Concussion Is a Rehabilitation Problem. Physiotherapists Should Lead the Way.

Concussion Is a Rehabilitation Problem. Physiotherapists Should Lead the Way.

David Bartlett, ISEH Concussion Clinic

For too long, concussion has been treated as something for the doctor to diagnose and for time to fix. Remove the athlete, prescribe rest, wait for the symptoms to settle. That made sense when we understood little about concussion. It doesn't any more, and physiotherapists are among the clinicians best placed to lead what comes next.

The evidence has changed. The Amsterdam consensus moved firmly away from long periods of rest and towards early activity, guided by symptoms. Persistent symptoms are now seen less as one brain problem and more as a group of treatable impairments: vestibular dysfunction, oculomotor disturbance, cervical spine involvement, exercise intolerance, and the psychological strain that often comes with them. Look at that list again. Physiotherapists assess and treat almost every item on it every working day.

We understand graded loading. We examine the cervical spine as a matter of routine. Vestibular rehabilitation grew up within our profession. We are trained to reason across body systems. We can see how a stiff upper neck, a sensitised vestibular system and an anxious athlete can add up to someone who remains symptomatic. And we see patients regularly over weeks, which is exactly where recovery is won or lost.

What has held us back is measurement, not ability. Concussion is invisible. There is no fracture, no blood test and no scan that tells you when the brain is ready. Our tools have relied on symptom checklists and clinical judgement. In a high-stakes return-to-play decision, judgement without data is easy to challenge.

That is changing fast. At the ISEH Concussion Clinic we use eye tracking to measure eye movement after injury: its accuracy, speed and coordination. Our vestibular-ocular editorial in the British Journal of Sports Medicine suggests these tests can not only pick up dysfunction after injury, but they may also show differences in athletes that matter for performance. We are collecting normal values for how head position affects balance, because we can't confidently call something abnormal until we know what normal looks like. In acute cases, the data from instrumented mouthguards is being fed into our mathematical brain models with Imperial College London to estimate the brain strain caused by different forces.

None of this replaces clinical reasoning. It sharpens it. And notice who is best placed to use it. Eye movement, balance and head and neck control are the language of physiotherapy. Technology is giving us more precise data.

The last piece is bringing the information together. A single test on its own tells you little. Baselines, SCAT6 results, eye movement and balance data, and mental health screening with the GAD-7 and PHQ-9 become powerful when you look at them together over time. That is why we built ScreenIT, and why its been rolled across the UK Sport landscape. A club physiotherapist can track an athlete's recovery against that athlete's own baseline, rather than guessing against a population average.

So here is my challenge to our profession. We need to stop seeing concussion as something we manage for others and start owning our part of it. That means making vestibular and eye movement skills part of core training, not something left to a few specialists. It means recording objective measures, not just ticking symptom boxes. And it means physiotherapists taking their place at the centre of care, alongside sport and exercise medicine doctors, neurologists and psychologists, instead of waiting at the edge for a referral.

Concussion will always need a team. But getting an athlete, a schoolchild or a weekend rugby player back to full function is rehabilitation. That is our expertise. The evidence supports us, the tools are available, and our patients need us to step forward.