Exercise following concussion
Cocooning, or complete bedrest, following concussion, is a thing of the past. The seminal work of Dr. John Leddy and his colleagues at the University of Buffalo Concussion Management and Research Center has informed much of present-day best-practice clinical care for individuals with concussions. They have reported that restriction of activity following concussion prolongs recovery and may even make symptoms worse. [1] Though this may seem at first blush to be counter-intuitive, both science and anecdotal evidence back it up.
There is ample clinical evidence to support a progressive, individualized subthreshold aerobic exercise treatment program for safely returning patients to sport, notably derived from systematic assessments of exercise tolerance using the Buffalo Concussion Treadmill Test. The key terms here are progressive and individualized. Aerobic exercise may be used as non-pharmacological medicine, but like with any medicine, type and dosage are determined individually. Numerous factors contribute to a prescription for exercise, including injury severity, pre-existing conditions, and support systems. One thing is clear, however, and that is that no concussed i—p-p1‘“ndividual should return to pre-injury activities within at least 48 hours post- injury.
From an elite athlete to a weekend warrior to an individual who attends physical fitness class once or twice per week, none should return to strenuous sports in the first couple of days following concussion but should start moving with low-impact exercises such as walking, cycling, or swimming. Too much too soon could cause setbacks in physical function, cognitive function, and even emotional stability. Paradoxically, too much rest could even cause fatigue. Too little exercise, such as “cocooning,” as recommended in years past, could result in the development of post-concussion syndrome, a condition in which symptoms may last weeks or even months or more.
Resting during the first 48 hours following a concussion is essential, but this should not entail a lack of movement or thinking. Sports and other strenuous activities should be avoided, such as attending school or work, doing homework, using electronic devices, listening to or playing loud music, and reading. Though this sounds highly restrictive, there are plenty of ways to occupy one’s time during the earliest stages of concussion, and adherence to this advice will pay enormous dividends. So, what may one do during the earliest stages of recovery? Listening to audiobooks, meditation, arts and crafts, simple cooking, massage, taking a short walk in the fresh air, making quiet visits with friends, playing gently with a pet, and playing simple board games are some of the things that could occupy one’s time.
One needs to pay close attention to how it feels when introducing increasingly complex or challenging activities. Is brain fog present? Is there dizziness? Irritability? Weakness or fatigue? Symptoms may appear a few hours or more following activity, so paying close attention to how one feels is critically essential. Know when to stop!
Dr. Leddy and his colleagues’ research has found that progressive, paced, and moderate aerobic activity beginning 48 hours post-concussion results in a speeding up of a return to regular activity and a decrease in symptoms, with a greater chance of restoration of function.[2] If symptoms worsen once the exercise starts, a rest period is in order, and after a couple of days, another attempt should be made. Of course, specific physical and cognitive symptoms may interfere with a smooth return to exercise, including headache, dizziness, fatigue, insomnia, decreased concentration, diminished memory, and autonomic nervous system (ANS) dysfunction. Again, only the individual will know what feels “off” and should thus be encouraged to listen to what their body and mind are saying.
Low-impact sports such as a recumbent bike are recommended as a return to physical activity as there is less gravitational pull on the bloodstream pumping to the heart. Other beneficial exercises are walking, aqua aerobics, or water running, as the pressure of the water facilitates healthy blood flow. Dr. Robert Scales, the director of cardiac rehabilitation and wellness at the Mayo Clinic, underscores the direct relationship between cardiovascular health and brain health, noting that increased vasodilation (opening of blood vessels) results in better flow to the brain. Subthreshold aerobic exercise normalizes cerebrovascular physiological dysfunction.
FITT is a vital acronym when using exercise to facilitate brain health, referring to Frequency, Intensity, Time, and Type. Frequency refers to how often you exercise; the point is to meet your goals without overtraining the body. Intensity is how laborious an exercise is and will be determined by heart rate increase. Time, of course, refers to the duration of each exercise, with a gradual rise of notable importance. Type refers to the exercise you’ll do under cardio or strength training. All of these elements should be determined by your healthcare specialist and monitored closely by them.
Even careful adherence to a plan set forth by one’s healthcare professional may not yield the desired rate of change as numerous factors contribute to prolonged recovery. Some contributing factors are loss of consciousness of more than one minute, repeated concussions, age of injury (the younger the person, the more time is required for recovery), and specific pre-existing conditions, including migraine, cognitive dysfunction, and depression or anxiety. No two individuals are the same; thus, no two recovery patterns are the same. However, one’s best chance at recovery is to go slowly, not be afraid, and know that a return to pre-injury level will likely happen.
[1]
Current Opinions in Neurology (2018) Dec;31(6):681-686.
[2] issue of Current Sports Medical Report