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

Abstract

Background: Concussion is common, and up to 30% of youth develop persistent symptoms. Preliminary data suggests treatment with rehabilitative exercise is beneficial, but most programs require frequent in-person visits, which is challenging for youth in rural areas, and has been made more difficult for all youth during the COVID-19 pandemic. We have adapted an exercise intervention to be delivered via telehealth using Zoom and personal fitness devices, which could ensure access to this type of treatment.Objective: The goal of this study was to assess feasibility and acceptability of a telehealth delivered exercise intervention for concussion, the Mobile Subthreshold Exercise Program (MSTEP), and collect pilot data regarding efficacy.Materials and Methods: All youth received the 6-week MSTEP intervention which included wearing a Fitbit and setting exercise heartrate and duration goals weekly over Zoom with the research assistant. Youth completed standardized measures of concussive symptoms (Health Behavior Inventory, HBI), fear-avoidance (Fear of Pain Questionnaire, FOPQ) and health-related quality of life (Pediatric Quality of life Assessment, PedsQL), as well as a structured qualitative exit interview. We examined change in measures over time using mixed effects modeling, controlling for age, sex, prior concussion and duration of symptoms. We coded qualitative interviews using Thematic analysis.Results: We recruited 19 subjects, 79% female with average age 14.3 (SD 2.2) and mean duration of symptoms 75.6 days (SD 33.7). Participants wore the Fitbit on 80% of days, and completed 94% of surveys and 96% of Zoom calls. Concussive symptoms (HBI) decreased significantly over the 6 week intervention (−10.6, 95%CI: −16.0 to −5.1) as did fear-avoidance (−21.6, 95%CI: −29.8 to −13.5). PedsQL improved significantly during the same time period (+15.1, 95%CI: 8.6–21.6). Approximately three-quarters (76%) of youth rated their care as “excellent.” Participants appreciated the structure of the guided exercise program and the support of the RA. They also enjoyed being able to track their progress with the Fitbit.Conclusion: This study provides evidence for the feasibility and acceptability of a telehealth delivered rehabilitative exercise intervention for youth with concussion. Further research utilizing a randomized controlled trial is needed to assess efficacy.Clinical Trial Registration:https://clinicaltrials.gov, identifier: NCT03691363. https://clinicaltrials.gov/ct2/show/NCT03691363

Tele-Active Rehabilitation for adolescents with concussion: a feasibility study

“…Results from this study extend prior research supporting a telehealth approach to exercise for youth with concussion 33. The Mobile Subthreshold Exercise Programme intervention used heart rate monitors and weekly video appointments to guide adolescents in adjusting exercise parameters based on their symptoms, which was found to be tolerable and acceptable 33.…”

“…Results from this study extend prior research supporting a telehealth approach to exercise for youth with concussion. 33 The Mobile Subthreshold Exercise Programme intervention used heart rate monitors and weekly video appointments to guide adolescents in adjusting exercise parameters based on their symptoms, which was found to be tolerable and acceptable. 33 The Tele-AR intervention trains similar self-monitoring skills and provides a structured and supervised exercise programme for those without access to exercise testing or heart rate monitors.…”

“… 33 The Mobile Subthreshold Exercise Programme intervention used heart rate monitors and weekly video appointments to guide adolescents in adjusting exercise parameters based on their symptoms, which was found to be tolerable and acceptable. 33 The Tele-AR intervention trains similar self-monitoring skills and provides a structured and supervised exercise programme for those without access to exercise testing or heart rate monitors. High satisfaction ratings and the lack of adverse events reported here suggest that this approach may also be safe and appropriate.…”

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

“…We also have noted improvement in psychologic factors such as fear avoidance following subthreshold exercise in our prior trials [ 16 , 17 ], a unique finding given that research on exercise as a treatment for PPCS has primarily focused on physiologic change rather than psychological factors [ 18 ]. Fear avoidance is a concept that has been used to understand the development and perpetuation of chronic pain in adults and youth [ 34 – 36 ].…”

“…Individuals with PPCS often have increased symptoms when engaging in physical activity, and such exertional symptoms can lead to avoidance of physical activity and subsequent disability [ 6 ]. 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 ].…”