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rest is not best for concussion: how gentle, structured activity speeds recovery
prolonged rest after a concussion can slow recovery and raise the chance of persistent symptoms.
5 minute read
doing light exercise beneath your threshold for symptoms is better than resting when you have a concussion.
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for years, people were told to rest in a dark room after a concussion, and many still are. people are also told to avoid light, noise, school, and work for days or even weeks. this is what most people, including many clinicians, still assume is the proper protocol. over the past decade, research has shown that prolonged rest after a concussion is not helpful. it can slow recovery and raise the chance of persistent symptoms, previously called post-concussion syndrome. there is a better approach. gentle, planned activity that stays under your symptom limit helps you recover faster and more completely 1–4.
your brain and body work together. after a concussion, the body’s “fight or flight” system often shifts out of balance. blood flow to the brain can change and may not respond normally when you think or move. this is one reason everyday tasks can make you feel worse after a concussion 5–8. understandably, patients and well-meaning clinicians often think the safest choice is to do nothing. in reality, extended inactivity can make you deconditioned and can worsen autonomic imbalance. the best evidence now supports only brief relative rest, usually 24 to 48 hours, followed by a gradual return to activity that respects symptoms 1–3.
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sub-symptom threshold exercise is one of the most studied and effective strategies in concussion care. when started within the first week to 10 days after injury in adolescents, randomized trials show faster recovery and about a 48 percent lower risk of developing persistent post-concussive symptoms compared with stretching or usual care 3,4. exercise is also helpful for people who have been struggling for months. carefully dosed aerobic activity can improve symptoms and function in adults with persistent post-concussive symptoms 9,10.
what does “the right way” look like? it means starting with light activity and staying below your symptom ceiling, also called your threshold. a small and brief increase in symptoms can be okay. big spikes are not. trials and expert consensus agree that short, mild symptom bumps during activity usually settle the same day and do not slow recovery when you stay under your limit 1,3.
how to find your safe level
a trained concussion provider can use the buffalo concussion treadmill test, or a validated bike alternative, to gradually increase intensity while monitoring your heart rate and symptoms. the heart rate where your symptoms start to rise marks your threshold. your clinician then gives you a target heart rate zone for daily exercise. after a week or two, you retest and adjust. this stepwise, sub-symptom plan is one of the most researched methods in concussion rehabilitation and is supported by protocols and systematic reviews 1,6,11–14. beyond symptoms, this approach appears to help rebalance the autonomic nervous system, improve regulation of brain blood flow, and support better sleep and mood. when it comes to concussion, exercise really is medicine 5–8,11.
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if you do not have access to a concussion clinic, you can still start safely. begin with simple walks. try five minutes a day for a week. if that is easy, add two to three minutes each week until you reach about 30 minutes a day. if symptoms climb too much, slow down or shorten the session. in concussion recovery, you do not push through. slow and steady wins.
here is the bottom line. your brain was injured, but the brain is also plastic. with the right support, it can adapt and heal. prolonged rest lowers your tolerance for physical and mental effort and makes everyday stimuli like light, noise, and crowds harder to handle. the strongest evidence over the past decade supports sub-symptom threshold exercise as a key part of recovery. it is normal to feel nervous about getting started. a small, short-lived rise in symptoms does not mean you are causing harm. it is your system learning again. stay under your limit, be consistent, track how you feel, and get skilled support when you can 1,3.
dr. cameron marshall, dc, frccss(c) is a sport-specialist chiropractor and founder of complete concussions, as well as a co-founder of concussion fix.
references
- patricios j, ardern cl, schneider kj, et al. consensus statement on concussion in sport: the 6th international conference on concussion in sport, amsterdam, october 2022. br j sports med. 2023;57(11):695-711.
- leddy jj, burma js, toomey cm, et al. rest and exercise early after sport-related concussion: a systematic review and meta-analysis. br j sports med. 2023;57(12):762-773.
- leddy jj, haider mn, ellis mj, willer bs. early subthreshold aerobic exercise for sport-related concussion: a randomized clinical trial. jama pediatr. 2019;173(4):319-325.
- haider mn, leddy jj, pavlesen s, et al. early targeted heart-rate aerobic exercise versus placebo stretching for sport-related concussion in adolescents: a randomized controlled trial. lancet child adolesc health. 2021;5(11):792-799.
- meier tb, bellgowan psf, mayer ar, et al. cerebral blood flow in sport-related concussion: a longitudinal asl-mri study. jama neurol. 2015;72(11):1276-1283.
- wang y, nelson ld, laroche aa, et al. cerebral blood flow alterations during recovery from sport-related concussion using arterial spin-labeling mri. neurology. 2016;86(23):2243-2250.
- len tk, neary jp. cerebrovascular pathophysiology following mild traumatic brain injury. brain inj. 2011;25(7-8):653-666.
- leddy jj, baker jg, haider mn, hinds al, willer bs. a physiological approach to prolonged recovery from sport-related concussion. j athl train. 2017;52(3):299-308.
- arora nj, chai-corey a, lazowski r, et al. evaluating a 12-week aerobic exercise intervention in adults with persistent post-concussive symptoms: a prospective cohort nested within the actbi trial. front neurol. 2024;15:1482266.
- silverberg nd, iverson gl, et al. management of concussion and persistent post-concussive symptoms for neurologists. curr neurol neurosci rep. 2021;21(7):36.
- leddy jj, kozlowski k, donnelly jp, pendergast dr, epstein lh, willer b. a preliminary study of subsymptom threshold exercise training for refractory post-concussion syndrome. clin j sport med. 2010;20(1):21-27.
- haider mn, leddy jj, willer bs, et al. buffalo concussion treadmill test instruction manual. supplement to j sci med sport. 2020.
- haider mn, leddy jj, willer bs, et al. buffalo concussion bike test instruction manual. supplement to j sci med sport. 2020.
- mcgeown jp, hassan i, pook s, et al. clinical application of the buffalo concussion treadmill and bike tests: a systematic review. sports med open. 2024;10:xx.
- thomas dg, apps jn, hoffmann rg, mccrea m, hammeke t. benefits of strict rest after acute concussion: a randomized controlled trial. pediatrics. 2015;135(2):213-223.
- grool am, aglipay m, momoli f, et al. association between early participation in physical activity following acute concussion and persistent post-concussive symptoms in children and adolescents. jama. 2016;316(23):2504-2514.
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