Exercise Intolerance

What is Exercise Intolerance?

Exercise intolerance is a decrease in the ability to be able to exercise or perform physical tasks at a level or duration which would be normal for your age.

If you are suffering from exercise intolerance following a TBI, it may be linked to other symptoms of TBI such as fatigue, sleep deprivation, headaches and migraines, and vestibular system function. Your GP can advise as to the best way to improve your symptoms of exercise intolerance and may refer you to a physiotherapist who can manage a graded return to exercise.

Exercise intolerance following a mild Traumatic Brain Injury

Mild TBI or concussion can affect the autonomic nervous system. This in turn affects cerebral blood flow, which may explain why a person suffers from exercise intolerance following their injury.1

Return to Activity

There is general agreement that the best treatment for a mild TBI is a period of rest from both physical and mental activities (24 – 48 hrs). Following this, it is recommended that a graded return to activity is undertaken. 2

Example of graded return to sport.2

Table 1. Graduated return-to-sport (RTS) strategy

StageAimActivityGoal of each step
1Symptom-limited activityDaily activities that do not provoke symptoms.Gradual reintroduction of work/school activities.
2Light aerobic exerciseWalking or stationary cycling at slow to medium pace. No resistance training.Increase heart rate.
3Sport-specific exerciseRunning or skating drills. No head impact activities.Add movement.
4Non-contact training drillsHarder training drills, eg, passing drills. May start progressive resistance training.Exercise, coordination and increased thinking.
5Full contact practiceFollowing medical clearance, participate in normal training activities.Restore confidence and assess functional skills by coaching staff.
6Return to sportNormal game play.
  • NOTE: An initial period of 24–48 hours of both relative physical rest and cognitive rest is recommended before beginning the RTS progression.
  • There should be at least 24 hours (or longer) for each step of the progression. If any symptoms worsen during exercise, the athlete should go back to the previous step. Resistance training should be added only in the later stages (stage 3 or 4 at the earliest). If symptoms are persistent (eg, more than 10–14 days in adults or more than 1 month in children), the athlete should be referred to a healthcare professional who is an expert in the management of concussion.


Children and Adolescents graded return to sport.3

Step Goal
1. Symptom-limited activity

Simple daily activities that do not provoke symptoms.

A gradual return to typical activities.
2. Light aerobic exercise

Gradually introduce walking, swimming or stationary cycling at a slow to medium pace. Do not allow resistance training at this stage.

To gradually increase heart rate.
3. Sport-specific exercise

Your child can begin activities such as running, warm-up drills and practicing ball skills (with a soft ball). Do not allow any activities that involve head contact.

To add movement.
4. Non-contact training drills

Introduce harder training drills, such as passing drills. Your child may start progressive training.

To introduce exercise, coordination and increased thinking.
5. Full contact practice

Following medical clearance, participate in normal training activities.

Restoring confidence. Allowing coaching staff to assess functional skills.
6. Return to sport

Your child can now progress to normal game play.

Resume regular sporting activity.




    1. Leddy, J., Hinds, A., Sirica, D. and Willer, B. (2016), The Role of Controlled Exercise in Concussion Management. PM&R, 8: S91-S100. DOI:1016/j.pmrj.2015.10.017
    2. McCrory P, Meeuwisse W, Dvorak J, et al Consensus statement on concussion in sport—the 5th international conference on concussion in sport held in Berlin, October 2016 British Journal of Sports Medicine 2017;51:838-847.
    3. https://www.rch.org.au/kidsinfo/fact_sheets/Head_injury-return_to_sport/ Developed by The Royal Children’s Hospital Emergency, Neurosurgery and Neuropsychology departments.