What Changed About Concussion Since You Last Heard
Read this first
A recent head injury needs to be looked at in person, by a physician, an athletic trainer, or a physical therapist trained in concussion, before any of the advice below applies to it. That visit is there to rule out the small number of head and neck injuries that look like a concussion at first and are not one.
Go to an emergency department, or call 911, if any of these are present now, or have appeared at any point since the injury:
Severe or increasing headache
Repeated vomiting
Seizure or convulsion
Loss of consciousness
Deteriorating conscious state (not fully alert or oriented, or getting less so)
Double vision
One pupil larger than the other
Weakness, numbness, or tingling and burning in more than one arm or in the legs
Increasingly restless, agitated, or combative
Slurred speech, or not recognizing people or places
Visible deformity of the skull
Neck pain or tenderness
Someone who seemed fine and is now getting worse is the most important line on that list. Bleeding inside the skull can take hours to show itself.
Four situations change the threshold on their own: a blood thinner, age over 65, a second head knock before the first had settled, and neck pain that sits midline over the bones with a neck that will not turn. Those are covered here: When to go to the ER after a concussion.
Everything below assumes that has been cleared, including the neck, which changes meaning entirely once it has.
The SparkNotes
Strict rest until symptoms resolve is no longer recommended. The evidence says it does not help.
Light activity starts in the first day or two, not at the end.
Sub-symptom-threshold aerobic exercise started within two to ten days reduces the chance of symptoms that drag on.
Lingering dizziness, neck pain or headache after ten days has a treatment, not a waiting list.
The panel itself did not reach full agreement on what a concussion even is.
The Whole Story
If your idea of concussion care was formed more than a few years ago, it probably involves a dark room.
Rest completely. No screens. Wait until every symptom has gone, and only then start doing things again.
That advice is no longer supported. The current international consensus statement, built by 31 experts from nine countries on ten systematic reviews, says recommending strict rest until symptoms fully resolve is not beneficial.
Here is what replaced it, and it is close to the opposite.
One: rest got shorter and lighter
What is recommended now is RELATIVE rest, not strict rest, and only for about two days. Normal daily activities continue. Screen time is reduced rather than banned.
Light physical activity, walking for instance, can start in the first 24 to 48 hours, as long as it does not more than mildly worsen symptoms.
After that, activity as tolerated, with one firm boundary: nothing carrying a risk of contact, collision or a fall until a qualified clinician says otherwise.
Two: exercise became a treatment
This is the part that would have sounded reckless fifteen years ago.
Prescribed aerobic exercise below the symptom threshold, started within two to ten days of the injury, is effective at reducing how often symptoms persist beyond a month. It also helps people who are already past a month and still struggling.
Below the symptom threshold means an intensity worked out from testing. It is a heart rate that does not provoke more than a mild, brief bump in symptoms. It is prescribed, monitored and progressed. It is not “go for a run and see.”
What changed in my own practice
When I was trained, active recovery for concussion was the cutting edge. The evidence behind it was mostly case reports and case series, and the strongest thing they concluded was that exercise in the sub-acute stage was not harmful and did not prolong symptoms.
Watching that become mainstream is the biggest shift I have seen in this area. The days of sitting in a dark room after a concussion are gone.
Three: a mild flare stopped being a setback
A lot of families spend the first two weeks terrified of doing anything, because every twinge feels like damage.
The consensus is reassuring and specific. Mild symptom exacerbation during activity is typical, and if it is brief, under an hour, it does not delay recovery.
If it is more than mild, or it lasts, you stop and pick it up again once they are back to baseline. That is a different instruction from “do nothing.”
Four: lingering symptoms got a pathway
Dizziness, neck pain or headaches still present after ten days now have a named treatment: cervicovestibular rehabilitation, aimed at the neck and the balance and eye-movement systems.
Symptoms lasting beyond four weeks are formally defined as persisting, and the recommendation is a full multimodal assessment, ideally by a team, rather than more waiting.
That matters because the default for a long time was patience. Patience is not a plan.
Five: physical therapy stopped being the thing you do afterwards
There is now a clinical practice guideline for physical therapy after concussion, published by the American Physical Therapy Association. That is a different kind of document from a consensus statement. It grades its recommendations by the strength of the evidence behind them.
Two of its Grade A recommendations matter to anyone reading this. A symptom-guided, progressive aerobic exercise program should be implemented for people with exertional intolerance or who intend to return to vigorous activity. And if benign paroxysmal positional vertigo is identified, it should be treated with repositioning, a specific maneuver rather than a wait.
The guideline also states plainly that physical therapy early after a concussion is safe, and that starting it earlier may lead to a faster recovery.
That is close to the reverse of the model most people are still working from, where physical therapy is what you try if things have not resolved on their own.
Six: an assessment is four separate examinations
“Getting your concussion looked at” sounds like one thing. In the guideline it is four domains, examined in an order determined by what is most irritable.
THE NECK: the cervical and thoracic spine, because neck pain, headache, dizziness and trouble focusing on a target can all come from there rather than from the brain.
THE VESTIBULAR AND OCULOMOTOR SYSTEM: balance, eye movement, gaze stability, how you tolerate busy visual environments.
AUTONOMIC FUNCTION AND EXERTIONAL TOLERANCE: including blood pressure and heart rate measured lying, sitting and standing, and a graded exertion test to find out what your system will actually take.
MOTOR FUNCTION: static and dynamic balance, coordination, and dual tasking, which is doing a movement and a thinking task at once.
The triage order is deliberate: neck first, then dizziness and headache. Sorting out a neck can resolve symptoms that look like they belong to the brain.
Seven: it is not too late
This one deserves saying on its own.
The guideline states that time since injury should not be the primary determinant of whether physical therapy is appropriate. It can be applied whether the concussive event was recent or in the more distant past.
It also says physical therapists should evaluate for signs of an UNDIAGNOSED concussion in people who had a concussive event but were never diagnosed. That covers a very large number of people who got hit, felt off for a while, and never told anyone.
If you had a head knock two years ago and something has not been right since, that is not a closed file.
And one thing that did not get settled
Worth knowing, because it tells you something about how to read any of this.
The panel voted on its own definition of sport-related concussion. It passed with 78.6% agreement, below the 80% they had set in advance as the threshold for consensus.
So the group could not fully agree on the definition of the thing they had spent three and a half years reviewing. They published the disagreement rather than smoothing it over, which is the correct way to handle it and also a reminder that this is a field still in motion.
What to do with this
If someone in your house had a concussion in the last few years and was told to sit in the dark until it passed, that was reasonable advice at the time and it is not the advice now.
And if they are still not right, whether that is headaches, dizziness, a neck that has never settled, or the feeling that they came back but not all the way, that is not something to wait out. Cervicovestibular rehabilitation and graded aerobic work are physical therapy, and they are things this practice does.
Evidence note
SECOND SOURCE: Quatman-Yates CC, Hunter-Giordano A, Shimamura KK, Landel R, Alsalaheen BA, Hanke TA, McCulloch KL. 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 of the American Physical Therapy Association. Journal of Orthopaedic & Sports Physical Therapy. 2020;50(4):CPG1–CPG73. doi:10.2519/jospt.2020.0301
RED FLAGS: adapted from the Concussion Recognition Tool 6 (CRT6), Echemendia RJ et al., British Journal of Sports Medicine 2023;57:692–694, with the emergency danger signs published by the Centers for Disease Control and Prevention.