A graded exercise protocol with added cognitive load: a standardised approach for assessing symptom responses following a sports related concussion?

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To examine the self-reported concussion symptoms provoked with a controlled sub-maximal exercise protocol, incorporating a cognitive load, in athletes recovering from a sports-related concussion.


A three group repeated measures study with follow-up.


University laboratory.


University aged athletes (12 males, 3 females) with a recent (<14 days) sports-related concussion and 30 (24 males and 6 females) matched recreationally active, non-concussed persons.


Three groups: Concussed (Con), Control+exercise+cognitive load (CECL); and Control+exercise (CE) undertook a 19 min standardised sub-maximal progressive exercise protocol. The Con and CECL groups simultaneously completed a package of reaction time tasks (cognitive load).The Con group completed an identical protocol on a subsequent visit. Participants were instructed to “stop” the test any time they wished.

Outcome measures

The symptom severity score (SSS) obtained from the SCAT2 post-concussion symptom scale was determined prior to, immediately following, and 15 min aftercompleting the exercise protocol.

Main results

The groups X time interaction (F4,84=31.9, p<001)indicated that the Con group was different from both control groups at all 3 time intervalswith differences between the time points for the Con group, but not for the others.Three members from the Con group did not complete the protocol. A significant visit X time interaction (F1,9=56.04) was seen for the Con group which completed the protocol on 2 occasions.


The protocoldifferentially provoked symptoms in recently concussed athletes suggesting its potential in standardising assessment procedures to inform return to play decisions.

Competing interests

Paul McCrory is a co-investigator, collaborator, or consultant on grants relating to mild TBI funded by several governmental organisations. He is Co-Chair of the Australian Centre for Research into Sports Injury and its Prevention (ACRISP), supported by the IOC. He has been reimbursed by the government, professional scientific bodies, and sporting bodies for presenting research relating to mild TBI and sport-related concussion at meetings, scientific conferences, and symposiums. He received support since 2001 from CogState Inc for research costs and the development of educational material. He does not hold any individual shares in any company related to concussion or brain injury assessment or technology.

Competing interests


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