Beta Blockers Change the Cardiovascular Response to Exercise Beta blockers reduce heart rate response. The medication blocks beta-adrenergic receptors that drive heart rate increases during exercise. The result is lower maximum heart rate, slower heart rate increase during exercise, and faster heart rate recovery. The cardiovascular response that exercise normally produces is substantially modified (Patricios et al., 2023). Blood pressure response is similarly blunted. Beta blockers reduce blood pressure increases during exercise. Both systolic and diastolic responses are smaller than expected. The autonomic response that exercise produces is therefore measured differently in patients on beta blockers. The medication is appropriate for many conditions. Beta blockers treat hypertension, atrial fibrillation, migraine prevention, anxiety, and some other conditions. The medication is often important for the conditions it treats. The question is not whether to take it but how to manage exercise prescription while on it. The Buffalo Concussion Treadmill Test Problem BCTT uses heart rate to identify exercise threshold. The standard test increases treadmill speed and grade while monitoring heart rate and symptoms. The heart rate at symptom onset becomes the threshold. Sub-symptom exercise prescription uses 80% of this heart rate (Leddy et al., 2019). Beta blockers make heart rate threshold meaningless. The blunted heart rate response means the patient may not reach the heart rate that produces symptoms within the test duration. Or they may produce symptoms at a heart rate that does not reflect the true exercise stress. The heart rate-based prescription does not work. Symptom-based assessment must replace heart rate. When BCTT is invalid due to beta blockers, exercise prescription must use other markers: rating of perceived exertion (RPE), specific symptom triggers, and time to symptom onset. The prescription is less precise but still effective with careful attention. Modified Exercise Prescription on Beta Blockers Use Rating of Perceived Exertion (RPE). The Borg scale (6-20) or modified scale (0-10) provides exercise intensity guidance without heart rate. Aim for RPE of 11-13 on the 6-20 scale (light to somewhat hard). This typically corresponds to sustainable sub-symptom intensity. Time exercise before symptom onset. Test how long you can exercise at moderate effort before symptoms appear. Prescribe exercise at 80% of this duration. If symptoms appear at 25 minutes, prescribe 20-minute exercise sessions. The duration limit replaces the heart rate limit. Use the Talk Test. The simplest field test: you should be able to speak in full sentences during exercise, but not sing comfortably. This corresponds to moderate sub-symptom intensity for most patients. Below this is too easy; above this risks exceeding threshold. Monitor symptoms more closely. Without heart rate guidance, symptom monitoring becomes more critical. Check symptom level (0-10 scale) every 5 minutes during exercise. Stop at first sign of symptom worsening. Increase exercise duration before intensity. Build sustainable duration at moderate effort before attempting harder workouts. The duration progression mimics what heart rate progression would provide. Mobility Support During Modified Exercise JME 155 Diaphragmatic breathing supports the autonomic regulation that exercise stimulates. With beta blockers blunting the cardiovascular response, the autonomic regulation work becomes more important for recovery. 10 breaths before and after exercise sessions, plus 90-minute interval breathing throughout the day. JME 14 Chin tucks address the cervical contribution that compounds with exercise demands. The medication-related modifications to exercise do not affect cervical needs. 10 repetitions with 5-second holds. JME 1 Cervical rotation maintains proprioceptive function during the modified exercise protocols. 10 repetitions each direction. JME 150 Thoracic rotation supports breathing depth that beta blockers do not affect. The mobility provides exercise support independent of medication effects. 8 repetitions per direction. Start your 3-day free trial for medication-modified exercise programming. Coordinating with Prescribing Provider Discuss timing of beta blocker doses. Some patients can exercise before taking the daily dose, allowing more accurate cardiovascular response during exercise. Others cannot due to symptom rebound between doses. Discuss with prescribing provider whether timing modifications are appropriate. Consider whether the indication still applies. If beta blockers were prescribed for hypertension that has resolved, anxiety that has improved, or other conditions that may have changed, reassessment may be appropriate. Sometimes medication can be reduced or eliminated when underlying condition improves. Switching to different beta blocker may help. Some beta blockers (atenolol, metoprolol) primarily affect cardiac function. Others (propranolol) affect both cardiac and CNS function. The choice may affect concussion recovery. Discuss whether alternative beta blockers may work better. Migraine prevention is often beta blocker indication. Beta blockers are commonly prescribed for migraine prevention. Concussion-related headaches may respond to beta blockers, making this indication particularly common in PCS patients. The benefit must be weighed against exercise prescription complications. Daily Movement Routine JME 3 Lateral cervical flexion daily addresses tension regardless of medication status. 8 repetitions per side with 15-second holds. JME 42 Shoulder circles maintain mobility through the modified exercise progression. 10 repetitions each direction. JME 15 Cervical extension supports posture and cerebral blood flow. 8 repetitions. JME 151 Lateral side bends with breathing combine mobility and autonomic support. 8 repetitions per side. Support medication-modified recovery with simplmobility's mobility programming. Other Medications That Affect Exercise Prescription Calcium channel blockers. Similar effects on heart rate response. Require similar modifications to exercise prescription. Often used for migraine prevention or hypertension. SSRIs and SNRIs. Some affect heart rate variability and exercise tolerance. Effects vary by specific medication and individual response. Less dramatic than beta blockers but can affect prescription accuracy. Stimulant medications (ADHD treatments). Increase heart rate at baseline and during exercise. May invalidate heart rate-based prescription in opposite direction (lower threshold needed than non-medicated). Sleep medications. May produce next-day grogginess that affects exercise tolerance. Schedule exercise away from medication effects. Vasodilators. Affect blood pressure response to exercise. May produce hypotension during or after exercise. Monitor for symptoms. Should I stop beta blockers to do concussion exercise treatment? Generally no. The medication is treating a condition that needs treatment. The exercise prescription can be modified to work with the medication. Discuss with prescribing provider about timing or alternatives before considering discontinuation. Will my exercise tolerance improve while on beta blockers? Yes, with modified prescription. The recovery still occurs, though heart rate-based tracking is not available. Use perceived exertion and symptom monitoring to track progress. Improvement typically occurs at similar timeline to non-medicated patients. Can I do the Buffalo Concussion Treadmill Test on beta blockers? The test can be performed but interpretation is modified. The heart rate threshold is not meaningful, but the symptom response provides useful information about exercise tolerance. Some clinics modify their protocols for patients on beta blockers. References Leddy, J. J., et al. (2019). Early subthreshold aerobic exercise for sport-related concussion. JAMA Pediatrics, 173(4), 319-325. PubMed Patricios, J. S., et al. (2023). Consensus statement on concussion in sport: the 6th International Conference on Concussion in Sport, Amsterdam, October 2022. British Journal of Sports Medicine, 57(11), 695-711. PubMed