Post Concussion Syndrome (PCS) is a condition that occurs in an estimated 10-15% of individuals who suffer a concussion. It is defined by persistence of concussion symptoms in the weeks, months or even years following the initial head injury. A concussion is considered a mild traumatic brain injury (mTBI) with or without loss of consciousness. There is no formal cure for PCS, but a holistic and individualized approach grounded in pacing strategies can aid in recovery and alleviate symptom severity and duration. If you or a loved one have ever suffered from a concussion or PCS, physical therapy can help address ongoing symptoms. This blog details what PCS is, what symptoms are usually prevalent and the treatment options available to alleviate symptoms and shorten recovery timeline.
Symptoms:
The DSM-IV bases diagnosis of PCS on “the presence of cognitive deficits in attention or memory and at least 3 of the following:
- Fatigue
- Sleep disturbance
- Headache
- Dizziness
- Irritability
- Affective disturbance
- Apathy or personality changes that persist for 3 months or longer”
Conversely, ICD-10 defines PCS as the above symptoms persisting for longer than 3 weeks. Other common symptoms of PCS include vision changes (especially with screentime), disturbances in balance, confusion, noise or light sensitivity, nausea and difficulty concentrating.
The pathophysiology of PCS is based in autonomic nervous system damage affecting both the sympathetic and parasympathetic nervous systems (and therefore has effects throughout the body). Cerebral blood flow can be affected, altering blood pressure and heart rate (HR). These changes cause a cascade effect resulting in dizziness, headache, confusion, poor concentration and fatigue. From a mental health lens, it is common for patients to also experience depression and anxiety (either new or heightened from baseline). As one can imagine, this symptom cluster can make daily activities, work demands and exercise very challenging.
Treatment
Treatment tends to be multidisciplinary and multifactorial depending on symptom qualities, severity and history of head injury or mood disorders. Neurologists may recommend cognitive therapy, vestibular and/or oculomotor therapy to address balance and dizziness, graded aerobic exercise to aid in oxygenation of the brain, psychological and behavioral therapy to address mood changes and physical therapy. A dietician consult may be warranted to support in brain healing, as well, since smart nutrition choices can reduce inflammation, support brain repair and improve cognitive function.
In the immediate interim following a concussion, screen time avoidance is highly advised, as well as practicing cognitive rest due to the increased risks of developing post-concussive syndrome. The broad recommendation based on existing research is to limit screen time based on symptom flares and only increase as tolerated. “To tolerance” is a vague term, but we advise our patients to check in throughout a triggering activity (e.g. watching television, talking to a friend on FaceTime, or computer work) and if they are experiencing >3-4/10 severity (with 10 being the most severe symptoms, 0 being asymptomatic), they should take a break to prevent symptoms from worsening.
The CDC guidelines for post-concussive care state that “return-to-work planning should be based upon careful evaluation of symptoms and neurocognitive status. To help expedite recovery from MTBI, patients may initially need to reduce both physical and cognitive exertion. Restricting work during initial stages of recovery may be indicated to help facilitate recovery.” They also advise individuals seek additional care if:
- “The symptoms worsen at any time,
- The symptoms have not gone away after 10-14 days, or
- The patient has a history of multiple concussions or risk factors for prolonged recovery. This may include a history of migraines, depression, mood disorders, or anxiety, as well as developmental disorders such as learning disabilities and ADHD.”
Physical Therapy Treatment
Most individuals are unaware that physical therapy can help address several symptoms of post concussive syndrome. While individual to the client, treatment tends to involve the following domains (if applicable based on patient presentation):
- Eye tracking interventions to address oculomotor deficits
- Oculomotor training is an evidence-backed intervention when symptoms include blurred vision, eye strain, difficulty focusing, headaches, or dizziness. These symptoms often stem from oculomotor dysfunction, which is common after concussion due to impaired coordination between the eyes and central nervous system.
- Specific dysfunction may be present in saccades (rapid eye movements), smooth pursuits (tracking moving objects), vergence (depth perception), accommodation (shifting focus from near to far), visual motion sensitivity (dizziness with movement or scrolling)
- Oculomotor training is an evidence-backed intervention when symptoms include blurred vision, eye strain, difficulty focusing, headaches, or dizziness. These symptoms often stem from oculomotor dysfunction, which is common after concussion due to impaired coordination between the eyes and central nervous system.
- Balance interventions to address vestibular deficits
- Just as oculomotor function can be affected by PCS, vestibular function can also be altered. Because balance involves an interaction of vestibular, visual, proprioceptive and central processing functions, you can imagine how stability can be affected following a head injury.
- Cervical strengthening and range of motion (often connected to headaches)
- Deep neck flexor strengthening: chin tuck variations are very commonly prescribed due to the evidence-backed benefits in reducing headache intensity and frequency
- In female athletes, stronger neck muscles have been associated with lower risk of concussion. Cervical strength may reduce head acceleration during impact
- Collins et al. (2014) – concussion risk decreased by 5% for every 1-lb increase in neck strength
- Energy conservation techniques: fatigue (both mental and physical) and cognitive overload are very common in individuals struggling with post-concussive syndrome (PCS). Strategies including pacing, scheduled rest, prioritization, planning and managing overstimulating environments via sensory regulation (eyewear, headphones etc.) are all recommended to manage overloading the brain and aid in work responsibilities (whether working following concussion or preparing for a return to work).
- Gradual return to aerobic exercise & heart rate monitoring
- This may involve heart rate testing via the Buffalo Treadmill Test and a graded exercise program to facilitate a safe return to sport
- Dysautonomia (dysregulation of the autonomic nervous system) is common in PCS cases due to healing brain regions that control heart rate, sweating, blood pressure and digestion. Common signs include: elevated resting heart rate, orthostatic intolerance, reduced heart rate variability and blunted heart rate response to exercise.
- Gall et al. found that concussed athletes had impaired HRV and delayed return to autonomic baseline post-injury.
- Leddy et al. found that sub-threshold aerobic exercise (exercise below symptom-exacerbation threshold) improved heart rate regulation and symptoms in PCS patients
- Screentime tolerance and graded exposure
- Screentime (phones, computers, tablets, TVs) can provoke and/or worsen PCS symptoms such as headaches, eye strain, blurred vision, dizziness, cognitive overload and fatigue. While screentime avoidance is recommended immediately following a concussion in the acute phase (24-48 hours after initial injury), gradual, graded reintroduction to tolerance is recommended in PCS cases to prepare for return to work and life responsibilities
- Screen intolerance typically occurs in individuals struggling with PCS due to visual-vestibular impairment, light sensitivity and cognitive overload
- Consider duration/volume, brightness, mode and complexity (text, videos, interactive task, etc) of screentime in the reintroduction process. Modifications to ease the transition include: blue light filters and glasses, adjusting text size and brightness and taking thoughtful breaks
- A 2021 study in The Clinical Journal of Sport Medicine reported that screen time over 2 hours/day in the first 48 hours post-concussion delayed recovery, but structured reintroduction improved tolerance later.
- Rehab for associated injuries sustained during initial head injury
- Rarely does a concussion occur in isolation and PT is typically indicated for any acute orthopedic injuries associated with the initial onset
- Return to work planning
- Because Physical Therapists are typically the healthcare provider spending the most time with patients consistently in their rehab process (aside from a potential psychologist or therapist), we are uniquely positioned to provide a return to work recommendation based on all the aforementioned domains to ensure a safe and appropriate return to work.
On evaluation, a patient is assessed for deficits in these domains and we create an individualized plan of care to address the most pertinent and bothersome symptoms.
Recovering from PCS requires a holistic, multidisciplinary and individualized approach. If you’re interested in working with us in PT to supplement your concussion recovery, reach out to us today for a free 15-minute discovery call or reach out to us at:
Perfect Stride Physical Therapy
32 Union Square East, Suite 215
New York, NY 10003
Phone: 917-494-4284
Email: info@perfectstridept.com
Resources:
Managing return to activities. Centers for Disease Control and Prevention. Available at: https://www.cdc.gov/heads-up/hcp/clinical-guidance/?CDC_AAref_Val=https%3A%2F%2Fwww.cdc.gov%2Fheadsup%2Fproviders%2Freturn_to_activities.html (Accessed: 29 April 2025).
Permenter CM, Fernández-de Thomas RJ, Sherman AL. Postconcussive Syndrome. [Updated 2023 Aug 28]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK534786/
Macnow T, Curran T, Tolliday C, et al. Effect of Screen Time on Recovery From Concussion: A Randomized Clinical Trial. JAMA Pediatr. 2021;175(11):1124–1131. doi:10.1001/jamapediatrics.2021.2782
Mucha A, Collins MW, Elbin RJ, Furman JM, Troutman-Enseki C, DeWolf RM, Marchetti G, Kontos AP. A brief vestibular/ocular motor screening (VOMS) assessment to evaluate concussions: preliminary findings. Am J Sports Med.2014;42(10):2479-2486. doi:10.1177/0363546514543775
Leddy JJ, Haider MN, Ellis MJ, Willer BS. Exercise is medicine for concussion. Curr Sports Med Rep. 2018;17(8):262-270. doi:10.1249/JSR.0000000000000505
Gall B, Parkhouse W, Goodman D. Heart rate variability of recently concussed athletes at rest and exercise. Med Sci Sports Exerc. 2004;36(8):1269-1274. doi:10.1249/01.MSS.0000135788.73706.9C
Ciuffreda KJ, Rutner D, Kapoor N, Suchoff IB, Craig S, Han ME. Vision therapy for oculomotor dysfunctions in acquired brain injury: a retrospective analysis. Optometry. 2008;79(1):18-22. doi:10.1016/j.optm.2007.10.011
Heyer GL, Idris SA, Schaffer CE, Hague CM. Relationships of athletic identity and concussion history to persistent post-concussive symptoms in youth. J Neurotrauma. 2016;33(9):787-792. doi:10.1089/neu.2015.3910
