Pediatric sport and exercise medicine: Eight things clinicians and patients should question

Abstract

Choosing Wisely Canada (CWC) is the national voice for reducing unnecessary tests and treatments in Canada. A small working group created by the Canadian Academy of Sport and Exercise Medicine developed a list of pediatric sport and exercise (SEM) recommendations based on existing research, experience, and common practice patterns. These recommendations identify tests and treatments commonly used in pediatric musculoskeletal assessments that are not supported by evidence and could expose patients to harm. Iterative feedback from key stakeholders informed the final list. The final list comprises eight recommendations including imaging recommendations for Osgood Schlatter’s disease, shoulder and knee injuries, back pain, scoliosis, spondylolysis, distal radial buckle fractures, minor head injury/concussion, and management of chronic pain syndromes. Adopting these CWC pediatric SEM recommendations as part of routine practice may optimize care and minimize unnecessary investigations and treatments.

INTRODUCTION

Choosing Wisely Canada (CWC) (1) is the national voice for reducing unnecessary tests and treatments in Canada. Professional societies representing different clinical specialties in Canada develop recommendations (“Things Physicians and Patients Should Question”) based on practice patterns of frequently overused tests and treatments that are not supported by evidence-based medicine and may expose patients to harm.

The Canadian Academy of Sport and Exercise Medicine (CASEM) has partnered with CWC to develop the “Pediatric Sport and Exercise Medicine: Eight Things Clinicians and Patients Should Question” list which launched on the CWC and CASEM websites on April 12, 2022 (1,2).

THE NEED FOR A PEDIATRIC SPORT AND EXERCISE MEDICINE LIST

Musculoskeletal (MSK) concerns and sport injuries are common presentations for children and adolescents seeking medical care, with a study in Ontario finding one in eight children and adolescents aged 0–19 years visited a physician for MSK concerns in a year (2006/2007) (3). Almost 3% of children and youth in Ontario visited an Emergency Department for injury and related MSK conditions (3). Amongst adolescents, two-thirds of all injuries are sport injuries (4,5), which can have a significant negative impact on quality of life in this age group. Sport injuries can potentially require weeks to months of time away from sport and activity, and weeks to months of physiotherapy or even surgery, especially if injuries are misdiagnosed. Sport injuries may also result in school absence, negatively affect academic achievement, and may cause children and adolescents to drop out of sports, reducing physical activity levels in adolescence and adulthood (6). Given the frequency of sport injuries in the pediatric age group, it is important that all clinicians who see pediatric patients are knowledgeable about MSK/sport injuries in children and adolescents and use an evidence-based approach in their practices.

Current lists of “Things Clinicians and Patients Should Question” on the CWC website do not address pediatric-specific SEM or pediatric-specific MSK issues (1). We are addressing this gap with the “Pediatric Sport and Exercise Medicine: Eight Things Clinicians and Patients Should Question” list.

THE DEVELOPMENT PROCESS

A small working group created by CASEM (2) identified a gap in CWC guidelines addressing pediatric-specific sport and exercise medicine (SEM) issues. The core-working group (LP, EP, KH) of three pediatric sport and exercise medicine specialists reviewed existing CWC recommendations and created a list of suggested pediatric-specific SEM recommendations based on existing research, experience, and common practice patterns. The list was reviewed by the Pediatric Interest Group of CASEM, and by a pediatric orthopedic surgeon and pediatric musculoskeletal radiologist. Recommendations and feedback were incorporated into a revised list, which was sent to CASEM’s national membership in electronic survey format for feedback on each recommendation. The list was further revised and sent to CASEM’s publication committee for review. Final edits were approved by the CASEM board and the list was submitted to and approved by CWC.

THE PEDIATRIC SEM LIST

The “Pediatric Sport and Exercise Medicine: Eight Things Clinicians and Patients Should Question” list includes eight imaging and management recommendations for knee and shoulder injuries, back pain, scoliosis, distal radius buckle fractures, CT scans in minor head injuries/concussion, and management of chronic pain syndromes. This list launched on April 12, 2022, on the Choosing Wisely and CASEM websites (1,2). (https://choosingwiselycanada.org/wp-content/uploads/2022/04/Pediatric-Sport-and-Exercise-Medicine_EN.pdf) (Table 1).

Table 1.

Eight tests or treatments to question in: Pediatric Sport & Exercise Medicine

1. Don’t order knee radiographs to diagnose Osgood Schlatter Disease in children.

2. Don’t order ultrasound as an initial investigation for shoulder/knee injuries in children.

3. Don’t order scoliosis radiographic series for back pain.

4. Don’t order thoracic spine radiographs if there is clinical concern about scoliosis.

5. Don’t order oblique radiographic views for investigation of spondylolysis.

6. Don’t order a head CT scan for minor head injuries/concussion.

7. Don’t immobilize a joint with suspected amplified pain syndrome (complex regional pain syndrome).

8. Don’t order follow-up radiographs for buckle fractures of the distal radius if there are no clinical symptoms at the time of follow-up.

Additional information and context for each item in Table 1 is available on the Choosing Wisely Canada website (https://casem-acmse.org/news/choosing-wisely-launch-8-pediatric-sem-tests-or-treatments-to-question/)

CONCLUSIONS

Adopting these CWC pediatric SEM recommendations as part of routine practice may optimize care and minimize unnecessary investigations and treatments. We encourage all clinicians who see pediatric patients—nurse practitioners, family physicians, pediatricians and pediatric subspecialists, orthopedic surgeons, and sport and exercise medicine doctors—to consider these recommendations and have a conversation with their patients about what is appropriate and necessary treatment.

DATA AVAILABILITY

The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request.