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Which of the following has the lowest overall risk of injury?

a) football
b) ice hockey
c) boxing
d) soccer


c) boxing is the lowest overall

all the associations pretty much oppose boxing, support a complete ban on boxing for young people
(including CPS and AAP)
while overall risk of injury lower, boxing support blows to head and neck


In the Canadian Hospital injury reporting programs and database, which of the following combat sportssports is related to the greatest injury requiring admission to hospital?

a) boxing
b) judo
c) karate
d) wrestling


a) boxing (4.8%) vs judo 3.6% karate (3.1%), wrestling (2.9%)
of those hospitalized - 58% had facial fractures, 25% closed head injuries
increase in overall injuries from 1999-2007, most in sparring and competition


How old were most of the children injured with boxing injuries found in the Canadian Injury Prevention Database ?

a) 5-9 year old
b) 10-14 year old
c) 15-18 year old
d) >19 year old


c) 15-18 year old - 39.2 %

19 year old

overall rate of injury in boxing lower than in lots of other sports, but increased facial and head injuries (70% of injuries were face and head)


Which of the following injuries were found to be the most common in boxers in research studies?

a) open wounds/lacerations/cuts
b) fractures
c) eyebrow and nose injuries
d) concussion


d) most common in prospective cohort study, similar to results in Canadian Injury Reporting and Prevention Data

concussion - 33%
open wounds 29%
fractures 19%
eye/nose 19%

lower extremity - less common
amateur boxers are at increased risk of structural brain injuries, cognitive abnormalities and neurological deficits from the sport
MRI shows microhemorrhages
increased CSF markers after bouts
more abnormal EEGs compared to other athletes
diminished neuropsych testing compared even without concussions, despite using head gear


Which of the following has not been shown in boxers?

a) MRI showing microhemorrhages
b) increased neuropsychological testing in boxers who used headgear
c) increased abnormal EEGs
d) increased CSF markers of neuronal injury after multiple blows to the head


b) decreased neuropsych testing in boxers, even those without concussions who use headgear


Which of the following regarding concussion is true?
a) the risk of chronic traumatic encephalopathy is higher in amateur boxers than professional
b) wearing a head gear decreases the risk of concussion
c) in research studies younger children with concussion have prolonged memory dysfunction compared to older athletes


c) true
neurocognitive studies showed more prolonged memory dysfunction in teen athletes compared to college athletes
7 days vs 3 days where test results were lowered
memory impairment up to 10 days
return to play guidelines - no return to play the same day
cognitive rest- limit activities is step 1 (each step minimum of 1 day but could take longer if symptoms occur)
USA boxing ban of 30 days does not follow guidelines
a) false - higher in professional boxers because longer matches (12 rounds vs 3)and more strong blows. aka dementia pugilistica
b) false - no evidence that head gear protects against concussion, only amateur players wear head gear
multiple concussion in high school students - more issues with attention/cognition as well as amnesia


Please put the following steps of return to play guidelines in order:

a) sport specific exercise
b) return to game play
c) no contact drills
d) light aerobic activity
e) complete rest
f) full contact drills


e) complete rest
d) light aerobic activity
a) sport specific exercise
c) no contact drills
f) full contact drills
b) game play

each step at least 24 hours if no symptoms, longer until no symptoms, then move on to next step. no RTP same day in children


Which of the following is not a risk of using dehydration to “make weight” for boxing matches?

a) impaired reaction time
b) electrolyte imbalances
c) acidosis
d) improved thermoregulation


d) actually have more trouble with thermoregulation - increased risk of cramps, heat exhaustion and heat stroke


Which of the following is not an appropriate message from a paediatrician to a teen?

a) encourage them to take part in boxing because it will help with overall fitness
b) children who box should have routine ophthalmological screening exams
c) children who box should have routine neuropsychological testing
d) encourage children to take part in other sports such as soccer


a)is the answer

vigorously oppose boxing for children
CPS says - oppose boxing, especially by children and adolescents, CMA wants to ban all boxing in Canada

can lead to significant cumulative head injury, even lead to death, educate parents.

the rest are true, also continue pre participation physicals etc


Which of the following is false of concussion?

a) older children may have persistent symptoms for longer than younger children
b) photophobia can be a symptom of concussion
c) fatal cerebral swelling is rare after concussion
d) concussion can lead to behavioural changes, cognitive changes and sleep disturbances


a) false - the opposite, younger children might have symptoms for longer than older children (typically 7-10 days for older children and adults), younger children can sometimes last weeks to months

the rest are true

physical - h/a, n/v, photo/phonophobia, LOC, amnesia, loss of balance/poor coordination, decreased playing ability
behavioural - irritability, emotional lability, sadness, anxiety, inappropriate emotions
cognitive- difficulty remembering, slower reaction time, confusion, feeling in a fog, affects school work, affect memory and concentration
sleep disturbance - trouble falling asleep, drowsy, sleeping more/less than usual

fatal diffuse cerebral syndrome (aka second impact syndrome) is a rare compilation of head injury in children and adolescent, leads to brain herniation and death


Which of the following is part of the routine management for concussion?

a) medical and cognitive assessment as soon as possible
b) wake them periodically for 24-48 hours after the injury
c) diagnostic imaging including CT head
d) regular acetaminophen dosing to stop headache


a) is the answer

history should include previous facial/head injuries, ADHD, learning difficulties, mental illness, headaches/migraines, sleep troubles in patient or family - can predict who will take longer to recover

the rest are false

b) sleep is important, parent should check on them while they sleep but only wake them if they show signs of deterioation, i.e. seizure, headache, vomiting, difficulty breathing -to ER if these happen
c) don’t need imaging unless focal neurological injury is suspected , studies have shown some changes on functional MRI but this is more experimental, may show physiological and structural changes
d) may not give NSAIDs because of risk of bleeding, don’t want to mask symptoms during recovery

concussion assessment tools - include the SCAT 3, Concussion recognition tool; have not been validated


Which of the following is not true of neuropsychological testing for concussion?

a) neuropsych testing for children/adolescents with multiple concussions
b) neuropsych testing can help guide return to play decisions
c) baseline neuropsych testing may be needed as often as every 6 months because of developing minds
d) preinjury baseline neuropsych testing is mandatory for young athletes


d) false - can help with concussion evaluation in this age group but not recommended/mandatory because of time and cost
also, changes frequently so would need to repeat every 6 months

athletes with multiple concussions may need more detailed neurological testing


Please put the following steps in order

a) modified school attendance, homework 15-20 minute blocks
b) increased cognitive tasks in 15-20 minute increments
c) complete cognitive rest including no school
d) increase school attendance to full attendance as symptoms allow, with accommodations if necessary



c) complete rest - no school, decrease and limit cognitive tasks at home and at school
b) as symptoms improve, increase activities in 15-20 minute intervals
a) start school attendance with half days, certain classes (avoid gym, music, shop), limit homework assignments to 15-20 minute blocks
d) increase school attendance to full as symptoms allow, may need accommodations, tests one per day in quiet area with unlimited time and frequent breaks


Which of the following is not the appropriate accommodation for the symptom?

a) difficulty concentrating - having someone else read aloud
b) difficulty remembering - more time for assignments
c) photophobia - limit computer work
d) anxiety - decreased workload


b) false - this is for difficulty concentrating

see table for details
difficulty concentrating - reduce workload, more breaks , have someone else read aloud, quiet area for work

difficulty remembering - written instruction, smaller amounts to learn, repetition


Which of the following is false?

a) acetaminophen and ibuprofen may decrease the severity and duration of symptoms of concussion
b) students need to be symptom free to return to school
c) full return to academics should precede return to sports
d) children should stay at no activity (complete rest) stage of return to play until no symptoms for several days


b) false - do not need to be symptom free to return to school, may need accommodations or modifications to return to school without return of symptoms.

a) true, but not shown in research studies. other meds, NSAIds sometimes not recommended post head trauma. risk of bleeding. shouldn’t give meds that mask concussion symptoms
c) true -
d) true - optimal 7-10 days, then do stepwise increase of activity. if have symptoms then go back to last symptom free level for 24-48 hours.

no double blind trial examining return to play guidelines in young athletes


Which of the following is not a targeted treatment for persistent post concussion headache ?

a) prophylactic migraine medication
b) improve hydration and sleep
c) neurology referral
d) regular acetaminophen/ibuprofen dosing


d) false - can get rebound headache also could mask symptoms

persistent symptoms may need more imaging and speciality care, either by neurology or multidisciplinary team

other symptoms
neck pain - physio
balance problems - vestibular rehab
sleep - hygiene +/- melatonin


Which of the following is false?

a) good sportsmanship reduces the risk of head injury
b) helmets should be worn in sports to prevent injuries
c) helmets prevent concussion
d) province should require that sporting associations and schools have a written policy on concussion recognition and management


c) false - helmets and mouth guards don’t prevent concussion - shown to protect against other head injuries such as skull fracture

need to remind athletes and coaches that helmets are not concussion proof, since they might adopt a more aggressive playing style if they think that they are protected against concussion


Which of the following is false?

a) the majority of trampoline injuries occur in the 5-14 year old age group
b) trampoline injuries result in greater harm than other sports/recreational injuries
c) CHIRPP (Canadian Hospital Reporting and Prevention Program) data reflects exposure and participation rates
d) Between 1990-2001, there was a 56% increase in hospital admissions resulting from trampoline related injuries
e) most trampoline injuries occur as a result of falls on the trampoline mat


c) false, doesn’t, so increase might just reflect an increase in utilization, also doesn’t include people presenting to doctors offices etc.

trampoline injuries on the rise in Canada
mostly in paediatrics
between 1990-1998, almost 4x increase in injuries in CHIRP data, also increase between 1999-2003

the rest true - trampoline injuries less often but more hospital admissions (12.4% vs other sports, see table)

e) so enclosures, supervision etc likely has limited effects


Which of the following is true?

a) most trampoline injuries occur with home recreational use
b) most trampoline injuries occur under adult supervision
c) fractures of the lower limbs account for the most hospital admissions
d) most trampoline injuries happen at gyms


a) true

the rest false (based on compilation of studies)
- most not with adult supervision (only 10%)
- fractures (32-75%) most common, lead to hospital admission, more of the upper limbs (30-80%)
1/2 patients injured on trampoline mat, 14.3%when multiple people on mat at same time
- most in 5-14 year old (majority 7-10)
- most trampoline injuries occur at home or at a neighbours house (71-99%), 83% when more than one child on the trampoline at a time
- severe injuries include cervical spine, most happened in athletes with significant training


Which of the following are the 2005Health Canada Recommendations for Trampoline use?

a) should not use a trampoline at home, trampolines should not be on playgrounds or phys ed, in supervised training programs limited use
b) caution with restrictions; one person on the trampoline at a time, adequate supervision, older than 6 years of age, no ladders, no somersaults, shock absorbing pads, enclosure netting, trampoline at ground level
c) only one person at a time, no somersaults, shock absorbing pads covering springs, hooks, farm, trampoline away from play structures, no ladders, older than 6 years old, supervision at all times
d) trampoline should not be used for unsupervised activity and never for children


b) is the answer

the others

a) AAP 1999(and Safe Kids Canada (2005) endorses the AAP recommendations), for training programs need safety pads, harnesses, spotting belts, trampoline at ground level, only one person at a time, competent spotters, also should use harnesses for difficult maneuvers and avoid maneuvers beyond skill level
c) Consumer Product Safety Commission (2000)
d) American Academy of Orthopedic Surgeons (2005)


Which of the following is not consistent with CPS recommendations regarding trampoline use?

a) physicians should warn parents of dangers of trampolines at health supervision visits
b) should not be used for recreational purposes
c) should not be part of outdoor playgrounds or regarded as play equipment
d) known to be low risk in training environments


d) false, need more research to learn about what trampolines are like in training environments

physicians should advocate for legislation with warnings


Which of the following statements is false?

a) stressors including parental separation, bullying, abuse, living in foster care can lead to overeating
b) oversleeping is a risk factor for obesity
c) stress can increase risk of URTIs
d) stress can lead to increased abdominal adiposity, insulin resistance and metabolic syndrome
e) only children are at greater risk for obesity


b) opposite - inadequate sleep is a risk factor for obesity

the rest are true
bullying might decrease how much kids play outside, they might also eat to cope with their feelings.

having better routines at home and limit setting better - those who don’t have that are at greater risk of obesity

e) perhaps because these parents spend more time doing screen time with their kids, or serving more adult like portions


Which of the following does not increase the risk of obesity?

a) lower SES
b) first nations
c) more education
d) living in public housing


c) does not, the rest too
harder to get produce that is affordable in some remote regions of Canada
apartments and public housing, less access to parks, etc.
gym - lots of schools have eliminated gym class, but studies show that gym class actually helps academic performance by reducing stress


Which of the following is not increased in obese children?

a) decreased risk of eating disorders
b) anxiety and depression
c) poor self esteem
d) poor sleep


a) false - obese Canadian girls have increased body image disatisfation and risk of binge eating and bulimia nervosa

the rest are increased
not sure which is cause and effect with obesity and depression but they are certainly linked, longer that kids are overweight the greater the risk for depression and other mental health disorders
depression ->crave carbohydrates, less likely to exercise, insulin resistance in some depressive syndromes
poor sleep and health related quality of life - youth with OSA (common comorbidity) reported poorer sleep and lower quality of life, poorer perception of physical activity skills so want to exercise less


Which of the following is not a helpful approach to help an obese child?

a) using food as a reward for good behaviour
b) encourage the entire family to change their food behaviours, by linking family history of certain diseases to the child’s obesity
c) encourage parents to model healthy eating behaviours
d) not skipping breakfast
e) encourage all primary caregivers to be present at counselling meetings


a) using food as a reward or compelling a child to eat when he/she doesn’t want to is not helpful

the rest are helpful discourage food pushing - while recognizing that food insecurity in culture of origin might be behind this
immigrants>10 years in Canada greater risk of obesity than new immigrants (possibly from combo of fast food and food pushing)
more obesity in those who skip breakfast (higher prevalence of obesity)
e) part of motivational interviewing , ensure consistence message, ensure supports in place for mental health

systems wide - get legislation to ban promotion of unhealthy foods on children’s TV show, help get more activities and more affordable healthy food for first nations, immigrants etc.


Which of the following is true?

a) older Canadian kids spend more time exercising than younger kids
b) Canadian Youth with >2 hours of screen time per day are more likely to be overweight than those watching


b) is the answer

consequences of obesity - all the usual plus non alcoholic steatohepatitis
26% of young people, 41% of Aboriginal young people

the rest are false
older kids exercise less
average of 4 hours in light PA and 8.6 hours in sedentary activities

lower SES with TV in bedroom even higher risk, TV more obesity risk, less exercise, eat more crap which is advertised on TV


Which of the following is not associated with increased screen time?

a) poor school performance
b) metabolic syndrome
c) strong self image
d) inattention


c) in fact low self image is associated


Which for the following is false?

a) 24% of young Canadians actively commute to school daily
b) 35% of Canadian provinces have completely implemented mandated PE times
c) school based physical activity decreases school grades
d) sports participation drops significantly between grades 6-12 (more in girls)
e) multifaceted school based programs addressing physical activity are most effective when implemented in multiple settings


c) opposite, in fact might help, exercise improve math grades in overweight children

the rest are true

special needs populations
neuromuscular - need stretching exercises
high impact - promotes bone health
strength training - increases neuromuscular learning and muscle/bone strength


Which of the following is false?

a) infants should take part in supervised physical activity multiple times a day
b) 1-4 year olds should take part in 180 minutes of both structured and unstructured play/day
c) ten minutes of high impact activity 2-3 days/week can have a positive effect on bone mineral density
d) excergaming (ie video games) can replace sports


d) false - is better than sedentary activities but shouldn’t replace active play, PE or sport


How much screen time is appropriate for a 3 year old?

a) none at all
b) < 1 hour/day
c) 2 hours/day
d) 4 hours/day


b) should be limited to < 2 year old, shouldn’t watch screen based activities
encourage movement in young children by reducing passive tranportation (car/stroller), and time spent “resting” during the day


Which of the following is not paired correctly (based on the Canadian Sedentary Behaviour and physical activity guidelines?

a) 5 year old - 60 minutes of energetic play
b) 2-4 year old - 180 minutes of physical activity of any intensity spread during the day
c) being restrained for


c) false - in fact, shouldn’t be restrained (high chair, stroller) for >1 hour/day

encourage movement in young children by reducing passive tranportation (car/stroller), and time spent “resting” during the day

d) vigorous intensity 3 days per week, (i.e. aerobic), activities that strengthen muscle and bone 3 days per week


Which of the following is not an appropriate exercise regime for the specified age?

a) 10-12 year old doing squat lifts
b) 5-9 year old playing co-ed soccer
c) 13-17 year old - focus on individual interests of the youth
d) 13-17 year old- weight training with heavier weights and fewer reps


a) false, not appropriate -
strength training can use small free weights with 15-20 reps, avoid heavier weights and maximum lifts (squat lifts, clean and jerk, dead lifts)
5-9 year olds - co -ed participation okay, skill acquisition
10-12 year old - contact sports based on physical maturity rather than age might help reduce risk of injury
13-17 - 75% of teens drop out of organized competitive sports by age 15, so should likely focus more on individual interests
once growth complete, can do more weights

the rest true


Which of the following is true?

a) pediatricians promote aerobic exercise more than other physicians
b) “passport to health program” can identify childhood obesity and engage families in behavioural change
c) family based FITT prescriptions do not help
d) paediatricians should plot BMI at least once every 2 years


b) true - this program promotes 5 fruits/veggies/day, 2 hours of screen time, 1 hour of physical activity, and zero sweetened drinks

the rest false

a) less than internists and family physicians
c) they do help with promoting activity,
d) should be at least every year, and also look at RFs for obesity - diet/exercise

need more school programs and strategies for poor families
children’s tax credit - may be helping with PA enrolment but need more strategies
100% tax rebate for municipal programs promoting HAL
keep TV out of bedrooms


Which of the following is not a risk of exercise in JIA?

a) increased risk of cervical spine fracture
b) increased risk of dental injury
c) increased risk of eye injury
d) increased risk of poor bone health


d) is the answer
in fact weight bearing injury helps improve bone health
aquatic exercise helps with range of motion, strength and fitness
decreases obesity
decreases disease activity

JIA 1/1000
the rest are risks
- muscle atrophy increases osteopenia and risk of fracture
- tissue loading on growth plates unknown risk
-cervical spine involvement - greater risk of injury with collision sports
- TMJ- dental injury
- uveitis/visual impairment - eye injury increased
-cardiac - myocarditis, pericarditis, aortic root in HLAB27 arthritis
- aerobic fitness in one study of JIA 22% lower than peers, related to disease duration rather than severity


Which of the following does not need to be done for a patient with JIA prior to sports involvement?

a) X-rays of C1 and C2 when spinal disease
b) fit for mouth guard
c) continue full activity during disease flare
d) wear eye protection


c) false - when having flare should take it easy with using pain as a guide
can participate in activities and contact sports when disease well controlled and adequate physical capacity
severe joint disease - should have individualized training


Which of the following is false of haemophilia?

a) aerobic exercise can help with coagulation
b) children who limit physical activity have less bleeding events
c) Fitness, anaerobic power and muscle strength are lower in children with hemophilia
d) children should receive appropriate factor prophylaxis to reduce the risk of bleeding in sport.


b) false b) the opposite, active have less bleeding events; muscle strength might protect against hemarthrosis; physical therapy prophylactically to reduce bleeding events
the rest true

a) true, can cause transient increase in factor VIII (haemophilia is AR


Which of the following is false?

a) exercise training in EIB can cause improvement in PFTs
b) exercise induced bronchospasm(EIB) occurs in 90% of asthmatics
c) EIB can be diagnosed with exercise challenged PFTS that show FEV1 decreased by 10-15% after 6-8 minutes of vigorous exercise
d) Endurance athletes may have permanent bronchial changes as a result of EIB


a) the opposite, improves aerobic capacity but not PFTs . refractory period 4 hours after exercise, with decreased bronchoconstriction during subsequent exercise

exercise induced bronchospasm 90% asthmatics 40% with allergic rhinitis
prevalence in athletes (high school, college, olympic is 12%)
might be first presentation of asthma, bronchoconstriction after 8-15 minutes of activity and resolves within 1 hour
land based activities > water based (i.e. swimming)

the rest are true
testing is these PFTs, plus positive response to beta agonist
eucapnic voluntary hyperventilation testing is recommended in athletes because of poor sensitivity to pharmacological tests in this setting
high intensity exercise can trigger EIB with increased minute ventilation and respiratory heat/water losses; swimming less likely to trigger in general
asthma related deaths are rare but have been reported in youth


Which of the following is true of scuba diving in exercise induced asthma?

a) is contraindicated
b) requires special equipment
c) should have normal spirometry prior to diving


c) should have normal spirometry at rest and with exercise (especially residual volume) prior to diving, it is controversial

should not dive if having asthma symptoms


Which of the following is false?

a) patients with advanced CF have cardiac dysfunction
b) patients with CF can have lower maximum HR with exercise than healthy peers
c) patients with CF have limited exercise tolerance
d) decisions regarding scuba diving should be based on PFTS testing


d) FALSE ->all CF patients can develop air trapping and air embolus/pneumothorax, therefore should NOT scuba dive. should absolutely avoid scuba diving

the rest true
a) advance CF ->FEV1


Which of the following is a reasonable recommendation for a 12 year old girl with CF who wants advice on exercise?

a) should only have supervised home exercise regimes that increase HR to 70-80% of maximum capacity
b) should always stop activity if coughs
c) should take sodium containing flavoured drinks above thirst levels during exercise
d) no need to avoid contact sports


c) true - to prevent hyponatremic dehydration with prolonged exercise (1.5-3 hours), those with diabetes may need additional carbohydrates during exercise since can get dehydration and hypoglycaemia from polyuria
sodium 50 mmol/L
if have splenomegaly or liver disease should avoid contact sports

severe disease - should identify what the maximum heart rates are and levels where O2 desaturation and ventilation limits occur, as well as exercise related bronchospasm, and response to therapy

some patients cough with exercise, causes brief desat but no evidence that this is harmful
V/Q mismatch, R->L shunting