Following my colleague David Bartlett’s recent review of the Townsend et al. (2025, BJSM) paper, which quantified real-world heading forces using instrumented mouthguards across Premier League and WSL players, I turned my attention to the next logical question: how do we reduce those loads safely and effectively?

Townsend’s work confirmed that match-like drills (crosses and long balls) produce the highest rotational accelerations, and that female players consistently experience greater rotational forces than males. These findings gave us the most objective dataset yet on what happens when players head the ball. But measurement is only half the story; the real challenge lies in translating that knowledge into modifiable protective strategies.

Why Rotational Load Matters

Rotational acceleration has long been implicated as the more injurious component of head motion. Finite-element brain models show that rotational strain, particularly in cortical sulci, better predicts diffuse axonal injury and potentially chronic traumatic encephalopathy (CTE). Townsend et al. note that cumulative exposure to these rotations may predict pathology more accurately than a history of diagnosed concussions.

For clinicians, this reinforces that sub-concussive load management should focus on quality of movement, neck control, and task design, not only symptom surveillance.

The Role of Neck Strength and Control

Complementary evidence now strengthens this message.

• Fownes-Walpole et al. (2025) combined systematic review and Delphi consensus to outline the essential components of neck-training programs for impact mitigation. Their expert panel emphasised that effective training should target:
• • Multi-planar strength and endurance
  • Dynamic stabilisation and anticipatory control
  • Sport-specific movement patterns rather than isolated static holds
• Garrett et al. (2023, JOSPT) meta-analysed team-sport data and found a moderate negative correlation between neck strength and head-impact magnitude. Stronger necks absorb and redirect more of the incoming force, but only when activation is well-timed and directional.
• Kavyani et al. (2025) reported that athletes with a prior concussion history demonstrate persistent neck-strength deficits, highlighting the importance of post-injury reconditioning before return to contact drills.
• Peek (2022) provided a clear clinical framework for measurement, recommending handheld dynamometry or fixed-rig setups that capture flexion, extension, and lateral strength in neutral head posture. Reliable measurement underpins both screening and training progression.

Together, these studies shift the conversation: neck training is not an optional extra, but a primary prevention and rehabilitation strategy for athletes exposed to repetitive head loads.

Technique and Tactical Preparation

Prevention also extends beyond musculature.

• Peek et al. (2025) urged a “re-think” of head-injury prevention through tactics and technique. Coaching points such as body positioning, timing of jump, and angle of approach can meaningfully alter both impact location and rotational torque.
• Ross et al. (2025, HeaderPrep) demonstrated that targeted heading-readiness programs for youth female players are both feasible and well-accepted, improving confidence and technique while limiting high-force exposures.

For practitioners, these findings support a progression model: prepare before exposure. Blending neuromuscular control, technical education, and measured load increments.

Translating Evidence Into Practice

Quantify and Monitor

Whenever possible, use objective measures such as validated digital tools like instrumented mouthguards or video coding to track exposure patterns over time. Even periodic sampling can highlight positional or drill-specific risk.

Structure Heading Drills

• Begin with low-velocity, “thrown” headers, focusing on timing and neck control.
• Progress to aerial crosses and long-ball scenarios only once mechanics and anticipatory activation are stable.
• Limit overall high-force exposures, particularly across congested training weeks or in younger players.

Integrate Neck Training Year-Round

• Combine isometric holds, dynamic perturbation exercises, and multi-directional resistance (e.g., band or partner drills).
• Train in football-relevant postures: semi-flexed trunk, reactive stance, rather than supine positions.
• Review progress every 4–6 weeks using consistent testing positions.

Educate and Communicate

Ensure players understand why load management matters. Encourage disclosure of dizziness, neck fatigue, or delayed headache after repetitive headers, symptoms that can reflect both musculoskeletal and vestibular strain.

Implications for Female and Youth Athletes

Townsend et al. found higher rotational loads in female players, aligning with other data showing increased concussion incidence in women’s football. Potential contributors include lower baseline neck strength, smaller head-to-ball mass ratios, and different heading mechanics.
Clinicians should therefore:

• Establish sex-specific baselines for neck strength and control.
• Introduce graduated “header readiness” programs for adolescent and female players before exposure to match-like drills.
• Advocate for equitable inclusion in future research. Female cohorts remain markedly under-represented.

The Bigger Picture

Collectively, these studies provide the framework football has long needed:

• Townsend 2025 quantifies how much and how hard players head the ball.
• Fownes-Walpole, Garrett, and Kavyani explain how the neck contributes to mitigating load.
• Peek and Ross show how to coach and measure it in real settings.

For clinicians, this convergence of evidence allows more precise conversations with coaches, strength staff, and governing bodies about “smart exposure” — protecting brain health without losing the skill of heading.

Take-Home Summary

Closing Thought

As Townsend et al. conclude, the aim is not to eliminate heading but to guide it. With a deeper biomechanical understanding, targeted neck-training protocols, and modern monitoring technology, clinicians can lead football toward a future where every header is both skilful and safe.

The recent British Journal of Sports Medicine paper by Townsend et al. (2025) marks a significant step forward in our understanding of heading exposure during football training. For the first time, elite male and female footballers were monitored using instrumented mouthguards (iMGs) to capture the real-world frequency and intensity of headers, moving beyond laboratory estimates and self-report data that have long limited this area of research.

Across 63 professional training sessions, the study recorded nearly 1,500 heading events. The results revealed average peak linear accelerations of 18 g and rotational accelerations of ~1,000 rad/s², with female players consistently experiencing higher rotational accelerations than males. Crucially, match-like scenarios such as crosses and long balls produced the highest forces, while throw-ins, more common in training drills, resulted in lower impacts.

A step forward for football science

This research represents tangible progress. The methodology adheres to the Consensus Head Acceleration Measurement Practices (CHAMP) framework, using a validated iMG technology (Protecht) to produce the most reliable dataset yet on heading in elite football. It provides an evidence base for training-load management and begins to inform guidance on limiting repetitive head impacts, a necessary foundation for future policy and practice.

The use of wearable technology across both men’s and women’s elite tiers should be recognised as a milestone for player welfare. For the first time, we can meaningfully quantify what a “typical” training exposure looks like, rather than relying on conjecture or extrapolation from match data.

But peak force understanding remains limited

While the study provides robust quantification of how often and how hard players head the ball, it stops short of answering the critical question; what do these forces mean for the brain?

The peak linear and rotational accelerations recorded remain well below concussive thresholds, yet our understanding of the cumulative or sub-concussive impact of repetitive exposure remains incomplete. Rotational acceleration, in particular, is thought to exert greater strain on neural tissues, but the clinical consequence of these training-related exposures remains speculative.

This is especially relevant for women’s football, where the study identified significantly higher rotational accelerations but could not determine why. Possible explanations include differences in neck strength, head-neck segment mass, or heading technique, all of which demand closer biomechanical and neuromuscular scrutiny.

The practical takeaway: neck strength and neuromuscular control matter

What this study reinforces, perhaps more than anything, is the need for targeted cervical spine conditioning as part of concussion-prevention and performance programmes.

Strong, well-coordinated neck musculature could reduce head acceleration by stabilising the head–neck complex at the moment of impact. In practical terms, this means progressive strength and proprioceptive training, ideally integrated into existing strength and conditioning or physiotherapy routines.

For female athletes, who may be more susceptible to higher rotational forces, this may carry even greater importance. Tailored neuromuscular interventions that improve timing, co-contraction, and dynamic control could be key to mitigating risk without compromising performance.

Progress made

Townsend et al. should be commended for delivering the most comprehensive quantification of training-related heading to date. Their findings are a clear advance in the ongoing effort to understand, and ultimately manage, the neurological load placed on footballers.

But quantification is not the same as comprehension. Until we better understand how these forces translate into brain strain, metabolism, and long-term neurodegenerative risk, our response must combine data-driven exposure management with proactive neck-control conditioning.

In short: progress has been made, but the science of protection is only just beginning.

By David Bartlett, Physiotherapist at Welsh Fire

When Jordan Cox sprinted toward the boundary and plucked a soaring ball to dismiss Steve Smith in the Hundred this summer, the crowd saw a moment of pure athletic brilliance.
Those of us working at the intersection of brain health and performance saw something more: a live demonstration of world-class gaze stability.

The Invisible Work Behind the Catch

Tracking a cricket ball that is descending at over 100 km/h while your own body is accelerating is a neuromechanical challenge of the highest order. As Cox turned and ran back, his cervical spine moved from deep extension and left rotation to a neutral posture, all while the visual backdrop shifted abruptly from the uniform blue of the sky to the high-contrast chaos of a packed grandstand.

For the ball to remain sharply focused on his fovea, Cox’s vestibulo-ocular reflex (VOR), cervico-ocular reflex (COR) and smooth pursuit eye tracking functions all had to perform flawlessly. These oculomotor functions integrate information from semicircular canals of the inner ear, neck muscle spindles, and joints to control extra-ocular muscles, driving equal-and-opposite eye movements within roughly ten milliseconds of head motion. Any deficit in gaze stability gain, even mild, would have produced compensatory corrective saccades, causing the ball to blur or “jump” in his visual field. In that scenario, the catch simply doesn’t happen.

Implications for Performance

This is where what we know from concussion management and performance science needs to converge. We know from both clinical research and daily practice that even subtle vestibular, cervical and oculomotor impairments after head trauma degrades oculomotor functions and dynamic visual acuity. Cervico-vestibular dysfunction, common after rapid head acceleration injuries, together with physiological injury to brain and brainstem pathways, adds another layer, as proprioceptive input from the neck is essential for accurate gaze control.

Yet traditional return-to-play assessments often stop at symptom checklists or static balance tests. Cox’s catch is a compelling reminder that sport demands far more. If an athlete cannot maintain visual clarity while sprinting, rotating, and reacting to a shifting background, they are not truly match-ready.

Training and Screening the Invisible System

The good news is that gaze stability can be trained and measured. Dynamic visual-acuity tests, head-impulse assessments, oculomotor tests and progressive vestibular rehabilitation (the classic X1 and X2 drills, for example) and sports specific gaze stability exercises provide both objective metrics and effective interventions. Embedding these in pre-season screening and post-concussion protocols should now be as routine as hamstring strength testing.

A Broader Lesson

What fans celebrated as a spectacular dismissal was, at its core, a triumph of incredible neuro-ocular-vestibular-cervical integration. For performance and medical teams, it highlights a simple but critical truth: protecting and optimising the brain–eye–neck axis is not a niche clinical concern, it is a competitive necessity.

Elite catches are born not only of athletic talent but of a nervous system tuned to keep a stable gaze on moving targets, while the body moves at speed. In professional sport, that is as worthy of training and safeguarding as any other physical skill.

Concussion isn’t simply a brain injury – it’s a biomechanical event.

As Professor Mike Loosemore, MBE, aptly puts it: concussion is a “rapid head acceleration injury”. In practical terms, this means the impact is not confined to neural tissue alone. The same acceleration–deceleration forces can strain the cervical spine, disrupt vestibular networks, and impair proprioceptive control. These interconnected systems explain why patients often present with overlapping symptoms—headache, dizziness, balance disturbance, and neck pain—that cannot be attributed to brain injury in isolation.

Why the Cervicovestibular System Matters

The evidence is now clear: concussion is rarely a single-system injury. Whiplash-type cervical involvement and central vestibular disruption often coexist, producing overlapping symptoms such as dizziness, headache, balance impairment, and neck pain.

• Persistent Symptoms: RCTs (Schneider et al., 2014) show that patients receiving combined cervical physiotherapy and vestibular rehab were nearly four times more likely to be medically cleared within 8 weeks compared to rest plus aerobic exercise alone.
• Objective Gains: More recent trials in adults demonstrate that while symptoms may improve similarly with aerobic exercise, the addition of cervicovestibular rehab improves objective function (vestibulo-ocular reflex, cervical ROM, proprioception).
• Prognostic Relevance: Cervicogenic pain and dizziness in the early days after concussion are strong predictors of prolonged recovery. Early, targeted treatment may shorten this trajectory.

Conclusion

Concussion is heterogeneous. For some athletes, symptoms are driven primarily by vestibular dysfunction; for others, cervical whiplash is dominant; and often, both systems are involved. The new study in elite female athletes reinforces the importance of screening both domains systematically.

With the right tools and training, health professionals can identify cervicovestibular dysfunction early, target treatment precisely, and track recovery transparently. At Your Brain Health, we’re committed to equipping clinicians with the skills, confidence, and technology to make that possible.

How We Support Clinicians

At Your Brain Health, our Essential Practical course devotes significant time to hands-on cervicovestibular rehabilitation. We know that physiotherapists and allied health professionals are uniquely positioned to address these impairments—but confidence and skill in assessment and treatment are essential. The reality is that many physiotherapists that have experience in sports and musculoskeletal practice are less confident when it comes to vestibular practice. While many vestibular and neurological physiotherapists have less experience with cervical assessments and treatments. However, it does not take long for us to upskill both groups!

The recent Herald Sun article¹, based on a new Swinburne University study using transcranial magnetic stimulation (TMS)², highlights what many clinicians have long recognised: concussion recovery is not as simple as counting down the days.

In sport, return-to-play (RTP) rules are often based on arbitrary timelines; 12 days in elite AFL, 21 days in community levels, rather than an accurate picture of brain recovery. This study found that while athletes reported feeling symptom-free after about 12 days, measures of cortical inhibition (via TMS) were still abnormal for up to 26 days.

Every day in Australia, we hear that an athlete is sidelined due to “concussion protocols”, rather than what is really happening; the athlete is recovering from a concussion injury. Concussion is a rapid head acceleration injury with neurophysiological, musculoskeletal, and psychological consequences. Just like a hamstring or shoulder injury, recovery requires an individualised, multimodal assessment, not an arbitrary timeline. You don’t hear of players out with “hamstring protocols”, they are recovering from a hamstring injury. And running without pain symptoms certainly does not mean you have fully recovered!

This reinforces what we see clinically every week: symptom resolution does not necessarily mean full recovery.

Why This Matters

Every athlete deserves recovery care that is:

• Individualised – no two concussions recover the same way
• Comprehensive – covering brain, body, and psychological health
• Transparent – so players, families, and clinicians can track progress together

This is one of the reasons we built ScreenIT, software that integrates all these clinical measures, streamlining care for the individual while also creating robust, longitudinal datasets to advance concussion research.

References

1. Clarke, B. (2025, August 17). When do you recover from a concussion? Shock new findings. Herald Sun. https://www.heraldsun.com.au/health/mental-health/concussion-recovery-periods-may-be-too-short-new-brain-study-suggests/news-story/73aa4cf85aa55e875b42c3497f96651b
2. Pearce, A. J., Middleton, K., & Clarke, A. (2025). Time-course responses following sports-related concussion: a multi-modality study. The Physician and Sportsmedicine, 00913847.2025.2541579, 1–9.
3. Fong, D. H. C., Cohen, A., Boughton, P., Raftos, P., Herrera, J. E., Simon, N. G., & Putrino, D. (2020). Steady-state visual-evoked potentials as a biomarker for concussion: A pilot study. Frontiers in Neuroscience, 14, 171.

Over the past decade, vestibular education has strongly emphasized the role of the Head Impulse Test (HIT) and its video-based cousin (vHIT), particularly in acute settings. This focus stems from their pivotal role in the Head Impulse, Nystagmus, Test of Skew (HINTS) protocol, which—when applied accurately and in the right context—can help differentiate central causes (e.g., stroke) from peripheral vestibulopathies (e.g., vestibular neuritis). Rightly so: it’s a powerful, bedside decision tool in emergency neurology. 

However, I have noticed over the past 5 years, this stroke-centric application of HIT/vHIT taught in many vestibular courses has disproportionately shaped the broader clinical conversation—especially in rehabilitation and sports medicine. Too often, clinicians are left with the impression that a normal vHIT rules out significant dysfunction. In reality, this is where functional vestibular assessment should begin. 

Functional Gaze Stability = Everyday Brain Performance 

Patients don’t live in a vHIT lab. They live in dynamic environments—navigating busy streets, scanning playing fields, or walking through supermarkets. These real-world tasks require gaze stability across a variety of head speeds, directions, and cognitive loads. 

We must assess gaze stability across a range of speeds and tasks to: 

• Identify direction and speed specific subtle deficits 

• Track rehab progress 

• Assessing cervical-vestibular coordination and compensatory strategies 

• Tailor VOR retraining 

• Guide return-to-play and return-to-learn decisions 

Even simple tools like Dynamic Visual Acuity (DVA) and the VOMS battery can reveal critical deficits missed by vHIT. 

Recalibrating Our Focus 

vHIT is a starting point. To support recovery, clinicians could incorporate: 

• Smooth pursuit and VOR cancellation 

• DVA at varied speeds 

• Active VOR tools (e.g., NeuroFlex®) 

• Head precision and proprioceptive control (e.g., HeadX Kross) 

• Functional movement with gaze tasks 

Final Thought 

If symptoms persist, dig deeper than just HIT and vHIT. Gaze stability is not binary. Like all brain functions, it must be assessed across varied speeds, loads, and contexts to understand and treat it most effectively. 

In 2022, Your Brain Health (YBH) was in its embryonic stages as an organisation. At that time, we held clear ambitions to promote a multimodal, community‑focused approach to brain health. By combining clinical experience, domain expertise, and emerging technologies, our goal was to enable better, evidence‑informed care.

We recognised an urgent need for integrated brain‑health solutions across diverse settings—concussion, mental health, ageing, and neurorehabilitation. This vision became the foundation for developing digital tools and clinical pathways that empower both healthcare professionals and the people they serve.

YBH was born from the belief that optimal outcomes are achieved when brain health is assessed and managed using a collaborative, multidisciplinary, and data‑driven model. From this initial vision, our future direction began to take shape.

Driven by this unmet need and our clinical insights, we developed ScreenIT software to address these challenges. ScreenIT is designed to:

Easily capture previously fragmented data from validated questionnaires and objective multimodal outcome measures, alongside emerging assessment technologies. A selection of trusted tools allowing for clinician choice and autonomy to suit their contextual needs.

Automate comprehensive reports within seconds, saving administrative time.

Track measures longitudinally with intuitive timeline graphs.

Support clinics, clubs, and organisations through flexible permission structures for clinical and administrative staff, enhancing multidisciplinary collaboration.

Securely store a scalable, real‑world longitudinal database that can power future research and AI/machine‑learning insights.

When an athlete sustains a potential concussion, the decisions made in the moments that follow are critical. Healthcare Professionals and medical staff are often required to act quickly, using the best tools available to assess injury severity and guide next steps. The SCAT6 (Sport Concussion Assessment Tool, 6th Edition) has emerged as the leading sideline and clinical evaluation tool—but is it truly the best we have?

SCAT6 is widely used as the go-to concussion assessment tool for the acute phase of injury. It encourages a holistic view of the athlete, prompting clinicians to consider symptom progression, cognitive status, and observable signs rather than relying on any one domain.

It also reinforces a culture of athlete safety. The emphasis on standardised removal-from-play protocols and serial assessments helps mitigate the risks associated with premature return-to-play decisions.

Persistent Limitations

Despite its strengths, SCAT6 is not without limitations. It remains a tool—not a diagnostic verdict—and is dependent on the clinical judgment and skill of the person administering it. Its validated window of utility is confined to the first 72 hours post-injury, limiting its role in ongoing management.

That distinction—tool, not diagnosis—is crucial, yet often misunderstood. Many research studies still use SCAT6 outcomes as de facto diagnostic criteria for inclusion or exclusion, despite the fact that SCAT6 was never intended to serve as a standalone diagnostic standard. This creates inconsistencies in the literature and can contribute to overreliance on thresholds that were meant to guide, not define, clinical decision-making.

Practical barriers also persist. The tool’s comprehensiveness can be a double-edged sword in time-pressured environments. Administering SCAT6 efficiently requires training, familiarity, and ideally, baseline data—which not all settings can support.

Historically, one of the major constraints has been the lack of a digital format. Paper-based assessments can be cumbersome, prone to inconsistencies, and difficult to integrate into broader EMR systems or performance tracking platforms.

A Tool That Keeps Improving

So, is SCAT6 the best we have? For the acute assessment of sport-related concussion, it is certainly the most complete tool currently available. And with the shift to digital formats, some of its practical limitations are being actively addressed—making it more accessible, efficient, and clinically useful.

But like any tool, its effectiveness depends on context, competence, and careful application. SCAT6 should support—not replace—clinical judgment. As our understanding of concussion continues to evolve, so too must our tools and technologies.

Step 1: Confirming the Concussion

Think of this as saying, “Yep, you’ve had a knock.” It’s an important first step — but it’s only the beginning.

Imagine a car that’s been in a minor crash. The first thing you do is check for visible damage. Confirming a concussion is similar. The brain — along with the neck and brainstem — has taken a hit, and there’s been a temporary change in function.

In the immediate aftermath, the top priority is determining whether emergency medical care is needed. We look for red flags that require an immediate medical response. Following this we monitor physical, cognitive, and emotional symptoms over the next few days. This process should be overseen by a responsible adult — not your mates while out at the pub.

To help guide decision making in this acute phase, the Concussion Recognition Tool 6 (CRT6) is the go-to resource. It’s simple, safe, and designed for use by coaches, trainers, parents, and anyone involved in player care. It helps recognise red flags and core symptoms and provides helpful advice for what to do next.

Yes, emerging technologies like blood biomarkers, saliva tests, and wearable sensors are exciting — but they need to add value. That means improving decisions and guiding actions. These tools must be co-designed with those on the front lines: players, physios, coaches, and carers. Plenty of apps and other portable measures of specific brain functions are now hitting the market. However, if it doesn’t support and enhance decision-making, it’s not helping.

Why It Matters

When we know which systems are affected, we can deliver targeted support — whether it’s neck physiotherapy, balance training, vision rehab, heart rate-guided aerobic exercise, or structured rest strategies.

We’re not just managing the concussion — we’re tuning the whole system. That includes identifying pre-existing conditions (e.g. migraine, anxiety, ADHD) that might influence how we approach rehabilitation and recovery.

This leads to:

• Faster, safer return to activity
• Reduced risk of prolonged symptoms
• Better outcomes across the board

So, the next time you hear about a “new tool” to diagnose concussion, ask: Does it help improve care? Does it inform recovery planning?

Diagnosis is step one. But multimodal brain health profiling continues to evolve — and it’s here to stay!

This week, I’ve been fielding a lot of questions about the recent Herald Sun coverage (also picked up in the Adelaide Now) on a new concussion detection tool, BrainEye. You can read the article here:

🔗 BrainEye app delivers 100% concussion detection rate 

 Naturally, I was curious to dive into the new research backing this product: 

 Clough, M., Bartholomew, J., White, O., & Fielding, J. (2025)
Investigating the utility of the BrainEye smartphone eye tracking application and platform in concussion management. Sports Medicine – Open, 11(1), 24. 

Optimism vs. Reality: The Big Picture 

Let’s start with what’s promising: 

• Objective data in eye movement and pupil response is increasingly recognised as a key part of the concussion puzzle. 

• Having rapid, accessible tools could help in environments where expert clinicians aren’t available pitchside. 

• BrainEye’s attempt to move this tech onto a mobile device is a logical step forward in usability. 

But here’s the catch: 

• The study only tracked 11 concussed players, all of whom were already clinically diagnosed using standard tools like SCAT6. So, the real-world added value of BrainEye in this context remains unclear. 

• Two of the four test domains weren’t usable in this setup. 

• It’s not yet known if the smartphone-only app (without the infrared hardware used in the study) can deliver the same data quality. 

• Implementation was low—just 3 of 10 clubs actually used the tool post-concussion, citing logistical barriers. 

Where We Stand at Your Brain Health 

At Your Brain Health, we’ve been using several high-resolution, oculomotor tests as part of a multimodal brain health screen for over three years. And that’s just one part of our toolkit. 

We’re not just assessing injury—we’re tracking recovery and guiding referral pathways for: 

• Vision and vestibular therapy 

• Cervical dysfunction 

• Cognitive and balance rehab 

• Psychological wellbeing 

• Improved performance 

We’re also capturing longitudinal data across elite and community cohorts, helping athletes, clinicians and clubs make truly informed decisions. 

We welcome new tech that brings value—but we also believe in specific validation and transparency in research fundings, and clear distinctions between marketing hype and clinical utility. 

Innovation in concussion care is essential—and it’s exciting to see oculomotor testing get the attention it deserves. But tools like BrainEye needs more independent research (2 authors of this study were part of the company in this case), broader usability testing, and clearer real-world application pathways before they can claim a central role in sideline or recovery protocols. 

We’re always open to integrating new tools into our platform. But until then, we’ll continue to focus on delivering the most comprehensive, evidence-informed brain health assessments available.