Physical activity and recovery from sport-related concussion

Imagine you’re on the field, adrenaline pumping, and ready to give your all. Suddenly, a collision occurs, and everything changes in an instant. This is the reality of a sport-related concussion, which many athletes know all too well. A sport-related concussion is a brain injury that happens when a blow to the head or body during a sporting event causes the brain to move rapidly within the skull, leading to a temporary disruption of normal brain function (Patricios et al., 2023). Symptoms can include headaches, dizziness, forgetfulness, impaired vision, ringing in the ears, nausea, sensitivity to light, drowsiness, and difficulty concentrating (Patricios et al., 2023). These symptoms stem from functional disturbances in the brain (Patricios et al., 2023; McCrory et al., 2017). 

In recent years, there has been a shift in concussion management, moving away from the traditional method of complete rest and instead emphasizing active rehabilitation. This new approach highlights the benefits of early physical activity in recovery process, not only speeding up recovery but also helping athletes regain their physical and mental health more effectively (McCrory et al., 2013; McCrory et al., 2017). 

The impact of exercise on brain health 

Exercise is great for both the body and mind. Physiologically, it enhances brain function by improving blood flow, promoting neuronal plasticity, and reducing the risk of cognitive decline (Nishijima et al., 2016). Athletes, due to their high levels of physical activity, may have different brain profiles that potentially protect against the adverse effects of concussions (Tremblay et al., 2017; Gay & Slobounov, 2018; Prince et al., 2020; Taylor et al., 2015). Psychologically, exercise is linked to improved mental health, reducing symptoms of anxiety and depression in various populations, including healthy, overweight, and obese individuals (Elkington et al., 2017; Nezlek et al., 2018). Specifically, aerobic activity has been shown to decrease psychological distress and contribute to feelings of well-being in adults and adolescents (Elkington et al., 2017; McMahon et al., 2017). 

Helping athletes return to exercise soon after an injury can help them maintain the benefits of being active and in sport, which in turn may support their recovery. Studies, like the one done by Janelle Prince (2020), indicate that athletes who are used to regular exercise may struggle more with the inactivity that often follows a concussion compared to those who are less active. 

Exercise during the early stages of recovery 

In the past, the early stages of concussion recovery were managed with strict rest. However, new research suggests that complete rest after the first 24 to 48 hours can actually slow down recovery (Gupta, Summerville, & Senter, 2019; Leddy et al., 2019). Instead, engaging in light aerobic exercise that doesn’t worsen symptoms can be safe and effective especially when tailored to the individual athlete (Henke et al., 2020; Lempke et al., 2019).  

READ MORE: Concussion guide for parents and caregivers 

The idea, according to the new guidelines, is to keep the intensity level low enough to avoid significantly increasing symptoms. If they do rise, it shouldn’t be by more than 2 points in symptom severity (on a scale of 1-10) and shouldn’t last more than 1hour (Prince, 2023). 

Key findings from recent studies: 

1. Low-intensity exercise: Athletes who did low-intensity aerobic exercise like walking or stationary biking within the first 10 days post-concussion recovered faster than those who only stretched or rested (Henke et al., 2020). 
2. Personalized plans: Adolescents with customized aerobic exercise plans recovered more quickly, even if their symptoms were severe at the start (Chizuk et al., 2022). 
3. Reduced symptom duration: Early aerobic exercise was linked to reduced symptom duration and faster return to normal functioning, even among those at high risk for persistent post-concussion symptoms (PPCS) (Howell et al., 2022). 

Persistent Post-Concussion Symptoms (PPCS) and exercise 

For some athletes, concussion symptoms can last for weeks or months. When symptoms last more than 4 weeks, it’s known as persistent post-concussion symptoms (Patricios et al., 2023). Regular, structured aerobic activity may reduce the risk of PPCS, helping athletes return to sport sooner (Howell et al., 2019; Leddy et al., 2019). 

Key research insights: 

1. Reduced PPCS risk: Adolescents at moderate to high risk for PPCS who participated in an early, individualized aerobic exercise program were less likely to develop PPCS compared to those who received standard care without specific exercise recommendations (Howell et al., 2022). 
2. Long-term improvement: Adolescents who participated in sub-symptom threshold exercise programs continued to show symptom improvement up to 6 months post-intervention (Chrisman et al., 2019). 
3. Safe and effective: Mild to moderate aerobic exercise is safe for treating sport-related concussion and PPCS. After a sport-related concussion, both spontaneous physical activity and sub symptom threshold aerobic exercise are safe with the latter speeding up recovery and reducing symptoms in those with PPCS (Haider et al., 2021)​. 
4. Active rehabilitation programs: Programs including low-intensity aerobic exercise, sport-specific drills, relaxation exercises, and comprehensive education and support, have shown significant improvements in mood-related symptoms such as anger and anxiety in youth with PPCS (Hunt et al., 2020)​. 

Psychological effects of concussions 

Concussions can take a toll on an athlete’s mental health and well-being, leading to issues such as anxiety and depression. Getting athletes back to activity and sport, when cleared to do so, can help reduce the psychosocial consequences of these injuries by restoring their routine and participation in sports. While many athletes experience low levels of depression and anxiety that go away once they return to play, those with pre-existing or concurrent anxiety may face a higher risk for prolonged recovery (Hutchinson et al., 2017; Kontos et al., 2016; Turner et al., 2017; Broshek et al., 2015; Wiese-Bjornstal et al., 2015). 

READ MORE: The 4 R’s: Steps to a Safe Recovery 

Understanding these psychological aspects is essential for developing comprehensive care strategies that address both the physical and mental health needs of athletes recovering from concussions. Coaches and parents should be aware of the potential mental health implications, such as anxiety and depression, and look for signs of mental illness in their children or players who are recovering. Youth and adolescents often hide signs of mental illness or fear reaching out for help due to stigma (Ferrie, 2020). Therefore, parents and coaches should be vigilant in observing any signs of mental illness. If they notice changes in behaviour or signs of withdrawal, they should promptly seek help from a doctor or mental health professional.  

Fact or Myth: Children and youth who sustain a concussion have a higher risk of experiencing mental health issues than children and youth who experience other types of injuries. By Dr. Roger Zemek, MD, pediatric emergency physician at Children’s Hospital of Ontario (CHEO).  

Tailored support can facilitate better recovery outcomes and help athletes manage the dual challenges of physical injury and psychological distress, ultimately aiding their return to activity and sport. 

Moving forward with active recovery 

In light of the evolving understanding of sport-related concussions, there is strong evidence that active rehabilitation and individualized exercise can improve recovery outcomes. Early exercise can support both physical recovery and mental recovery post-injury. 

MORE INFORMATION: Living Guideline Return to Activity/Sports Protocol 

As we learn more about the complexities of concussion recovery, it’s crucial to continue exploring new approaches and refining our understanding of the best practices for helping athletes return to their sport safely and effectively. Those recovering from a concussion should adhere strictly to their physician’s recommendations.