Sport Specialization Classification and Injury Risk in Female High School Athletes

Primary Author/Presenter: Alexandra Abbott, MD

Ehiamen Okuwura, MD, Alexandra Abbott, MD, Michaela Stamm, and Mary Mulcahey, MD

Affiliation: University of California, Los Angeles

Presentation Type: Rising with Research Presentation

Purpose: Our study aimed to characterize risk factors associated with early sport specialization in female athletes, specifically related to injury, concussion, body images and menstrual function. We also evaluated existing specialization scales by applying 3 different scales to the same cohort of athletes.

Methods: Questionnaires related to sport participation and injury history were applied to high school female athletes (n = 229; 13-18 years of age). Three peer-reviewed specialization classification scales were utilized: a 3-point, 6-point and a self-classification scale. Scores were compared to determine differences in screening scales. Odds ratios and confidence intervals used for risk associations.

Results: 219 athletes completed the specialization portion of questionnaires and were included in the study. Using the 3-point specialization scale, 41.6% were categorized as low specialized (LS), 26.9% as moderately specialized (ModS) and 31.5% as highly specialized (HS). ModS athletes were more likely to have a history of stress fractures compared to LS athletes. HS athletes were more likely to have injury history and history of concussion than LS athletes. Our study did not find associations between specialization and menstrual history or body image issues. Among 69 athletes categorized as HS using the 3-point scale, 31.9% were classified by the different 6-point scale as multi-sport non-specialized athletes. 8.7% of the "HS" athletes did not qualify as specialized based on the 6-point scale. Among the 91 LS athletes by the 3-point scale, 70.3% were classified by the self-classification scale as single-sport, specialized athletes; only 3.3% were considered specialized on the 6-point scale.

Conclusions: Among female high school athletes, our study found associations between specialization and concussion, stress fracture and injury overall. Our study did not find associations between specialization and body image issues or menstrual dysfunction. The established scales are likely effective to screen for specialization risk. However, given the inter-scale differences in the same cohort, combining scales may screen athletes more accurately.

Significance: Our study corroborates the association between specialization and injury, concussion and stress fracture. Differing screening results using different scales led to our recommendation to consider screening with multiple classification modalities.

Concentrations of Interleukin-1 Family Members in Synovial Fluid of Patients With Osteoarthritis

Primary Author/Presenter: Temilola Abdul, MD

Christopher Evans, PhD, Christopher Morelli, DO, Kelly Armstrong, Kelly Armstrong, and Tao Yang, PhD

Affiliation: Mary Free Bed Rehabilitation Hospital, Grand Rapids, Michigan Rehabilitation Medicine Research Center, The Mayo Clinic, Rochester, MN Van Andel Research Institute, Grand Rapids, MI.

Presentation Type: Rising with Research Presentation

Purpose: To determine the concentrations of interleukin-1 (IL-1) family members in the synovial fluid of patients with osteoarthritis (OA). Members of interest include the two isoforms of IL-1 (α and β), its receptor antagonist (IL-1Ra) and its soluble receptors 1 and 2 (sIL-1R1 and sIL-1R2).

Methods: 21 synovial fluid (SF) samples were aspirated from knee joints of OA patients. Informed consent was obtained and demographics as well as subjective pain rating on a visual analog scale of 1 to 10 were recorded. Samples were treated with hyaluronidase to reduce viscosity. The levels of IL-1α, IL-1 β, IL-1Ra, sIL-1R1 and sIL-1R2 were determined using multiplex analysis.

Results: Of the 21 SF samples tested, only 4 had detectable IL-1α levels, only 4 had detectable sIL-1R1 levels and only 2 had detectable IL-1 β levels. In contrast, 20 samples had detectable IL-1Ra levels and all samples had detectable sIL-1R2 levels. There was a strong positive correlation between IL-1α and IL-1 β levels (R2 0.8069, P < 0.05), between IL-1α and IL-1Ra levels (R2 0.9299, P < 0.05) and between IL-1 β and IL-1Ra levels (R2 0.6508, P < 0.05). There was a moderate positive correlation between IL-1α and sIL-1R1 levels (R2 0.3325, P < 0.05) and between IL-1Ra and sIL-1R1 levels (R2 0.3373, P < 0.05). There was a weak positive association between IL-1 β and sIL-1R1 levels (R2 0.2154, P < 0.05). There were no statistically significant correlations between sIL-1R2 and any of the other cytokines tested (IL-1α, IL-1 β, IL-1Ra or sIL-1R1). Similarly, there were no statistically significant correlations between the subjective pain scale and any of the five cytokines tested.

Conclusions: Detectable levels of IL-1α or IL-1 β were present in only 20% of the synovial fluid samples. This may represent a sub-set of patients whose OA is driven by IL-1. Alternatively, because IL-1α is membrane-bound, it may not enter synovial fluid to a large degree. The presence of soluble inhibitors of IL-1 in synovial fluids may restrict the activities of IL-1 to the pericellular environment within cartilage and synovium.

Significance: A subset of OA patients likely have IL-1 mediated disease. IL-1 inhibition for knee OA is under investigation (ClinicalTrials.gov Identifier: NCT02790723). Identifying patients that benefit from IL-1 inhibition would help optimize treatment.

Acknowledgements: Medical assistants and resident physicians at Mary Free Bed Rehabilitation Hospital. Rachel Hren and the Center for Research and Innovation at Mary Free Bed Rehabilitation Hospital.

Incidence of Menstrual Dysfunction in Female Collegiate Athletes

Primary Author/Presenter: Ashley Austin, MD

Beatrice Caballero, MD, and Bridget Whelan, MPH

Affiliation: University of Washington, Seattle, WA.

Presentation Type: Rising with Research Presentation

Purpose: Menstrual dysfunction (MD) commonly effects the quality of the life of young women but many are unaware that it can be proactively identified and treated. This study investigated the incidence of menstrual dysfunction (MD) in female collegiate athletes and assessed their baseline knowledge about MD.

Methods: 116 female collegiate athletes (age 18-23) without MD-associated comorbidities participated in a survey from June 1, 2021 to November 1, 2021. The primary outcomes were incidence of MD and student athlete knowledge of MD. Secondary outcomes were presence of impact on daily function, history of treatment for MD and association between MD and sport, BMI and hours of exercise per week.

Results: We surveyed 116 female collegiate athletes (mean 19.9 years; 8 basketball, 6 beach volleyball, 13 cross country, 12 gymnastics, 39 crew, 11 softball, 17 track & field, 10 volleyball). Of these athletes, 72.2% reported having MD, defined as an abnormal menstrual cycle recurrence (off by days/weeks/months), multiple menstrual cycles per month, prolonged cycles >7 days, or painful or heavy cycle bleeding. Cross country had the highest incidence of MD (85%), followed by gymnastics (83%), track & field (76%) and crew (72%). There was an association between MD and hours of exercise per week (p = 0.001) but no statistical significance with BMI (p = 0.129) and sport (p = 0.304). Athlete knowledge about MD was measured by athletes being "very knowledgeable" (12.1%), "somewhat knowledgeable" (58.6%), or having "no knowledge" (29.3%). Gymnastics had the highest reporting of "no knowledge" (41.7%). Of athletes with MD, 40.5% reported it had an effect on daily function and 28.8% sought medical care.

Conclusions: Over 70% of student athletes had MD and nearly half of them attested that MD affected their daily function. However, approximately 30% had "no knowledge" of menstrual dysfunction and an even smaller percentage sought medical are. Gymnasts had the second highest incidence of MD but the most athletes who reported having "no knowledge" of MD. These results highlight an important role for more formal education on MD for female collegiate athletes.

Significance: The high incidence of MD in female collegiate athletes in all sports necessitates more education on MD and guidance for seeking medical care, which may improve student athlete quality of life and reduce secondary risks to health and performance.

Mental Health Impact of Specialization in Softball in Adolescents

Primary Author/Presenter: Brett Bentley, MD

Aaron Lear, MD, Suzy McNulty, MD, Eric Post, PhD, ATC, and Anne Marie Zeller, DO

Affiliation: University of Alabama Sports Medicine, Tuscaloosa, Alabama.

Presentation Type: Rising with Research Presentation

Purpose: Youth softball popularity is on the rise and with it, the pressure to specialize early. Although it's been widely reported that early specialization is a growing trend in sports, the focus has been on injury risks. The mental health ramifications, specifically in softball, demand investigation.

Methods: An online,cross-sectional survey was sent to a national sample of softball players ages 12 to 18 in fall 2021. The patient health questionnaire 9 (PHQ-9) was used to evaluate symptoms of depression;the generalized anxiety disorder scale (GAD-7) for symptoms of anxiety.Differences in PHQ-9 and GAD-7 scores based on specialization behaviors were compared using independent t-tests and one-way ANOVAs.

Results: A total of 1489 individuals accessed the survey and 1326 participants (mean age 15.1 ± 1.7y) met the inclusion criteria, fully completed the survey and were included in data analysis (89.1% completion rate). Highly specialized athletes reported lower scores on both the PHQ-9 (8.2 ± 6.3) and GAD-7 (6.3 ± 4.9) compared to moderate (PHQ-9: 12.4 ± 4.2, p < .001; GAD-7: 9.6 ± 3.4, p < .001) and low specialization athletes (PHQ-9: 11.7 ± 4.8, p < .001; GAD-7: 8.6 ± 4.2, p < .001). Athletes who reported traveling overnight for competitions or showcases at least once a month reported higher scores than athletes who did not travel regularly on both the PHQ-7 (11.8 ± 5.1 vs. 9.8 ± 4.2, p < .001) and GAD-7 (9.1 ± 4.1 vs. 7.4 ± 3.7, p < .001). Similarly, athletes who received private coaching reported higher scores than athletes who did not receive private coaching on both the PHQ-7 (12.4 ± 4.6 vs. 7.9 ± 5.2, p < .001) and GAD-7 (9.5 ± 3.8 vs. 6.2 ± 4.1, p < .001).

Conclusions: Based on the oft-used 3-point specialization score (Jayanthi, AJSM 2015), highly specialized athletes fare better in terms of PHQ-9 and GAD-7 scores. However, when more specific specialization behaviors (regular travel, private coaching, showcase participation, etc.) are considered, these athletes exhibited worse scores. Our findings challenge whether the 3-point scale evaluates the full scope of sport-specific specialization.

Significance: This study, the first and largest of its kind, exhibit the results from a diverse survey of > 1300 adolescent softball players and will help inform players, parents,coaches and others of the mental health impact of early specialization in softball.

Acknowledgements: AMSSM and the Young Investigator Grant (awarded to one of our authors, Anne Marie Zeller) The National Fastpitch Coaches Association Akron (OH) Racers Foundations The authors' respective local athletic trainers.

Perception of Exercise Prescriptions in Patients Presenting With Musculoskeletal Complaints

Primary Author/Presenter: Noel Blanco, DO

Joseph Wong, MD, Sarah Richards, Jennifer Harding, and David Ross, MD

Affiliation: Geisinger Medical Center.

Presentation Type: Rising with Research Presentation

Purpose: To evaluate the perception of patients with musculoskeletal complaints in regards to exercise prescriptions when compared to medication and injection modalities as a significant therapeutic intervention and what potential barriers may be implicated in these preconceived values.

Methods: There were 1057 patients that participated in an IRB-approved, prospective cohort study. The patients completed a survey composed of 12 questions upon initial presentation to a musculoskeletal clinic at a large academic center over the course of one year. The Chi-Square, Fisher's exact test, Kruskal-Wallis test and T-test were used to evaluate the responses along with the SAS v9.4.

Results: Results from the survey revealed 97.3% of responses agreeing that exercise was an important aspect of life; however, 86.6% of responses felt that normal daily activities, such as their employment or household chores, would be considered as exercise. If a medical provider gave a patient a personal and detailed exercise prescription, 86% of patients felt that they would be likely to complete the regimen with a 95.8% satisfaction rate. A lower median age (43.5 v. 52.0, p < 0.0001) favored exercise versus injection and/or medication. Compared to the patients favoring medication/injections, there was a statistically significant difference (p < 0.0001) in people who preferred exercise as they responded enjoying exercise more, tend to exercise more often and for longer periods of time. Additionally, they are more likely to complete an exercise program (p = 0.0022) and were more satisfied with exercise prescriptions as the main treatment modality offered by the provider (p < 0.0001).

Conclusions: An overwhelming number of responses felt that exercise prescriptions were an important therapeutic intervention and would be greatly satisfied with this intervention for musculoskeletal complaints, but data revealed mixed results when offered the option between an exercise prescription and medical intervention. The definition of exercise remains a potential educational focus as many individuals perceived normal daily activities as exercise.

Significance: Exercise has long been a mainstay of fitness, well-being and significant utility as primary prevention of disease. Exercise prescriptions are an underutilized modality and allow for patient-centered education in progressing patient care goals.

Acknowledgements: Geisinger Medical Center

Baseline Sleep Characteristics in NCAA Division I Collegiate Athletes

Primary Author/Presenter: Brian Donohoe, MD

Nelson Boland, MD, Fernando Avila-Garibay, MD, Calvin Duffaut, MD, and Joshua Goldman, MD, MBA

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

Presentation Type: Rising with Research Presentation

Purpose: To determine baseline sleep characteristics, including sleep duration and sleep architecture (total sleep time, slow wave sleep time, rapid eye movement time), as well as daytime sleepiness and subjective sleep quality of NCAA Division I collegiate athletes.

Methods: This is a longitudinal study with 42 NCAA Division I athletes across multiple sports (basketball, soccer, baseball, softball, swimming). Athletes wore a validated sleep monitoring device during the offseason that collected total sleep time and sleep architecture. Subjective sleep quality was assessed with the Single-Item Sleep Quality Scale and daytime sleepiness with the Epworth Sleepiness Scale.

Results: Only athletes with more than seven recorded sleeps (n = 42) were considered for this analysis. Data were first averaged across the individual so each athlete was only represented once and these aggregated data were used to calculate the means and standard deviations within teams. Mean total sleep duration (reported in minutes ± SD) across all sports was 383.3 ± 61.4 with sleep cycle breakdown as follows: light sleep (208.0 ± 47.5), slow-wave sleep (72.1 ± 16.9), REM sleep: (103.2 ± 26.8) and wake time (42.1 ± 12.7). Mean total sleep duration by sport was: men's basketball (n = 3, 332.5 ± 112.0), women's basketball (n = 8, 381.1 ± 57.2), softball (n = 7, 395.0 ± 48.9), women's soccer (n = 11, 359.9 ± 52.4) and women's swimming (358.9 ± 53.7). The mean Epworth Sleepiness Scale score (assesses daytime sleepiness) was 7.4 ± 3.6 (n = 41) and the mean Single-Item Sleep Quality Scale score (assesses subjective sleep quality on a scale of 1-10) was 6.8 ± 1.8 (n = 41).

Conclusions: Collegiate student-athletes in our study demonstrated inadequate sleep habits. Whereas the American Academy of Sleep Medicine recommends adults obtain 7-9 hours and adolescents obtain 8-10 hours of sleep per night for optimal health, our athletes averaged 6 hours and 23 minutes per night. Despite this, athletes reported "good" subjective sleep quality (on the SISQ scale) and had "normal" daytime sleepiness scores (on the ESS), on average.

Significance: To our knowledge, this is the first study to track sleep architecture in such a large cohort of NCAA athletes (final data set to include > 150 athletes). Next, we plan to examine sleep extension and sleep consistency interventions in this population.

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

Shear Wave Assessment of Tendon Biomechanics and Clinical Outcomes in Chronic Lateral Epicondylitis: PRP Vs. Corticosteroids

Primary Author/Presenter: Tyler Dorobek, BS

Grant Quilling, BS, Phillip Sasser III, MD, Kenneth S Lee, MD, and John J. Wilson, MD, MS

Affiliation: University of Wisconsin School of Medicine and Public Health, Madison, WI.

Purpose: To investigate the efficacy of a single intratendinous Platelet-Rich Plasma (PRP) vs corticosteroid injection (CS) for treatment of chronic lateral epicondylosis (CLE) at 26 and 52 weeks. Secondary aim is to correlate morphologic and quantitative ultrasound (US) changes to clinic outcomes.

Methods: Randomized double-blind controlled trial. 47 individuals from UW Hospitals and Clinics were randomly assigned to ultrasound (US) guided PRP (n = 25) or CS injection (control group, n = 22). Post-treatment imaging measures assessed US morphologic changes and shear wave speed (SWS). Grip strength and clinical outcome surveys measured at the same timed intervals post-treatment (t = 0, 26 and 52 weeks).

Results: At baseline, mean SWS was 6.70 (1.98) m/s, 0.50 (0.11) for thickness, 1.84 (0.75) for echogenicity and 2.10 (0.97) for hyperemia. SWS was significantly associated with pain, DASH and PRTEE adjusting for timepoint (p < 0.001). For every 1 m/s increase in SWS, pain decreases by -0.21 (95% CI: -0.41, -0.01). Moreover, for every 1 m/s increase in SWS, DASH and PRTEE decreased by 1.17 (95% CI: -1.91, -0.43) and 3.76 (-6.34, -1.19), respectively. For every 1 unit increase in echogenicity, pain increased by 0.76 points (95% CI: 0.04, 1.48) but no association between echogenicity and function was identified. Finally, no statistically significant association between hyperemia and pain/function was identified; however, there is evidence of potential associations between hyperemia and function (p = 0.09 and p = 0.06). Grip Strength was significantly increased in the PRP group when compared to the CS group at 52-weeks post-injection (p < .027).

Conclusions: PRP is an effective treatment alternative for chronic refractory lateral epicondylosis. Results show significantly improved VAS Pain Score, QuickDASH and Grip Strength at 26 and 52-week assessments. SWS has potential to be a useful modality for quantitative biomarker evaluation of the tendon healing response. SWS may be a useful tool in correlating tendon regeneration with improved patient clinical presentation in the setting of CLE.

Significance: This study suggests PRP shows superior outcomes compared to CS at 52 weeks for primary outcome measures studied. PRP may lead to improved clinical outcomes and shows improvement in tendon biomechanics characterized by shear wave elastography.

Acknowledgements: UW Department of Orthopedics UW Biostatistics UW Department of Radiology UW Institute for Clinical Translational Research RSNA Scholar Grant (RSCH 1317) NBA-GE Collaborative Grant.

Retirement From Collegiate Athletics: Presence and Characterization of Mental Health Programming

Primary Author/Presenter: Courtney Duckworth, BS

Siobhan Statuta, MD, and Jason Freeman, PhD

Affiliation: University of Virginia School of Medicine, Charlottesville, VA.

Presentation Type: Rising with Research Presentation

Purpose: Proactive mental health care has the potential to offer protection to college athletes who face an increased risk for depression at the end of their athletic careers. This study assesses existing and ideal mental health programming to prepare college athletes for retirement from competitive sport.

Methods: A 20-question survey was designed to assess three domains: 1) the presence of proactive mental health programming addressing retirement in collegiate athletes 2) features of existing programming 3) features of ideal programming. The survey was administered over the AMSSM electronic mailing list. Responses were collected anonymously between October 2021and December 2021 with Qualtrics software.

Results: 108 collegiate sports medicine professionals took part in the survey. 53% belonged to athletic programs with mental health programming to prepare students for retirement from collegiate athletics. Existing programming was mostly: required (53%) and delivered by behavioral health specialists (53%) the 1st semester senior year (21%) with 70% delivered multiple semesters. Prior to COVID-19, programming was mostly in-person seminars (24%) and small group meetings (22%) and is now mostly virtual seminars (20%). Sports medicine professionals indicated their ideal programming would be required (78%) in individual or small groups and delivered by a behavioral health specialist (50%) the 1st semester senior year (22%) and in additional semesters (59%). Themes from the goals of ideal programming include: insight into potential mental health concerns, awareness of resources, normalization of transition difficulties, self-compassion and finding purpose outside of athletics.

Conclusions: Collegiate sports medicine professionals are concerned about athletes as they retire from competitive sport, yet only around half of athletic programs prepare athletes for this transition. Wider adoption of similar programming is needed. Promisingly, characteristics of existing and ideal programming is similar with many shared goals, offering guidance in the design and delivery of proactive mental health care.

Significance: Characterizing existing and ideal mental health programming to prepare college athletes for retirement from competitive sport can encourage adoption of these practices and inform the creation of effective and realistic proactive mental health care.

Obsessive Compulsive Disorder Symptoms in U.S. Collegiate Athletes

Primary Author/Presenter: Giorgia Garrett, MD

Jonathan Sladky, MD, Linda Nahulu, MD, and Andrew Nichols, MD

Affiliation: University of Hawaii, Honolulu, HI.

Presentation Type: Rising with Research Presentation

Purpose: To determine the prevalence, severity and risk factors of obsessive compulsive disorder (OCD) symptoms in a cohort of NCAA Division I collegiate athletes using the Yale-Brown Obsessive Compulsive scale (Y-BOCS) survey.

Methods: The Y-BOCS, a 10-item validated survey instrument that measures the presence, severity and type of OCD symptoms, was administered to college student-athletes (S-As) during pre-participation physical evaluations at one NCAA D-I institution. Demographic data was collected to identify OCD risk factors. Statistical software was used for logistic regression analysis to yield odds ratios (OR).

Results: The survey response rate was 46% (233/504). Fifty-nine percent of respondents were female and the mean age was 20 years (SD = 1.6; range = 17-26). Surveys were completed by S-As in 19 sports (7 female, 10 male and 2 co-ed). Based upon the Y-BOCS score, 54% (126), 36% (85), 7% (17), 2% (4) and 0.8% (1) were categorized as having "no or subclinical", "mild," "moderate," "severe" and "extreme" OCD symptoms, respectively. Logistic regression analysis demonstrated that each additional year of age was associated with a 25% increased risk of experiencing more severe OCD symptoms (OR = 1.25; CI = 1.05-1.5; P = 0.017). Gender and sport did not identify any statistically significant associations with OCD symptom severity.

Conclusions: The study reveals a high prevalence of OCD symptoms in S-As, with severity categorized as ">mild" in 46% and ">moderate" in 9%. In comparison, the adult U.S. population has a lifetime OCD incidence of 2% and 28% report occasional OCD symptoms. Certain OCD traits may actually be beneficial and enhance sport performance, whereas more severe symptoms are likely to be detrimental to sport performance and quality of life.

Significance: Awareness of the high occurrence of OCD symptoms in college athletes can prompt team physicians to consider whether an OCD diagnosis is present and whether the condition impacts the athlete's quality of life and overall functionality.

Changes in Quality of Life Among Collegiate Athletes During COVID-19

Primary Author/Presenter: Thomas Harris, MD

Jennifer Sanfilippo, MS, LAT, Kristin Haraldsdottir, PhD, and Andrew Watson, MD, MS

Affiliation: University of Wisconsin-Madison, Madison, WI.

Presentation Type: Rising with Research Presentation

Purpose: This study was aimed at evaluating the impact and relationship of the COVID-19 pandemic on collegiate athletes and their quality of life.

Methods: The Veterans RAND 12 item health survey was provided to collegiate athletes at a Division I institution repeatedly from January 2018 to May 2021. Mixed effects models were used to compare the physical component scores (PCS) and mental component scores (MCS) over time (pre-COVID, during COVID) as well as evaluate the interactions between gender and time and sport type (team, individual) and time.

Results: A total of 4668 surveys were collected from 1814 athletes (907 male, 907 female). For all athletes, the PCS increased (54.7, [95% CI = 54.5-54.9] to 55.5 [55.2-55.9], p < 0.001) and the MCS decreased (54.7 [54.4-55.0] to 53.1 [52.6-53.7], p < 0.001) from pre-COVID to during COVID. When evaluating the interaction between gender and time, females demonstrated a greater increase in PCS (1.0 ± 0.35, p = 0.005) and greater decrease in MCS (1.7 ± 0.56, p = 0.001) from pre-COVID to during COVID relative to males. With respect to sport type, participants in individual sports demonstrated a greater decrease in MCS (2.4 ± 0.56, p < 0.001) relative to team sports, but no interaction was identified with respect to PCS (0.41 ± 0.36, p = 0.25).

Conclusions: When compared to pre-COVID, collegiate athletes demonstrated a decrease in their mental quality of life during the COVID-19 pandemic, particularly among females and those participating in individual sports. On the other hand, athletes reported an increase physical quality of life during COVID that was also larger in females, but unrelated to sport type.

Significance: This study demonstrates the impact of the COVID-19 pandemic on collegiate athletes' quality of life, including negative effects on mental health. It also identifies cohorts of athletes (female, individual) who may be more significantly affected.

Acknowledgements: The authors would like to acknowledge the Sports Medicine staff at the University of Wisconsin-Madison Division of Intercollegiate Athletics for their commitment to the welfare of the student-athletes and contributions to the Badger Athletic Performance program.

Reliability of The Pitch Efficiency Rating (PER) A Novel Tool For Assessing Mechanical Efficiency and Injury Risk

Primary Author/Presenter: Charles Kenyon, DO, MS, CSCS

Kirk Easley, MS, Alexander Dawes, Corey Spencer, MD, Troy Royal, ATC, Neeru Jayanthi, MD, and Robert Bowers, DO, PhD

Affiliation: Emory University Department of Orthopedics, Atlanta, GA.

Presentation Type: Rising with Research Presentation

Purpose: Despite numerous biomechanical studies, there is no validated model for a standardized assessment of efficiency and injury risk in baseball athletes. We aim to create a novel Pitch Efficiency Rating (PER) based on current evidence to assess throwing mechanics in developing pitchers.

Methods: This cross-sectional observational study evaluated 14 Division 1 male baseball pitchers ages 18-22. Video was captured utilizing an iPhone and Dartfish mobile app on a series of pitches from 3 angles at 90-degree intervals. Two raters scored the PER for each athlete at two different time intervals. Statistical analysis was performed to determine inter- and intra-rater reliability of the PER.

Results: A 1-sample paired t-test was used to compare the mean total score difference between the first and second readings for each rater and to compare the mean total score difference between rater 1 and rater 2 for the first reading and to compare the mean total score difference between- rater 1 and rater 2 for the second reading. The intraclass correlation coefficient (ICC) was used as a measure of the magnitude of reliability agreement and was estimated with variance components from a mixed effects linear model. Total score inter-rater reliability at first readings demonstrated an intraclass correlation (ICC) of 0.61 with 95% confidence interval (CI) of 0.28-0.86. Readings at the second interval demonstrated ICC of 0.23 with 95% CI of 0.02-0.83. Intra-rater reliability for rater 1 comparing separate time intervals demonstrated ICC of 0.77 and 95% CI of 0.50-0.92 between the first and second readings. Intra-rater reliability for rater 2 demonstrated ICC of 0.65 and 95% CI of 0.33-0.87.

Conclusions: Good to excellent intra-rater reliability was demonstrated with ICC of 0.77 and 0.65 for rater 1 and rater 2 respectively. At the first rating inter-rater reliability was determined as moderate with ICC of 0.61. At the second interval ICC decreased to 0.23, possibly suggestive of rater fatigue.

Significance: PER was efficiently applied using low-cost technologies. High intra-rater reliability indicates effective application by different observers. Future studies will optimize the PER to prospectively evaluate injury risk in developing athletes.

Acknowledgements: Ben King, Georgia Tech Baseball

Effect of Socioeconomic Factors on Exercise Prescription Following Injury

Primary Author/Presenter: Jessica Knapp, DO

Bianca Gray, MSIV

Affiliation: MAHEC.

Purpose: The purpose of this study is to explore the potential differences between demographic groups in prescription of home exercise program (HEP), referral to physical therapy (RPT) and attending physical therapy (APT) given that certain socioeconomic factors may affect referrals and attendance.

Methods: Retrospective chart review conducted at a sports medicine clinic (2018-2020) to determine number of patients in each group of HEP, RPT and APT based on race, sex, primary language, or percent below poverty level (PBPL). PBPL and percent above poverty burden (PAPB) found on The North Carolina Census ACS Poverty Status Tract database. Data was analyzed using chi-square and yates tests.

Results: There was no difference in RPT and APT or HEP over PT referral found based on gender (149 males RPT, 380 females RPT, 83 males APT, 207 females APT, 54 males HEP and 111 females HEP) and race (419 caucasians RPT, 51 Persons of Color RPT, 244 caucasians APT, 27 Persons of Color APT, 116 caucasions HEP and 21 Persons of Color HEP). There was no difference in language for attendance of PT (504 english speakers RPT, 24 non english speakers RPT and 282 english speakers APT, 8 non english speakers APT), while there was a significant difference (p = 0.005) found for 247 english patients given HEP and 18 non english speakers given HEP. A significant difference (p = < 0.03) between patients who were PBPL (<15.1 %) and 233 were above poverty burden (>15.1 %) and 161 attended physical therapy in the PBPL and 108 attended PAPB. There was not a significant difference found for prescription of HEP to PT referral (73 PBPL and 78 PAPL).

Conclusions: These findings suggest that language of care, PAPB and PAPL may influence prescription of HEP over PT and attendance of PT while gender and race do not in this sample.

Significance: Retrospective chart review is an important tool for self audit to determine equity patterns, so that we can continue to be aware of where the greatest need for increased care lies in our day to day clinic.

Acknowledgements: Thank you for reviewing our paper.

Overcoming COVID Vaccine Hesitancy in Our College Athlete Population

Primary Author/Presenter: Joshua Knudson, MD

Sahir Gharib, MD, and Amanda Phillips, MD

Affiliation: LSU Health Science Center, Lafayette, LA.

Presentation Type: Rising with Research Presentation

Purpose: The purpose of our study was to determine if interventions in the form of on-site vaccination clinics, informative email/text messages and physician presentations were impactful in overcoming vaccination hesitancy in our college athlete population.

Methods: Our goal was to assess vaccination rates following on-site vaccination clinics, informative email/text messages and physician presentations and compare vaccination rates to state and national data. Vaccinate Data was collected from all rostered players for the 2020-2021 season. It was further categorized into vaccinated vs unvaccinated, specific sport, gender and ethnicity.

Results: Significant increase of new vaccinations seen in all sports/races/genders following intervention #2 (campus vaccine clinic), with football athletes most affected. New football vaccination rates were second highest following intervention #6 (ZOOM presentation by Infectious Disease) and #9 (email/text outlining UL Policy on unvaccinated athlete testing requirements sent to all athletes). For all other sports, there was a spike in new vaccinations after intervention #9. Largest increase in new vaccinations after intervention #9 was seen in baseball, women's basketball, women's track and softball. Looking at new vaccination rates regarding gender, both men and women had significant increases after intervention #9. Additionally, men had a spike after intervention #6, though women did not. When looking at race, a significant increase in both Caucasian and BIPOC occurred following interventions #6 and #9. In comparison to CDC data, UL athletes exceeded state and national vaccination rates.

Conclusions: A significant increase in vaccination rates occurred following the on-site vaccination clinic, infectious disease presentation and email/text outlining UL Policy on unvaccinated athlete testing requirements. The largest effect was seen with the vaccine clinic and final policy email. We noted increases in vaccinations across multiple sports, races and genders. Our study was stopped when the university vaccine mandate was issued after 8/23/21.

Significance: The significance of our study results aims to decrease vaccination hesitancy in student athletes and increase vaccination rates. Repeated education on vaccination appears to be a key component in combating hesitation and increasing vaccination rates.

Acknowledgements: The University of Louisiana Lafayette Athletic Department LSU Health and Sciences Center

Is Previous COVID-19 Diagnosis Associated With Fatigue or Sleep Disturbance in Incoming College Athletes?

Primary Author/Presenter: Katie Krebs, MD

James R. Borchers, MD, MPH, FACSM

Affiliation: Ohio State University, Columbus, OH.

Presentation Type: Rising with Research Presentation

Purpose: Persistent symptoms including fatigue after COVID-19 have been noted in the general population. Less is known regarding persistent symptoms in athletes. This study sought to investigate whether college athletes with a previous COVID-19 infection had increased complaints of fatigue or sleep concerns.

Methods: Preparticipation physicals (PPEs) of incoming athletes at a large Division 1 university were reviewed with IRB approval from the sponsoring institution. The presence of extreme fatigue, athletes' wishing for more energy and sleep concerns were analyzed and compared between athletes with a previous COVID-19 diagnosis and those without using Fisher's exact testing defining significance as p < 0.05.

Results: PPEs of 306 athletes were reviewed. Of these, 62 athletes reported a previous positive COVID test and 233 reported no history of infection. 11 athletes did not answer the question and were excluded. No athletes reported current extreme fatigue. 21% of athletes (n = 62) wished they had more energy most days of the week, but there was no difference between the previously infected athletes and control population (p = 0.596). There was no difference between previously infected athletes and controls in regards to difficulty falling asleep (p = 0.441), difficulty staying asleep (p = 0.527), or feeling worried or distressed about one's sleep pattern (p = 0.891). Similarly, when asked whether sleep patterns interfere with daily functioning as it pertains to daytime fatigue, ability to function at work/school/practice, concentration, memory and mood there was no difference between previously infected athletes and those without COVID history (p = 0.409).

Conclusions: Previous COVID-19 diagnosis was not associated with increased concerns regarding fatigue, energy, or sleep disturbance in incoming college athletes. Concerns regarding falling asleep, staying asleep and sleep pattern were low in both groups; this is not surprising given the beneficial effect of exercise on sleep.

Significance: There does not appear to be an association between previous COVID-19 infection and fatigue in this student athlete population.

Virtual Wilderness Medicine Boot Camp Successfully Educates A National Audience

Primary Author/Presenter: Jayson Loeffert, DO

Arthur Berg, PhD, Shawn Phillips, MD, and Cayce Onks, DO

Affiliation: Penn State Health, Hershey, PA.

Presentation Type: Rising with Research Presentation

Purpose: A 2019 in-person wilderness medicine (WM) boot camp was converted to a virtual experience in 2020 and 2021 and offered to Primary Care Sports Medicine (PCSM) fellows across the country. The ability of this virtual boot camp to improve knowledge and comfort of WM topics was studied.

Methods: Boot camps occurred over two consecutive years. Information regarding WM and the sports medicine CAQ exam was taught. A pre/post survey assessed comfort level of altitude sickness, heat and cold injury, splinting, extraction decision making and mass casualty using a Likert scale. A pre/post multiple choice test assessed knowledge. The results were analyzed to determine statistical significance.

Results: 161 individuals (101 fellows, 60 faculty) participated in the 2020 boot camp and 128 individuals (85 fellows, 43 faculty) participated in the 2021 boot camp. Significant improvement was seen in nearly all areas of investigation for both fellows and faculty. In the 2020 boot camp, fellows and faculty had statistically significant improvements (p < 0.001) in comfort level regarding altitude sickness, cold injury, heat injury, splinting, extraction decision making and mass causality. Both groups showed improvement on their knowledge posttest (p < 0.001). For the 2021 boot camp, similar results were seen with statistically significant improvement (p < 0.001) of both groups for altitude sickness, cold injury, extraction decision making, mass casualty and the knowledge posttest. Fellows and faculty showed improvement in heat injury comfort (p < 0.001, p < 0.05 respectively). Fellows showed improvement for splinting (p < 0.001) but faculty improvement was not statistically significant.

Conclusions: These virtual boot camps where successfully able to teach wilderness medicine topics to fellows and faculty from across the country. A statistically significant improvement occurred for comfort in nearly all categories for both fellows and faculty. Improvement in knowledge was seen as well for both fellows and faculty, with a statistically significant improvement seen on the post boot camp multiple choice test.

Significance: The COVID-19 pandemic forced learning opportunities to become virtual. The effectiveness of this teaching method was unknown. These events are the largest reported boot camps and significantly improved comfort and knowledge across many WM topics.

Acknowledgements: The authors would like to acknowledge the sports medicine faculty at Penn State Health in Hershey Pa for their contribution to the boot camps. Their terrific lectures helped to make these results possible. They also thank Alicia Smith, coordinator, for her assistance with organization of the boot camp.

Light And Sound Sensitivity Predict Recovery From Sport-Related Concussion

Primary Author/Presenter: Sean Loose, MD

Thomas Schumann, DO, Michael Suffredini, DO, Kevin Walpole, DO, Amber Char, DO, and Kevin DuPrey, DO

Affiliation: Crozer Healthplex Sports Medicine Institute, Springfield, PA.

Presentation Type: Rising with Research Presentation

Purpose: The purpose of this study was to evaluate the relationship between self-reported light and sound sensitivity on the SCAT5 assessment at initial office visit after a sport-related concussion (SRC) in adolescent athletes and risk of prolonged recovery lasting > 28 days.

Methods: The study was a retrospective cohort study of 519 athletes aged 12-18 years presenting with SRC. Exclusion criteria included pre-existing neurologic and psychiatric disorders. SCAT5 symptom scores were recorded as follows: none = 0; mild = 1-2; moderate = 3-4; severe = 5-6). Prolonged recovery was defined as > 28 days from injury until the athlete was cleared to start the return to play (RTP) protocol.

Results: Athletes who reported mild, moderate, or severe light sensitivity took 9.59 (p = 0.041; 95% CI 0.4-18.8), 22.86 (p < 0.001; 95% CI 12.6-33.1) and 35.09 (p < 0.001; 95% CI 20.8-49.3) days longer to recover than those reporting no light sensitivity, respectively. For every 1 point increase in SCAT symptom score reported for light sensitivity there was a 1.61 (p < 0.001; 95% CI 1.4-1.8) fold increased risk of prolonged recovery. Athletes who reported mild, moderate, or severe sound sensitivity took 17.5 (p < 0.001; 95% CI 8.7-26.4), 12.01 (p = 0.048; 95% CI 0.1-23.9) and 31.89 (p = 0.001; 95% CI 13.1-50.7) days longer to recover than those reporting no sound sensitivity, respectively. For every 1 point increase in SCAT symptom score reported for sound sensitivity there was a 1.50 (p < 0.001; 95% CI 1.3-1.7) fold increased risk of prolonged recovery.

Conclusions: Athletes 12-18 years old reporting mild, moderate or severe light sensitivity or sound sensitivity at initial office visit, were at increased risk of prolonged recovery when compared to athletes reporting no such symptoms.

Significance: Severity of light sensitivity and sound sensitivity scoring on the SCAT5 questionnaire may be of use in guiding treatment and counseling patients on expected recovery time after SRC with higher scores correlating to increased recovery time.

Risk of Concussion After Return to Sport Following COVID-19 Infection

Primary Author/Presenter: Gregory Mines, MD

Calan Sowa, MD, Franklin Sease, MD, Scott Annett, MD, Alyssa Barre, Emily-Rose Zhou, John Thorpe, ATC, and Vicki Nelson, MD, PHD

Affiliation: Prisma Health—Steadman Hawkins Clinic of the Carolinas, Greenville, SC.

Presentation Type: Rising with Research Presentation

Purpose: Little is known about the relationship between SARS-CoV-2, the virus that causes COVID-19 infection and predisposition to concussion injuries. This pilot study serves to evaluate associations between COVID-19 and the risk of subsequent sports-related concussion after returning to play.

Methods: During the 2020-2021 season, COVID-19 infection among scholastic athletes was tracked using return to play clearance questionnaires. 100 athletes with a history of COVID-19 were paired with controls from teammates of the same grade level selected by random number generation. Retrospective identification of sport-related concussion within 12 months of COVID-19 diagnosis was performed.

Results: 100 high school and collegiate athletes (27% male, 51% collegiate) who had a positive COVID-19 diagnosis during the 2020-2021 athletic season were identified. These athletes were paired with teammates without a history of COVID infection sharing similar athletic attributes (same sport, school, gender) and exposures (practice and game schedules) to minimize differences in risk of injury based on factors such as exposure, training, schedule or level of competition. Out of these 200 athletes, 10 concussions were identified. 3 concussions were identified in the control group while 7 concussions were identified in athletes with a history of COVID-19 diagnosis. Thus, concussion occurrence rate was 7% in the athlete group with a history of COVID-19 diagnosis versus 3% in the paired control group. Paired t-test (2-tailed) was performed revealing a p-value of 0.21.

Conclusions: This pilot study demonstrates a doubling in concussion rate (7% v 3%) amongst high school and collegiate athletes that had a recent history of COVID-19 diagnosis when compared to paired controls. While not significant, this trend warrants further investigation and a larger population will be enrolled to evaluate this risk further.

Significance: Although this pilot did not reveal statistical significance, it demonstrates a trend deserving further inquiry. A doubling in concussion risk among scholastic athletes returning from Covid-19 infection could be clinically significant.

Performance of The SMHAT-1 During Mental Health Screening in Collegiate Athletes

Primary Author/Presenter: Vicki Nelson, MD, PhD

Vicki Nelson, MD, PhD

Scott Annett, MD, and Franklin Sease, MD

Affiliation: Prisma Health—Upstate, Greer, SC.

Presentation Type: Rising with Research Presentation

Purpose: This study aimed to evaluate the performance of the IOC Sports Mental Health Assessment Tool-1 (SMHAT-1) in an NCAA collegiate athlete population for mental health screening.

Methods: All athletes at a single institution (n = 558, 63.7% male) underwent mental health screening including the IOC SMHAT-1 component APSQ, GAD-7, PHQ-9, ASSQ and CAGE instruments. Individuals with positive triage (APSQ) also underwent reflex AUDIT-C and BEDA-Q screening. Internal validity (Cronbach's alpha) was calculated for comparison with published values in elite athletes.

Results: Only 7.0% (39/558) of athletes were positive during triage, less than published in elite athletes. Internal validity was moderate to good (0.77 male, 0.84 female) and comparable to published values. Of those athletes, 29 (74.4%) were positive on screening (at least one instrument). Overall, 87 (15.6%) athletes were screen positive with most missed during triage (58/87, 66.7%). Evaluating each test independently shows mixed triage performance detecting a majority of GAD-7 (75% detected), PHQ-9 (86%) positive cases while missing the majority of ASSQ (25% detected) an