When Your Athlete's Post-Injury Scores Look Fine but They Still Feel Terrible: The Limits of Baseline Comparison

It is entirely possible — and not uncommon — for a concussed athlete to produce post-injury cognitive test scores that appear normal relative to their baseline while still experiencing significant, debilitating symptoms. Understanding why this happens is essential for safe concussion management.

Cognition isn’t everything

Cognitive testing captures one domain of brain function: processing speed, memory, and attention. But concussion affects multiple systems. An athlete might have fully recovered cognitive processing while still experiencing vestibular dysfunction (dizziness when turning their head), oculomotor problems (difficulty reading, tracking moving objects, or focusing at near distances), cervicogenic symptoms (headache originating from neck injury that co-occurred with the concussion), emotional dysregulation (irritability, anxiety, mood lability), or persistent sleep disruption. None of these deficits will show up on a cognitive test like ImPACT.

The six trajectories

Research by the UPMC Sports Medicine Concussion Program — published by Collins et al. in the American Journal of Sports Medicine— has identified six distinct clinical trajectories for concussion: cognitive/fatigue, vestibular, ocular, post-traumatic migraine, cervical, and anxiety/mood. An athlete on the “vestibular” trajectory may have perfect cognitive scores but severe functional impairment. An athlete on the “anxiety/mood” trajectory may have normal cognition and balance but be experiencing debilitating emotional symptoms.

Why multi-domain assessment matters

This is the strongest argument for multi-domain baseline testing and multi-domain post-injury assessment. If the only tool available is a cognitive test, a clinician might reasonably (but incorrectly) conclude that recovery is complete when cognitive scores return to baseline. Adding VOMS, balance testing, and symptom tracking creates a more complete picture — one that captures the domains where impairment may persist even after cognition normalizes.

Our approach to clearance

At Headquarters, we never clear an athlete based on a single domain. Recovery means return to baseline performance across all tested domains, combined with symptom resolution at rest and under exertion. The data has to match the person’s experience.

Frequently asked questions