Physical Therapy for Concussion: Assessment and Treatment

Physical therapy helps reduce certain symptoms and facilitates a return to activities after a concussion. Treatment may combine balance exercises, neck care, eye exercises, and gradual physical activity. Research on sports-related concussions supports an active, gradual return to activity rather than^prolonged, strict rest ^{.¹, ²}

Headaches, dizziness, and difficulty concentrating can make daily life challenging after a head injury. Many people recover, but the recovery time varies, and some symptoms may persist. A suspected concussion requires a medical evaluation. In sports, leave the game as soon as a concussion is suspected. A confirmed concussion means you cannot return to play that same day. The Amsterdam Consensus outlines this evaluation and removal from play².

A severe headache or one that worsens, repeated vomiting, or a decline in alertness require immediate evaluation in the emergency room following an impact. Our comprehensive guide to concussions outlines other warning signs. Do not wait for a physical therapy session or for exercises to take effect if you experience these signs.

What conditions can physical therapy help treat?

Physical therapy can help relieve neck-related headaches, dizziness and vertigo, balance problems, and neck pain. It also helps patients resume physical activity. Fatigue, sensitivity to light or noise, visual disturbances, and difficulty concentrating should be evaluated; treating these conditions may require the collaboration of several professionals.

A concussion can be accompanied by several issues at the same time. A physical therapist trained in managing these conditions will assess the relevant factors and develop a plan based on your symptoms, activities, and goals.

A concussion may be accompanied by a neck injury and^balance problems ^{.³, ⁴} These issues require their own evaluation. Their presence alone is not sufficient to determine whether the brain has recovered or to assess the severity of the concussion. Addressing neck, balance, and visual problems is part of appropriate care.

What to Expect During Your First Assessment?

At the first appointment, the physical therapist will assess your symptoms, your range of motion, and the activities you find difficult in order to develop a plan with you. The consultation will focus on the accident and how your condition has progressed since the injury. Tests of your neck, balance, vision, or exertion will be selected based on your condition and any necessary precautions. The goals and initial instructions will then be discussed.

The Initial Questionnaire

The physical therapist will ask you how the accident happened, which symptoms have changed, and what makes them worse or better. He or she will also ask about your work, your studies, your sports and hobbies, your current physical activity level, as well as any past concussions or headaches. These answers help determine which tests to perform and set treatment goals.

Physical Assessment

A balance assessment may include standing with the eyes open or closed and walking in a tandem pattern, where one foot is placed just in front of the other. Some tests observe the eyes during a brief head movement or determine which movements trigger symptoms. The professional assesses their relevance following the injury.

The neck examination assesses your range of motion, muscle strength, areas that are sensitive to finger pressure, and your response to movement. The eye examination can assess your ability to track an object, shift your gaze between two targets, see an object approaching your nose, and maintain a stable gaze while your head moves.

If your condition allows, a treadmill test—such as the Buffalo test—measures your tolerance for progressive exertion and changes in symptoms⁵. The exercise test can also be performed on a stationary bike. This test is used to guide exercise prescriptions; it should not be repeated on your own at home.

What Happens Next

After the evaluation, the physical therapist explains the issues identified and the available options. You agree on goals, a follow-up plan, and criteria for measuring progress. You may begin some exercises at home if your condition allows. The recovery plan and expectations are revised based on your progress.

What treatments can be included in the plan?

The plan may combine balance exercises, neck care, gradual physical activity, eye exercises, and advice on managing activities and temporarily adjusting positions that worsen your symptoms. The physical therapist will choose the right combination based on the difficulties observed and the activities you want to resume.

Neuroplasticity refers to the ability of the nervous system—which transmits messages throughout the body—to change its connections and functioning. The precise mechanisms by which each exercise helps after a concussion are still being studied. Physical therapy improves observable abilities, such as walking, maintaining balance, and tolerating physical exertion.

Regain exercise tolerance

Aerobic exercise is sustained physical activity that increases heart rate and breathing, such as walking or cycling. When tailored to the patient’s symptoms, it can aid recovery from a concussion; the exact mechanism is still^{being studied.¹, ⁶} A treadmill stress test can help identify the intensity at which symptoms^worsen.^{⁵, ⁷} The healthcare professional uses this response to select a training regimen that the patient can tolerate.

Some programs use a percentage of the heartbeats measured at the threshold at which symptoms begin to worsen. A preliminary 2010 study of 12 people with persistent symptoms used approximately 80% of that threshold, five to six days a week. This was a small follow-up study without a randomized control group; it was not a universal dosage. Leddy describes this program⁸.

The professional determines the duration and intensity of your exercise, then adjusts them based on your tolerance and the results of new tests. Brisk walking, a stationary bike, or an elliptical machine can be used if your balance and the environment allow it. The goal is to exercise without the risk of a head injury or a fall.

In a trial involving 103 athletes aged 13 to 18 who were evaluated within ten days of sustaining a concussion, adapted aerobic exercise resulted in a median recovery time of 13 days, compared with 17 days for a stretching program. The median means that half had recovered by that point and the other half after. Leddy’s trial describes this benefit⁹. The result does not specify the recovery time for each individual.

Treating neck problems and certain types of headaches

Headaches are common after a concussion. Neck pain or stiffness may contribute to them, but they are not the only possible explanation. The evaluation also takes into account migraines, sleep patterns, and other symptoms. A tender spot alone is not enough to identify the exact cause of each headache.

An impact can cause both a concussion and a neck injury. Muscles, joints, and ligaments—the bands that connect bones—may be affected. Severe stiffness may resemble a stiff neck, but an evaluation must determine the consequences of the trauma. Neck pain can contribute to headaches or accompany dizziness. This is why a neck evaluation is part of the follow-up care after a concussion.⁴

Neck treatment, also known as cervical treatment, may combine exercises for the muscles that support the neck, gentle movements, joint mobilizations guided by the physical therapist to improve mobility, and manual techniques applied to the neck muscles to provide short-term relief. The professional first determines whether this treatment is appropriate following the injury. A slight backward movement of the chin may be part of the neck assessment exercises. The choice of exercises and their progression are based on the evaluation.

Physical therapy identifies the factors contributing to your headaches and selects appropriate treatments. Neck and balance rehabilitation—which trains movements and abilities that have become difficult—is recommended when dizziness, neck pain, or headaches persist for more than 10 days after a^{sports-related} concussion^{.², ¹⁰} In a small randomized controlled trial involving 31 participants aged 12 to 30 with these persistent symptoms, the addition of neck and balance therapy resulted in medical clearance to return to sports within eight weeks for 11 out of 15 participants, compared to 1 out of 14 in the control group. Both groups were already receiving advice, movement exercises, and a gradual return to physical activity¹¹. This result supports combined care; it does not predict your individual timeline.

Improving balance and tolerance to movement

The vestibular system consists of structures in the inner ear and their connections to the brain; it plays a role in balance and visual stability.

Dizziness can create the sensation that the room is spinning, a feeling of floating, or a loss of balance. It may be related to the vestibular system, but its presence alone is not sufficient to pinpoint the problem as originating in the inner ear. Vestibular rehabilitation uses exercises that gradually challenge balance and visual stability. Langevin’s diagnostic protocol describes this approach³.

Vestibular rehabilitation can improve eye stability and balance. It primarily involves eye exercises, movement habituation exercises, and balance exercises. The specific exercises chosen depend on the test results; not all cases of dizziness require the same treatment plan.

At a specialized clinic, combined balance and eye movement disorders affected 28.6% of the young people seen within 30 days of a concussion. They affected 62.5% of those who had had at least three symptoms for a month or longer.¹² Another pediatric study also examined these disorders and the factors associated with them.¹³ These specialized clinic cohorts do not represent all young people with concussions.

The brain combines visual input, information from the inner ear, and proprioception to maintain balance. Proprioception is the perception of the position and movement of body parts. After a concussion, the processing of this information may be disrupted. The evaluation aims to identify which tasks trigger difficulties, without attributing all dizziness to a single mechanism.

To improve visual stability, focus on a target while moving your head in a controlled manner. This exercise engages the vestibulo-ocular reflex, which helps maintain a stable image when the head moves. Habituation exercises gradually repeat certain movements that cause discomfort. Balance exercises can start with feet together and then progress to standing on one leg or on an unstable surface. Closing your eyes also increases the difficulty. These progressive exercises require a safe environment and the professional’s approval to prevent a fall.

The goal is to make functional movements easier and to resume activities with greater confidence. The intensity and duration are adjusted according to symptoms; the idea is not to push yourself if your condition worsens significantly.

Exercise can help improve tolerance for movement and stabilize eye gaze. In a trial published in 2022 involving 60 adults with persistent symptoms, adding neck and balance rehabilitation to physical exercise improved certain measures of neck and eye gaze stabilization. However, this addition did not show a clear benefit regarding overall symptoms or return to activities compared to exercise alone. Both groups showed improvement. Langevin’s trial elaborates on these findings¹⁴.

Supporting Eye Movement and Reading

After a concussion, your eyes may have difficulty tracking an object, focusing together on a nearby object, or coordinating your gaze with head movements. These difficulties can cause eye strain or be accompanied by headaches while reading and trouble concentrating.

Oculomotor exercises train the eyes to make precise movements. Tracking involves slowly following an object without moving the head. Saccades involve shifting the gaze from one target to another. Convergence directs both eyes toward a nearby object, such as when a target moves closer to the nose. The choice of exercises and the progression through them are determined following an appropriate examination.

The professional determines the duration and progression of the exercises based on the specific difficulty level and your tolerance. The exercises recommended for home use complement your treatment; they do not replace an eye exam when one is necessary.

In the CONCUSS trial, young people aged 11 to 25 had confirmed convergence difficulties and persistent symptoms lasting 4 to 24 weeks after a concussion. The program included two in-clinic sessions per week, in addition to usual care. After six weeks, 88% of the group that received immediate in-clinic treatment met the criteria for improvement on both primary measures of convergence, compared with 8% of the group that received delayed treatment. Each group consisted of 52 participants. Both groups received standard concussion care. This result supports this structured program for this specific difficulty; it does not validate each individual exercise for all visual disorders. The CONCUSS trial describes the participants and results¹⁵.

How do the drills progress between games?

Home exercises allow you to stay active between appointments. Your healthcare provider will explain the movements, how often to do them, and the signs that indicate you should reduce or stop. Keep track of the exercises you’ve done, the activities you’re able to do again, and how long symptoms last after exercise. This information is used to adjust your program. If a recommendation is difficult to follow, discuss it with your healthcare provider rather than pushing yourself too hard.

Follow-up care assesses your symptoms using the same questions at each visit, as well as your ability to resume activities. These assessments allow us to tailor your treatment to your progress. The at-home program should remain manageable and be adjusted if symptoms or other constraints prevent you from following it.

Stay active while getting plenty of rest at the beginning

In the past, complete rest was recommended—sometimes in the dark and without any activity—until symptoms subsided. Current recommendations favor relative rest during the first 24 to 48 hours: reducing strenuous activities while continuing to perform light tasks that are tolerable. Prolonged strict rest does not improve recovery². This is one of the myths about concussions.

Even in the early stages, relative rest does not mean you have to isolate yourself. You can continue to interact with loved ones and engage in light daily activities as tolerated. Avoid activities that could result in another blow to the head, a collision, or a fall.

Adjust the exercises based on how symptoms respond

A slight and brief increase in symptoms may occur during the first few exercises and does not necessarily mean that recovery is^{delayed.¹⁶, ⁹} The criteria for sports participation are outlined in the following section. A more significant or prolonged worsening of symptoms requires stopping and adjusting the activity. These guidelines do not constitute permission to resume an activity that carries a risk of a head injury, collision, or fall.

How can you prepare to return to school, work, and sports?

The rehabilitation program organizes the return to school, work, and sports in stages. Rehabilitation helps patients regain the abilities they need for daily life. Symptoms, tolerated activities, and medical evaluations guide progress; the number of days that have passed is not sufficient on its own to authorize high-risk activities.

Stages for Returning to Cognitive Activities

The resumption of cognitive activities—those that require thinking or concentration—progresses according to the patient’s tolerance. After 24 to 48 hours of relative rest, activities can be gradually increased:

1. Light daily activities, including short reading sessions if tolerated, with less screen time at first.
2. Reading, homework, or other intellectual tasks at home, with breaks.
3. A partial return to school, with shorter school days, extra time, or an adjusted homework load.
4. A return to the usual school schedule and activities, without any additional accommodations once tolerance has been restored.

Light walking can resume at the same time. Physical and intellectual activities do not have to wait for one to end before the other begins. The INESSS brochure from Quebec provides guidance on this resumption¹⁷.

Returning to school may involve modified exams, breaks, extra time for assignments, or a temporary reduction in the workload. The goal is to resume learning and school life without a significant or prolonged increase in symptoms. These accommodations are gradually reduced as tolerance improves.

Returning to Work

The return to work is tailored to the tasks and risks of the job. Reduced hours, more frequent breaks, a quiet workspace, comfortable lighting, or tasks that require less concentration can help. These accommodations are phased out as the employee makes progress. Professional advice is necessary before resuming high-risk tasks, such as working at heights or driving, if symptoms compromise safety. INESSS describes workplace accommodations¹⁷.

Your physical therapist, often in collaboration with your doctor, also plans your gradual return to work or school as soon as it becomes possible. They can advise you on necessary accommodations, such as limiting the amount of physical strain at work.

Stages for Returning to Sport

The return to sports follows a six-step progression. Each step generally takes at least 24 hours. The first steps also serve as part of the treatment; the final steps reintroduce the demands of the sport. The rules regarding symptoms and clearance become stricter before high-risk activities.

The roadmap proposed by the Amsterdam Consensus includes the following steps:

1. Permitted daily activities. Gradually reintroduce light activities, such as walking, during the initial period of relative rest.
2. Light aerobic exercise, followed by moderate aerobic exercise. Walk or ride a stationary bike according to your tolerance and the instructions.
3. Sport-specific individual exercises. Run or practice changes of direction away from the group, without the risk of a blow to the head. Authorization from a qualified healthcare professional must be obtained before proceeding to this step if there is a possibility of accidental impact.
4. Non-contact practice. Resume higher-intensity and more complex exercises, such as passing drills or group drills, after receiving authorization and meeting the criteria below.
5. Full-contact practice. Participate in the regular practice after successfully completing the previous step.
6. Return to play and competition. Resume normal participation after completing a full training session.

The consensus describes this athletic progression². The protocol can be adapted to the sport, age, and the organization’s rules.

Progression criteria

In steps 1 through 3, a slight and brief increase in symptoms is acceptable: no more than 2 points on a scale of 0 to 10, lasting less than one hour, compared to the level before the activity. If the increase exceeds this level or lasts longer, stop the activity and wait for symptoms to return to their previous level. To continue progressing in your workout, try the exercise again the next day, adjusting the intensity.

Before proceeding to steps 4 through 6, concussion-related symptoms must have resolved at rest, during exercise, and after exercise. Difficulties with thinking and relevant abnormalities identified during the examination must also have resolved. Approval from a qualified healthcare professional must be obtained before proceeding with these steps and, if accidental impact is possible, before step 3. Your sports organization’s medical requirements also apply.

If concussion-related symptoms return during steps 4 through 6, go back to step 3 and have your progress reevaluated before resuming any high-risk activity. Waiting 24 hours is not, on its own, sufficient to move on to the next step.

Quebec's Guide to Resuming Intellectual Activities

The Amsterdam Consensus calls for a full return to academic studies before resuming sports without restrictions. The INESSS brochure sets an earlier milestone in the recovery process: intellectual activities must be fully resumed without any modifications before Stage 4, which involves exercises with or without teammates, without contact. The International Consensus² and the Quebec brochure¹⁷ do not, therefore, formulate this criterion in the same way.

To follow the Quebec guidelines, wait until intellectual activities have fully resumed without any adjustments before moving on to Stage 4, in addition to meeting the symptom and authorization criteria described above. You can gradually resume your studies and physical activity in parallel starting in the early stages. Your healthcare professional will tailor your progress to your situation and the rules of your sports organization.

How do we determine the duration and frequency of follow-up?

The duration and frequency of follow-up are determined based on your needs, your progress, and any necessary adjustments to the program. The physical therapy programs studied last several weeks; some include a weekly session at the clinic and exercises to do at home. For example, the Schneider trial¹¹ included weekly sessions for up to eight weeks, until clearance to return to sports was granted. This research schedule does not determine the number of visits you will have.

When should you adjust the plan or consult another professional?

The plan should be reassessed if your condition worsens, if progress remains limited, or if you are having difficulty resuming activities. INESSS recommends seeking consultation if there is little improvement after two weeks, if symptoms still limit your activities after one month, or if you are unable to reach a milestone after several attempts. Significant concern also warrants a medical consultation. The INESSS brochure specifies these reasons for follow-up¹⁷. The warning signs listed at the beginning require urgent care, without waiting for these timeframes to elapse.

Treating a concussion requires knowledge and skills specific to this condition. The physical therapist must be able to assess balance issues, neck and eye movement difficulties, and then guide the patient’s return to activities. Additional training can help develop these skills. Another professional, such as an optometrist or a physician, may be involved in the treatment depending on the problems observed.

Treatments for migraines, sleep issues, anxiety, or other problems can complement physical therapy. The physical therapist assesses how these issues interact, tailors the treatment plan, and refers you to other professionals when your needs go beyond the care they can provide. Even after several weeks of symptoms, appropriate treatments can help you resume your activities. Our team can support you and refer you to other professionals as needed.

Frequently Asked Questions About Physical Therapy After a Concussion

Frequently asked questions include when to start, screen time, returning to sports, and direct access to physical therapy.

Should you wait until you no longer have any symptoms before starting?

You do not have to wait for all symptoms to disappear before walking or doing the prescribed light exercises. Active treatment can begin early, depending on the evaluation. The intensity and duration should be adjusted based on your response; activities that carry a risk of another head injury require extra precautions.

When can I use the screens again?

Limit screen time during the first two days. Then gradually resume screen time based on how well you tolerate it, taking breaks if symptoms worsen. It’s not necessary to set the same time limit for everyone. Reading and working on a screen may require temporary adjustments.

Does "tolerated" mean I can go back to playing my sport?

Walking or using a stationary bike can be resumed early if the activity is well tolerated and poses no risk of a fall or head injury. Contact sports, collisions, and high-risk activities must await authorization and meet the criteria for gradual return to sports. A slight increase in symptoms during an authorized exercise does not mean permission to resume contact sports.

Do I need a doctor's prescription?

In Quebec, you can see a physical therapist directly without a doctor’s prescription. The Quebec Professional Order of Physical Therapy explains access to physical therapy¹⁸. A suspected concussion also requires a medical evaluation. Physical therapy can then contribute to the treatment and refer patients to other professionals, without delaying urgent care.

An assessment helps you choose your treatment, set goals, and track your progress. The goal is to resume the activities that are important to you, with the necessary adjustments during your recovery. We’ll review the plan and its steps together.

Sources

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Our physical therapists defined the research strategy, plan, and clinical content of this article. An AI tool assisted with the literature review and text editing to ensure consistency in content and writing style.