Early targeted heart rate aerobic exercise versus placebo stretching for sport-related concussion in adolescents: a randomised controlled trial

Leddy, John J.; Master, Christina L.; Mannix, Rebekah; Wiebe, Douglas J.; Grady, Matthew F.; Meehan, William P.; Storey, Eileen; Vernau, Brian T.; Brown, Naomi; Hunt, Danielle; Mohammed, Fairuz; Mallon, Andrea; Rownd, Kate; Arbogast, Kristy B.; Cunningham, Adam; Haider, Mohammad Nadir; Mayer, Andrew R.; Willer, Barry

doi:10.1016/s2352-4642(21)00267-4

Cited by 90 publications

(130 citation statements)

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“…An early intervention in concussion management that is increasingly accepted includes sub-symptom threshold activity, which provides evidence in decreasing symptom burden,14 and additional research supporting this notion was published since the 2017 CISG consensus statement was reported 15–18. In the present study, we were not able to detect whether or when athletes may have pursued subthreshold exercise as treatment for concussion.…”

Section: Discussionmentioning

confidence: 64%

Progression through return-to-sport and return-to-academics guidelines for concussion management and recovery in collegiate student athletes: findings from the Ivy League–Big Ten Epidemiology of Concussion Study

2022

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ObjectiveTo examine the progression of collegiate student athletes through five stages of a return-to-activity protocol following sport-related concussion (SRC).MethodsIn a multisite prospective cohort study, we identified the frequency of initial 24–48 hours physical and cognitive rest, and the sequence of (1) symptom resolution and return to (2) exertion activity, (3) limited sport, (4) full sport and (5) full academics. In resulting profiles we estimated the likelihood of return to full sport ≤14 days or prolonged >28 days and tested for variability based on timing of the stages.ResultsAmong 1715 athletes with SRC (31.6% females), 67.9% had 24–48 hours initial physical and cognitive rest. The median was 6 days to return to full academics, 8 days to symptom resolution and 9 days to exertion. Three profiles emerged; all had the same sport-specific return progression, but varied in the relative timing of full academics. In unadjusted analyses, full academics as the first stage corresponded to the longest time to return to full sport, and initiating exertion the same day as symptom resolution resulted in the shortest time. In adjusted regression analyses, athletes initiating full academics while still symptomatic were 21.5% less likely (95% CI −27.4% to −15.5%) to return to full sport ≤14 days and, analogously, 19.1% more likely (95% CI 13.4% to 24.7%) to have prolonged return >28 days. While additionally controlling for initial rest, sex, symptom count and concussion history, the likelihood of prolonged return >28 days was 37.0% (95% CI 25.2% to 48.8%) in athletes initiating exertion considerably before symptoms resolved (ie, 7+ days), but only 3.6% (95% CI −1.4% to 8.6%) in athletes initiating exertion shortly before achieving symptom resolution (ie, 3–4 days).ConclusionWe found evidence that sequential progressions were consistent with current recommendations including brief initial rest, and the initiation and relative timing of each stage impacted the final return-to-sport outcome.

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Section: Discussionmentioning

confidence: 64%

Progression through return-to-sport and return-to-academics guidelines for concussion management and recovery in collegiate student athletes: findings from the Ivy League–Big Ten Epidemiology of Concussion Study

2022

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“…The MSTEP study is also unique in that it has been powered to examine potential mechanisms underlying treatment effects, particularly whether increases in MVPA are responsible for benefit [ 9 ] or whether other processes may matter more, such as decreases in fear of concussive symptoms [ 16 ]. Exploring mediators of treatment effects is key to optimizing these approaches in the future, as this information can guide our decisions regarding how to amplify treatments in future work.…”

Section: Discussionmentioning

confidence: 99%

“…Prior studies of subthreshold exercise interventions required intensive in-person visits weekly over several months [ 8 , 9 , 11 ]. Removing the need for in-person visits and converting the intervention to a virtual space improves access to youth who are distant from a medical center and is thus essential for ensuring equitable access to treatment.…”

Section: Discussionmentioning

confidence: 99%

“…Subthreshold exercise interventions have been shown to be effective for youth with concussion [ 9 , 10 ], but the approaches utilized require extensive in-person visits which impedes access for many youth, particularly those distant from a major medical center or those concerned about undertaking an in-person visit due to risk of infection. We are testing the efficacy of a virtually delivered subthreshold exercise program for youth with concussion (MSTEP), using HIPAA-compliant video conferencing and physical activity tracking.…”

Section: Discussionmentioning

confidence: 99%

“…Research, including our own work, has examined potential benefit of subthreshold (or rehabilitative) exercise [ 7 – 17 ], with the hypothesis that exercise performed below the threshold that results in symptoms will facilitate recovery. Several randomized controlled trials (RCTs) have been conducted using exercise to treat youth with concussion, showing significant benefit of exercise compared to control [ 8 , 9 , 11 ], but all have required weekly in-person visits, which impedes access for many youth, particularly rural or underserved youth [ 18 – 23 ]. Delivery of physical activity (PA) interventions virtually can help to transcend geographic barriers, thereby improving access [ 24 , 25 ].…”

Section: Introductionmentioning

confidence: 99%

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Mobile Subthreshold Exercise Program (MSTEP) for concussion: study protocol for a randomized controlled trial

Chrisman

Bollinger

Mendoza

et al. 2022

Trials

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Background Subthreshold exercise, defined as aerobic exercise below the level that causes symptoms, has been utilized as a treatment for youth with persistent postconcussive symptoms (PPCS), but there is currently little evidence to guide use. In addition, prior studies of exercise for PPCS have all required multiple in-person visits. We developed a virtual approach for delivering subthreshold exercise to youth with PPCS called the Mobile Subthreshold Exercise Program (MSTEP), and we have now been funded to conduct a large national randomized controlled trial (RCT) to test its efficacy for reducing concussive symptoms and improving health-related quality of life. Methods This investigation is an RCT comparing MSTEP to an active control. We will recruit 200 adolescents 11–18 years old with postconcussive symptoms persisting for at least 1 week but less than 1 year. Youth will be randomized to receive either 6 weeks of subthreshold exercise (MSTEP) or a stretching condition (control). Youth and parents will complete surveys of concussive symptoms at baseline, weekly during the intervention, and at 3 and 6 months. The primary outcomes will be trajectory of concussive symptoms and health-related quality of life over the 6 months of the study. Secondary outcomes will include depression, anxiety, and sleep quality. We will also assess potential mediators of treatment effects including moderate-vigorous physical activity and fear avoidance of concussive symptoms. Discussion This multisite RCT of MSTEP will provide vital information regarding the efficacy of a virtually delivered subthreshold exercise program for youth with PPCS, and insight regarding potential mediators of treatment effects, including objectively measured physical activity and fear avoidance of concussive symptoms. Trial registration ClinicalTrials.gov NCT04688255. Registered on December 29, 2020.

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Association Between Early Return to School Following Acute Concussion and Symptom Burden at 2 Weeks Postinjury

et al. 2023

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ImportanceDetermining how the timing of return to school is related to later symptom burden is important for early postinjury management recommendations.ObjectiveTo examine the typical time to return to school after a concussion and evaluate whether an earlier return to school is associated with symptom burden 14 days postinjury.Design, Setting, and ParticipantsPlanned secondary analysis of a prospective, multicenter observational cohort study from August 2013 to September 2014. Participants aged 5 to 18 years with an acute (&lt;48 hours) concussion were recruited from 9 Canadian pediatric emergency departments in the Pediatric Emergency Research Canada Network.ExposureThe independent variable was the number of days of school missed. Missing fewer than 3 days after concussion was defined as an early return to school.Main Outcomes and MeasuresThe primary outcome was symptom burden at 14 days, measured with the Post-Concussion Symptom Inventory (PCSI). Symptom burden was defined as symptoms status at 14 days minus preinjury symptoms. Propensity score analyses applying inverse probability of treatment weighting were performed to estimate the relationship between the timing of return to school and symptom burden.ResultsThis cohort study examined data for 1630 children (mean age [SD] 11.8 [3.4]; 624 [38%] female). Of these children, 875 (53.7%) were classified as having an early return to school. The mean (SD) number of days missed increased across age groups (5-7 years, 2.61 [5.2]; 8-12 years, 3.26 [4.9]; 13-18 years, 4.71 [6.1]). An early return to school was associated with a lower symptom burden 14 days postinjury in the 8 to 12-year and 13 to 18-year age groups, but not in the 5 to 7-year age group. The association between early return and lower symptom burden was stronger in individuals with a higher symptom burden at the time of injury, except those aged 5 to 7 years.Conclusions and RelevanceIn this cohort study of youth aged 5 to 18 years, these results supported the growing belief that prolonged absences from school and other life activities after a concussion may be detrimental to recovery. An early return to school may be associated with a lower symptom burden and, ultimately, faster recovery.

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Early targeted heart rate aerobic exercise versus placebo stretching for sport-related concussion in adolescents: a randomised controlled trial

Cited by 90 publications

References 25 publications

Progression through return-to-sport and return-to-academics guidelines for concussion management and recovery in collegiate student athletes: findings from the Ivy League–Big Ten Epidemiology of Concussion Study

Progression through return-to-sport and return-to-academics guidelines for concussion management and recovery in collegiate student athletes: findings from the Ivy League–Big Ten Epidemiology of Concussion Study

Mobile Subthreshold Exercise Program (MSTEP) for concussion: study protocol for a randomized controlled trial

Association Between Early Return to School Following Acute Concussion and Symptom Burden at 2 Weeks Postinjury

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