Concussions are more than just a bump on the head, or “getting your bell rung”; they are a type of mild traumatic brain injury that can have serious, long-lasting effects if not properly managed. They are caused by sports injuries, motor vehicle accidents, falls, or any blow to the head, neck, or body that creates movement of the brain inside the skull. Historically, the only recommendation for treatment that was offered was simply “rest and wait.” It was believed that concussion was not a treatable injury, and patients were advised that the best way to heal was to avoid cognitive and physical activities until symptoms resolved.
However, it turns out that physical activities and regular exercise not only help people with head injuries heal more quickly but also more completely. Gone are the days when ‘taking it easy’ or staying in a dark room was the only option for recovery. Today, concussion experts advocate for early, active treatment to enhance healing and minimize the potential for long-term complications like post-concussion syndrome (or persistent post-concussion symptoms).
In this comprehensive post, we’ll explore the transition from the old paradigm of ‘rest and wait’ to the progressive world of active rehab. We’ll analyze current research, highlight the benefits of this approach, and provide a roadmap for its implementation. We’ll also look at the critical role stakeholders play in ensuring a safe and effective return to everyday life — school, work, and sports.
For many years, the “cocoon therapy” approach (i.e., avoidance of physical and cognitive activities) was universally given as safe advice for healing after a head injury. However, as the harm that prolonged inactivity has on physical and mental health became more evident, medical experts started to re-evaluate this one-size-fits-all approach. Many studies suggest that long periods of rest can be detrimental to healing and delay concussion recovery for patients.[1] And a growing body of evidence suggests that certain types of exercise may speed up recovery rather than worsen symptoms. [2] This new thinking does not advocate for an immediate return to full-contact sport. Still, it does encourage a graduated, progressive increase in physical activity tailored to an individual’s head injury symptoms.
The 6th International Consensus Statement on Concussion in Sport states that “strong evidence exists regarding the benefits of physical activity and aerobic exercise treatment as early interventions.” [3] Studies led by Dr. John Leddy and his colleagues from the University at Buffalo illustrate how sub-threshold aerobic training programs are beneficial for promoting recovery without exacerbating symptoms.[4] A 2023 study published in the Journal of Athletic Training also showed that engaging in aerobic exercise during recovery from a concussion can improve brain function and decrease symptoms [5], further supporting the shift towards active rehabilitation.
Snowden T, Morrison J, Boerstra M, Eyolfson E, Acosta C, Grafe E, Reid H, Brand J, Galati M, Gargaro J, Christie BR. Brain changes: aerobic exercise for traumatic brain injury rehabilitation. Front Hum Neurosci. 2023 Dec 20;17:1307507. doi: 10.3389/fnhum.2023.1307507. PMID: 38188504; PMCID: PMC10771390.
This updated approach addresses three fundamental aspects: symptom management, physical restoration, and cognitive recovery.
Active rehab benefits individuals by:
In addition to accelerating recovery, active rehabilitation offers an array of benefits. Physical activity helps people to cope with stress, build resilience, and lessen the risk of developing persistent post-concussion symptoms (also referred to as ‘post-concussion syndrome’). Furthermore, exercise can improve cognitive function, including memory and attention — skills often affected by concussion. Depression, anxiety, and mood changes– both pre-injury and post-injury– can also be improved with regular physical activity. Exercise can also help mitigate sleep disturbances that often occur post-concussion. [6]
Active rehabilitation isn’t a one-size-fits-all solution, and it should be tailored to each individual’s specific needs. The first step towards active recovery is an accurate diagnosis of the concussion by a qualified healthcare professional. This will help identify any potential risk factors or underlying conditions that may affect treatment recommendations. Many experts agree that symptom origins can be grouped into one or more categories: Physiologic (which can include Autonomic and/or Metabolic sub-profiles), Visual/Vestibular, Cervical, and Psychological. Not only can this help patients understand the nature of their symptoms, it also aids concussion management specialists in targeting therapies more specifically. For instance, if there is a whiplash-like neck injury, addressing neck pain will be important as physical activities are designed.
Leddy JJ, Haider MN, Noble JM, Rieger B, Flanagan S, McPherson JI, Shubin-Stein K, Saleem GT, Corsaro L, Willer B. Management of Concussion and Persistent Post-Concussive Symptoms for Neurologists. Curr Neurol Neurosci Rep. 2021 Nov 24;21(12):72. doi: 10.1007/s11910-021-01160-9. PMID: 34817719.
Next, a personalized treatment plan should be developed in collaboration with the patient, their family, and medical providers. This plan should incorporate a balance of physical and cognitive activities that gradually increase in intensity as symptoms improve. Individuals are guided through a progressive increase in physical and cognitive activities that challenge — but do not overwhelm — the concussed brain. It’s important to note that each person may progress at a different pace, and it’s essential to listen to the body and adjust accordingly.
Throughout the recovery process, ongoing monitoring and communication with the healthcare professional team is crucial to ensure that progress is being made safely and effectively. This may involve regular check-ins, assessments, or modifications to the treatment plan as needed. Implementing an active rehabilitation program requires close collaboration between the individual, their medical provider, and, if relevant, their sports team or workplace.
Now that we have established that activity is better than strict rest after a concussion, how is this best achieved? Just like Goldilocks, too little exercise can be as much of a problem as too much. Knowing the right amount and timing leads to the best outcomes.
Similar symptom-limited, gradual progression also applies to cognitive activity, and the above guidelines are recommended for academic and work-related activities. For instance, light reading or short, timed computer work can progress to longer and more difficult cognitive activities, such as tests or projects. It is recommended to take regular breaks for mental rest between tasks and limit activities that worsen symptoms like headache or difficulty concentrating.
While actively rehabilitating a concussion, certain activities should be avoided to prevent setbacks.
These include:
In addition to the healthcare team, many stakeholders are involved in ensuring concussion-supportive therapy. These include educators, employers, coaches, and family members. All of these individuals should be educated on the importance of active rehabilitation and how to support those recovering from a concussion.
Furthermore, policies and guidelines should be in place to ensure that concussed individuals are given adequate time to recover before returning to full school or work responsibilities. Employers and educators should be aware of tailored schedules and accommodations that may be necessary for a successful return, including reduced workload or modified duties.
Engaging in sports after a concussion requires a well-structured reintegration process. Athletes, coaches, and healthcare professionals should work together to design a stepwise return-to-play protocol to assist an athlete in gradually returning to competitive sports.
The return-to-play process involves six stages, each with increasing physical exertion and contact levels. Athletes must not proceed to the next stage if they experience symptoms during any level of exercise. Graduated return-to-play protocols vary by location but generally agree that this approach ensures that the athlete has fully recovered before returning to competition.
Before returning to play, athletes must be entirely symptom-free at rest, during, and following physical exertion. They should also be off all medications used to treat concussion symptoms, have normal balance and neurocognitive function, and have returned to their pre-injury baseline on all physical exertion tests. The healthcare professional may want to complete a final neurological exam to ensure the brain has fully recovered before final clearance to return to sport is issued.
In conclusion, the shift towards active rehabilitation is an exciting development in the field of concussion care. By challenging the status quo of ‘rest and wait’ and introducing individualized, active strategies, we have the opportunity to redefine what recovery means for those affected by concussions. It’s imperative that all stakeholders — from the healthcare professional to the teacher, the employer, or the coach — take an active role in promoting and implementing these innovative approaches. Together, we can ensure a safer, more efficient, and comprehensive recovery process for all individuals dealing with the complexities of concussion.
Find a Clinic
Near You.
Baseline Testing, Treatment, and Rehabilitation to get you back to work and play
Browse our network of trained multidisciplinary healthcare practitioners that collaborate with physicians to co-manage concussion injuries.