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Early Subthreshold Aerobic Exercise for Sport-Related ConcussionA Randomized Clinical Trial

Educational Objective
To assess the effectiveness of subsymptom threshold aerobic exercise vs a placebo-like stretching program prescribed to adolescents in the acute phase of recovery from sport-related concussion.
1 Credit CME
Key Points

Question  What is the effectiveness of subsymptom threshold aerobic exercise vs a placebo-like stretching program prescribed to adolescents in the short term after sport-related concussion?

Findings  In this randomized clinical trial of 103 adolescents, those assigned to aerobic exercise recovered faster (13 days) than those assigned to placebo-like stretching (17 days), a significant difference.

Meaning  Early subthreshold aerobic exercise appears to be an effective treatment for adolescents after sport-related concussion.


Importance  Sport-related concussion (SRC) is a significant public health problem without an effective treatment.

Objective  To assess the effectiveness of subsymptom threshold aerobic exercise vs a placebo-like stretching program prescribed to adolescents in the acute phase of recovery from SRC.

Design, Setting, and Participants  This multicenter prospective randomized clinical trial was conducted at university concussion centers. Male and female adolescent athletes (age 13-18 years) presenting within 10 days of SRC were randomly assigned to aerobic exercise or a placebo-like stretching regimen.

Interventions  After systematic determination of treadmill exercise tolerance on the first visit, participants were randomly assigned to a progressive subsymptom threshold aerobic exercise or a progressive placebo-like stretching program (that would not substantially elevate heart rate). Both forms of exercise were performed approximately 20 minutes per day, and participants reported daily symptoms and compliance with exercise prescription via a website.

Main Outcomes and Measures  Days from injury to recovery; recovery was defined as being asymptomatic, having recovery confirmed through an assessment by a physician blinded to treatment group, and returning to normal exercise tolerance on treadmill testing. Participants were also classified as having normal (<30 days) or delayed (≥30 days) recovery.

Results  A total of 103 participants were included (aerobic exercise: n = 52; 24 female [46%]; stretching, n = 51; 24 female [47%]). Participants in the aerobic exercise group were seen a mean (SD) of 4.9 (2.2) days after the SRC, and those in the stretching group were seen a mean (SD) of 4.8 (2.4) days after the SRC. There were no differences in age, sex, previous concussions, time from injury, initial symptom severity score, or initial exercise treadmill test and physical examination results. Aerobic exercise participants recovered in a median of 13 (interquartile range [IQR], 10-18.5) days, whereas stretching participants recovered in 17 (IQR, 13-23) days (P = .009 by Mann-Whitney test). There was a nonsignificant lower incidence of delayed recovery in the aerobic exercise group (2 participants [4%] in the aerobic group vs 7 [14%] in the placebo group; P = .08).

Conclusions and Relevance  This is, to our knowledge, the first RCT to show that individualized subsymptom threshold aerobic exercise treatment prescribed to adolescents with concussion symptoms during the first week after SRC speeds recovery and may reduce the incidence of delayed recovery.

Trial Registration  ClinicalTrials.gov identifier: NCT02710123

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Article Information

Accepted for Publication: October 11, 2018.

Corresponding Author: John J. Leddy, MD, UBMD Orthopaedics and Sports Medicine, State University of New York at Buffalo, 160 Farber Hall, Buffalo, NY 14214 (leddy@buffalo.edu).

Author Contributions: Dr Leddy had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Leddy, Haider, Ellis, Darling, Leiter, Willer.

Acquisition, analysis, or interpretation of data: Leddy, Haider, Ellis, Mannix, Darling, Freitas, Suffoletto, Cordingley.

Drafting of the manuscript: Leddy, Haider, Mannix, Leiter, Willer.

Critical revision of the manuscript for important intellectual content: Leddy, Haider, Ellis, Mannix, Darling, Freitas, Suffoletto, Cordingley.

Statistical analysis: Haider, Mannix.

Obtained funding: Leddy, Leiter.

Administrative, technical, or material support: Leddy, Haider, Ellis, Freitas, Cordingley, Willer.

Supervision: Leddy, Haider, Ellis, Darling, Leiter.

Conflict of Interest Disclosures: None reported.

Funding/Support: This study was supported by the National Institute of Neurological Disorders and Stroke of the National Institutes of Health (grant 1R01NS094444) and the National Center for Advancing Translational Sciences of the National Institutes of Health (grant UL1TR001412; the State University of New York at Buffalo).

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Data Sharing Statement: See Supplement 2.

Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

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