Treating prolonged post-concussion symptoms in a pediatric patient with the simultaneous application of cognitive behavioral therapy and subthreshold exercise: A case study


Use a novel, simultaneously applied cognitive behavioral therapy (CBT) and subthreshold exercise treatment (STE) for a 14-year old patient with persistent post-concussion symptoms (PPCS) to facilitate a return to function in school/sport.


Patient sustained a mild TBI while playing basketball on October 29, 2016. Neurologic exam on July 7, 2017 was negative, but the patient reported PPCS, with a graded symptom checklist (GSC) score of 26. Primary symptoms were headache and anxiety in relation to cognitive and/or physical exertion. The patient attributed anxiety to anticipating the onset of symptoms after exercise.


The 6-week combined CBT/STE intervention included psychoeducation, cognitive restructuring, and relaxation training combined with the STE protocol. Supervised physical exertion exposure began with aerobic exercise on a stationary bike and progressed to sport-specific activity while the patient simultaneously engaged in CBT. Pre- and post-intervention data included physiologic measures (heart rate [HR] and power output [PO] on exercise bike), a subjective measure of exertion (Borg’s Rating of Perceived Exertion [RPE]), and psychological self-report questionnaires.


After 6 sessions, patient was able to engage in strenuous exercise with reduced symptom exacerbation as demonstrated by his ability to reach 175 bpm HR with 350 watts of PO with decreased reported symptoms, a significant improvement from the first session. The patient reported a decrease in anxiety and psychological distress as well as an increase in emotional and school functioning. Parent report indicated an increase in the patient’s overall health, social, and emotional functioning.


Engaging in a six-week combined CBT/STE protocol resulted in improvements in ability to tolerate physical exertion, decreases in psychological distress, and a return to function. This case study demonstrated the feasibility & positive impact of simultaneous, dual treatment model for PPCS in adolescents. It also highlighted the need to address the psychological distress that occurs in patients with PPCS.

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