Growing evidence indicates early exercise may improve symptoms and reduce clinical recovery time after concussion, but research examining collegiate student-athletes is scarce.
The aim of this study was to compare symptom recovery time, clinical recovery time, and persisting post-concussion symptom (i.e., symptoms ≥ 28 days) prevalence by the timing of light exercise initiation before the graded return to play (RTP) protocol among concussed participants.
Collegiate student-athletes (n = 1228; age 18.4 ± 0.9 years; 56.5% male, 76.3% division I; 33.7% ≥ 1 prior concussion) across 30 institutions enrolled in the CARE Consortium completed post-concussion assessments and were monitored over time. Symptom recovery (days from injury to symptom resolution) and clinical recovery (days from injury to return to play protocol completion) was determined by the student-athletes’ clinicians. Student-athletes were categorized by timing of light exercise initiation. Early (< 2 days post-concussion; n = 161), typical (3–7 days post-concussion; n = 281), and late exercise (≥ 8 days post-concussion; n = 169) groups were compared with the no-exercise group (n = 617; i.e., did not exercise prior to beginning the RTP protocol) for all analyses. Multivariable Cox regression models with hazard ratios (HR) and survival curves and a multivariable binomial regression model with prevalence ratios (PR) compared recovery outcomes between exercise groups while accounting for covariates.
Compared to the no-exercise group, the early exercise group was 92% more probable to experience symptom recovery (HR 1.92; 95% CI 1.57–2.36), 88% more probable to reach clinical recovery (HR 1.88; 95% CI 1.55–2.28) and took a median of 2.4 and 3.2 days less to recover, respectively. The late exercise group relative to the no-exercise group was 57% less probable to reach symptom recovery (HR 0.43; 95% CI 0.35–0.53), 46% less probable to achieve clinical recovery (HR 0.54; 95% CI 0.45–0.66) and took 5.3 days and 5.7 days more to recover, respectively. The typical exercise group did not differ in hazard for symptom or clinical recovery (p ≥ 0.329) compared with the no-exercise group. The prevalence of persisting post-concussion symptoms in the combined sample was 6.6%. Early exercise had 4% lower prevalence (PR 0.96, 95% CI 0.94–0.99) and typical exercise had 3% lower prevalence (PR 0.97, 95% CI 0.94–0.99) of persisting post-concussion symptoms, while the late exercise group had an elevated prevalence (PR 1.11, 95% CI 1.04–1.18) compared with the no-exercise group.
Exercise < 2 days post-concussion was associated with more probable and faster symptom and clinical recovery, and lower persisting post-concussion symptom prevalence. When considering our findings and existing literature, qualified clinicians may implement early exercise into their clinical practice to provide therapeutic treatment and improve student-athlete recovery.
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The authors would also like to thank Jody Harland, Janetta Matesan, Michael Menser (Indiana University School of Medicine); Ashley Rettmann, Nicole L’Heureux, (University of Michigan); Melissa McEachern (Medical College of Wisconsin); Michael Jarrett, Vibeke Brinck, and Bianca Byrne, (Quesgen); Melissa Baker, Christy Collins, Will Felix, (Datalys Center for Sports Injury Research and Prevention); and the research and medical staff at each of the CARE participation sites. We are grateful for the participation of the student athletes without whom this research would not be possible. Contributing CARE Consortium Investigators include Louise A. Kelly, PhD (California Lutheran University); Justus D. Ortega, PhD (California State Polytechnic University Humboldt); Christina L. Master, MD, FAAP, CAQSM, FACSM (Children’s Hospital of Philadelphia); Nicholas Port, PhD (Indiana University); Christopher C. Giza, MD (University of California, Los Angeles); Thomas W. Kaminski, PhD, ATC (University of Delaware); Luis A. Feigenbaum, DPT, ATC (University of Miami); Micky Collins, PhD (University of Pittsburgh Medical Center); Sara P. O. Chrisman, MD, MPH (University of Washington); Alison Brooks, MD, MPH (University of Wisconsin-Madison); Adam Susmarski, DO (United States Naval Academy); Stefan Duma, PhD (Virginia Tech); James R. Clugston, MD, MS (University of Florida).
All authors contributed to the study conception, study design, critical review, and interpretation of findings, and drafting and/or critique of the manuscript. All authors read and approved the final manuscript. Specifically, LBL and EFT contributed to conceptualization, methodology, data analysis and interpretation, and original and revised manuscript drafts. RCL, NLH, TAB, and JTE contributed to conceptualization, analysis interpretation, and original and revised manuscript drafting. MAM, TWM, and SPB contributed to conceptualization, methodology, data analysis, manuscript critique, and funding acquisition. JDS contributed to conceptualization, analysis interpretation, original and revised manuscript drafting, and funding acquisition. The CARE Consortium Investigators contributed to critical critique and review of methodology, data analysis, and original manuscript review.
This study was made possible, in part, with support from the Grand Alliance Concussion Assessment, Research, and Education Consortium, funded by the National Collegiate Athletic Association and the Department of Defense. The US Army Medical Research Acquisition Activity, 820 Chandler Street, Fort Detrick, MD 21702-5014, USA is the awarding and administering acquisition office. This work was supported by the Office of the Assistant Secretary of Defense for Health Affairs through the Psychological Health and Traumatic Brain Injury Program under Award no. W81XWH-14-2-0151. Opinions, interpretations, conclusions, and recommendations are those of the authors and are not necessarily endorsed by the Department of Defense (Defense Health Program funds).
Conflict of interest
All authors declare that they have no conflicts of interest relevant to the content of this manuscript outside the acknowledged funding source.
All disclosures below are not directly related to the current project, but are reported for full transparency to readers. Dr Landon Lempke has current or prior funding unrelated to the current project from the National Athletic Trainers’ Association (NATA), American College of Sports Medicine, Eastern Athletic Trainers’ Association, VALD, internally from university affiliations, and has received various speaker honorarium and travel reimbursement for talks given. Dr Elizabeth Teel has current or prior funding from the Canadian Institutes of Health Research and the Fonds de recherche du Québec- Santé. Dr Robert Lynall reports current or prior funding from the Department of Defense (DoD), National Football League (NFL), Andee’s Army foundation, internal funding from university affiliations, and has received conference travel support from the Southeast Conference for athletics and internal institutional awards. Dr Thomas Buckley reports current or prior funding from NIH, Henry F. Jackson Foundation for the Advancement of Military Medicine, and State Space, Inc. Dr James Eckner reports current or prior funding from NIH, NSF, and internal university funding. Dr Eckner also reports being a co-author (stipend received) for a book chapter in “Concussion Management for Wheelchair Athletes”, on the editorial board (unpaid) for the journal Physical Medicine & Rehabilitation, and a co-inventor on US Patent #8,657,295, and a Data and Safety Monitoring Board member for an unrelated NIH project. Dr Michael McCrea has received research funding from the NIH, CDC, DoD, NCAA, NFL, and Abbott Laboratories. Dr Thomas McAllister reports current or prior grant support from NIH, DoD, and NCAA, as well as textbook royalties from the “Textbook of Traumatic Brain Injury” from the American Psychiatric Association Publishing, Inc., and is an unpaid member for the concussion Scientific Advisory Committee for the Australian-Rules Football Conference. Dr Steven Broglio has current or past research funding from the NIH, CDC, DoD, NCAA, NATA, NFL/Under Armour/GE; Simbex; and ElmindA. Dr Broglio has consulted for US Soccer (paid), US Cycling (unpaid), University of Calgary SHRed Concussions external advisory board (unpaid), medico-legal litigation, and received speaker honorarium and travel reimbursements for talks given. Dr Broglio is also a co-author of “Biomechanics of Injury (3rd edition)” and has a patent pending on “Brain Metabolism Monitoring Through CCO Measurements Using All-Fiber-Integrated Super-Continuum Source” (U.S. Application No. 17/164,490). Lastly, Dr Broglio is/was on the editorial boards (all unpaid) for Journal of Athletic Training (2015 to present), Concussion (2014 to present), Athletic Training & Sports Health Care (2008 to present), and British Journal of Sports Medicine (2008 to 2019).
Availability of data and material
The CARE Consortium datasets generated and analyzed during the current study are available in the FITBIR repository (https://fitbir.nih.gov/).
Research involving human participants
The study was performed in accordance with the standards of ethics outlined in the Declaration of Helsinki.
All study procedures were reviewed and approved by the University of Michigan IRB, the US Army Medical Research and Materiel Command Human Research Protection Office (HRPO), as well the local IRB at each of the performance sites. Participants provided written informed consent prior to participation.
Members of the ‘CARE Consortium Investigators’ are given in the Acknowledgements section.
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Lempke, L.B., Teel, E.F., Lynall, R.C. et al. Early Exercise is Associated with Faster Concussion Recovery Among Collegiate Athletes: Findings from the NCAA-DoD CARE Consortium. Sports Med 53, 1987–1999 (2023). https://doi.org/10.1007/s40279-023-01861-w