The Feasibility and Efficacy of a Virtual, Symptom-Guided Aerobic Exercise Intervention to Improve Cognition in Mild Traumatic Brain Injury: A Single-Blind Pilot Randomized Control Trial With an Active Comparator Group

BACKGROUND: Mild traumatic brain injury (mTBI) affects millions worldwide, with cognitive impairment substantially affecting daily functioning. Despite this burden, evidence-based nonpharmaceutical interventions remain lacking in clinical practice. Emerging evidence suggests aerobic exercise may improve post-mTBI cognition; however, the methodological limitations, particularly inadequate control groups, prevent definitive conclusions. OBJECTIVE: This pilot randomized controlled trial examined the feasibility and preliminary efficacy of a 12-week virtual exercise intervention for community-dwelling adults aged 18-55 years with mTBI within 1 year of injury. METHODS: Thirty-seven participants were randomized to either symptom-guided aerobic exercise or active balance control; both delivered virtually 3 times weekly for 30 minutes over 12 weeks. Primary outcomes assessed feasibility metrics; secondary outcomes examined cognitive function including Trail Making Test (TMT) Part A and Part B. RESULTS: Of enrolled participants, 75% completed the intervention with 94.2% session adherence and zero adverse events, demonstrating excellent feasibility and safety. The aerobic group demonstrated greater improvements in executive function compared with balance controls, with large effect sizes for TMT B-A difference scores in both postintervention comparisons (Hedges' g = 1.20, 95% CI [0.00-2.41]) and Group × Time interactions (Hedges' g = 1.38, 95% CI [0.27-2.49]). In addition, the aerobic group self-reported fewer sleep disturbances postintervention (g = 1.65, 95% CI [0.22-3.09]). CONCLUSION: These findings establish that virtual, supervised, symptom-guided exercise interventions are feasible and safe for mTBI populations, with preliminary evidence suggesting aerobic exercise specifically benefits cognitive flexibility and sleep quality after mTBI. A fully powered randomized controlled trial is warranted to confirm these effects.