2026 Concussion Update: Why “Wait Until Symptom Free” is Officially Obsolete

It has been two years since the 6th International Conference on Concussion in Sport (Amsterdam, October 2022) produced the updated consensus statement, published in the British Journal of Sports Medicine in June 2023. In that time, the global approach to sport-related concussion (SRC) management has undergone a fundamental shift -- one that Australian clinicians must understand and implement.

The central message is this: the era of “sit in a dark room until your symptoms go away” is over. In its place, we now have a structured, evidence-based framework that moves from documentation to active rehabilitation. This article summarises the three most important clinical changes that define concussion management in 2026.

If your current protocol still centres on complete rest until symptom resolution, you are not only behind the evidence -- you may be inadvertently prolonging your patients' recovery.

For over a decade, the standard advice following concussion was strict physical and cognitive rest until all symptoms resolved. The Amsterdam 2023 Consensus Statement changed this decisively. The evidence now shows that strict rest beyond 48 hours increases the risk of persistent post-concussion symptoms(formerly “post-concussion syndrome”).

The physiological rationale is straightforward. Prolonged inactivity leads to cardiovascular deconditioning, social isolation, anxiety, depression, and disruption to sleep-wake cycles -- all of which worsen concussion symptoms rather than alleviating them. In other words, the treatment itself becomes the disease.

The key concept is sub-symptom threshold exercise. This means physical activity at an intensity that does not provoke or significantly worsen symptoms. Multiple randomised controlled trials (Leddy et al., 2019; Willer et al., 2019) have demonstrated that early, controlled aerobic exercise reduces the duration of concussion symptoms by an average of 4-5 days compared to strict rest protocols.

For clinicians, this means prescribing heart-rate-monitored walking by 72 hours post-injury should now be the standard. The Buffalo Concussion Treadmill Test (BCTT) provides a validated method for determining the individual symptom-exacerbation threshold and prescribing exercise accordingly.

One of the most significant -- and most commonly misunderstood -- changes from the Amsterdam Consensus is the introduction of a two-tool system. Previously, the SCAT (in its various editions) was used as a single instrument from sideline to follow-up. This is no longer appropriate.

The critical rule is simple: SCAT6 is for the acute phase (sideline to 72 hours). SCOAT6 is mandatory for every office follow-up from Day 3 onwards. The SCOAT6 is significantly more comprehensive, incorporating a structured neuro-ophthalmological assessment, cervical spine examination, and the full VOMS battery -- none of which are included in the SCAT6.

Despite this clear delineation, audit data from Australian primary care suggests that a substantial proportion of GPs continue to use SCAT6 (or older SCAT versions) for all follow-up visits. This represents below standard of care. It misses vestibular and oculomotor dysfunction, cervical spine involvement, and structured return-to-play progression -- all of which are critical for safe management.

For any clinician seeing concussed athletes in an office setting after Day 3, the SCOAT6 is not optional. It is the Amsterdam Consensus standard.

If there is a single clinical skill that defines modern concussion management, it is vestibular-ocular motor screening (VOMS). Developed by Mucha et al. (2014) at the University of Pittsburgh, the VOMS has emerged as perhaps the most important advancement in concussion assessment since the introduction of symptom checklists.

The rationale is compelling. Research consistently demonstrates that ocular-motor dysfunction is one of the strongest predictors of prolonged concussion recovery. Patients with vestibular and oculomotor deficits have recovery times 2-3 times longer than those without. Yet these deficits are entirely invisible to standard symptom checklists and cognitive screening.

The VOMS takes approximately 5-10 minutes to administer and requires no specialised equipment -- only a target (pen tip or fingertip) and a ruler for NPC measurement. It is entirely feasible in a standard clinical setting.

Critically, VOMS allows early identification of patients who require specialist referral to vestibular physiotherapy, neuro-optometry, or a multidisciplinary concussion clinic. Without VOMS, these patients are often left on “wait and see” protocols that delay appropriate treatment by weeks or months.

The 2026 position is clear: VOMS is not an optional add-on. It is a fundamental component of competent concussion assessment. Clinicians who are not performing vestibular-ocular screening are missing a critical diagnostic domain and potentially delaying appropriate care.

The trajectory of concussion management over the past two years has been clear and consistent. The field has moved decisively away from passive, rest-based protocols toward structured, evidence-based active recovery. The three pillars of this transition are:

1. Early controlled exercise replaces prolonged rest. Sub-symptom threshold aerobic activity by Day 3 is the new standard.
2. Two-tool assessment replaces the single-instrument approach. SCAT6 for acute assessment, SCOAT6 for all office follow-up.
3. Vestibular-ocular screening replaces symptom-only monitoring. VOMS identifies the patients most at risk of prolonged recovery and directs them to appropriate specialist care.

For Australian healthcare professionals, these changes are not theoretical. They represent the current standard of care as defined by the Amsterdam Consensus, endorsed by Concussion in Sport Australia, and aligned with AHPRA continuing professional development requirements.

The clinicians who adopt these practices will deliver measurably better outcomes for their patients. Those who do not will find themselves increasingly out of step with both the evidence and their regulatory obligations.