Mobile Subthreshold Exercise Program (MSTEP) for Youth With Prolonged Concussion Recovery: A Randomized Clinical...

Research suggests that aerobic exercise improves recovery for youth with concussion; however, prior studies primarily focused on acute concussion and required multiple in-person visits.

To determine whether a virtually delivered aerobic exercise program improves recovery following concussion compared to a stretching control and examine potential moderators.

A randomized clinical trial was conducted from 2021 to 2025 comparing the Mobile Subthreshold Exercise Program (MSTEP) to a stretching control for 11- to 18-year-olds with concussion up to 1 year from injury. Participants were recruited from a variety of outpatient locations in 4 US states (Washington, Utah, Wisconsin, and Oregon). Recruitment and data collection occurred from March 2021 until October 2025, and data analysis occurred from November 2025 to April 2026.

Youth randomized to MSTEP were provided activity trackers and an aerobic exercise program initiated at 60% of heart rate maximum. Exercise was advanced in intensity and duration over 6 weeks through weekly videoconferencing calls. Youth in the control group were given stretching exercises and similar weekly calls.

Primary outcomes included (1) concussive symptoms and (2) health-related quality of life (HRQoL). Secondary outcomes included sleep, depression, and anxiety. Moderation by sex, age, and time since injury was examined. Patients were followed up for 6 months.

The sample included 210 participants, among whom 122 (58.1%) were female, mean (SD) age was 15.1 (2.2) years, and mean (SD) time since injury was 73.3 (63.3) days. Covariate-adjusted regression analysis showed significant improvement in concussive symptoms and HRQoL at all time points, with greater improvement in MSTEP compared to control at the 3-month time point for both concussive symptoms (β, -3.15; 95% CI, -6.05 to -0.25; adjusted P = .04) and HRQoL (β, 4.15; 95% CI, 0.64-7.66; adjusted P = .04). No significant differences by group were seen at 6 months. Nonlinear mixed-effects modeling with exponential decay showed significantly faster symptom recovery in MSTEP compared to control (difference in rates, -0.68; 95% CI, -2.22 to -0.04; P = .002). Secondary outcomes (sleep, depression, and anxiety) improved in all participants but were not different by group. Benefit of the intervention was only significant for individuals less than 3 months from injury (concussive symptoms: β, -4.44; 95% CI, -7.99 to -0.90; unadjusted P = .01; HRQoL: β, 6.64; 95% CI, 2.55-10.72; unadjusted P = .002). No evidence was found for moderation by other factors.

Per the results of this randomized clinical trial, an aerobic exercise program improves speed of recovery following concussion for youth compared to stretching and can be delivered remotely. However, this type of program appears to be most beneficial for individuals with acute or subacute injury (<3 months since injury).

ClinicalTrials.gov Identifier: NCT04688255.