The 4-Photo Concussion Protocol That Standard Tests Miss

A Novel mTBI and Concussion Screening Protocol

Shake a bell, the clapper hits the inner surface and the bell rings. Quickly decelerate a head, as occurs in auto accidents and sports impacts, the brain moves, potentially slamming into the inner skull. As with a bell, your seat of consciousness becomes the clapper and your world rings. Neurons stretch, or along with tiny blood vessels, tear—and the ringing goes on, sometimes forever.

Brains process information in and send information out. That’s essentially their function. Scrambling these neural messages can be a minor problem, like a misspelled word easily overlooked, or a much bigger problem, like trying to make sense of words scrambled into different order on a page.

When symptoms are minor, it’s classified as mTBI (Minimal Traumatic Brain Injury). When more severe, a full concussion. Either way, it’s a far more serious problem than most people realize. The old “tough it out” approach is not only outdated—it’s dangerous.

The Hidden Reality of “Minor” Brain Trauma

“Minor” brain trauma isn’t minor at all. Neurologic trauma doesn’t heal simply when symptoms disappear. Without sufficient time and proper care, the effects of brain trauma become cumulative, and small changes easily compound into major problems.

Consider the evidence: Top athletes like boxing legend Mohammed Ali, along with thousands of NFL players, have suffered the devastating consequences of repeated “minor” brain trauma. One landmark study of deceased NFL players found 99% had Chronic Traumatic Encephalopathy (CTE). Even among college, semi-pro and high school athletes, CTE rates ranged from 21% up to 91%*.

Current Screening Tools Fall Short

While new helmet technology helps prevent initial injury, existing concussion screening tools have significant limitations. Current protocols include the BESS (Balance Error Scoring System) and Sensory Organization Test (SOT), which use force plate technology and VR headsets to test neurologic disconnects between true and virtual reality. These tools evaluate balance as an indicator of brain dysfunction by identifying errors between sensory perception and motor output—our moment-to-moment dance to stay vertical.

However, these assessments often lead to disagreements and unclear judgment calls about when athletes can safely return to activity. Each person’s unique physiology and recovery pattern makes standardized cutoffs problematic. This is where photographic postural assessment becomes crucial—and why a novel protocol integrating interoception offers a no-cost way to benchmark and screen for mTBI.

The Science Behind Interoceptive Assessment

The interoceptive system represents the fourth sensory system involved in posture and balance. Alongside proprioception, interoception informs the brain about the body’s internal spatial relationships. Sherrington first differentiated exteroceptive senses (vision, hearing, touch) from interoceptive ones like hunger and thirst.

Over the past two decades, fMRI, PET, and other imaging technologies have sparked an explosion of research focused on the insula (the cortical center of interoception), the vagus nerve, and clinical applications for psychological and mind-body medicine.

The insula, sometimes called the “hidden sense,” plays a crucial role in both energy management and postural control. As the only mammalian obligate bipeds, humans require exceptional neural control to manage energy efficiently—a key evolutionary development in which the insula plays a pivotal role in keeping us upright and maintaining both physical and emotional equilibrium.

Introducing the Interoceptive Posture Picture (IPP)

An Interoceptive Posture Picture (IPP) consists of four standardized photographs that capture how an individual perceives the relative position of their postural body masses with respect to true vertical. This novel protocol, published in Frontiers of Neuroscience in 2024, provides insight into interoceptive perception and serves as a tool to determine if someone has truly returned to their neurological baseline—even when they appear symptom-free.

The Four-Zone Framework

Human posture involves four zones of postural mass (ZPM, also known as the 4 PostureZones®) that must be continuously coordinated relative to each other, gravity, and the environment:

Head (ZPM4) – The control center for visual observation
Torso (ZPM3) – Drives upper extremity positioning
Pelvis (ZPM2) – The foundation that determines torso location
Lower Extremities (ZPM1) – The mobile base supporting the entire structure

Efficient bipedal gait requires alternating single-leg balance of the whole body and operates most efficiently when the ZPMs align toward center. The computational demands of bipedal control explain why the human brain, though only 2% of body mass, consumes 20% of the body’s total energy.

The IPP Protocol: Four Simple Photos

The IPP protocol consists of four standardized photographs taken against a grid background:

Frontal Bipedal View – Standing tall with relaxed posture, centered to a dot aligned with the grid centerline
Lateral Bipedal View – Side view to assess forward head posture and lateral ZPM positions
Left Single Leg Stance (SLS) – Frontal view balancing on left leg with right thigh raised
Right Single Leg Stance (SLS) – Frontal view balancing on right leg with left thigh raised

The standardized grid background allows visualization of how individuals position their four ZPMs in space relative to the centerline. The grid serves as a gravity line proxy, while the IPP represents interoceptive perception and expression of postural symmetry.

4-Photo-Concussion-Protocol-Standard-Test

Clinical Red Flags for mTBI Screening

Grossly asymmetric and incongruent patterns of ZPM alignment during single-leg stance indicate asymmetric motor control and inefficient energy management by the brain’s neurokinetic network.

Key Screening Indicators:

Lateral body lean during single-leg stance
Contralateral leg midline crossover indicating compensatory effort
Marked asymmetry in ZPM alignment patterns between left and right sides
Asymmetric whole-body balance between sides

Like blood pressure provides a snapshot of arterial health that motivates better lifestyle choices, an IPP can enhance clinical communication by facilitating discussion of physical structure and unconscious compensatory movement patterns.

Why This Revolutionizes Concussion Management

The IPP provides a non-pathologizing biomechanical reference of an individual’s unique static standing posture against a standardized background, potentially strengthening subjective awareness of body positioning in space.

Traditional concussion assessments frequently miss subtle neurological changes that persist after obvious symptoms resolve. The IPP can benchmark interoceptive postural awareness and accuracy (IPA&A) while building greater multi-sensory awareness of optimal biomechanical alignment.

Clinical Benefits:

Objective documentation of postural patterns
Rehabilitation progress tracking
Identification of asymmetries indicating incomplete recovery
Visual feedback for patient education
Data-driven support for return-to-play decisions

Implementation Across Healthcare Settings

The IPP protocol represents a significant advancement in concussion screening because it:

Requires no expensive equipment
Can be performed in any clinical setting
Provides both objective and subjective assessment data
Tracks often-overlooked interoceptive aspects of brain function
Offers a standardized approach to postural assessment

A Call to Action for All Practitioners

For Rehabilitation Professionals: Investigate integrating IPP into initial assessments and progress tracking protocols.

For Sports Coaches and Trainers: Consider implementing IPP for pre-season baseline testing and post-injury clearance decisions.

For All Practitioners: Abandon the outdated approach of waiting for symptoms to disappear. Like chronic conditions, concussion involves reinforcing cycles of physical, cognitive, and emotional factors requiring multidisciplinary biopsychosocial collaboration to prevent chronicity.

Healthcare providers should incorporate protocols that promote self-efficacy and strengthen somatic body awareness for positive behavioral change. Evidence-based approaches like Yoga, Tai Chi, and clinical StrongPosture® protocols that focus interoceptive awareness toward objective symmetry warrant investigation.

The Bottom Line

By incorporating IPP screening into standard concussion protocols, healthcare providers can:

Better identify subtle neurological deficits
Make more informed return-to-activity decisions
Provide patients with objective recovery feedback
Reduce the risk of cumulative brain trauma

The brain isn’t a bell that simply stops ringing—it’s a complex network requiring sophisticated assessment to ensure true neurological recovery. The IPP protocol offers a practical, evidence-based tool to make that assessment more accurate and actionable.

KEY REFERENCES

For more information about the IPP protocol and implementation guidelines, refer to:
Weiniger SP & Schilaty ND (2024) Interoceptive posture awareness and accuracy: a novel photographic strategy towards making posture actionable. Front. Neurosci. 18:1359594.

*Mez J, Daneshvar DH, Kiernan PT, et al. Clinicopathological Evaluation of Chronic Traumatic Encephalopathy in Players of American Football. JAMA. 2017;318(4):360–370.