Aerobic Tolerance and Movement-Provoked Symptoms After Sport-Related Concussion: A Critical Review of Assessment and Rehabilitation Endpoints

Abstract

To examine the clinical significance of tolerated aerobic exercise when head movement or visual activity continues to provoke symptoms after sport-related concussion, and to distinguish rehabilitation improvement from readiness for sport. In a 2019 adolescent trial, median recovery was 13 days with aerobic exercise and 17 days with stretching. A 2014 cervicovestibular trial favoured clearance by eight weeks, whereas a 2022 adult trial found physical cervical and vestibular improvement without superiority in overall symptoms or return to function. These differences reflect distinct populations, comparators, and endpoints. Tolerance of low-intensity activity does not establish normal exertional capacity, and a positive head-motion screening item does not isolate an anatomical cause. Interpretation requires an adequately demanding graded exercise assessment, a specified movement task, and documentation of symptoms before, during, and after each activity. Additional rehabilitation should address an identified impairment and its functional restriction. The available trials do not directly establish the optimal treatment for athletes with normal aerobic tolerance and persistent movement-provoked symptoms. Clinical improvement must be assessed against the demands and risk of the next participation stage.