Table 5.

Concussion Activity-Exertion Management: Progressive Activities of Controlled Exertion (PACE)

Stage	Treatment Component	Description
Set the Positive Foundation	1. Establish a positive, active problem-solving context	Provide the student, family, and school with a psychologically positive, active problem-solving context for rehabilitation. Framing the injury and its recovery in a positive, constructive, reassuring manner is critical.
	2. Assess and manage emotional response to injury	Explore the emotional response of the child and family to the injury. Assess how it has disrupted their lives. Ask what stresses or demands they are facing (school, peer, athletics).
	3. Developmentally appropriate education about mTBI and its effects	Provide developmentally appropriate education regarding the dynamics of mTBI (i.e., software injury, energy deficit), and the relationship between the student’s level of activity and symptom exacerbation (exertional effects). Review the sources of exertion: physical, cognitive, emotional – and the need to manage these energy demands.
Define the Parameters of Activity-Exertion	4a. Define daily schedule 4b. Define type, intensity & duration of cognitive & physical activities and their exertional effects	a. Define the student’s typical daily schedule (before, during, after school, weekends), b. Define times of the day when activities present the greatest exertional challenges (“hot spots”) and lesser challenges (“cool spots”). Identify the type, intensity and duration of cognitive and physical activities within the daily schedule.
	5. Define tolerability for activity intensity and duration	Define limits of tolerability for activity intensity/duration. Identify when symptoms do not increase substantially. This should be done for each key class. Sample question: “How long can you typically go in your classes before you notice your symptoms worsening and affecting your learning?” Use time/intensity limits to schedule “work-rest” breaks.
Teach Activity-Exertion Monitoring Skills	6. Teach “Not too little, not too much” concept	Teach the concept of moderated activity - engaging in “Not too little, but not too much” activity. The student’s goal is to find the activity “sweet spot” where activity time and effort are maximized without symptoms worsening.
	7. Teach “reasonable” symptom monitoring	Teach “reasonable” symptom monitoring and recording. Be aware of child or parent that isoverly anxious or oblivious. Coach them to monitor symptoms reasonably.
	8. Teach working to tolerable limits – using a work-rest-work-rest approach	Instruct the student to work up to their symptom limits, but to not exceed them, by being aware of (i.e., reasonable monitoring) their symptoms. Emphasize tolerance of a mild increase in symptoms, but not excessive increase.
Reinforce Progress	9. Recovery is dynamic; activity-exertion management will reduce symptoms	Instruct that the recovery process is dynamic, controlled activity-exertion management will feel better, and symptoms will decrease. Highlight examples of resolving symptoms as evidence of progress toward recovery.
	10. Gradual increase activity time/intensity.	As symptoms reduced with greater tolerance for activity, gradually increase the time/intensity of activity. The “sweet spot” of activity-exertion will move closer to their norm.