An Early Return to Aerobic Exercise after Sports-Related Concussion

    Allowing athletes to participate in a sub-threshold level of aerobic exercise soon after sustaining a sports-related concussion can help reduce the time to recovery, according to a recently published study.


    Elizabeth Barchi, MD


    Leddy, JJ, Haider MN, Ellis MJ, et al. Early subthreshold aerobic exercise for sport-related concussion: a randomized clinical trial. JAMA Pediatr. 2019; 173(4):319-325.


    In a parallel randomized controlled trial, adolescent athletes who sustained a sports-related concussion underwent early initiation of aerobic exercise, with the goal of decreasing the duration of symptoms and reducing the incidence of delayed symptoms.

    For the study, Leddy et al identified 103 male and female athletes (ages 13 to 18 years) who had been diagnosed with a sports-related concussion within 10 days of presentation. The athletes were randomized into 2 groups:

    • Aerobic exercise (n-52)
    • Stretching (n=51)

    For participants in the aerobic exercise group, the target heart rate was calculated at the first visit as 80% of the heart rate achieved at symptom exacerbation on the Buffalo Concussion Treadmill Test (BCTT). They were directed to use a stationary bike or treadmill each day at the prescribed target heart rate while wearing a heart rate monitor; they could walk or jog if they did not have access to exercise equipment.

    A new target heart rate was calculated in the clinic weekly by BCTT for the duration of symptoms. Participants were instructed to stop aerobic exercise if their symptoms increased by 2 or more points from their pre-exercise symptom level or at 20 minutes, whichever came first. They were instructed not to stretch or to participate in contact activities.

    Participants in the stretching group were prescribed a stretching regimen from a booklet with a whole-body progressive stretching program that did not significantly raise the heart rate. They were instructed to do the stretches for 20 minutes per day while also wearing a heart rate monitor. As with the aerobic exercise group, participants in the stretching group performed the BCTT in the clinic each week for the duration of their symptoms. Their stretching program was advanced each week similarly to the aerobic exercise group. Participants from both groups reported symptoms each evening on a password-protected website.

    Participants in the aerobic exercise group recovered in a median of 13 days, while participants in the stretching group recovered in a median of 17 days (P=0.009). There was also a lower incidence of prolonged symptoms (more than 30 days) in the aerobic exercise group, but this did not reach significance.

    Clinical Relevance

    Sports-related concussion is a significant public health problem without an effective treatment. Up to 30% of children and adolescents remain symptomatic 30 days after injury, which becomes an acute disruption to their psychosocial development and academic progress. Any time away from the social environment of school and sports can be detrimental and result in increased anxiety and depressive symptoms.

    The study by Leddy et al is part of a paradigm shift away from the traditional “cocoon therapy,” which kept young athletes out of school and sports for several days at a time until they were no longer symptomatic. Over the years, several studies have shown the benefits of early introduction back into the academic setting. Leddy et al built on this concept by introducing athletes into aerobic activity early within the concussion course, resulting in significantly decreased recovery time.

    This study suggests a safe and effective treatment to reduce symptom duration in adolescent patients who have sustained a sports-related concussion.

    Author Information

    Elizabeth Barchi, MD is an Assistant Professor with the Department of Orthopedic Surgery at NYU Langone Health – Orthopedic Hospital, New York, New York.

    Disclosures: Dr. Barchi has no disclosures relevant to this article.