Concussion Rehab Exercises: Tools to Support Recovery and Safe Return to Play

Aerobic Exercise: Setting the Foundation for Recovery

The autonomic nervous system plays a critical role in regulating cardiovascular responses to exercise. After a concussion, many athletes exhibit dysautonomia—characterized by heart rate variability changes and poor exercise tolerance. Subthreshold aerobic exercise, performed at an intensity below the symptom exacerbation threshold, can help restore autonomic balance.

A study published in JAMA Pediatrics found that early subthreshold aerobic exercise resulted in faster recovery than stretching-based control interventions among adolescents with sport-related concussions (source). Participants exercised on treadmills or stationary bikes at 80% of their symptom threshold, guided by daily symptom monitoring.

Clinical implementation involves a controlled environment—ideally supervised by a physical therapist or athletic trainer—with structured protocols like the Buffalo Concussion Treadmill Test to determine safe heart rate zones. The goal is to promote cerebral autoregulation without provoking symptoms.

Vestibular Rehabilitation: A Key Intervention for Persistent Dizziness and Visual Disturbance

Vestibular dysfunction is one of the most common reasons athletes remain symptomatic post-concussion. Complaints such as dizziness, imbalance, and motion sensitivity often stem from impaired vestibulo-ocular reflexes and cervical-vestibular integration.

Vestibular Rehabilitation Therapy (VRT) aims to restore gaze stability, postural control, and sensory integration through a variety of exercises—typically including gaze stabilization, habituation, and dynamic balance challenges.

A 2023 systematic review of VRT for athletes with persistent dizziness found measurable improvements in dizziness severity and functional performance, though the evidence base calls for further randomized controlled trials (source).

Another review focused specifically on pediatric populations showed that structured VRT protocols—30 to 60-minute sessions, 1–2 times per week for 4–10 weeks—helped improve vestibular function and balance control in children recovering from concussion (source).

In clinical settings, therapists often use the Vestibular/Ocular Motor Screening (VOMS) tool to assess deficits and guide therapy plans. Exercises such as smooth pursuit, saccadic eye movements, and visual motion sensitivity training are introduced gradually based on symptom response.

Balance and Dual-Task Training: Bridging the Gap to Sport

Balance impairment is one of the earliest observable deficits following a concussion. However, traditional static balance testing may not reflect the dynamic demands of sport. Incorporating dual-task balance exercises—where athletes perform cognitive tasks while maintaining postural control—better mimics return-to-play scenarios.

Postural stability training is particularly relevant in sports requiring rapid direction changes, proprioception, and visual-motor coordination. Integration of foam surfaces, reactive balance boards, and perturbation training adds complexity and challenge.

A 2023 systematic review on physical therapy interventions confirmed that multimodal approaches—combining aerobic activity, vestibular work, and balance training—produce faster return-to-play outcomes than single-modality or rest-alone protocols (source).

Rehabilitation professionals should tailor balance activities to sport-specific requirements, progressing from single-leg stances to agility ladders, plyometrics, and reactive decision-making drills, ensuring they align with the athlete’s cognitive and physical readiness.

Clinical Scenario: Integrating Rehab into a Return-to-Play Protocol

Consider a 16-year-old soccer player evaluated 48 hours post-concussion with symptoms of mild dizziness, fogginess, and light sensitivity. Initial management includes daily symptom tracking, academic accommodations, and hydration support. By day 4, symptoms plateau, and supervised subthreshold aerobic exercise begins on a stationary bike at 60% of symptom threshold heart rate.

By day 7, vestibular screening indicates provocation with VOR testing, so the athlete begins gaze stabilization exercises paired with walking. Balance training is introduced using foam pads with eyes closed and later progressed to dual-task drills. The athlete is symptom-free by day 14 and progresses through a 5-step exertion protocol under athletic trainer supervision.

By day 18, neurocognitive scores return to baseline, and the athlete completes full-contact practice without incident. Clearance is granted following a collaborative review between the athletic trainer, physician, and coaching staff—consistent with the staged return-to-play model.

Addressing Barriers: Timing, Resources, and Education

Despite growing evidence, some programs remain hesitant to initiate early rehabilitation due to liability concerns or outdated protocols. Additionally, access to vestibular-trained clinicians or aerobic testing tools may be limited in certain school systems.

Education remains critical. Athletic trainers and physical therapists are uniquely positioned to advocate for evidence-based protocols within their settings. When time and resources are constrained, integrating short, guided exercises into daily injury check-ins or using mobile symptom tracking can support consistency.

Collaboration with physicians and administrators is equally essential. A shared understanding of recovery timelines, evidence thresholds, and risk-reduction strategies helps ensure the entire care team supports the athlete’s progression.

Summary and Clinical Considerations

Research has clearly moved the field of concussion recovery from passive rest to active, individualized rehabilitation. Safe and timely return to play hinges on exercise prescription that is functional, targeted and adaptable.

• Subthreshold aerobic exercise can safely begin within days of injury, helping to reset autonomic function and shorten symptom duration.
• Vestibular rehabilitation addresses one of the leading causes of persistent symptoms—dizziness—and improves gaze stability and postural control.
• Balance and dual-task training support real-world sport demands and aid in preventing secondary injury by restoring neuromuscular control.

The message to athletic professionals is clear: exercise isn’t just safe—it’s essential. With proper assessment tools, clinical monitoring, and interdisciplinary teamwork, rehab exercises empower athletes to recover with confidence and return safely to the sports they love.