Children aged five to 12 years who are able to reach at least 70% of their age-predicted maximum heart rate during graded treadmill testing without an increase in concussion symptoms are considered exercise tolerant and near physiological recovery, according to a practical management article published in Clinical Journal of Sport Medicine. Earlier symptom provocation during exertion may indicate clinically relevant exercise intolerance and can help inform concussion management decisions in this younger pediatric population.
That principle underlies the Pediatric Concussion Treadmill Test, an age-appropriate exertional assessment developed to address limitations of existing concussion protocols, which are primarily designed for adolescents and adults.
Researchers described the Pediatric Concussion Treadmill Test as a modification of the Buffalo Concussion Treadmill Test tailored for children aged five to 12 years. The protocol was designed to account for pediatric developmental and physiological differences, including shorter leg length, lower cardiovascular capacity, and variable cognitive and equipment familiarity. The test aligns with American Heart Association guidelines for pediatric cardiac stress testing and is intended to complement, not replace, a comprehensive clinical concussion evaluation.
Before testing, clinicians record baseline resting heart rate and concussion symptom severity. Children are given the opportunity to acclimate to the treadmill at a self-selected walking pace, with testing discontinued if symptoms increase or change during acclimation, indicating an early exercise intolerance threshold. Testing begins at a zero-degree incline using age-specific starting speeds derived from six-minute walk test normative data, ranging from 2.1 mph for five-year-olds to 2.8 mph for 11-year-olds. Each minute, treadmill incline increases by 1% and speed increases by 0.2 mph, with testing limited to a maximum of 10 minutes.
Heart rate is recorded at the end of each stage, while symptom severity is assessed using a visual analog scale combined with the Wong-Baker FACES Pain Rating Scale. Perceived exertion is measured using a modified Children’s OMNI rating of perceived exertion scale, which incorporates age-appropriate language and examples. “The systematic identification of the degree of exercise intolerance can inform the treating clinician about the severity of the concussion and provide specific data to help prescribe the only effective treatment known to facilitate concussion recovery: subsymptom threshold aerobic exercise,” wrote lead study author Cathlyn Corrado, PT, DPT, PCS, of the Sports Medicine Department at the University of Rochester Medical Center in Rochester, New York, and colleagues.
Testing is terminated with any worsening of concussion-related symptoms, voluntary exhaustion defined as a perceived exertion rating greater than eight, patient request to stop, observed safety concerns, attainment of 70% of age-predicted maximum heart rate, or completion of the full protocol. Heart rate at symptom exacerbation is recorded as the threshold value, followed by a standardized cool-down and monitoring until heart rate and symptoms return to baseline.
Although prospective validation studies are ongoing, the Pediatric Concussion Treadmill Test offers clinicians a structured and practical approach to assessing exercise tolerance in children aged five to 12 years following concussion. By systematically identifying the degree of exercise intolerance, the test may help inform clinical decision-making and guide individualized management when used as part of a comprehensive concussion evaluation, the researchers concluded.
The researchers reported no conflicts of interest.
