Pilot Randomized Controlled Trial of an Exercise Program Requiring Minimal In-person Visits for Youth With Persistent Sport-Related Concussion

Abstract

Objective: To evaluate feasibility and acceptability of a sub-threshold exercise program with minimal in-person visits to treat youth with persistent sport-related concussion, and explore efficacy for improving concussive symptoms, health-related quality of life, and fear-avoidance. Study design: We conducted a pilot randomized controlled trial comparing a 6 week sub-threshold exercise program requiring only two in-person visits to active control (stretching) for 12–18 year old youth with persistent sport-related concussion. We measured moderate-to-vigorous physical activity pre- and post-intervention using accelerometry, and increased goals weekly via phone contact. We examined feasibility and acceptability using qualitative interviews. We used exponential regression to model differences in trajectory of concussive symptoms by experimental group, and linear regression to model differences in trajectory of health-related quality of life and fear-avoidance of pain by experimental group. Results: Thirty-two subjects randomized, 30 completed the study ( n = 11 control, n = 19 intervention), 57 % female. Youth and parents reported enjoying participating in the study and appreciated the structure and support, as well as the minimal in-person visits. Exponential regression modeling indicated that concussive symptoms declined more rapidly in intervention youth than control ( p = 0.02). Health-related quality of life and fear-avoidance of pain improved over time, but were not significantly different by group. Conclusions: This study indicates feasibility and potential benefit of a 6 week subthreshold exercise program with minimal in-person visits for youth with persistent concussion. Potential factors that may play a role in improvement such as fear-avoidance deserve further study.

Pilot Study of Telehealth Delivered Rehabilitative Exercise for Youth With Concussion: The Mobile Subthreshold Exercise Program (MSTEP)

“…In other words, youth with PPCS may have developed a fear-avoidance response to physical activity, similar to what has been described in youth with chronic pain (25)(26)(27). Other researchers have confirmed elevated levels of fear-avoidance in individuals with PPCS (28,29), and our pilot study of an in-person delivered exercise program for concussion (the Subthreshold Exercise Program, or STEP) (18), demonstrated that fear-avoidance decreased in parallel with concussive symptoms (18). Interventions that encourage youth to exercise despite fears of exacerbating symptoms have been shown to be an effective approach to improving function in individuals with chronic pain (30).…”

“…Future research with a randomized controlled trial is needed to ensure improvement in symptoms is not due to the passage of time. The MSTEP intervention effect (i.e., decline in concussive symptoms) was similar to an in-person exercise program (STEP) at 3 weeks, but slightly less strong at 6 weeks (18). We also noted improvements in depression, anxiety, sleep, and health-related quality of life, all of which paralleled declines in concussive symptoms.…”

“…Prior research on exercise as a treatment for PPCS has been grounded in the theory that physiologic change is responsible for treatment effects (8). We propose that positive outcomes associated with encouraging youth to exercise may also be mediated by psychologic change (18). In other words, youth with PPCS may have developed a fear-avoidance response to physical activity, similar to what has been described in youth with chronic pain (25)(26)(27).…”

“…Studies have reported benefit of rehabilitative exercise for youth with concussion, thought due to retraining the autonomic nervous system, thereby facilitating more rapid recovery (8,11,13). Our prior study of an intervention using two in-person visits (Subthreshold Exercise Program, STEP) found benefit for aerobic exercise compared to an active control (stretching) (18). However, requiring in-person visits was challenging for youth who lived far from our urban location, and appeared to impede access.…”

“…Methods were very similar to our previous study (18), but with the transition of all visits to telehealth. Subjects completed online surveys at baseline, 3 and 6 weeks via REDCap (31).…”