Historically, physicians recommended that individuals who suffered a sports-related concussion should heal through complete rest in a dark room until all symptoms had disappeared. Neuroscience research now shows that progressive, targeted exercise ranks among the most effective treatments for a healing brain. In respecting the brain’s healing process, however, personal trainers and coaches typically need to completely overhaul a client’s workout protocol. In this article, we will explore the symptoms that follow a sports-related concussion and outline suggestions for why certain exercises work best when reacclimating the injured brain to active movement.
Grasping the Severity of a Concussion
Coaches and trainers who work with athletes in contact sports—soccer, football, boxing—have undoubtedly witnessed the following scenario: after receiving a physician’s clearance, a highly motivated client returns to the gym a few weeks after a concussion. As fitness professionals, our eagerness to pick up where the client left off seems reasonable. However, after several minutes of the client’s former regimen of squats, pull-ups, and weighted dips, the client’s skin pales, and the client complains of dizziness and a severe headache. This scenario suggests we may need to establish a safer return-to-exercise protocol.
First and foremost, trainers must appreciate the neuroscience behind a concussion, a term that implies a mild traumatic brain injury. All concussions, regardless of how they present, create an energy crisis in the brain: they disrupt the autonomic nervous system, alter vestibular function, and impair spatial awareness. As such, even though medical providers have cleared a client to return to exercise, they have really given the green light for sub-symptom threshold training rather than an immediate return to former high-intensity interval training or advanced aerobics.
The Theory of Graduated Exercise Therapy
In a research study centered on returning individuals who had suffered concussions to their previous exercise routines, Dr. John Leddy discovered that among pediatric patients, early aerobic exercise improved time to recovery, as compared to a strictly stretching-only protocol, following sport-related concussions. Patients who used aerobic exercise recovered in an average of 13 days, while patients in the stretching-only group recovered in an average of 17 days. Additionally, 50 out of 52 patients in the aerobic exercise treatment “had recovered by 30 days and therefore did not require additional medical therapies, which often involve substantial time and resources.”
A similar study conducted on post-concussion individuals of a wider range of ages found multiple mental health benefits from using aerobic exercise after a sports-related concussion. Some of the key improvements displayed by the patients included the following:
- increased synaptic plasticity in the brain (helps with learning and memory)
- increased production of a protein (brain-derived neurotrophic factors, BDNF) that aids in the survival of nerve cells
- increased cortical connectivity (helps with neuron firing in brain response)
The specific rehab protocol known as Graduated Exercise Therapy works by reintroducing physical activity in stages to reduce concussion symptoms. While most physicians prefer this protocol for patients working with trained post-concussion specialists, such as physical therapists, trainers can use these guidelines to create safe workout programs when their clients return to their usual training schedules.
One of the basic tenets of this therapy revolves around ensuring that the client’s symptom severity does not increase significantly, only reaching a mild “2 out of 10” increase in symptoms while exercising. In addition, what was once an hour-long training session may need to be abridged. If a client feels up to attempting a full hour, trainers should ensure any symptoms return to pre-workout levels within an hour of ending the session. If not, the following workout should require less strenuous movement.
“At all costs, personal trainers should avoid increasing a client’s risk of secondary injury, or what experts call “Second-Impact Syndrome.” If an individual should incur a second concussion before having fully recovered from the first, he runs a greater risk of the brain rapidly swelling. This catastrophic event creates tremendous pressure inside the skull. In rare cases, this pressure may compromise brainstem function, potentially leading to coma, permanent disability, and/or death.”
Gravity and Orthostatic Intolerance
A common pitfall in post-concussion programming stems from the fact that most personal trainers tend to forget about the effects of gravity on a post-concussive individual. Because the autonomic nervous system lags, sudden changes in body position can cause significant drops in blood pressure, which clients may experience as severe lightheadedness or a spike in symptoms. Instead of returning to a workout program that alternates between floor-based core work and standing high-intensity exercises, personal trainers might minimize level changes. Post-concussion clients can comfortably perform all standing exercises in one block, transition to all seated or half-kneeling exercises, and finish with all supine exercises toward the end of the session. Similarly, trainers might temporarily avoid exercises that require extreme head positions. Movements like Romanian deadlifts, bent-over rows, or a “downward dog” yoga pose place the head below the heart, which can increase intracranial pressure and lead to severe headaches.
Creating New Body-Brain Connections
As most fitness professionals progress in their careers, they begin to learn the subtleties of the brain-body connection. This experience takes on even more importance when working with a client recovering from any sports-related concussion.
Following a concussion, motor cortex excitability decreases. The brain’s sense of how the body moves in space gets slightly blurred, reducing force output and altering movement mechanics. To keep the client safe, we essentially bear the burden of rebuilding brain-body connections by intentionally slowing movements from their previous speeds. For example, instead of asking the client to execute Bulgarian split-squats at the usual down-up tempo, we suggest a 10-second hold at the bottom of the move. In so doing, the client experiences a high degree of central nervous system engagement at a very low cardiovascular cost. Similarly, designing workouts that include slow eccentrics helps re-map neuromuscular pathways.
Brain-Derived Neurotrophic Factor
Earlier, we mentioned BDNF, or brain-derived neurotrophic factor. This protein promotes the survival of nerve cells (neurons) by supporting their growth, differentiation, and maintenance. In the brain, BDNF activity occurs at synapses, where cells communicate. The synapses can change and adapt over time in response to experience, a phenomenon known as synaptic plasticity. The BDNF protein helps regulate this process, which plays a key role in learning and memory and also contributes to the management of daily functions such as eating and drinking.
Studies show that each time an individual exercises, the body produces BDNF. Regular exercise increases its production and provides even greater benefits. This post-exercise cognitive boost can last for hours and may support healing from brain trauma by improving cognitive function. Encouraging BDNF production is a major reason medical professionals now encourage a return to exercise soon after a concussion, to allow the brain to access and use these chemicals in the healing process.
Exercise Intolerance and Autonomic Nervous System Dysregulation
While elite athletes may display an eagerness to resume their previous workouts following a concussion, our average clients may display some reticence, especially if exercise intolerance should surface. This common component of post-concussion syndrome includes most of the typical symptoms such as headache, fatigue, some dizziness, and even “brain fog”. In some cases, however, these symptoms feel so unpleasant that individuals choose to avoid exercise altogether rather than continue easing back into their routines. However, studies show this only prolongs the recovery process.
Post-concussion exercise intolerance can come about as a result of some or all the following:
- Autonomic nervous system dysfunction
- Cerebral autoregulation
- Vision problems
- Vestibular problems
Concussion patients returning to even less rigorous workout routines may sometimes experience all of these problems, since mild traumatic brain injuries often affect more than one area of the brain. Why, in particular, do we find such involvement by the autonomic nervous system?
Even at a lower-than-usual level, exercise places certain demands on the body. Heart rate and blood pressure increase, as does blood flow throughout the body. Upon cessation, these parameters should ideally return to their homeostatic levels. The brain needs this rest period in order to heal. When one experiences exercise intolerance, however, the sympathetic nervous system overreacts and continues to do so. Blood flow and blood pressure may not function properly (vascular dysregulation), inviting headaches, the sensation of the heart pounding inside the skull, nausea, and/or shortness of breath.
Understandably, a client experiencing these sensations would want to stop the workout; however, this creates a vicious cycle that only makes things worse. Exercise remains crucial for returning the ANS to normal function and for healing other post-injury problems.
A Sample 4-Phase Post-Concussion Program
Once a physician clears the client to return to the gym, personal trainers will want to get the client back up and running as soon as possible. Before writing a new program, however, personal trainers must remind themselves that their professional scope of practice prevents them from either diagnosing or treating medical conditions, especially one as delicate as a concussion. Therefore, working with a client’s medical team remains the ideal choice while moving forward. Remember, symptom severity and exercise tolerance will vary greatly from client to client.
Here we offer a sample 4-phase post-concussion exercise plan. This can serve simply as an outline or guide; specific exercises will depend on the client’s history and current abilities.
Phase 1: Plan a very light aerobic activity, about 5 to 7 minutes long. Walking outside, on a treadmill, or riding a recumbent bike works well at this level. Do not push clients past their comfort levels. Assess heartbeat, rate of perceived exertion, and overall coordination throughout the session. At the end of the first week, the trainer and the client may decide to remain at this level for another week or two.
Phase 2: Along with very light aerobic activity, still no longer than 10 minutes, trainers can begin introducing some balance exercises. Again, to assess coordination, make sure the client stands close to a wall, chair, or other support in case of a sudden balance/coordination issue. If a client would like to do some gentle stretching, do so seated or on the floor.
As stated above, remain at this level for as long as it takes for the client to improve and feel ready to move on.
Phase 3: If the client feels comfortable doing light aerobic activity for up to 15 minutes, the trainer can increase the treadmill’s incline or speed; if using a recumbent bicycle, add a bit more resistance.
Along with balance exercises, begin to integrate some flexibility training. Repeat this week until the client shows good improvement and greater comfort.
Phase 4: At this point, the client can probably tolerate up to 20 minutes of aerobic activity, 2x/week. If this seems acceptable, set a goal of graduating to 3x/week. If the client’s heart rate rises too quickly, taper back to Phase 3.
Continue balance, flexibility, and stretch exercises in this phase. If the medical team agrees, the personal trainer can begin adding basic resistance training moves, starting with resistance bands and bodyweight exercises. As always, monitor the client’s parameters both during and immediately after the training session.
The first rule of post-concussion program design — “Do No Harm” – must take ultimate precedence. If symptoms increase significantly at any time during the workout, pause the session. Have the client sit down, hydrate, and breathe. If symptoms don’t resolve within 10 to 15 minutes, don’t hesitate to end the day’s session.
While monitoring sub-symptom thresholds, trainers should keep an eye on certain symptoms that may indicate a severe medical emergency rather than a typical flare-up. If the client exhibits any of the following “red flag” symptoms during a session, halt and call for emergency medical services:
- A headache that rapidly intensifies
- Fainting, blacking out, profound drowsiness or inability to stay awake
- Slurred speech, unusual weakness, numbness or decreased coordination
- One pupil appears noticeably larger than the other
- Nausea, progressing to vomiting
- Confusion, agitation, restlessness or an inability to recognize familiar people
- Convulsions or sudden, uncontrolled body movements
References
nfpt.com/the-gravity-of-concussions/
pubmed.ncbi.nlm.nih.gov/23243113/
issaonline.com/blogs/safety-and-injuries/post-concussion-exercise-how-to-program-for-recovery
cognitivefxusa.com/blog/exercise-after-a-concussion
fit-pro.com/article-4934-Beyond-Clearance-A-Guide-to-Post-Concussion-Training.html
bjsm.bmj.com/content/57/11/695#ref-30
concussionalliance.org/aerobic-exercise-therapy
nfpt.com/concussion-impact-exploring-novel-prevention-and-rehabilitation-techniques/
