Graduated Exercise Therapy
Graduated Exercise Therapy, or Graded Exercise Therapy, is a type of rehab therapy for patients who have sustained a concussion. The treatment employs the introduction of physical activity in stages to reduce concussion symptoms. On this page:
Information on an individualized graduated exercise program
General guidelines for a gradual return to activity and sport
Information for children, elders, and those unable to do aerobic exercise
M Nadir Haider, MD, from University at Buffalo's Concussion Management Clinic, has reviewed this exercise therapy page for content accuracy. haider@buffalo.edu.
This page was researched and written by Shelly Seth.
Table of Contents
Current at-home best practice: How to do graduated exercise therapy based on perceived symptoms
Options for Individualized Graduated Exercise Therapy
1. BCTT with a Physical Therapist
2. Personalized Regimen from a physical therapist without taking the BCTT Test
General guidelines for a gradual return to activity and sport
Physical activity for children, elders, or those unable to do aerobic exercise
Overview
Graduated Exercise Therapy is a personalized plan that is separated into multiple stages of exercises to help build back tolerance for daily activities. The first stage is a 48 hour period of rest, which is crucial for the brain to heal and to prevent further injury. After the initial resting stage, the patient gradually increases their physical workload in small increments until they are medically cleared to resume their normal activities. This type of therapy should be customized to fit the patient’s age, level of fitness, and medical condition, and should also be done under the supervision of a trained professional.
Myth: Concussions are best treated by rest until the symptoms subside
Drs. Ellis and Leddy (et al.) recently conducted clinical trial with 103 teenage athletes (starting within ten days of sport-related concussion) and concluded that "moderate levels of physical activity, including prescribed sub-symptom threshold aerobic exercise, after the first 48 hours following sport-related concussion can safely and significantly speed recovery."
This means that rest (48 hours) immediately after an injury is essential, but exercise must be integrated into the recovery process, as noted in the Consensus Statement on Concussion in Sport. Further research is at the bottom of this page.
Takeaway: initial rest after an injury is important, followed with gradually increased, voluntary exercise.
This is a slide from the American Academy of Neurology Sports Concussion Conference that gives different benefits of exercise in the body and mind. Click here or on the image to see a larger version of this slide.
Current at-home best practice: How to do graduated exercise therapy based on perceived symptoms
You can begin light aerobic exercise, such as walking or easy stationary cycling, as soon as you can tolerate it – even within the first 48 hours after injury. Your goal is to gradually increase both the time and intensity of this exercise until you can tolerate at least 30 minutes of moderate-level aerobic exercise each day.
It is OK to exercise while you have persisting concussion symptoms. Resting and avoiding any exercise while you have persisting symptoms is outdated advice and slows recovery.
While you are exercising, your symptom severity should not increase more than 1-2 points out of 10 (a mild symptom increase). Use the chart below to help you rate your symptoms. If your symptoms increase by more than 2 points, stop exercising and reduce the intensity the next time you exercise.
The amount of time that your symptoms increase should also be brief. Within an hour after exercising, your symptoms should return to the level before you started the exercise session – your baseline. If your symptoms don’t return to your baseline within an hour, then make your next day’s exercise less vigorous.
If running or other types of exercise cause an increase in neck pain, headaches, dizziness, or balance issues, stop the exercise. Consult your healthcare provider about a referral to a cervicovestibular physical therapist for evaluation of neck or vestibular issues that may require rehabilitation. Consider switching to a stationary bike until those issues are treated.
See our Graduated Exercise Therapy resource for an in-depth explanation.
Prevent re-injuring your brain while exercising
Don’t do activities with risk of contact, collision, or falls, such as playing contact sports. Be careful if you experience dizziness or light-headedness, which may cause a fall; a stationary bike is safest in this case.
If you are returning to sports, get medical clearance before participating in non-contact training drills that have a risk of accidental head impact, such as a misdirected soccer ball or unexpected contact with another player. Read more about returning to sports here.
Options for individualized graduated exercise therapy
These options were described in a 2020 study*; we have listed the more ideal option first.
BCTT with a Physical Therapist: the patient takes the BCTT with a physical therapist and uses a heart rate monitor for their personalized at-home exercise routine.
Personalized regimen from physical therapist without taking the BCTT Test: the patient takes a different stress test to find their max sub-symptom heart rate. The physical therapist designs a personalized at-home exercise routine for the patient without taking the BCTT.
Aerobic exercise managed by the patient without access to a PT: the patient uses their own heart rate monitor to exercise. They calculate their maximum heart rate and exercise in stages that use gradually increasing percentages of their maximum heart rate.
*Bezherano I, Haider MN, Willer BS, Leddy JJ. Practical Management: Prescribing Subsymptom Threshold Aerobic Exercise for Sport-Related Concussion in the Outpatient Setting. Clin J Sport Med. 2020 Feb 13. Epub ahead of print. PMID: 32058454
1. BCTT with a Physical Therapist
The Buffalo Concussion Treadmill Test (BCTT) and the Buffalo Concussion Bike Test (BCBT) are stress tests designed to assess the level of exercise that a patient’s autonomic nervous system can tolerate before their symptoms worsen. These tests use a heart rate monitor to yield a maximum sub-symptom heart rate, which is the heart rate at which the patient can no longer continue due to their symptoms. These two tests are performed by the patient in the clinic, followed by the use of a heart-rate monitor during their at-home exercise routine.
This video from the University of Buffalo explains the BCTT and shows a scenario of a patient being evaluated by a physical therapist, which will be used to design a personalized exercise regimen.
Dr. Elizabeth Sandel, author of her book Shaken Brain: The Science, Care, and Treatment of Concussion, cited the BCTT from the University of Buffalo as an effective treatment to the recovery process.
She writes, “The exercise protocols that [Dr. John] Leddy and his group utilize are controlled and graded (sequenced) exercises, and provide an exercise prescription unique for a person, given his or her symptoms, physical examination, medical conditions, and other factors that might determine best outcomes. A physician or physical therapist must guide the program.”
Note that in Leddy’s newest study, the researchers provide a method for the patient to design their own individualized aerobic exercise plan (with a heart rate monitor) if they do not have access to a healthcare provider.
2. Personalized regimen from physical therapist without taking the BCTT Test
If patients are not able to do the BCTT but still have access to a physical therapist, following a personalized exercise regime designed by the physical therapist is still an effective option. Sometimes a physical therapist does not use the BCTT, or the patient is unable to take the test. The physical therapist can make an exercise routine that matches the patient’s maximum sub-symptom heart rate (this is calculated by conducting a stress test). This will be beneficial to help the patient gradually get back into their daily routine.
Dr. Lindsay Watson, a physical therapist, discusses how physical therapy may be a good option for concussion recovery. She also goes into detail after 11:00 about how graduated exercise therapy is helpful for easing back into daily activities and easing symptoms.
3. Aerobic exercise managed by the patient without access to a PT; the patient uses their own heart rate monitor
If patients do not have access to a provider to conduct the Buffalo Concussion Treadmill Test, aerobic exercise done at home is beneficial to speed up recovery and reduce the severity and length of symptoms. A method designed by the creators of the BCTT outlines how to design stages of exercise intensity using a heart rate monitor. This method is described below.
The recovery process will be divided into stages that start at 50% of your maximum heart rate (max HR) for 20 minutes.
The stages will increase by 5% of your max HR until 80% of your max HR is reached.
Before exercising, rate your current symptom level on the Visual Analog Scale (VAS). Exercise at your current target HR for 20 minutes (your target HR will be a percentage of your max HR, starting at 50% on day 1). During your exercise, keep track of your symptom level with the VAS. Use your increase in symptoms (+0, +1, +2, +3 or more) to determine your next steps in this procedure.
How do I calculate my maximum heart rate?
Your maximum heart rate is 220 minus your age (HRmax = 220 -age)
For example, if you are 37, your maximum heart rate is 220 - 37 = 183. Learn more
How do I rate my symptoms while I’m exercising?
Evaluate symptoms before and during exercising using the Visual Analog Scale (VAS). This is a resource that is commonly used to measure the intensity of symptoms across a range and is measured from 0-10 (0 being the least severe symptoms and 10 being the most severe symptoms).
How do I combine my max HR and my symptom load?
If you record a symptom increase of 0 or 1, move on to the next stage of recovery the next day that you exercise, increasing the target HR by 5% of your max HR.
If you report an increase of 2 on the VAS scale, this is considered to be ideal exercise intensity for recovery. Exercise at this target HR until you record no symptom increase (+0) for 2 contiguous days. After this, increase your target HR by 5% and exercise at this HR the next day.
If you record a symptom increase of 3 or more on the VAS, the current stage is too intense and you should return to the previous stage, decreasing your target HR by 5%. You must then experience no symptom increase (+0) for 2 contiguous days at this target HR to move to the next stage. After this, increase your target HR by 5% and exercise at this HR the next day.
This visual flow chart, created by Ben Preiss (2019 Concussion Alliance extern), explains how to move through the stages when beginning aerobic exercise. Click on this image for a printable PDF.
Patients should keep a daily symptom tracking log to document their recovery and see what heart rate they start having their symptoms. Dr. Nadir Haider from the University of Buffalo provided this document for patients to use to log their symptoms (shown below). By tracking their daily symptoms, patients can see if they are able to exercise without symptoms at higher heart rates or if they need to exercise at the same heart rate.
Click the image for a printable PDF to track your symptoms
As patients progress through the stages and increase their heart rate, they will also increase their tolerance to exercise. However, they need to be careful not over exert themselves because pushing past symptoms may do more harm than good. Dr. Haider mentions that too much exercise or exerting the brain when it is unable to handle wide swings in blood pressure is associated with longer recovery times. Be cautious when moving through the stages of recovery to ensure that the brain is not being overworked.
General guidelines for a gradual return to activity and sport
Graduated exercise therapy can be utilized for a patient to return to an activity or sport. It is split into stages that focus on specific types of exercises in order to acclimate the patient to physical activity.
This infographic is from a cattonline course for concussion management for parents and caregivers.
Click this image for a printable PDF
Physical activity for children, elders, or those unable to do aerobic exercise
Dr. John Leddy and Dr. Barry Willer suggest that concussion patients will benefit from whatever physical activities they can perform after the initial rest period (48 hours). This applies to young children, those for whom aerobic exercise is foreign, or those who are physically unable due to age or disease process, This can be in the form of:
Walks in their neighborhood or at a park
Playing in the park (for children)
Yoga
Physical therapy
Yoga Resources
The nonprofit organization LoveYourBrain.com provides Free online yoga and meditation videos for people with a concussion will allow you to do yoga at home, or help you decide if you want to take their classes. LoveYourBrain also provides free, in-person FUNdamental 6-week series of yoga classes for people with TBI and concussions. Classes are available in most US states and Canada.
Classes provide gentle yoga to improve strength and balance, meditation practices to reduce stress, class themes to foster resilience and compassion, and facilitated group conversation to build community.
Yoga YouTube Videos for Concussion Patients
“treeing yoga” on YouTube has multiple videos on yoga exercises for patients post-concussion.
There are three levels of difficulty, and each video is around 40-60 minutes.
Further research
Aerobic exercise can be beneficial to speed up recovery from a TBI. In a 2019 study from the University of Buffalo, Dr. John Leddy et al. found that among pediatric patients, early aerobic exercise improves time to recovery compared to stretching after pediatric sport-related concussion. The patients who utilized an aerobic exercise treatment recovered in an average of 13 days, while patients in the control group recovered in an average of 17 days. Additionally, 50 out of 52 patients in the aerobic exercise treatment “had recovered by 30 days and therefore did not require additional medical therapies, which often involve substantial time and resources.”
A similar study conducted by Dr. Michael Popovich et al. utilized a wider age group and found multiple mental health benefits from using aerobic exercise after a sports-related concussion. Key improvements included:
increased synaptic plasticity in the brain (helps with learning and memory)
increased production of a protein (brain-derived neurotrophic factors, BDNF) that aids in the survival of nerve cells
increased cortical connectivity (helps with neuron firing in brain response).
This article from the University of Michigan discusses the study above, listing additional positive effects of aerobic exercise during recovery from a TBI. See our page on Aerobic exercise as therapy.
This video from Mayo Clinic describes the Return to Play protocols for patients sustaining a concussion. This treatment utilizes Graduated Exercise Therapy so that the patient is accustomed to their normal routine in stages.
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A study found a significant reduction in symptom relapse rates related to premature Return to Learn but not for Return to Play, indicating the need for more emphasis on implementing Return to Learn protocol.