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Association of simple step test with readiness for exercise in youth after concussion

Review written by Mike Studer info

Key Points

  1. Physical activity has been proven to be a key part of comprehensive concussion rehabilitation.
  2. At present, we have no reliable screening tools that can help medical practitioners to advise readiness for exercise during recovery from concussion.
  3. Current graded exercise tests require equipment and often 15-20 minutes of time to perform, limiting their clinical utility.
  4. This examination shows sensitivity for persons across various subtypes of concussion, testing more than their fitness, but also pain, imbalance, and vestibular symptom capacities.


As emerging research indicates that children and adolescents with concussion who engage in physical activity within 7 days of injury have a more effective recovery (1-3), practitioners need more objective tools to make appropriate activity recommendations. As such, the authors of this study attempted to develop a simple graded exercise test to determine tolerance to exercise, in order to objectively stratify concussed patients appropriately for early activity versus relative rest.

Emerging research indicates that children and adolescents with concussion who engage in physical activity within 7 days of injury have a more effective recovery.
Healthcare professionals need reliable tools to assess and make accurate recommendations for people recovering from concussion.


The graded exercise test (GXT) employed in this research is known as the Kasch Pulse Recovery test (KPR), which is essentially a 3-minute paced step test. This study superimposed concussion-specific criteria on the KPR including measured symptom response (dizziness, imbalance, nausea, pain, visual changes); heart rate response; imbalance (needing to use upper extremity support); and perceived exertion.

Subjects were required to step-up onto a 30 cm step with both feet, and then step back down, leading with the same foot on the up and down. The lead foot changed after 1.5 minutes. The rate of stepping was directed by a metronome at 96 beats per minute with the participant performing one step at each beat.

Subjects were given permission to stop based on symptoms – parameters being an increase in symptom severity score by 3 or more points on the Wong Baker FACES Pain Rating Scale from baseline score. They were required to stop the test for: imbalance (touching nearby chair to steady), inability to maintain stepping rate, or failure for heart rate to increase.


Better exercise performance on the KPR was significantly and inversely correlated with normal (negative) vestibular/oculomotor and balance performance. These findings were independent of time since concussion.


The KPR is a submaximal GXT. Returning back to sport may, and often does, include maximal or near-maximal exertion. While the KPR has been shown to work participants to a level useful for decision making to commence graded exercise, it does not replicate the level of effort required for full sports performance.


Healthcare professionals need reliable tools to assess and make accurate recommendations for people recovering from concussion. When we do not have a firm assessment tool, the tendency can be to err on the more conservative side, believing that we are doing less harm this way. Recent studies have clearly pointed to the physiologic benefits of early return to activity for the concussed brain (3), however this approach cannot be without clinical decision making or we are no better than we were recommending that everyone rest for 72 hours.

While recommending limited to no physical activity can be unhelpful, practitioners need a reliable test to recommend graded exercise. This test, in contrast with treadmill and cycle-based tests, requires minimal equipment and can be performed with symptoms, balance, and signs all considered. Other tests including the Buffalo Concussion Treadmill Test (BCTT), Modified Balke, or McMaster All-Out Progressive Continuous Cycle Tests do require equipment and have standards that do not uniformly consider athlete capacity, height, or other injuries sustained in the concussion that might preclude running or all-out cycling.

Overall, the KPR is a simple and practical tool to determine whether it is appropriate for a child or adolescent with concussion to commence graded (submaximal) exercise. This study additionally validates the KPR as a safe and feasible method of determining post-concussive physiological readiness for graded exercise in youth.


Fyffe A, Bogg T, Orr R, Browne G (2020) Association of Simple Step Test With Readiness for Exercise in Youth After Concussion. J Head Trauma Rehabil, 35(2), E95-E102.


  1. Grool AM, Aglipay M, Momoli F, et al. Association between early participation in physical activity following acute concussion and persistent postconcussive symptoms in children and adolescents. JAMA. 2016;316(23):2504–2514. doi:10.1001/jama.2016.17396.
  2. Howell DR, Mannix RC, Quinn B, Taylor JA, Tan CO, Meehan WP III. Physical activity level and symptom duration are not associated after concussion. Am J Sports Med. 2016 Apr;44(4):1040– 1046. doi:10.1177/0363546515625045.
  3. Lawrence DW, Richards D, Comper P, Hutchison MG. Earlier time to aerobic exercise is associated with faster recovery following acute sport concussion. PLoS One. 2018;13(4):e0196062. doi:10.1371/journal.pone.0196062.
  4. McCrory P, Meeuwisse W, Dvorak J, et alConsensus statement on concussion in sport—the 5th international conference on concussion in sport held in Berlin, October 2016British Journal of Sports Medicine 2017;51:838-847.
  5. McCrory P, Meeuwisse WH, Aubry M, et alConsensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012British Journal of Sports Medicine 2013;47:250-258