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Dynamic Exertion Testing (EXiT): An Assessment to Inform to Return to Play/Activity following Sport-related Concussion

Sinnott, Aaron and Connaboy, Christopher and Kontos, Anthony and Sparto, PJ and Flanagan, Shawn D and Elbin, RJ (2021) Dynamic Exertion Testing (EXiT): An Assessment to Inform to Return to Play/Activity following Sport-related Concussion. Doctoral Dissertation, University of Pittsburgh. (Unpublished)

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BACKGROUND: Recently developed dynamic exertion testing (EXiT) incorporates a combination of treadmill running, functional movements, and agility tasks to inform return to play and activity (RTP/A) decision making following sport-related concussion. The identification of an assessment’s stability on repeated assessments, inter-rater agreement, minimal detectable change (MDC), and examination of age, sex, body mass index (BMI), and sport-type are necessary to interpret EXiT. Additionally, previously injured athletes upon medical clearance to RTP/A should have similar physiological, performance, and clinical outcomes on EXiT as healthy athletes, including heart rate variability (HRV) responses to EXiT as a proxy of autonomic nervous system functioning.
PURPOSE: The aims of the current investigation included the following:
Aim 1) Establish intra-rater, test-retest and inter-rater reliability for EXiT physiological (age estimated percentage of maximum heart rate (HR %max)) and blood pressure (BP)), performance (agility task completion time and errors), and clinical (endorsed symptoms and rating of perceived exertion (RPE)) outcomes.
Aim 2) Compare age, sex, BMI, and sport-type subgroups across EXiT physiological, performance, and clinical outcomes among a heterogeneous physically active sample.
Aim 3) Determine concurrent validity of EXiT by comparing physiological, performance, and clinical EXiT outcomes and ultrashort heart rate variability responses to EXiT between athletes at medical clearance to RTP/A from SRC with healthy controls.
METHODS: Aim 1) From a total sample of 92 healthy physically active adolescents and adults, 79 (F:34, 43%) completed a demographic questionnaire, weight and height measurements for BMI ([BMI]= weight [kg]/height[m]2), and the EXiT across 2 visits (8.7±4.7 days apart). EXiT included an aerobic component: 12- min treadmill run; and dynamic component: dynamic circuit, ball toss, box-drill shuffle and carioca, zig zag, pro agility, and arrow agility tasks. A 2nd rater separately assessed agility task completion time and errors for 15 healthy participants and 15 athletes upon medical clearance to RTP/A. Two-way, mixed, intra-class correlation coefficients were used to evaluate agility task completion time between consecutive trials (intra-rater reliability), fastest trial across visits (test-retest reliability), and agreement between raters (inter-rater reliability). Paired samples t-tests were used for HR %max and agility task completion time, and Wilcoxon tests were used for endorsed symptoms, RPE, and errors. Internal consistency of symptoms at each visit was determined with Cronbach’s alpha, and MDC of EXiT outcomes were calculated using the equation: MDC= standard deviation x √((1-ICC) ) • 1.96 • √(2 ).
Aim 2) 87 (F= 55, 37.4%; 19.5 ± 4.4 years) participants (from aim 1) were categorized in adolescent (14- 17 years) or adult (≥18 years), male or female (self-report), LO-BMI (BMI < 50th percentile) or HI-BMI (BMI ≥50th percentile), and collision, contact, or non-contact sport-types. Independent samples t-tests were conducted for HR %max, BP, and agility task completion time, and Mann-Whitney U tests for RPE, endorsed symptoms, and errors between age, sex, and BMI groups across aerobic and dynamic components. A series of 1-way ANOVAs were conducted to compare HR %max, BP, and agility task completion time, and Kruskal Wallis- H tests to compare RPE, symptoms, and committed errors between collision, contact, and non-contact sport-types.
Aim 3) A sample of 46 healthy athletes including 23 (F= 10, 43.5%) healthy control (from aim 1; CONTROL) and age-, sex-, and sport- matched to patients completing EXiT at medical clearance to RTP/A (CONCUSS) completed a 5-minute seated rest period prior to and following EXiT. The final 3-min were used to calculate ultrashort HRV outcomes, including the root-mean-square of successive differences (RMSSD) and standard deviation of successive heart beats (SDNN). Independent samples t-tests were conducted to compare CONTROL and CONCUSS groups for HR %max, BP, and agility task completion time, and Mann-Whitney U tests were utilized for endorsed symptoms, RPE, committed errors. A series of 2X2 (GROUP X TIME) mixed model ANOVAs were conducted to compare CONCUSS and CONTROL groups on RMSSD and SDNN outcomes across time points (pre- and post-EXiT rest periods).
RESULTS: Aim 1) Pre- and post-EXiT resting HR %max and BP, and HR %max were reliable throughout aerobic and dynamic components (ICC=.696-.838). Symptoms and RPE were similar across visits but less errors were committed at the 2nd visit. Agility task completion time (MDC range=0.75-8.70 seconds) had good to excellent test-retest (ICC=.703-.948) and inter-rater reliability (ICC=.932-.965), but ratings of committed errors have acceptable agreement for committed errors for only the ball toss and pro agility tasks. Endorsed symptoms had a high internal consistency at both visits (α =.805-.894) and were reliable across visits during aerobic (ICC=.765) and dynamic components (ICC .519) were reliable across visits.
Aim 2) Adolescents were faster than adults on arrow agility (p=.01); males were faster than females on box drill carioca (p=.01), zig zag (p<.001, pro agility (p=.02), and arrow agility (p=.04) tasks; and the LO-BMI group was faster than the HI-BMI group on arrow agility(p<.001). Males also reported greater RPE than females after the box drill shuffle, box drill carioca, and arrow agility tasks (p<.03), but statistical differences were within established minimal detectable change scores. HR %max, errors, and endorsed symptoms were equivocal throughout and following aerobic and dynamic components across age, sex, BMI, and sport-type groups (p>.05).
Aim 3) The CONCUSS group had group had lower (faster) completion time during zig zag p=0.048 and pro agility p=0.018) tasks and had lower (less variable) SDNN (F=4.569, p=.047, Ƞ_p^2=. 212) and RMSSD (F=4.517, p=.049, Ƞ_p^2=.=.209) than CONTROL group. CONCUSS and CONTROL groups had similar HR %max, total endorsed symptoms, and RPE (p>.05).
CONCLUSION: EXiT physiological, performance, and clinical outcomes are reliable, and generalizable to physically active population of varied age, sex, BMI, and sport-type factors. The multiple objective outcomes of EXiT present a new evidence-based approach to inform clinical recovery from SRC and RTP/A decision making.


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Item Type: University of Pittsburgh ETD
Status: Unpublished
CreatorsEmailPitt UsernameORCID
Sinnott, Aaronams626@pitt.eduams626
Kontos, Anthonyakontos@pittledu
Sparto, PJpsparto@pitt.eduPSPARTO
Flanagan, Shawn Dsdf29@pitt.edusdf29
ETD Committee:
TitleMemberEmail AddressPitt UsernameORCID
Committee ChairConnaboy,
Committee CoChairKontos, Anthonyakontos@pittledu
Committee MemberSparto, PJpsparto@pitt.eduPSPARTO
Committee MemberFlanagan, Shawn Dsdf29@pitt.edusdf29
Committee MemberElbin,
Date: 11 June 2021
Date Type: Publication
Defense Date: 19 March 2021
Approval Date: 11 June 2021
Submission Date: 31 March 2021
Access Restriction: 2 year -- Restrict access to University of Pittsburgh for a period of 2 years.
Number of Pages: 189
Institution: University of Pittsburgh
Schools and Programs: School of Health and Rehabilitation Sciences > Sports Medicine and Nutrition
Degree: PhD - Doctor of Philosophy
Thesis Type: Doctoral Dissertation
Refereed: Yes
Uncontrolled Keywords: Concussion, Mild Traumatic Brain Injury, Exertion, Injury
Date Deposited: 11 Jun 2021 21:25
Last Modified: 11 Jun 2023 05:15

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