Discriminant and Prognostic Validity of the Multimodal Exertional Test (MET) for Athletes with Concussion
7 affiliations
- 1Centre for Sport-Related Concussion Research, Innovation, and Knowledge, University of Toronto, 100 Devonshire Pl., Toronto, ON M5S 2C9 Canada
- 2Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, ON Canada
- 3Defence Research and Development Canada, Toronto Research Centre, Toronto, ON Canada
- 4Department of Occupational Science and Occupational Therapy, University of Toronto, Toronto, ON Canada
- 5Rehabilitation Sciences Institute, University of Toronto, Toronto, ON Canada
- 6Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, ON Canada
- 7Tanenbaum Institute for Science in Sport, Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, ON Canada
Abstract
Background: Exertional tests have become an informative tool to assist with clinical concussion management and return-to-sport medical decisions. However, current tests are resource intensive and thus, we developed a widely accessible, multimodal exertional test (MET). The objectives of this study were: (1) To evaluate the discriminant validity of the MET by examining sex-stratified differences in symptoms, heart rate (HR), and performance metrics between concussed and healthy athletes; and (2) To assess the predictive (prognostic) validity of the MET by determining whether week 1 MET performance predicts time to medical clearance.
Methods: This study was conducted at a single academic institution and affiliated sport medicine clinic in Toronto, Canada, with participants recruited between August 2022 and November 2024. 115 interuniversity athletes (female n=49, male n=66) completed the MET at off-season and 55 interuniversity athletes with concussion (female n=37, male n=18) completed the MET up to six times at 1-, 2-, 3-, 4-, 6-, and 8-weeks post-injury. Average and maximum HR, symptoms, performance metrics, and MET pass/fail status were measured prior to and during the protocol. Probabilistic hierarchical models were implemented to estimate differences between concussion and healthy athletes (discriminant validity) and negative binomial analyses were used to examine whether MET performance predicted time to medical clearance (predictive validity).
Results: At 1-week post injury, concussed athletes exhibited greater symptom provocation during the MET compared to healthy athletes, with differences after each task. MET failure rates were highest during weeks 1 (63%) and 2 (49%) and declined through week 8. Athletes who passed the MET at week 1 recovered 20.6 days faster (90% Credible Interval [CrI] = 4.9–36.8 days, posterior probability [pprob] > 0 = 97.7%) than those who failed.
Conclusion: The MET demonstrates discriminant validity by eliciting greater symptom provocation in athletes with concussion compared to healthy athletes. Improvements in symptoms and completion rates over 8 weeks indicate recovery-related gains in exertional tolerance. The MET also demonstrates predictive validity, as passing the test at week 1 was associated with faster time to medical clearance, supporting its potential utility as an early prognostic tool in concussion management.
Supplementary Information: The online version contains supplementary material available at https://doi.org/10.1186/s40798-026-01135-5.
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BibTeX
@article{pyndiura2026discriminant,
title = {{Discriminant and Prognostic Validity of the Multimodal Exertional Test (MET) for Athletes with Concussion}},
author = {Kyla L. Pyndiura and Alex P. Di Battista and Doug Richards and Nick Reed and David W. Lawrence and Michael G. Hutchison},
journal = {Sports Medicine - Open},
year = {2026},
month = nov,
doi = {10.1186/s40798-026-01135-5},
url = {https://doi.org/10.1186/s40798-026-01135-5},
note = {CC BY-NC-ND 4.0},
}
RIS
TY - JOUR
TI - Discriminant and Prognostic Validity of the Multimodal Exertional Test (MET) for Athletes with Concussion
AU - Kyla L. Pyndiura
AU - Alex P. Di Battista
AU - Doug Richards
AU - Nick Reed
AU - David W. Lawrence
AU - Michael G. Hutchison
PY - 2026
DA - 2026/11/03
JO - Sports Medicine - Open
DO - 10.1186/s40798-026-01135-5
UR - https://doi.org/10.1186/s40798-026-01135-5
AB - Background: Exertional tests have become an informative tool to assist with clinical concussion management and return-to-sport medical decisions. However, current tests are resource intensive and thus, we developed a widely accessible, multimodal exertional test (MET). The objectives of this study were: (1) To evaluate the discriminant validity of the MET by examining sex-stratified differences in symptoms, heart rate (HR), and performance metrics between concussed and healthy athletes; and (2) To assess the predictive (prognostic) validity of the MET by determining whether week 1 MET performance predicts time to medical clearance. Methods: This study was conducted at a single academic institution and affiliated sport medicine clinic in Toronto, Canada, with participants recruited between August 2022 and November 2024. 115 interuniversity athletes (female n=49, male n=66) completed the MET at off-season and 55 interuniversity athletes with concussion (female n=37, male n=18) completed the MET up to six times at 1-, 2-, 3-, 4-, 6-, and 8-weeks post-injury. Average and maximum HR, symptoms, performance metrics, and MET pass/fail status were measured prior to and during the protocol. Probabilistic hierarchical models were implemented to estimate differences between concussion and healthy athletes (discriminant validity) and negative binomial analyses were used to examine whether MET performance predicted time to medical clearance (predictive validity). Results: At 1-week post injury, concussed athletes exhibited greater symptom provocation during the MET compared to healthy athletes, with differences after each task. MET failure rates were highest during weeks 1 (63%) and 2 (49%) and declined through week 8. Athletes who passed the MET at week 1 recovered 20.6 days faster (90% Credible Interval [CrI] = 4.9–36.8 days, posterior probability [pprob] > 0 = 97.7%) than those who failed. Conclusion: The MET demonstrates discriminant validity by eliciting greater symptom provocation in athletes with concussion compared to healthy athletes. Improvements in symptoms and completion rates over 8 weeks indicate recovery-related gains in exertional tolerance. The MET also demonstrates predictive validity, as passing the test at week 1 was associated with faster time to medical clearance, supporting its potential utility as an early prognostic tool in concussion management. Supplementary Information: The online version contains supplementary material available at https://doi.org/10.1186/s40798-026-01135-5.
SN - 2199-1170
SN - 2198-9761
ER -