Concussion - To rest, or to exercise, that is the question.
Hibernating after concussion… could delay your recovery.
After a concussion, most people assume the following are mandatory:
No exercise
No school/work
No screens
Just sit in a quiet and dark bedroom, wear sunglasses, and hermit until you miraculously recover.
We’re finding that 24-48hrs is about all you really need.
When I say “we,” I’m saying that the leading consensus statement on concussion care suggests this based on conclusions made from interpreting lots of research:
“There is currently insufficient evidence that prescribing complete rest achieves these objectives. After a brief period of rest during the acute phase (24–48hours) after injury, patients can be encouraged to become gradually and progressively more active while staying below their cognitive and physical symptom-exacerbation thresholds (ie, activity level should not bring on or worsen their symptoms). It is reasonable for athletes to avoid vigorous exertion while they are recovering. The exact amount and duration of rest is not yet well defined in the literature and requires further study.” - Berlin Consensus 2016
The goal is to find YOUR unique sweet spot for activity.
If you read that whole quote, you’ll notice that your activity should stay below symptom-exacerbation thresholds. This means that if an activity (mental or physical) makes your symptoms worse, then we should probably pull back a bit and stick to lighter or easier activities.
The goal is a “graded” or “progressive” reintroduction of exercises and rehabilitation exercises. By doing this, we see that you recover faster and, thus, get to return to your sport or life faster.
Here’s a simple analogy… Let’s break your arm.
When you break your arm, medicine sets and casts your arm to allow the bone to heal. During this time, though, your muscles are not being used and are atrophying (“shrinking”). Additionally, the maps of your arm in your brain are also shrinking. So, if you want your arm to function back at full strength you need to rehab it. You may need some soft-tissue mobilization, some resistance training, some coordination and mobility drills, and some sport-specific rehab if you’re an athlete.
We would find it absolutely silly to think that we could cast an arm for 6-12 weeks and then go use our arm at full strength and capacity without any rehab… So, why do we think this is the best approach for our brains after a concussion?
Why it’s not all about rest.
The evidence favors “sub-symptom threshold aerobic exercise” over ‘rest/cocoon therapy” in concussion recovery. This is because the longer you cocoon and rest, the longer you can expect your recovery to take. Below is just one of image from one reference used for the making of this blog post. This was a 2019 JAMA study that made pretty exciting waves in the concussion world.
For those of you wanting the jargon and details, be sure to check out the references at the end of the article.
How can you find your physical activity “sweet spot?”
In-office we can perform something called the Buffalo Concussion Treadmill Test (BCTT). This is a test where we have you walk on the treadmill and then slowly increase the incline over time to see if and/or when your concussion symptoms start to get worse.
Generally speaking, we can say that it is at that intensity (heart rate) where your “symptom threshold” exists. For rehab, we have you exercise at a steady 70-80% of that heart rate for 20-30min each day, and then re-test. And so the cycle goes until you can perform at your maximal intensity without symptoms.
One of my teachers and mentors in the neurology world had a beautifully practical way for you to approach exercise from home, during the quarantine. You can view that Instagram post here.
What does this look like over time?
Your doctor should be getting your BCTT (or another form of autonomic testing) within the first week after your concussion.
If your doctor has not performed a treadmill test (or another form of autonomic testing) EARLY in your management, find a new doctor.
From here, you will re-up your results weekly based on your unique exercise tolerance. The goal is that you should be able to increase exercise intensity weekly until (often sooner than you’d predict) you can complete the entire BCTT to full exertion or without symptoms flaring up. Pretty cool stuff when that happens!
At this point things differ for athletes and non-athletes:
Athletes are not off the hook. Passing the BCTT simply means you are now ready for non-contact practice and non-contact sport-specific training. As you progress through this, you will move onto more high-intensity training, then another high-intensity cardio test… then if you pass through all of that you get cleared to play. This can take up to 21-30 days.
Non-Athletes are cleared! Woo! If you’re simply returning to work or school, or a sport without high cardiovascular demand (e.g., baseball, snowboarding, etc...), then you are free to go.
But wait, there’s more!
Concussion rehab is not only steady-state cardio.
A complete concussion rehab protocol will address the autonomic/physiologic (“blood flow”) piece of concussion through exercise AND:
Will address any metabolic or hormonal issues
Will address any visual or vestibular issues
Will address any cervical spine or musculoskeletal issues
Will help you to build a resilient and winning mindset throughout your recovery and beyond
Dr. Mark Heisig is a licensed naturopathic doctor with continuing mTBI education from The American Academy of Neurology (AAN), Complete Concussion. Management (CCMI) and The Carrick Institute. His office is located in Scottsdale, AZ.
References (some of these overlap in meta-analysis):
Banks, R. E., & Salvatore, A. P. (2019, February). Concussions: activity avoidance and rest recommendation. In Seminars in speech and language (Vol. 40, No. 01, pp. 027-035). Thieme Medical Publishers.
Chan, C., Iverson, G. L., Purtzki, J., Wong, K., Kwan, V., Gagnon, I., & Silverberg, N. D. (2018). Safety of active rehabilitation for persistent symptoms after pediatric sport-related concussion: a randomized controlled trial. Archives of physical medicine and rehabilitation, 99(2), 242-249.
Kurowski, B. G., Hugentobler, J., Quatman-Yates, C., Taylor, J., Gubanich, P. J., Altaye, M., & Wade, S. L. (2017). Aerobic exercise for adolescents with prolonged symptoms after mild traumatic brain injury: an exploratory randomized clinical trial. The Journal of head trauma rehabilitation, 32(2), 79.
Leddy, J., Hinds, A. L., Miecznikowski, J., Darling, S., Matuszak, J., Baker, J. G., ... & Willer, B. (2018). Safety and prognostic utility of provocative exercise testing in acutely concussed adolescents: a randomized trial. Clinical journal of sport medicine: official journal of the Canadian Academy of Sport Medicine, 28(1), 13.
Leddy, J. J., Haider, M. N., Hinds, A. L., Darling, S., & Willer, B. S. (2019). A preliminary study of the effect of early aerobic exercise treatment for sport-related concussion in males. Clinical journal of sport medicine, 29(5), 353-360.
Leddy, J. J., Haider, M. N., Ellis, M. J., Mannix, R., Darling, S. R., Freitas, M. S., ... & Willer, B. (2019). Early subthreshold aerobic exercise for sport-related concussion: a randomized clinical trial. JAMA pediatrics, 173(4), 319-325.
Leddy, J. J., Wilber, C. G., & Willer, B. S. (2018). Active recovery from concussion. Current opinion in neurology, 31(6), 681-686.
McCrory, P., Meeuwisse, W., Dvorak, J., Aubry, M., Bailes, J., Broglio, S., ... & Davis, G. A. (2017). Consensus statement on concussion in sport—the 5th international conference on concussion in sport held in Berlin, October 2016. British journal of sports medicine, 51(11), 838-847.
Neary, J. P., Dudé, C. M., Singh, J., Len, T. K., & Bhambhani, Y. N. (2020). Pre-frontal cortex oxygenation changes during aerobic exercise in elite athletes experiencing sport-related concussion. Frontiers in Human Neuroscience, 14, 35.
Sawyer, Q., Vesci, B., & McLeod, T. C. V. (2016). Physical activity and intermittent postconcussion symptoms after a period of symptom-limited physical and cognitive rest. Journal of athletic training, 51(9), 739-742.
Schneider, K. J., Leddy, J. J., Guskiewicz, K. M., Seifert, T., McCrea, M., Silverberg, N. D., ... & Makdissi, M. (2017). Rest and treatment/rehabilitation following sport-related concussion: a systematic review. Br J Sports Med, 51(12), 930-934.
Teel, E. F., Register-Mihalik, J. K., Appelbaum, L. G., Battaglini, C. L., Carneiro, K. A., Guskiewicz, K. M., ... & Mihalik, J. P. (2018). Randomized Controlled Trial Evaluating Aerobic Training and Common Sport-Related Concussion Outcomes in Healthy Participants. Journal of athletic training, 53(12), 1156-1165.
Thomas, D. G., Apps, J. N., Hoffmann, R. G., McCrea, M., & Hammeke, T. (2015). Benefits of strict rest after acute concussion: a randomized controlled trial. Pediatrics, 135(2), 213-223.
Willer, B. S., Haider, M. N., Bezherano, I., Wilber, C. G., Mannix, R., Kozlowski, K., & Leddy, J. J. (2019). Comparison of Rest to Aerobic Exercise and Placebo-like Treatment of Acute Sport-Related Concussion in Male and Female Adolescents. Archives of physical medicine and rehabilitation, 100(12), 2267-2275