Welcome to Stay in the Game, a monthly blog where the team from The Queen's Health Systems share the latest tips on the treatment and prevention of sports injuries. We want to help you play hard and be well - a winning combination that will keep you in the game all season long.

Exertional therapy for concussions


What is 'exertional therapy?'

Exertional therapy is a gradual exercise approach to help athletes and others with concussions return to their sport or activities in a safe and systematic way.  An exertional exam such as the Buffalo Concussion Bike or Treadmill Test is helpful in placing a patient at the appropriate exertion levels. This therapy may be performed under the guidance of licensed physical therapist or athletic trainer.

Who may be a good candidate for exertional therapy?

The current recommendation to initiate exertional therapy is after approximately 24-48 hours of deliberate rest. The best candidates to participate in exertional therapy are:

• Athletes with minimal or no concussion symptoms at rest
• Athletes who may be symptomatic or experience chronic Post Concussion Symptoms (PCS)
• Those who are anxious or have experienced depression symptoms
• Those who suffer from migraines (within reason)

Athletes who engage in moderate levels of activity, both in school and in normal physical exercise, have the best performance when tested with the computerized ImPACT assessment after a concussion.  This research compared athletes who were either given complete rest and athletes who were allowed to return to full participation and high levels of activity early on.

What happens if we don't exert concussed patients?

Research suggests that without a gradual return to activity, concussion symptoms may contribute to increased stress, inability to return to school or work, becoming deconditioned, a loss of social and support network, or mood dysregulation with increased irritability.

What are the stages of a graduated return-to-sport plan?

The International Conference on Concussion in Sport, held in Berlin in October 2016, outlined six recommended stages for an athlete to return to play.

• Stage 1:  symptom-limited activity, including a gradual reintroduction of school or work activities.
• Stage 2:  light aerobic exercise, with the goal to gradually increase heart rate.
• Stage 3:  sport-specific exercise, to begin adding in more movement.
• Stage 4:  non-contact training drills, to increase exercise, coordination, and mental thinking.
• Stage 5:  full contact practice, to restore confidence and assess the athlete's functional skills.
• Stage 6:  return to sport, with full unrestricted game play.

Stay tuned for more updates on concussions next month, as we continue to discuss different types of concussion treatment. In the meantime, for questions on concussion prevention or treatment contact our experts at the Queen's Center for Sports Medicine at 808-691-4449 or click the link below.

Request an Appointment


Materials referenced from:

• Majerske, et al. Concussion in Sports: Post concussive Activity Levels, Symptoms, and Neurocognitive Performance. 2008. Journal of Athletic Training. 43(3): 265-274.
• McCrory, et al. Consensus statement on concussion in sport - the 5th international conference on concussion in sport held in Berlin. Oct 2016. Br J Sports Med. Apr 2017. 51(11): 838-47.


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