Concussion assessments are frequently performed immediately following training or competition, often when an athlete is fatigued and physiologically stressed. This raises an important clinical question: does recent exercise influence the results of commonly used concussion assessment tools, potentially affecting clinical decision-making?

A recent pilot study by Howell and colleagues sought to answer this question by investigating the effect of performance training on several key components of the SCAT6 and the modified Vestibular Ocular Motor Screen (mVOMS) within the SCOAT6 in healthy adolescent athletes.

The Study

Twenty-three healthy high school athletes completed a battery of concussion assessments immediately before performance training, immediately after training, and again 20 minutes later. The assessment battery included:

• Modified Vestibular Ocular Motor Screen (mVOMS)
• Standardized Assessment of Concussion (SAC)
• Modified Balance Error Scoring System (mBESS)
• Timed Tandem Gait (TTG)
• Dual-Task Tandem Gait (DTTG)

The aim was to determine whether exercise alone altered test performance in individuals without concussion.

Key Findings

The results were reassuring. Most assessment components remained stable despite recent exercise, including the mVOMS, SAC and mBESS. These findings suggest that moderate physical exertion does not substantially influence many of the clinical measures commonly used during sideline concussion assessment.

However, the researchers identified significant improvements in both Timed Tandem Gait and Dual-Task Tandem Gait following exercise. Rather than reflecting a physiological benefit of exercise, the authors suggest these changes are more likely explained by a practice or learning effect, with participants becoming more familiar with the testing procedures over repeated administrations.

Why This Matters

This study highlights an important principle in clinical assessment: changes in performance do not necessarily reflect changes in neurological function. Repeated testing may introduce learning effects that influence performance independently of injury or recovery.

For clinicians, this reinforces the importance of interpreting assessment results within the broader clinical context rather than relying on any single measure in isolation. It also highlights the importance of understanding the measurement characteristics of commonly used concussion assessments, including the potential influence of practice effects when interpreting repeated measurements over time.

Ultimately, understanding how our assessment tools behave is just as important as understanding the conditions they are designed to measure.

These pilot findings provide preliminary evidence that several commonly used components of best-practice concussion assessment are not substantially influenced by moderate exercise. This has practical implications for clinicians who assess athletes immediately following physical activity, whether during acute concussion evaluation, serial follow-up or baseline testing.

Looking Beyond This Pilot Study

As a pilot study involving a relatively small sample of healthy adolescent athletes, these findings should be interpreted with appropriate caution. Whether similar results would be observed in elite athletes, younger children, para-athletes, community sport participants or individuals recovering from concussion remains unknown.

This represents an important opportunity for future research. Larger, longitudinal studies across diverse sporting and clinical populations are needed to better understand how commonly used concussion assessments perform under real-world conditions.

With increasing use of standardised digital assessment platforms, collaborative collection of anonymised clinical data now makes this type of research increasingly achievable. Such work has the potential to refine concussion assessment protocols, improve interpretation of change scores and strengthen the evidence underpinning everyday clinical practice.

Clinical Take-Home Message

This study provides encouraging evidence that moderate exercise does not appear to meaningfully influence most components of the SCAT6 or mVOMS. At the same time, it reminds us that performance-based measures such as Timed Tandem Gait and Dual-Task Tandem Gait may be susceptible to learning effects. As clinicians, understanding the measurement properties of our assessment tools is just as important as understanding the conditions we use them to assess.

Return to work (RTW) is often regarded as one of the most important markers of recovery following concussion. Yet despite increasing advances in concussion assessment and management, many individuals continue to experience challenges when attempting to resume employment. While much of the concussion literature has traditionally focused on symptom burden, prognostic factors and clinical recovery, a recent scoping review in the Journal of Head Trauma Rehabilitation by Shahzad and colleagues in Toronto, Canada, reminds us that successful return to work is influenced by far more than the injury itself.

The authors reviewed 20 studies exploring factors that facilitate or hinder return to work following concussion. Their findings were organised into four broad domains:

• the person affected by concussion,
• the medical system,
• funders and insurers, and
• the workplace.

Collectively, these findings highlight the complex interaction between individual, clinical, organisational and societal factors that shape recovery and work participation.

A Shift Away from the Biomedical Model

Historically, concussion management has been heavily influenced by a biomedical model that emphasises symptom resolution and impairment-based assessment. However, as Shahzad et al. note, many of the commonly cited prognostic factors for prolonged recovery—including sex, age and pre-existing mental health conditions—are largely non-modifiable.

In contrast, the current review highlights the importance of modifiable psychosocial and environmental influences. Factors such as personal agency, self-advocacy, social support, workplace flexibility and access to appropriate rehabilitation services emerged as important facilitators of successful work reintegration.

This aligns with a growing body of literature suggesting that concussion recovery should be viewed through a biopsychosocial lens, recognising that symptoms occur within the context of an individual’s work demands, social environment, psychological state and access to healthcare.

The Importance of Personal Agency

One of the more interesting findings was the role of personal agency in the return-to-work process. Several studies reported that successful work reintegration was facilitated when individuals were actively involved in decision-making regarding their recovery and work schedule. Self-awareness, self-advocacy and the ability to establish appropriate boundaries between work and personal life were repeatedly identified as important factors.

The authors suggest that return to work should not be viewed simply as a clinical outcome but rather as a behavioural and adaptive process. Individuals often need to adjust expectations, develop coping strategies and establish a new understanding of their abilities during recovery.

This observation is particularly relevant for clinicians. Successful rehabilitation may require not only symptom management but also supporting patients to develop confidence, self-management skills and realistic expectations regarding recovery.

The Critical Role of Healthcare Systems

The review also highlights several healthcare-related factors associated with improved RTW outcomes. Tailored rehabilitation programs, interdisciplinary care, concussion-specific services and vocational rehabilitation were all identified as beneficial.

Conversely, delays in diagnosis, mistimed and inappropriate referrals, poor follow-up and insufficient mental health support were consistently identified as barriers.

Notably, the findings reinforce contemporary concussion management principles that emphasise active rehabilitation and gradual progression rather than prolonged rest. One study included in the review found that individuals advised to rest for more than two days were less likely to have resumed work or study within one to two months of injury.

These findings support current international concussion recommendations advocating early education, symptom-guided activity and targeted rehabilitation interventions.

Workplace Culture Matters

Perhaps unsurprisingly, workplace factors emerged as one of the strongest influences on RTW outcomes. Supportive employers, flexible scheduling, graduated duties, environmental modifications and positive workplace relationships were consistently associated with successful work reintegration.

In contrast, poor concussion awareness, stigma, discrimination and a lack of meaningful accommodations were commonly reported barriers.

A particularly important observation was that accommodations are not universally beneficial. Some individuals reported that workplace modifications inadvertently increased social isolation or failed to align with their actual post-injury capabilities. This highlights the importance of individualised workplace planning rather than relying on generic return-to-work recommendations.

Implications for Future Research

One of the most striking findings from the review is the relative absence of research examining the role of funding systems and insurers. While several studies identified administrative burden, adversarial interactions and poor continuity of case management as barriers, no studies identified funder-related facilitators.

This represents an important gap in the literature. Given the significant influence that compensation systems, insurers and workplace injury schemes can have on access to treatment and vocational rehabilitation, future research should seek to better understand how these systems can either facilitate or hinder recovery.

The review also highlights the need for more longitudinal data examining how individuals transition back into work over time. Return to work is not a single event but a dynamic process that may involve fluctuations in symptoms, multiple domains of brain functions, changing workplace demands and evolving rehabilitation needs. Understanding these trajectories may help inform more personalised approaches to concussion management.

Conclusion

The review by Shahzad and colleagues provides a timely reminder that return to work after concussion is influenced by far more than symptom resolution alone. Recovery occurs within a broader ecosystem that includes healthcare providers, workplaces, family supports, funding systems and the individual themselves.

As concussion management continues to mature, there is increasing recognition that successful outcomes require more than accurate diagnosis and symptom monitoring. Supporting sustainable participation in work demands an integrated approach that considers the biological, psychological and social dimensions of recovery.

For clinicians, researchers and policymakers alike, the challenge moving forward will be developing and utilising streamlined systems that support not only recovery from concussion, but successful reintegration into meaningful work and daily life.

Women report more concussions, experience worse symptoms, and take longer to recover than men in comparable sports. But is this simply over reporting or is something more fundamental going on?

The evidence increasingly says: both. And the distinction matters clinically.

Across football, rugby, basketball, lacrosse, and beyond, female athletes consistently show higher concussion rates than male counterparts playing the same sport. A growing body of research, spanning systematic reviews, meta-analyses, prospective cohort studies, and now neuroimaging and preclinical data, has set out to explain why. The answer is not a single mechanism. It is a convergence of biomechanical, structural, hormonal, cognitive, and social factors that interact in ways we are only beginning to unpick.

The Biomechanical Case: It Starts With the Neck

Perhaps the most consistently supported explanation in the literature concerns neck strength and head-neck dynamics.

Female athletes typically have less neck muscle mass and smaller neck girth relative to head size than males. This matters because the neck acts as a dynamic shock absorber: a stronger, better-conditioned neck can attenuate and redirect the forces generated at impact, reducing the accelerations that ultimately cause neural strain. Research suggests that every additional pound of neck strength is associated with roughly a 5% reduction in concussion odds in high school athletes (Fahr et al., 2024; Lin et al., 2018; Sundaram et al., 2022). It is a modest but meaningful effect, and critically, a modifiable one.

The nature of the impact itself also differs by sex. Female athletes are more likely to sustain concussions from ball, equipment, or surface contact, whereas male athletes are more commonly injured by direct player-to-player contact (Ling et al., 2020; Sundaram et al., 2022). These different impact vectors, often less anticipated and arriving from unexpected directions, reduce the opportunity for anticipatory neck bracing, amplifying the rotational accelerations that reach the brain.

Taken together, the biomechanical picture suggests that female athletes face a lower threshold for brain injury from equivalent impact magnitudes (McGroarty et al., 2020; Fahr et al., 2024). This is not a matter of fragility. It is physics applied to anatomy.

The Structural Picture: What Happens Inside the Brain

Biomechanics explains how forces reach the brain. A growing body of preclinical and neuroimaging research is beginning to explain why those same forces cause more damage once they do.

A 2024 study using a swine model, one of the most biomechanically comparable to humans, found that female brains contain a higher proportion of small-diameter axons in white matter compared to males. This is clinically significant. Smaller axons have less structural reserve and are more susceptible to the shear forces that characterise rapid acceleration-deceleration injury. Following a concussive impact, the female brains in this study showed more widespread axonal swelling and greater loss of sodium channels, proteins essential for neuronal signalling, even when the applied force was identical across sexes. Twenty-four hours after injury, the burden of axonal pathology was measurably greater in females.

This is a biological difference in tissue-level vulnerability, not a behavioural or reporting difference. And it has direct clinical implications: the disruption of sodium channel function impairs communication between brain regions, which may help explain why women consistently report more severe acute symptoms and longer recovery trajectories across observational studies.

Neuroimaging reviews add a further layer to this picture, identifying sex-based differences in white matter organisation, connectivity patterns, and regional vulnerability to shear strain (Macleod et al., 2025; Koerte et al., 2020). Together, these structural differences may influence how mechanical forces propagate through neural tissue during impact, meaning the same event that causes a mild concussion in one person may produce greater pathological change in another.

The Hormonal Question: Plausible, and Getting More Specific

Beyond structure, sex hormones, particularly oestradiol and progesterone, have attracted significant research attention as potential modulators of concussion risk and recovery.

Proposed mechanisms that may delay recovery include hormonal influences on cerebral blood flow, neuroinflammatory responses, and brain excitability. Some studies suggest that concussion may disrupt the hypothalamic-pituitary-ovarian (HPO) axis, with reports of menstrual irregularities following head injury and associations between cycle phase and symptom severity (McGroarty et al., 2020; Lin et al., 2018; Biegon, 2021). Elevated concussion rates have been observed in the luteal phase in some prospective cohort studies, adding temporal specificity to what had previously been treated as a static hormonal explanation.

For now, the hormonal contribution remains a credible and increasingly specific hypothesis, but one that still requires prospective studies with direct hormonal measurement to establish causation (Koerte et al., 2020; Macleod et al., 2025; Musko & Demetriades, 2023).

The Cognitive Dimension: A Piece of the Puzzle That Has Been Missing

One of the most overlooked contributors to injury risk in female athletes is cognition. Most research has focused on biomechanical mechanisms; far less has considered whether fluctuations in cognitive function across the menstrual cycle might independently modulate injury risk.

A UCL study by Ronca et al. (2024), published in Neuropsychologia, addressed this directly. Researchers tested 248 participants, including males, females on hormonal contraception, and naturally cycling females, on a sport-oriented cognitive battery measuring reaction times, sustained attention, inhibition, 3D spatial cognition, and crucially, spatial timing anticipation: the ability to predict when two objects moving at different speeds will collide, a process central to heading, tackling, and other time-critical sporting situations.

The within-subject findings in naturally cycling females were striking in two respects.

First, objective cognitive performance was best during menstruation, with faster reaction times, fewer errors, and less intra-individual variability, even though subjective mood and symptom burden were at their worst during the same phase. A significant proportion of women believed their symptoms were impairing their performance during menstruation. The data showed the opposite. This incongruence between perception and performance is clinically important: it suggests that the symptoms female athletes experience during menstruation do not reliably indicate that their cognitive function is impaired, and that assumptions to the contrary may be unfounded.

Second, and more concerning from an injury-risk perspective, performance on spatial timing anticipation was consistently and significantly worse during the luteal phase, regardless of test-retest learning effects. Reaction times were slower, timing errors were greater, and intra-individual variability was higher. The luteal phase is characterised by high progesterone, which has inhibitory effects on cortical excitability, potentially slowing the millisecond-accurate motor processes that underpin collision avoidance in fast-paced sport. This aligns with reports of elevated concussion and non-contact injury incidence during the luteal phase in other prospective studies.

Broader evidence on concentration across the cycle reinforces this picture. Peak cognitive performance, including better working memory, faster attention switching, and improved processing speed, tends to occur in the late follicular phase, when oestradiol is highest ahead of ovulation. The luteal and premenstrual phases are consistently associated with subjective concentration difficulties; some objective testing also demonstrates slower processing in these windows, and a 2025 longitudinal study found that sex differences in processing speed between men and women were most pronounced during menstruation specifically.

The critical clinical takeaway from this body of work is that neither cognitive performance nor injury risk tracks neatly with subjective symptom experience. Women may underperform cognitively in phases where they feel relatively well, and perform better in phases where they feel worse. This has direct implications for how clinicians, coaches, and sports scientists support female athletes across the training and competition cycle.

Reporting, Context, and the Social Layer

Any honest reading of this evidence must also grapple with reporting behaviour. Female athletes are generally more likely to disclose concussion symptoms than males (McGroarty et al., 2020; Merritt et al., 2019; Dick, 2009). This is well documented. More open reporting cultures, different social expectations around injury disclosure, and greater general health-seeking behaviour all contribute.

But, importantly, greater reporting does not fully account for the observed differences. Studies that have controlled for reporting behaviour still find higher symptom burden and longer recovery times in women (Covassin et al., 2017; Hannah et al., 2021). Women’s sports also typically involve less physical contact and lower-magnitude impacts than men’s equivalents, yet concussion rates remain elevated (Fahr et al., 2024; Dick, 2009). Higher disclosure partly explains the picture, but it does not complete it.

What the Research Does and Doesn’t Tell Us

The evidence is now strongest across multiple domains: neck strength and biomechanics as a modifiable risk factor; axonal microstructure and sodium channel vulnerability as a biological susceptibility; cognitive fluctuations across the menstrual cycle as a potential injury determinant that operates independently of symptom perception; and greater symptom burden in female athletes that persists even after controlling for reporting differences.

The hormonal literature, while increasingly specific, remains underpowered and awaits studies that directly measure hormone levels alongside injury and recovery outcomes. Many foundational studies rely on college-aged, predominantly white athletic populations, limiting generalisation (Brook et al., 2016; Macleod et al., 2025). The cognitive evidence, including Ronca et al. (2024), is proof-of-principle and needs replication in elite athletic populations with confirmed cycle tracking.

What the research tells us unambiguously is that the current evidence base was largely built on male athletes. Female-specific data across all these domains, structural, hormonal, and cognitive, remains sparse relative to the scale of female participation in sport.

What This Means in Practice

For clinicians working with female athletes, this evidence points to several practical priorities:

The Bigger Picture

The persistent assumption that concussion presents, progresses, and resolves in the same way regardless of sex is no longer defensible. It was never well evidenced. It simply reflected who the research was built around.

Female athletes are not men with different hormone levels. They present with different injury mechanics, different tissue-level vulnerability, cyclically fluctuating cognitive profiles that do not track with symptom perception, and, the evidence suggests, a genuinely different risk profile at every level from axon to sideline decision-making. Understanding all of that is not a niche concern for women’s sport specialists. It is a basic requirement of good concussion care.

The field is moving in the right direction. But the pace needs to match the scale of female participation in sport at every level, from grassroots to elite.

A recent paper published in the Journal of Science and Medicine in Sport has provided one of the most comprehensive reviews to date of concussion return-to-play (RTP) protocols across FIFA Member Associations (MAs). The findings provide both encouragement and constructive insights that may help inform improved practice. While concussion management is now clearly recognised as an important issue within world football, the practical implementation of concussion care remains highly variable across organisations and countries.

The study reviewed concussion-related information from 95 FIFA Member Associations and found that 73 had formal RTP protocols in place. However, despite broad agreement around a six-stage return-to-play framework, there were still major differences in how concussion management was implemented in practice.

Some organisations recommended “relative rest” immediately after concussion, allowing light daily activity provided symptoms did not significantly worsen, which is consistent with current recommendations at Your Brain Health. Others still recommended complete physical and cognitive rest. Some protocols allowed progression through rehabilitation stages despite mild symptom aggravation, while others required athletes to be completely symptom-free before advancing.

The differences in return-to-play timing were particularly striking. Across the protocols reviewed, total stand-down periods ranged from as little as 30 hours to as long as 23 days. While many organisations followed FIFA or international consensus guidance recommending approximately one week between injury and return-to-play, the paper highlights growing evidence suggesting that recovery timelines are often substantially longer, particularly in women, amateur athletes, and non-elite populations.

There was also substantial variability in who was permitted to provide medical clearance. Some organisations required specialist concussion expertise or neurologist review, whereas others allowed clearance by general practitioners, nurses, or team medical staff. One protocol even permitted coaching staff involvement in assessing return-to-play readiness.

Another important finding was the inconsistent approach to return-to-learn and return-to-work pathways. Some organisations integrated these directly alongside return-to-play progression, while others treated them as entirely separate processes or provided minimal guidance. This is highly relevant as concussion management increasingly extends beyond sport participation alone and into broader educational, occupational, and psychosocial functioning.

Interestingly, only 38% of protocols mentioned baseline testing. Given the growing interest in personalised concussion care, this raises important questions regarding the future role of multimodal preseason screening and longitudinal athlete profiling. Increasingly, clinicians are recognising that concussion recovery may be influenced by individual factors extending well beyond symptom checklists alone, including vestibular and oculomotor function, sleep, mental health, fatigue, exercise tolerance, and previous injury history. These factors may also assist in informing assessments and supporting long-term brain health surveillance.

The paper also highlighted major disparities in access and transparency. Many protocols were difficult to locate publicly, and significant regional differences existed between confederations. UEFA Member Associations had the highest availability of concussion-related information online, whereas much lower levels of accessible information were identified across some other regions, likely reflecting broader differences in infrastructure and resources.

Importantly, the authors emphasise that these inconsistencies do not necessarily reflect poor practice. Rather, they may reflect differing resources, healthcare systems, medical staffing structures, cultural attitudes toward concussion, and varying interpretations of evolving evidence. However, the findings do reinforce an important reality: the challenge in football is no longer simply recognising concussion — the challenge is implementing consistent, scalable, evidence-informed brain health pathways across vastly different sporting environments.

This may represent the next major frontier in sports medicine.

Modern concussion care is increasingly moving beyond isolated “sideline diagnosis” models toward broader longitudinal brain health frameworks. Football organisations are now facing growing pressure to integrate education, digital workflows, clinician communication, symptom tracking, mental health screening, rehabilitation monitoring, and return-to-play governance into cohesive systems that function across elite, semi-professional, amateur, youth, and community sport.

Ultimately, this impressive paper raises a much broader question than concussion protocols alone:

How does football build real-world brain health systems that are practical, scalable, evidence-based, and adaptable across different sporting cultures and healthcare environments?

This will no doubt become one of the defining priorities in sports medicine over the next decade. In just a few weeks, 48 countries will compete across 104 games at the FIFA World Cup Finals. While we respect and admire different playing styles, cultures, and training philosophies across the globe, it is encouraging to think that we can also strive toward more consistent best-practice brain health and concussion care for players at all levels of the game.

Last month I had the opportunity to speak at the Royal Society of Medicine about concussion in elite sport. What struck me most during the discussion afterwards was something that has increasingly concerned me in clinical practice: protocols designed to improve care may, paradoxically, be undermining clinical reasoning.

This is not a criticism of the intent behind concussion protocols. Their introduction was both necessary and overdue. But their implementation has had unintended consequences that deserve reflection.

A brief history of good intentions

Across UK sport, concussion protocols emerged largely in the 2010s in response to growing recognition of head injury risks. The Rugby Football Union introduced structured return-to-play pathways and head injury assessments in elite rugby earlier than most sports. The England and Wales Cricket Board adopted formal concussion management guidance in the mid-2010s and later introduced concussion substitutions following international regulation changes. The Football Association followed with formal concussion guidelines shortly afterwards.

Each governing body introduced graduated return-to-play pathways, typically involving staged progression over a minimum number of days before an athlete could return to competition. These frameworks were created to address a genuine problem: historically, athletes returned to play too quickly, often under pressure from competitive environments.

And while these protocols created structure, safety, and accountability, they also created something else.

When timelines become the diagnosis

Today, it is not uncommon to hear clinicians, coaches, and even athletes speak about “being on stage 3 of the concussion protocol”.

The timeline becomes the treatment.

The implication is that concussion behaves like a fracture: a defined injury with a predictable biological healing timeline. But concussion is not a fracture. In fact, “concussion” is itself a problematic term. The clinical term describes the outcome of a rapid head acceleration rather than the specific functional disturbance that results.

The clinical question should not simply be: Has the protocol timeline elapsed?

The question should be: What functions have been disrupted by this rapid head acceleration, and have they recovered?

That requires clinical reasoning, not simply protocol adherence.

The misuse of tools

One example of this shift toward protocol-driven care is the ongoing misuse of assessment tools.

The Sport Concussion Assessment Tool 6 (SCAT6) is a valuable instrument in the initial assessment of suspected concussion. It provides structured evaluation of symptoms, cognition, balance, and neurological signs.

But it was never intended to be used indefinitely. In fact, its diagnostic utility declines significantly after the first 48–72 hours.

Yet in our clinic at the Institute of Sport Exercise and Health, we still routinely see professional athletes who have had SCAT6 assessments repeated throughout their  “concussion protocol”. At that stage, the tool adds little. What is required instead is clinical evaluation of the systems affected by the rapid head acceleration .

The tool designed to fix this problem

The irony is that the most recent international consensus attempted to address precisely this issue.

The introduction of the Sport Concussion Office Assessment Tool 6 (SCOAT6) was intended to support clinicians in structured post-acute evaluation. Unlike the SCAT6, the SCOAT6 is designed for use in the clinical environment and emphasises assessment of domains such as:

• Vestibular-ocular function
• cervical spine involvement
• cognitive function
• autonomic regulation
• mental health disturbance

In other words, it supports clinical reasoning about which systems have been functionally affected.

Yet in practice, its dissemination and implementation have been limited. Many clinicians remain far more familiar with the SCAT6, despite it being the wrong tool for the later stages of recovery.

Confusion across sports

Adding further complexity is the fact that concussion protocols differ between sports. Elite rugby, cricket, and football all have slightly different return-to-play timelines. For athletes, clinicians, and support staff working across sports, these inconsistencies can be confusing.

More importantly, they reinforce the idea that recovery is governed by a predetermined number of days, rather than by individual clinical recovery.

The risk of protocol medicine

Protocols are valuable. They protect athletes from premature return and provide clear guidance in high-pressure environments.

But protocols should support clinical reasoning, not replace it.

If clinicians begin to rely on timelines instead of functional assessment, we risk replacing one problem with another. Instead of athletes returning too early, we risk athletes progressing through pathways without truly understanding what has recovered, and what has not. Concussion care should not be about counting days. It should be about identifying which neurological systems were disrupted by rapid head acceleration and determining when they have recovered. That requires skill, assessment, and judgement. In other words, it requires clinicians.

A call for better clinical thinking

If concussion protocols achieved one thing, it was to ensure that head injuries are taken seriously and that was a vital step forward. The next step must be ensuring that protocols remain tools for clinicians, not substitutes for them. Better dissemination of tools such as the SCOAT6, greater emphasis on domain-specific assessment, and continued education in concussion pathophysiology are essential.

Otherwise, the well-intentioned structures designed to improve care may inadvertently do the opposite.

1. Bimanual Upper Limb Rehabilitation for Stroke

Stroke upper limb recovery research is finally moving beyond basic reach-and-grasp movements to address the complexity of real-world activities. Historically, much of the research has been overly simplified, with improvements demonstrated in functional outcome measures, particularly in higher-functioning stroke survivors, but with limited translation into meaningful real-world activity.

New approaches are now beginning to address this gap. Recent data shows that bimanual performance (using both hands together) improves most significantly within the first six months post-stroke. Importantly, admission grasp function and stroke severity have been identified as the strongest predictors of how well a patient will manage two-handed tasks at one year.

The introduction of clinical decision trees offers a more structured and realistic way for therapists to set goals, helping to better align rehabilitation outcomes with the demands of daily life.

Key paper:
Van Gils, A., Zou, Y., Meyer, S., Michielsen, M., Lafosse, C., Beyens, H., Schillebeeckx, F., Kos, D., & Verheyden, G. (2025). Tracking bimanual recovery after stroke: Grasp function and stroke severity predict 1-year performance. Clinical Rehabilitation.

2. Non-Invasive Brain Stimulation (NIBS): Precision and Synergy

After decades of development within research settings, non-invasive brain stimulation (NIBS) is now moving closer to mainstream clinical application, driven by advances in precision targeting and combined treatment approaches.

In Alzheimer’s care, meta-analyses demonstrate that repetitive Transcranial Magnetic Stimulation (rTMS) targeting the dorsolateral prefrontal cortex (DLPFC), alongside transcranial Direct Current Stimulation (tDCS) targeting temporal regions, can significantly improve memory symptoms.

In depression treatment, 2025 saw a notable breakthrough in combination therapy. Using tDCS to “precondition” neuronal activity prior to rTMS has produced response rates of up to 85% within two weeks in treatment-resistant cases.

As understanding of functional brain networks continues to improve, increasingly precise and synergistic applications of these techniques are expected to drive further clinical impact.

Key paper:
Rektorová, I., Pupíková, M., Fleury, L., Brabenec, L., & Hummel, F. C. (2025). Non-invasive brain stimulation: current and future applications in neurology. Nature Reviews Neurology, 21(12), 669–686.

3. A Shift in Managing Migraine

The International Headache Society (IHS) has called for a fundamental shift in migraine management; from treating individual attacks to preventing disease progression.

With the emergence of highly effective anti-CGRP therapies, there is now a strong emphasis on early intervention. Treating migraine proactively, before it becomes chronic or high-frequency, offers the potential to reduce both individual burden and wider societal impact, while preserving long-term brain health.

This shift aligns closely with ongoing efforts to improve clinical education and standards across both pharmacological and non-pharmacological management of migraine, supporting a more preventative and holistic approach to care.

Key paper:
Pozo-Rosich, P., et al. (2025). Early treatment in migraine – A call to shift prevention from attacks to disease progression: A position statement from the International Headache Society. Cephalalgia.

4. Exercise for Cognition: The Power of the “Weekend Warrior” and Beyond

With up to 50% of dementia cases now considered preventable, exercise has become a central pillar of brain health and longevity.

New longitudinal research has validated the “weekend warrior” model, showing that individuals who complete their physical activity in one or two sessions per week achieve a 25% reduction in mild dementia risk, outperforming the 11% reduction seen in those who exercise more frequently. This suggests that total volume of activity may be more important than frequency, particularly for individuals with time constraints.

Further strengthening this evidence base, a large umbrella review and meta-meta-analysis published in 2025 confirms that exercise delivers measurable improvements in cognition, memory, and executive function, reinforcing its role as a key intervention in both prevention and treatment.

Key papers:
O’Donovan, G., et al. (2024). Associations of the ‘weekend warrior’ physical activity pattern with mild dementia. British Journal of Sports Medicine.
(2025). Effectiveness of exercise for improving cognition, memory and executive function: a systematic umbrella review and meta-meta-analysis. British Journal of Sports Medicine.

5. Proactive Brain Health Screening for Serious Falls

Proactive brain health surveillance is gaining traction as a practical way to identify risk early and intervene before significant decline occurs.

Simple, measurable markers such as gait speed, grip strength, and mental health indicators are proving to be powerful predictors of outcomes. Research shows that combining gait speed and grip strength can effectively identify individuals at higher risk of serious falls, while monitoring depression and anxiety is increasingly recognised as essential to comprehensive assessment.

A useful way to conceptualise this approach is to think of brain health like a high-performance vehicle. Rather than waiting for a major failure, proactive screening acts as a dashboard of warning lights, allowing early adjustments and maintenance to support long-term performance and resilience.

Digital platforms such as ScreenIT support this multimodal approach, enabling longitudinal health profiling and earlier identification of risk patterns and one of the key reasons why we have developed it.

Key paper:
Raru, T. B., et al. (2025). Contribution of gait speed, grip strength, and depression on the risk of serious falls among older adults. Archives of Gerontology and Geriatrics Plus.

Over the past decade, research has linked traumatic brain injury (TBI) and repetitive head impacts with neurodegenerative disease. Links with Dementia and Chronic Traumatic Encephalography (CTE) in particular ha dominated headlines, but links between head impacts and MND (also known as ALS) remains less clearly understood.

In October 2025, a major UK population study published in JAMA Network Open in October 2025 attempted to clarify this relationship using national electronic health records.

What the Research Found

Zhu et al. (2025) analysed health records from 342,760 adults, including over 85,000 individuals with documented traumatic brain injury.

Three findings stand out.

1) A higher observed risk of MND after TBI

Individuals with a history of TBI showed approximately a 2.6-fold higher risk of later receiving an MND diagnosis compared with matched members of the general population. In absolute terms, 69 of 85,690 people with TBI developed ALS (about 0.08%), while 81 of 257,070 matched controls developed ALS (about 0.03%).

At face value, this appears alarming, and it is easy to interpret this as evidence that brain injury causes MND, but the story is more nuanced.

2) No difference in disease timing or survival

The researchers found no difference in age at diagnosis or age at death between people with and without prior TBI.

If traumatic brain injury were directly accelerating disease progression, we might expect earlier onset or shorter survival. That was not observed.

3) The risk was confined to the first two years

The finding that deserves the most attention, is that increased risk existed only within two years after the injury. After that period, risk returned to baseline levels.

This led researchers to propose a concept many outside academia rarely hear discussed: reverse causality.

What is Reverse Causality?

MND often develops silently before diagnosis. Early symptoms can include subtle weakness, coordination changes, or balance issues long before disease is recognised.

Zhu et al. (2025) suggests that, in some individuals:

• early, undiagnosed MND may increase falls or accidents
• those events result in a recorded traumatic brain injury
• the neurological disease is diagnosed months or years later

In other words, the injury may not be causing the disease; the disease may be contributing to the injury. This distinction matters enormously for athletes, governing bodies, and public perception.

What This Means Sport

The current evidence does not prove that traumatic brain injury causes MND.

What it does show is an observable association, a strong possibility of reverse causality and significant gaps in long-term data.

The journeys of Rob Burrow and Doddie Weir increased awareness of MND in the public eye and Lewis Moody’s diagnosis reminds us that this is not a historical conversation, but an ongoing one. Rugby has already implemented meaningful change; increasing concussion awareness, introducing stricter protocols, appointing independent match-day doctors, enforcing graduated return-to-play pathways, and adapting laws to reduce head contact. Each represents a step forward.

Yet we are only at the beginning of understanding brain health across an athlete’s lifetime. The next breakthroughs may not come from looking harder at the brain in isolation, but from understanding the wider system around it, how forces move through the body and brain in different sports, how athletes adapt over time, and how subtle changes accumulate long before symptoms appear, and monitoring all known risk factors that influence brain health  both during and well beyond an athletes sporting career.

Standing at the top of the skeleton run at the 2018 Winter Olympics in PyeongChang, the cold was aggressive. It was -27 °C. Cold enough that icicles had formed in my beard as I watched athletes prepare to hurl themselves head-first down an ice chute at motorway speeds – a perfectly normal way to spend a Tuesday morning, obviously.

PyeongChang was my 4th Olympic Games, but my first as Chief Medical Officer for Team GB. You might think three decades in Sports and Exercise Medicine would dull your curiosity, but if anything, experience just refines the questions. As I looked down the run that morning, two things occupied my mind.

First: would Lizzy Yarnold retain her Olympic gold? (Spoiler: She did, magnificently).

Second, and the one that has nagged at me far longer: what truly causes the symptoms skeleton athletes call “Skelly Head” (or “Sled Head” to our North American colleagues)?

The first question was answered on the podium. The second remains one of the more interesting, unresolved puzzles in our field.

A career defined by head injuries

Skelly Head has always fascinated me, and not by accident. My academic background is in concussion. I’ve spent over thirty years as Chief Medical Officer for GB Boxing; a sport where rapid, precise symptom recognition and knowing the difference between structural injury and functional disturbance is critical.

Here is the challenge: Skeleton athletes often present with symptoms that look, on the surface, suspiciously like concussion; headache, dizziness, disorientation, visual disturbance, neck discomfort.

Yet, in most cases, they haven’t hit their head. There is no big impact, no rotational acceleration, and no consistent post-traumatic cognitive profile.

My position is clear: Skelly Head is not concussion, despite the superficial similarities. Conflating the two is like treating a migraine with a neck brace, it risks misunderstanding both conditions.

When the physics hits the physiology

Skeleton is one of those brilliant sports that captures global attention for two weeks every four years, then largely vanishes from view.

But the physiological demands don’t disappear when the TV cameras leave. These athletes are repeatedly exposed to one of the most extreme mechanical environments in sport. Over multiple Olympic cycles, I’ve seen a recognisable pattern emerge: athletes reporting dizziness, visual strain, and stiff necks following runs. Sometimes transient, sometimes cumulative, and often without any identifiable “crash.”

So, what is happening?

It has become increasingly clear that the culprit is repeated, high-frequency vibration transmitted through the sled, the ice, the helmet and right into the cervical spine.

We need to stop viewing this vibration as just an incidental nuisance of the sport. It is an active sensory stressor. It occurs within specific frequency ranges known to bother vestibular organs (our balance system) and the sensors in our neck responsible for spatial orientation.

The “Snow Globe” Effect: A Mechanistic Framework

Rather than a single pathology, I believe Skelly Head is best understood as a transient disturbance of how the brain integrates multiple senses under load.

1. The Vestibular Shake-Up Imagine your inner ear getting shaken like a snow globe. Repeated vibration seems to transiently scramble vestibular signalling-specifically the inputs that sense linear acceleration and head position. The result is subtle reductions in reflex stability and a “visual–vestibular mismatch.” The eyes and ears are telling the brain different things. Crucially, this happens without permanent damage, which explains why standard vestibular tests usually come back looking normal.
2. The Cervical Response The neck is not a passive passenger. Vibration transmitted through the sled–helmet interface modifies signals from the neck to the brain. The body responds with protective stiffness-increasing muscle tone. This stiffness is both adaptive (trying to stabilise the head) and contributory to the problem, leading to secondary headaches and discomfort.
3. Central Processing Overload At a central level, the poor brain has to reconcile noisy signals from the ears, altered input from a stiff neck, and heavily relied-upon visual information, all while moving at 80mph. It’s a massive increase in processing demand.

Symptoms arise not because tissue is broken, but because the integration system becomes inefficient under extreme, repeated load.

Why this matters (beyond the ice track)

Why fuss over a niche condition in a niche sport? Because precision in diagnosis is everything.

Misclassifying Skelly Head as concussion is unhelpful. It risks inappropriate management, unnecessary restriction, and misplaced anxiety about brain injury, while failing to address the true underlying mechanisms.

Athletes deserve explanations grounded in physiology, not just convenient labels. Clinicians need frameworks that recognise functional, load-dependent disturbances rather than forcing symptoms into diagnostic categories that don’t quite fit.

Skelly Head isn’t mystical. It is a predictable physiological response to high-frequency vibration acting on tightly coupled body systems. Standing in that -27 °C freezer in PyeongChang, it was clear to me that getting this right mattered.

In the work we do at the clinic today-applying that same rigorous curiosity to all head symptoms, whether from an Olympic sled or a fall at home, it matters even more.

At Your Brain Health, staying ahead of the evidence is core to our mission. It is essential that we incorporate this knowledge into our educational courses and resources, and use it to evolve and improve ScreenIT.

There was a plethora of concussion research in 2025. Here are our nominations for the five biggest themes in concussion research in 2025 based on our own biases and interests!

1. Mental Health & Fear Avoidance

Mental health is finally (and rightly) recognised as a central component of concussion recovery and persisting symptoms. Two major studies this year emphasise that catastrophising thoughts, fear-avoidance behaviours, and perceptions about symptoms strongly influence long-term outcomes—sometimes more than the injury itself.

Key insights:

• Mental health concerns are common but often overlooked in concussion care.
• People may avoid seeking help due to fear or misunderstanding of their symptoms.
• Education and early support remain essential.
• Including mental health in routine brain health surveillance helps normalise monitoring and encourages early intervention.

Key papers:

Hecker, L., King, S., Wijenberg, M., Geusgens, C., Stapert, S., Verbunt, J., & Van Heugten, C. (2025). Catastrophizing thoughts and fear-avoidance behavior are related to persistent post-concussion symptoms after mild traumatic brain injury. Neurotrauma Reports, 6(1), 148–157.

Otamendi, T., Sanghera, S. K., Mortenson, W. B., Li, L. C., & Silverberg, N. D. (2025). Patient perceptions of persistent symptoms after mild traumatic brain injury and their influence on mental health treatment-seeking: A grounded theory study. Disability and Rehabilitation, 1–9.

2. Functional Neurological Disorder & Functional Overlay After Concussion

FND has historically fallen between neurology and psychiatry, but 2025 marks a shift. There is a stronger recognition of functional overlay following concussion: best-practice now promotes positive “rule-in” diagnostics and targeted rehabilitation, providing new clarity for clinicians.

Key insights:

• Functional overlay after concussion is common, including functional cognitive symptoms.
• FND and Persisting Symptoms Post Concussion share both risk factors and clinical presentations, which clinicians should be aware of. I recently met Dr Ioannis Mavroudis in Leeds UK, who has a wealth of knowledge and experience in both concussions, TBI and FND. Ioannis was lead author in an excellent discussion that I recommend everyone read!
• Understanding these mechanisms can prevent misdiagnosis and ineffective management.
• Oculomotor data—such as saccades, anti-saccades and smooth pursuit—already collected across the YBH network may prove particularly informative.
• Longitudinal brain-health surveillance can help distinguish functional recovery patterns.

Key insights:

Mavroudis, I., Petridis, F., Karantali, E., Ciobica, A., Papagiannopoulos, S., & Kazis, D. (2025). Post-concussion syndrome and Functional Neurological Disorder: Diagnostic interfaces, risk mechanisms, and the Functional Overlay Model. Brain Sciences, 15(7), 755. 

Sangare, A., de Liège, A., Gaymard, B., Rivaud-Péchoux, S., Bonnet, C., Růžička, E., May, J., Serranová, T., Mesrati, F., Roze, E., Vidailhet, M., Louapre, C., Naccache, L., & Garcin, B. (2025). Ocular motor abnormalities in functional neurological disorder: A video-oculography study. Movement Disorders Clinical Practice. https://doi.org/10.1002/mdc3.70394

3. Football Headers: Technique, Demands & The Future of Prevention

One of the defining questions in sport science today is: How can we reduce head-impact exposure in football without changing the game itself?

In 2025, several landmark papers have begun to answer this

Key insights:

• Townsend et al. produced the first high-resolution dataset of heading demands for elite men and women, establishing an important foundation for accurate load monitoring. Impressive work!
• Peek and colleagues at FIFA argue that prevention will be most effective when focused not only on neck strength, but also whole-body technique and tactical decision-making. This is a shift that places coaches at the centre of injury-prevention strategy. A smart approach, so keep coaches involved as we progress this knowledge together!
• Multimodal cervical training in women shows promising early results. A you may have already gathered, we (at YBH) think the neck is a crucial part of concussion rehabilitation in many cases!
• At YBH, these findings reinforce our view that performance data, biomechanics, and applied coaching must sit alongside medical care in concussion-prevention frameworks.

Key papers:

Peek, K., Georgieva, J., Wilson, B., Massey, A., & Serner, A. (2025). Re-thinking head injury prevention in football: The role of tactics and technique. Journal of Science and Medicine in Sport. https://doi.org/10.1016/j.jsams.2025.07.009

Thompson, B. J., & Lattimer, L. J. (2025). A pilot study on the effects of multimodal cervical exercise training on clinical concussion risk factors in female athletes. Physical Therapy in Sport, 72, 39–45.

Townsend, D. C., Jones, C., Patel, S., Green, M., Riley, P., Brownlow, M., Gillett, M., & Belli, A. (2025). Heading to guidance: Understanding in-training heading demands for elite men’s and women’s football. British Journal of Sports Medicine. bjsports-2024-109525.

4. Sport-Specific Considerations: From Circus to Cricket

Best-practice guidelines are essential—but athletes rarely fit into one generic model. This year, we’ve seen excellent work applying concussion evidence to very specific performance environments.

Highlights:

• Circus artists face complex inverted positions, spinning, aerial rotations and extreme physical demands. I had the pleasure of meeting David Munro this year, an experienced concussion physiotherapist from Melbourne. David and colleagues have produced a much-needed extension of the CISG guidelines tailored to circus performance—something I deeply appreciate after meeting with the Cirque du Soleil medical team ealier this year.
• Cricket, currently in the spotlight with the Ashes, requires nuanced return-to-play (RTP) considerations: batting reaction timing, fast-bowling workloads, fielding exposure, travel fatigue, and more. Golding et al. provide an excellent framework for cricket-specific concussion care.

Key papers:

Munro, D., Greenspan, S., Nicholas, J., & Stuckey, M. I. (2025). Circus-specific extension of the 6th international consensus statement on concussion in sport. BMJ Open Sport & Exercise Medicine, 11(2), e002524.

Golding, L., Orchard, J. W., & Swan, M. (2025). Concussion in cricket: Risk, mechanism, identification and return to play. In Cricket Sports Medicine (pp. 333–339). Springer Nature Singapore.

5. Concussion in Older Adults: A Critical Knowledge Gap

While most assume concussion is primarily a youth-sport issue, the truth is stark: most concussions occur due to falls in older adults. Yet research in this population is decades behind.

Key insights:

• Concussion symptoms in older adults often overlap with dementia, depression, delirium or medication effects.
• Little is known about their recovery trajectories.
• Falls risk itself is rising with ageing populations.
• Without structured monitoring, concussion may remain undetected—or misattributed—for months.
• Many of our cognitive, balance and vestibular outcome measures used in concussion care, overlap with measures that relate to falls risk. ScreenIT will hold some valuable data soon that will give interesting insights!

Key papers:

Joghataie, G., Hundal, S., Mushtaque, A., Tator, C. H., & Tartaglia, M. C. (2025). Critical gap in practice—Lack of attention to falls and possible fall-related post-concussion symptoms in older adults and individuals with neurodegenerative disease. GeroScience, 47(1), 1269–1276.

Okrah, A. K., Tharrington, S., Shin, I., Wagoner, A., Woodsmall, K. S., & Jehu, D. A. (2025). Risk factors for fall-related mild traumatic brain injuries among older adults: A systematic review highlighting research gaps. International Journal of Environmental Research and Public Health, 22(2). https://doi.org/10.3390/ijerph22020255

We think these research papers in 2025 were worth sharing. But plenty of great research was not included. We are happy for anyone in our growing Your Brain Health community to share other research in 2025 that we missed.

Also, keep an eye out for our Top 5 Topics Brain Health Research next!

Brand new Evidence is now changing our approach!

Three high-quality studies published in 2025 mark a strategic shift in concussion rehabilitation. Collectively, they demonstrate that early, structured oculomotor therapy — particularly vergence and accommodative exercises — is both safe and effective in accelerating recovery after sport-related concussion.

The CONCUSS Trial – Alvarez et al., 2025 (BJSM)

The CONCUSS randomised clinical trial was the largest to date to evaluate vergence and accommodative therapy for concussion-related convergence insufficiency. Compared with usual care, participants receiving targeted vision therapy showed significant improvements in near-point convergence, symptom severity, and reading performance.
This study validates vergence/accommodative therapy as a priority evidence-based, neuro-optometric intervention, not merely an optional adjunct to general rehabilitation.

Haider et al., 2025 (Applied Sciences)

Haider and colleagues trialled a self-guided oculomotor rehabilitation program for adolescents early after concussion. Exercises were simple, short, and home-based, focusing on smooth pursuit, saccadic, and convergence control. The results were impressive: participants who began these tasks early recovered visual symptoms more rapidly and reported better functional outcomes than those in usual care.
Crucially, the study confirmed that early oculomotor training is feasible, safe, and well-tolerated, supporting a paradigm shift toward active early management with foundation exercises rather than just delayed visual rehabilitation.

Trbovich et al., 2025 (Journal of Neurotrauma)

Trbovich and colleagues conducted a randomised controlled trial of Brock string vision therapy for individuals with receded near-point of convergence (NPC >5cm) following concussion. Even with a short protocol, participants achieved measurable improvements in convergence and symptom reduction compared with controls.
This trial suggests that structured vergence exercises, long used in vision therapy, can be effective tools within mainstream concussion rehabilitation programs.

Our Updated Clinical Approach

We are evolving our concussion rehabilitation guidance to reflect this evidence.

– Continue sub-threshold aerobic and cervico-vestibular rehabilitation as foundational elements.
– Introduce very basic early oculomotor and vergence exercises such as near–far focus, smooth pursuits, saccadic training and even Brock string when tolerated.
– Maintain clear and early referral pathways to orthoptists, and ophthalmologists for complex or persisting visual deficits.
– Use longitudinal tracking — such as vestibular-ocular assessment tools within ScreenIT — to monitor recovery trajectories and guide rehabilitation progression.

This updated approach embraces an “early, active, and integrated” model of concussion care. One that aligns visual, vestibular, cervical, and cognitive systems from the earliest stages of recovery.

Key Takeaway

Concussion rehabilitation is evolving from “wait and refer” to “treat early, integrate and refer”
Just as sub-threshold aerobic and vestibular interventions transformed concussion outcomes over the past decade, early oculomotor therapy now stands as the next frontier — restoring efficient eye-brain coordination, accelerating recovery, and reducing long-term symptom burden.

So, what are we going to do in Your Brain Health? We will provide more guidance on early foundation oculomotor exercises within our courses. We encourage more orthoptists, ophthalmologists and some behavioral optometrists to join our network, as this is becoming a great ecosystem where clinicians can not only find each other but can share and ask important clinical questions.