Before revealing the plan, appreciate the neuroscience. Concussions are mild traumatic brain injuries. All brain injuries create an energy crisis in the brain. They disrupt the autonomic nervous system, alter vestibular function and impair spatial awareness. When a medical provider clears a client for exercise, they are typically giving the green light for sub-symptom threshold training, not an immediate return to high-intensity interval training or heavy one-rep maxes.

Historically, the prescription for a concussion was complete rest in a dark room until all symptoms vanished. Today, neuroscience shows that progressive, targeted exercise is among the most effective treatments for a healing brain. In respecting the brain’s healing process, however, your standard program design needs an overhaul. Training an athlete or fitness enthusiast post-concussion is like rebooting a computer with a corrupted operating system: demanding software requires a stable foundation first. Resting the stable foundation begins with the program design tips that follow.

Concussions often damage the autonomic nervous system’s ability to regulate blood flow to the brain. When a client’s heart rate rises too quickly or too high, the brain struggles to manage the cerebral blood flow. In this case, the client may complain of headaches, fogginess and dizziness.

Before your client touches a weight, the fitness professional is responsible for establishing their safe heart rate zone. The gold standard for this is not based on 220-age, but rather the Buffalo Concussion Treadmill Test or its cycling equivalent, the Buffalo Concussion Bike Test. These protocols are designed to find the exact heart rate at which the brain can no longer compensate.

During the test, the client exercises at a gradually increasing workload (increasing the treadmill incline or bike resistance by one level every minute). Throughout the test, the fitness professional monitors the client’s heart rate, rating of perceived exertion (RPE) and symptom severity on a 0-10 scale. When concussion symptoms increase by two or more points from their pre-workout resting baseline, the test is stopped, and their heart rate is recorded. That specific number is the symptom threshold.

For the next few weeks of their programming, all cardiovascular and resistance training should be kept at or below 80% of that threshold heart rate. For example, if symptoms flared at 130 bpm during the Buffalo protocol, their maximum training heart rate is 104 bpm. As the brain heals, this threshold will naturally increase, allowing intensity progression.

A common pitfall in post-concussion programming is forgetting about the effects of gravity. Because the autonomic nervous system is lagging, sudden changes in body position can cause blood pressure to drop, leading to severe lightheadedness or a spike in symptoms. A standard circuit that alternates between floor-based core work and standing high-intensity work is a recipe for disaster. Instead, minimize level changes by grouping exercises by physical position. Have your client perform all standing exercises in one block, transition to all seated or half-kneeling exercises in another, and finish with all supine exercises at the end.

Clients should also temporarily avoid extreme head positions. Movements like Romanian deadlifts, bent-over rows, or downward dog place the head below the heart. This increases intracranial pressure and is notorious for exacerbating headaches in recovering athletes. Substitute these with seated leg curls, cable rows or zombie walk dynamic hamstring stretches until the client can safely tolerate head positional shifts without a dizzy spell.

Just like the aging athlete, the post-concussion client often suffers from vestibular and visual dysfunctions. The brain’s ability to stabilize the eyes while the head is moving, known as the vestibulo-ocular reflex (VOR) is frequently impaired. Training that focuses on muscle output while ignoring sensory input feeds the client’s sense of instability and discoordination.

One solution is integrating short, 30-to-60-second micro-doses of visual-vestibular work into their rest periods or dynamic warm-ups. Simple gaze stabilization drills work wonders here. Have the client hold a thumb out in front of them, keeping their eyes locked on the thumbnail while slowly shaking their head "no" and nodding "yes."

To challenge visual tracking, gently toss a balloon or a brightly colored ball, asking the client to track it strictly with their eyes without moving their neck. You can also introduce balance perturbations by utilizing a narrow-stance or single-leg balance while they focus on a fixed target on the wall. This minimizes their reliance on peripheral vision, which is often easily overwhelmed by moving gym environments post-injury.

Following a concussion, motor cortex excitability decreases. The brain’s map of the body becomes slightly blurred, reducing force output and altering movement mechanics. Expecting a client to perfectly execute high-velocity plyometrics or complex Olympic lifts early in their recovery is both unrealistic and potentially dangerous.

Instead, rebuild the brain-body connection by intentionally slowing movements down. Isometric exercises are incredibly valuable here. Using yielding and overcoming isometrics, like a 10-second hold at the bottom of a split squat or an anti-rotation Pallof press, demands high central nervous system engagement but carries a very low cardiovascular cost. Similarly, programming slow eccentrics helps re-map neuromuscular pathways. Try a 3-to-5-second lowering phase on main lifts, such as goblet squats and push-ups. This prolonged time under tension requires deliberate motor control without spiking the heart rate past that 80% Buffalo protocol threshold.

In a healthy brain, running, cutting and balancing are largely subconscious tasks. After a concussion, these physical movements require increased amounts of conscious cognitive energy. If an athlete returns to their sport or a client returns to their busy daily life without retraining this capacity, they are at a highly elevated risk for secondary orthopedic injuries, like ACL tears or ankle sprains. Their brain simply cannot process their environment fast enough to protect their joints.

This challenge can be overcome through program design. Once clients can perform standard resistance training without symptoms, the brain can be trained for divided attention. In the fitness environment, combining a physical movement with a cognitive challenge serves the purpose. For example, a client can perform walking lunges while counting backwards from 100 by 7s. Once clients master dual-tasking at their self-selected pace, progressions can include reactionary drills. Incorporate reactionary drills by calling out "left" or "right" as they shuffle. This requires to client to process an auditory cue and produce an immediate physical output. As another example, you can even play catch with a multi-colored medicine ball, asking the client to call out the color they see rotating toward them right before they catch it.

Overall, more is not better. The first rule of post-concussion program design is "Do No Harm." Check in frequently, and if symptoms increase by more than two points at any time during the workout, pause the session. Have the client sit down, hydrate and breathe. If symptoms don't resolve within 10 to 15 minutes, the workout is over for the day.

While monitoring sub-symptom thresholds is a standard part of post-concussion training, certain symptoms indicate a severe medical emergency rather than a typical flare-up. If your client exhibits any of the following "red flag" symptoms during a session, halt and call for emergency medical services:

As a fitness professional, you are on the front lines of observation. When in doubt, err on the side of caution. While safety awareness is essential, helping clients return to highly active lifestyles can also be rewarding for everyone involved.

Post-concussion training doesn't mean abandoning the traditional fitness elements that the client knows and loves; it simply means restructuring elements to respect the healing brain's energy limits.

A safe, effective session might start with a 5-to-10-minute warm-up focused on linear mobility, gaze stabilization drills and diaphragmatic breathing while foam rolling to enhance parasympathetic nervous system drive. From there, move into 10 minutes of cardiovascular training on a stationary bike. This could be steady-state or interval-based, as long as the intensity is below 80% of the Buffalo threshold and the client is asymptomatic. From here, the resistance training segment can be blocked by body position. Block A could feature standing exercises, pairing slow-eccentric goblet squats with standing resistance band rows, allowing a 90-to-120-second rest between sets so heart rate can settle. Block B moves to the floor, perhaps pairing half-kneeling overhead presses with seated leg extensions. Finally, wrap up the session with supine core work, such as dead bugs, followed by a few minutes of eyes-closed breathing to reduce visual stimuli and help regulate their nervous system.

When a client returns from a concussion, the goal isn't to test their limits, but to expand their capacity safely. By first ensuring medical clearance and then using the Buffalo protocol to manage positional changes, integrate sensory work, and challenge their dual-tasking abilities, fitness professionals bridge the gap between medical clearance and high-performance living.