A preliminary study of subsymptom threshold exercise training for refractory post-concussion syndrome

Objective: To evaluate the safety and effectiveness of subsymptom threshold exercise training for the treatment of post-concussion syndrome (PCS). DESIGN: Prospective case series. SETTING: University Sports Medicine Concussion Clinic. PARTICIPANTS: Twelve refractory patients with PCS (6 athletes and 6 nonathletes). INTERVENTION: Treadmill test to symptom exacerbation threshold (ST) before and after 2 to 3 weeks of baseline. Subjects then exercised 5 to 6 days per week at 80% ST heart rate (HR) until voluntary peak exertion without symptom exacerbation. Treadmill testing was repeated every 3 weeks. MAIN OUTCOME MEASURES: Adverse reactions to exercise, PCS symptoms, HR, systolic blood pressure (SBP), achievement of maximal exertion, and return to work/sport. RESULTS: Pretreatment, ST occurred at low exercise HR (147 ± 27 bpm) and SBP (142 ± 6 mm Hg). After treatment, subjects exercised longer (9.75 ± 6.38 minutes to 18.67 ± 2.53 minutes, P =.001) and achieved peak HR (179 ± 17 bpm) and SBP (156 ± 13 mm Hg), both P <.001 versus pretreatment, without symptom exacerbation. Time series analysis showed significant change in rate of symptom reduction for all subjects and reduced mean symptom number in 8/11. Rate of PCS symptom improvement was related to peak exercise HR (r =-0.55, P =.04). Athletes recovered faster than nonathletes (25 ± 8.7 vs 74.8 ± 27.2 days, P =.01). No adverse events were reported. Athletes returned to sport and nonathletes to work. CONCLUSIONS: Treatment with controlled exercise is a safe program that appears to improve PCS symptoms when compared with a no-treatment baseline. A randomized controlled study is warranted.