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The following represent additions to UpToDate from the past six months that were considered by the editors and authors to be of particular interest. The most recent What's New entries are at the top of each subsection.
ADOLESCENT AND PEDIATRIC SPORTS MEDICINE
Multidisciplinary approach to children and adolescents with persistent concussion symptoms (September 2016)
For patients with prolonged post-concussion symptoms, a multidisciplinary approach that includes mental health care by a psychologist or psychiatrist is associated with better outcomes. In a randomized trial of 49 children and adolescents (11 to 17 years of age) with persistent symptoms for one month or longer after a sports-related concussion, collaborative treatment consisting of care management, cognitive-behavioral therapy, and, when needed, psychopharmacologic consultation was associated with significant reductions in postconcussive and depression symptoms at six months when compared to usual treatment . (See "Concussion in children and adolescents: Management", section on 'Persistent symptoms'.)
Ultrasound for the detection of distal forearm fractures in children (July 2016)
Distal forearm fractures are among the most common fractures in children. Plain radiographs of the forearm are considered the gold standard for definitive diagnosis. However, there is a growing interest in ultrasound diagnosis of distal forearm fracture due, in part, to the absence of exposure to radiation. In a metaanalysis of 12 studies (951 children 18 years of age and younger) comparing ultrasound with the reference standard of conventional radiography, ultrasound detected distal forearm fractures with a pooled sensitivity of 98 percent and a specificity of 96 percent . These findings correspond to an estimated 3 out of 100 distal forearm fractures missed by ultrasound. Detection of distal forearm fractures is a developing use of bedside ultrasound, especially when plain radiographs are not readily available. However, most centers still use plain radiographs for diagnosis of forearm fractures. (See "Distal forearm fractures in children: Diagnosis and assessment", section on 'Ultrasound'.)
BMI during adolescence and cardiovascular mortality during adulthood (April 2016)
A variety of studies have shown associations between obesity during adolescence and multiple cardiovascular risk factors (eg, hypertension, dyslipidemia, diabetes). Now, a large population-based study from Israel found that higher body mass index (BMI) during late adolescence is associated with cardiovascular mortality in mid-adulthood . Of note, this association was seen even within the range of BMIs considered to be normal in adolescents, with a graded increase in risk of death as adolescent BMI rose above the 50th percentile (figure 1). This study supports and expands the body of evidence suggesting that the processes causing coronary heart disease begin during adolescence. (See "Comorbidities and complications of obesity in children and adolescents", section on 'Adult coronary heart disease'.)
MANAGEMENT AND REHABILITATION OF MUSCULOSKELETAL INJURIES
Factors associated with longer recovery from hamstring injury (September 2016)
Hamstring injuries vary widely in severity, and therefore general recommendations about returning to sport following such injury are unhelpful. Nevertheless, understanding the factors associated with a prolonged recovery can be useful. According to a systematic review of 24 articles discussing return to play following an acute hamstring injury, clinical factors associated with a prolonged recovery include the following :
●Injuries requiring >1 day before normal ambulation
●Substantial deficits in range of motion
●Extensive or severe injury based on magnetic resonance imaging (MRI) or ultrasound findings
●Stretching- (as opposed to sprinting-) type injury (eg, dance-related)
These factors can be used to identify patients who may have a delayed return (several months) to sport. (See "Hamstring muscle and tendon injuries", section on 'Return to work or sport'.)
Treatment of degenerative meniscal tears (September 2016)
Acute meniscal tears often benefit from surgical treatment, but the appropriate management of chronic, degenerative tears, particularly in middle-aged adults, has been a source of debate. A recent trial randomly assigned 140 middle-aged adults (mean age 49.5) with a degenerative meniscal tear (and no evidence of osteoarthritis on magnetic resonance imaging [MRI]) to receive exercise therapy or partial meniscectomy . The trial found no clinically significant difference in knee function or pain at two years of follow-up. This finding is consistent with several other small randomized trials that have reported no clinically significant benefit from arthroscopic surgery in such patients. In the absence of persistent joint effusions or mechanical dysfunction, we suggest physical therapy as the initial management for middle-aged patients with degenerative meniscal tears. (See "Meniscal injury of the knee", section on 'Chronic degenerative meniscal injury'.)
Tai Chi for patients with knee osteoarthritis (June 2016)
Tai Chi, a multicomponent traditional Chinese mind-body practice, combines slow and graceful movements with meditative relaxation techniques and can reduce pain and improve physical function in patients with osteoarthritis (OA), compared with control interventions. In a recent randomized trial involving over 200 patients with knee OA, a Tai Chi program (twice weekly for 12 weeks, with instruction to practice Tai Chi daily), resulted in benefit similar to an active comparator, outpatient physical therapy and a home exercise program . After 12 weeks, both groups exhibited statistically and clinically significant reduction in the Western Ontario and McMaster Universities Arthritis Index (WOMAC) pain score, and differences between the groups were not statistically significant. Benefits were maintained at 52 weeks of follow-up. The Tai Chi group had greater improvements in depression and the physical quality-of-life measure. (See "Nonpharmacologic therapy of osteoarthritis", section on 'Tai Chi'.)
MEDICAL ISSUES RELATED TO SPORTS AND EXERCISE
Rhabdomyolysis and sickle cell trait (August 2016)
Sickle cell trait is a benign carrier condition with a normal life expectancy. However, concerns have been raised regarding an increased risk of rhabdomyolysis and sudden death with prolonged physical activity. These risks were addressed in a cohort study of almost 50,000 black soldiers in the United States army for whom sickle cell trait status and other clinical information was available . While the risk of rhabdomyolysis was increased (hazard ratio, 1.5), this magnitude of risk is similar to that conferred by obesity or smoking and less than that due to antipsychotic or statin medications. Mortality was not increased over that in black soldiers without sickle cell trait, and the sole death from rhabdomyolysis occurred in an individual without sickle cell trait. Interventions to reduce exertion-related injuries should be aimed at all athletes and members of the military, regardless of sickle cell trait status. (See "Sickle cell trait", section on 'Rhabdomyolysis and sudden death during strenuous physical activity'.)
Chronic sleep-wake disturbances after traumatic brain injury (July 2016)
Sleep-wake disturbances are very common in the weeks to months following traumatic brain injury (TBI), and a new study suggests that many of these symptoms persist long term. In a prospective case-control study in which 31 patients with TBI of any severity were evaluated at 18 months after injury, 67 percent of patients had evidence of excessive daytime sleepiness on objective testing, compared with only 19 percent of healthy controls . Patients also had persistent pleiosomnia (increased need for sleep), requiring an average of one more hour of sleep per 24 hours than controls. As in earlier studies, patients tended to underestimate their symptoms, emphasizing the importance of both subjective and objective sleep testing in patients with sleep-wake complaints after TBI. (See "Sleep-wake disorders in patients with traumatic brain injury", section on 'Natural history'.)
- McCarty CA, Zatzick D, Stein E, et al. Collaborative Care for Adolescents With Persistent Postconcussive Symptoms: A Randomized Trial. Pediatrics 2016.
- Douma-den Hamer D, Blanker MH, Edens MA, et al. Ultrasound for Distal Forearm Fracture: A Systematic Review and Diagnostic Meta-Analysis. PLoS One 2016; 11:e0155659.
- Twig G, Yaniv G, Levine H, et al. Body-Mass Index in 2.3 Million Adolescents and Cardiovascular Death in Adulthood. N Engl J Med 2016; 374:2430.
- Fournier-Farley C, Lamontagne M, Gendron P, Gagnon DH. Determinants of Return to Play After the Nonoperative Management of Hamstring Injuries in Athletes: A Systematic Review. Am J Sports Med 2016; 44:2166.
- Kise NJ, Risberg MA, Stensrud S, et al. Exercise therapy versus arthroscopic partial meniscectomy for degenerative meniscal tear in middle aged patients: randomised controlled trial with two year follow-up. BMJ 2016; 354:i3740.
- Wang C, Schmid CH, Iversen MD, et al. Comparative Effectiveness of Tai Chi Versus Physical Therapy for Knee Osteoarthritis: A Randomized Trial. Ann Intern Med 2016; 165:77.
- Nelson DA, Deuster PA, Carter R 3rd, et al. Sickle Cell Trait, Rhabdomyolysis, and Mortality among U.S. Army Soldiers. N Engl J Med 2016; 375:435.
- Imbach LL, Büchele F, Valko PO, et al. Sleep-wake disorders persist 18 months after traumatic brain injury but remain underrecognized. Neurology 2016; 86:1945.