Exercise is Medicine for Concussion

Sport-related concussion (SRC) is a physiological brain injury that produces cerebral and systemic effects, including exercise intolerance. Exercise intolerance after concussion is believed to be the result of autonomic nervous system (ANS) dysfunction. Ventilation is inappropriately low for the level of exercise intensity, raising arterial carbon dioxide (PaCO2) levels. Elevated PaCO2 increases cerebral blood flow (CBF) out of proportion to exercise intensity, which is associated with symptoms that limit exercise performance. Thus, elevated exercise PaCO2 may signal incomplete recovery from SRC. This article reviews recent observational and experimental data and presents the evidence that subthreshold aerobic exercise normalizes the cerebrovascular physiological dysfunction and is medicine for patients with concussion and persistent postconcussive symptoms (PPCS). It discusses the systematic evaluation of exercise tolerance after concussion using the Buffalo Concussion Treadmill Test (BCTT) and reviews the utility of the Buffalo Concussion Bike Test (BCBT), the data from which are used to establish an individualized heart rate dose of subthreshold exercise to safely speed recovery, which also may work in the acute recovery phase after SRC with the potential to reduce the incidence of PPCS. Evaluation and treatment approaches based on the physiology of concussion suggest that exercise is medicine for concussion, potentially adding a new dimension to concussion care to help safely speed recovery and prevent PPCS in some patients.