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Early Aerobic Exercise Encouraged for Concussion Treatment

Most consensus and agreement statements for managing concussions in
sport recommend that athletes rest completely, both physically and
cognitively, until they become symptom-free. Prescribed total rest for sports
related concussion is one of the most widely used recommendation for the
treatment of the school age athlete, with no physical activity mandated until
completely asymptomatic for one week.

To date there is insufficient evidence that prescribing complete rest
promotes recovery or eases symptoms.  Anecdotally, it appears not allowing
an athlete to return to school and not allowing them to exercise, may lead to
worsening of symptoms and even more depressive symptoms.

A recent randomized clinical control study in JAMA Pediatrics found
adolescent athletes who sustained concussions who underwent a supervised
aerobic regimen recovered more quickly than those allowed to only stretch.

After a brief period of rest of 1 to 2 days after sustaining a concussion, with
no worrisome or significant signs or symptoms, concussed athletes should be
encouraged to gradually and progressively increase activity while staying
below their cognitive and physical symptom-exacerbation threshold; that is
allow to participate in cognitive and light aerobic activity that does not bring
on or worsen their symptoms. Stationary bicycle, treadmill walking, or
outdoor walking can be initiated to start.  Lifting heavy weights while
bearing down (valsava) should be avoided, as should extreme motion and
movement activity.

To determine exercise intensity each athlete could sustain without worsening
symptoms, the researchers in the study had each athlete undergo the Buffalo
Concussion Treadmill Test, to determine at what level their symptoms
worsen. As the patient walked on a treadmill, the incline was gradually
increased and the heart rate was recorded at the point where concussion
symptoms intensify.  Exercise was prescribed at 80% of that heart rate
threshold.  A word of caution is that in my experience, many athletes can't
determine that threshold as symptoms may worsen post exercise, so make
sure your athletes start real easy making sure they are listening to their mind
and body.

References: John J. Leddy, Mohammad N. Haider, Michael J. Ellis,
Rebekah Mannix, Scott R. Darling, Michael S. Freitas, Heidi N. Suffoletto,
Jeff Leiter, Dean M. Cordingley, Barry Willer. Early Subthreshold Aerobic
Exercise for Sport-Related Concussion. JAMA Pediatrics, 2019.

Consensus statement on concussion in sport—the 5th international
conference on concussion in sport held in Berlin, October 2016.
https://bjsm.bmj.com/content/51/11/838
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