Impact IQ - Brain Health, Concussion, and the Gray Areas Nobody Talks About
Impact IQ Series: Inside the Work
Brain Health, Concussion, and the Gray Areas Nobody Talks About
A conversation with Dr. Alice Barnes
This is part of the Impact IQ Series: Inside the Work, real conversations with elite practitioners on how performance is actually built. If you missed our first conversation with Bernard Condevaux, PT, DPT, SCS, CES on how recovery works at the highest level of sport, start there.
Most concussion conversations start and end with symptoms.
Are they gone? Good. Get back out there.
We sat down with Dr. Alice Barnes, the next conversation in our series, to push past that. What does a thorough concussion assessment actually look like? Where do recovery decisions go wrong? And how should athletes be thinking about brain health, not just when they're hurt, but as a performance system?
She didn't hold back.
The Assessment Goes Deeper Than You Think
When an athlete comes in with a suspected concussion, the symptom report is just the beginning.
"Beyond symptom report, I'm looking at objective markers across multiple systems, oculomotor function, vestibular integration, autonomic response to exertion, cervical spine involvement, and overall cognitive load tolerance."
Each of those systems tells a different part of the story. Saccades and smooth pursuits reveal how the eyes are tracking. Vestibular testing shows how the brain is processing balance and spatial orientation. Autonomic response to exertion tells you how the nervous system is handling stress. Cervical spine involvement, often missed entirely, can drive symptoms that look like concussion but are coming from somewhere else.
"Concussion is rarely just a 'brain-only' injury. Understanding how these systems interact early on is critical to guiding the plan of care."
Dr. Barnes also incorporates reaction time and dual-task assessment early. Not just to have a baseline, but to make the evaluation sport-specific from the start. An athlete whose job requires split-second decisions under physical stress needs to be assessed under conditions that reflect that reality.
Ready to Progress Means More Than Feeling Fine
One of the most consequential mistakes in concussion management is treating symptom resolution as the finish line.
"It's less about being symptom-free at rest and more about how the athlete tolerates progressively increasing load."
What Dr. Barnes is looking for: normalization of objective testing, the ability to handle sport-specific movement and cognitive demands without symptom exacerbation, and appropriate recovery within 24 hours of each exposure.
That last part is worth slowing down on. One good day doesn't mean anything. Consistency across multiple exposures does.
"Consistency across multiple exposures, not just a single good day, is key."
She also completes a full assessment of where the athlete stands nutritionally, how their sleep and recovery are holding up, and what's happening with their mental health. Because an athlete who is physically progressing but under-fueled, sleep-deprived, or emotionally overwhelmed is not actually progressing, they're managing.
The Gray Areas Nobody's Talking About
We asked Dr. Barnes where she sees recovery decisions go wrong most often. Her answer was direct.
The biggest gap: over-reliance on symptom resolution alone.
"Athletes can feel 'fine' but still demonstrate deficits in reaction time, visual tracking, or autonomic regulation."
Feeling fine and being ready are not the same thing. An athlete who has learned to tolerate their symptoms, or whose symptoms have quieted while underlying deficits remain, can pass a subjective screen and still be at risk.
The second gap: underappreciating the role of the cervical spine and vestibular system.
"These can significantly influence symptoms and recovery timelines if not addressed."
Both are frequently overlooked. Both can produce or sustain symptoms that look like post-concussion syndrome but respond to targeted treatment, if someone's actually looking for them.
And there's a third thing she flagged that often gets lost in the caution around concussion: athletes need to be pushed in their return.
"We need to address any additional deficits, such as decreased single-leg stability, to avoid a secondary musculoskeletal injury or another concussion."
The protective instinct to hold athletes back can create its own risks. An athlete who returns to sport deconditioned, with unaddressed movement deficits, is vulnerable in ways that have nothing to do with the original concussion.
Brain Health Is a Performance System
The question we always end with: how should athletes be thinking about this when they're healthy?
"Brain health should be trained and supported just like any other system."
That means sleep. Nutrition. Stress management. And, this is the part that's still underused in most performance environments, integrating cognitive and visual training into regular performance work, not just as a rehab tool.
"From a rehab standpoint, we should be progressively loading the brain alongside the body — building resilience, not just waiting for symptoms to disappear."
That framing is important. Resilience. Not just recovery. The goal isn't an athlete who returns to where they were. It's an athlete whose brain, like the rest of their system, has been trained to handle more.
This conversation is part of the Impact IQ Series: Inside the Work — real conversations with elite practitioners on how performance is actually built.