Physiotherapy Treatment for Post-Concussion Syndrome (PCS)

By: Elias Peixoto, PT
March 25, 2024
Editors: Ryan Davey, PhD and Lindsay Davey, MScPT, MSc, CDT

The many faces of Post Concussion Syndrome symptoms.For some individuals concussion symptoms can persist long after their concussion event occurred. It’s not easy to predict who might go on to suffer prolonged symptoms, know as “Post Concussion Syndrome (PCS)”, but effective treatment options do exist. Below we’ll explain a little about concussions and the Physiotherapy treatment of Post Concussion Syndrome.

Concussion

Concussion is a common brain injury acquired most often through sport, falls, and car accidents. Concussions occur when there is blunt trauma to the head, any event that causes a whip-like recoil motion of the neck (such as being “rear ended” in a vehicle), or any large trauma to the body that shakes the head and neck. When the brain is quickly stretched or ‘jostled’ inside the skull in this way, physical and metabolic damage occur. Neurochemical changes in the brain during concussion cause an imbalance of ions like potassium and calcium along with a reduction in blood flow, and potential damage to neurons and axons – the functional cellular structures of the brain. All of this can leave an individual in a state of physical and mental fatigue along with a multitude of symptoms that can vary greatly between individuals.

While most symptoms will fade on their own, some people have persistent concussion-related symptoms for months or even years.  This prolonged condition is termed “Post Concussion Syndrome” or “PCS” and it can be treated with specialized Physiotherapy approaches.

What is Post Concussion Syndrome (PCS)?

Post concussion syndrome (PCS) is a defined as a condition where concussion symptoms persist, lasting on the order of weeks to months after the triggering event. Many people who have suffered a concussion progress to this state, and most need clear guidance on how to improve their symptoms and return to work, sport, or even day-to-day life. Approximately 90% of acute concussion symptoms resolve in the first 10-14 days following the initial injury. PCS can be thought of as a chronic concussion syndrome that persists for an extended period and that alters a broad range of normal brain functions.

PCS occurs in a subset of people who sustain a concussion; once estimated at 15%, current studies suggests that the true frequency of PCS may be far greater. Common symptoms include headache, dizziness, sleep impairment, and to a lesser extent anxiety or depression. Not surprisingly, PCS can have detrimental effects on and individual’s cognitive, behavioural, emotional, and physical function.

Lastly, because there can be damage to the brain tissue that connects the cortex to the vagal nerve, the body’s “autonomic” nervous system can be affected. This branch of our nervous system takes care of our ‘rest and digest’ and ‘fight or flight’ responses. This system influences many of our body’s automatic functions like blood pressure and heart rate. As a result, when this area of the brain is injured in a concussion, individuals with resulting PCS can experience prolonged headaches, dizziness, and exercise intolerance. Disruption to the autonomic nervous system is also likely in part responsible for any depression-like symptoms that some sufferers of PCS experience.

Who develops PCS?

Interestingly, there appears to be no strong correlation between the likelihood of developing PCS and the severity of the concussion event. In other words, having a ‘big’ concussion event doesn’t necessarily make you more susceptible to suffering from PCS then having a smaller concussion. This makes it more difficult to predict who might go on to develop PCS and increases the odds of missed PCS diagnoses in individuals who have suffered milder concussions. In our experience at our clinics, this results in delayed diagnosis and initiation of concussion rehabilitation and physiotherapy interventions.

Factors that do appear to increase the risk of developing PCS include being female, being of older age, and having a history of chronic pain.

Treatment for PCS

The most effective treatment for an individual with PCS can vary greatly from individual to individual. This is because concussion symptoms and contributing factors can also be so varied. The standard advice used to be that those suffering from concussion symptoms should limit all exposure to light, noise, exertion, and general stimulation. But not anymore. Thanks to a large and growing body of concussion research there has been a significant paradigm shift in the approach taken to treat concussion in recent years. In a nutshell, the era of advising everyone who sustains a concussion to sit and rest in a dark room for weeks on end is certainly behind us. The best evidence shows that 2 days is likely the ideal amount of time for complete rest after a concussion. After that, it is now recommended that a gradual approach to resuming physical and mental activities be initiated. This approach is found to be equally effective in athletes as well as the general population. Early return to physical activities could be as simple as starting a walking program, attending school or work for a portion of the day, or starting a light resistance exercise routine.

Physiotherapy treatment of Post Concussion Syndrome can help. A physiotherapist experienced in concussion rehabilitation can act as a meaningful resource for recovery. They will provide a thorough assessment to assess the scope and severity of PCS, and to tailor the most effective treatment path forward for the individual. The physiotherapist will monitor for symptoms throughout their assessment, and in some cases will need to assess the patient over multiple sessions if the patient’s tolerance is limited (which is common).

Below are the most frequent symptoms of PCS, along with a description of how physiotherapy can play a role in treatment:

  1. Neck Dysfunction. Stiffness and tension in certain areas of the neck can significantly contribute to headache and dizziness symptoms, so treating this area is highly beneficial to improving these features of PCS. Your physiotherapist will perform an evaluation of the cervical spine for any neck joint glide limitations, soft tissue guarding or spasm, range of motion limitation, compensatory postural features, and muscular weakness. Issues at the neck can be significantly improved with manual therapy, graduated and specific exercises, postural and pillow and ergonomic suggestions, and other dos and don’ts that can meaningfully help improve symptoms of this nature.
  2. Exercise/Activity Intolerance. This is a well studied and essential aspect to concussion recovery. Your physiotherapist will start by assessing for baseline tolerance to exercise/exertion. This can involve a treadmill walking test, use of a stationary bike, and/or specific exercises that are meaningful to the patient to include in their program. A tailored, graduated at-home exercise plan is designed which often involves a graduated walking program at first.
  3. Headache/Migraine Symptoms. Headaches are common in PCS and can arise from numerous contributing factors. Concussion headaches can be frontal and/or temporal in nature and are often triggered by cognitive challenges or activities where eye-tracking or visual stimulation is involved (such as walking along a busy street or staring at a screen). Disturbances in brain metabolism and high fatigue experienced following concussion can contribute to these types of headaches. If an ocular-motor dysfunction is present (eye-tracking tasks provoking headache, for example), treatment can involve retraining the ocular-motor system in a graduated way. This retraining is often incorporated into an at-home exercise program provided by the physiotherapist. Neck dysfunction can significantly contribute to headaches and migraines after concussion, and treatment of the neck with manual therapy and home exercises is highly effective.
  4. Cognitive Deficits. Difficulty with memory, organization of thoughts, and multi-tasking can be experienced in PCS. Reduced blood flow and metabolic changes in the brain after concussion injury is thought to be the primary cause, with headaches, fatigue, and neck pain also contributing to cognitive dysfunction in some individuals. Like the progressive return to physical activity, a gradual return to cognitive challenges is also recommended. This can include normal activities of daily living and may also include additional memory and organizational task homework, on a case-by-case basis.
  5. Dizziness, Vertigo and Vestibular Dysfunction. Dizziness is a symptom experienced in some individuals with PCS that can be caused by a combination of factors – neck dysfunction, ocular-motor dysfunction, and headaches. If dizziness persists despite concussion treatments for the above, it’s possible that there is a vertigo component to the dizziness. Vertigo is a particular type of dizziness classically described as the sensation of spinning – either the individual feels they are spinning, or that the world around them is. Vertigo is often provoked by a change in head or body position. Vertigo arising after concussion is often the result of inner ear (vestibular) dysfunction. Specialized physiotherapists trained in Vestibular Rehabilitation can assess and treat this particular type of dizziness. Click here to learn more about vestibular physiotherapy.

Post Concussion Syndrome Physiotherapy Treatment: In Summary

Physiotherapy treatment of Post Concussion Syndrome can be very effective.

Due to the variability of PCS symptoms, working with a physiotherapist experienced in PCS assessment and treatment is essential for effective and efficient care. Their assessment will document the symptoms and underlying features of your case. Since aspects of concussion testing can be aggravating to some patients, this assessment may need to be spread out over a couple of visits. Once your physiotherapist identifies the most prominent functional deficits (for example, exercise intolerance, neck motion limitation or pain, or dizziness) they will devise an appropriate treatment plan to address underlying causes. Treatment typically consists of hands-on care – a combination of manual therapy and exercises designed to retrain the neck, eyes, and balance systems again, as well as general cardiovascular re-conditioning and tailored guidance for a graduated return to activities.

We understand that managing post concussion symptoms can often be a prolonged and frustrating journey for those suffering from PCS. Thankfully, physiotherapy approaches have been shown to be highly effective in the treatment of concussion symptoms, particularly if initiated in the first few weeks after injury. A thorough assessment to identify the contributing factors at play, a balanced and customized rehabilitation program, and having open lines of communication between the rehabilitation team and the patient will ensure the smoothest path to recovery. The road may be winding when it comes to healing after longer-term concussion symptoms, but getting back to normal is possible with patience and hard work!

References

https://www.ncbi.nlm.nih.gov/books/NBK534786/

Concussion – The American Journal of Medicine (amjmed.com)

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6548833/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4995355/

Concussion Guidelines Step 2: Evidence for Subtype Classification – PMC (nih.gov)

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