Beyond Rest
A Criteria-Based Approach to Concussion Assessment, Rehab, and Return to Activity
“It definitely can make things worse if you don’t take the time that you need to recover your brain properly."
The old concussion playbook was simple, and Meghan Braun, PT, DPT, MTC, CSCS, HSP, remembers it well. "You'd get injured, you'd feel funky. Doctors would tell you to rest, you'd wait until you didn't feel funky, and then you'd just get right back into your sport."
A board-certified physical therapist, and owner of Body Mechanics Physical Therapy in Jacksonville, Florida, Braun has spent about 14 years treating athletes and active adults, and she has sustained several concussions of her own. Her message to a large audience of physical and occupational therapists on a recent October evening was that the model no longer holds up: "The goal isn't just symptom resolution anymore. We're actually trying to get them back into sport in a progressive way."
A Condition Showing Up in Every Caseload
Concussions now reach rehab clinics from many directions: youth sports, collegiate and professional athletics, military service, and the general population. Some patients, Braun shared, arrive with a different diagnosis entirely. After a motor vehicle accident, Braun noted, "you'll notice, hey, this person might have a concussion, what can I do for that?" That is why she argues that clinicians who rarely see diagnosed concussions still need to know the territory.
The American Medical Society for Sports Medicine's position statement and the Sixth International Consensus Statement on Concussion in Sport both emphasize multimodal diagnosis and active management, including about 24 to 48 hours of relative rest and reduced screen time rather than extended inactivity. The consensus statement also produced a family of tools: the SCAT6 and Child SCAT6 (for ages 8 to 12) are sideline tools for clinicians. The SCOAT6 and Child SCOAT6 are office-based assessments that can be used from about 72 hours to months after injury, and the Concussion Recognition Tool (CRT6) gives coaches and parents a way to spot red flags without a health background.
104813 Stick With It: The Science & Skill of Using Kinesiology Tape
Kinesiology Tape has become a widely used tool across rehabilitation and performance settings, yet many clinicians lack confidence in when and how to use it effectively. This live-interactive presentation breaks down the fundamentals of using Kinesiology Tape—what it is, how it works, and the physiological principles behind its use in the neuromuscular system to its role in pain modulation and...
A Brain Running on Backup Power
A concussion, Braun pointed out, is a functional disturbance, not a structural one. "They get a CT or an MRI at the ER. Everything looks fine, but they're not feeling well. It's very, very common." Imaging is mostly used to rule out a bleed. Concussion, Braun continued, also isn't graded. "You can't just have like a mild concussion versus a severe concussion. It's all just based off of symptoms."
What drives those symptoms is a neurometabolic cascade. Mechanical force, whether direct or transmitted through the body, triggers an ion flux and a surge of glutamate. The brain then spends more energy trying to restore balance just as cerebral blood flow drops, leaving supply and demand mismatched. "Your brain is metabolically vulnerable," Braun said. "It's not structurally broken." During her October presentation, Braun made the comparison that the body treats a concussion similar to a city after an earthquake: "There may be parts of the city that the power comes back on quicker. But if it doesn't all come back on at the same time, it takes a while for things to kind of move through and get back to more balance."
The clinical payoff is the logic behind graded, sub-symptom-threshold activity. Early on, taxing the brain constantly "is just taking away those energy stores that it's trying so hard to balance." Braun recalls the time they treated a lawyer who fell off a mountain bike, shrugged it off, and returned to a high-stress job. Trying to work through their injury, the lawyer's concentration dropped, fatigue and irritability climbed, and she developed a severe autonomic response. "She couldn't drive anymore, she could barely walk." Braun described how their vision nearly failed. Recovery took a long time, which Braun links to the missed recovery window: "It definitely can make things worse if you don't take the time that you need to recover your brain properly."
Countless Patients Impacted, But So Often Unrecognized
Concussion symptoms tend to fall into a few familiar groups: somatic complaints like headache, dizziness, nausea, and sensitivity to light and sound; cognitive changes like fogginess and slowed processing; emotional shifts like irritability, anxiety, and sadness; and disrupted sleep.
These domains overlap, and a single patient rarely stays in just one.
As Braun put it, “all of these things can happen across all the ages. It just kind of varies with different populations.” Age, mechanism of injury, and daily demands change how the injury shows up, how it gets reported, and what recovery should look like, and much of the available research is built on male adult brains. Four groups are worth keeping in mind.
- Children
- Developing brains differ in myelination, connectivity, and executive function, and younger kids often can't describe their symptoms, so clinicians rely on parents, teachers, and coaches. Changes in feeding, sleep, play, and behavior with peers can be clues. Recovery tends to be slower, with a heavy focus on return-to-learn accommodations. "There's nothing for kids under age 8 right now," Braun noted of standardized tools, so observation does much of the work.
- Adults and athletes
Most return-to-sport protocols were developed in this group. Prior concussions and comorbid cervical or vestibular problems can shape recovery. Occupation matters too. Braun said she sees this "a lot with my motor vehicle accident patients": people with stressful jobs keep pushing, drain their reserves, and slide backward.
- Older adults
- Falls are the leading cause. Recovery is slower and harder to recognize because dementia, medications, and other conditions can mimic symptoms. Without baseline metrics, "you're just looking for those changes in function, behavior, gait, cognition." Bleeding risk rises with anticoagulants and vascular disease, and fall prevention belongs at the top of the plan of care.
- Female athletes
- Most of the research draws on male participants, leaving "a big chunk, obviously, like 50%, right, of athletes that we're missing as far as data goes." Females tend to report higher symptom burdens and longer durations. Braun listed possible contributors: neck and core strength relative to head mass, hormonal influences on ligament laxity, reporting behavior, and equipment differences. Her takeaway: "We want to not assume the male norm recovery timeline."
104590 The Meniscus Matters: Modern Management from Injury to Function
Meniscus injuries are among the most common knee pathologies encountered across orthopedic, sports, and occupational settings—yet they remain frequently misunderstood and inconsistently managed. This presentation will explore the anatomy, biomechanics, and injury mechanisms of the meniscus while differentiating between traumatic and degenerative tears. We will explore clinical presentation, red flags, imaging considerations, and current evidence surrounding surgical versus conservative management....
Red Flags and the Value of Following a Gut Feeling
Some findings call for emergency referral, not outpatient management: worsening headaches, repeated vomiting, seizures or posturing, increasing confusion or agitation, focal neurological deficits, slurred speech, unequal or unresponsive pupils, a declining Glasgow Coma Scale score, and neck pain with a mechanism concerning for cervical injury. Signs of a skull fracture, such as bleeding from the ears or bruising behind them, belong on the list too. "This is not an outpatient thing that you guys should be handling at that point."
On the sideline, the rule is blunt: "When in doubt, sit them out." Braun cautioned against letting others override clinical judgment, especially with young athletes. "Don't let other people influence your decisions, especially if you have a gut feeling about something," and the documented results give you something to stand behind. She also recommends an emergency action plan worked out with coaches ahead of time, and notes that symptoms can be delayed, so a child who passes a screen right after a hit may still fail later.
Building the Exam Around the Impairments
No single measure sorts a concussion out. "There's no single test that clears or diagnoses concussions. Clinical judgment, again across the full battery, is required." The goal of a multi-domain exam is to find what is specific to each patient. "Gone are the days of like, okay, we're just going to do some balance stuff, and then make sure your eyes are moving in the direction they need to do."
A thorough history covers mechanism, symptom onset, prior concussions and TBIs, migraine, cervical and vestibular history, sleep, mental health, medications, and activity level before and after the injury.
The exam then works through several domains:
- Vestibular
- The vestibulo-ocular reflex, dynamic visual acuity, gaze stability, and positional testing to rule out BPPV, plus the Dizziness Handicap Inventory as a self-report.
- Ocular motor
- Smooth pursuits, saccades, near point of convergence, and accommodation. Ocular motor disturbances, Braun said, show up in "like 60 to 90% in concussion patients." The King-Devick test and the Vestibular/Ocular Motor Screening (VOMS) are the formal options. VOMS is positive when symptoms rise by 2 or more points on any item or the near point of convergence is greater than 5 centimeters.
- Cervical
- Range of motion, joint position error, deep neck flexor endurance, and the flexion-rotation test for upper cervical contributions to dizziness and headache.
- Balance
- The Balance Error Scoring System, the modified Clinical Test of Sensory Interaction on Balance, and force plates, with dynamic and dual-task challenges for higher-level athletes.
- Cognitive and mood
- Orientation, memory, concentration, and dual-tasking, with computerized options like ImPACT where available, and screens such as the GAD-7 and PHQ.
- Exertional
- The Buffalo Concussion Treadmill or Bike Test establishes a symptom-limited heart rate threshold, which guides exercise prescription.
Autonomic dysfunction can be missed because it overlaps with typical symptoms. Red flags include a heart rate disproportionate to effort, orthostatic intolerance, exercise intolerance despite normal vestibular and ocular motor results, and temperature or sweating changes. If these occur consistently, not only during exertion, Braun recommends neurology involvement and watching for conditions like POTS.
104731 Fast Track Flexibility for Rapid Functional Gains: Muscle Energy MET & Proprioceptive Neuromuscular Facilitation PNF Essentials
Muscle stiffness, pain, and restricted mobility affect a significant portion of the population and are increasingly prevalent in today’s sedentary, technology driven lifestyle. Flexibility limitations interfere with performance, recovery and function. Be the go-to clinician for mobility optimization with these gentle, effective, efficient, and evidence based interventions. This interactive webinar provides allied health professionals with a practical and research supported...
Rest Less, Rehab Sooner
"Strict rest, not supported as the [one-size-fits-all] answer anymore," Braun said. Past 24 to 48 hours, it can prolong recovery, bringing cardiovascular deconditioning, disrupted sleep and circadian rhythms, and in kids and teens, isolation and psychological effects. The comparison she draws is with joint replacement: "They're literally getting up and walking and moving and going home that same day. We're learning that movement is medicine, right? This is our job."
Treatment mirrors the exam. Vestibular rehab uses gaze stabilization (VOR x1 and x2), habituation through head turns, sit-to-stand, and busy environments, and balance progressions from stable to unstable and single-task to dual-task. When BPPV is present, canalith repositioning resolves it in about 80% of cases. Ocular motor work includes pencil push-ups, the Brock string, saccade and dot sheets, and smooth-pursuit tracking. Cervical work includes mobilization, deep neck flexor endurance, proprioceptive retraining, and posture. Everything progresses as it would after an ankle sprain: "You start with basic range of motion."
Dosing is conservative. Braun suggests 3 to 5 sessions per week, starting at roughly 60 to 70% of maximum heart rate or wherever symptoms allow, with 10 to 20 minutes of activity and symptoms kept around 2 to 3 out of 10 that resolve quickly. The clinician should act as the brake: "You're the one that's kind of holding the reins a little bit." Progress one variable at a time, usually duration first, and if a patient has no symptoms, resist advancing further that same day. "You can get those latent or delayed symptom spikes, right? It's kind of like a cumulative effect in your brain."
Pacing the Brain
The brain uses about 20% of the body's energy, so Braun teaches a two-thirds stopping rule: "You want to stop before you crash." The goal is to avoid the boom-bust cycle across screens, reading, work, school, and social time. Practical tools include structured time blocks with 5-minute rests, a longer break after three or four blocks, front-loading demanding tasks in the morning when symptoms are typically lower, and reducing noise and visual clutter. Social time counts as cognitive load. Another patient with autonomic issues found crowded settings drained her "battery" quickly.
Headache type matters. Cervicogenic headaches are typically one-sided and neck-driven. Migraine-like headaches pulse, can bring nausea and light sensitivity, and last 4 to 72 hours. Tension headaches are bilateral and squeezing. Exertional headaches arise during or after effort. Mood, anxiety, depression, fear avoidance, and catastrophizing can all drive persistent symptoms, so screening and referral to psychology, neuropsychology, or counseling belong in the plan. "Concussion care is a team sport."
104729 Mastering the Hip With OA: Deep Dive Into the New APTA's Framework for Clinical Excellence
Is your hip OA toolkit truly up to date? In late 2024 and early 2025, the APTA Academy of Orthopedic Physical Therapy introduced significant revisions to the Hip Osteoarthritis Clinical Practice Guideline, redefining best practice for today’s clinician. These updates elevate dry needling to a high‑level intervention, refine expectations for therapeutic exercise dosing, and clarify which traditional modalities should be...
Response, Not the Calendar
Return-to-learn begins with the 24 to 48 hours of cognitive rest, then light low-demand tasks at home, then school with accommodations such as reduced workload, more breaks, and extended time. Return to work depends on cognitive and physical job demands, safety-sensitive duties, and environment. It is supported by graduated duties, modified schedules, and communication with employers or HR.
Return to sport moves through symptom-limited activity, light aerobic exercise, sport-specific drills, non-contact training with dual-tasking and resistance, full-contact practice after medical clearance, and then competition. Each stage has a minimum duration with 24 hours of symptom monitoring before moving on, and any exacerbation scales the patient back. "Progression is driven by response and not the clock."
Final clearance is a medical decision, but rehab clinicians shape it. Braun encourages writing a short synopsis of objective data for the physician. Her case for patience is longer-term. She cited that 44% of people returning too soon experience severe symptom recurrence, that cellular vulnerability can last up to four weeks even without symptoms, and that returning too fast carries 2 to 2.5 times the likelihood of lower-extremity injury, along with the risk of second impact syndrome.
Insurance pressure, she acknowledged, is real. Her position is plain, and she compares it to an ACL: "I don't want that on my conscience of sending someone back way too soon." And when the picture is unclear, her rule applies: "When in doubt, refer out. When in doubt, keep them out." ◼
Want to make the most of everything Impact CE has to offer?
The Ignite Membership unlocks Premium events and Masterclasses, Unlimited Live Webinars, Hundreds of Self-Paced Courses, a Growing Library of Recorded Content, and Free E-Library access — all in one place, for one low annual price. Learn more about Ignite today.
