New approaches to assessment and treatment can help players return to play gradually and safely after a blow to the head.

Only about 10% of concussions result in loss of consciousness, and often a concussion is not the result of one large impact but a series of small collisions to the head.

A concussion is an impact to the head caused by a fall, collision, or blow that can result in physical, emotional, cognitive, or sleep impairments. Due to the signs, symptoms, and impairments associated with a concussion, the Centers for Disease Control and Prevention (CDC) is now classifying concussion as a traumatic brain injury.1 It is estimated by the CDC that approximately 300,000 sports-related concussions occur per year in the United States.2 According to the injury report from the National Football League, 154 concussions were documented in 2010 regular season play; this is a large increase from the 127 concussions reported in 2009.3 A study performed by McCrea et al in 2004 showed that out of 1,532 varsity high school football players, 465 sustained a concussion, and only 220 reported the event.2 Although it may appear as if concussions are on the rise, what more likely is on the rise is awareness of concussions, as well as preseason and postconcussion cognitive testing such as ImPACT testing, which determines whether a player suffers cognitive deficits after a high impact blow to the head. Educating health care providers to efficiently recognize the signs of concussion, utilize testing, such as ImPACT, and create guidelines for return to sport following concussion will aid in a smooth transition for a player from injury to recovery after a concussion.


Concussions seemingly should be easy to recognize; a player takes a significant blow to the head during the game, falls to the field, and experiences a loss of consciousness. Unfortunately, recognizing concussion is not this easy. Only about 10% of concussions result in loss of consciousness, and often a concussion is not the result of one large impact but a series of small collisions to the head.4 Recognizing concussion also becomes a significant concern because of the potential of “Second Impact Syndrome,” a condition in which a player receives a second impact to the head before full recovery from the original impact. This second collision may cause severe cerebral vascular swelling, and, potentially death.4

One of the first signs of concussion is amnesia. Events surrounding the play in which the injury occurred may not be easily recalled by the player, if they can be recalled at all.

One of the first signs of concussion is amnesia. Events surrounding the play in which the injury occurred may not be easily recalled, if at all. Therefore, the player should be questioned about occurrences before, during, and after the event. If any gaps in information are revealed through questioning, the player is automatically assumed to be concussed. Some players may not present with symptoms of a concussion at the time of the event, and deterioration in their status and signs and symptoms may not manifest until days after the injury. The typical signs and symptoms that accompany concussion are divided into four categories; physical, emotional, cognitive, and sleep.4 Table 1 shows components of these categories to look for3:

If any of these signs and symptoms are noted, the player should be referred for ImPACT testing, if and where available to the player.


Many schools around the country have implemented ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing) as a preseason measure of cognition as well as a postconcussion measure of change in cognition. By establishing a baseline for athletes, determining whether the player suffered a concussion and/or if he or she experienced any extreme changes in cognition becomes easier. If no baseline is established, a concussion can still be determined through ImPACT testing, but will not have the reliability of a comparison. ImPACT testing has been proven to be a very valid measure of processing speed and reaction time.5 ImPACT also has very strong sensitivity and specificity of 81.9% and 89.4%, respectively.6

Table 1

The ImPACT test looks at four sections specifically: Demographics and Health History Questionnaire, Current Symptoms and Conditions, Neuropsychological Testing, and Injury Description. Within the neuropsychological testing, there are six modules upon which the player is evaluated: word discrimination, design memory, x’s and o’s, symbol matching, color match, and three-letter memory.7

Although a player may pass neuropsychological testing, that individual can still be diagnosed with a concussion based on certain symptoms. The physician responsible for interpreting the test will hold return to play until the patient is achieving baseline scores and displaying no symptoms of concussion. Often, physicians can use ImPACT testing to determine what type of therapy the patient will need to resolve the condition. When ImPACT or concussion testing is not readily available, the most important factor in determining return to practice or play is report of symptoms with increased exertion. The typical return to play protocol will consist of starting at no activity, to light-aerobic activity, sports-specific exercise, noncontact training drills, full contact practice, and return to game.3 Advancement to the next stage is predicated on the player’s response to the exercise. For instance, if the player has no symptom with light-aerobic activity, he or she is permitted to move on to sports-specific exercise after 24 hours. If that player notices symptom (ie, headache, dizziness) with sports-specific activity, he or she is to stop immediately, and try again after 24 hours of being symptom free.4 Actual return to play requires a doctor’s clearance, and must be at least 5 days after the initial episode. At any sign of concussion during play, the player is automatically pulled from the game.

Neuro-based physical therapy is warranted after concussion when a player has balance and vestibular deficits. Photo by Chris Harvey/


At the University of Pittsburgh Medical Center, where ImPACT testing is readily available and frequently utilized, a player will either return to the team athletic trainer for gradual return to play, be referred to a balance and vestibular specialist if the player displays difficulty in these areas, and/or receive exertional therapy.

Neuro-based physical therapy is warranted after concussion when a player has balance and vestibular deficits. The therapy provided will be very symptom dependent. Patients are often placed in a very calm, dimly lit environment so not to enhance symptoms. They are provided with exercises to work on vestibular ocular reflex (VOR), conjugate gaze activities, and proprioceptive activities for the body. Following are descriptions of exercises to provide in balance/vestibular therapy.)


Have the patient place a card in front of the face at arm’s length. Start with the head in midline and eyes focusing on the card. The patient should then rotate the head from left to right while maintaining gaze on the card. (Head may also be moved in a vertical or diagonal fashion.) This exercise is important for stabilizing gaze with head motions.


The patient will start out the same as VOR 1, but as the patient moves the head to the left, the card should move to the right, and vice versa for the opposite side.


While holding a card, the patient should keep the eyes focused on the target. The card is then moved side to side while the patient’s head stays still. This can be performed horizontally, vertically, or diagonally. The exercise will help with restoring the patient’s eye movements while the head is stabilized.


The patient will hold two cards, one in each hand, and place them about 6 inches apart to start. As the head remains stable, the patient will move the eyes quickly back and forth between the two objects.


The patient will stand on one leg, with no external support. To progress this activity, the patient may close the eyes or add foam/air discs to the weight-bearing leg. Proprioceptive activities are to be done to help the patient increase awareness of the body in space. This is something that may be lost as trauma occurs to the brain, and must be restored in post-concussion.


As the patient stands on one leg, a ball will be tossed back and forth between the arms or bounced off a wall. To progress this activity, add foam/air discs to the weight-bearing leg.


While walking on a solid surface, keep eyes focused straight ahead and move the head side to side, or up and down. To progress this activity, have the patient walk on unstable surfaces (ie, grass, sand).

While these patients will start out in a very controlled environment, they will be incorporated gradually into more functional environments with brighter lights and more visual distractions. As with many realms of therapy, if the patient has a negative reaction to progression, it is important to take a step back and allow for the patient’s symptoms to resolve before progressing.

“Second Impact Syndrome” is a condition in which a player receives a second impact to the head before full recovery from the original impact. This second collision may cause severe cerebral vascular swelling and, potentially, death. Photo by Glen Jones,

As balance and vestibular symptoms resolve, the player may be placed into an exertional program. The following exertional program is based on the Karvonen Heart formula ([ {Max. H.R. (220-Age) – Resting H.R.} X Target % ] + Resting H.R.), in which the player will remain within a percentage of their target heart rate. A player remains in each stage until activities are completed symptom free.8

The classification of each stage follows8:

Stage 1 Minimal Exertion (30% to 40% Max Heart Rate)
  • Very light aerobic activity
  • Submaximal stretching
  • ROM/stretching
  • Very low level balance activities
Stage 2 Light-Moderate Exertion (40% to 60% Max Heart Rate)
  • Moderate aerobic activity
  • Light resistive exercises with weights
  • Stretching (active)
  • Low level balance activities
Stage 3 Moderately Aggressive (60% to 80% Max Heart Rate)
  • Moderately aggressive aerobic exercise
  • All forms of strength exercise
  • Active stretching
  • Impact activities, running, plyometrics (no contact)
  • Challenging proprioceptive activities
Stage 4 Functional Training (80% to 90% Max Heart Rate)
  • Noncontact physical training
  • Aggressive strength exercise
  • Impact activities, plyometrics
  • Sports-specific training
Stage 5 Full Exertion with Contact (90% to 100% Max Heart Rate)
  • Resume full physical training activities with contact
  • Continue aggressive strength/conditioning exercise
  • Sports-specific activities

If the player can get through stages 4 through 5 without symptom, they will be cleared to participate in the game. This protocol has not yet been validated or proven reliable, but has shown positive results in athletes at the University of Pittsburgh Medical Center.


Certainly, many advances have been made in recognizing concussions and establishing parameters for return to sport. Although improvements have been made, it is crucial for health care professionals to continue to progress in their ability to recognize concussion symptoms, determine need for cognitive testing, and create effective rehabilitation programs.

Christin C. Donofrio, PT, DPT, and Rebecca Campbell, PT, DPT, are sports residents at UPMC Centers for Sports Medicine, Pittsburgh. For more information contact

  1. Centers for Disease Control and Prevention. August 31, 2010. Concussion in Sports. Accessed January 13, 2011.
  2. McCrea M, Hammeke T, Olsen G, Leo P, Guskiewicz K. Unreported concussion in high school football players. Clin J Sports Med. 2004;14:13-17.
  3. NFL. December 13, 2010. Concussions Reported in NFL Up 21 Percent from Last Season. Accessed January 14, 2011.
  4. Halstead ME, Walter KD; Council on Sports Medicine and Fitness. Sports related concussion in children and adolescents. Pediatrics. 2010;126:597-615.
  5. Iverson GL, Lovell MR, Collins MW. Validity of ImPACT for measuring processing speed following sports-related concussion. J Clin Exp Neuropsychol. 2005;27:683-9.
  6. Schatz P, Pardini JE, Lovell MR, Collins MW, Podell K. Sensitivity and specificity of the ImPACT Test Battery for concussion in athletes. Arch Clin Neuropsychol. 2006;21:91-99.
  7. ImPACT. Overview and Features of the ImPACT Test. Accessed January 14, 2011.
  8. Learish S. December 10, 2009. 5 Stage Exertion Program. Pittsburgh.