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Concussion Assessment

Original Editor - Megyn Robertson

Top Contributors - Jess Bell, Simisola Ajeyalemi, Ewa Jaraczewska, Mandy Roscher, Megyn Robertson, Kim Jackson, Samuel Adedigba, Robin Tacchetti, Rachael Lowe, Tony Lowe, Naomi O'Reilly, Tarina van der Stockt, Shaimaa Eldib, Olajumoke Ogunleye and Nupur Smit Shah  

Introduction

Concussion symptoms can be grouped into five key domains: cognitive, emotional, sleep, physical, and autonomic. The concussion assessment must therefore be multifaceted, considering all domains. This page introduces the core areas of concussion evaluation. Together, these assessments help physiotherapists build a detailed clinical picture and determine appropriate interventions and referral pathways.

Emotional Domain and Screening Tools

Emotional and mood symptoms are common after concussion.[1] For many patients, symptoms resolve as recovery progresses. For some, however, they become more significant, causing new or worsening depression or anxiety.[2]

Formal diagnosis of a mental health condition is outside the scope of physiotherapy.[3] The physiotherapist's role is to recognise, screen and refer on.[4][5] Screening tools such as the Generalised Anxiety Disorder-7 (GAD-7) and the Patient Health Questionnaire-9 (PHQ-9) for anxiety and depression are basic self-report screens that can be used to identify patients who need additional support.[3]

Practical tip: anxiety and vestibular dysfunction share overlapping symptoms. Physiotherapists must be alert to this crossover during vestibulo-oculomotor screening, especially as untreated anxiety can limit how well a patient engages with and responds to rehabilitation.[6][3]

If you would like to learn more about mental health in rehabilitation, see: Psychological Support in Rehabilitation.

Cognitive Assessment

Cognitive symptoms, such as memory issues, brain fog, or concentration difficulties, are best assessed and managed by a multidisciplinary team. This team will ideally include neuropsychologists and speech and language therapists who can formally assess memory, attention, reasoning, and executive function, as well as occupational therapists who are trained to develop strategies for persistent symptoms. Again, the physiotherapist's role is limited here, but they can assess one aspect of cognitive function: clinical reaction time.[3]

Reaction Time

Impaired reaction time can be an indicator of cognitive change after concussion. It has been found to correlate with neck pain, dizziness, balance problems, light sensitivity, and feeling "foggy" or slowed down,[7] and may also contribute to the raised injury risk seen in athletes after they return to sport.[8] The evidence is not, however, entirely consistent. Some studies report that clinical reaction time recovers on a timeline similar to other cognitive measures,[9] while others find deficits persist even once other symptoms resolve.[10][11] Reaction time is therefore best used as one part of a multidimensional cognitive assessment rather than relied on alone.[12]

Normative clinical reaction time values for healthy collegiate athletes are shown in Table 1 to give an indication of reaction times based on sex and sport contact level. Note that values vary across studies depending on the test method used.

Table 1. Clinical reaction time in healthy collegiate athletes, by sex and sport contact level[13]
Group Non-contact Limited contact Contact
Female 211.5 ± 25.8 ms 212.1 ± 24.3 ms 203.7 ± 21.5 ms
Male 199.4 ± 26.7 ms 196.3 ± 23.9 ms 195.0 ± 23.8 ms

Practical tip: any validated, reliable reaction time method is acceptable. What matters most is consistency. This means using identical testing conditions at baseline and reassessment, so results are directly comparable (i.e. comparing "apples with apples").[3]

Neurocognitive Assessment Tools (NCATs)

Beyond reaction time, broader cognitive function is often assessed using neurocognitive test batteries. These are typically administered and interpreted by a specialist rather than a physiotherapist, but it is useful to understand what they measure and where they fit. They can support baseline and post-injury comparison, though their psychometric properties and clinical utility remain uncertain, particularly beyond the acute phase.[14][15] 

Note: NCATs should never be used in isolation or prioritised above a multidimensional clinical assessment.[3]

Examples of NCATs

Cogstate (also known as Axon or CogSport) is a computerised battery measuring psychomotor function, processing speed, visual attention, vigilance, and verbal and visual learning and memory.[16] Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) is another computerised battery, with reported construct validity for concussion-related cognitive function.[17]

Vestibulospinal Assessment

Balance and postural stability are commonly affected after concussion.[18][19][20] They are therefore a core component of the physiotherapy assessment, informing treatment and return-to-sport decisions. Risk also extends beyond recovery: athletes have around twice the odds (OR 2.11) of a lower-extremity musculoskeletal injury in the year after concussion compared to their peers without concussion.[21] This is thought to reflect altered neuromuscular control, balance deficits and delayed reaction time.[3]

Postural stability can be assessed with the modified Balance Error Scoring System (mBESS), or, where equipment allows, the Sensory Organization Test (SOT).

Modified Balance Error Scoring System (mBESS)

The mBESS can be used to quickly evaluate stability and balance following a concussion or head injury.[22] It has higher sensitivity than the standard BESS in the acute phase of concussion.[23]

Testing method: The patient stands barefoot, eyes closed, hands on their iliac crests, on a firm surface, for 20 seconds per stance. The stances are:[24]

  1. Feet together
  2. Single-leg stance on the non-dominant leg
  3. Tandem stance, non-dominant foot at the back

Score: one error point is recorded each time the patient lifts their hands off the iliac crests, opens their eyes, steps, stumbles or falls, flexes or abducts their hip more than 30 degrees, or lifts their forefoot or heel. If the patient cannot maintain a stance (i.e. remains out of test position for more than 5 seconds), that stance is scored as the maximum of 10 errors. A higher score indicates worse performance.

Sensory Organization Test
Sensory Organization Test (SOT)

The SOT uses a force plate to create six sensory conditions, systematically removing visual and proprioceptive cues to isolate vestibular contribution to balance. It has low sensitivity, but high specificity for concussion. However, it is unsuitable for sideline use.[25]

Vestibular Oculomotor Screening (VOMS)

Vestibular and oculomotor impairments are common after concussion.[26] The VOMS is a brief screen that identifies impairments by testing whether specific eye and head movements provoke symptoms.[27] It assesses smooth pursuit, saccades, near point of convergence, the vestibulo-ocular reflex (VOR), and visual motion sensitivity (VMS). It should be paired with a cranial nerve screen, as cranial nerves III, IV and VI supply the eye muscles and are vulnerable to injury in concussion.[3]

How it works: before testing, the patient rates their baseline symptoms (headache, dizziness, nausea and fogginess) on a 0–10 scale. After each item, they rate the same symptoms again. A rise of 2 or more points on any symptom, or a near point of convergence of 5 cm or more, increases the probability of concussion.[28] Interpret the results based on which items provoke symptoms and by how much they rise from baseline.

Set-up: the patient is seated except when testing VMS. The target is held around 90 cm away. A metronome is used to pace the saccade, VOR and VMS items, and a tape measure to record convergence distance.

Table 2. Vestibular oculomotor screening[27][3]
Domain Method Repetitions (reps)
Smooth pursuit Target moved smoothly ~40-45 cm to the right and left of midline (~2 sec each direction), then ~40-45 cm up and down. 2 reps in each plane
Saccades (horizontal) Two targets held ~45 cm to the right and left (30° gaze each side); eyes move quickly point-to-point. 10 reps
Saccades (vertical) Two targets held ~45 cm up and down (30° gaze); eyes move quickly point-to-point. 10 reps
Near point of convergence (NPC) A target with 14-point font text is brought slowly toward the patient's nose; stop at diplopia or observed outward eye drift (not blurry vision). Record the distance from the nose. 3 measures, average recorded. Normal NPC = target within 5 cm of the nose before diplopia/divergence.
Vestibulo-Ocular Reflex (VOR) (horizontal and vertical) Metronome at 180 beats per minute (bpm); the patient rotates their head 20° left/right, then up/down while they fix their eyes on a static target 90 cm away 10 reps in each plane
Visual Motion Sensitivity (VMS) Metronome at 50 bpm; standing, arm outstretched, eyes on thumb, head, eyes and trunk rotate together 80° each way facing a busy area 5 reps

Cervical Spine Assessment

The neck is commonly injured in concussion, and it should be assessed routinely, even when the patient does not report neck pain. If you would like to read more about the full cervical assessment, see: Overview of Cervical Spine Assessment. Physiotherapists should also consider the temporomandibular joint (TMJ), as the TMJ is anatomically and functionally linked to the cervical spine and frequently affected alongside it in whiplash and concussion. Read more about this here: Clinical Application of Temporomandibular Joint Structure.[3]


This video shows the cervical spine assessment in concussion:


Alongside the standard cervical examination, three assessments are especially relevant after concussion: joint position error, smooth pursuit neck torsion, and cervical strength and endurance.

Cervical Joint Position Error

The cervical joint position error (JPE) test assesses a person's ability to return their head to a neutral position after movement.[29] Increased repositioning error is thought to reflect impaired cervical proprioception and sensorimotor control, and is more common in people with whiplash-associated disorders.[30][31]

Testing method: the patient is seated 90 cm from a wall with a bullseye target. A laser is mounted to their forehead. The patient holds their head in neutral with the laser on target. They then close their eyes, rotate their head to one side, and attempt to return to neutral. Then, they open their eyes. The distance from the target is recorded. The test is repeated three times on each side, and the average distance is recorded.[32]

Score: Errors of more than 4.5 degrees (around 6-7 cm) are likely to be significant.[32]

During testing: note jerky movements, "searching" for midline, or overshoot (signs of altered cervicocollic reflex), and any dizziness or unsteadiness.[32]

Smooth Pursuit Neck Torsion Test

The smooth pursuit neck torsion (SPNT) test assesses the cervical proprioceptive reflexes to help distinguish a cervical cause of smooth pursuit disturbance from a vestibular, brainstem, or central cause. Smooth pursuit is tested first with the head and trunk in neutral, then with the trunk rotated to 45 degrees. Because this position stimulates the cervical receptors but not the vestibular receptors, any change in symptoms between the two positions points to a cervical cause.[33]

Part 1: the patient is seated, with their head and trunk in neutral. Ask the patient to follow a horizontally moving target with their eyes (no body or head movement).[32] During testing, note any saccadic (catch-up) eye movements, dizziness or blurred vision.

Part 2: the patient keeps their head still but rotates their trunk 45° to one side. Once they are in this position, the smooth pursuit task is repeated. Repeat with the trunk rotated to the opposite side.[32]

Note that this test can also be performed in standing if the patient can safely and freely rotate their trunk 45 degrees to the left and right while keeping their head completely steady.

Positive test: the test is positive when new saccades and/or dizziness appear with trunk rotation compared with neutral. This indicates a cervical contribution to the symptoms.[32]

The following videos show how to perform and interpret the smooth pursuit neck torsion test:

[34]
[35]
Cervical Strength and Endurance Tests

Cervical strength and endurance tests assess neck muscle performance and offer moderate-to-good intra/inter-rater reliability.[36] Key tests are shown in Table 3. Note that hold times vary in the literature depending on the population and test conditions, so always use clinical judgment and reasoning when interpreting results.[3]

Table 3. Cervical strength and endurance baseline
Test Position Normative data Assesses
Craniocervical Flexion Test (CCFT) Supine in crook-lying, with a pressure biofeedback unit placed suboccipitally and inflated to a baseline of 20 mmHg. The patient "nods" their head, increasing the pressure on the biofeedback unit. They aim to increase pressure in 2 mmHg increments up to 30 mmHg. The original test assessed the pressure level the patient could hold for 10 repetitions x 10 seconds. An updated protocol divides the CCFT into two stages. Stage 1 assesses the pressure level the patient can hold for 2-3 seconds with correct action. Stage 2 assesses endurance. The target hold time in stage 2 is 10-second holds at each level.[37] The baseline assessment is recorded as the pressure level the patient can hold steady for repeated 10-second holds, without compensatory strategies and with minimal superficial muscle activity.[37] A cross-sectional study of healthy adults reported a mean CCFT score of 25.5 mmHg.[38] Deep neck flexor (longus colli/capitis) endurance and motor control.[3]
Cervical Flexor Endurance (CFE) Supine crook-lying, chin tucked, head lifted a short distance off the table (~2.5 cm). Reported mean times of 39 seconds for asymptomatic men and 29 seconds for asymptomatic women.[39] Deep cervical flexor endurance; stop if chin tuck is lost or occiput touches the supporting hand for more than 1 second.[3]
Cervical Extensor Endurance (CEET) Prone, head off the edge of the table, chin tucked, torso stabilised. Reported normative CEET hold times vary widely between studies, reflecting differences in test protocol.[40][41][42] In general, the cervical extensor muscles possess about 2 to 2.4 times greater endurance capacity compared to cervical flexors in healthy adults.[43] Hold times are best interpreted against the individual's own baseline, where possible, rather than a single normative cut-off.[3]

A shorter version of the test uses a fixed 20-second sustained chin-tuck hold, scored on whether the position can be maintained rather than on total hold time.[44]

Deep and superficial extensor endurance; stop if >5° position change for >3 sec, or pain/fatigue. Note:

if the chin tuck is lost first (skin wrinkling, chin lengthening), this indicates deep extensor weakness. If the whole head drops into flexion, it indicates global (deep + superficial) extensor weakness.[3]

Post-Concussion Autonomic Dysfunction

Exercise intolerance is common after concussion and is considered an indirect indicator of autonomic dysfunction.[45] Graded exertional testing identifies impaired autonomic tolerance and informs safe, individualised return to activity.

Buffalo Concussion Treadmill Test (BCTT)

The Buffalo Concussion Treadmill Test (BCTT) is a graded exercise test used to identify exertional and autonomic intolerance after concussion. It is a supplementary test only and should never be used alone to diagnose concussion or to clear return-to-play. Results must always be interpreted alongside the full history and physical examination.[46]

Testing method: after a brief warm-up, the patient walks on the treadmill at a fixed pace. The initial speed is set based on the patient's height. For people under 178cm (5 feet 10 inches), the treadmill is set at 3.2 miles per hour (~5.14 km/h). For people over 178cm, it is set at 3.6 miles per hour (~5.8km/h). The starting incline is 0 degrees.[47] The incline is increased by 1 degree each minute. Once the maximum incline is met (15 degrees, ~15 minutes), speed increases by 0.4 mph each minute thereafter. Throughout, the clinician monitors the patient's heart rate, rate of perceived exertion, and symptoms. The test is stopped when the patient's symptoms rise by 3 or more points from their resting score, or when they reach voluntary exhaustion (RPE above 17 without significant symptom exacerbation).[3][47]

Contraindications to the BCTT

The BCTT should not be performed if the patient has:[47]

  • cervical dysfunction severe enough that walking on a treadmill could cause considerable pain or harm
  • vestibular or balance impairment that would compromise safe treadmill walking
  • a lower extremity or spinal injury that would compromise safe treadmill walking

Absolute contraindications:[47]

  • acute myocardial infarction (within 2 days)
  • high-risk unstable angina
  • uncontrolled cardiac arrhythmias causing symptoms or haemodynamic compromise
  • symptomatic severe aortic stenosis
  • uncontrolled symptomatic heart failure
  • acute pulmonary embolus or infarction
  • acute myocarditis or pericarditis
  • acute aortic dissection

Relative contraindications to exercise testing:[47]

  • left main coronary stenosis
  • moderate stenotic valvular heart disease
  • electrolyte imbalance
  • severe arterial hypertension (>200 mmHg systolic or >110 mmHg diastolic)
  • tachyarrhythmia or bradyarrhythmia
  • hypertrophic cardiomyopathy and other forms of outflow tract obstruction
  • mental or physical impairment leading to an inability to exercise adequately
  • high-degree atrioventricular block

Please watch the following video to learn more about the BCTT:

[48]

Selected Outcome Measures in Concussion

The concussion assessment must consider symptoms across multiple domains. No single test can diagnose, clear, or exclude a concussion on its own. Physiotherapists should base their clinical impression on the pattern across domains, keep baseline testing methods consistent, and refer promptly where symptoms fall outside physiotherapy scope, such as anxiety, persistent cognitive symptoms, or autonomic red flags.[49] The following outcome measures can be useful in concussion.

Table 4. Outcome Measures
Outcome Measure Description Notes
Post-Concussion Symptom Inventory (PCSI)[50][51] Self-report, with age-appropriate versions across ages 5–18, plus parent (and teacher) versions Covers cognitive, emotional, sleep, physical domains
Post-Concussion Symptom Scale (PCSS) 22-item, 7-point Likert self-report Strong evidence base in adolescents; not validated under age 11. Can help to discriminate between athletes with and without concussion
Dizziness Handicap Inventory (DHI) [52] Perceived impact of dizziness on daily life Sensitive to clinical change
Headache Disability Inventory (HDI)[53] 25-item headache disability measure Good reliability and construct validity
King-Devick[54] Rapid number naming, saccadic screen (~2 min) Does not test pursuit/convergence/accommodation; insufficient evidence alone
Sport Concussion Assessment Tool 6th Edition (SCAT6)[55] Standardised sideline/clinical tool, age 13+ For suspected concussion and baseline testing
Child SCAT6 Ages 5–12 A "normal" result does not rule out concussion
Functional Gait Assessment (FGA) 10-item dynamic gait test, 0–3 scale per item (max 30) Useful for vestibular-related gait deficits

Resources

References

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  46. ↑ Vuu S, van den Berg ME, Hutchins S, Howie J, Gough C, Barr CJ. Performance and Physiological Response to the Buffalo Concussion Treadmill Test Can Identify Autonomic Dysfunction in the General Adult Population With Mild Traumatic Brain Injury: A Prospective Observational Study. Journal of Head Trauma Rehabilitation. 2026 Mar 30;41(2):120-9.
  47. ↑ 47.0 47.1 47.2 47.3 47.4 Leddy JJ, Haider MN, Willer BS. Buffalo Concussion Treadmill Test (BCTT) – Instruction Manual. Available from: https://ubortho.com/wp-content/uploads/2020/10/Buffalo-Concussion-Treadmill-Test-Manual.pdf (last accessed 26 August 2026).
  48. ↑ BrainInjuryHawkesBay. Buffalo Concussion Treadmill Test - Instructional Video. Available from: http://www.youtube.com/watch?v=N_zdwERSQrc [last accessed 26/08/2026]
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  54. ↑ Leong DF, Balcer LJ, Galetta SL, Evans G, Gimre M, Watt D. The King-Devick test for sideline concussion screening in collegiate football. J Optom. 2015 Apr-Jun;8(2):131-9.
  55. ↑ Echemendia RJ, Burma JS, Bruce JM, Davis GA, Giza CC, Guskiewicz KM, Naidu D, Black AM, Broglio S, Kemp S, Patricios JS. Acute evaluation of sport-related concussion and implications for the Sport Concussion Assessment Tool (SCAT6) for adults, adolescents and children: a systematic review. British journal of sports medicine. 2023 Jun;57(11):722-35.
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