Beyond the Injured Brain: Integrated Physiological Regulation as a Framework for Recovery after Sport-Related Concussion

Care for sport-related concussion is organized largely around one question: is it safe to return to play? The graded return-to-play protocol answers that question well and has made sport measurably safer. Yet an important clinical problem remains. Some athletes complete every stage, are medically cleared, and still do not return to their previous level of performance. This paper argues that part of the explanation lies in how concussion is conceptualized. Rather than an injury confined to the brain, concussion disrupts multiple interacting physiological systems, including brain energy metabolism, autonomic function, cerebral blood flow, neuroendocrine function, breathing, and sleep. Taken together, these disturbances suggest that recovery is the restoration of integrated physiological regulation, and that symptom resolution alone may not demonstrate its recovery. The paper advances three testable and falsifiable hypotheses centered on this concept. It argues that current concussion care lacks a framework for characterizing and monitoring integrated physiological regulation across recovery, and proposes Distemperantia Allostatica Onerosus (DAO) as one candidate operational framework for addressing that gap. DAO is presented as a hypothesis for prospective scientific evaluation rather than as a validated clinical tool.