Can Exercise be an Effective Treatment for Concussions?

by Sean Phillips, PT, DPT, OCS

Sports-related concussion (SRC) is a very common sports injury in America and can affect people of all ages. Concussions are a physiological event in which the brain and head are rapidly moved, typically as a result of a hit or sudden loss of momentum. Although the CDC classifies concussions as a mild traumatic brain injury (TBI), the symptoms can be severely limiting and long-lasting. In the article, “Exercise is Medicine for Concussions” by Leddy et al., researchers reviewed the treatment approaches for athletes with concussions utilizing low-threshold exercise intensity for rehabilitation. 

Concussions can produce many symptoms in an athlete, but one of the most common is exercise intolerance. Current research suggests that this is caused by a concussion’s effects on an individual’s autonomic nervous system (ANS), which plays a large role in respiration. When the ANS is damaged, ventilation can be limited in proportion to activity or exercise intensity leading to an accumulation of CO2 in the arterial blood (PaCO2). Once this occurs the cerebral blood flow will also be out of proportion to exercise and produce the intolerance that many people display. 

Through a variety of experimental and observational data, researchers have identified that sub-threshold aerobic exercise can help normalize these levels and reduce a person’s symptoms. Therefore, exercise is essentially “medicine” for athletes or individuals recovering from a concussion. 

This article reviewed two different techniques of finding the proper heart rate dosing for the correct level of sub-threshold exercises. These included the Buffalo Concussion Treadmill Test (BCTT) and Buffalo Concussion Bike Test (BCBT). Once the target heart rate is determined, an individual may be able to safely speed recovery from a concussion. This is most effectively accomplished with consistent supervision from an experienced healthcare professional such as a physical therapist in order to ensure the athlete stays within his or her target levels. 

In conclusion, this article provided evidence for safe and effective ways to reduce or prevent prolonged symptoms from SRC utilizing individualized exercise dosing and monitoring. If you are experiencing any lingering exercise intolerance following a concussion, consult your doctor or contact a physical therapist near you to help return to your normal levels. 


Article: Exercise is Medicine for Concussions; Leddy JJ, Haider MN, Ellis M, Willer BS; Curr Sports Med Rep. 2018 August ; 17(8): 262–270. doi:10.1249/JSR.0000000000000505


A Proposed Return-to-Sport Program for Patients With Midportion Achilles Tendinopathy: Rationale and Implementation

Article summarized by: Evan Peterson PT, DPT

Achilles injuries, more specifically tendinopathies, are one of the most common injuries seen by physical therapists. Achilles Tendinopathy is an overuse injury which typically causes pain at the insertion of the tendon near the heel or at the mid portion of the tendon. This injury has a propensity to last for several years without proper rehabilitation. Typically, the injury is brought on by excessive utilization of the tendon or increasing intensity of training to rapidly. Unfortunately, reoccurrence or re-injury of the tendon is high with too little time in between rehabilitation and returning to usual activities. This specific article being reviewed had the goal of creating a return to sport program for those with mid portion Achilles tendinopathy injuries.

What Is Achilles Tendinopathy?

As described above, Achilles tendinopathy is an overuse injury which has hallmark signs such as swelling, pain, and impaired performance of function. The diagnosis of insertional versus mid portion is based on the distance from the calcaneus (heel). Mid portion is typically located 2-6 cm above the calcaneus whereas insertion is located at the bottom of the heel. Mid portion tends to be the more common of the two at 55-65% of all cases of Achilles tendinopathy. Both are categorized by pain, stiffness in the morning, tenderness to palpation or a thickening of the tendon, and gradual onset of pain and symptoms.

How Do We Treat It?

The treatment of Achilles tendinopathy has been extensively researched and has several systematic reviews investigating numerous interventions. Exercise time and again has shown significant benefits for Achilles rehabilitation, more specifically eccentric exercises. Many other interventions have shown benefits such as orthoses, shockwave therapy, and low-level laser but none as effective as exercise when used in isolation. There has been some evidence that the use of low-level laser or shockwave therapy alongside exercise can help to speed recovery.

What Exercise is Specifically Used?

At the present moment, exercise for Achilles tendinopathy revolves around eccentric heel raise activities with knee both bent and straight. It is suggested each exercise be performed 2x daily for 15 repetitions of 3 sets. This is a model that has been shown effective in the athletic population but has had mixed results in the general population. Therefore, it has been suggested that a more fine-tuned approach is important, considering age, sex, and activity level, in order to properly dose the intervention. More often it is suggested to utilize a numeric pain rating scale (NPRS) to establish the correct loading during exercise.

When Can the Patient Return to Sport?

When attempting to return to participation in sport, it is important to have gradual progression and loading of the tendon with adequate recovery in order to prevent re-injury after return to sport. Re-injury rate in soccer players was shown to be 27% to 44% when returning to sport to soon or with inadequate recovery. The clinician should be aware of symptoms the following day after sport activities that include stiffness, pain, and swelling. These are good indicators of readiness for returning to full activity. Some research advocates for no running or jumping until symptoms have subsided; however, others believe this is not always necessary. Instead there are numerous factors that must be considered when implementing a return to sport program. The level of pain with physical activity should be considered as well as the healing time of the tendon, the strength, range of motion, and functionality of the Achilles, and the physical demands of the specific sport.

Major Principles

The most important aspect of return to sport for Achilles tendinopathy is to progressively load the tendon while considering the intensity, duration, and frequency of the forces placed on the tendon. Before a patient begins jumping and running the patient should have a maximum of 2/10 pain while performing activities of daily living. Rehabilitation should be performed daily, despite having performed plyometric tasks during that day. One of the most important steps in returning an athlete to their sport, is to educate the patient on healing times and instilling a routine to increase adherence as they move closer to participating in sport again. The athlete must also understand the differences between light, medium, and heavy activities. These can be classified by pain during and after the activity performed. These activities are fluid and can change based on the patient’s response to pain.

Physical Therapy First

At Physical Therapy First, the therapists are trained to work with athletes or recreational athletes to implement plans of care that allow a person to return to their sport of choice. We utilize the aspects discussed in this article to minimize reoccurrence of injury when the patient feels they are ready to begin participation again. If you are someone who has experienced Achilles pain in the past or are currently experiencing Achilles pain, we here at Physical Therapy First are here to assist you.


A Proposed Return-to-Sport Program for Patients With Midportion Achilles Tendinopathy: Rationale and Implementation | Journal of Orthopaedic & Sports Physical Therapy (

Gut Check on holistic treatment of Parkinson’s

Summarized by Mark Boyland PT,DPT, CSCS 

This was an interesting perspective paper due to the implications it has on how we can potentially test for Parkinson’s earlier and opens up avenues for treatment methods in a holistic style incorporating diet and nutrition in addition to exercise and pharmaceuticals.  While this perspective primarily focuses on Parkinson’s Disease, the paper also mentions potential effects on other conditions including Alzheimer’s and Huntington’s.

Parkinson’s is the second most common neurodegenerative disorder.  It has been primarily thought to be a brain disorder.  However there have been suggestions that changes in the gut microbiome, gut dysbiosis, could be linked to Parkinson’s.  Common symptoms of gut microbiome disruptions include constipation and increased inflammation.  Neurodegenerative diseases such as Alzheimer’s, Huntington’s, and Parkinson’s gut dysbiosis has been linked to cognitive impairments/reduced performance and motor dysfunction. Motor dysfunction includes postural instability and gait impairments. The authors indicate that dysbiosis can be improved with exercise, which calls to question how? 

First, we must understand how dysbiosis can affect the brain.  The gut biome regulates immune function, signaling of neurotransmitters including dopamine (over 50% of dopamine production comes from the gut), and metabolism support.  If there is disruption in our gut (dysbiosis) the impacts include increased inflammation, decreased neurotransmitter signaling, and deregulates metabolic function.  This perspective paper suggests that Parkinson’s can begin at the gut level and that as the condition progresses it impacts the motor system progressively.

As mentioned previously, exercise can restore the gut microbiome.  In those without Parkson’s having higher exercise capacity (aerobic/muscular strength) has been associated with higher bacterial diversity and reduced gut inflammation.  Restoration of the gut microbiome comes with both aerobic and resistance based exercise.  There are some differences in the benefits provided by each exercise modality however resistance exercise has been less studied at this point. 

Exercise to promote physical capacity may not be the sole factor for improving patient outcomes however.  For those with Parkinson’s exercise is now integral to their care but could be related to learning new skills which helps to keep the brain plastic (neuroplasticity). Additionally, as we begin to exercise more we also tend to eat a greater variety of healthy foods which could promote holistic changes as well. 

The gut and its bacteria are the recent quick fix hot topic but may have implications for our future in prevention and care of neurodegenerative conditions and maybe more.  Further research and study is required to establish a better understanding of the gut biome and it’s relation to our health at this time. Fortunately, improving gut health can be as simple as completing regular exercise and meeting the daily activity recommendations of the AHA as opposed to taking an unknown pill or supplement.  Eat well, stay active, be well

Direct link to article:

2022 Bern Consensus Statement on Shoulder Injury Prevention, Rehabilitation, and Return to Sport for Athletes at All Participation Levels

Article Reviewed by: Evan Peterson PT, DPT

“Return to sport” (RTS) has been a topic of discussion throughout the physical therapy community and has been researched for a variety of sports related injuries. One of the most common injuries looked at is ACL reconstruction or other lower extremity injuries. Not as widely discussed in return to sport is for athletes with shoulder injuries. In response to minimal high-quality evidence or guidelines to direct the return to sport decision making process, The Athlete Shoulder Consensus Group convened. Their goal was to create guidelines for clinicians, athletes, and coaches in order to provide the best quality care following shoulder injury. This particular statement was ascertained through the use of several rounds of questionnaires to obtain a consensus for rehabilitation in athletes. Following these surveys, the group had an in person discussion to solidify the results of the questionnaires. The consensus that was established is categorized into 4 main points. 1) Managing injury risk 2) Managing and progressing load 3) Shoulder injury rehabilitation and 4) evidence to support RTS decisions.

Managing Injury Risk

One of the first ideas brought up in managing risk is to understand the risk factors and predispositions athletes my have for each sport, as each sport involves different types of shoulder mechanics. Some risk factors have been pulled out that encompass many shoulder related sports include: loss of ROM, strength imbalances in rotational planes, change in load, player positions, level of sport (i.e. amateur or professional), previous history of shoulder injury, and psychosocial aspects. Attempting to screen athletes to prevent injury has not shown good evidence; however, it may be important for the RTS decision making process.

The consensus agreed that injury risk can be managed with both primary and secondary prevention programs. Primary programs should be initiated at young ages, particularly in overhead athletes, to allow decreased injury rates and increase the likelihood of adhering to healthy shoulder programs. It is recommended that secondary programs begin soon after injury. The article discusses general principles for training, including sport specific exercise, multiple joint exercises, emphasis on team training, and programs that take no more than 15 minutes at a time. They suggest these programs should be done at a minimum of twice per week to encourage adherence and self-efficacy.

Managing Shoulder Specific Loads in Athletes

Two types of load exist in the shoulder athlete. There is the external load such as a swimming pool’s resistance or the number of pitches in a game. Then there is the internal load, which is the physiological forces placed on the shoulder. It has been difficult to determine which of these factors is most important when managing load and currently there is no measure in order to determine the internal load. External load is much easier to measure (for example, number of pitches thrown); however, in games such as handball it is hard to have a “pitch count” due to the more chaotic nature of the game. At the consensus meeting, it was proposed to utilize a rating of perceived exertion scale to measure the internal load the shoulder. A combination of perceived exertion of the shoulder and overall fatigue of the body are good indicators to help assess a patient’s overall load. One study supported the idea that decreased external shoulder rotation strength or scapular dyskinesis is an indicator of decreased tolerance for load during sport.

Key Principles for Quality Rehab After Shoulder Injury in Athletes

Experts at the consensus meeting agreed that rehabilitation programs should emphasis on:

  • Improving sport specific mechanics
  • Challenging the patient in rehab at the limit of their capacity
  • Building resilience in patients’ ability to load at the physiological and physiological level
  • Multi-disciplinary decision making

The Key principles proposed are as follows:

  • Let Irritability Guide Rehab Process
  • Address Glenohumeral Range of Motion Deficits Using Active Therapy
  • Address the Scapula but Do Not Screen for Dyskinesis
  • Injury Tolerated Exercises
  • Introduce Plyometric Activities Early
  • Retrain the Brain/ Expose Shoulder to Fearful Positions Safely
  • Sport Specific Tasks
  • The consensus suggested objective repeated measures on a weekly basis to assess response to rehab

Return to Sport

The authors suggest that “Return to Sport” is a continuum consisting of three aspects: Return to participation, Return to sport, and Return to performance.

  • Return to Participation: the athlete is continuing rehabilitation, but participating in modified training in their sport at a level lower than their usual; they are not physically or psychologically ready for regular sport activities.
  • Return to Sport: the athlete can return to their sport but is not performing at an optimal level or their desired level
  • Return to Performance: the athlete is performing at their usual level without any restrictions

6 Domains to Consider when Returning to Sport

  • Pain: pain may be present when returning to participation but should not be present in return to performance
  • Active Shoulder Joint ROM: this is a sport specific criterion and should be evaluated as such. For example, pitchers require much more rotational ROM as compared to a collision athlete (i.e. football)
  • Strength, Power, Endurance: the importance of each is sport specific; however, the importance of overall strength in internal and external rotation as well as shoulder stability is crucial for return to sport
  • Kinetic Chain: be able to identify issues outside of the shoulder including the elbow, wrist, and thoracic spine
  • Psychological Readiness: athletes must be able to demonstrate confidence in muscle testing or activities that cause collisions before returning to participation and sport
  • Sport Specific: if possible compare to norms of other athletes in sport to determine readiness for play


One of the major takeaways from this consensus is that there is room for improvement in how we measure athlete performance in rehab and how to prevent injuries from happening/reoccurring. This consensus did however highlight the importance of multidisciplinary and all-encompassing approach for an athlete to return to their sport following injury.

Here at Physical Therapy First, therapists are trained to assess for shoulder abnormalities and detect faulty mechanics in those who have shoulder pain or sport injury. We also look to work with the patient and all involved with their care to prevent future injuries while returning to a high level of performance.


Schwank A, Blazey P, Asker M, Møller M, Hägglund M, Gard S, Skazalski C, Haugsbø Andersson S, Horsley I, Whiteley R, Cools AM, Bizzini M, Ardern CL. 2022 Bern Consensus Statement on Shoulder Injury Prevention, Rehabilitation, and Return to Sport for Athletes at All Participation Levels. J Orthop Sports Phys Ther. 2022 Jan;52(1):11-28. doi: 10.2519/jospt.2022.10952. PMID: 34972489

Aerobic and Resistance Training for Individuals with Spinal Cord Injuries: a summary

by Mark Boyland, PT, DPT, CSCS

The joy of training allows for many populations of people to be able to exercise and as trainers and strength coaches we need to be aware of individual differences between some of these unique populations. There are some considerations to make prior to training a client with a spinal cord injury however they fall into the same targets set by the ACSM and AHA for exercise targets: 75 minutes of vigorous aerobic activity or 150 minutes of moderate aerobic activity per week or some combination of these with the exercise sessions spread throughout the week. Strength training and stretching should also be performed multiple days per week focusing on total body strengthening/stretching. While there are more significant considerations to be made in regards to creating a fitness plan for your client with a spinal cord injury these plans should be specific to their current presentation and their goals.

At this time there are about 300,000 people in the United States with a spinal cord injury, or approximately 10% of the current US population, meaning there is a good chance for a potential client with a spinal cord injury could come through your door trying to maintain or improve their health and wellness. Considerations for these clients include: partial/incomplete injury, level of the client’s injury, paraplegia/tetraplegia, overuse injuries, autonomic dysreflexia, and current medications. Considerations for you and your gym are temperature/humidity control and accessibility in regards to parking, accessing the gym from the outside, as well as being able to navigate between equipment at your gym while using a wheelchair or other assistive device.

Regarding your client’s specific considerations in regards to their injury: a complete spinal cord injury is one that results in a total loss of sensation and motor activity including the lowest sacral nerve levels. An incomplete spinal cord injury is where there is still partial sensation or motor activity below the level of injury. Most spinal cord injuries results in tetraplegia with 59.5% of spinal cord injuries being considered tetraplegic and only about 40% of injuries being considered paraplegic. About two-thirds of spinal cord injuries are a result of vehicular accidents or falls. Another consideration is the level of the patient’s injury and their ASIA score. The ASIA score describes the amount of sensation/motor function available to the patient based on their injury level. There are online resources to explore each level and what motions/sensations are preserved based on the patient’s level of injury. An additional consideration is your client’s medications. Your client may be on several medications that are directly related to their injury and other non spinal cord injury related conditions so be sure to review their medications, the intended effects, side effects, and red flags prior to beginning working with your client. While this article and blog are meant to cover the basics of working with clients with spinal cord injuries it cannot be an exhaustive review especially when considering medications. Commonly spinal cord injury patients may be placed on medication for pain management, tricyclic drugs, antispasmodics, bladder control, and autonomic dysreflexia. Common side effects of medications across these classes include but not limited to: drowsiness, dizziness, fatigue, sedation, and weakness which could lead to generally reduced exercise tolerance and balance.

Client and gym/training center considerations include being aware that due to the loss of neurological control beyond the level of injury there can be negative reactions that your client may experience while training with you. These include your client overheating due to a loss of the ability to sweat below the level of their injury so a gym that is excessively hot/humid can cause a negative reaction. Make sure to monitor your client’s status while training with them to avoid overheating and monitor the ambient temperature/humidity of your training facility. Another serious reaction is Autonomic Dysreflexia. Autonomic Dysreflexia is a reaction to a noxious stimulus which can result in: abnormal systolic blood pressure elevation of greater than 20 mmHg, pounding headache, flushing above the level of the injury, increased heart rate, and can also be asymptomatic. Autonomic Dysreflexia can also be asymptomatic and can become life threatening quickly. Common causes for Autonomic Dysreflexia include muscle spasms, pressure sores, bladder/bowel distension, lower extremity injuries (broken bones). One of the most common causes is due to a kinked catheter which results in an inability to empty the bladder resulting in a back up of urine in the bladder.

Having gone past the major considerations clients with spinal cord injuries coming to you are similar to clients without a spinal cord injury. Their training to should be specific to their needs/goals and with what they are capable of doing. Initially clients with spinal cord injuries may only be able to tolerate 1 or 2 sessions of aerobic/resistance training per week using an arm crank ergometer, Nustep, or wheel chair treadmill for aerobic conditioning. For a beginner resistance training program the use of household items such as can is advised, however you can also use dumbbells, elastic bands/tubes, wrist weights. As your client progresses they can advance their resistance training with use of machine-based resistance training, dumbbells, and medicine balls. You can progress your clients to multiple training sessions per week progressively increasing the duration/intensity to match the recommendations by the ACSM/AHA however you must consider that your clients may be reliant on their upper extremities for most of their daily activities and training. This increased use of their upper extremities to manage their daily life can result in overuse injuries so exercise programming to avoid overuse injuries is important.

Training clients with a spinal cord injury can be initially intimidating but so are most things that you are not familiar with. You can familiarize yourself with the levels of impairment present depending on the level of the injury, the ASIA scale, and reach out to your client’s Doctor’s and Therapists to form a relationship with them early on to help your client as a team. Keep your clients safe, don’t be afraid to ask questions, and always look to learn more.

For more details you can read the full article at the NSCA
Aerobic and Resistance Training for Individuals with Spinal Cord Injuries
Joshua M Miller, DHSc, CSCS, ACSM-EP
Department of Kinesiology and Nutrition, University of Illinois-Chicago, Chicago, Illinois
1. Following a spinal cord injury, if there is some feeling or activity lower than the injury site, this is called a(n) ____________ injury.
b. Incomplete

2. How many people in the United States are likely living with a spinal cord injury at this moment?
c. Nearly 300,000

3. Which of the following is the most accurate representation of the amount of spinal cord injuries that result in paralysis of the lower body?
b. Less than 1/2

4. Which of the following recommendations for training is true for both paraplegics and tetraplegics?
c. 75 minutes per week of vigorous aerobic activity

5. Thermoregulation is a major environmental concern in those with a spinal cord injury due to _______________.
c. The inability to sweat below the level of the injury

6. Which of the following would be considered an advanced resistance training method for those with a spinal cord injury?
b. Dumbbells and resistance machines

7. Acute changes in systolic blood pressure during exercise can be an issue in those with spinal cord injuries and it is primarily due to _____________.
a. The lack of communication between the nerves and brain below the injury site

8. A common site of overuse injury related to locomotion in those with spinal cord injuries is __________.
c. The shoulder

9. A frequent side effect of medication on exercise in clients with spinal cord injuries is ____________.
b. A reduction in exercise capacity

10. A frequent potential adverse effect of pain and antispasmodic medication is __________.
a. Dizziness