Feb 5 • Graded Exercise
Graded Exercise
Current recommendations for graded exercise prescription post-concussion have evolved significantly, moving away from prolonged rest toward early, carefully monitored active rehabilitation.
The latest evidence supports early introduction of sub-symptom threshold aerobic exercise (typically within the first week after injury, once initial rest of 24-48 hours is complete). This represents a major shift from older protocols that emphasized extended rest periods.
Sub-symptom threshold training is central—exercise should be performed at an intensity that doesn't exacerbate symptoms beyond mild, temporary increases. If symptoms worsen significantly or persist beyond the exercise session, the intensity was too high.
Progressive stages typically include:
- Light aerobic exercise (walking, stationary cycling) at 50-60% max heart rate
- Sport-specific exercise without contact
- Non-contact training drills with increased complexity
- Full-contact practice (if applicable)
- Return to unrestricted activity
Each stage usually lasts at least 24 hours, with progression only if symptoms remain stable.
Many clinicians now use the Buffalo protocol or similar approaches, which involve supervised treadmill testing to establish a heart rate threshold where symptoms emerge, then prescribing exercise at 80% of that threshold for 20 minutes daily.
Research shows that appropriate exercise may actually facilitate recovery through improved cerebral blood flow, neuroplasticity, and autonomic regulation, while reducing secondary complications like deconditioning and mood disturbances. However, premature return to high-risk activities or exercising well above symptom threshold can prolong recovery.
The key is individualization, some patients tolerate early exercise well, while others with more severe injuries or complications may need modified approaches. Close monitoring by healthcare providers familiar with concussion management is essential.
But what if someone isn't able work with an athletic therapist or a physiotherapist? Patients can many times feel at a loss to sort out how to go about adding in exercise and end up doing too much.
I will attach, a version of the Rated of Perceived Exertion that has been adapted for the post concussion community. As always, it's preferred that you would work with a professional to make sure you are working within your specific ranges however in the meantime, this can be a safe and easy way to make your way back to exercise.
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Graded Exercise
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