Active Rehabilitation Protocol (ARP)

What is the Active Rehabilitation Protocol (ARP) for Traumatic Brain Injury (TBI)?

“Active Rehab” is the step-wise progression of light aerobic exercise used to reduce the length of concussion and post concussion syndrome. The benchmark for concussion management has long been complete cognitive and physical rest until concussive symptoms had fully resolved. These recommendations were based on long standing treatment practices with little evidence showing a positive effect on prognosis. However, recent evidence by The University of Pittsburg, Buffalo, Children’s Montreal, and McGill University Health Centre among others has shown that early return to controlled exercise reduces recovery time of simple concussions and secondary symptoms of concussions in the setting of prolonged symptoms. Specifically, improvements in physical symptoms, cognition, mood, sleep, and energy levels have all been documented with the proper exercise dose at the right time. Exactly when that right time is and what dose or intensity of controlled exercise is appropriate remains a complex question. The 5th concussion consensus released in April of 2017 by BJSM has heavily supported with the ARP as early as 24-48hrs post injury. However, because everyone’s injury is different it is critical that monitored exertional testing is performed in the clinic to determine how early and at what intensity the ARP may be initiated.

Who is a good candidate for the Active Rehabilitation Protocol (ARP)?

Patients diagnosed with TBI or Post Concussive Syndrome (PCS) with prolonged symptoms are potential candidates for Active Rehab. Even patients with secondary injuries that limit their ambulation may be able to participate with a modified program.  Patients with medical conditions that limit their ability to perform aerobic activity are unable to participate in Active Rehab.

When should I start active rehab?

Active rehab is typical begun between around 3 weeks after the onset of concussion in the general population. Patients will be tested for light exercise for 10 min (Step 1 of the ARP) and if they remain asymptomatic WITHOUT signs of neurogenic dysautonomia (abnormal control of cardiovascular response to exercise by the brain seen on cardiac monitoring) they may continue with Step 1 parameters at home for the next 1-2 weeks prior to returning to test for Step 2.  The ARP progression is a gradual 10-20% weekly increase of both intensity and duration as one progresses from Step 1 (light exercise) to Step 4 (maximal heart rate exercise).  New research published in the Journal of the American Medical Association in December of 2016 has shown that physical activity started within 7 days of acute concussion reduces the risk of prolonged symptoms. However, further clinical trials are need before current recommendations for active rehab can be safely changed.

How does active rehab help TBI?

The exact mechanism of how active rehab reduces the length of TBI/PCS is not completely understood. It has been proposed that aerobic exercise may increase blood flow to the brain and promote the formation of neurological connections.  In TBI neurological pathways are damaged and are unable to send electrical impulses efficiently. Active rehab provides the brain with the nutrition and oxygen to build new neurological pathways and improve cognition. Furthermore, exercise is directly linked to hormones that control mood, sleep, and energy, which can impact all other PCS symptoms.

What are the steps of the ARP and when can I progress to the next step?

Active Rehab is a progression of aerobic exercise from light to maximal exertion steps 1 through 4, followed by high intensity functional movements (Step 5). Patients typically increase their intensity every 1-2 weeks as long as they do not have worsening symptoms with exercise. Quicker progression may be possible under the supervision of a medical professional depending on exercise tolerance testing results. This should not be done by the patient on their own as it can increase the risk for prolonged and worsening symptoms. Each of the first 4 steps of the Active Rehab Protocol are based on a percentage of maximum heart rate (MHR) and rating of perceived exertion (RPE). RPE is a way of measuring physical activity intensity level. Perceived exertion is how hard you feel like your body is working. Step 5 integrates maximal exercise with functional movements to help transition athletes back to sport demands.

Below is the 5-step ARP:

Step 1 (Light intensity): 10-12 min 5-6 days a week at a heart rate of 100-120 (50-60% MHR) or RPE of 2-3/10.

Step 2 (Moderate intensity): 12-15 min 5-6 days at a heart rate of 120-140 (60-70% MHR) or RPE of 5-6/10.

Step 3 (Vigorous intensity): 15-18 min 5-6 days at a heart rate of 140-160 (70-80% MHR) or RPE of 6-7/10.

Step 4 (Maximal intensity): 20-25 min 3-5 days at a heart rate of 160-180 (80-90% MHR) or RPE of 8-9/10.

Step 5 (Functional movement at Maximal intensity): 30-45 min 3-5 days at maximal exertion (80-90% of MHR) performing advanced functional movement testing (multidirectional, plyometrics, proprioception, resistance, and cognitive integration). Patient cleared to participate in all non contact and low risk sports with multidirectional movement. Duration may be gradually increased back to full. Resistance training and lifting progression to normal. Advised to avoid high risk contact sports in the red zone until full clearance by MD.

*All steps are tested in the clinic with review of both subjective symptoms and/or objective signs of dysautonomia on continuous monitoring prior to progression.

What should I do if may symptoms worsen during Active Rehab?

Patients may experience exacerbation of their symptoms even though they had been asymptomatic with the same exertion on previous treatments. If this occurs the patient should stop aerobic exercise that day and rest. They may resume activity the next day at the same intensity. If they continue to have symptoms they should be downgraded to a lower step the next day and contact their physician. If patient become symptomatic during step 1 for consecutive days the patient should discontinue active rehab until seen by their physician.

What kind of exercise can I do for Active Rehab?

Any aerobic exercise that is low risk for repeat head trauma can be used in active rehab. For example, jogging, stationary bicycling and swimming are commonly used in active rehab. Once Step 4 is passed certain low risk sports such as swimming, track, and dance may be considered. Secondary injuries, such as knee injuries, should be considered when choosing what type of exercise can be used.

Are there any side effects for Active Rehab?

Side effects for active rehab are generally very low when the proper protocol is followed with testing prior to progression. Patients may experience acute worsening of symptoms during exercise. When this occurs the patient should follow the protocol above. Failure to follow the proper protocol may result in the worsening and prolongation symptoms.

Zachary Sprague, MD and Mo Mortazavi, MD
Updated Sept. 22, 2017

What is the Active Rehabilitation Protocol (ARP) for Traumatic Brain Injury (TBI)?

“Active Rehab” is the step-wise progression of light aerobic exercise used to reduce the length of concussion and post concussion syndrome. The benchmark for concussion management has long been complete cognitive and physical rest until concussive symptoms had fully resolved. These recommendations were based on long standing treatment practices with little evidence showing a positive effect on prognosis. However, recent evidence by The University of Pittsburg, Buffalo, Children’s Montreal, and McGill University Health Centre among others has shown that early return to controlled exercise reduces recovery time of simple concussions and secondary symptoms of concussions in the setting of prolonged symptoms. Specifically, improvements in physical symptoms, cognition, mood, sleep, and energy levels have all been documented with the proper exercise dose at the right time. Exactly when that right time is and what dose or intensity of controlled exercise is appropriate remains a complex question. The 5th concussion consensus released in April of 2017 by BJSM has heavily supported with the ARP as early as 24-48hrs post injury. However, because everyone’s injury is different it is critical that monitored exertional testing is performed in the clinic to determine how early and at what intensity the ARP may be initiated.

Who is a good candidate for the Active Rehabilitation Protocol (ARP)?

Patients diagnosed with TBI or Post Concussive Syndrome (PCS) with prolonged symptoms are potential candidates for Active Rehab. Even patients with secondary injuries that limit their ambulation may be able to participate with a modified program.  Patients with medical conditions that limit their ability to perform aerobic activity are unable to participate in Active Rehab.

When should I start active rehab?

Active rehab is typical begun between around 3 weeks after the onset of concussion in the general population. Patients will be tested for light exercise for 10 min (Step 1 of the ARP) and if they remain asymptomatic WITHOUT signs of neurogenic dysautonomia (abnormal control of cardiovascular response to exercise by the brain seen on cardiac monitoring) they may continue with Step 1 parameters at home for the next 1-2 weeks prior to returning to test for Step 2.  The ARP progression is a gradual 10-20% weekly increase of both intensity and duration as one progresses from Step 1 (light exercise) to Step 4 (maximal heart rate exercise).  New research published in the Journal of the American Medical Association in December of 2016 has shown that physical activity started within 7 days of acute concussion reduces the risk of prolonged symptoms. However, further clinical trials are need before current recommendations for active rehab can be safely changed.

How does active rehab help TBI?

The exact mechanism of how active rehab reduces the length of TBI/PCS is not completely understood. It has been proposed that aerobic exercise may increase blood flow to the brain and promote the formation of neurological connections.  In TBI neurological pathways are damaged and are unable to send electrical impulses efficiently. Active rehab provides the brain with the nutrition and oxygen to build new neurological pathways and improve cognition. Furthermore, exercise is directly linked to hormones that control mood, sleep, and energy, which can impact all other PCS symptoms.

What are the steps of the ARP and when can I progress to the next step?

Active Rehab is a progression of aerobic exercise from light to maximal exertion steps 1 through 4, followed by high intensity functional movements (Step 5). Patients typically increase their intensity every 1-2 weeks as long as they do not have worsening symptoms with exercise. Quicker progression may be possible under the supervision of a medical professional depending on exercise tolerance testing results. This should not be done by the patient on their own as it can increase the risk for prolonged and worsening symptoms. Each of the first 4 steps of the Active Rehab Protocol are based on a percentage of maximum heart rate (MHR) and rating of perceived exertion (RPE). RPE is a way of measuring physical activity intensity level. Perceived exertion is how hard you feel like your body is working. Step 5 integrates maximal exercise with functional movements to help transition athletes back to sport demands.

Below is the 5-step ARP:

Step 1 (Light intensity): 10-12 min 5-6 days a week at a heart rate of 100-120 (50-60% MHR) or RPE of 2-3/10.

Step 2 (Moderate intensity): 12-15 min 5-6 days at a heart rate of 120-140 (60-70% MHR) or RPE of 5-6/10.

Step 3 (Vigorous intensity): 15-18 min 5-6 days at a heart rate of 140-160 (70-80% MHR) or RPE of 6-7/10.

Step 4 (Maximal intensity): 20-25 min 3-5 days at a heart rate of 160-180 (80-90% MHR) or RPE of 8-9/10.

Step 5 (Functional movement at Maximal intensity): 30-45 min 3-5 days at maximal exertion (80-90% of MHR) performing advanced functional movement testing (multidirectional, plyometrics, proprioception, resistance, and cognitive integration). Patient cleared to participate in all non contact and low risk sports with multidirectional movement. Duration may be gradually increased back to full. Resistance training and lifting progression to normal. Advised to avoid high risk contact sports in the red zone until full clearance by MD.

*All steps are tested in the clinic with review of both subjective symptoms and/or objective signs of dysautonomia on continuous monitoring prior to progression.

What should I do if may symptoms worsen during Active Rehab?

Patients may experience exacerbation of their symptoms even though they had been asymptomatic with the same exertion on previous treatments. If this occurs the patient should stop aerobic exercise that day and rest. They may resume activity the next day at the same intensity. If they continue to have symptoms they should be downgraded to a lower step the next day and contact their physician. If patient become symptomatic during step 1 for consecutive days the patient should discontinue active rehab until seen by their physician.

What kind of exercise can I do for Active Rehab?

Any aerobic exercise that is low risk for repeat head trauma can be used in active rehab. For example, jogging, stationary bicycling and swimming are commonly used in active rehab. Once Step 4 is passed certain low risk sports such as swimming, track, and dance may be considered. Secondary injuries, such as knee injuries, should be considered when choosing what type of exercise can be used.

Are there any side effects for Active Rehab?

Side effects for active rehab are generally very low when the proper protocol is followed with testing prior to progression. Patients may experience acute worsening of symptoms during exercise. When this occurs the patient should follow the protocol above. Failure to follow the proper protocol may result in the worsening and prolongation symptoms.

Zachary Sprague, MD and Mo Mortazavi, MD
Updated Sept. 22, 2017

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