Importance Research suggests that aerobic exercise improves recovery for youth with concussion; however, prior studies primarily focused on acute concussion and required multiple in-person visits. Objective To determine whether a virtually delivered aerobic exercise program improves recovery following concussion compared to a stretching control and examine potential moderators. Design, Setting, and Participants A randomized clinical trial was conducted from 2021 to 2025 comparing the Mobile Subthreshold Exercise Program (MSTEP) to a stretching control for 11- to 18-year-olds with concussion up to 1 year from injury. Participants were recruited from a variety of outpatient locations in 4 US states (Washington, Utah, Wisconsin, and Oregon). Recruitment and data collection occurred from March 2021 until October 2025, and data analysis occurred from November 2025 to April 2026. Interventions Youth randomized to MSTEP were provided activity trackers and an aerobic exercise program initiated at 60% of heart rate maximum. Exercise was advanced in intensity and duration over 6 weeks through weekly videoconferencing calls. Youth in the control group were given stretching exercises and similar weekly calls. Main Outcomes and Measures Primary outcomes included (1) concussive symptoms and (2) health-related quality of life (HRQoL). Secondary outcomes included sleep, depression, and anxiety. Moderation by sex, age, and time since injury was examined. Patients were followed up for 6 months. Results The sample included 210 participants, among whom 122 (58.1%) were female, mean (SD) age was 15.1 (2.2) years, and mean (SD) time since injury was 73.3 (63.3) days. Covariate-adjusted regression analysis showed significant improvement in concussive symptoms and HRQoL at all time points, with greater improvement in MSTEP compared to control at the 3-month time point for both concussive symptoms (β, -3.15; 95% CI, -6.05 to -0.25; adjusted P = .04) and HRQoL (β, 4.15; 95% CI, 0.64-7.66; adjusted P = .04). No significant differences by group were seen at 6 months. Nonlinear mixed-effects modeling with exponential decay showed significantly faster symptom recovery in MSTEP compared to control (difference in rates, -0.68; 95% CI, -2.22 to -0.04; P = .002). Secondary outcomes (sleep, depression, and anxiety) improved in all participants but were not different by group. Benefit of the intervention was only significant for individuals less than 3 months from injury (concussive symptoms: β, -4.44; 95% CI, -7.99 to -0.90; unadjusted P = .01; HRQoL: β, 6.64; 95% CI, 2.55-10.72; unadjusted P = .002). No evidence was found for moderation by other factors. Conclusions and Relevance Per the results of this randomized clinical trial, an aerobic exercise program improves speed of recovery following concussion for youth compared to stretching and can be delivered remotely. However, this type of program appears to be most beneficial for individuals with acute or subacute injury (<3 months since injury). Trial Registration ClinicalTrials.gov Identifier: NCT04688255.
This Viewpoint aims to help guide clinicians in supporting emerging adults through the transition to a Medicaid work requirement.
Importance Smartphone use has been associated with poor sleep, but existing evidence primarily relies on self-reported, cross-sectional data. Objective To examine within-person and between-person associations between passively sensed evening smartphone use and objectively measured sleep outcomes in adolescents. Design, Setting, and Participants This intensive longitudinal cohort study assessed passively sensed data from US youths in the Adolescent Brain Cognitive Development Study. Participants were Android users with at least 14 days of concurrent Effortless Assessment Research System application data and Fitbit-measured sleep. Data were collected between November 30, 2020, and February 5, 2024, and analyzed from February 2 to June 1, 2026. Analysis used within-between decomposition in multilevel models to separate within-person from between-person associations. Exposures Smartphone use after each hourly cutoff from 8 pm to midnight (cumulative) and within 5 to 30 minutes before sleep onset (proximal) were quantified. Main Outcomes and Measures Fitbit-derived sleep measures were assessed, including total sleep time (TST), onset, offset, and sustained and total wake after sleep onset (WASO). Results A total of 425 participants (mean [SD] age, 14.8 [1.1] years; 216 [50.8%] female) contributed 7591 person-nights of data. On nights when adolescents used their phones more than their own evening average (after 10 pm ), they slept a mean (SD) of 20.05 (49.42) minutes less and fell asleep a mean (SD) of approximately 64.73 (50.95) minutes later. Adjusting for covariates, within-person analyses revealed that each additional minute of smartphone use after 10 pm above a participant’s own average was associated with sleep onset that was 0.87 (95% CI, 0.84 to 0.90) minutes later, sleep offset that was 0.37 (95% CI, 0.33 to 0.41) minutes later, and a TST change of −0.43 (95% CI, −0.47 to −0.39) minutes (all P < .001). Estimates increased monotonically across cutoffs from 8 pm to midnight. Proximal use was associated with greater sustained WASO, largest in the final 5 minutes of use before sleep onset (0.74 [95% CI, 0.50 to 0.98] additional minutes of wakefulness; P < .001) and negligible when looking at the final 20 minutes of use before sleep onset. This association was concentrated in the first 30 minutes after sleep onset. Conclusions and Relevance This cohort study found that greater cumulative late-evening phone use was associated with later sleep onset, delayed sleep offset, and shorter TST. Smartphone use immediately before sleep onset was associated with greater WASO, primarily during the first 30 minutes after sleep onset. These findings suggest that reducing evening smartphone use, particularly after 10 pm and immediately before bedtime, may help improve sleep health in adolescents.
Importance Research suggests that aerobic exercise improves recovery for youth with concussion; however, prior studies primarily focused on acute concussion and required multiple in-person visits. Objective To determine whether a virtually delivered aerobic exercise program improves recovery following concussion compared to a stretching control and examine potential moderators. Design, Setting, and Participants A randomized clinical trial was conducted from 2021 to 2025 comparing the Mobile Subthreshold Exercise Program (MSTEP) to a stretching control for 11- to 18-year-olds with concussion up to 1 year from injury. Participants were recruited from a variety of outpatient locations in 4 US states (Washington, Utah, Wisconsin, and Oregon). Recruitment and data collection occurred from March 2021 until October 2025, and data analysis occurred from November 2025 to April 2026. Interventions Youth randomized to MSTEP were provided activity trackers and an aerobic exercise program initiated at 60% of heart rate maximum. Exercise was advanced in intensity and duration over 6 weeks through weekly videoconferencing calls. Youth in the control group were given stretching exercises and similar weekly calls. Main Outcomes and Measures Primary outcomes included (1) concussive symptoms and (2) health-related quality of life (HRQoL). Secondary outcomes included sleep, depression, and anxiety. Moderation by sex, age, and time since injury was examined. Patients were followed up for 6 months. Results The sample included 210 participants, among whom 122 (58.1%) were female, mean (SD) age was 15.1 (2.2) years, and mean (SD) time since injury was 73.3 (63.3) days. Covariate-adjusted regression analysis showed significant improvement in concussive symptoms and HRQoL at all time points, with greater improvement in MSTEP compared to control at the 3-month time point for both concussive symptoms (β, −3.15; 95% CI, −6.05 to −0.25; adjusted P = .04) and HRQoL (β, 4.15; 95% CI, 0.64-7.66; adjusted P = .04). No significant differences by group were seen at 6 months. Nonlinear mixed-effects modeling with exponential decay showed significantly faster symptom recovery in MSTEP compared to control (difference in rates, −0.68; 95% CI, −2.22 to −0.04; P = .002). Secondary outcomes (sleep, depression, and anxiety) improved in all participants but were not different by group. Benefit of the intervention was only significant for individuals less than 3 months from injury (concussive symptoms: β, −4.44; 95% CI, −7.99 to −0.90; unadjusted P = .01; HRQoL: β, 6.64; 95% CI, 2.55-10.72; unadjusted P = .002). No evidence was found for moderation by other factors. Conclusions and Relevance Per the results of this randomized clinical trial, an aerobic exercise program improves speed of recovery following concussion for youth compared to stretching and can be delivered remotely. However, this type of program appears to be most beneficial for individuals with acute or subacute injury (<3 months since injury). Trial Registration ClinicalTrials.gov Identifier: NCT04688255
