The New Standard for Concussion Recovery: A Practical Guide to Graded Aerobic Exercise

For years, the standard advice for concussion recovery was rest, rest, and more rest. We told our patients to avoid physical and cognitive activity until their symptoms subsided. However, a growing body of evidence is not just challenging that notion, but turning it on its head. The new thinking, backed by solid research, is that early and controlled aerobic exercise can significantly speed up recovery from a concussion. This brief will break down the what, why, and how of using graded aerobic exercise, specifically with the Buffalo Concussion Treadmill Test (BCTT), to help our patients with subacute concussion. So, what’s the science behind it? After a concussion, the brain’s autonomic nervous system, which controls things like heart rate and blood pressure, can get out of whack. This dysfunction is a major reason why symptoms like headaches, dizziness, and fatigue can persist. The theory is that by engaging in controlled, sub-symptom threshold aerobic exercise, we can help to recalibrate the autonomic nervous system and improve cerebral blood flow, which in turn helps to alleviate symptoms and promote recovery. The research is backing this up. A systematic review of nine randomized controlled trials (n=346) found that high-to-moderate intensity aerobic exercise can improve concussion-related symptoms, especially when started in the acute stage. The key is to find the sweet spot where the patient is exerting themselves enough to create a therapeutic effect, but not so much that they exacerbate their symptoms. That’s where the Buffalo Concussion Treadmill Test comes in. The BCTT is a graded exercise test designed to determine a patient’s exercise tolerance after a concussion. It’s a simple and safe way to figure out the exact heart rate at which their symptoms start to worsen. This is called the heart rate threshold (HRt). Once we know the HRt, we can prescribe a personalized aerobic exercise program that keeps them just below that threshold. The protocol for the BCTT is straightforward. The patient walks on a treadmill at a set speed, and the incline is gradually increased. The test is stopped when the patient’s symptoms increase by three or more points on a 10-point scale, or when they feel they can’t continue. The heart rate at that point is their HRt. Once you have the HRt, the exercise prescription is simple. The patient should engage in aerobic exercise (like walking, running, or cycling) for 20 minutes, 4-5 days a week, at 80% of their HRt. They should use a heart rate monitor to ensure they are staying in the right zone. It’s important to re-evaluate the patient weekly and adjust the HRt as their tolerance improves. This progressive approach ensures that we are constantly challenging the patient’s system to adapt and recover. Of course, not every patient with a concussion is a candidate for the BCTT and graded aerobic exercise. It’s crucial to rule out any absolute contraindications to exercise, such as acute myocardial infarction, unstable angina, or uncontrolled cardiac arrhythmias. There are also relative contraindications to consider, like severe arterial hypertension or electrolyte imbalance. The BCTT is also not recommended within 24 hours of the injury or if the patient’s symptoms are too severe (a 7/10 or higher on the symptom severity scale). Patient selection is key. This approach is most effective for patients in the subacute phase of recovery (from about 3 days to 3 weeks post-injury) who are still experiencing symptoms but are medically stable. In conclusion, the evidence is clear: graded aerobic exercise is a safe and effective treatment for subacute concussion. By using the Buffalo Concussion Treadmill Test to establish a heart rate threshold and prescribing a personalized exercise program, we can help our patients recover faster and get back to their lives. It’s a paradigm shift from the old rest-is-best model, and it’s one that we as clinicians should be embracing.