What are the guidelines for a patient to return to the gym after experiencing a concussion?

Return to Gym After Concussion

Patients should not return to any gym activities on the day of concussion, must be completely asymptomatic at rest before beginning any exercise, and should follow a minimum 5-day graduated return-to-exercise protocol with each step lasting at least 24 hours. 1

Initial Rest Period

• Complete physical and cognitive rest is required for 24-48 hours immediately after concussion 1, 2
• All physical exertion must be avoided until the patient is asymptomatic at rest 1
• Most concussions resolve within 7-10 days, though pediatric and adolescent patients often require longer recovery periods (7-10 days or more) compared to adults 1, 2
• Immediate removal from activity after concussion is associated with approximately 3 fewer days missed from sport and shorter symptom duration 3

Graduated Return-to-Exercise Protocol

Once asymptomatic at rest for 24 hours, begin the following stepwise progression: 1

Stage 1: Light Aerobic Activity

• Walking, swimming, or stationary cycling at <70% maximum heart rate 1
• No resistance exercises permitted 1
• Duration: Minimum 24 hours if asymptomatic 1

Stage 2: Moderate Aerobic Activity

• Increased cardiovascular exercise intensity 1
• May begin light resistance training 1
• Duration: Minimum 24 hours if asymptomatic 1

Stage 3: Heavy Non-Contact Exercise

• More complex resistance training and sport-specific drills without head impact 1
• Duration: Minimum 24 hours if asymptomatic 1

Stage 4: Full Training Activities

• After medical clearance from a healthcare professional experienced in concussion management 1
• Normal training activities may resume 1

Critical Management Rules

• If any symptoms return during any stage, immediately stop all activity 1
• Rest for 24 hours after symptoms resolve, then restart at the previous asymptomatic stage 1
• The minimum time to complete the full protocol is 5 days, assuming no symptom recurrence 1
• Never return to gym activities while taking medications to mask concussion symptoms, as this may hide worsening symptoms 1, 2

When to Seek Specialist Care

• Symptoms persisting beyond 10 days require multidisciplinary management by healthcare professionals experienced in concussion 1
• Patients with multiple prior concussions require more conservative timelines and specialist evaluation 1, 2
• Recent evidence supports that controlled subsymptom threshold exercise may benefit patients with prolonged symptoms (>4-6 weeks), but this requires supervised medical management 4, 5

Special Populations

• Pediatric and adolescent patients require more conservative management with longer cognitive recovery periods and should not rush return to activity 1, 2
• Pre-existing conditions (mood disorders, learning disorders, ADHD, migraines) complicate recovery and warrant closer monitoring 6

Common Pitfalls to Avoid

• Returning to gym activities on the same day of injury significantly increases risk of prolonged recovery 1, 3
• Progressing through stages faster than 24 hours per stage increases reinjury risk 1
• Exercising while still symptomatic at rest exacerbates the brain's metabolic crisis and prolongs recovery 1, 7
• Prolonged complete rest beyond 48 hours may actually hinder recovery and lead to deconditioning 7, 4, 5