Every year, at least 3.8 million concussions occur in the United States, at least one million of which cause mild brain injuries [1, 2]. Returning to exercise after a concussion is an important part of the recovery process. Exercise is not only valuable because it prevents various diseases and enhances cognitive performance, but also because, in the absence of physical stimulus, people can quickly become physically deconditioned and experience reactive depression [3, 4]. The issue, however, is that returning to exercise could aggravate concussion symptoms and hinder recovery. As a result, medical practitioners have to be careful when considering when to advise patients to restart exercise, what kind of exercise patients should engage in, and what precautions they should take to avoid harm.
Practitioners have traditionally advised concussion patients to take a few days of rest before returning to exercise after their injury [4]. However, recent research has encouraged medical professionals to deviate from this recommendation. Leddy and colleagues reported in 2016 that “prolonged rest beyond the first couple of days after a concussion might hinder rather than aid recovery” [4]. Similarly, Hutchinson et al. found that patients could safely resume an aerobic exercise protocol a week after experiencing a sport-related concussion [5].
After the initial return to exercise, research and guidelines suggest that patients should progressively increase the intensity of their workout regimes over time. Baker et al. noted how previous research demonstrated the benefits of progressive exercise programs “controlled quantitatively” for patients with postconcussion syndrome (PCS) [6]. The researchers subsequently conducted their own study, wherein PCS patients were offered two types of progressive exercise rehabilitation, either a graded exercise treadmill test or the freedom to exercise to capacity [6]. These results demonstrated an association between participating in the progressive rehabilitation program and returning to full functioning, suggesting the advantages of this type of regimen [6].
In line with this finding, the CDC recommends a six-step program for young concussed athletes to return to exercise [7]. The first step involves recommencing regular activities and then partaking in light-to-moderate exercise, like walking or riding a stationary bike, so long as such activities do not aggravate symptoms [7]. From there, the steps progress from five to ten minutes of light aerobic exercise; moderate activities (such as jogging, brief running, or moderate-intensity weightlifting); heavy, non-contact activities (i.e. regular weightlifting or certain sport-specific drills); practice and full contact; and, finally, competition [7]. Patients should only move from one step to the next if they do not experience any symptoms after partaking in that form of exercise [7]. If symptoms occur, patients are pushing themselves too hard; they should stop exercising and consult with their provider [7].
To avoid developing persistent post-concussion symptoms (defined as symptoms persisting at least a month after the initial injury), patients should resume exercise as soon as their bodies can handle it [8]. Although the aforementioned studies suggest that patients may be able to begin light exercise within a few days of injury, the ideal amount and form of exercise appropriate post-concussion depend on the patient and the severity of the injury. Medical professionals should design post-concussion exercise routines in accordance with each person’s unique profile in mind and incorporate multiple check-ins throughout to ensure that symptoms do not worsen.
References
[1] UT Health San Antonio, “Concussions: Symptoms, Treatment and What You Need to Know,” Updated March 1, 2022. [Online]. Available: https://www.uthscsa.edu/patient-care/physicians/news-item/concussions-symptoms-treatment-and-what-you-need-know.
[2] P. J. Skerrett, “New Concussion Guidelines Day ‘When in Doubt, Sit It Out’,” Harvard Health Publishing, Updated March 18, 2013. [Online]. Available: https://www.health.harvard.edu/blog/new-concussion-guidelines-say-when-in-doubt-sit-it-out-201303185994.
[3] G. S. Griesbach, “Exercise After Traumatic Brain Injury: Is it a Double-Edged Sword?,” PM&R, vol. 3, no. 6, pp. S64-S72, June 2011. [Online]. Available: https://doi.org/10.1016/j.pmrj.2011.02.008.
[4] J. Leddy et al., “The Role of Controlled Exercise in Concussion Management,” PM&R, vol. 8, no. 3, pp. S91-S100, March 2016. [Online]. Available: https://doi.org/10.1016/j.pmrj.2015.10.017.
[5] M. G. Hutchinson et al., “Randomized controlled trial of early aerobic exercise following sport-related concussion: Progressive percentage of age-predicted maximal heart rate versus usual care,” PLoS One, vol. 17, no. 12, pp. 1-16, December 2022. [Online]. Available: https://doi.org/10.1371/journal.pone.0276336.
[6] J. G. Baker et al., “Return to Full Functioning after Graded Exercise Assessment and Progressive Exercise Treatment of Postconcussion Syndrome,” Rehabilitation Research and Practice, vol. 2012, pp. 1-7, January 2012. [Online]. Available: https://doi.org/10.1155/2012/705309.
[7] CDC, “Returning to Sports and Activities,” Updated February 12, 2019. [Online]. Available: https://www.cdc.gov/headsup/basics/return_to_sports.html.
[8] J. Leddy et al., “Exercise is Medicine for Concussion,” PM&R, vol. 1, no. 3, pp. 262-270, August 2019. [Online]. Available: https://doi.org/10.1249%2FJSR.0000000000000505.