Pediatric Health Care Provider Awareness, Perceptions, and Utility of Sport Specialization Recommendations

Participants

Health care providers who regularly worked with pediatric patients were recruited from the research survey services of 4 professional organizations: the American Medical Society for Sports Medicine (AMSSM), the National Association of Pediatric Nurse Practitioners (NAPNAP), the National Athletic Trainers’ Association (NATA), and the Pediatric Research in Sports Medicine Society (PRiSM). Three of the organizations are profession specific (AMSSM, NAPNAP, and NATA), whereas the PRiSM is a multidisciplinary organization whose members include physicians (PHYSs), physical therapists, athletic trainers (ATs), nurse practitioners (NPs), and physician assistants. The inclusion criteria were having worked as a licensed HCP treating youth athletes (18 years old or younger) in the previous 12 months and being fluent in English. The study was approved by the Education Social/Behavioral Science Institutional Review Board at the University of Wisconsin-Madison.

Instrumentation

We developed a cross-sectional online survey to assess pediatric HCP awareness, perceptions, confidence in knowledge, and clinical use of sport specialization recommendations. The survey addressed (1) personal demographics; (2) professional demographics; (3) knowledge and perceptions of sports specialization; (4) awareness, confidence in knowledge, and use of recommendations; and (5) HCP program training and professional development background specific to sport specialization. The survey was created using questions from a previously validated survey designed to assess awareness of various sport specialization recommendations among youth sport parents¹⁶ and coaches.¹⁷ Questions consisted of dichotomous (yes or no) response items for the perceptions and awareness of recommendations and Likert-scale response items for confidence, use, and barriers. These recommendations included not participating in a single sport for more than 8 months in a year, not participating in organized sports for more hours per week than the child’s age, and not participating on multiple teams of the same sport at the same time. Questions were added to the original survey instrument to evaluate the awareness of various professional medical association recommendations (American Academy of Pediatrics [AAP],¹⁰ AMSSM,¹¹ American Orthopaedic Society for Sports Medicine [AOSSM],⁸ NATA⁹) and sports governing body recommendations (IOC,¹² NBA,⁷ MLB,¹⁴ and USA Hockey¹⁵). Face and content validity were determined through expert feedback from members of the PRiSM Sports Specialization Research Interest Group, a multidisciplinary group of HCPs with expertise in research methodology and sport specialization content. For this study, only the personal and professional demographic sections, knowledge and perceptions, and additional survey items specific to awareness, confidence, use, and barriers of recommendations were analyzed.

Procedures

We used the internal research survey services of the 3 professional organizations and 1 multidisciplinary organization focused on pediatric sports medicine research, previously identified, that distributed emails to their membership. The email contained consent language and an explanation of the survey and its purpose, along with a link to the online survey platform (Qualtrics). Clicking on the link signaled consent to participate in this study.

Survey links were sent between October 2019 and June 2020. Surveys were sent to the NATA list in fall 2019 and the PRiSM list in January 2020. A delay in recruiting from the AMSSM and NAPNAP email lists occurred until July 2020 due to the start of the COVID-19 pandemic and discussions among the research team to pause sending emails to the PHYS and NP groups. The survey was open for 4 weeks for each distribution service, with an email reminder sent once 2 weeks after the initial distribution.

Statistical Analysis

The independent variable was HCP group, which was self-identified through a survey question. Dependent variables were responses to the awareness, perceptions, confidence, use, and barriers sections of the survey. Data were analyzed with descriptive statistics, and comparisons between health care professions were made via χ² and Kruskal-Wallis tests with significance set at P < .05 a priori. Post hoc analyses were completed through pairwise Mann-Whitney U tests with Bonferroni adjustments made for multiple comparisons. All analyses were conducted in SPSS (version 28; IBM Corp).

Access and Completion Rates

Initial emails were sent to 15 313 HCPs (AMSSM = 4118, NAPNAP = 5872, NATA = 5000, PRiSM = 323). The survey was accessed by 810 respondents (access rate = 5.2%) and completed by 770 HCPs (completion rate = 95.1%).

Participants

The respondents consisted of 770 pediatric HCPs: 378 ATs, 123 NPs, and 269 PHYSs. On average, the HCPs had 11.97 ± 9.44 years providing care to youth athletes (ATs = 10.96 ± 9.4 years, NPs = 14.8 ± 10.22 years, PHYSs = 11.91 ± 8.99 years) and had completed their training in the year 2007 ± 10 years (ATs = 2007 ± 9.5 years, NPs = 2002 ± 11.97 years, PHYSs = 2008 ± 9.1 years). The PHYS specialty distribution is presented in Figure 1. The NP respondents were primarily working in pediatrics (89.4%; 110 of 123), with fewer working in family medicine (4.1%; 5 of 123) or other specialty areas (6.5%; 8 of 123). Table 1 provides practice settings by profession.

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Table 1 Respondent Employment Settings by Profession

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Awareness

Respondents noted differences in awareness specific to common suggestions contained within the formal recommendations. Specifically, a greater percentage of PHYSs (78.8%) were aware of recommendations for the maximum number of months in a year that athletes should participate, compared with 56.1% of ATs and 17.9% of NPs (P < .001). With respect to the maximum number of hours in a week that youth should participate, more ATs (55.8%) and PHYSs (54.8%) were aware compared with NPs (19.5%, P < .001). Similarly, ATs (53.3%) and PHYSs (69.4%) were more aware of the recommendations about the number of teams on which a youth athlete should participate at 1 time compared with NPs (24.4%, P < .001). Responses regarding the maximum number of months that it is appropriate for a youth athlete to participate in a single organized competitive sport varied among disciplines, with PHYSs noting a higher number of months (8.22 ± 1.68; range = 3–12) compared with ATs (6.66 ± 2.25; range = 2–11) or NPs (6.85 ± 2.51; range = 2–12).

The responses for each profession regarding general awareness of recommendations published by various professional or sports organizations are provided in Table 2. Differences (P < .001) regarding awareness were seen among professions for all recommendations except for those from USA Hockey (P = .232). Post hoc analyses identified that PHYSs were more likely to be aware of recommendations from the AAP, AMSSM, AOSSM, IOC, MLB, and NBA. Athletic trainers had greater awareness of the NATA recommendations compared with NPs and PHYSs. Generally, all respondents had greater awareness of recommendations from the 4 medical organizations (AAP, AMSSM, AOSSM, NATA) and less awareness of the recommendations from the 4 sports organizations (IOC, MLB, NBA, USA Hockey).

Table 2 Health Care Providers’ Awareness of Each Organization’s Sport Specialization Recommendations

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Perceptions

In regard to perceptions about sport participation and sport specialization, respondents differed on several items (Table 3). Close to one-quarter of ATs and PHYSs reported being extremely concerned about the risk of injury in youth sports, compared with only 9% of NPs (Figure 2). Only 8.2% of ATs felt it was appropriate for a youth to participate on multiple teams of the same sport at the same time, compared with 21.9% of NPs and 19.3% of PHYSs (P < .001). In contrast, a higher percentage of PHYSs (75.5%, P < .001) felt it was appropriate for a youth to participate on multiple teams of different sports at the same time, compared with only 65.6% of NPs and 43.6% of ATs. The age at which respondents perceived it best for a youth athlete to begin specializing in a single sport was also different among provider groups: ATs = 16.12 ± 1.62 years (range = 8–18 years), NPs = 13.56 ± 2.15 years (range = 6–18 years), and PHYSs = 15.06 ± 1.65 years (range = 8–18 years). Athletic trainers (18.0% ± 18.7%) and NPs (15.5% ± 13.5%) perceived that a higher percentage of youth athletes received college athletic scholarships compared with PHYSs (8.4% ± 9.7%, P < .001).

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Table 3 Health Care Providers’ Perceptions of Sport Specialization Items

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Confidence in Knowledge

Respondents’ confidence in their knowledge of organizational recommendations is shown in Table 4. Differences among professions were noted for confidence in knowledge of the 4 medical organization recommendations (P < .05), whereas no differences among professions existed for the 4 sports organization recommendations. Specifically, one-fourth to one-half of all respondents were not confident at all in their knowledge regarding the 4 sports organization recommendations. Physicians had greater confidence in their knowledge than at least 1 other profession regarding the AAP, AMSSM, and AOSSM recommendations. Athletic trainers had greater confidence in their knowledge regarding the NATA recommendations compared with NPs and PHYSs. Nurse practitioners were the least confident in their knowledge of the recommendations; at least half stated they were not confident at all or minimally confident in their knowledge of each recommendation.

Table 4 Health Care Providers’ Confidence in Their Knowledge Regarding Sport Specialization Recommendations, %

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Use of Recommendations

The degree to which each recommendation was used by respondents across the different professions to counsel patients regarding overuse injuries is shown in Table 5. Differences among professions (P < .05) were present for use of the AAP, AMSSM, and NATA recommendations, with ATs using the NATA recommendations more than all other professions but using the AAP and AMSSM recommendations less than NPs and PHYSs, respectively. No differences in use of the sports organization recommendations were found among professions.

Table 5 Health Care Providers’ Use of Each Organization’s Sport Specialization Recommendations

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Barriers

Respondents’ perceptions of barriers that limit the use of recommendations in clinical practice are listed in Table 6. Differences were reported among professions for all barriers except do not believe recommendations will reduce risk. Post hoc analyses indicated that ATs and NPs tended to perceive that all other barriers would have a greater effect in limiting their use of the recommendations compared with PHYSs.

Table 6 Health Care Providers’ Perceptions of Barriers to Using Each Organization’s Sport Specialization Recommendations

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Awareness

In regard to awareness of general recommendations, higher percentages of PHYS and AT participants commented that they were aware of key recommendations regarding participation volume and duration. This may not be surprising, given the efforts that the NATA and AMSSM have made in recent years with respect to educational campaigns related to sport specialization and overuse injury. In addition to public-focused infographics and social media campaigns,¹⁸ conferences¹⁹ and special journal issues^20,21 on this topic have been directed at researchers and clinicians. Interestingly, with respect to the suggested number of months of participation in a single sport, both ATs and NPs were more conservative in their responses, noting 6.66 and 6.85 months, respectively, whereas most organizations recommended no more than 8 months of the year.

Related to published recommendation documents, HCPs had greater awareness of recommendations from their own or like organizations, with PHYSs most aware of the AMSSM, ATs most aware of the NATA, and NPs most aware of the AAP recommendations. Although this may not be surprising, as HCPs are likely more in tune with the literature from their respective organizations or receive special communications from their own organizations when important statements are published, it does highlight the need for improved communication among organizations and interprofessional collaboration. As we are the first to evaluate awareness of these statements, further study is needed to refine our understanding of this awareness and to determine the best methods for improving it. Interestingly, fewer than 50% of all HCPs were aware of the MLB recommendations, fewer than 25% were aware of the IOC recommendations, and fewer than 17% were aware of the NBA and USA Hockey recommendations. This could be due to those organizations promoting their recommendations to athletes and parents or the HCPs surveyed not caring for a high percentage of patients engaged in those particular sports. Another explanation for low levels of awareness is limited publication in medical journals, with these recommendations often being published in 1 journal with little to no promotion of the recommendations to a wider variety of health professions that may be involved in the care of young athletes. Developing robust dissemination plans to share important recommendations with numerous medical organizations should be a consideration of those organizations developing recommendations and guidelines. However, it is interesting to note the lower level of awareness of the MLB recommendations, as a greater number of baseball publications linked pitch volume to injury among youth^22–24 and pitch count limits were some of the first recommendations put into practice among youth sports leagues. Regardless, this finding is similar to the results of a recent investigation²⁵ of youth baseball caregivers in which 83% of respondents were unaware of existing safe pitch guidelines and just over half noted they did not monitor their child’s pitch count. Similarly, Bell et al¹⁶ observed that more than 80% of parents of youth athletes were not aware of safe sports recommendations related to the volume of participation. Thus, although awareness of the MLB recommendations in HCPs was better than in parents, improvement in HCP education about all sport specialization recommendations is essential.

Perceptions

Across all 3 professions, perceptions of sport specialization’s potential negative consequences were higher than has been reported in parents,^16,26 athletes,²⁶ and coaches.¹⁷ Specifically, nearly one-quarter of ATs and PHYSs were extremely concerned about the risk of injury in youth sports, whereas fewer than 7% of parents,^16,26 3.7% of athletes,²⁶ and 11.1% of coaches were extremely concerned.¹⁷ With respect to participating on multiple teams of the same sport concurrently, fewer than 10% of ATs felt it was appropriate, whereas around 20% of NPs and PHYSs felt it was appropriate, similar to percentages reported for parents¹⁶ and coaches.¹⁷ In contrast, a more consistent response was evident regarding participating in 2 different sports concurrently, with approximately 60% of parents¹⁶ and coaches¹⁷ indicating that such behavior would be appropriate and an even greater percentage of ATs and PHYSs concurring. Although greater concerns and more conservative perceptions among HCPs should not be surprising given the role of medical providers in youth sports safety, this does highlight areas for future educational efforts regarding sport specialization recommendations.

Confidence in Knowledge

In regard to confidence in their knowledge of the recommendations, PHYSs tended to be the most confident regarding the AAP, AMSSM, and AOSSM recommendations, with ATs being most confident in their knowledge of the NATA recommendations. The NPs were the least confident across all medical recommendations; this perhaps is related to most working in a primary care setting, where they may not be counseling as many young athletes regarding overuse injuries and causes, such as sport specialization. Additionally, NPs did not have a specialty-specific sports medicine organization with specialization recommendations, and this may have contributed to their lower confidence level. Interestingly, one-third to one-half of all respondents were not confident in their knowledge of the sports organization recommendations, suggesting an area for improved professional development across all HCPs.

Use of Recommendations

A high percentage of all HCPs did not use the recommendations in their practice. Those who did tended to use the recommendations from their own organizations. For example, nearly 50% of ATs noted that they used the NATA recommendations most of the time or always and nearly 50% of PHYSs conveyed that they used the AMSSM recommendations most of the time or always. In contrast, recommendations from the sports organizations were never used by 25% to 50% of respondents. When comparing these results with HCPs’ use of other recommendations, we found that use of the sports medicine organization recommendations did appear to be better than the use of recommended concussion tools, as measured in the DocStyles survey²⁷ of family PHYSs, internists, pediatricians, and NPs. In that study,²⁷ almost half reported that they seldom or never used screening or assessment tools recommended for pediatric traumatic brain injury (24.6% and 22.0%, respectively). The authors described an ongoing need to improve the awareness, dissemination, and implementation of concussion assessment tools to better empower HCPs to use the recommended tools routinely in practice.²⁷

Barriers

When investigating the use of any health care recommendation, it is important to understand the barriers to use. In our research, all HCPs disagreed with the statement that “Sport specialization recommendations do not reduce the risk of injury,” highlighting the value of these recommendations among all HCP groups as a means of risk reduction. The other acknowledged barriers differed among HCP groups, with NPs citing awareness as a key barrier and ATs attributing parent and patient behavior (ie, lack of compliance) as the primary barrier. Thus, for NPs, the first step to overcoming the barrier to use of the recommendations is education. Curiously, PHYSs did not recognize many of the response options as barriers, perhaps because of their confidence that patients and parents may listen to the suggestions provided. However, although PHYSs did not indicate significant barriers in using the sport specialization recommendations, only their use of the AMSSM recommendations was higher than that of other HCPs. Identifying barriers specific to individual professions or settings may guide further efforts to improve the access and confidence of all HCPs and, in turn, improve the use of the established recommendations. Furthermore, when an organization publishes new or updated guidelines, concerted efforts should be targeted toward dissemination strategies that include other professional organizations in order to better inform HCPs across disciplines. The promotion of recommendations across professions may serve as a catalyst for increased knowledge among all HCPs and enhance interprofessional collaboration and practice for the benefit of patients.

Limitations

Our work was not without limitations. Selection bias in the respondents may have been a factor, as we sent the survey through professional organizations and only members of those organizations were eligible to respond. Moreover, the access rate was low, perhaps contributing to a response bias toward HCPs interested in this topic. Repeating this study to evaluate results among a general pediatrician group would help to further elucidate the awareness, confidence in knowledge, and use of sport specialization recommendations, including those from medical and governing body organizations not included in our survey. We also relied on participants’ reports of their awareness of the recommendations without requiring them to correctly describe the elements of each recommendation.