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Treating Post-Concussive Syndrome: systems affected, why balance/vision suffer, and what evidence-based PT looks like

What is a concussion?

A concussion is a mild traumatic brain injury caused by biomechanical forces (direct or indirect) that trigger a neurometabolic cascade—a functional disturbance more than a structural lesion. Symptoms can involve physical, cognitive, vestibulo-oculomotor, sleep, and mood domains, and recovery is heterogeneous. Current international guidance emphasizes early, guided activity over strict rest and a targeted, impairment-based approach.British Journal of Sports MedicineJOSPT

Which systems are affected?

1) Vestibular system (peripheral + central)

Concussion frequently disrupts the vestibular pathways (including the VOR), producing dizziness, visual motion sensitivity, imbalance, and gait instability—key drivers of delayed recovery.PMC

2) Oculomotor/visual system

Convergence insufficiency, accommodative deficits, saccadic/pursuit abnormalities, and visual motion sensitivity are common. These vestibular/ocular symptoms relate to functional limitations and can predict slower recovery trajectories.Oxford AcademicSpringerLink

3) Cervical spine (proprioception + pain generators)

Cervical injury can contribute to headache, dizziness, postural dysfunction, and impaired joint position sense (JPS). Assessment/training often uses head-mounted laser relocation tasks to quantify and retrain cervical kinesthesia.PMC

4) Autonomic/physiologic dysregulation

Some patients develop exercise intolerance (impaired cerebrovascular/autonomic control). Sub-symptom threshold aerobic testing (e.g., Buffalo Concussion Treadmill Test) profiles tolerance and guides graded exercise.PMCBritish Journal of Sports Medicine

Why do balance and visual processing suffer?

Balance depends on vestibular, visual, and somatosensory integration. After concussion, VOR inefficiency, oculomotor deficits (e.g., convergence insufficiency), and altered cervical afference degrade sensory integration; the result is dizziness, blurred/unstable vision with head movement, and impaired postural control—especially in visually complex environments.Oxford AcademicPMC

What are clinicians doing now? (Best-evidence overview)

1) Education + relative rest (24–48 h) → early, symptom-limited activity

Contemporary guidance discourages prolonged “cocooning.” After brief relative rest, patients progress to light activity below symptom threshold and follow a graded return-to-learn/play pathway.British Journal of Sports MedicineJOSPT

2) Sub-symptom threshold aerobic exercise

Systematic reviews and CPGs support aerobic exercise started early (as tolerated) to reduce symptoms and speed recovery versus rest-only care. A 2023 systematic review of RCTs in athletes showed aerobic or multimodal PT approaches shortened recovery and reduced symptoms.PMC

3) Vestibular rehabilitation

Targeted gaze stabilization (VOR x1/x2), habituation, balance & gait tasks, and BPPV maneuvers (when indicated) improve dizziness and balance in persistent post-concussion cases. Evidence includes RCTs and systematic reviews (including adolescent cohorts) showing benefit of precision vestibular rehab and vestibular therapy programs.Journal of PediatricsMDPI

4) Oculomotor/vision therapy (with referral when needed)

Interventions addressing convergence, accommodation, saccades, pursuits and vestibulo-ocular interaction are increasingly integrated, with ongoing trials to refine protocols/dosage; referral to neuro-optometry when deficits persist is recommended.Digital Commons

5) Cervical spine manual therapy + proprioceptive retraining

A landmark RCT showed cervicovestibular physiotherapy (manual therapy, DNF control, proprioceptive training) plus graded exercise led to faster medical clearance versus control in athletes with persistent symptoms. Objective JPS training with a head-mounted laser is part of best practice.British Journal of Sports MedicinePMC

The JOSPT 2020 PT CPG and updated consensus endorse individualized programs combining the elements above; multimodal PT outperforms rest and aligns with faster functional recovery.JOSPTPMC

 

How MotionGuidance® fits (clinician-designed visual feedback drills)

BASH-N™

BASH-N™ is an acronym to assist in organizing and applying somatosensory exercises to post-concussive rehab, that involves key areas of dysfunction.

👉 “BASH-N” → “BASH-N dizziness.”

BASH-N™ stands for:

  • Balance

  • Adaptation

  • Substitution Strategy

  • Habituation

  • Neck Proprioception

 

***where does visual convergence fit in?

 

Lets go through all 5 key areas, with examples of how to perform a drill that challenges this specific skill.

KEEP IN MIND:

We are huge proponents of patient specific care. The BASH-N Concept is designed to give structure to treatment ideas that are Some patients develop exercise intolerance (impaired cerebrovascular/autonomic control). Sub-symptom threshold training is recommended. This means performing the exercise in bouts that starts to reproduce mild symptoms, and then stopping and resting.

 

B: Balance and Gait Training: Combining vestibular and occulomotor

Below are ideas on challenging balance with real time feedback to performance. General progressions move from:

  • Static balance: standing with narrow base, foam surface, eyes closed. Closing eyes helps remove outside stimulus, to keep things tamed down.

  • Dynamic balance: tandem walking, walking with head turns, dual-task balance activities. Here is where adding visual feedback is a great addition. Have the user marching on foam, while doing butterfly motions on the tracking grid, our reacting to random interactive pods as they light up with MG-INTERACTIVE.

  • Progressed to sport-specific or higher-level mobility tasks when tolerated. This may be adding strobe visual manipulation while playing interactive games, dribbling a ball, handling a puck or (insert athlete task here) while also reacting to interactive pods as they light up, or hitting called out numbers on the clock.

A: Gaze Stabilization (Adaptation Exercises): Treating impaired oculomotor/visual system

  • VOR x1 and VOR x2: patient focuses on a stationary or moving target while moving the head horizontally/vertically.

  • Progression: start seated → standing → walking; increase speed and duration (typically 1–2 min sets, multiple times daily).

 

S: Substitution Strategies: Combining vestibular and occulomotor

  • Use of visual and somatosensory cues to compensate for vestibular deficits that are not responding to adaptation or habituation exercises. substitution strategies can be designed for individuals who have difficulty maintaining balance or postural control after head trauma — meaning their vestibular system wasn’t adequately compensating on its own.

  • Substitution strategies aim to “replace” or compensate for the missing or reduced vestibular input by training other sensory systems to help maintain balance and spatial orientation. In other words, Substitution strategies can be task-based balance and mobility exercises designed to help patients with unsteadiness retrain their brain to use visual and somatosensory input to compensate for impaired vestibular function.

    In vestibular science terms:

    • When vestibular reflexes (like the vestibulo-ocular or vestibulo-spinal reflex) are impaired, the brain learns to rely more on vision and somatosensory (proprioceptive) feedback.

    • Substitution exercises encourage the central nervous system to use these alternate cues more effectively for postural stability and gaze control.

  • Examples: eye–head coordination tasks, using visual fixation with latent head movement, stepping with head turns. True substitution of MGI targets, Eyes first then head movements. Infinity walking.

 

H: Habituation Exercises: Treating impaired vestibular system (peripheral + central)

  • Repeated exposure to symptom-provoking head or body movements (e.g., bending forward, turning head quickly, sit-to-stand).

  • Goal: reduce motion sensitivity by graded repetition

 

N: Neck Proprioception and ROM: Treating impaired cervical spine with manual therapy + proprioceptive retraining

 

  • Stretching and mobilization for restricted cervical range.

  • Integration of neck proprioceptive exercises (head repositioning tasks)



BASH-N™

 

Category

Primary Goal

Physiologic Mechanism

Example Exercises

Clinical Emphasis / When to Use

  

BALANCE

Rebuild postural stability and confidence in dynamic environments

Improves vestibulo-spinal reflex (VSR) and central sensory integration of visual, somatosensory, and vestibular inputs

Foam stance, tandem, or single leg + butterfly tracing with MG, dialing out numbers, or moving head toward interactive pods.

For patients with instability, gait deficits, or fear of falling

  

ADAPTATION (gaze stability)

Improve ability to keep eyes stable during head motion

Promotes vestibulo-ocular reflex (VOR) recalibration — strengthens residual vestibular input and neural adaptation in the brainstem and cerebellum

VOR x1 (eyes on bullseye moving head/laser from 9-3;

VOR x2 (look at 9, bring laser to 3); visual tracking (butterfly);

For patients with blurred vision, oscillopsia, or dizziness when moving head

  

SUBSTITUTION

Teach the brain to rely on other senses to compensate for vestibular deficits

Enhances visual and somatosensory (proprioceptive) substitution for balance and orientation

Standing eyes closed, walking with head turns, narrow-base walking,

catching/throwing ball, walking on soft surfaces

For patients with vestibular loss or unsteadiness; when adaptation is limited

  

HABITUATION

Reduce dizziness triggered by specific movements or environments

Uses central desensitization — repeated exposure to motion stimuli decreases over-responsiveness in vestibular pathways

Repeated sit-to-stand, bending forward, head turns, rolling in bed, positional changes

For patients who report motion sensitivity, nausea, or dizziness with specific triggers

  

NECK / Proprioceptive Training

Restore accurate head–neck position awareness and reduce cervicogenic dizziness

Retrains neck joint and muscle proprioceptors that coordinate with vestibular and visual systems

Deep neck flexor activation, joint position error correction, head repositioning tasks, gentle cervical mobility and manual therapy

For patients with neck pain, stiffness, or mismatch between head movement and gaze stability

  

Sample progression (PCS with dizziness + neck pain)

  1. Phase 1 (symptom-limited): Buffalo-style walk/bike, cervical JPS laser relocation, seated VOR x1 with laser target.PMC

  2. Phase 2: Banner tracing with head turns; stance → foam; NS2 pods on wall with laser activation for visual-motor targeting while maintaining posture.

  3. Phase 3: Dynamic balance (BOSU/foam), dual-task pods (reaction + head movement), then sport-specific exertion below threshold; progress to RTP criteria per consensus.British Journal of Sports Medicine

Want to go deeper?

sources 

  • International Consensus (Amsterdam 2022/23): early activity, domain-specific rehab, updated RTP.British Journal of Sports Medicine

  • JOSPT PT CPG (2020): evaluation & impairment-targeted interventions; relative rest then graded activity.JOSPTneuropt.org

  • Systematic review (2023, IJSPT): aerobic/multimodal PT improves symptoms & time to recovery in athletes.PMC

  • RCT (J Pediatr 2021): precision vestibular rehab improves adolescent outcomes with vestibular impairment.Journal of Pediatrics

  • RCT (BJSM 2014): cervicovestibular PT speeds medical clearance in persistent post-concussion symptoms.British Journal of Sports Medicine

  • Conceptual model (IJSPT 2017): vestibulo-ocular, cervical, and exertional domains; head-mounted laser for JPS.PMC

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