study-Act cycles to address our key drivers. Proper implementation of questionnaire data and restructuring of the Epic BPA promoted identification and diagnosis of MD. The clinician discussed the diagnosis with the patient and family and provided an educational handout on MD. Results: The rate of appropriate diagnosis of MD in athletes greater than 12 years of age seen at a pediatric sports medicine clinic increased from a baseline of 2.1% to 30% over ten months. Identification of three key drivers ultimately drove the success and achievement of our aim. Conclusions: Using Quality Improvement methodology, we optimized the EPIC BPA and subsequently increased the rate of appropriate diagnosis of MD. Identification of the proper diagnosis improves our patient education. Ultimately, this project provided the framework for applicable discussion, interventions, and work-up for at-risk athletes.

Abstract We reviewed charts of 14,446 sports medicine patients, children aged 5 to 18 years, over a 3-year period to determine the discriminant validity of Exercise Vital Sign (EVS) questions. A logistic regression analyzed factors related to any moderate to vigorous physical activity (MVPA). A linear regression analyzed factors related to amount of MVPA for those who participated in any weekly MVPA. Overall, 48% of children reported meeting physical activity guidelines for 420 min·wk−1. Overall, children reported 400.36 ± 280.04 min·wk−1 of MVPA. Those with depression had significantly less MVPA than those without (95% confidence interval [CI], −96.65 to −26.31). Girls had significantly less MVPA than boys (95% CI, −59.15 to −40.31). Overweight and obese children reported less MVPA compared with normal weight children (95% CIs, −42.65 to −17.29 and −91.61 to −65.50, respectively). EVS demonstrates strong discriminant validity to detect differences between groups as a function of sex, body mass index, and depression.

INTRODUCTION: Anxiety and depression can impact all aspects of an adolescent’s life. The effect musculoskeletal disorders and concussions have on mental health is important to understand and can help to identify risk factors for the development of anxiety or depression in adolescents. PURPOSE: To determine if a relationship exists between anxiety and depression screening scores in adolescents with acute and chronic musculoskeletal (MSK) disorders or concussion. METHODS: Adolescents reporting to a sports medicine clinic completed the generalized anxiety disorder (GAD-7) and patient health questionnaire (PHQ-9) to assess anxiety and depression, respectively. Scores greater than five were considered elevated for each. Age and sex were recorded. Injuries were categorized into overuse, acute or concussion. Overuse injuries included those with an insidious or chronic mechanism of injury and a physician diagnosis of apophysitis, tendonitis, stress fractures, patellofemoral pain and or insidious pain. Acute diagnoses included mechanisms of falls, twisting or direct contact and diagnoses of a fracture, contusion, strain, sprain or ligament tear. RESULTS: Forty-two participants were included. Average age was 14.83 ± 1.59 and 57% were female. Average GAD-7 and PHQ-9 scores were 3.17 ± 3.32 and 3.48 ± 3.72, respectively. Nineteen percent had elevated PHQ-9 scores and 24% had elevated GAD-7 scores. There were 12 acute injuries, 5 concussions and 25 overuse injuries. Two one-way ANOVAs examined differences for anxiety and depression between groups. There were no significant differences found between those with acute, overuse or concussion injuries on GAD-7 (p = .90) or PHQ-9 (p = .70). CONCLUSIONS: While there were no significant differences between anxiety and depression scores for individuals suffering acute or chronic musculoskeletal injuries as well as concussion injuries, the examination of anxiety and depression is warranted. Previous research has demonstrated that injured adolescents had high rates of elevated scores for anxiety and depression, yet type of injury (i.e., acute MSK, chronic MSK, concussion) did not demonstrate differences in screening questionnaire scores. Clinicians should consider screening all types of injured adolescents for anxiety and depression to aid in early intervention.

PURPOSE: Adolescent musculoskeletal injury and musculoskeletal pain potentially influence the quality of life of an individual. Screening adolescent patients for self-reported emotional functioning and quality of life is important and plays a role in clinical evaluation in the office setting. METHODS: Adolescents (n = 63), between 12-18 years of age, were screened for physical activity, emotional functioning, and quality of life in a tertiary pediatric sports medicine clinic. The screening occurred during the outpatient visit for musculoskeletal pain or injury. Adolescents self-reported pain and physical activity in minutes per week. Anxiety and depression screening tools, the GAD-7 and PHQ-9 respectively, evaluated emotional functioning. The Pediatric Quality of Life Inventory (PedsQL) assessed physical, emotional, social, and school functioning. RESULTS: The population consisted of adolescents with mean age of 14.57 ± 1.52 years and 59% were female. The average pain score documented was 4.16 ± 2.78. The GAD-7 recorded average scores of 3.39 ± 3.76. The PHQ-9 recorded average scores of 3.70 ± 4.30, respectively. The average PedsQL score recorded was 78.45 ± 10.52. Pain, anxiety, and physical activity were all significant predictors of Pediatric Quality of Life (p = 0.002, 0.017 and 0.000, respectively). Depression (p = 0.104) and sex (p = 0.553) each did not reach statistical significance with PedsQL. CONCLUSIONS: Self-reported quality of life is important to screen in a clinical setting of musculoskeletal injury and musculoskeletal pain. Factors such as pain, anxiety, and physical activity were all predictors of self-reported quality of life. These screening tools can aide the clinician to simultaneously address the musculoskeletal complaint and discuss emotional functioning, pain, physical activity, and the quality of life.

PURPOSE: Approximately 20% of adolescents meet the minimal standards of moderate to vigorous physical activity (PA) national guidelines. Adolescents that accrue lower PA have greater depression and anxiety symptoms when compared to adolescents that engage in higher amounts of PA. Musculoskeletal injuries are common in adolescents and may exacerbate depression or anxiety symptoms that were decreased due to the ability to partake in PA. In addition, injuries may cause new anxiety and depression symptoms. While PA has generally been shown to help decrease and protect against both depression and anxiety symptoms in adolescents, some recent work has questioned the impact of PA on adolescent mental health. The purpose of this study was to determine if adequate levels of PA in adolescents that have experienced an injury had less anxiety and depression symptoms. METHODS: A total of 63 adolescents (59% female; mean age = 14.57 ± 1.52 years) between the ages of 12-18 that were being treated by a tertiary sports medicine clinic were enrolled. Participants filled out the Patient Health Questionairre-9 (PHQ-9) and the Generalized Anxiety Disorder-7 (GAD-7) to measure depression and anxiety symptoms, respectively. Scores greater than 5 were considered elevated for each scale and prompted further evaluation by the attending physician. PA was self-reported by asking exercise vital sign questions to obtain days per week and minutes per day of moderate to vigorous physical activity from the past week. RESULTS: Average PHQ-9 score was 3.63 ± 4.11, average GAD-7 score was 3.33 ± 3.60 and average weekly PA was 319.37 ± 261.12 minutes. There were 22% with elevated PHQ-9 scores, nearly 24% with elevated GAD-7 scores and 35% reported meeting the PA guidelines in the last week. There were no differences between those who met or did not meet PA guidelines on the proportion of those with elevated depression or anxiety scores (p = .47, p = .93, respectively). CONCLUSIONS: While there were no differences between the prevalence of elevated depression or anxiety scores between those who met or did not meet PA guidelines, injured adolescents had high rates of elevated scores for anxiety and depression. Clinicians should consider screening injured adolescents for anxiety and depression to aid in early intervention.

The benefits of physical activity cross all domains of health. Unfortunately, many children are not meeting the current American College of Sports Medicine recommendations of 60 minutes of moderate to vigorous physical activity (MVPA) 7 days a week. This is especially deleterious since physical activity patterns during childhood may carryover to adulthood. Research has also shown that participating in one sport may increase the risk of injury. The purpose of this study was to examine self-reported exercise levels in children reporting to a tertiary sports medicine clinic over a three year period. Subjects were asked “How many minutes of moderate to vigorous physical activity per day?” and “How many days per week do you participate in moderate to vigorous physical activity”. Minutes per week of MVPA was calculated. Age, sex, and current sports and recreational activities were recorded. There were 7427 unique patients (53% female) with an average age of 13.8±2.6. The average minutes per day of exercise was reported as 85.6±44.4, average days per week was 4.4±1.6 and minutes per week was 410.8±266.9. Females reported less minutes per day (83.5 vs. 87.8, p<.001), less days per week (4.2 vs 4.7, p<.001) and less minutes per week (384.1 vs 440.2, p<.001) than males. On average, females reported 56 minutes less activity per week than their male counterparts. There were 3618 participants who only reported one activity and were categorized as specialized in a single physical activity. Those that specialized in a single activity were significantly older (14.1 vs 13.4, p<.001). There were no significant differences between reported minutes per day between specialized and unspecialized athletes (85.8 vs 85.2, p=.57). Those who specialized in one activity reported more days per week (4.6 vs 4.2. p<.001) and more minutes per week (423.8 vs 397.0, p=.001) than unspecialized athletes. Research has consistently shown that females are less active than males. Those who specialized in one activity participated in more minutes per week of activity, mainly through participating in more days of physical activity. Children should be encouraged to participate in a variety of activities on a daily basis to ensure they receive the benefits of physical activity.

PURPOSE: The purpose of this study was to examine which factors were related the number of days per week of physical activity in children. METHODS: Patients presenting to sports medicine clinics between the ages of 5-18 were asked “On average, how many days per week did you participate in MVPA” and “On average, how many minutes per day did you participate in MVPA”. Age, sex, BMI percentile, as well as the history of asthma, attention deficit hyperactivity disorder, depression and diabetes were recorded. A linear regression was utilized to determine which factors were associated with increased days of physical activity. RESULTS: Data were recorded on 14,440 subjects. Average age of was 13.91±2.49 years, average BMI percentile was 65.50±27.74, and 54.1% were female. A total of 2340 (16.2%) reported asthma, 818 (5.7%) reported ADHD, 308 (2.1%) reported depression, and 92 (.6%) reported diabetes. Average days per week of MVPA was 4.31±1.68. Approximately 5% of patients reported 0 days of MVPA/week, whereas only 6% of patients reported daily MVPA. Females reported .48 less days of MVPA per week (p<.001). Those with a history of depression reported .59 less days of MVPA than those without a history of depression (p<.001). Those with a history of ADHD reported .23 days less of MVPA when compared to those without ADHD (p<.001). Older children completed more days of MVPA (p<.001). DISCUSSION: The current MVPA recommendations require 60 minutes of daily MVPA for all school aged children. The vast majority of children in our study were not participating in MVPA 7 days per week. All children should be screened for MVPA to identify and counsel those who are not active daily to ensure that they gain all the benefits from physical activity. Assessment of total weekly activity should be compared to daily activity to evaluate which factor is more important for reaping the benefits of children’s physical activity.

PURPOSE: The purpose of this study was to determine which factors were associated with increased weekly moderate to vigorous physical activity (MVPA) measured by Exercise Vital Sign (EVS) questions. METHODS: Patients presenting to a sports medicine clinic between the ages of 5-18 were asked “On average, how many days per week did you participate in MVPA” and “On average, how many minutes per day did you participate in MVPA”. Weekly physical activity, age, sex, BMI percentile, as well as history of asthma, attention deficit hyperactivity disorder, depression and diabetes were recorded. A linear regression analysis was utilized in those who reported any physical activity to determine which factors were associated with increased MVPA. RESULTS: Data were recorded on 14,440 subjects. Average age was 13.91±2.49 years and average BMI percentile was 65.50±27.74 percent. Females made up 54.1%. Asthma was reported by 2340 (16.2%), ADHD was reported by 818 (5.7%), depression was reported by 308 (2.1%), and diabetes was reported by 92 (.6%). Overall, 45.6% of subjects reported 420 minutes or more of weekly MVPA. Those who reported any physical activity (n=13,708) averaged 424.14±287.45 minutes per week of MVPA. Those with a history of depression had almost 60 minutes/week less MVPA when controlling for age, sex, BMI percentile, asthma, ADHD, and diabetes (p>.001). Females reported 45 minutes less MVPA than males when controlling for age, BMI percentile, asthma, ADHD, depression and diabetes (p>.001). Discussion: Physical activity is an important health determinant in childrens’ current and future health. The majority of youth do not meet current physical activity recommendations. Children suffering from depression should be screened for MVPA to encourage meeting physical activity recommendations. As females continue to obtain significantly less MVPA than males, targeted interventions need to be developed for this population. Regular screenings of MVPA levels should be implemented for children to help identifying and counsel those who are insufficiently active.

We examined the effect of a noncontact, subsymptom exacerbation early exercise recommendation on recovery from sports-related concussion. Retrospective analysis of adolescents, 10-17 years old, with symptomatic concussion, within 30 days of injury was performed. Time to recovery was measured between the early exercise group and a comparison group. A total of 187 patients studied—112 in the exercise group and 75 in the comparison group; 55% were male (n = 103). The exercise group had a significantly longer duration of concussion symptoms (18.5 days vs 14, P = .002), although both groups recovered within the expected time to recovery for concussion. When analyzed separately, males experienced longer time to recovery from injury (19 days vs 14, P = .003), than females, respectively (18 days vs 14.5, P = .18). Recommendation of early exercise resulted in significantly longer recovery from concussion in male adolescents but had no significant effect in female adolescents; both groups recovered within the expected time frame.