Graded Combined Aerobic Resistance Exercise (CARE) to Prevent or Treat the Persistent Post-concussion Syndrome

  • Karen A. SullivanEmail author
  • Andrew P. Hills
  • Grant L. Iverson
Neurotrauma (D. Sandsmark, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Neurotrauma


Purpose of Review

To review the growing body of indirect and direct evidence that suggests that exercise can be helpful for children, adolescents, and adults with persistent symptoms following a mild traumatic brain injury (mTBI).

Recent Findings

The direct evidence shows that graded exercise assessments are safe, and that aerobic exercise interventions are associated with improvement of multiple symptoms and other benefits, including earlier return-to-sport. The indirect evidence supports this approach via studies that reveal the potential mechanisms, and show benefits for related presentations and individual symptoms, including headaches, neck pain, vestibular problems, sleep, stress, anxiety, and depression. We document the forms of exercise used for the post-acute management of mTBI, highlight the knowledge gaps, and provide future research directions.


We recommend trialing a new approach that utilizes a graduated program of individually prescribed combined aerobic resistance exercises (CARE) if mTBI symptoms persist. This program has the potential to improve patient outcomes and add to the management options for providers.


Head trauma Concussion Mild traumatic brain injury Exercise Treatment Rehabilitation 


Funding Information

This publication was produced without a direct external funding source. Further development of the exercise program is supported by a research grant from the Royal Brisbane and Women’s Hospital Foundation and the Queensland University of Technology. Grant Iverson acknowledges unrestricted philanthropic support from the Mooney-Reed Charitable Foundation.

Compliance with Ethical Standards

Conflict of Interest

Karen Sullivan and Andrew Hills each declare no potential conflicts of interest. Grant Iverson has a clinical and consulting practice in forensic neuropsychology involving individuals who have sustained mild TBIs. He has received research funding from several test publishing companies, including ImPACT Applications, Inc., CNS Vital Signs, and Psychological Assessment Resources (PAR, Inc.). He has received salary support from the Harvard Integrated Program to Protect and Improve the Health of National Football League Players Association Members. He acknowledges unrestricted philanthropic support from the Mooney-Reed Charitable Foundation and ImPACT Applications, Inc.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

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Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Karen A. Sullivan
    • 1
    • 2
    • 3
    Email author
  • Andrew P. Hills
    • 4
  • Grant L. Iverson
    • 5
    • 6
    • 7
    • 8
  1. 1.School of Psychology and CounsellingQueensland University of TechnologyBrisbaneAustralia
  2. 2.Institute of Health and Biomedical InnovationQueensland University of TechnologyBrisbaneAustralia
  3. 3.O Block B Wing, Kelvin Grove Campus, Queensland University of TechnologyKelvin GroveAustralia
  4. 4.College of Health and MedicineUniversity of TasmaniaLauncestonAustralia
  5. 5.Department of Physical Medicine and RehabilitationHarvard Medical SchoolBostonUSA
  6. 6.Spaulding Rehabilitation HospitalBostonUSA
  7. 7.MassGeneral Hospital for Children™ Sport Concussion ProgramBostonUSA
  8. 8.Home Base, A Red Sox Foundation and Massachusetts General Hospital ProgramBostonUSA

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