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