The Canadian Academy of Sport and Exercise Medicine (CASEM) has partnered with Choosing Wisely Canada (CWC) to generate a list of pediatric sport and exercise medicine (SEM) recommendations. Choosing Wisely Canada is a national campaign that has partnered with numerous professional medical organizations and associations representing several clinical specialties to generate lists of tests and treatments to avoid, in the form of recommendations for clinicians and information for patients. The objective of producing these lists is to reduce the number of unnecessary tests, treatments, and procedures that occur in Canada that could expose patients to harm, lead to further testing owing to false-positive results, create unnecessary stress for patients and families, and consume time and limited resources.1
A list of 8 tests and treatments to question in pediatric SEM (Box 1)2 was launched on April 12, 2022, and is available in both English and French on the CWC and CASEM websites.2,3
Eight tests or treatments to question in pediatric sport and exercise medicine
Do not order knee radiographs to diagnose Osgood-Schlatter disease in children
Do not order ultrasound as an initial investigation for shoulder or knee injuries in children
Do not order scoliosis radiographic series for back pain
Do not order thoracic spine radiographs if there is clinical concern about scoliosis
Do not order oblique radiographic views for investigation of spondylolysis
Do not order a head CT scan for minor head injuries or concussion
Do not immobilize a joint with suspected amplified pain syndrome (complex regional pain syndrome)
Do not order follow-up radiographs for buckle fractures of the distal radius if there are no clinical symptoms at the time of follow-up
CT—computed tomography.
Reproduced with permission from Choosing Wisely Canada.2
Why a pediatric SEM list?
Family doctors are often the first point of contact for children and youth seeking medical care. Musculoskeletal concerns are common presentations in this age group, accounting for almost 25% of primary care visits by adolescents.4 Two-thirds of all injuries in adolescents are sports injuries5,6; these injuries can have a substantial negative impact on quality of life, possibly requiring weeks to months of time away from sport and activity, many sessions of physiotherapy, or even surgery, particularly if the injuries are not diagnosed and managed properly. Sports injuries can also result in lost time from school, with negative effects on academic achievement, and can result in children and adolescents dropping out of sports altogether, thereby reducing physical activity levels in adolescence and possibly decreasing physical activity into adulthood.7 Given the frequency of sports injuries in the pediatric age group, it is vital that family doctors are knowledgeable about these issues and apply available evidence in their daily practices. Choosing Wisely Canada lists of tests and treatments to question have very few pediatric-specific SEM or musculoskeletal recommendations.8 We aimed to address that gap with our newly developed list.
How the list was developed
In August 2021 the CASEM board approved the development of pediatric SEM recommendations for CWC. A small working group was formed by CASEM, consisting of the 3 authors (L.P., E.P., and K.H.), all of whom are pediatricians and sport medicine specialists. We reviewed existing CWC information and then developed a list of recommendations based on existing research, experience, and common practice patterns. We drafted 9 recommendations and e-mailed them to CASEM’s pediatric interest group, a pediatric orthopedic surgeon, and a pediatric musculoskeletal radiologist for review; we asked if they agreed or disagreed with the list and for them to provide comments. The list was briefly reviewed by Dr Wendy Levinson, chair of CWC, to ensure proper CWC format; at that point the list was decreased to 8 recommendations. This list was then e-mailed to the general CASEM membership as an electronic survey. Members were asked if they agreed or disagreed with the recommendations and were asked to provide comments. The publications committee of CASEM provided input on the list before the recommendations were sent to the CASEM board for approval. The final list of pediatric SEM recommendations was then submitted to CWC for its own internal review process and approval.
Final pediatric SEM list
The list identifies investigations and practices commonly used during pediatric SEM and musculoskeletal assessments but are not evidence-based. Overuse of these investigations and practices may expose patients to harm, unnecessary stress, and additional unnecessary testing. This list includes 8 imaging and management recommendations for knee and shoulder injuries, back pain, scoliosis, distal radius buckle fractures, computed tomography scans for minor head injuries or concussion, and management of chronic pain syndromes.2
Conclusion
We encourage all family physicians who see pediatric patients with sports injuries and musculoskeletal complaints to adopt these pediatric SEM recommendations as part of routine practice to optimize care of children and youth and to minimize the use of unnecessary investigations and treatments.
Notes
We encourage readers to share some of their practice experience: the neat little tricks that solve difficult clinical situations. Praxis articles can be submitted online at http://mc.manuscriptcentral.com/cfp or through the CFP website (https://www.cfp.ca) under “Authors and Reviewers.”
Footnotes
Competing interests
Dr Laura Purcell is President Elect and Dr Erika Persson is President, both at the Canadian Academy of Sport and Exercise Medicine. They receive travel expenses to meetings but no other financial support.
This article is eligible for Mainpro+ certified Self-Learning credits. To earn credits, go to https://www.cfp.ca and click on the Mainpro+ link.
La traduction en français de cet article se trouve à https://www.cfp.ca dans la table des matières du numéro janvier 2023 à la page e17.
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