Prescribed exercise after sport-related concussion promotes recovery, according to international systematic review

John Leddy watches as a study participant walks on a treadmill.

John Leddy watches as a study participant uses a treadmill in the UB Concussion Management Clinic. Photo: Douglas Levere

For the first time, prescribed aerobic exercise is being recommended early after concussion, validating the findings of multiple clinical trials led by UB researchers

Release Date: June 14, 2023

John Leddy.
“'Cocooning’ is officially out, and early, proactive advice and treatment are in. ”
John J. Leddy, MD, Clinical professor of orthopedics
Jacobs School of Medicine and Biomedical Sciences

BUFFALO, N.Y. – Prescribed aerobic exercise after a sport-related concussion speeds recovery, according to a systematic review and meta-analysis led by University at Buffalo researchers and published online on June 14 in the British Journal of Sports Medicine.

The UB paper is part of a special issue of the journal devoted to new scientific evidence and updated recommendations from the 6th International Conference on Concussion in Sport held in Amsterdam last fall. Released earlier this week, the new guidelines govern concussion management at the high school and college level, and throughout professional sports worldwide.

It is the first time that the Concussion in Sport Group is recommending that individuals who have had a sport-related concussion engage in physical activity, including prescribed aerobic exercise treatment, in the early days after concussion while still symptomatic.

John J. Leddy, MD, clinical professor of orthopaedics in the Jacobs School of Medicine and Biomedical Sciences at the University at Buffalo, is first author on the paper that examined rest and exercise immediately following a concussion.

For more than two decades, Leddy and colleague and co-author Barry Willer, PhD, professor of psychiatry in the Jacobs School, have been developing and studying prescribed aerobic exercise to speed recovery in individuals who’ve had a concussion.

“Early in their research, Dr. Leddy and Dr. Willer realized that prescribed exercise could benefit individuals who experienced a sport-related concussion,” said Allison Brashear, MD, vice president for health sciences and dean of the Jacobs School. “For clinician-researchers like them, there is nothing more gratifying than seeing their investigator-driven studies unequivocally impact the international standard of care.”

Barry S. Willer and John J. Leddy are photographed with a treadmill in Farber Hall. Their research through the UB Concussion Management Clinic developed the Buffalo Concussion Treadmill Test. Photographer: Douglas Levere.

John Leddy (right) and colleague Barry Willer were early advocates of using prescribed aerobic exercise to facilitate recovery from sport-related concussion. Photo: Douglas Levere

Through randomized clinical trials published in top journals, their method, known as the Buffalo Protocol, has been shown to not only facilitate faster recovery from sport-related concussion but, importantly, to prevent persisting post-concussive symptoms (PPCS) primarily in adolescents, the most vulnerable group. This regimen of prescribed exercise after a sport-related concussion is designed to be performed at the sub-symptom threshold heart rate identified on systematic exercise testing, meaning a level of exercise that doesn’t more than mildly exacerbate symptoms.

The new paper, based on a systematic review of more than 30 international studies, confirms the validity of using prescribed sub-threshold aerobic exercise starting as soon as 48 hours after a sport-related concussion to facilitate recovery and prevent PPCS. It also confirms that strict rest is unnecessary and can even be detrimental to recovery.

“I was pleasantly surprised by the consistency of the evidence,” said Leddy, who is also a physician with UBMD Orthopedics & Sports Medicine. “The studies clearly demonstrate a beneficial effect of early physical activity, such as walking and light activities of daily living, and of early prescribed exercise treatment for safely facilitating recovery from sport-related concussion and for preventing some athletes from having a delayed recovery.”

On average, the studies showed that early prescribed exercise resulted in recovery from concussion five days sooner than without prescribed exercise. Leddy added that is a typical school week for adolescents.

The paper notes that light physical activity is recommended starting within the first 48 hours after a concussion, provided it doesn’t exceed the mild symptom exacerbation threshold. The paper defined “mild” as no more than a 2-point increase in concussion symptoms when compared with the pre-activity value on a 0-10 point scale.

But, Leddy pointed out, prescribed exercise treatment is different.

“Prescribed exercise is based upon the individual’s response to exercise testing and uses progressive dosing of ‘exercise as medicine’ to treat concussion,” Leddy said, adding that this type of exercise keeps the heart rate below the point where symptoms worsen more than mildly.

The data showed that prescribed aerobic exercise that begins within 2-10 days following concussion is beneficial and speeds recovery; it also reduces the incidence of symptoms persisting beyond one month after injury, which is important because it is those students who suffer reduced quality of life and trouble returning to school and to sport.

“‘Cocooning’ is officially out,” said Leddy, “and early, proactive advice and treatment are in. It is no longer acceptable for clinicians to tell athletes after concussion to rest from all cognitive and physical activity until all their symptoms resolve. Patients should stop cognitive or physical activity that more than mildly increases symptoms but can resume after a brief period of relative rest once the symptoms return to the former level. This is particularly important for female adolescent athletes, who appear to have been particularly harmed by ‘cocooning.’”

Another major new message from the review and included in the new guidelines is that cognitive or physical activity that produces a mild increase in symptoms is safe. “Mild symptom exacerbation does not harm the brain or delay recovery from sport-related concussion,” he said.

In addition to Leddy and Willer from UB, other co-authors are Joel S. Burma, Alix Hayden, Paul E. Ronksley and Kathryn J. Schneider of the University of Calgary; Clodagh M. Toomey of the University of Limerick; Gavin A. Davis of the Murdoch Children’s Research Institute; Franz E. Babl of the University of Melbourne; Isabelle Gagnon of McGill University; Christopher C. Giza of UCLA; Brad G. Kurowski of the University of Cincinnati; and Noah D. Silverberg of the University of British Columbia.

Funding for the study was provided by the Organizing Committee for the Sixth International Consensus on Concussion in Sport.

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