ISSA, International Sports Sciences Association, Certified Personal Trainer, ISSAonline, Post-Concussion Exercise—How to Program for Recovery

Safety and Injuries

Post-Concussion Exercise - How to Program for Recovery

Reading Time: 7 minutes 8 seconds


Date: 2021-07-09T00:00:00-04:00

Many personal trainers are aware of things like how to train clients who are recovering from an injury. It can be a slow and arduous process, ensuring that you're giving something that offers a challenge while remaining safe and within their physician's instructions.

But what about injuries beyond joint issues and surgeries? What about issues with the brain, like traumatic brain injury (TBI) and concussions?

When a client's injuries involve head trauma, it's important to play by a more cautious set of rules. Research is still being conducted on how to reintroduce exercise in a safely, but one thing holds supreme in this instruction: always defer to a client's doctor. Concussion management is no laughing matter, and your client's health is the most important.

Symptom exacerbation is a real risk when talking about any sort of head injury, and as such, it is essential that you follow their doctor's orders to the letter.

What is a Concussion?

A concussion is also known as a Mild Traumatic Brain Injury (MTBI). This often happens following some sort of impact to the head or body. Force moves through the body like a shockwave in some impacts, and as such, even if the head isn't directly impacted, a concussion can still result with enough force, or more often, from a whiplash effect from a body blow.

What are the Symptoms of a Concussion or MTBI?

According to the Mayo Clinic, common symptoms of concussion patients involve:

  • Fatigue

  • Nausea/vomiting

  • Headache

  • Ringing in the ears

  • Blurry vision

  • Sensitivity to light

  • Memory loss

  • Dizziness

Oftentimes, there will also be cognitive issues relating to concentration and focus, in addition to mood swings. These are just issues to be aware of in case your client has had a recent head injury and didn't seek medical attention.

It's essential that you keep an eye out for this and check in with your clients if they start showing persistent symptoms, just to make sure they haven't recently been injured. Sometimes, these symptoms will continue for months. This then becomes post-concussion syndrome (PCS), and PCS symptoms can be similar to the concussion itself.

If they have been injured, they should stop all training and get evaluated by a doctor immediately and seek treatment if deemed necessary by the physician.

When it comes to concussion rehabilitation, do not push your client back into exercise immediately. Persistent concussion symptoms and persistent post-concussive symptoms also mean that there will be a prolonged recovery. Even light exercise intensity too early in recovery can jeopardize the health and safety of your clients.

Returning to Physical Activity

From the beginning, personal trainers need to remember that their scope of practice does not involve diagnosing or treating conditions. It is essential that you work in concert with your client's doctor to determine what's right for them.

Concussion recovery will require a unique plan for each individual case, as different patients will have different exercise tolerance, and each one will have a unique symptom exacerbation threshold. This is the symptom threshold at which even light aerobic activity can make things worse. Symptom severity will likely vary from client to client.

Remember that, due to the nature of impact injuries, physical therapy might be required as well to tend to other injuries resulting from the same trauma.

Once a client has been given the OK by their doctor to return to moderate exercise, make sure you get a list of things to avoid. Start small, and keep in mind that you shouldn't gauge their workouts by your previous metrics. Progress will likely be lost, and this must be dealt with patiently to ensure your workouts don't make their condition worse.

Even though some studies have determined that physical activity can help with recovery, this is ultimately a medical decision and is outside the purview of a personal training certification.

How to Program for Recovery

Everything, when it comes to exercise post-concussion, is determined by one's exercise threshold. Sometimes, this means five minutes of walking on a treadmill is how they start back up. It's highly advisable that you monitor their heart rate throughout exercise to ensure that they aren't pushing themselves too hard too soon.

Patience is the name of the game in this. One of the best services you can offer a client during their sessions is monitoring them to ensure they don't accidentally harm themselves by pushing too hard.

Gauge the increase in activity by both their doctor's recommendation and how they're feeling. It can be miserable to even complete five minutes of aerobic exercise in this state. Grow slowly and gently increase the time.

Furthermore, it can be very productive to focus on very light balance and coordination exercises like standing on one foot and stretching. Turning your sessions from lifting and heavy exercise to light aerobic activity and balance training could seem extreme, but it will help your clients to start developing a tolerance to exercise.

This is a great time to focus on flexibility that often goes overlooked for the sake of heavier workouts. It's unfortunate that your client is in this circumstance, but this is a wonderful method of finding a silver lining.

By engaging in balance and stretching, you will also be helping them from a day-to-day perspective, as they will still need these skills in negotiating their lives.

So What Does This Look Like In Practice?

Just remember that no one program is going to be the solution. However, the following is a great outline that you can adapt for your own clients as needed.

Within 48 Hours of Injury

In this time frame, do not engage in any physical activity. The client should seek medical attention and get a determination about the severity of their concussion. Hopefully, this will include instructions and guidelines for returning to exercise as well.

Begin exercise again only with the approval of their physician.

Week 1 (Once Getting a Doctor's Approval to Exercise)

Focus: Very light aerobic activity.

In this period, it's likely that your client might not be able to do much more than five minutes of light cardio. This could be walking on a treadmill, or very light activity on a recumbent bike or elliptical machine.

Don't push it. Celebrate getting to five minutes. For many concussion patients, these five minutes can be miserable.

Talk to them about how their coordination is. Don't push too much more than this basic exercise until they start to develop a higher exercise tolerance.

At the end of the week, assess things like their heart rate during training and perceived exertion. Repeat this week as long as is necessary before moving on. Don't move on from this until it's safe to do.

Week 2

Focus: Very light aerobic activity with some balance work.

Similar to Week 1, you will want to only increase the time they're doing cardio for a few minutes at a time. Once they're capable of doing five minutes, graduate to seven minutes. Then ten. In this week, don't move beyond ten minutes just yet.

However, start adding in basic balance movements. Make sure there is a chair, a wall, or a bar to grab in case they need it. Some people will be severely constrained by balance, especially as they age.

Some basic seated stretches can also be useful, but don't push this too far. And definitely do not conduct any standing stretches. These increase the likelihood of injury from falls, as concussions can often cause dizziness and confusion.

Repeat this week as many times as necessary until your client shows improvement.

Week 3

Focus: Light aerobic activity with balance and stretch work.

Once they can engage in aerobic activity for 10-15 minutes, you can start to pick things up a little. Perhaps increase the treadmill speed or inclination a little, or the resistance in the recumbent bike. Make small, incremental progress so as to not overload the client.

Incorporate more involved balance exercises, and, at this point, start increasing the flexibility training. Even if they aren't able to workout like they were, this provides a great opportunity for making advances in flexibility while getting their balance back.

Repeat this week until the client improves.

Week 4

Focus: 20 mins aerobic activity 3x per week; balance and stretch

Note: Only incorporate resistance training when their doctor says it's ok!

Now try to increase aerobic activity to 20 minutes, three times per week. This might take a little pushing, but if their heart rate gets too high too quickly, go back to Week 3.

Also during this week, continue the balance exercises and stretch workouts. With their physician's approval, start working in very basic resistance exercises. Ideally, stick to resistance bands and heavily modified bodyweight exercises. Do not push this too far.


Ultimately, before your client gets back to workouts more intensive than this, they need to be totally free of concussion symptoms and they need to get approval from their physician. This can be a challenge for people who were very active prior to their concussion, but it is imperative that you check their desire to exercise hard again with the reality that hard exercise can make everything worse.

The worst thing you can do is make their situation worse. So just make sure that you're being as careful as possible to keep your client healthy and safe.

The essential elements for this are to check in regularly with your clients, how they're feeling after workouts, and how they recover. Make certain that they're getting adequate rest and recovery, as even basic effort will likely be exhausting.

If you're interested in learning more about how to safely train your clients during recovery, check out this article on active recovery to reduce fatigue.

Then take the next step and expand your knowledge with the ISSA Corrective Exercise Specialist Certification. This course is designed to help personal trainers identify and correct the most common movement dysfunctions. Sign up online and complete your course at your own pace from the comfort of your home!

ISSA, International Sports Sciences Association, Certified Personal Trainer, ISSAonline, Post-Concussion Exercise—How to Program for Recovery, Handout

Download this FREE handout here!

References 2021. What is a Concussion? | Brain Injury Research Institute. [online] Available at: [Accessed 9 June 2021]

Mayo Clinic. 2021. Concussion - Symptoms and causes. [online] Available at: [Accessed 9 June 2021]

Leddy, John J. MD, FACSM, FACP1; Haider, Mohammad N. MD1; Ellis, Michael MD, FRCSC2; Willer, Barry S. PhD3 Exercise is Medicine for Concussion, Current Sports Medicine Reports: August 2018 - Volume 17 - Issue 8 - p 262-270

doi: 10.1249/JSR.0000000000000505

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