Robert Scales, PhD

Exercise in the Management of Post-Concussion Symptoms

Robert Scales, PhD, explains how concussion victims can exercise their way to better brain health

Cardiovascular health is directly related to brain health. “There’s a lot of people out there suffering from medical conditions where cardiology-based exercise physiology can help—and post-concussion syndrome happens to be one of them,” says Dr. Robert Scales, Director of Cardiac Rehabilitation and Wellness at the Mayo Clinic in Scottsdale, Arizona.

The phrase “Use it or lose it” applies both to cardiac and brain health, but, Dr. Scales says, with the right frequency, intensity, time and type (FITT) of exercise, “You can get it back quickly.”

This perspective dates back to a 1968 landmark bed rest study, where researcher Dr. Bengt Saltin recruited young men from the University of Texas Southwestern Medical Center to rest in bed for three weeks, measuring their heart function and fitness performance. This coincided with a dramatic decline in fitness, heart function and other metrics, including blood volume, says Dr. Scales. “Within 10 days of resuming exercise, blood volume returned to normal along with cardiovascular fitness and heart function. All of these measures continued to improve with consistent exercise training over a two-month period.”

The benefits of becoming active

The symptoms of a head injury include headache, dizziness, fatigue, insomnia, difficulty concentrating, memory lapses and a disturbed autonomic nervous system, which can throw off heart rate and blood pressure. Appropriately monitored cardiovascular exercise, however, can help improve the way the heart and blood vessels respond, which results in a slower stronger heartbeat. “Control of the blood flow to the brain normalizes and therefore, the symptoms can improve,” Dr. Scales says. “So, aerobic continuous exercise can work on some of the disturbances that happen when you get hit on the head, and start to help bring it back to what it should be.”

At the Mayo Clinic’s Heart Health and Performance Program, Dr. Scales manages a gym within a cardiology clinic and often works with patients with post-concussion syndrome—persistent symptoms beyond three months post injury. “My role is to help people become more active again from a cardiovascular standpoint, which prevents deconditioning and helps normalize some of the symptoms that these people may be having,” says Dr. Scales.

Based on research from John Leddy, MD, FACSM, FACP, Dr. Scales uses a scaling system for patients to identify their symptoms while they exercise so that they can exercise below the exertion threshold that exacerbates concussion symptoms like headache or dizziness. “A conservative but progressive plan improves exercise tolerance,” Dr. Scales says, eventually normalizing post-concussion symptoms.

There are strategic forms of activity for concussion recovery: recumbent stationary biking puts less gravitational pull on the bloodstream pumping to the heart; in aqua aerobics or deep water running with a flotation belt, the hydrostatic pressure of the water facilitates blood flow and improves cardiovascular efficiency in the body. With improved symptom management, athletes can then gradually return to more strenuous upright land-based exercise like jogging.

Exercise can normalize symptoms

Dr. Scales has helped train former NFL players who have endured numerous concussions over the years. “They’ve also experienced orthopedic injuries and metabolic changes that have adversely impacted their blood pressure, cholesterol, blood glucose and body weight. We find that they have aged prematurely, partly because of their sport,” Dr. Scales says. However, “Even with those individuals, we can help them normalize the symptoms and live a healthy life.”

The collaboration between neurology and cardiology, Dr. Scales believes, is an untapped potential therapy. “It can help people,” he says. “And I think as evidence-based research continues to grow, we will be able to write clinical practice guidelines that are more defined.”


Robert Scales, PhD, is a Scientific Advisory Board Member of the International Concussion Society. The International Concussion Society sponsored website Concussion.Org is the number one destination for information related to concussion prevention, diagnosis and treatment. Our mission is to serve medical professionals, athletes, administrators, coaches, patients and the public by providing a central repository of accurate and scientifically vetted concussion research. Working alongside our world-class scientific advisory board, Concussion.org aims to be the most trusted global index on one of the most common, yet least understood, forms of traumatic brain injury. If you would like to be interviewed for an influencer profile, please fill out this form.