The debate over the best methods for concussion recovery has been a key challenge to sports medicine providers over the last several decades. While rapid return to play, particularly when still symptomatic, is obviously inappropriate, the early recommendations suggested complete rest. This is sometimes referred to as “cocoon therapy,” where the patient is instructed to stay in a dark room and avoid electronics, reading and other stimuli that would produce increased mental or physical activity. Not surprisingly, this approach, while well intentioned, was not effective. Currently, the importance of exercise and physical activity in concussion recovery has been recognized to be beneficial, with patients experiencing reduced symptoms and quicker recoveries. However, these exercise programs typically start after several days of rest, and the effects of acute activity are unknown.

In our study published in the February 2022 issue of Medicine & Science in Sports & Exercise®, we assessed patients’ self-reported physical and mental activity levels over the first two days post-concussion. Our aim was to determine if the activity levels were associated with changes in recovery time while controlling for known recovery factors. We tested 78 NCAA Division I student-athletes (Male: 40) from a variety of sports with physician-diagnosed sport-related concussions. The patients all underwent similar management and graduated return to sport protocols, which was consistent with the “Consensus Statement on Concussion in Sport.” The student-athletes were then tracked to determine if, when they self-reported, they were symptom free (about seven days) and cleared for full, unrestricted return to sports participation. This occurred, on average, after about 15 days. The participants’ self-reported physical, but not mental, activity was significantly associated with time to both recovery time points (symptom free and cleared for participation). Interestingly, the relationship was quadratic, whereby very low and very high levels of physical activity were associated with slower recovery. However, mild to moderate activity was associated with quicker recovery.

The key takeaway from this study was an identified “U” curve, or “Goldilocks” findings, whereby mild to moderate exercise facilitated recovery as compared to too much or too little activity. Another key takeaway was that mental activity was not associated with recovery. Taken together, these findings can help sports medicine clinicians make recommendations during the acute phase post-concussion and allow symptom-tolerated activity.

Because this study was done with Division I collegiate student-athletes, we don’t know if these results would extrapolate to high school-aged or other populations, and future studies need to closely investigate sex differences and activity during recovery. Also, the activity levels in this study were self-reported. Additional research is needed to evaluate if more objective measures of activity could further guide concussion rehabilitation to improve recovery. Our research group and others continue to advance the study of post-concussion activity with the ultimate goal of providing tailored and individualized concussion-recovery programs to improve the health of student-athletes. 

About the Authors:

Thomas Buckley, Ed.D., ATC, is an associate professor in the Department of Kinesiology and Applied Physiology at the University of Delaware, where he conducts concussion-related research. Dr. Buckley has been a member of ACSM for 14 years.

Barry Munkasy, Ph.D., is an associate professor in the School of Health and Kinesiology at Georgia Southern University, where he conducts biomechanics research with a primary focus on postural control during jumping and landing tasks.

Moving effective interventions to new settings, with new people, can be a real hurdle for researchers attempting to get evidence-based programs into community settings. How do we maintain effectiveness while adapting the intervention for new contexts and new populations? Recently, the University of Alabama at Birmingham had a unique opportunity to apply “implementation science,” the process of examining methods or strategies that facilitate regular use of evidence-based research in practice, within exercise oncology. This opportunity moved forward the translational process of efficacy to effectiveness for our program¹.

Regular physical activity improves health and well-being while reducing mortality risk in cancer survivors^2,3, yet many cancer survivors do not meet the recommended guidelines for general health of at least 150 weekly minutes of moderate-intensity physical activity^3-6. A variety of factors (including limited access to facilities, lack of awareness of resources and/or low motivation) likely contribute. Those living in rural locations are even less physically active, which may add, in part, to poorer health and quality of life in these populations⁷. As such, we were interested in delivering an exercise intervention to cancer survivors living in rural areas.

The Better Exercise Adherence after Treatment for Cancer (BEAT Cancer) intervention included supervised exercise, home-based (unsupervised) exercise and discussion group sessions for behavior-change support⁸. We demonstrated that this three-month physical-activity intervention for women with breast cancer significantly improved physical-activity adherence, with accompanying improvements in fitness, quality of life and a variety of patient-reported outcomes^9-10.

We wondered if program delivery by non-research staff, such as community-based exercise professionals or discussion leaders in a non-research setting, would lead to similar program benefits. And could we expand the program to all women with a prior diagnosis of cancer, not just women who had experienced breast cancer?

We looked to principles from implementation science to guide our translation of an efficacious exercise oncology program in a rural setting.

The two main intervention adaptations made to the original BEAT Cancer intervention included new education materials (e.g., text, worksheets) for participants that were simplified and modified for application to any cancer type rather than only breast cancer, and new training materials to support the community interventionists. Additional adaptations included simplifying logistics by scheduling group sessions or supervised sessions more evenly over time rather than on a strictly tapered schedule, shortening group meeting duration, using exercise modes other than walking and shortening staff documentation formats. These adaptations improved the fit with the community organization’s staffing and resources while maintaining the core components of the original program.

How well did our transformation work?

Our results were similar to those of the original study, showing comparable within-group improvements related to physical activity, self-reported physical functioning, fatigue, mood, self-efficacy and overcoming barriers, thus providing proof-of-concept support for BEAT Cancer effectiveness. These results are particularly notable because the inclusion criteria for cancer survivors in this study were much less strict than for the original efficacy study, therefore facilitating a sample more representative of the “real world.”

In our Translational Journal of ACSM (TJACSM) article, we not only report on the adaptations used (an important concept in the field of implementation science),¹ but also uniquely communicate the translation of a physical activity program for rural cancer survivors. We provide modification ideas and implementation challenges, such as logistical preparation, ensuring appropriate knowledge related to exercise training, resource considerations (cost, staff, etc.), program flexibility and longer participant follow-up. One main takeaway was the great value of and need for investment in building readiness and capacity for the delivery of exercise-oncology programs by non-research staff in community settings. Doing so will reap broad public health benefit.

To read more about our translational trial, and to gain insights about the exercise interventionists’ perspective on this translation of the exercise-oncology program, you can view the full article in TJACSM.


Laura Q. Rogers, M.D., MPH, FACP, FACSM, is a professor, Division of Preventive Medicine, Department of Medicine at the University of Alabama at Birmingham.

References

1. Phillips SM, Alfano CM, Perna FM, et al. Accelerating translation of physical activity and cancer survivorship research into practice: recommendations for a more integrated and collaborative approach. Cancer Epidemiol Biomarkers Prev. 2014;23(5):687–99. doi:10.1158/1055-9965.EPI-13-1355.

2. Campbell KL, Winters-Stone KM, Wiskemann J, et al. Exercise guidelines for cancer survivors: consensus statement from International Multidisciplinary Roundtable. Med Sci Sports Exerc. 2019;51(11):2375–90. doi:10.1249/MSS.0000000000002116.

3. Patel AV, Friedenreich CM, Moore SC, et al. American College of Sports Medicine roundtable report on physical activity, sedentary behavior, and cancer prevention and control. Med Sci Sports Exerc. 2019;51(11):2391–402. doi:10.1249/MSS.0000000000002117.

4. LeMasters TJ, Madhavan SS, Sambamoorthi U, et al. Health behaviors among breast, prostate, and colorectal cancer survivors: a US population-based case-control study, with comparisons by cancer type and gender. J Cancer Surviv. 2014;8(3):336–48. doi:10.1007/s11764-014-0347-5.

5. Thraen-Borowski KM, Gennuso KP, Cadmus-Bertram L. Accelerometer-derived physical activity and sedentary time by cancer type in the United States. PLoS One. 2017;12(8):e0182554.

6. Littman AJ, Tang MT, Rossing MA. Longitudinal study of recreational physical activity in breast cancer survivors. J Cancer Surviv. 2010;4(2):119–27. doi:10.1007/s11764-009-0113-2.

7. Meit M, Knudson A, Gilbert T, et al. The 2014 Update of the Rural–Urban Chartbook. Bethesda (MD): Rural Health Reform Policy Research Center; 2014. 

8. Rogers LQ, McAuley E, Anton PM, et al. Better exercise adherence after treatment for cancer (BEAT Cancer) study: rationale, design, and methods. Contemp Clin Trials. 2012;33(1):124–137. doi: 10.1016/j.cct.2011.09.004.

9. Rogers LQ, Courneya KS, Anton PM, et al. Effects of the BEAT cancer physical activity behavior change intervention on physical activity, aerobic fitness, and quality of life in breast cancer survivors: a multicenter randomized controlled trial. Breast Cancer Res Treat. 2015;149(1):109–19. doi:10.1007/s10549-014-3216-z.

10. Rogers LQ, Courneya KS, Anton PM, et al. Effects of a multicomponent physical activity behavior change intervention on fatigue, anxiety, and depressive symptomatology in breast cancer survivors: randomized trial. Psycho-Oncology. 2017;26(11):1901-1906. doi:10.1002/pon.4254.

Technogym and ACSM recently hosted an industry-presented webinar with Sheri Colberg, Ph.D., FACSM, entitled The Role of Physical Activity in Type 2 Diabetes Management and Prevention.

One Continuing Education Credit (CEC) is available as part of this webinar.

To earn your CEC, you will view the course content, pass the quiz (you must earn 70% or better to pass), and print your certificate of completion.

Learn more here

Q: Can you speak to the ability or inability to “cure” T2D? Does it have to do with the loss of the pancreatic beta cells?

A: Yes, it has generally been shown that new-onset type 2 diabetes is easier to “reverse,” meaning that blood glucose levels can be so well managed that it appears diabetes has been cured. Over time, a loss of some insulin-making capacity occurs in people with long-standing T2D, particularly if it has not been well-managed, related both to the impairment of pancreatic β-cell function and the decrease in β-cell mass. (PMID: 27615139)

Q: Isn't insulin resistance now found to be in T1DM as well?

A: Yes, anyone can develop insulin resistance, and it occurs in at least a third of people with type 1 diabetes as well, although it is not always associated with excess weight gain or overweight. Since people with T1D lack insulin due to the body’s own immune system killing off the pancreatic β-cells, greater resistance increases the total doses of insulin needed (whether injected, pumped, or inhaled). Thus, they have developed characteristics of both types and have “double diabetes.” (PMID: 34530819)

Q: Under lifestyle goals, would you include stress management?

A: Stress management was not assessed in the large multi-center clinical trials on type 2 diabetes prevention, but mental stress can certainly raise blood glucose levels due to the greater release of glucose-raising hormones like cortisol and adrenaline. It certainly would be beneficial to address better ways to manage mental stress as part of lifestyle goals for optimal blood glucose outcomes. (PMID: 29760788)

Q: As each person has their own limitations how important is it to get a physician clearance and exercise guidelines before working with the client?

A: It really depends on the person’s circumstances. How intense will the planned activities be? Is the person currently sedentary? Has he/she been getting annual checkups to monitor blood glucose management and to check the status of any complications? Does he/she have diabetes-related or other health complications that could be worsened by physical activity? The lower the intensity, the more active an individual has been, and the lower the risk for cardiovascular complications, the less likely medical clearance is absolutely necessary.

The latest ACSM Consensus Statement on activity and T2D will be released in early 2022 in Medicine & Science in Sports & Exercise and states, “For most individuals planning to participate in a low- to moderate-intensity physical activity like brisk walking, no pre-exercise medical evaluation is needed unless symptoms of cardiovascular disease or microvascular complications are present. In adults who are currently sedentary, medical clearance is recommended prior to participation in moderate- to high-intensity physical activity.”

Q: Can flexibility training be used for warmups, or do you recommend it only after the workout?

A: While it is possible to do flexibility training at any point during a workout, joints tend to have a greater range of motion after blood flow to those areas has been increased with a light or short aerobic warmup. It may be prudent to do a quick aerobic warmup, some stretching, the full workout, and then more extensive stretching afterwards for optimal results.

Q: Was there any particular protocol for strength training? sets, reps, periodization? What is considered "intense" resistance work? Would fatigue based off of several sets of moderate intensity be recommended then?

A: That is a tough question, and it depends on who you ask. I have seen a lot of debate over the optimal strength training protocol during the many years I have been in the exercise/fitness world. If people are just starting out with resistance training, they will gain from doing even a minimal amount of training.

Starting out with 1-3 sets of 8 to 10 main exercises that work all of the large muscles groups at a light to moderate intensity is considered appropriate for most older or sedentary adults, many of whom have joint limitations or health issues. Moderate intensity is considered 50%-69% of 1-RM (1 repetition maximum) and vigorous is 70%-85% of 1-RM. Both intensity (fewer reps at a higher intensity) and the number of sets (3-5) or days of training (starting at 2, progressing to 3 nonconsecutive days) can increase over 2 to 3 months. Periodization is usually not undertaken by older adults, but may be appropriate for younger, fitter ones.

Q: Do you have any insight or are aware of any studies that involve high intensity (%1-RM) resistance training and T2DM? Or any studies that compare resistance training volume (Sets x Reps x Load)?

A: Some older studies have determined that glycemic management is improved by supervised high-intensity resistance training in people with type 2 diabetes (PMID 12351469). Others have also found that home-based (and, therefore, unsupervised) resistance training results in a lesser impact on blood glucose levels, likely due to reductions in adherence and exercise training volume and intensity (PMID 15616225).

Q: I'm still confused about glucose response to acute exercise. Which is better if you want to bring down your BG right now? Can you speak to the possibility of increased blood sugars with intense aerobic exercise?

A: Most light-to moderate-intensity aerobic exercise will lower blood glucose levels, assuming that some insulin is present in the body. (People who are very insulin deficient may have a rise in blood glucose from doing any activity.) Any activity that gets up into the intense/vigorous range, even if only during occasional intervals, has the potential to raise blood glucose due to a greater release of glucose-raising hormones during the activity. This is particularly true if the activity is short and intense. In individuals with any type of diabetes, declines in blood glucose during high-intensity interval exercise are smaller than those observed during aerobic exercise.

That said, if someone wants to lower blood glucose right now with exercise, it also depends on the timing of exercise. Doing something light to moderate for at least 10 to 30 minutes is the best bet, particularly after a meal when insulin levels are generally higher. Avoid doing intense aerobic or heavy resistance training as those may have the opposite effect. For early morning exercise, any intensity can potentially raise blood glucose due to higher levels of insulin resistance then and lower circulating levels of insulin in the body.

Q: I had an endocrinologist say that long runs or walks are better, and another one said to do a bit of weights.

A: Which activities someone chooses to do should depend on the goal of the training. Is it increased fitness, lowering blood glucose levels acutely, or gaining strength and improving overall blood glucose management? Long, slow aerobic training does have the benefit of increasing cardiorespiratory fitness and lowering blood glucose levels (in most cases). Resistance training, on the other hand, increases muscular strength and endurance and helps people gain and preserve muscle mass, which is where most carbohydrates are stored in the body. It may not, however, lower blood glucose levels, at least not acutely.

Both have their place in a weekly training regimen. Insulin resistance is lowered for 2 to 72 hours following a bout of aerobic training. Resistance training has more of a long-term impact on insulin action by enhancing carbohydrate storage capacity. The best advice is to do some aerobic training at least every other day and some resistance training at least 2, and preferably 3, nonconsecutive days per week. These activities can be done on the same days or different ones.

Ok, so, we’ve taken the liberty to slightly “stir” the famous James Bond line. Hopefully you get our point that chilly is ok, but bone-shaking cold isn't. Particularly when referring to exercising safely in the cold.

As we continue through winter, many of your clients will be physically active or working outdoors. While we want to encourage people to get out there and enjoy the winter weather, exercising and working in lower temperatures can result in cold injury. Further, it can also impair performance and cause disability or death. A recent consensus statement from the American College of Sports Medicine covers the breadth and seriousness of the challenge represented by cold weather and provides insights on approaches to diminish that threat.

Most folks understand that a frostbite injury can occur with prolonged cold exposure, but depending on factors like body tissue exposure, protective clothing, degree of physical activity, as well as individual factors, cold injury can occur within extremely short time frames (i.e., < minutes). Your clients may be less familiar with how to prevent other types of cold injuries (e.g., nonfreezing cold injury, cold water injuries, hypothermia, snow blindness, etc.). Further, outdoor conditions that combine cold, wind, altitude, or wetness can create additional stressors.

Individually, these all effect the body’s physiology and function, but in combination they can dramatically increase the chance of injury. Your clients may look to you for information on how to prevent cold injuries. Here are a few approaches that you can share to prepare your clients to stay safe and enjoy the outdoors this winter:

Suit up with multiple layers

• Inner layer: Direct contact with the skin to absorb moisture (think moisture wicking fabrics such as wool).
• Middle layer: Provides insulation and traps body heat to create a warm air barrier (down).
• Outer layer: Waterproof, windproof, breathable. Clothing with zippers in arm pits or ventilation holes allow heat accumulation from exercise to release, instead of building up moisture inside your clothing or skin.

Protect your eyes and skin from the sun

• We don’t think of sunglasses in winter, but the sun can reflect off the snow and damage our eyes.
• Wear a brimmed hat to help shield your eyes, face, and ears.
• Wear sunscreen too!

The right fit

• Restrictive footwear can decrease blood flow and increase cold injury risk.
• Change socks frequently if sweaty.
• Use thinner gloves under mittens for dexterity.

 Fuel up and hydrate

• Staying hydrated and eating enough calories can decrease your cold injury risk.

Keep moving

• Prolonged inactivity/immobility/rest periods can increase risk.
• Exercise creates body heat.

Here are some early warning signs that can alert you to possible vulnerability:

• Feeling cold
• Cold extremities (hands, face, feet especially)
• Skin numbness
• Pale spots

Other risk factors for cold injury include:

• Exercising too hard/too long
• Fatigue
• Exhaustion
• Smoking
• Drugs
• Intoxication
• Advanced age
• Trauma
• High altitude

Finally, the consensus statement highlights things you can do to assist someone who is experiencing a cold injury. Quick recognition and action can increase the likelihood of a positive outcome. We encourage you to download the consensus statement and share this information with your clients. The winter months can provide a great opportunity to mix up your fitness routine with fun outdoor activities. Let’s all have a safe and active winter! Remember: chilled, not shaking!

Related links:
Infographic | Exercising in Hot and Cold Environments
Blog | High Altitude and Cold Weather Sport: Are There Nutritional Concerns?

Laura Young, Ph.D. is a science assistant at ACSM. She holds a Ph.D. in health and kinesiology from the University of Utah.

Lynette L. Craft, Ph.D., FACSM is the Chief Science Officer at ACSM. She holds a Ph.D. in kinesiology from Michigan State University.

The field of clinical exercise physiology strives to advance the scientific and practical application of exercise interventions for the betterment of the health, physical fitness and quality of life of persons at high risk of, or living with, chronic disease (CD). Clinical exercise physiologists (CEPs) are health care professionals trained to work with persons with CD using exercise for therapeutic benefit. Despite the central role CEPs play in delivering exercise interventions across various health care settings, their professional recognition and privileges are limited when compared with those of other allied health care professionals (e.g., nurses, physical therapists). For instance, there is no mechanism by which patients can be referred to receive billable services provided by CEPs as they can with other health care professionals. Recognizing and identifying prominent barriers has fostered exciting and momentous efforts to bolster the profession and facilitate greater levels of autonomy for CEPs within U.S. health care settings.

Former ACSM President Bill Kraus, M.D., assembled in March 2021 a task force of professional leaders, including those from academia, representatives from the Clinical Exercise Physiology Association and other key stakeholders to pursue three main goals: (1) promote the formal recognition of CEPs as qualified health care professionals, (2) empower CEPs to deliver exercise and healthy lifestyle counseling and supervision to patients according to their scope of practice and (3) ensure CEPs are able to bill and be reimbursed for services. Although the task force is driving higher-level discussions in the U.S., the movement requires the collective efforts of individuals and academic programs to bring these goals to fruition. The most significant step is for programs to receive accreditation through the Commission on Accreditation of Allied Health Education Programs, ensuring CEPs graduate from programs that adequately prepare them for the field. Many academic programs have taken this important step, benefiting from the COVID-19 accreditation application fee waiver, which extends into the 2022 spring semester.

The path to reimbursement for CEPs’ services will be challenging, with hurdles along the way. However, achieving accreditation will certainly be worth the effort, particularly when considering the success Australia has had with their accredited exercise physiologists (AEPs). Australian legislators recognized AEPs’ important role in CD prevention and treatment by granting AEPs the ability to provide primary and secondary preventive exercise services with a general practitioner’s referral. Early evidence suggests physicians are already embracing the model, with exponential increases in the number of annual referrals to AEPs and indications of enhanced patient care in the reduction of acute CD-related hospitalizations. These early outcomes have also prompted CEPs within the United Kingdom and New Zealand to advocate for recognition as allied health professionals.

In the U.S., the growing burden CD places on individuals and health care systems demands the recognition of CEPs as providers delivering evidence-based strategies to slow and reverse this trend. The field of CEP must move both programmatically and as a group of individual advocates in order to transform the profession.

About the Authors:

Cemal Ozemek, Ph.D., FACSM, president-elect of the Clinical Exercise Physiology Association, received his doctoral degree in human bioenergetics with a concentration in clinical exercise physiology at Ball State University. He is a clinical associate professor at the University of Illinois at Chicago, where he also serves as director of the Cardiac Rehabilitation and Professional Doctor of Clinical Exercise Physiology programs. His research interests include cardiac, vascular and cardiorespiratory adaptations to exercise interventions in patients with chronic health conditions and investigating the efficacy of community-based health- and wellness-promotion strategies.

Laura A. Richardson, Ph.D., FACSM, is president of the Clinical Exercise Physiology Association and a registered clinical exercise physiologist. She is a clinical associate professor of applied exercise science and movement science at the University of Michigan School of Kinesiology. She is also a dedicated clinician with more than two decades in health care, working with patients diagnosed with immunological, metabolic, pulmonary, neuromuscular, cardiovascular and orthopedic disorders using exercise as a mode of therapeutic intervention. Her expertise is working with metabolic patients utilizing behavior-modification strategies for lifelong weight management with bariatric surgery. Dr. Richardson is committed to research exploring obesity stigmatization and fat bias.