Concussion Management Strategies: Early Assessment, Subtypes, and Treatment

Concussion recovery doesn’t have to mean “wait and see.” Gone are the days of prescribing strict rest and waiting for symptoms to subside. With the right tools and timing, rehab professionals can actively guide recovery, helping patients regain function faster and reducing the risk of persistent symptoms. Today’s concussion management is rooted in early assessment, targeted treatment, and evidence-based clinical reasoning.

In this article, we’ll explore the evolution of concussion care, how to identify key impairment domains, and practical strategies to help clinicians improve outcomes for patients recovering from mild traumatic brain injury.

From rest to rehab: How concussion management has evolved

For decades, concussion management followed a passive model: extended rest and activity avoidance until symptoms resolved. While this approach aimed to protect the brain, it often led to unintended consequences like physical deconditioning, emotional withdrawal, and prolonged functional impairments.^1,2

Today, the emphasis has shifted toward an active rehabilitation model. After a brief period of relative rest, typically 24 to 48 hours, patients benefit from a guided, gradual return to activity. Clinical evidence shows that both extremes (too much rest or premature high-intensity activity) can delay recovery.³ The best outcomes come from a balanced, supervised reintroduction to movement and function through symptom-guided rehabilitation.

Screening and diagnosis of concussion

Accurate and early identification is the foundation of effective concussion management. Rehabilitation professionals are often the first to evaluate post-injury symptoms and determine whether a patient is appropriate for physical therapy or requires medical referral.

The following recommendations are drawn from the Clinical Practice Guidelines for evaluation and treatment after concussion and mild traumatic brain injury:

1. Start with a comprehensive intake interview

(A-level recommendation)

Begin with a detailed intake to better understand the mechanism of injury, current symptom profile, and relevant health history. At a minimum, this interview should explore:

• Past medical and mental health history

• Mechanism and timing of injury

• Injury-related symptoms and severity

• Any early interventions already attempted (e.g., rest, medications, school or work accommodations)

2. Screen for red flags and emergency conditions

(A-level recommendation)

Before proceeding with physical therapy evaluation, screen for signs of serious or unstable pathology that may require immediate referral, including:

• Severe or worsening headache

• Repeated vomiting

• Slurred speech, confusion, or disorientation

• Neck pain with suspected instability, especially with traumatic mechanism of injury

• Seizure or prolonged loss of consciousness

If red flags are present, pause your exam, provide appropriate patient education, and refer to the necessary medical provider.

3. Consider differential diagnosis and coexisting conditions

(A-level recommendation)

Not all patients who have experienced a concussive event will arrive with a formal diagnosis. You are expected to evaluate for undiagnosed concussion using:

• Symptom checklists appropriate to the patient’s age

• Physical observation

• Input from the patient, caregivers, or witnesses

• History of mental health or cognitive conditions that may affect recovery

In addition, screen for common coexisting impairments such as vestibular dysfunction, vision or oculomotor issues, cognitive symptoms, and psychological stressors. Identifying these early supports a more accurate diagnosis and helps you tailor care more effectively.

Improving concussion management with clinical decision tools

Concussion recovery is rarely linear—and never one-size-fits-all. Patients may present with a wide range of symptoms, impairment profiles, and levels of irritability. That’s why a structured clinical reasoning framework is essential to delivering safe, effective care.

A visual decision tree for concussion management can help streamline your approach and support confident, individualized care. This evidence-informed tool walks you through key decision points, helping you:

1. Determine whether a patient is appropriate for physical therapy evaluation

2. Organize and sequence examination procedures based on symptom irritability

3. Clarify impairment domains to inform a targeted, function-focused plan of care

Rather than replacing your clinical judgment, this tool enhances it, offering a structured way to reduce uncertainty, minimize symptom exacerbation, and align your care plan with the latest clinical guidelines. Download the Concussion Management Decision Tree PDF below to support your evaluations.

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Understanding concussion subtypes and impairment domains

After confirming a diagnosis and screening for red flags, the next step in concussion management is identifying which impairment domains are involved. This classification guides your evaluation strategy and informs personalized concussion treatment planning.

There are four key subtypes of concussion that align with movement-related impairments and commonly fall within the scope of rehabilitation professionals:³

1. Cervical musculoskeletal

• Symptoms: Neck pain, headache, dizziness, and postural imbalance

• Associated impairments: Decreased cervical mobility, muscle tenderness, cervicocephalic proprioception deficits

2. Vestibulo-oculomotor

• Symptoms: Dizziness, blurred vision, gaze instability, difficulty tracking or reading, motion sensitivity

• Associated impairments: Impaired vestibulo-ocular reflex, saccadic or smooth pursuit dysfunction, visual motion hypersensitivity

3. Exertional tolerance

• Symptoms: Fatigue, symptom flare-ups with activity, reduced exercise capacity

• Associated impairments: Autonomic dysregulation, reduced exertional thresholds, orthostatic intolerance

4. Motor function

• Symptoms: Impaired balance, slowed coordination, difficulty multitasking or performing dynamic tasks

• Associated impairments: Static and dynamic balance deficits, impaired dual-task performance, subtle motor control changes

Correctly identifying the subtype (or combination of subtypes) streamlines evaluation and delivers targeted, symptom-guided care. It also helps prevent overgeneralization and ensures patients receive the right intervention at the right time.

Evidence-based treatment strategies for concussion recovery

Once the relevant impairment domains have been identified, you can begin a personalized treatment approach grounded in clinical guidelines and guided by symptom irritability. Below are evidence-informed strategies for each subtype:³

Cervical musculoskeletal

Targeted interventions for the cervical spine can improve mobility, proprioception, and strength, which are key factors in supporting recovery and reducing reinjury risk. Even when cervical impairments aren't the primary symptom driver, addressing them may reduce symptom burden and support faster progress.

Recommended strategies include:

• Range of motion and strengthening exercises for the cervical and scapulothoracic muscles, such as neck retraction and scapular retraction with resistance

• Postural retraining to optimize alignment and reduce compensatory strain

• Manual therapy techniques to improve cervical and thoracic joint mobility or address soft tissue tenderness

• Sensorimotor training focused on cervicocephalic proprioception, such as joint position error correction tasks

If dizziness is present, evaluate and treat the cervical spine as a potential contributor, especially when vestibular impairments are also involved.

Vestibulo-oculomotor

Vestibulo-oculomotor dysfunction is one of the most common post-concussion impairments and often responds well to early intervention. Identifying and addressing deficits in this domain can help reduce dizziness, visual motion sensitivity, and difficulty with gaze stabilization or reading.

Recommended strategies include:

• Gaze stabilization exercises to improve visual focus during head movement, such as seated gaze stabilization with head rotation and seated gaze stabilization with head nod

• VOR x1 and VOR x2 exercises to retrain the vestibulo-ocular reflex

• Oculomotor training targeting saccades, smooth pursuits, vergence, and gaze-holding

• Visual motion habituation protocols for patients with heightened sensitivity to busy or dynamic environments

• If BPPV is identified through positional testing (such as the Dix-Hallpike), use Canalith repositioning maneuvers, such as the Epley maneuver.

Closely monitor symptom irritability throughout treatment. For patients with coexisting cervical impairments, vestibular activities involving head movement may exacerbate symptoms. Modify these tasks as needed to support tolerance and prevent setbacks.

Exertional tolerance

Addressing exertional intolerance is critical to helping patients regain confidence, improve autonomic regulation, and safely return to school, work, sport, or military duty. A symptom-guided approach ensures safety and promotes recovery without overloading the system.

Recommended strategies include:

• Conduct a symptom-guided, graded exertional test (e.g., treadmill or stationary bike) once symptoms are stable at rest

• Monitor heart rate and blood pressure in supine, sitting, and standing positions to assess for autonomic dysfunction

• Choose testing modality based on patient comfort and symptom profile. Use a stationary bike if cervical or vestibular impairments are present

• Apply test findings to guide aerobic training and return-to-activity planning

These assessments can also be valuable for patients who don’t report exertional symptoms but experience fatigue, headache, or fogginess. They can help clarify whether underlying factors like deconditioning or autonomic dysfunction are contributing to the patient’s presentation.

Motor function

Motor impairments may not always be obvious, but they can interfere with safety, coordination, and performance when tasks require multitasking or dynamic movement.

Recommended strategies include:

• Assessing static and dynamic balance

• Evaluating coordination and motor control

• Integrating dual or multitask activities to reflect real-world cognitive-motor demands

Clinicians should tailor motor performance assessments based on the patient’s age, current abilities, and functional goals. Even subtle deficits in motor control can be addressed to support a safer return to activity and reduce the risk of reinjury.

Real-world applications: Putting concussion management into practice

Understanding impairment domains is essential, but applying that knowledge in the clinic is where it truly matters. Below are real-world scenarios to help you sharpen your clinical reasoning. Read each case and consider: What subtype(s) of concussion might be involved? How would you prioritize your evaluation and treatment plan?

Scenario 1

A 34-year-old patient presents two days after being rear-ended in a motor vehicle accident. They walked away from the scene but developed increasing neck pain later that evening. The patient has not yet been medically screened. During your evaluation, they can sit upright, but cervical range of motion is severely limited to less than 45 degrees bilaterally, and you note midline tenderness along the cervical vertebrae on palpation.

What should your next step be?

This patient meets red flag criteria for potential cervical spine injury and should be referred for imaging per the Canadian C-spine rules. Before proceeding with further evaluation or treatment, rule out serious structural pathology. Your clinical reasoning should always prioritize patient safety, and in this case, that means pausing the exam and coordinating appropriate medical referral.

Scenario 2

A 16-year-old presents two weeks post-concussion with complaints of blurry vision, frontal headaches during near work, and increasing fatigue during school tasks. She reports difficulty copying notes from the board and says crowded hallways worsen her symptoms. Vestibular/ocular motor screening reveals symptom provocation during smooth pursuits and convergence testing. Cervical screening is unremarkable.

What impairment domain should guide your treatment plan?

If you identified vestibulo-oculomotor dysfunction, you're on track. This patient’s symptoms point to deficits in gaze stability and visual motion tolerance, which are common barriers to school reintegration. Treatment should include oculomotor retraining (e.g., saccades, convergence), gaze stabilization, and graded exposure to visually stimulating environments, alongside academic modifications to reduce overload.

Scenario 3

A 21-year-old collegiate runner reports that he feels “fine” at rest but develops brain fog, dizziness, and fatigue within five minutes of jogging. He denies headaches, neck pain, or visual changes. Supine-to-stand vitals reveal a 25 bpm rise in heart rate and transient lightheadedness. His BESS balance score is normal, and cervical and oculomotor screenings are negative.

What domain should be prioritized in your evaluation?

This patient is demonstrating exertional intolerance with signs of possible autonomic dysfunction. A symptom-limited Buffalo Concussion Treadmill Test or stationary bike protocol with heart rate and blood pressure monitoring can guide safe aerobic progression. This domain is critical for return-to-play decisions and restoring physiological tolerance to physical stress.

Scenario 4

A 45-year-old warehouse employee presents three weeks after a fall-related concussion. He reports persistent dizziness, balance issues when turning quickly, difficulty focusing visually during head movement, and neck discomfort. He notes that walking while talking to coworkers worsens symptoms. Clinical testing reveals decreased cervical ROM with muscle tenderness, impaired VOR function, and increased sway during dual-task balance activities.

What combination of impairments may be contributing to his functional limitations?

This is a classic example of a mixed subtype presentation involving cervical musculoskeletal, vestibulo-oculomotor, and motor function impairments. A multi-domain approach is warranted: cervical ROM and proprioception exercises, vestibular rehabilitation (including VOR and habituation), and motor control tasks with dual-task integration. This holistic plan can support a safe return to work and reduce reinjury risk.

Concussion management, reimagined

Concussion care has entered a new era—one that prioritizes early intervention, domain-specific treatment, and structured clinical reasoning. By identifying key impairments and adapting your approach based on symptom irritability, you can deliver more efficient, individualized care that accelerates recovery and reduces the risk of persistent symptoms.

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References

1. Grool, A. M., Aglipay, M., Momoli, F., Meehan, W. P., Freedman, S. B., Gagnon, I., Gioia, G. A., Dick, P., Wright, M., Craig, W., Zemek, R., & for the Pediatric Emergency Research Canada (PERC) Concussion Team. (2016). Association between early participation in physical activity following acute concussion and persistent postconcussive symptoms in children and adolescents. JAMA, 316(23), 2504–2514. https://jamanetwork.com/journals/jama/fullarticle/2593568

2. Schneider, K. J., Leddy, J. J., Guskiewicz, K. M., Seifert, T., McCrea, M., Silverberg, N. D., Feddermann-Demont, N., Iverson, G. L., Hayden, A., & Makdissi, M. (2017). Rest and treatment/rehabilitation following sport-related concussion: A systematic review. British Journal of Sports Medicine, 51(12), 930–934. https://bjsm.bmj.com/content/51/12/930

3. Quatman-Yates, C. C., Hunter-Giordano, A., Shimamura, K. K., McCulloch, K. L., Bailes, J. E., Savica, M., & the Concussion CPG Team. (2020). Physical therapy evaluation and treatment after concussion/mild traumatic brain injury: Clinical practice guidelines linked to the International Classification of Functioning, Disability and Health from the Academy of Orthopaedic Physical Therapy, American Academy of Sports Physical Therapy, Academy of Neurologic Physical Therapy, and Academy of Pediatric Physical Therapy of the American Physical Therapy Association. Journal of Orthopaedic & Sports Physical Therapy, 50(4), CPG1–CPG73. https://www.jospt.org/doi/full/10.2519/jospt.2020.0301