A clinical assessment of sports and physical exertion (case) in children with concussion

The National Institute of Child Health and Human Development awarded The Spaulding Rehabilitation Hospital Corporation $480,192 on July 1, 2026, to conduct a single-arm cohort study evaluating the Clinical Assessment of Sports and Physical Exertion (CASE)—a sub-maximal exercise test designed to determine readiness for return to play and activity in children with concussion.

The CASE addresses gaps in existing physical exertion clinical tools by employing a multimodal approach to assessing human performance, including dynamic and multidirectional exercise, and using cost-effective equipment scalable to secondary school settings. Current return-to-play protocols rely on subjective symptom reporting that may not indicate physiological recovery; the CASE aims to establish ongoing physiological dysfunction to supplement clinical decision-making. The study will enroll 25 children ages 13–18 of all genders, races, and ethnicities.

This project grant falls under the Child Health and Human Development Extramural Research program (CFDA 93.865) and supports NICHD's scientific priority to improve child and adolescent health and the transition to adulthood. Performance occurs in Dallas, Texas, with period of performance from July 1, 2026, through June 30, 2028.

Abstract

Determining a child's readiness for return to play/activity (RTP/a) after concussion is a critical clinical decision due to the risk of repeat injury and prolonged recovery associated with premature RTP/a, highlighting a significant need for clinical tools to aid in RTP/a decision-making. Currently, children with concussion must complete a graduated 6-step RTP/a protocol before being medically cleared by a physician. However, progression through the RTP/a protocol is reliant on subjective symptom reporting, which may not indicate physiological recovery. Physical exertion clinical tools may be employed to establish ongoing physiological dysfunction in children with concussion and thereby supplement the RTP/a protocol to aid in RTP/a decision- making. Yet, existing physical exertion clinical tools fail to assess multiple domains of human performance, exclude dynamic exercise, and require expensive equipment which may limit their scalability to secondary school settings. Alternatively, the clinical assessment of sports and physical exertion (case), a sub-maximal exercise test to assess a child's ability to tolerate dynamic and multidirectional movements after concussion, addresses these gaps by (1) adopting a multimodal approach to assessing human performance, (2) including dynamic exercise, and (3) using cost-effective equipment. The long-term goal is to develop and test interventions that improve the clinical care of children with concussion and ensure safe return to sport and physical activity, addressing goal #4 improving child and adolescent health and the transition to adulthood 2025 nichd scientific priority. The overall goal of this project is to evaluate the utility of the case to determine readiness for RTP/a in children with concussion. In this single-arm cohort study, 25 children of all genders, races, and ethnicities, 13-18 years of age diagnosed with a concussion while participating in school sanctioned sport will complete the case during the RTP/a protocol. Physiological (heart rate, blood pressure, oxygen saturation) and clinical (rating of perceived exertion, post-concussion symptom scale) outcomes will be assessed at baseline (pre-case), after each case component (aerobic, anaerobic, strength, speed/agility), and post-case (15- minutes after). The specific aims of this proposed project are to: (1) evaluate the utility of the case to determine readiness for RTP/a in children with concussion, (2) evaluate the positive predictive value of the case to determine readiness for RTP/a, and (3) describe the enrollment and implementation feasibility of delivering the case. Expected outcomes are (1) the percentage of children categorized as ready for RTP/a, (2) participant characteristics associated with unreadiness for RTP/a, (3) performance of the case to correctly identify children ready for RTP/a, and (4) clinician perceptions on the feasibility of delivering the case to children with concussion. Results of this proposed study will provide foundational evidence to facilitate future research efforts to examine the efficacy of the case to determine readiness for RTP/a in children with concussion.