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Physiothérapie Avantex / concussion  / Graded Exercise Therapy for Concussion and Persistent Symptoms

Graded Exercise Therapy for Concussion and Persistent Symptoms

Over the last 20 years, recommendations for how to heal from a concussion have changed enormously. 20 years ago, when someone had a concussion, we used to recommend what is called “cocoon therapy”. Basically, it was recommended to stay in bed, in the dark, until you felt better. But, what happened if you never felt better? Or if lying in the dark for days, weeks or months actually made you feel worse? Thankfully, research over the past 20 years has shown us that this approach was completely wrong, and recommendations for early care have changed significantly. In this article today, we will review what the recommendations are for managing a concussion in the first few days, as well as discuss at what time point it is safe and beneficial to start aerobic exercise.


Initial Symptoms – What is Happening in the Brain?


Immediately after a concussion, symptoms that are often reported are headache, dizziness, fatigue, brain fog, and a feeling of slowness. Why are these complaints features of concussion? When a concussion happens, there can be a change in blood flow and ion transport in the brain. This can lead to something commonly referred to as an ‘energy crisis’ in the brain. It has also been theorized that changes in nervous system functioning following concussion can account for some of the symptoms listed above. There is also evidence that changes in blood flow to the brain, caused by increased sensitivity to blood CO2 levels is responsible for the exercise intolerance that we see in concussion. So, what can help to normalize brain and nervous system function after a concussion? Aerobic exercise!


Aerobic Exercise – When to start?

Initial recommendations for early concussion care are to rest for 24-48 hours, then to gradually restart normal activities. After that initial 24-48 hours of rest, it is safe to start gentle exercise like walking outside. It is important to avoid ANY activity that might cause a second concussion, as well as any activity that causes an increase in symptoms. At this point in time, what we’re aiming for is “symptom-limited activity”, basically you can start getting back to your usual routine, as long as your symptoms don’t worsen.


When can you start exercising?


Research has shown us that it is safe to start exercising early after concussion, there are even some research groups looking into starting aerobic exercise day 1 and 2 after a concussion. Is this the right approach for everyone? Probably not. We do know that it is safe to start symptom-limited aerobic exercise early, within the first few days, especially if your initial symptoms resolve early on. 


The current consensus guidelines state that we can start exercise as early as 3 or 4 days after injury if symptoms are improving. What does that mean? Does it mean going to the gym and lifting the heaviest weights possible? Does it mean going to the track and doing wind sprints? Does it mean getting on the ice for a hockey practice? NO!


What we normally recommend starting with first off is an exertion test to measure what level of intensity your body can tolerate at this point in time. Once that has been established, we recommend starting with some simple cardio like walking, easy jogging or stationary biking, depending on what you can tolerate, what equipment you have access to, and what you like doing. As the days and weeks go by, it is recommended to gradually increase the intensity of your workouts little by little. In this way, your body adapts and gets stronger and can eventually tolerate tougher and tougher workouts. 


We can also reassess exertion levels from time to time to make sure that you are always working at the maximum level that is safe for you, and that you are progressing as quickly as is safe for you.


How does aerobic exercise help US heal?


As we mentioned earlier, there are changes in cerebral blood flow and blood CO2 sensitivity following concussion. Research has shown us that gradual, progressive aerobic exercise helps to normalize cerebral blood flow, improve CO2 sensitivity and reduce concussion symptoms during exercise. What does this mean? Exercising at an appropriate level for you helps to normalize blood flow to the brain, improve the body’s physiological response to exercise and overall help you be able to tolerate higher and higher levels of exertion, until you’re back to normal.


The beauty of graded exercise therapy as treatment for concussion is that we can start it at any point during the recovery process. It can be helpful in the acute phase, in the days following concussion, but we know that it can also have very good benefits in cases where symptoms are prolonged. Even if you have been suffering from prolonged symptoms many weeks or months after injury, graded exercise therapy can still help you get better.


Next steps in the return to play protocol: sports!


One of the questions that I get asked very very often is “When can I go back to practice?”. According to the Consensus Guidelines, returning to sport should happen AFTER you can tolerate a normal level of aerobic exercise. What is very important is avoiding any activity that can cause a second concussion while you are still recovering. Before getting back to sport, we need to be sure that your body can tolerate multi-directional movements, and all the skills and coordination that your sport requires. This is why we work through a stepwise return to sport protocol that includes light practices, full contact practices and eventually games and competitions.


How to get started?


Not sure how to get started with exercise after a concussion? See a trained physiotherapist today. They can assess your exercise tolerance and prescribe an appropriate exercise plan. This will help you heal your concussion and get back to normal!

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