Publication Q&A: Mobile Subthreshold Exercise Program (MSTEP) for Youth With Prolonged Concussion Recovery

Sara Chrisman, MD, MPH, a principal investigator in the Center for Child Health, Behavior and Development, led a study showing that structured, sub-threshold aerobic exercise — even when delivered entirely virtually — significantly accelerated concussion recovery in youth compared to an active control group performing stretching.

This research highlights Seattle Children’s leadership in health access and digital health innovation, proving that youth can participate in effective, remote concussion recovery programs right from home. By empowering teens to take an active role in their healing process, this research provides strong new evidence to help providers deliver targeted, time-sensitive interventions.

Read the article in JAMA Pediatrics.

Tell us about your study.

The standard of care for concussion has for years been what is called “sub-threshold exercise” – structured physical activity performed at an intensity just below the heart rate or exertion level that triggers concussion symptoms. However, no one had really studied this on a large scale, and past programs needed to be in person. We studied a virtually administered physical activity program (Mobile Subthreshold Exercise Program or MSTEP) in a little over 200 kids (ages 11 to 18), comparing it to an active control group doing a stretching program. We found there was benefit and a faster rate of recovery with the MSTEP program, even delivered virtually.

Is this research a first in any way?

Yes, in three key ways:

1. This is the first study to study a virtually delivered exercise program for concussion.
2. It's also the largest study of subthreshold exercise for concussion (with over 200 kids, doubling previous studies of about 100 individuals).
3. It's the first study to look at response to these kinds of interventions based on time since injury.

What was the need for this research, and why is it important?

Historically, structured sub-threshold exercise (the current standard of care) has required frequent visits to physical therapy in-person, which is challenging for patients, especially those in rural locations or far from an academic center. As a result, concussion care varies widely depending on where you’re seen. We wanted to test a structured approach that could eventually be scaled and disseminated more broadly.

How can this research lead to better ways to treat concussion?

• Improved Access and Flexibility: This study provides more evidence supporting aerobic exercise as an intervention for concussion, and shows it can be delivered virtually.
• Tailored Interventions Based on Injury Timing: Our data suggested that this kind of intervention isn't as helpful for people more than three months from injury. This helps clinicians recognize when to think about different types of interventions such as care management or concussion-focused cognitive behavioral therapy.
• Patient Empowerment: These results demonstrate that teens do well when they’re given autonomy in the injury recovery process.

What are the next steps and long-term goals for this research?

My ultimate goal is to help kids get better faster. Next steps include finishing analyzing the data on what types of things are driving benefit from the intervention. We want to know whether recovery is due to the exercise itself or a concept called fear-avoidance. Essentially, is it the exercise that matters or the permission to exercise?  Finally, we’re looking at implementation and how we would help kids get access to this kind of program in a primary care setting or in a sports medicine setting.

Related Categories

• Concussion