Treatment guide · 9 min read
Physical Therapy and Concussion: What It Treats and When to Go
A physical therapist treats the parts of a concussion that are physical: your neck, your balance system, your eyes, and how much exertion you can tolerate before symptoms flare. The American Physical Therapy Association describes the assessment as covering the neck, body control and balance, the eye and inner-ear systems, and exercise capacity. Nobody is treating the bruise on your brain directly. They're treating the systems that got knocked out of sync and haven't reset.
This isn't fringe. The 6th international consensus statement on concussion in sport says that if dizziness, neck pain and/or headaches persist for more than 10 days, cervicovestibular rehabilitation is recommended — that's neck plus vestibular physical therapy, named as the treatment. The same statement says clinicians with access to exercise testing can safely prescribe subsymptom threshold aerobic exercise within 2 to 10 days after injury, based on the individual's heart rate threshold.
Below: what a concussion physical therapist actually examines and treats, why your neck may be the real problem, what vestibular and oculomotor work involves, what happens on a treadmill and why, what a session looks like, when to go, and where the evidence is genuinely thin.
What does a physical therapist actually do for a concussion?
They test four things and then treat whichever ones are broken.
The neck first — range of motion, joint mobility, muscle tension, strength, and your sense of where your head is in space. Then balance and body control. Then the vestibular and oculomotor systems: how well your eyes hold a target while your head moves, how your eyes track and converge, and what makes you dizzy. Then exertion — how hard you can work before symptoms come back.
Treatment follows the findings. The APTA describes physical therapists doing hands-on neck work, specific exercises for the inner-ear system, work to improve tolerance to reading and screens, and symptom-guided paced progressive exercise. If your dizziness turns out to be a stiff, irritated neck rather than a vestibular problem, you get neck treatment. If it's both, you get both.
There is a formal clinical practice guideline behind this. Four APTA academies — orthopedic, sports, neurologic and pediatric — jointly published evidence-based recommendations for physical therapist management of patients who have experienced a concussive event in 2020. Concussion PT is a defined specialty area, not something a therapist improvises.
Physical therapy is one part of a broader plan. Our guide to concussion treatment overall covers where PT sits alongside the medical, cognitive and behavioral pieces.
Is it my neck or my brain?
Often it's your neck, and this is the single most useful thing to understand before your first appointment.
The force that moves your brain inside your skull also whips your head on your neck. Researchers examining this note that concurrent injury to the cervical spine is acknowledged as a potential source of common persistent symptoms such as headache, dizziness and neck pain — the exact three symptoms people assume must be coming from the brain. In that same review of 46 patients with persistent post-concussion symptoms referred for cervical assessment, 32 were identified as having a cervicogenic component, distinguished by physical examination findings rather than by how they described their symptoms.
The numbers in referred groups are striking. In a retrospective study of 73 children and adolescents sent for cervical physical therapy after concussion, 90 percent had impairments in at least three of five assessment categories, with posture and myofascial impairment the most frequent. Read that carefully: these were people already referred for neck problems, so the rate isn't the rate in everyone who gets concussed. But it tells you that when someone bothers to examine the neck properly, they usually find something.
Nobody can sort this out by describing symptoms over the phone. A cervicogenic headache and a concussion headache feel similar to the person having them. The difference shows up under a therapist's hands, on segmental examination of the neck — which is precisely why the examination matters more than the label on your discharge paperwork.
Does vestibular rehabilitation actually stop the dizziness?
It helps, on average, more than doing nothing. It's not a switch.
Vestibular rehab retrains the systems that keep your gaze steady and your body upright. In practice that means gaze stabilization drills — holding your eyes on a target while your head turns — plus habituation work that deliberately exposes you to the movements that provoke symptoms, and balance training that gets progressively harder by narrowing your base, closing your eyes, or standing on foam.
A 2024 systematic review and meta-analysis of vestibular rehabilitation for mild traumatic brain injury found significant improvement in perceived dizziness at the end of the intervention, along with improvements in vestibular/ocular motor screening and post-concussion symptom scores. A separate review pooling randomized trials reported a mean difference of nearly 7 points on the Dizziness Handicap Inventory in favor of vestibular rehabilitation.
Now the honest part. That same meta-analysis found no significant reduction in dizziness scores at two-month follow-up, and concluded that the low certainty of evidence limits the conclusions drawn. Balance scores and return to sport didn't separate significantly either. So: reasonable evidence of short-term symptom benefit, weak evidence about what happens months later, and the reviewers themselves asking for better trials.
Why would a physical therapist care about my eyes?
Because vision problems after concussion are common, and they masquerade as something else.
In a study of 100 adolescents assessed in a concussion program, 69 percent had one or more vision diagnoses — accommodative disorders in 51 percent, convergence insufficiency in 49 percent, and saccadic dysfunction in 29 percent. A later study of 113 adolescents assessed 4 to 12 weeks after injury found 70 percent had at least one oculomotor diagnosis, and that physician screening using near point of convergence, accommodative amplitude or symptom survey detected these with sensitivity between 43 and 63 percent.
That second finding is the practical one: standard screening misses roughly half of these problems. If reading a page gives you a headache after ten minutes, and someone checked your eyes for thirty seconds and pronounced them fine, that check was not sensitive enough to rule anything out.
What the treatment can do is less settled than what the testing can find. A systematic review of convergence after concussion concluded there is a moderate level of evidence that patients have impaired near point of convergence for months after injury, but only a low level of evidence that these impairments can be successfully treated with oculomotor therapy, limited by small samples and non-randomized groups. Oculomotor work is worth doing when the examination finds a deficit. Just don't let anyone sell it to you as proven.
What is the Buffalo Concussion Treadmill Test?
It's a way of measuring, in beats per minute, exactly how much exertion your brain will currently tolerate — so exercise can be prescribed as a dose rather than guessed at.
The protocol is deliberately gentle. You walk on a treadmill at a fixed speed — 3.2 mph, or 3.6 mph if you're taller than 5 feet 10 inches — starting at zero incline, with the incline rising one degree every minute. Every minute someone records your heart rate, your perceived exertion, and your symptom severity on a 0 to 10 scale.
The test stops at an increase of 3 or more points on the symptom scale from your resting score, and the heart rate at that moment is your threshold. Your exercise prescription then sits below 90 percent of that threshold heart rate — hard enough to be a real aerobic stimulus, deliberately under the line where symptoms start. That's what "sub-symptom threshold" means.
Why bother? Because a randomized trial in 103 adolescents seen within 10 days of a sport-related concussion found that those assigned to individualized sub-symptom threshold aerobic exercise recovered in a median of 13 days versus 17 days for a placebo-like stretching program. The reduction in delayed recovery in that trial did not reach statistical significance, so the honest headline is faster recovery, with a suggestion of fewer prolonged cases rather than proof of it.
A bike version exists for people who can't safely use a treadmill. Not every clinic owns the equipment — if yours doesn't, ask how they're setting your intensity instead.
What actually happens in a session?
The first appointment is mostly examination. Expect 45 to 60 minutes of being tested rather than treated: neck movement and palpation, balance with eyes open and closed, eye-tracking and convergence, head-movement tolerance, and exertion assessment. Some of it will provoke symptoms — that's the point. The therapist is looking for what reproduces your complaint.
After that, sessions are shorter and mostly repeat-and-progress. The APTA describes visits that include repeating the initial assessments to gauge progress, hands-on techniques, and progressive exercises prescribed specifically for your symptoms. Most of the actual work happens at home — gaze stabilization drills take minutes and get done daily, not weekly.
The rule that governs all of it comes from the consensus statement: you can keep advancing duration and intensity provided there is no more than mild — an increase of no more than 2 points on a 0 to 10 scale — and brief, meaning under an hour, exacerbation of symptoms. A 2-point bump that settles within the hour is acceptable. Being wiped out that evening is not, and it means the dose was wrong.
When should I start, and how does this fit with getting back to sport?
Earlier than most people think for exercise, and around the 10-day mark for neck and vestibular work.
The consensus statement supports returning to light-intensity physical activity, such as walking that does not more than mildly exacerbate symptoms, during the initial 24 to 48 hours, with relative rather than strict rest. Prescribed aerobic exercise has a window of 2 to 10 days. Cervicovestibular rehabilitation is the recommendation once dizziness, neck pain or headaches have persisted past 10 days. If symptoms run beyond four weeks, the statement calls for a multimodal clinical assessment, ideally by a multidisciplinary team — and that's also the territory covered in our guide to post-concussion syndrome.
The CDC's guidance for clinicians is to let any return of symptoms guide the level of exertion or activity that is safe, and to refer to a specialist if symptoms worsen or persist beyond two to four weeks.
Physical therapy and return-to-play are not the same process, though they overlap. The graded return-to-sport strategy has six steps, with each step typically taking at least 24 hours and a minimum of one week to complete the full strategy. A physical therapist often runs you through those steps and is the person who spots that step 3 keeps triggering your headache. Our return-to-play protocol guide walks through the stages in detail.
How good is the evidence, honestly?
Better than it was, and thinner than the marketing suggests.
The strongest single result is the cervicovestibular trial that underpins the consensus recommendation. In that randomized controlled trial, 73 percent of the treatment group were medically cleared within 8 weeks versus 7 percent of controls, making them 3.91 times more likely to be cleared. That's a large effect. It's also 31 people, aged 12 to 30, all with sport-related concussion.
The systematic review commissioned for the consensus process is the clearest picture available. Screening 6,533 studies, it found only 13 that met inclusion — 1 high-quality study, 7 acceptable, and 5 at high risk of bias — with interventions and outcomes varying so much that meta-analysis was not possible. That is the entire treatment evidence base for sport-related concussion rehabilitation.
What follows from that is worth holding onto. Cervicovestibular rehabilitation and early sub-symptom threshold aerobic exercise have real trial support. Vestibular rehab has short-term support with low certainty. Oculomotor therapy has low-level evidence. And most of these trials studied young athletes with sport-related concussions, which means someone in their fifties concussed in a car crash is being treated by reasonable extension rather than by direct evidence. That doesn't mean don't go. It means expect a therapist who tests, measures and adjusts — not one who runs everyone through the same protocol.
Where should I go from here?
Get examined by someone who will actually assess all four systems. The value of concussion physical therapy is almost entirely in the assessment: dizziness from a stiff upper neck and dizziness from a vestibular deficit look identical from the outside and need completely different treatment, and the difference is found by testing, not by guessing.
If you're not sure whether a physical therapist is the right first call at all — as opposed to a neurologist, a neuro-optometrist, or a sports medicine physician — our short specialist quiz maps your dominant symptom to the clinician who treats it. When you're ready to book, you can search the concussion clinic directory for physical therapists and concussion programs near you, and it's fair to call ahead and ask two questions: do you assess the cervical spine, and do you do exertion testing? A clinic that does both is doing concussion physical therapy properly.
Find a concussion specialist near you
Search 3,205 verified concussion clinics and specialists across all 50 states — filter by services like vestibular therapy, vision therapy, and neuropsychology.
Browse the largest state directories: California (148) · South Carolina (136) · Pennsylvania (125).
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Frequently asked questions
Does physical therapy help concussion symptoms?
For some symptoms, yes. The 6th international consensus statement recommends cervicovestibular rehabilitation when dizziness, neck pain or headaches persist beyond 10 days, and supports prescribed sub-symptom threshold aerobic exercise within 2 to 10 days of injury. The strongest trial found 73 percent of a cervicovestibular treatment group were medically cleared within 8 weeks, against 7 percent of controls.
How soon after a concussion should I start physical therapy?
Light walking that does not more than mildly worsen symptoms is supported within the first 24 to 48 hours, and prescribed aerobic exercise has a window of 2 to 10 days after injury. Neck and vestibular rehabilitation is recommended once dizziness, neck pain or headaches have lasted more than 10 days. The CDC advises specialist referral if symptoms worsen or persist beyond two to four weeks.
What happens at a concussion physical therapy appointment?
The first visit is mostly assessment, typically 45 to 60 minutes covering the neck, balance, eye movements, head-movement tolerance and exertion. Later sessions repeat those tests to track progress and add progressive exercises, with most of the actual work done daily at home. Symptoms may be provoked deliberately, because the therapist is looking for what reproduces your complaint.
Can my neck be causing my concussion symptoms?
Frequently. Concurrent cervical spine injury is recognized as a potential source of persistent headache, dizziness and neck pain, and in one series of 46 patients with persistent post-concussion symptoms, 32 were found to have a cervicogenic component. The distinction is made by physical examination rather than by how the symptoms feel, which is why a proper neck assessment matters.
What is the Buffalo Concussion Treadmill Test?
It is a graded treadmill walking test that measures the heart rate at which your symptoms begin. Incline rises one degree per minute at a fixed speed, and the test stops when symptoms rise 3 or more points from your resting score on a 0 to 10 scale. Exercise is then prescribed below 90 percent of that threshold heart rate, so you train hard enough to help without provoking symptoms.
Is there strong evidence that concussion physical therapy works?
It is mixed and more limited than most clinics suggest. The systematic review supporting the consensus statement found only 13 eligible treatment studies, of which just one was high quality and five were at high risk of bias, with meta-analysis not possible. Cervicovestibular rehabilitation and early aerobic exercise have the best support; vestibular rehabilitation shows short-term benefit with low certainty, and oculomotor therapy has only low-level evidence.
Educational content only — not a substitute for professional medical advice, diagnosis, or treatment. Reviewed by Jon MacKay, PharmD, BCACP against current clinical guidance; last updated August 2026.