Graded exercise therapy in concussion management

Exercise therapy and manual therapy in concussion management

Using graded exercise therapy and manual therapy in concussion recovery may be contrary to the “old way” of dealing with a concussion injury. Traditionally, patients were told to rest after a concussion. We all have a friend, family member or teammate who was told to hide out in a dark room and avoid all social contact, light and noise. They were told to wait until their symptoms to go away.

But, is this really all you can or should do?

Absolutely not.

An initial period of 24 to 48 hours of relative physical and cognitive rest is recommended immediately after a concussion.1 But, there are many studies that support progressive return to activity strategies – including return to learn, work and play. In most cases, manual therapy (i.e., hands on treatment of the neck) is also an important part of effective concussion management.

If a patient has been resting for more than a week and still has significant symptoms, it’s time to get help from a licensed healthcare practitioner with training in concussion management.

How can exercise therapy help?

A closely monitored active rehabilitation program, including controlled, sub-symptom-threshold, submaximal exercise is considered safe and may be beneficial to support recovery.1

Many studies show reduced blood flow in the early stages after a concussion, which may continue for some time after the injury.2,3,4 This may be why patients feel better when completely resting, but experience symptoms when they become physically or mentally active. Getting up, walking around, going to work, scrolling an iPad or reading a book can increase symptoms and make them feel worse following a period of rest.

The way the body and brain distributes blood after a concussion may be impaired. The blood is not going to the right places. Therefore, a specific, graded and guided exercise program can help to improve blood flow in the brain. This program has been proven to reduce concussion symptoms such as dizziness, headaches or confusion, for example.5,6,7

Having the exercise program supervised by a licensed healthcare practitioner is critical. A healthcare practitioner with training in concussion and exercise therapy can help to establish benchmarks, set points and develop a tailored approach for each patient.

What about manual therapy?

Injury or dysfunction of the neck can have the same symptoms of a concussion. Dizziness, headaches, balance problems, nausea, visual and hearing disturbances, brain blood flow issues, and reduced mental function are associated with both concussion and neck injuries, such as whiplash.8

Manual therapy of the neck

Manual therapy of the neck can help to reduce concussion symptoms.

Having a patient undergo a thorough neck examination by a licensed healthcare practitioner can help to address any underlying neck problems that may be contributing to symptoms. Importantly, many of these symptoms can be treated with manual or physical therapy of the neck by a physiotherapist, chiropractor, or other licensed healthcare professional.

For more information about exercise therapy or manual therapy following a concussion, visit our website to find a clinic near you.


1 McCrory et al. Consensus statement on concussion in sport – 5th international conference on concussion in sport held in Berlin, October 2016. BJSM. 2017.

2 Leddy JJ et al. Regulatory and autoregulatory physiological dysfunction as a primary characteristic of post-concussion syndrome: implications for treatment. NeuroRehabilitation. 2007;22(3):199–205.

3 Bartnik-Olson BL et al. Impaired neurovascular unit function contributes to persistent symptoms after concussion: a pilot study. Journal of Neurotrauma. 2014.

4 Len TK and Neary JP. Cerebrovascular pathophysiology following mild traumatic brain injury. Clinical Physiology and Functional Imaging. 2010.

5 Baker JG et al. Return to full functioning after graded exercise assessment and progressive exercise treatment of post-concussion syndrome. Rehabilitation Research and Practice. 2012;1–7.

6 Leddy JJ et al. Exercise treatment for post-concussion syndrome. Journal of Head Trauma Rehabilitation. 2013;28(4):241–9.

7 Leddy JJ et al. A preliminary study of sub-symptom threshold exercise training for refractory post-concussion syndrome. Clin J Sport Med. 2010;20(1):21–7.

8 Marshall CM et al. The role of the cervical spine in post-concussion syndrome. Phys Sportsmed. 2015;43(3):274–84.

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