The Effect of a Sub-symptom Threshold Aerobic Exercise Program on Recovery in Concussed Athletes

August 16, 2019 updated by: Emily Kosderka, Rocky Mountain University of Health Professions

The purpose of this randomized controlled trial is to examine whether systematic sub-threshold exercise is effective in improving recovery time in athletes after sport related concussion (SRC) compared to those who participate in a placebo/stretching protocol. subjects will be randomized into either an Exercise group or a Placebo/stretching group. subjects in the Exercise group will participate in an individualized exercise program supervised by their athletic trainer while the Placebo/stretching group will engage in a standardized stretching routine supervised by their athletic trainer throughout the duration of their recovery.

Hypothesis 1: subjects in the aerobic Exercise group will require fewer days to recover from SRC than those who follow a placebo/stretching protocol.

Hypothesis 2: heart rate threshold (HRt) achieved on the graded treadmill test will be associated with days to recovery (i.e., the lower the HRt, the longer the time to recovery).

Hypothesis 3: Vestibular Ocular Motor Screen (VOMS) performance will be indicative of time to clinical recovery from concussion as evidenced by a strong correlation between VOMS score and days to clinical recovery.

Hypothesis 4: Sub-threshold aerobic exercise will facilitate improvement in VOMS post-concussion.

Hypothesis 5: subjects in the aerobic exercise group will demonstrate greater dynamic stability as evidenced by greater reach in each of the 3 primary directions (anterior, posterior medial and posterior lateral) for their right and left lower extremity.

Study Overview

Status

Unknown

Conditions

Intervention / Treatment

Detailed Description

For this randomized controlled trial, a random number generator will be used to randomly assign subjects to either the Placebo/Stretching group or the Exercise group. Study physicians will be blinded to group assignment. Each subject will be given a subject ID number and will complete a brief medical history. They will then be escorted by a designated health care professional who is either the site-coordinator or another health care provider trained in the administration of the Buffalo Concussion Treadmill Test (BCTT) to the treadmill. There, they will be fitted with an ActiGraph activity monitor to be worn throughout their recovery period. The ActiGraph is a small, non-invasive unit that measures human rest and activity cycles. It will be worn similarly to a wrist watch and secured in place with a disposable wristband. Resting heart rate variability (HRV) will be assessed using the Elite HRV app for smartphone. Trained research personnel will assist the subject with fitting the Polar H7 heart rate sensor and finding a comfortable seated position. The heart rate sensor will then connect with the Elite HRV app for smart phone. Once connected, it will take approximately 2 minutes to record the data. Subjects will complete the BCTT in the clinic at the first available testing session no earlier than 48 hours following injury. VOMS and Y-Balance test will also be administered and recorded.

Stretching/Placebo Group Subjects assigned to the Stretching/Placebo group will be given a stretching protocol and instructions to report to their athletic trainer on a daily basis as soon as possible. Prior to the beginning of each intervention session, subjects will be assessed using standard of care protocols which include verbal feedback, symptom scale, and visual-analog scale (VAS). Subjects with a self-reported VAS of ≥7 will not stretch that day. Subjects with a score of ≤ 6 will then complete a 15-25 minute stretching program under supervision by the athletic trainer or other designated research personnel. Following completion of the stretching program for that day, the athletic trainer will record exercise duration and heart rate (HR) (as monitored by the Polar H7 Heart Rate Sensor). The stretching protocol will be progressive and will change weekly as subjects continue their recovery.

Exercise Group Subjects in the exercise group will be prescribed exercise at a target heart rate (THR) of approximately 80% of the achieved heart rate during the BCTT. They will be given this prescription in writing to provide to their athletic trainer. Prior to the beginning of each intervention session, subjects will be assessed using standard of care protocols which include verbal feedback, symptom scale, and visual-analog scale. Subjects with a self-reported Visual Analog Scale (VAS) of ≥ 7 will not exercise that day. Subjects with a score of ≤ 6 will then complete 30 minutes of daily exercise (including 5 minutes of warm up and 5 minutes of cool down) on an exercise bike or walking and supervised by an athletic trainer. Subjects will be instructed to terminate exercise at the first sign of symptom exacerbation or after 30 minutes, whichever occurs first. Athletic trainers will instruct subjects to cease exercise if additional symptoms appear or if symptoms worsen. This program may be modified by increasing heart rate threshold 5-10 beats per minute per week by the athletic trainer as the heart rate for symptom exacerbation increases. The supervising athletic trainer will record exercise duration and THR (as monitored by the Polar H7 Heart Rate Sensor).

Due to medical ethics, subjects will undergo any other individualized rehabilitation recommendations made by the physician or treating physical therapist throughout their individual treatment period. Common rehabilitation interventions include vestibular, oculomotor, cervicogenic, and balance exercises. Subjects may undergo one or all of these depending on their individual needs. Therefore, the exercise protocol identified in this application is a supplement to their standard care provided by medical personnel.

All Subjects All subjects will complete the Symptom Form daily for the duration of their symptom presentation. In addition to reporting to their athletic trainer, subjects will be provided with a link to a secured website on which they will be asked to enter their symptoms at approximately the same time each evening. An option will be to provide the surveys and envelopes to complete these in hard copy.

When symptoms are no longer reported to the athletic trainer by the subject, the athletic trainer will complete the clinical battery associated with their respective concussion protocol prior to the subject's appointment with the study physician to seek clearance for return to play. The study physician will conduct a standardized physical exam and determine if the subject has met the following criteria for clinical recovery:

  1. normal or baseline Standardized Assessment of Concussion;
  2. normal neurological exam; and
  3. can complete the BCTT without symptom exacerbation.
  4. VOMS and Y-Balance

Prior to the clearance BCTT, subjects will have Heart Rate Variability (HRV) measured using the Elite HRV app for smart phone. Trained research personnel will assist the subject with fitting the Polar H7 heart rate sensor and finding a comfortable seated position. The heart rate sensor will then connect with the Elite HRV app for smartphone. Once connected, it will take approximately 2 minutes to record the data.

The subject will then begin at Stage 3 of the stepwise return to sport (RTS) strategy as outlined in the Berlin guidelines and full RTS will be allowed when the subject has completed each step of the stepwise RTS criteria without symptom exacerbation. Number of days from date of injury to full RTS (including days in the Berlin RTS) will be recorded, analyzed, and compared for the Placebo/Stretching group and the Exercise group.

Study Type

Interventional

Enrollment (Anticipated)

65

Phase

  • Not Applicable

Contacts and Locations

This section provides the contact details for those conducting the study, and information on where this study is being conducted.

Study Locations

  • United States
    • Oregon
      • Portland, Oregon, United States, 97219
        • Recruiting
        • Oregon Health and Science University
        • Contact:
        • Principal Investigator:
          • Jim Chesnutt, MD
        • Sub-Investigator:
          • Emily Kosderka, MS
        • Sub-Investigator:
          • Doug Powell, PhD

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.

Eligibility Criteria

Ages Eligible for Study

13 years to 17 years (Child)

Accepts Healthy Volunteers

No

Genders Eligible for Study

All

Description

Inclusion Criteria:

  1. are aged 13-17, years and a high school student-athlete who attends school where an athletic trainer can supervise the exercise protocol;
  2. have sustained a concussion within 2-7 days of clinic presentation and diagnosed by a study physician;
  3. demonstrate symptom exacerbation during a graded treadmill exercise test and cannot complete the test;
  4. are currently participating in a school or club sport;
  5. are English speaking and capable of giving assent

Exclusion Criteria:

  1. have a reported history of neurological condition or disorder including but not limited to brain surgery, special education, seizure disorder, speech pathology, previous diagnosis of Post-Concussion Syndrome (PCS),
  2. are unwilling to exercise,
  3. have focal neurologic deficit that would represent risk for walking/running on treadmill,
  4. exhibit an inability to exercise due to injury, known heart disease, or increased cardiac risk,
  5. have experienced more than 3 previous concussions,
  6. have suffered a substantial comorbidity (eg,cervical injury),
  7. currently taking β-blockers, calcium channel blockers, or prophylactic headache medications (e.g., amitriptyline, topiramate), or
  8. have a resting blood pressure of > 140/90.
  9. If the potential participant or parent/guardian is unable to fully understand the study protocol or study risks due to injury or developmental delay, the potential participant will be excluded from the study.

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

How is the study designed?

Design Details

  • Primary Purpose: Treatment
  • Allocation: Randomized
  • Interventional Model: Parallel Assignment
  • Masking: Single

Arms and Interventions

Participant Group / Arm
Intervention / Treatment
Experimental: Exercise Group
Intervention: aerobic exercise Subjects in the exercise group will be prescribed exercise at a target heart rate (THR) of approximately 80% of the achieved heart rate during the Buffalo Concussion Treadmill Test (BCTT). They will be given this prescription in writing to provide to their athletic trainer. Subjects will complete 30 minutes of daily exercise (including 5 minutes of warm up and 5 minutes of cool down) on an exercise bike or walking and supervised by an athletic trainer. This program may be modified by increasing heart rate threshold 5-10 beats per minute per week by the athletic trainer as the heart rate for symptom exacerbation increases.
Other: Aerobic Exercise
Sub-symptom threshold aerobic exercise at a dose of 30 minutes per day, five days per week.
Placebo Comparator: Placebo/Stretching
Intrvention: stretching program Subjects assigned to the Stretching/Placebo group will be given a stretching protocol and instructions to report to their athletic trainer on a daily basis as soon as possible. . Subjects will then complete a 15-25 minute stretching program under supervision by the athletic trainer or other designated research personnel. The stretching protocol will be progressive and will change weekly as subjects continue their recovery.
Other: Placebo/Stretching
A detailed, progressive stretching program to be performed for approximately 20-30 minutes per day, five days per week

What is the study measuring?

Primary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Time to full clinical recovery
Time Frame: 0-45 days
days between injury and return to play
0-45 days

Secondary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Heart rate
Time Frame: Achieved HR measured and recorded on first Buffalo Concussion Treadmill Test (Week 0-baseline)-6 weeks
Relationship between achieved heart rate on the Buffalo Concussion Test (Monitored using a Polar heart rate monitor) and recovery time.
Achieved HR measured and recorded on first Buffalo Concussion Treadmill Test (Week 0-baseline)-6 weeks
Vestibular Ocular Motor Screening (VOMS)
Time Frame: Recorded on first visit (Week 0-baseline)-6 weeks
Improved vestibular and oculo motor function with the treatment, as reflected by lower scores
Recorded on first visit (Week 0-baseline)-6 weeks
Y Balance Test (YBT) score
Time Frame: Administered and recorded on the first visit (Week 0-baseline)-6 weeks
Improved balance as indicated by increased reach scores with the treatment
Administered and recorded on the first visit (Week 0-baseline)-6 weeks
Concussion symptom burden
Time Frame: Week 0 (baseline)- 6 weeks
Improvement on The Post-Concussion Symptom Scale with the treatment, as indicated by lower scores
Week 0 (baseline)- 6 weeks

Collaborators and Investigators

This is where you will find people and organizations involved with this study.

Sponsor

Rocky Mountain University of Health Professions

Collaborators

Oregon Health and Science University

Investigators

  • Principal Investigator: Emily Kosderka, MS, Rocky Mountain University of Health Professions
  • Study Chair: Douglas Powell, PhD, Rocky Mountain University of Health Professions

Publications and helpful links

The person responsible for entering information about the study voluntarily provides these publications. These may be about anything related to the study.

General Publications

Study record dates

These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Major Dates

Study Start (Actual)

February 27, 2019

Primary Completion (Anticipated)

July 1, 2020

Study Completion (Anticipated)

July 1, 2020

Study Registration Dates

First Submitted

February 27, 2019

First Submitted That Met QC Criteria

March 5, 2019

First Posted (Actual)

March 6, 2019

Study Record Updates

Last Update Posted (Actual)

August 20, 2019

Last Update Submitted That Met QC Criteria

August 16, 2019

Last Verified

August 1, 2019

More Information

Terms related to this study

Additional Relevant MeSH Terms

Other Study ID Numbers

  • ConcussionRecovery2019

Plan for Individual participant data (IPD)

Plan to Share Individual Participant Data (IPD)?

Undecided

Drug and device information, study documents

Studies a U.S. FDA-regulated drug product

No

Studies a U.S. FDA-regulated device product

No

This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.

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