Understanding concussion – Knowledge

This text is deliberately long. In few areas has advice changed as much over the past ten years as in concussion – and much of what many people were taught is now considered outdated. The darkened room, the week in bed, waking someone every two hours: all well-meant, and all more likely to slow recovery down.

You do not have to read it in one go. If it has just happened: read «When you need medical help immediately» and then «The first 48 hours». The rest can wait. If you want to understand why treatment today looks the way it does, «What happens inside the head» is the section for that.

One important note: this text does not replace an individual assessment. A concussion is diagnosed medically – what we describe here is what applies to the large majority, and what physiotherapy can contribute along the way. Every statement is referenced; the numbers in square brackets point to the reference list at the end.

1. What a concussion is – and what happens

A concussion is the mildest form of traumatic brain injury. In current scientific use it is largely treated as synonymous with mild traumatic brain injury (mTBI) [2].

The trigger is a force applied to the head, face, neck or elsewhere on the body, with the energy transmitted to the head. A fall onto your backside or a rear-end collision is enough – the head does not have to be struck. What matters is the rapid acceleration and deceleration of the brain inside the skull.

What happens then is above all a disturbance of function: on current understanding, nerve cell function and energy metabolism change temporarily – ions shift, and for days to weeks the cells need more energy than the metabolism can comfortably supply. This so-called neurometabolic cascade probably contributes to the symptoms: the sense of being under a bell jar, tiring quickly, tolerating stimulation badly. Exactly how it accounts for each individual symptom is not established. There is a detailed account in section 3 – worth reading, because the whole of today's treatment follows from it. These changes are normally not visible on standard clinical imaging – see section 5.

Typical symptoms in the first few days are headache, feeling dazed, dizziness, nausea, sensitivity to light and noise, blurred vision, neck pain, problems with concentration and memory, «brain fog», fatigue, disturbed sleep, irritability or low mood. They do not all occur together, and the mix differs from person to person.

Two points cause misunderstandings again and again:

• Loss of consciousness is not a requirement. Most concussions happen without any loss of consciousness. A concussion can be present without a «blackout» [2], [1].
• Symptoms can be delayed. Some people feel surprisingly normal straight after the event and only notice hours later that something is wrong. Hence the rule in sport: if a concussion is suspected, off the field immediately – and no return that day [1], [4].

For context in Switzerland: most traumatic brain injuries that reach a clinic are mild – FRAGILE Suisse gives a figure of about 80 per cent [3]. And concussions are by no means limited to sport: falls, road traffic accidents, accidents at work and at home account for a large share.

2. When you need medical help immediately

This list comes early on purpose, so that you can read the rest of the text more calmly. It follows the internationally used recognition tools and guidelines [4], [5].

Have any of these signs assessed as an emergency – with severe impairment, loss of consciousness, a seizure or a suspected cervical spine injury, call the emergency number (144 in Switzerland):

• loss of consciousness, or increasing drowsiness and difficulty waking the person
• a seizure
• repeated vomiting
• severe or increasing headache
• severe neck pain, neurological symptoms or tenderness directly over the cervical spine after a relevant injury mechanism (possible cervical spine injury – in that case do not move the person)
• double vision or loss of vision
• weakness, numbness or tingling in the arms or legs
• increasing confusion, unusual restlessness, aggression or a change in behaviour
• visible deformity of the skull, clear fluid from the nose or ear, bruising behind the ear or around both eyes

Medical assessment the same day – even without those signs – if there is:

• use of medication that inhibits blood clotting – especially anticoagulants such as DOACs, vitamin K antagonists (Marcoumar) or heparin – or a known clotting disorder
• previous brain surgery
• a memory gap for the event or for the time before or after it
• a brief loss of consciousness, even if it is over
• a high-energy accident (bicycle or car crash, fall from a height, high-speed skiing accident)
• alcohol or drug use at the time of the accident, which makes assessment unreliable
• a very old person, or anyone who cannot be observed after the accident
• infants and toddlers: the threshold for assessment is lower here, because symptoms are harder to recognise. Unusual behaviour, vomiting, altered consciousness, a relevant injury mechanism or simply being unsure all warrant assessment the same day – though not necessarily every minor bump on the head

And one point that comes later but matters just as much: seek advice again if symptoms clearly worsen after a few days instead of slowly improving. The usual course goes upwards, with fluctuations.

For reassurance: these warning signs are a sieve, not a diagnosis. The vast majority of people assessed because of them have no bleeding in the head. But the few who do need that assessment straight away.

3. What happens inside the head – and why that explains the treatment

This section goes a little deeper than the rest. It is here because much of the treatment only makes sense once you know the mechanism – above all the two things people find hardest: that you are supposed to move while symptoms are still there, and that you nevertheless cannot simply do as you please. If you are in a hurry, skip to section 10.

1. The energy crisis. The acceleration stretches and twists the extensions of the nerve cells. Channels in the cell wall open in an uncontrolled way: charged particles shift – potassium out, calcium in – and large amounts of the messenger glutamate are released. To restore the normal distribution, the cell's own pumps run at full tilt, and they need energy. So demand rises at exactly the moment when the cell is least able to meet it [34]. Specialists call this the neurometabolic cascade; you can picture it as a temporary energy crisis.

That is a plausible explanation for much of what you experience: that thinking is as tiring as physical work; that at a screen things do not get slowly worse but rather suddenly worse after twenty minutes; that mornings work better than evenings. Not weakness – an account that has become smaller.

2. Blood flow is regulated less well. Normally the brain adjusts its blood supply from second to second – more during exertion, less at rest, stable when you stand up. After a concussion this fine control is temporarily disturbed; in studies it shows up as an altered pattern of blood flow at rest and under load [33]. You notice it as light-headedness on standing, headache when climbing stairs, a sudden shutting-down feeling in the head.

3. The control of pulse and breathing no longer matches. One widespread explanation of exercise intolerance runs like this: during exertion breathing stays too shallow, carbon dioxide in the blood rises – and because carbon dioxide widens the vessels of the brain, cerebral blood flow overshoots what the effort would require. That is exactly when the symptoms appear [35]. This chain is not proven. But it explains well why an exercise test reproducibly provokes symptoms at the same point in the same person – and why training just below that point might achieve something.

4. It is not only the brain. The same acceleration loads the cervical spine and the balance organ in the inner ear. There, tiny crystals can come loose and end up in a semicircular canal – that is positional vertigo. The deep neck muscles, which continuously report to the brain where the head is, often work less precisely after such an event. And when eyes, balance organ and neck contradict each other, the result is dizziness, blurring and nausea. This is why a concussion is treatable by physiotherapy at all: a good part of the symptoms arises in structures that can be examined and trained.

And why «measured activity» follows from this. When a cell is in an energy crisis, rest sounds logical at first – and for one to two days it is. After that the balance reverses: rest provides no stimulus for resetting circulatory control, balance and fitness, and it costs sleep quality, mood and endurance. Hence the compromise that defines today's treatment – a load just below the threshold at which symptoms kick in. It challenges the disturbed control loops without overdrawing the energy account [35], [6]. The two-point rule in section 11 is nothing other than the everyday version of this idea.

What this section does not mean. These processes are measured in groups, not in you. None of the methods – blood flow, metabolism or blood markers – is precise enough to say how far recovery has come in an individual person [33]. And: the energy crisis explains the first days to weeks well. It does not explain symptoms that are still there after months – for those you need the drivers in section 8.

4. Concussion, mTBI, LTHV – three words for the same injury

People who receive paperwork after an accident rarely see the word «concussion» on it. More often it says mild traumatic brain injury (mTBI), in Switzerland leichte traumatische Hirnverletzung (LTHV, «mild traumatic brain injury»), or – older – commotio cerebri. That is unsettling, because «brain injury» sounds considerably more serious than «concussion». The same event is meant.

What the Swiss accident insurers use. Suva and the Swiss Insurance Association work with the term LTHV and define it as a «biomechanically induced, complex neuronal disturbance of brain function» [32]. The boundary at the top – towards moderate and severe brain injury – runs via the Glasgow Coma Scale, a points system for eye opening, speech and movement: for an LTHV the score must not be below 13 out of 15. Within the LTHV, further subdivision follows that score and the risk factors present; this determines whether a CT scan is done and whether someone is monitored in hospital [32].

And «concussion»? That is the term of sports medicine, and whether it means the same thing is one of the field's most durable terminological debates [2]. Three positions face each other:

• Suva states that «concussion» is not fully synonymous, because it is defined more broadly – it also takes into account, for example, complaints from the inner ear and balance organ and from the musculoskeletal system, that is, from the neck [32], [36].
• The American professional body ACRM reached the opposite conclusion in 2023: 30 of 32 experts (93.8 per cent) agreed that «concussion» and «mild TBI» may be used interchangeably when neuroimaging is normal or not clinically indicated [2].
• A third reading treats «concussion» as a subset of mild traumatic brain injury – namely the one without a visible structural injury [2].

What that means for you. In practice, little – and that is the good news: if your medical certificate says LTHV or mTBI and you read about «concussion» online, it is the same thing. One point does deserve attention, though. Suva justifies its reservation precisely on the grounds that the sports-medicine term includes the neck and the balance organ. For treatment that is exactly what counts: a good part of the symptoms that persist after a concussion does not come from the brain but from these co-injured structures – see section 3 and section 14. Anyone who looks only at «the brain» misses them.

Numbers for Switzerland. Suva estimates around 25,000 cases a year in Switzerland, somewhat more than 300 per 100,000 inhabitants; among those insured under the Swiss accident insurance act it is about 12,400 a year [32].

Two recommendations from the Swiss accident insurers that are not widely known:

• Written information already in the acute situation. Good information early after the event improves the prognosis; inadequate information raises the risk that symptoms become chronic [32]. That is one reason why this text is as detailed as it is.
• A medical follow-up within 14 days – for everyone injured. Not only for those who are doing badly. This follow-up appointment demonstrably helps to reduce symptom severity and everyday limitations [32]. Ask for it if it is not offered to you.

5. Why CT and MRI scans are usually normal

A CT or MRI scan of the head usually shows nothing abnormal after a concussion. That is neither a coincidence nor an oversight: we speak of a concussion – synonymous with an uncomplicated mild traumatic brain injury – precisely when standard imaging is normal or was not needed in the first place [2]. A mild traumatic brain injury can, however, occasionally come with a visible structural injury; that is then no longer an uncomplicated concussion, and management follows the finding.

So what is the CT scan for? It is there to detect the rare but dangerous accompanying injuries – above all bleeding – or to rule them out with a high degree of certainty. That is exactly why it is not done for everyone but according to risk criteria such as those in section 2 [5]. A scan «just for reassurance» is not harmless: it involves a relevant dose of radiation, particularly in children.

The psychologically difficult part: many people hear «everything is fine» and understand «there is nothing wrong with you» – while feeling unwell. The sentence should be: «There is no bleeding and no fracture to be seen – your symptoms come from a disturbance of function that scans cannot show.» Both are true at the same time.

6. How recovery typically unfolds

Numbers help here, because expectations shape the course.

Athletes. A systematic review with meta-analysis, prepared for the 2023 international consensus, summarises recovery after sport-related concussion as follows: a mean of 14.0 days until symptom free, a mean of 8.3 days until full return to school or training – 93 per cent were fully back within ten days without additional academic support – and a mean of 19.8 days until full return to sport [7].

Children and adolescents. In the Canadian 5P study of 3063 children and adolescents seen in emergency departments, 31.0 per cent still had symptoms after four weeks [8]. Put the other way round: a good two thirds were symptom free after a month.

Adults after accidents. Here the picture is more sobering, because this group is different – more road and fall injuries, more accompanying injuries, more pre-existing conditions. A meta-analysis of 43 studies found at least mildly severe persisting symptoms in 31.3 per cent (95% confidence interval 25.4 to 38.4) three to six months after the event; the authors point out, however, that once the many study dropouts are taken into account the true proportion is probably closer to one in six [9]. In the large US TRACK-TBI study, 53 per cent still had functional limitations twelve months after a mild traumatic brain injury – compared with 38 per cent among people with orthopaedic injuries and no head involvement [10]. That comparison figure matters: part of what is experienced as a consequence of concussion belongs to the experience of an accident as such – pain, shock, disturbed sleep, time off work.

What follows from this for you? First, the odds of being back on your feet in weeks rather than months are good. Second, if it does take longer, you are neither alone nor «a special case». Third – and this is the reason for everything else in this text: what is done in the first days and weeks measurably influences the course.

7. Why «symptom free» and «fully recovered» are not the same

The figures in the last section describe when the symptoms disappear. That is not quite the same question as when the brain is working the way it did before – and that difference is the reason for several rules that would otherwise look like harassment.

A systematic review collected 80 studies that tracked measurable physical quantities after a sport-related concussion: cerebral blood flow, metabolic products in magnetic resonance spectroscopy, brain waves, heart rate, exercise tests, blood markers, magnetic stimulation [33]. Two findings matter.

First: there is no single «physiological time window». The methods measure different things and normalise at different times; the studies are too heterogeneous to condense into one number [33].

Second: several of these measures return to normal later than the symptoms do. For the two most reliable areas – brain metabolism and cerebral blood flow – the review found measurable deviations lasting more than 15 but fewer than 30 days after the injury. That is longer than the average time to being symptom free in adults, and in individual studies people had recovered clinically before the measurements had [33]. The international consensus puts it with similar caution: there is evidence that a window of physiological change extends beyond clinical recovery – whether these residual findings are pathological, adaptive or benign is open, for lack of long-term data [1].

What follows from this. Precisely this gap is the reason for the minimum duration per step, for medical clearance before full contact, and for the last steps being demanding. The review speaks of a buffer zone of gradually increasing activity before another head impact becomes possible [33]. It fits that the energy crisis from section 3 is linked with an increased vulnerability to a second blow [34] – and that the risk of muscle and joint injury stays elevated after the return (section 13).

And what does not follow – three points that often land wrongly:

1. Not that you should take it easy. The buffer zone concerns the risk of another head impact, not movement. That measured activity shortens recovery still holds (section 11).
2. Not that such a measurement would be useful for you. None of these methods is precise enough to say how far recovery has progressed in an individual person. They come from research and for now belong there [33].
3. Not that you are «still ill» once the symptoms are gone. The vast majority of people recover completely. It only means: wait a little longer before risking a head impact and keep to the steps – not stay cautious in everyday life.

The sentence holds the other way round too. Symptoms that are still there after weeks or months do not mean the injury is still «active». Usually other drivers are at work by then – that is what the next section is about.

8. Why symptoms can persist – and why that is treatable

When symptoms last for weeks, the commonest question is: «Is my brain permanently damaged?» On current understanding the answer is, as a rule, no. Persisting symptoms after concussion can as a rule not be explained by ongoing structural brain damage. Usually several drivers act together; they can be named individually and, at least in part, treated in a targeted way [27], [21].

The six most important ones:

1. The neck. The same acceleration that shakes the brain loads the cervical spine. Neck pain, headache arising from the neck, dizziness from the neck muscles and balance problems are clinically hard to tell apart from «brain» symptoms – but they respond to different treatment.
2. The balance and visual system. Disturbances in the teamwork between eyes, balance organ and neck are very common: dizziness when turning the head, blurring while walking, nausea in a supermarket, trouble reading. There are standardised tests for this [22] and targeted training.
3. Migraine-type headache. A concussion can trigger a migraine-like headache pattern or amplify an existing one. That belongs in medical hands – and it is an important reason why daily painkillers over weeks are counterproductive (medication-overuse headache).
4. Sleep. Disturbed sleep demonstrably slows recovery [6] – and poor sleep makes almost every other symptom worse.
5. Exercise intolerance. In some people the regulation of circulation behaves differently after the injury: heart rate and blood pressure are controlled less well, and even light exertion provokes symptoms. This is measurable – and trainable [23]. In some it shows up without any exertion at all, simply on standing up: light-headedness, a pounding heart, a brief blackout of vision. That is why blood pressure and pulse belong measured lying down and standing before such symptoms are put down to the balance organ [1].
6. Tension, worry, deconditioning. Weeks of resting cost fitness; reading symptoms as a sign of damage leads to avoidance; avoidance costs more fitness. This loop is common and breaks well once it is named.

This is why the term «post-concussion syndrome» has fallen out of favour professionally. The sober term used today is persisting symptoms after concussion [1] – because it is not one uniform condition but a collective label for very different problems, each of which can be tackled.

9. What makes a longer course more likely

The large cohorts predict fairly well who will need more time. The 5P rule for children and adolescents is based on: female sex, age 13 or older, physician-diagnosed migraine in the history, a previous concussion with symptoms lasting more than a week, headache, sensitivity to noise, fatigue, answering questions slowly, and balance errors in tandem stance [8].

In athletes the strongest single predictor is the symptom burden in the first days. Also associated with longer recovery: continuing to play after the injury, and delayed access to healthcare providers [7]. For age and sex the evidence in that analysis was inconsistent – so we mention them as a pointer, not as a certainty.

In adults, add: previous concussions, migraine, previous mental health problems, high stress load, sleep disorders, and an ongoing insurance or legal process [27], [28].

Two honest qualifications. First, these are probabilities, not verdicts – plenty of people with several risk factors recover quickly. Second, «previous mental health problems as a risk factor» says nothing about whether your symptoms are real. They are. It only says where additional work is worth doing.

10. The first 48 hours

This is where the shift of recent years is clearest. Current advice is relative rest for 24 to 48 hours – and after that a step-by-step increase, rather than waiting to be symptom free [1], [6].

Relative rest means: doing everyday things, walking, eating, showering, talking, resting when you are tired. It does not mean: a darkened room, shutting out all stimulation, two days in bed. Strict rest until symptoms resolve has proved ineffective in the summary of the evidence [6].

Screens. In a randomised trial with 125 participants, screens were either permitted or avoided during the first 48 hours. Symptoms lasted a median of 3.5 days in the screen-abstinent group compared with 8.0 days in the group allowed screens [14]. The trial is small, and «no screens at all» is hard to keep to in real life. The practical conclusion still holds: cut screen use right down for the first two days, then build it back up gradually.

Also during the first 24 to 48 hours:

• do not stay alone as long as someone can keep an eye on you
• no alcohol, and no sedatives or sleeping tablets unless prescribed
• no driving, no cycling, no operating machinery
• no sport with a risk of falling or contact – a second blow during this phase is the scenario everyone wants to avoid
• for headache, paracetamol at the usual dose is generally the first choice; discuss other painkillers with your doctor, especially if you take anticoagulants

Sleep is allowed. The old advice to wake someone every hour during the night is outdated. Once the warning signs in section 2 have been dealt with and there is no cause for concern, sleeping is right and helpful [5].

11. From day two: movement is treatment

This is the most important message of this guide, and it is well supported.

The systematic review with meta-analysis on rest and exercise in the first 14 days pools 46 studies. Result: early physical activity and prescribed aerobic exercise shortened recovery by a mean of 4.64 days (95% confidence interval 2.59 to 6.69 days) [6]. The studies included are predominantly of younger people after sport-related concussion; whether the same magnitude holds for older people after a fall, or for adults after a road accident, is open. Early light activity in the first two days, prescribed aerobic exercise from day two to 14, and reduced screen time are considered safe and beneficial there.

Three of the individual studies behind this are worth a look:

• In an observational study of 2413 children and adolescents, those who were physically active within the first seven days had persisting symptoms at four weeks far less often: 24.6 versus 43.5 per cent (after statistical adjustment, relative risk 0.74; 95% confidence interval 0.65 to 0.84) [11]. Observational means association, not proven cause – those who move early may simply have been less severely affected.
• In a randomised trial with 103 adolescents, those doing prescribed aerobic exercise below the symptom threshold recovered in a median of 13 days, those doing stretching in 17 days [12].
• In a second randomised trial with 118 adolescents, the risk of persisting symptoms at four weeks was roughly halved with aerobic exercise compared with stretching (hazard ratio 0.52; 95% confidence interval 0.28 to 0.97) [13].

What does that look like in practice? «Below the symptom threshold» is the key. Concretely:

1. Light activity on most days – short walks to begin with, later brisk walking or a stationary bike for 15 to 20 minutes. Choose duration and pace so that symptoms increase only mildly and briefly. No sport with a risk of falling, no ball sports, no contact.
2. Pick an intensity at which you could still hold a conversation. If you want it more precise, an exercise test can establish your heart rate limit (section 14).
3. The two-point rule: your symptoms may rise by no more than two points on a scale from 0 to 10 during the activity, and should settle again within an hour. If they rise further or stay up, the dose was too high – then go shorter and lighter the next day, but do not stop [1].

The opposite of this approach is the pattern of «make the most of a good day, then spend two days flat out». Steady, predictable doses will get you further than the cycle of overdoing it and crashing.

12. Back to school and work

Mental load is built up in stages too – but not reduced to zero. The international consensus describes a stepwise return to school or work. It runs in parallel with the early steps of the return to sport; what should be completed first is the full return to school or work, before sport is resumed without restriction [1], [15].

Workplace adjustments that work well: shorter screen blocks with real breaks, reduced screen brightness, less noise, demanding tasks at your best time of day, shorter meetings, some working from home where possible. As a rule, what to aim for is a part-time return rather than weeks of staying away completely – the further out you go, the harder it is to come back. «As a rule» does not mean «always», though: with a very high symptom burden, or in jobs where the load cannot be dosed, being fully off work for a while can be the right thing. Even then the goal stays the same – a plan with dates rather than open-ended waiting.

If an accident insurer is involved: a written stepwise plan with dates, working percentage and planned adjustments helps everyone – you, your employer and the insurer. We are happy to draw one up.

13. Back to sport: the six steps

The same six-step strategy applies internationally for the return to sport [1]:

The rules: at least 24 hours per step; if symptoms clearly worsen, drop back a step and try again the next day; and medical clearance before any step at which a further impact to the head is possible – depending on the sport that can already apply to the sport-specific drills, and at the latest before full contact practice. Mild residual symptoms are acceptable for steps 1 to 3 – from step 4 onwards you should be back at your usual baseline. In practice the whole ladder usually takes at least a week, and typically longer in children and adolescents.

Why the patience? Two reasons. One is a second blow to a brain that has not yet recovered. The other is often overlooked: after a concussion the risk of a muscle or joint injury is raised – roughly twice as high in a meta-analysis of eight studies (odds ratio 2.11; 95% confidence interval 1.46 to 3.06) [25]. Why the risk is raised is not settled; the explanations discussed include reaction, coordination, attention and load tolerance that have not yet fully normalised. That is precisely why the later steps deliberately involve speed, changes of direction and decisions under pressure.

You can try out how quickly reaction and attention work together in our Reaction Lab – it also contains the sensory cockpit behind balance.

14. What physiotherapy can contribute

In the first few days what is usually not yet needed is specific neck or balance treatment. That phase is about medical assessment, information, relative rest and an early, measured restart. Physiotherapy can still be useful at this stage – for dosing activity, for the question of how much of what, and for setting up a stepwise plan for work, school and sport. A targeted assessment of the neck and the balance system is recommended when dizziness, neck pain or headache last beyond about ten days [1]. That ten-day mark comes mainly from the sport-related consensus; in other situations the right moment depends on symptoms, age, injury mechanism and the medical assessment. There is a dedicated physiotherapy guideline for exactly these situations [21], and the review summarising the evidence for the international consensus concludes that targeted measures – cervical and vestibular treatment plus prescribed aerobic exercise – can support recovery [16].

The core of our work: finding out what actually sets your symptoms off. That matters more than it sounds, because the same word can have quite different causes. «Dizziness» after a concussion can come from positional vertigo, from a disturbance of the balance organ, from sensitivity to moving visual scenes, from the neck, from how circulation is regulated on standing up, from physical exertion, from migraine – or from several of these at once. «Headache» can come from the neck or follow a migraine pattern. So we do not treat «the concussion»; we work through, one at a time, what triggers your symptoms: physical exertion, head movement, eye movement, change of position, load on the neck, or combined movement tasks. The treatment follows from that – and so does what does not need treating. That is part of it too: not every abnormal item on a screening test needs an exercise of its own [21].

What we do first: sort things out. An assessment that establishes which of the drivers in section 8 are actually involved in your case:

• symptom pattern, course, sleep, how load is distributed across your day – and a check of the warning signs
• cervical spine: mobility, load tolerance, activation of the deep neck muscles, joint mobility, whether headache and dizziness can be reproduced
• balance and visual system: standardised testing of smooth pursuit, saccades, near point of convergence and gaze stabilisation during head movement [22]
• Balance standing still – and balance in motion. Quiet standing on its own says little. After a concussion, difficulties often only show up once something is added: walking with head movements, changes of direction, soft or uneven ground, walking heel to toe (tandem gait) – and, where it fits, with a second task at the same time, such as counting backwards or reacting to a signal. Professionals call that a dual task; the international consensus explicitly provides for timed tandem gait as a single and as a dual task [1].
• Positional vertigo. Testing with the Dix-Hallpike manoeuvre when dizziness is brief, intense and position-dependent – and, if that stays unremarkable or the dizziness mainly comes on when rolling over in bed, additionally with the supine roll test. It examines the horizontal canal, which the Dix-Hallpike manoeuvre does not reliably capture [24], [30].
• Circulatory response to standing up. Blood pressure and pulse lying down and again after a minute of standing – above all if you feel light-headed on standing, notice your heart pounding or get dizzy. The international consensus sets out this measurement in just this way [1]. The reason is practical: symptoms on standing up and symptoms on exertion feel similar but call for different answers – and «dizzy when standing» is not automatically a problem of the balance organ.
• Exercise tolerance. A standardised treadmill or bike test that establishes the heart rate at which your symptoms increase [23]. It reliably shows where your limit is – but not why it is there. That is why we deliberately stay with the term exercise intolerance and do not turn it prematurely into a «disorder of the autonomic nervous system».

What we do with it: treat what was found.

• Prescribed aerobic exercise below the symptom threshold – with a concrete heart rate target rather than «as much as you can manage». This is the best supported active component [12], [13], [6]. The target is adjusted as tolerance improves.
• Treatment of the cervical spine – manual techniques, strengthening and motor control training for the deep neck muscles, work on head posture and on how load is dosed. In the first randomised trial on this, 73 per cent (11 of 15) of the treated adolescents and young adults were medically cleared within eight weeks, compared with 7 per cent (1 of 14) in the comparison group [17]. The trial is small – the result is striking, and the uncertainty is correspondingly large.
• Training for balance, gaze and tolerance of movement. Depending on the findings we train gaze stabilisation during head movements – seeing clearly while the head turns –, habituation to visually busy environments such as a supermarket, a station platform or traffic, and the teamwork of vision, balance organ and body awareness in standing and walking. It is built up from secure standing through walking with head movements and changes of direction to tasks that come close to your sport or your job – finally with a second task at the same time. A systematic review of randomised trials concludes that vestibular rehabilitation probably reduces symptoms after concussion, while pointing out large differences between the studies [20]. A meta-analysis found small improvements in perceived dizziness, in balance and eye-movement findings and in overall symptom burden, measured at the end of the programme – with explicitly low certainty of the evidence. Two months later the difference in perceived dizziness was no longer detectable [29].
• Repositioning manoeuvres for benign paroxysmal positional vertigo – which is more common after head injuries and can often be treated quickly and durably with a single manoeuvre [24]. After a head injury, though, it more often takes several sessions than in the spontaneous form, and more than one canal can be involved – which is why we check again after the first manoeuvre [30]. More on this under Dizziness.
• Rebuilding strength and fitness, and step-by-step support back into sport, work and everyday life – including the activities you are currently avoiding.
• Education and load management. Knowing what is happening, what is normal and how a dose is chosen is itself an effective part of treatment [27].

And where we refer on. Visual problems are common after a concussion. A review of 57 studies found disturbed eye movements and sensitivity to light in first place, followed by double vision, difficulty bringing the eyes together on something close (convergence) and difficulty focusing (accommodation) [31]. We work on some of that ourselves. But pronounced or persisting double vision and stubborn problems with converging or focusing also belong in an ophthalmological, neuro-ophthalmological or optometric assessment – not all of it belongs under the roof of balance treatment. And the evidence for vision training as a treatment in its own right is considerably thinner than the evidence for prescribed aerobic exercise or for neck and balance treatment [31].

And the honest side. Two more recent randomised trials in adults who already had persisting symptoms temper expectations: in a Canadian trial, a combined cervical and vestibular programme added to aerobic exercise was not superior to aerobic exercise alone in terms of symptoms and everyday function – although cervical and vestibular function did improve more [18]. And in a Norwegian trial published in 2026 with 81 adults, prescribed aerobic exercise clearly improved exercise tolerance and was safe and well tolerated – but symptom burden did not differ from the comparison group at twelve weeks or at six months [19].

What does that mean? Not that physiotherapy achieves nothing here. Rather: timing and selection decide. The best supported element is aerobic exercise below the symptom threshold in adolescents and young adults during the first weeks after a sport-related concussion. In adults whose symptoms have already persisted, it mainly improves exercise tolerance; an additional effect on overall symptom burden is less certain. The later and the less specific the treatment, the smaller the effects – and the more important it becomes to address the individual drivers rather than offering everything to everyone.

If you would like to feel what such a memory task is like: our learning game Memory Trail has you remember ten words and repeat number sequences backwards – the same format used at the sideline in the SCAT6 and afterwards, in the office, in the SCOAT6 [1]. It is a game, not a test: it has no reference values, and after a blow to the head a good result means nothing. Anyone who is dazed belongs off the pitch and in front of a specialist.

15. What you can do yourself

The most effective part happens between appointments. You can put these points into practice without us:

1. Brake for two days, then start. 24 to 48 hours of relative rest with little screen time – then light activity every day, short walks to begin with, brisker and longer as time goes on.
2. Move every day, in even doses. Better 15 minutes daily than one hour once a week. Dose it by the two-point rule.
3. Spread the load across the day. Short blocks with real breaks – and a break means eyes closed, a window, a walk, not your phone.
4. Protect your sleep. Regular times, no screens in the last hour, at most one short nap during the day. If sleep is still disturbed after two weeks, raise it actively.
5. Avoid alcohol to begin with – above all for as long as dizziness, concentration problems, balance disturbance or relevant headache persist. It worsens almost every symptom and disrupts sleep.
6. Limit painkillers. Useful short term, problematic taken daily over weeks. If, depending on the preparation, you need them on more than ten to fifteen days a month, that needs discussing with your doctor – the threshold is lower for triptans, opioids and combination preparations than for paracetamol or a single anti-inflammatory.
7. Keep a simple diary. Two lines a day: what I did, symptoms from 0 to 10. After two weeks you will see patterns that get lost in daily life – and the progress you cannot notice from one day to the next.
8. Stay in touch with people. Withdrawing is understandable and makes both mood and recovery worse. Meet in quiet surroundings, keep it short, and give yourself a way out.
9. No risk of a second blow until you have worked through the return-to-sport steps – not even «just joining in briefly».
10. Ask for help early rather than waiting. If things are not clearly improving after ten to fourteen days, that is the moment for a targeted assessment – not after three months.

16. Children and adolescents

The same principles apply to children and adolescents, with some additions [15]:

• Recovery takes longer on average than in adults; four weeks is not an alarm signal.
• School before sport. The full return to lessons is completed before the unrestricted return to sport.
• Adjustments at school – shorter days, less screen time, more time for tests, breaks in a quiet room – are temporary and should be actively wound down again.
• Here too: back to light activity early rather than weeks of resting [11].
• If a child is still clearly limited after four weeks, a structured assessment belongs in the plan – usually coordinated medically, with a physiotherapy component for neck, balance and exercise tolerance [16].

The hardest part for parents is the balance between taking it seriously and keeping it normal. Both at once is possible – «This is a real injury, and you will get completely well again; we will take it step by step.»

17. Older people, falls and blood thinners

In older people a concussion usually happens not in sport but in a fall – and the starting position is different:

• Medication that inhibits blood clotting increases the risk of bleeding inside the skull. That applies particularly to anticoagulants such as DOACs or vitamin K antagonists (Marcoumar); low-dose acetylsalicylic acid on its own is judged differently. After a fall onto the head it markedly lowers the threshold for medical assessment the same day, even if the person feels well – the exact approach depends on the medication, the injury mechanism and the symptoms [5].
• A slowly developing bleed can announce itself days or weeks later with increasing headache, confusion, unsteadiness or weakness. Those signs need immediate assessment.
• A fall almost always has a cause that can be treated – strength, balance, blood pressure, eyesight, medication, the home environment. Treating only the head injury after a fall treats half the problem. More on this in our guide Fall prevention.
• Dizziness and unsteadiness after the fall often lead to caution and less movement – and therefore to exactly the loss of strength and balance that makes the next fall more likely. That is another reason to get moving again early and in measured doses.

18. Six assumptions fact-checked

«Without loss of consciousness it is not a concussion.»
Wrong. Most concussions occur without any loss of consciousness; it is not a necessary criterion [2].

«You have to wake the person every hour at night.»
Outdated. Once the warning signs have been dealt with, sleep is right. Observing means being reachable and reacting if things get worse [5].

«I can only start moving again once I am symptom free.»
Wrong, and probably the most harmful of these assumptions. Strict rest until symptoms resolve is not effective; measured activity from day two shortens recovery [6].

«A normal MRI proves there is nothing wrong.»
A misunderstanding. CT and MRI serve to detect clinically relevant structural injuries such as bleeding or certain fractures, or to rule them out with a high degree of certainty. The disturbance of function causing your symptoms is not visible there [2].

«A helmet prevents concussion.»
Only in part. Helmets impressively reduce the risk of severe head injuries and skull fractures – but they do not reliably prevent the acceleration of the brain. Prevention measures with evidence behind them in sport include mouthguards in ice hockey, rule changes such as banning bodychecking in youth play, and neuromuscular warm-up programmes [1].

«Every concussion leads to dementia later on.»
Not supported in that form. A single concussion does not mean that dementia will follow. The available systematic review concerns mainly former athletes and repetitive head impacts rather than head injuries in general: among amateurs it found no increased risk of depression or suicide; individual studies in former professionals suggest an increased risk of neurological disease, but they control poorly for confounding and do not allow a firm conclusion [26]. For long-term exposure to repeated head impacts in professional contact sport, uncertainty therefore remains. That is neither an all-clear nor a reason to panic: repeated blows to the head are worth avoiding, and worry about them should not keep anyone from moving.

19. When symptoms persist

If things are not clearly better after four weeks, the strategy changes – away from waiting, towards addressing the individual drivers.

What makes sense then:

• Sort it out again. Which symptoms dominate – headache, dizziness, exercise intolerance, concentration, sleep, mood? Each of these groups has its own treatment.
• Coordinate several professions. With persisting symptoms, coordinated work between your family doctor, physiotherapy and – where needed – neurology, neuropsychology or psychotherapy is superior to isolated measures [27], [28].
• Build load rather than avoid it. Fitness can be rebuilt even with residual symptoms; exercise tolerance improves measurably [19].
• Work in steps, but with commitment. A plan with dates beats an open-ended «let's see».
• Realistic goals. Function before freedom from symptoms: what do you want to be able to do again – work eight hours, spend an hour at a screen, ski this winter? That can be planned and measured.

And a sentence we often use in this situation: the fact that recovery is taking longer does not mean it has stopped happening. Even after months, improvement is the rule rather than the exception.

20. What good physiotherapy can do – and what it cannot

What we can do: a structured assessment that establishes which systems are involved and keeps the warning signs in view. An exercise test with a concrete heart rate target. An examination of balance and gait extending to dual tasks. Blood pressure and pulse lying down and standing, if symptoms come on when you stand up. Treatment of the neck, the balance system and the eyes where they are involved. Repositioning manoeuvres for positional vertigo. A stepwise plan for work, school and sport that fits your everyday life. And an honest account of what we know and what we do not.

What we cannot do: «repair» the brain with passive techniques, or «put something back in place». Diagnose a concussion – that is a medical task. Replace an ophthalmological or neurological assessment: with persisting double vision or stubborn problems with focusing we refer on. Or promise you that your symptoms will be gone by a particular date.

And what only you can do: the daily dose. The studies that show the biggest difference all test the same thing – regular, measured movement over weeks. That repetition happens between appointments.

21. In summary

1. A concussion is first and foremost a disturbance of function. Loss of consciousness is not a requirement, and in the uncomplicated form CT or MRI scans are normally unremarkable. On medical certificates and insurance paperwork it is often called «mild traumatic brain injury» (mTBI) or, in Switzerland, «LTHV» – the same injury is meant.
2. There are warning signs that mean going to the emergency department immediately – they are in section 2.
3. 24 to 48 hours of relative rest with little screen time, then step-by-step more – not waiting to be symptom free.
4. Early, measured activity shortens recovery – by about four and a half days on average in studies predominantly of younger people after sport-related concussion.
5. Rule of thumb for the dose: no more than a two-point rise in symptoms on a ten-point scale, settling within an hour.
6. Why measured? After the injury the nerve cells need more energy for a while than they can comfortably supply, and blood flow is regulated less well. A load just below the symptom threshold challenges these control loops without overdrawing them – rest provides no stimulus for that.
7. In sport it takes on average about two weeks until symptom free and about three weeks back to sport; among children, close to a third still have symptoms after four weeks.
8. «Symptom free» and «fully recovered» are not quite the same: in studies, brain metabolism and blood flow take longer than the symptoms do. Hence the steps and the medical clearance before full contact – but no reason to take it easy in everyday life.
9. Persisting symptoms usually have several drivers – neck, balance and eyes, headache, sleep, exercise intolerance, tension. Many of them can be examined specifically and at least partly treated.
10. Physiotherapy works best when targeted. We do not treat «the concussion» but whatever sets your symptoms off: exercise testing and heart-rate-guided training, neck treatment, balance and gaze stabilisation training extending to walking with head movements and dual tasks, repositioning manoeuvres for positional vertigo, a stepwise plan.
11. Back to sport through six steps, at least 24 hours per step, medical clearance before any step at which a further head impact is possible and at the latest before full contact – not least because of the roughly doubled risk of muscle and joint injury.
12. If things are not clearly improving after ten to fourteen days: get it assessed rather than carry on waiting. The Swiss accident insurers recommend a medical follow-up within 14 days for everyone injured anyway.

If you are unsure

If you are not sure where you stand after reading this, we are happy to clarify it in a first consultation with an examination. We will tell you honestly whether we are the right address – and if not, who is. Book an appointment.

Last reviewed: August 2026. We revise this text when the evidence changes materially.

References

Where the evidence is weak or inconsistent, we have said so in the text. All Digital Object Identifiers (DOIs) were checked individually against the Crossref register. The links in the reference list lead via the DOI service to the publishers' pages. Some of these are outside Switzerland and the EU. When you click them your IP address is transmitted to the provider concerned – on our own site that does not happen.

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