Evidence-based medicine is what clinicians strive for when caring for their patients. It is “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.”1 A key component of evidence-based medicine is the judicious use of tests and treatments.
Choosing Wisely Canada (CWC) is a national campaign to help clinicians and patients make mutual decisions about appropriate management of health issues and to initiate discussions about unnecessary tests, treatments, and procedures. Since 2014, CWC has partnered with numerous professional medical organizations and associations representing several clinical specialties to generate lists of “Things Clinicians and Patients Should Question.”2 The goal is to reduce the number of unnecessary tests, treatments, and procedures that occur in Canada which potentially expose patients to harm, create unnecessary stress for patients and families, lead to more testing to evaluate false positives, and consume time and limited resources.
Partnering with Choosing Wisely Canada, the Canadian Academy of Sport and Exercise Medicine (CASEM) has generated a pediatric SEM list of “Eight Things Clinicians and Patients Should Question”. This list was launched on April 12, 2022, on the Choosing Wisely and CASEM web sites.2,3
WHY A PEDIATRIC SEM LIST?
Musculoskeletal (MSK) complaints are common in the pediatric age group, accounting for up to 25% of primary care visits by adolescents.4 Two-thirds of all injuries in adolescents are related to sports participation and can result in hundreds of thousands of emergency room visits annually.5,6 Sport injuries in children and youth can have a significant negative impact on quality of life, sometimes requiring weeks to months of time away from sport and activity as well as physiotherapy or even surgery, particularly if these injuries are not appropriately identified and managed. These injuries can also result in school absence, negatively affecting academic achievement, and can cause children and adolescents to drop out of sports altogether, reducing physical activity levels in adolescence and into adulthood.7 Given the frequency of sport injuries in the pediatric age group, it is vital that all clinicians managing these issues in children and youth are aware of and apply the available evidence in their daily practices.
Current lists on the Choosing Wisely Canada web site have very few pediatric-specific SEM or pediatric-specific MSK recommendations.2 CASEM has previously developed an SEM list but only one recommendation was specific to the pediatric population.8 We are addressing this gap with the new list.
HOW THE LIST WAS DEVELOPED
CASEM formed a small working group consisting of Drs Laura Purcell, Erika Persson, and Kristin Houghton, all pediatricians and sport medicine specialists, who identified a need to develop a list of recommendations specifically for pediatric SEM. This list was developed based on existing research, experience, and common practice patterns. We sought input from the Pediatric Interest Group of CASEM, as well as a pediatric orthopedic surgeon and a pediatric MSK radiologist at McMaster Children's Hospital. The general CASEM membership was also asked for their input by electronic survey. The Publications Committee of CASEM provided input before the list being approved by the CASEM Board. The list was then submitted to CWC, which approved it after their own internal review process.
THE PEDIATRIC SEM LIST
The Pediatric SEM list identifies investigations and practices commonly used in pediatric SEM/MSK assessments that are not supported by evidence and may expose patients to harm, unnecessary stress, and additional unnecessary testing, consuming time and constrained resources. The list includes 8 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. The list can be accessed using the following links:
Evidence-based medicine is what we aspire to in our daily practices. We encourage all clinicians who see pediatric patients—family physicians, pediatricians and pediatric subspecialists, orthopedic surgeons, and SEM doctors—to adopt these CWC pediatric SEM recommendations as part of routine practice to optimize care for children and youth and minimize the use of unnecessary investigations and treatments.
1. Sackett DL, Rosenberg WM, Gray JA, et al. Evidence based medicine: what it is and what it isn't. BMJ. 1996;312: 71–72.
2. Choosing Wisely Canada. Available at: https://choosingwiselycanada.org/about/
. Accessed June 3, 2022.
3. Canadian Academy of Sport and Exercise Medicine. Available at: https://casem-acmse.org/
. Accessed June 3, 2022.
4. Ziv A, Boulet JR, Slap GB. Utilization of physician offices by adolescents in the United States. Pediatrics 1999;104:35–41.
5. Injuries in Canada: Insights From the Canadian Community Health Survey 2009-2010. Available at: https://www150.statcan.gc.ca/n1/pub/82-624-x/2011001/article/11506-eng.htm
. Accessed June 3, 2022.
6. Patel DR, Yamaski A, Brown K. Epidemiology of sports-related musculoskeletal injuries in young athletes in the United States. Transl Pediatr. 2017;6:160–166.
7. Brenner JS; AAP Council on Sports Medicine and Fitness. Sports specialization and intensive training in young athletes. Pediatrics 2016;138:e20162148.