Symptom Provocation Patterns During Supervised Exercise in Adolescent Athletes with Concussion

Objective To understand which exercises provoke symptoms, as well as the type and frequency of symptoms, during supervised exercise (SE) following concussion, and to better understand how to interpret and utilize findings during SE. Background Exercise is increasingly used in the management of sport-related concussion, and SE has been shown to be associated with faster clearance to return to sport. However, the optimal use of exercise following concussion is not known, and findings during SE have not been studied. Design/Methods This study is a retrospective review of patients seen at a sport concussion clinic. Participants were concussed athletes under age 18 who underwent SE within 30 days of concussion. A typical SE session began with a basic cardiovascular exercise followed by dynamic exercise challenges. Data recorded included exercise type, pre-exercise symptoms, symptom exacerbation scores, and maximum heart rate during exercise. A symptom was considered provoked if a new symptom developed or if an existing symptom increased by ≥3 points on a 10 point scale. Outcome measures were referral to vestibular physical therapy and the number of days from concussion until clearance for return to sport. Data were analyzed using two-sample t tests, linear and logistic regression models. Results 66.2% of patients experienced symptom provocation during SE. Symptom provocation did not occur until the dynamic challenge portion of the workout in 55.6% of those symptomatic. Dizziness was the most common symptom (48.5%), and medicine ball exercises (50.0%) the most common provoking exercise. Dizziness provoked during SE predicted referral to vestibular physical therapy (OR 5.90, p = 0.015). Provocation of symptoms during basic cardiovascular exercises predicted a greater number of days until clearance for return to sport (p = 0.015). Conclusions Symptom provocation during SE provides useful information in return to play decision making, guidance for physical thearpy treatments, and prognostication of recovery time following concussion.