Concussion — Assessment, Management & Return to Sport

Physical Therapy · 2026 · Root Strength · 10 min read

Concussion — Assessment, Management & Return to Sport

A Doctor of Physical Therapy guide to current concussion science — what happens in the brain, how to assess it accurately, and the evidence-based 6-step return-to-sport protocol based on the 2023 Amsterdam Consensus Statement.

Written by the Root Strength physical therapy team. Our Doctors of Physical Therapy conduct concussion assessments on-site at 6332 6th Ave S, Georgetown, Seattle. For appointments: info@rootptseattle.com or (509) 596-0573. Most major insurance accepted — Premera, Regence, BCBS, Aetna, Anthem.

Concussion management has undergone more significant evidence-based revision in the past five years than in the preceding two decades. The publication of the 6th International Consensus Statement on Concussion in Sport — the Amsterdam Statement — in the British Journal of Sports Medicine in June 2023, following the October 2022 conference, represents the current gold standard for concussion identification, assessment, and management. Several of its recommendations represent meaningful departures from earlier guidelines that remain in widespread clinical use.

This post summarizes the current state of the evidence as it applies to our patient population at Root Strength — primarily active individuals and combat sports athletes — and outlines the clinical framework our PT team applies when assessing and managing concussive injury.

<10%

of concussions involve loss of consciousness — the majority present with subtler symptoms

10–14

days: typical recovery window for most adults with sport-related concussion when managed correctly

63%

reduction in recurrent concussions with mandatory removal and structured clearance protocols

Definition and Pathophysiology

The Amsterdam 2022 Consensus Statement defines sport-related concussion (SRC) as a traumatic brain injury caused by a direct blow to the head, neck, or body, in which an impulsive force is transmitted to the brain. The injury results in a range of clinical symptoms and signs that may or may not involve loss of consciousness, and which cannot be explained by drug, alcohol, or medication use, other injuries, or comorbid conditions.

Critically, concussion does not demonstrate abnormalities on standard structural neuroimaging — MRI and CT are typically normal. This is not because the injury is minor; it reflects the nature of the pathophysiology. Concussion produces a neurometabolic cascade: ionic flux across neuronal membranes, release of excitatory neurotransmitters, impaired mitochondrial oxidative metabolism, reduced cerebral blood flow, and axonal dysfunction. The brain's energy demand increases at the same time its capacity to generate energy is compromised — a cellular energy crisis that manifests as the clinical syndrome we recognize as concussion.

This metabolic vulnerability is why the period immediately following concussion carries elevated risk. A second impact during this window — before neurometabolic recovery is complete — can produce disproportionately severe consequences. Second-impact syndrome, while relatively rare, is associated with rapid catastrophic cerebral edema and remains a serious concern in return-to-sport decision-making.

Clinical Presentation — Symptom Domains

Concussion symptoms span four domains. A thorough assessment addresses all four, not just the most visible physical symptoms.

Physical / Somatic

Headache (most common), pressure in the head, nausea, vomiting, visual disturbance, photosensitivity, phonosensitivity, balance disturbance, dizziness, fatigue, sleep disruption.

Cognitive

Feeling "in a fog," slowed processing speed, difficulty concentrating, memory impairment (particularly anterograde), difficulty with word-finding, reduced academic or occupational performance.

Emotional / Behavioral

Irritability, emotional lability, anxiety, low frustration tolerance, depression. Often underreported, particularly in competitive athletes. The Amsterdam Statement emphasizes the importance of mental health assessment as part of the concussion evaluation.

Sleep

Hypersomnia (sleeping more than usual), hyposomnia (difficulty sleeping), or disrupted sleep architecture. Sleep disturbance both reflects and compounds other concussion symptoms, and often requires specific management.

Emergency Red Flags — Immediate Medical Attention Required

The following presentations require emergency evaluation before any further assessment: loss of consciousness (any duration), seizure or tonic posturing, repeated vomiting, progressively worsening headache, focal neurological deficit (weakness, numbness, double vision, slurred speech), deteriorating conscious state, or Glasgow Coma Scale below 15. These presentations may indicate intracranial hemorrhage or other structural injury requiring imaging and emergency intervention.

Assessment Tools — Current Best Practice

The Amsterdam 2022 Statement introduced updated versions of the primary concussion assessment tools. These replace earlier versions and are now the recommended standard.

Sideline assessment — CRT6 and SCAT6

The Concussion Recognition Tool 6 (CRT6) is designed for non-medical personnel — coaches, parents, and athletes themselves — to identify when a concussion may have occurred. The Sport Concussion Assessment Tool 6 (SCAT6) is the current clinical sideline tool for healthcare providers, including elements of symptom assessment, cognitive evaluation, and balance testing. Both tools are most effective within the first 72 hours post-injury. The SCAT6 and CRT6 replace their previous versions and should not be used interchangeably with SCAT5 or older iterations.

Subacute office assessment — SCOAT6

The Sport Concussion Office Assessment Tool 6 (SCOAT6) — a new tool introduced at Amsterdam 2022 — is designed for the clinical follow-up assessment beyond 72 hours. It incorporates multimodal evaluation: symptom scales, balance measures, cognitive testing, oculomotor and vestibular assessment, mental health screening, and sleep assessment. This comprehensive approach reflects the growing recognition that concussion is not a single-domain injury and that adequate assessment requires evaluating all affected systems.

What we assess at Root Strength

Our PT team's concussion assessment protocol includes symptom inventory across all four domains, cervical spine assessment (cervicogenic headache and neck pain frequently co-occur with SRC and require differentiation), vestibular and oculomotor screening, balance and postural control evaluation, and a graded exertion test where clinically appropriate. We work collaboratively with referring physicians and, for athletes, with their coaching staff at Muók Boxing to ensure assessment findings directly inform the return-to-sport timeline.

"Strict rest until complete symptom resolution is no longer supported by the evidence. The current literature supports early sub-threshold aerobic exercise as both safe and beneficial for recovery when properly supervised." — Amsterdam Consensus Statement, 2023

Management — What the Current Evidence Supports

The most clinically significant update in the Amsterdam 2022 Statement concerns rest recommendations. Earlier guidelines universally recommended complete physical and cognitive rest until all symptoms resolved. The evidence has shifted substantially from this position.

The relative rest period — 24 to 48 hours

A brief period of relative rest — reduced physical and cognitive demands without complete isolation — is still recommended immediately post-injury. This is not indefinite. After 24–48 hours, the evidence supports gradual reintroduction of light activity rather than continued rest.

Early sub-threshold aerobic exercise

Research published in JAMA Pediatrics demonstrated that individualized sub-threshold aerobic exercise — activity calibrated to stay below the heart rate threshold that exacerbates symptoms — prescribed as early as two days after SRC safely accelerated recovery and reduced the incidence of persistent post-concussion symptoms compared to strict rest. A systematic review and meta-analysis published in the British Journal of Sports Medicine (Leddy et al., 2023) confirmed these findings across multiple populations.

The clinical implication: the post-concussion period is not a period of complete inactivity for most patients. It is a period of carefully managed, symptom-guided progressive activity. The threshold concept is central — any activity that provokes symptoms is too much; activity that does not provoke symptoms is generally appropriate and often beneficial.

Cervicovestibular rehabilitation

The Amsterdam Statement introduced a new recommendation for cervicovestibular rehabilitation for athletes presenting with neck pain, headache, dizziness, or balance disturbance following SRC. Evidence supports that cervical and vestibular dysfunction frequently co-occur with concussion and contribute significantly to symptom burden and prolonged recovery. Early vestibular rehabilitation — initiated within the first week post-injury — has been associated with faster recovery in athletes compared to delayed initiation. This is an area where physical therapy has a direct, evidence-supported role in concussion management.

Root Physical Therapy · On-Site

Vestibular & Concussion Rehab

Our PT team provides cervicovestibular assessment and rehabilitation as part of our concussion management protocol — one of the most evidence-supported interventions for reducing recovery time. Learn about our PT department →

Book an Assessment →

The 6-Step Return-to-Sport Protocol — Amsterdam 2023

The structured return-to-sport (RTS) protocol from the Amsterdam Consensus Statement is the current evidence-based framework for progression from rest to full athletic participation. Each step requires a minimum of 24 hours. Athletes experiencing concussion-related symptoms during Steps 4–6 should return to Step 3 and re-establish full symptom resolution before progressing. Written medical clearance is required before Step 5.

Step 1 — Relative Rest 24–48 hours

Reduced physical and cognitive load. Not complete isolation.

• Normal activities of daily living permitted — light walking, basic self-care
• Reduced screen time, reduced academic or occupational cognitive load
• No sport participation of any kind
• This phase ends at 24–48 hours, not upon symptom resolution — a critical departure from older guidelines

Criteria to Progress 24–48 hours elapsed. Clinician assessment confirms no emergency red flags.

Step 2A — Light Aerobic Exercise Minimum 24 hours

Heart rate elevation below symptom threshold. ≤55% maximum heart rate.

• Stationary cycling, light walking, or easy swimming
• No resistance training, no body contact, no head movement risk
• Amsterdam 2022 introduced the sub-categorization of Step 2 into 2A (light, ≤55% HR max) and 2B (moderate, ~70% HR max) — a refinement of the earlier single aerobic step
• Mild symptom exacerbation (<2 points on 0–10 scale, resolving within 1 hour) is acceptable; significant or prolonged exacerbation is not

Criteria to Progress Light aerobic activity completed without symptom exacerbation for 24 hours.

Step 2B — Moderate Aerobic Exercise Minimum 24 hours

Increased heart rate elevation. ~70% maximum heart rate.

• Moderate jogging, brief running, moderate-intensity stationary cycling
• Moderate-intensity weightlifting at reduced load from baseline
• Body and head movement introduced but no contact risk
• Symptom monitoring throughout and for 24 hours following each session

Criteria to Progress Moderate aerobic activity completed without symptom exacerbation for 24 hours.

Step 3 — Sport-Specific Exercise Minimum 24 hours

Sport-specific movement patterns. No head impact risk.

• Running drills, agility work, sport-specific conditioning
• For Muay Thai athletes: shadow boxing, heavy bag work, footwork drills — no partner contact
• Full intensity of non-contact sport-specific training
• Cervicovestibular rehabilitation continues in parallel if indicated

Criteria to Progress Full symptom resolution at rest AND with exertion. This is the gateway criterion for Steps 4–6 — all subsequent steps require this baseline.

Step 4 — Non-Contact Training Drills Minimum 24 hours

Full technical training. Controlled partner work. No sparring or uncontrolled head impact.

• Pad work, partner drilling at controlled intensity, clinch technique with cooperative partners
• Full training intensity on non-contact elements of the sport
• Amsterdam 2022 introduced an explicit medical clearance requirement before Step 4 — this step requires clinician assessment confirming symptom resolution with exertion
• Cognitive function and other clinical findings must also have normalized — not just symptom absence

Criteria to Progress Written medical clearance from a clinician experienced in concussion management. Symptom-free at rest and with exertion for minimum 24 hours.

Step 5 — Full Contact Practice Minimum 24 hours

Return to sparring and full contact at controlled intensity.

• Full sparring at graduated intensity — light technical contact before full intensity
• Requires written determination of readiness from a healthcare provider
• Ongoing symptom monitoring — any return of concussion symptoms requires return to Step 3
• For Muay Thai athletes, this includes return to clinch sparring and checked kicks — monitoring for symptom provocation with each session

Criteria to Progress Two consecutive days of full contact training without symptom provocation during or in the 24 hours following sessions.

Step 6 — Return to Full Sport / Competition Unrestricted

Full training and competition clearance.

• Unrestricted return to all sport activities including competition
• Maintained symptom-free status with all levels of exertion
• Neuromuscular training and neck strengthening maintained as ongoing prevention measures
• Athletes with a history of multiple concussions: individualized discussion regarding retirement from contact sport, as recommended by the Amsterdam Statement

Full Clearance Criteria Symptom-free at all exertion levels. Cognitive function normalized. Medical provider written clearance for unrestricted participation.

Persistent Post-Concussion Symptoms

Most adults recover from sport-related concussion within 10–14 days. When symptoms persist beyond four weeks, the term persistent post-concussion symptoms (PPCS) is applied. The Amsterdam 2022 Statement notes that PPCS should be approached through a multidisciplinary lens — the symptoms frequently have multiple contributing drivers rather than a single pathophysiological cause.

The most common drivers of PPCS identified in current research include vestibular and visual dysfunction, cervical musculoskeletal dysfunction, autonomic dysregulation (particularly exercise intolerance), sleep disturbance, and psychological factors including anxiety and depression. Each of these requires specific targeted management rather than continued general rest.

For patients presenting with PPCS, our PT team conducts a systematic assessment to identify the primary drivers and address them directly — vestibular rehabilitation, cervical treatment, graded aerobic exercise protocols, and coordination with mental health providers where indicated. This is one of the most clear clinical applications of physical therapy in concussion management, supported by the Amsterdam 2022 recommendations.

Long-Term Risk and the CTE Question

Concerns about the long-term neurological consequences of repeated head trauma — including chronic traumatic encephalopathy (CTE) — are legitimate and deserve an honest clinical discussion. The Amsterdam 2022 Statement acknowledges that current evidence is insufficient to establish a definitive causal relationship between sport-related concussion and CTE at the population level. CTE remains a post-mortem neuropathological diagnosis and cannot be clinically diagnosed in living individuals.

What the evidence does support is that proper management of individual concussions — immediate removal, structured graduated return, no return while symptomatic — meaningfully reduces cumulative head trauma exposure. Research published in the British Journal of Sports Medicine (Eliason et al., 2023) demonstrated that structured concussion management programs were associated with a 63% reduction in recurrent concussion rates. The individual concussion that is well-managed represents a fundamentally different exposure than the same injury trained through.

For athletes training at Muók Boxing or in our Root Strength programs, this is the practical takeaway: how you manage each concussion is the variable within your control. The cumulative risk reduction from consistent proper management over a training career is substantial.

Need a Concussion Assessment?

Our Doctors of Physical Therapy conduct concussion assessments on-site at Root Strength Georgetown. No referral required. Most major insurance accepted. We'll evaluate your symptoms, assess vestibular and cervical function, and build a return-to-sport plan grounded in the current evidence.

Book an Assessment →

Keep Reading — Root Strength

Shoulder Pain — Why It Happens and How to Fix It Shin Splints in Athletes — Injury Mechanism & Rehab Protocol Return to Training After Injury — What Most People Get Wrong Our PT Department Is Now Accepting New Patients Concussion in Muay Thai — What Every Athlete Needs to Know (Muók Boxing) → Our Physical Therapy Department →

Sources

1. Patricios JS, Schneider KJ, Dvorak J, et al. Consensus statement on concussion in sport: the 6th International Conference on Concussion in Sport–Amsterdam, October 2022. British Journal of Sports Medicine. 2023;57(11):695–711. doi:10.1136/bjsports-2023-106898
2. Broglio SP, Harezlak J, Rowson S, et al. Bridge statement: management of sport-related concussion. Journal of Athletic Training. 2024;59(3):225–242. doi:10.4085/1062-6050-0046.22
3. Leddy JJ, Burma JS, Toomey CM, et al. Rest and exercise early after sport-related concussion: a systematic review and meta-analysis. British Journal of Sports Medicine. 2023;57(11):762–770.
4. Leddy JJ, Mannix R, Willer B, et al. Early subthreshold aerobic exercise for sport-related concussion: a randomized clinical trial. JAMA Pediatrics. 2019;173(4):319–325. doi:10.1001/jamapediatrics.2018.4397
5. Anderson M, et al. Early vestibular rehabilitation initiation is associated with faster recovery after sport-related concussion. Journal of Science and Medicine in Sport. 2025;28(3):222–227.
6. Eliason PH, Galarneau JM, Kolstad AT, et al. Prevention strategies and modifiable risk factors for sport-related concussions and head impacts: a systematic review and meta-analysis. British Journal of Sports Medicine. 2023;57(12):749–761.
7. Hallaçeli H, Davut S, Özbek A, et al. Epidemiological analysis of athlete injuries in Muay Thai in-ring matches. Injury Epidemiology. 2025;12:28. doi:10.1186/s40621-025-00569-x
8. Doherty CS, Barley OR, Fortington LV. Incidence of health problems in Australian MMA and Muay Thai competitors: a 14-month study. Sports Medicine – Open. 2025;11:60. doi:10.1186/s40798-025-00880-3
9. Kaguturu N, et al. Advancing sports-related concussion management: evidence-based protocols and emerging diagnostics. Journal of Integrated Primary Care. 2025;2(1):Art.3.
10. CDC HEADS UP. Returning to sports. Updated September 15, 2025. Centers for Disease Control and Prevention. cdc.gov/heads-up

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