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Relationship Between Exercise Tolerance and Event-Related Potentials on Recovery in Adults with Postconcussion

Nicholas Moser1,2, Milos R Popovic1,2,3,4, Sukhvinder Kalsi-Ryan1,4

  • 1KITE Research Institute-University Health Network, Toronto, Canada.

Journal of Neurotrauma
|October 30, 2025
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Summary

Objective measures like exercise tolerance and event-related potentials (ERPs) predict concussion recovery. Lower baseline exercise tolerance and reduced N400 amplitude correlated with poorer outcomes in adults with persistent postconcussion symptoms undergoing standard care.

Keywords:
EEGconcussionrecoveryrehabilitationtraumatic brain injury

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Area of Science:

  • Neuroscience
  • Sports Medicine
  • Rehabilitation Science

Background:

  • Clinical management of concussions and postconcussion syndrome (PCS) relies heavily on subjective symptom reporting.
  • Objective measures are needed to mitigate reporting biases and predict recovery trajectories.
  • Exercise intolerance is a known predictor of protracted recovery in adolescent concussion patients, but its role in adults is less understood.

Purpose of the Study:

  • To investigate the relationship between baseline exercise tolerance, event-related potentials (ERPs), and symptom improvement in adults with persistent postconcussion symptoms (PPCS) after a 6-week clinical trial.
  • To compare outcomes between a customized rehabilitation (CR) program and standard, symptom-based care (SC).

Main Methods:

  • Forty adult participants with PPCS were randomized to CR or SC.
  • Baseline assessments included an exercise tolerance test (measuring delta heart rate (ΔHR) and heart rate thresholds (HRt)) and quantitative electroencephalogram (qEEG) to assess auditory ERPs (N100, P300, N400).
  • Linear regression analyzed the association between baseline measures and changes in Rivermead Postconcussion Questionnaire (RPQ) scores.

Main Results:

  • The CR group showed significant improvements in symptoms (RPQ-3, RPQ-13) and exercise tolerance (ΔHR, HRt), with no baseline variables predicting outcomes.
  • The SC group showed no clinically meaningful symptom changes; however, baseline measures correlated with improvement.
  • Lower baseline ΔHR and HRt correlated with less symptom improvement (RPQ-3, RPQ-13). Reduced N400 amplitude correlated with less RPQ-3 improvement.

Conclusions:

  • Baseline exercise tolerance and ERPs are significant prognostic indicators for symptom improvement in adults with PPCS receiving standard care.
  • Lower exercise tolerance and reduced N400 amplitude predict poorer outcomes in the SC group.
  • A customized rehabilitation program may enhance recovery, potentially overriding baseline physiological and cognitive limitations.