New Exertional Test Flags Concussion Recovery Early in University Athletes

A simple exertional test that requires no treadmill, no stationary bike, and no specialized laboratory equipment may help clinicians gauge how far along an athlete is in recovering from a sport-related concussion, according to a prospective observational cohort study conducted at a single academic institution and its affiliated sport medicine clinic in Toronto, Canada. The study, published in Sports Medicine – Open, evaluated a protocol called the Multimodal Exertional Test, or MET, in 115 healthy interuniversity athletes and 55 interuniversity athletes diagnosed with a concussion. The findings suggest that the test can distinguish concussed athletes from healthy ones through symptom provocation during exertion, and that performance on the test in the first week after injury may carry preliminary prognostic information about recovery length.

The MET was developed to address practical limitations of existing exertional tests used in concussion care. The Buffalo Concussion Treadmill Test and its bike analogue have been widely adopted to guide rehabilitation and inform readiness to return to sport, but both lack head acceleration and sport-specific movements. Other protocols that add aerobic and plyometric or dynamic components have proven effective at identifying symptom provocation in individuals who were asymptomatic at rest, yet they may not be feasible for all clinical settings because they require specialized equipment such as a treadmill or stationary bike, or substantial space for administration. The MET, by contrast, is a four-stage, twelve-task test that progresses in complexity by adding a new component at each stage: cardiovascular load, then head acceleration, then cognitive tasks, and finally elements of coordination and multi-plane movements. Stages 1 through 3 consist of squats, lunges, and hip hinges, performed first at a prescribed number of repetitions, then as quickly as possible, and then with a concurrent cognitive task. Stage 4 consists of step-downs with a choice lateral jump, jump-overs, and jump-overs combined with a delayed-recall task.

The researchers recruited participants between August 2022 and November 2024. The healthy athletes completed the MET once during the off-season, while the concussed athletes completed it up to six times, at 1, 2, 3, 4, 6, and 8 weeks post-injury. Concussion diagnoses were made by a physician specializing in sport and exercise medicine at the university’s sport medicine clinic, in accordance with the Concussion in Sport Group definition. Before the test and after each task, athletes completed a 27-item symptom evaluation built on the 22 symptoms of the SCAT-5 and SCAT-6 symptom scales plus five additional symptoms related to sleep, ringing in the ears, and numbness and tingling. Each symptom was ranked on a 7-point Likert scale, and a total symptom severity score out of 162 was calculated. Athletes wore a chest strap heart rate monitor throughout the assessment, and average and maximum heart rates were recorded before the test and during each stage.

A pass on the MET meant successful completion of all 12 tasks. A failure, which triggered automatic termination of the test, could occur in three situations: a symptom severity score more than 10 points above the athlete’s initial score, the athlete stopping the test, or the examiner stopping the test because of visible signs such as instability or loss of balance, leaning or holding a wall, indicating light-headedness, or holding the head. The researchers noted that the 10-point threshold was selected to account for expected variability in symptom reporting in the absence of an established clinically meaningful cut-point, while providing a conservative safety margin to limit excessive symptom exacerbation, and was intended as an initial operational criterion to support safe test administration and inform future refinement of clinically relevant cut-points.

The discriminant results were clearest in the symptom data. At 1 week post-injury, the concussed group reported consistently higher symptom severity scores across all MET tasks compared with the healthy group. Modelled initial symptom severity scores in the concussion group at week 1 were an estimated 13 in both females and males, and scores increased through the protocol, peaking at an estimated average of 18 in females during the first jump-overs task of Stage 4 and 16 in males during the Stage 3 hip hinges combined with a verbal fluency task. The smallest modelled differences between concussed and healthy athletes at week 1 were 7 points in females and 8 points in males, and the greatest were 11 points in females and 12 points in males, all with 100% posterior probability that the difference was greater than zero. By week 2, the symptom severity scores of the two groups were aligned, and during weeks 3 through 8 the concussion group actually had lower symptom severity scores than the healthy group.

Failure rates told a similar story of gradually returning exertional tolerance. All 115 healthy athletes successfully completed all 12 tasks of the test. Among athletes with concussion, failure rates were 63.4% at week 1, 48.7% at week 2, 22.6% at week 3, 13.9% at week 4, 3.6% at week 6, and 3.8% at week 8. Across the 59 failure instances, 25 were due to symptom exacerbation, 21 were self-imposed stoppages, and 13 occurred when the examiner stopped the protocol because the athlete was exhibiting visible signs, most often instability or loss of balance. The authors also noted that at each time point several concussed athletes could not complete the test because of a musculoskeletal injury rather than their concussion.

Heart rate and performance measures painted a more nuanced picture. Heart rate was available for 86.1% of healthy athletes at baseline and for 95.5% of concussed athletes at week 1, with complete coverage during weeks 2 through 8. Following the test, athletes displayed progressive increases in heart rate on average compared with pre-test values, and the authors reported that comparable heart rate responses between healthy and concussed athletes indicate the MET provides a consistent physiological stimulus, allowing symptom and performance differences rather than variations in cardiorespiratory strain to reflect recovery status. For all performance metrics at week 1 post-injury, no differences were identified between the two groups, though the authors caution that the week 1 performance dataset represents only the subset of concussed athletes able to complete each task, potentially a self-selected group of higher-functioning individuals. From weeks 2 through 8, a consistent pattern emerged in which concussed athletes completed Stage 1 and Stage 3 tasks faster than their healthy counterparts and reported between 2 and 4 additional words on a verbal learning test, a pattern the authors attribute at least partly to task familiarity from repeated testing.

The prognostic analysis focused on whether week 1 performance predicted time to medical clearance, which required successful completion of a return-to-sport strategy aligned with Concussion in Sport Group guidelines, resolution of concussion-related symptoms, and return to baseline or normative performance on computerized neurocognitive testing. Of the 55 concussion cases, 45 completed a week 1 assessment; 4 were excluded because a musculoskeletal injury prevented test completion, and 5 cases without medical clearance dates were censored, leaving 41 cases in the final analysis. Among the 36 cases with a documented clearance date, the median recovery duration was 30.5 days. The modelled recovery time was an estimated 30.8 days for athletes who passed the MET at week 1, compared with 51.4 days for those who failed, a difference of 20.6 days with a 97.7% posterior probability that recovery was longer in the fail group. By 4 weeks post-injury, an estimated 60.0% of the pass group had been medically cleared, compared with 31.2% of the fail group.

The authors emphasized that this prognostic finding is preliminary. Given the modest cohort size and the staged, gated nature of the assessments, they wrote that the results should be interpreted cautiously and require confirmation in larger prospective cohorts before the MET can be considered a clinical predictor of recovery duration. They also flagged several other limitations: some test failures involved examiner-initiated stoppage without independent verification, introducing subjective variance; the pass/fail threshold was operationally defined without established psychometric support; healthy athletes were tested only once while concussed athletes were assessed serially, introducing potential learning effects and seasonal variation in fitness; the concussion group was predominantly female and differed in prior concussion history from controls, factors that were not adjusted for; and the sample consisted entirely of interuniversity athletes, limiting generalizability to youth, adolescent, older, and recreational populations. Approximately 20% of concussed athletes did not complete the week 1 assessment, so the week 1 findings may not be fully generalizable to the broader population of athletes with acute concussion.

Even with those caveats, the study supports the MET as a feasible and accessible addition to concussion management. All healthy athletes passed the protocol, which the authors say confirms feasibility and suggests that failure reflects deviation from recovery, and at every post-injury time point a proportion of concussed athletes failed, indicating incomplete readiness to return to sport. Notably, two athletes who were nearing scheduled clearance failed the test due to symptom exacerbation and subsequently shared their concerns about returning to sport, which the authors cite as evidence of the value of integrating exertional testing into clearance evaluations. The statistical approach was fully Bayesian, with hierarchical models estimating differences between groups and negative binomial analyses examining whether test performance predicted recovery time, and the authors have made the accompanying code publicly available. Collectively, the findings support the discriminant validity of the MET for symptom responses early after injury and its potential utility as an early prognostic tool in sport-related concussion management.

Subject of Research: Validation of a multimodal exertional test for discriminating concussion status and predicting recovery time in university athletes

Article Title: Discriminant and Prognostic Validity of the Multimodal Exertional Test (MET) for Athletes with Concussion

Article References: Pyndiura, K. L., Di Battista, A. P., Richards, D., Reed, N., Lawrence, D. W., & Hutchison, M. G. (2026). Discriminant and Prognostic Validity of the Multimodal Exertional Test (MET) for Athletes with Concussion. Sports Medicine – Open, 12(1), Article 165. https://doi.org/10.1186/s40798-026-01135-5

Image Credits: AI Generated

DOI: 10.1186/s40798-026-01135-5

Keywords: concussion, exertional test, return to sport, athletes, symptom provocation, heart rate, prognosis, recovery time, sports medicine, Bayesian analysis, interuniversity athletes, medical clearance