Post-concussion syndrome is the stretch after a concussion when symptoms linger long past the initial hit. Some people recover in a couple of weeks. Others wrestle with headache, dizziness, brain fog, light sensitivity, sleep disruption, neck pain, and anxiety for months. A few arrive in a physical therapy clinic feeling off-balance every time they turn their head in the grocery aisle, or like their eyes can’t keep up with the car’s motion at a stoplight. The story is familiar: a seemingly mild injury, clear head CT, then weeks of not feeling right.
Physical therapy services have matured a great deal in this space. Ten years ago, many patients were only told to rest and wait it out. Today, rehabilitation for post-concussion syndrome is far more specific. Therapists trained in vestibular, oculomotor, cervical spine, and exertional rehab know how to nudge the nervous system back toward normal. The work is careful, symptom-limited, and personalized, and it often succeeds where time alone has stalled.
What post-concussion syndrome means in day-to-day life
No two cases look the same. One patient complains that reading is miserable because words “swim” on the page. Another can’t handle fluorescent lights and feels nauseated in busy environments. Someone else sleeps 12 hours yet wakes exhausted and irritable. All of these can trace back to lingering changes in how the brain, inner ear, eyes, and neck coordinate movement and sensory input.
Symptoms frequently cluster. A stiff, painful neck aggravates headaches and alters balance reflexes. Eye tracking that is a half-beat slow makes grocery aisles look like a waterfall of motion. Reduced exercise tolerance causes deconditioning, then even small tasks feel draining. When this hits at once, it becomes hard to know where to start. A doctor of physical therapy with concussion training knows how to separate the threads, test each system, and set a sequence that moves the whole picture forward.
Why physical therapy belongs in post-concussion care
Concussion is a metabolic and functional injury. While rest matters in the first days, lingering symptoms usually reflect treatable dysfunctions across several systems. Rehabilitation can:
- Identify the specific drivers of symptoms, such as impaired vestibulo-ocular reflex, cervical joint hyperalgesia, or exertional intolerance, and target them with measured interventions. Progress activity safely, using objective thresholds to avoid crash-and-burn cycles.
In practical terms, PT bridges the gap between what imaging cannot show and what daily life demands. A skilled clinician tests how the eyes move, how the head and neck contribute to dizziness, whether balance sways abnormally with eyes closed, and how heart rate behaves during sub-symptom exercise. Each finding becomes a treatment lever.
The initial evaluation: what a thorough assessment looks like
A complete post-concussion examination is not a five-minute screen. Expect 60 to 90 minutes for a first visit at a physical therapy clinic that specializes in this work. The history matters more than most realize, including details that can seem trivial: the sound of the hit, the first symptoms, sleep patterns, what worsens headaches, prior neck issues, work tasks, and screen habits. Good therapists also ask about migraine history, learning differences, and prior concussions, all of which can influence recovery.
Testing usually includes:
- Cervical spine examination. Therapists check joint mobility, muscle tone, trigger points, and nerve tension. They screen for cervicogenic headaches and cervicogenic dizziness, which can mimic vestibular problems yet respond to different treatments. Vestibulo-ocular assessment. This includes smooth pursuit, saccades, vestibulo-ocular reflex (VOR), dynamic visual acuity, head impulse testing, and gaze stability. The patient’s symptoms during these tests matter as much as performance. Balance and sensory integration. Standing with feet together, in tandem, on firm and compliant surfaces, eyes open and closed, often with head turns. Postural sway can reveal visual dependency or vestibular underweighting. Oculomotor and visual comfort. Convergence, accommodation, and near point of convergence are measured. Light sensitivity and reading endurance are documented. Physiologic exertion tolerance. A graded heart rate test, often on a treadmill or bike, identifies the threshold where symptoms escalate. Common tools include a modified Buffalo Concussion Treadmill Test. The idea is not to push hard on day one, but to find safe, repeatable parameters for sub-symptom exercise.
The evaluation sets the hierarchy. If the neck is generating most of the pain and dizziness, start there. If exertion triggers a symptom spike at low workloads, build an aerobic base early. If eye strain dominates, prioritize short, precise oculomotor drills and environmental adjustments. A doctor of physical therapy weighs these trade-offs in the context of the patient’s goals and daily demands.
Treating the cervical spine without lighting up symptoms
Neck issues hide in plain sight after concussion. The whiplash mechanism is common even when the primary concern is the head hit. Cervical nociception can perpetuate headaches and dizziness and change how vestibular inputs are interpreted. Treatment blends gentle manual therapy, mobility work, and progressive strengthening.
Manual therapy is not about “cracking” a neck back into place. Think graded joint mobilizations to calm irritability, soft tissue work to reduce guarding in the suboccipitals and upper trapezius, and sustained natural apophyseal glides if indicated. Mobilizations are followed by movement restoration: deep neck flexor activation, scapular control, and thoracic extension drills. Early sessions use short bouts with long rests. The aim is to reduce the perception of threat in the system, not to chase a fleeting release.
One caution: symptom flares can occur if strengthening progresses faster than tolerance. A therapist tracks latency, not just immediate response. If dizziness spikes two hours after a session, the dose was too high. Adjustments might include fewer repetitions, slower tempo, or more support from the thoracic spine and scapula before loading the neck.
Vestibular and oculomotor rehab: the careful art of dosing
Dizziness and visual motion sensitivity often improve with targeted exercises, provided the dose is precise. Two patients may present the same on paper yet react differently to the same drill, which is why a stock home program copied from a handout rarely works.
Gaze stability is a cornerstone. VOR x1 exercises, where a patient keeps eyes on a fixed target while turning the head side to side, can rebuild the reflex that stabilizes vision. In the early stages, the arc is small and the speed slow. The test for a correct dose is whether symptoms rise slightly yet return to baseline within minutes after stopping. If symptoms spike and linger, the dosage is too high.
Saccade and pursuit work addresses quick eye movements and smooth tracking. Therapists may use metronomes or letter charts to add structure. Convergence and accommodation drills are added when reading and near work trigger fatigue or headaches. Prism or tinted lenses are sometimes considered in collaboration with neuro-optometry, but in many cases the right exercise plan reduces the need for optical aids.
Surface and environment matter. Practicing gaze stabilization while seated on a stable chair is not the same as standing on foam in a busy clinic with patterned walls. Therapists adjust one variable at a time. When people “fail” vestibular rehab, the culprit is often progression that jumped two or three variables at once. Better to progress background complexity, head speed, and stance gradually and separately.
Balance training that reflects real-world demands
Balance is a negotiation between vision, vestibular input, and somatosensation. After concussion, many patients lean hard on vision. They stand well with eyes open, then sway dramatically with eyes closed. Physical therapy nudges the system back to a balanced weighting of inputs.
The therapist starts simple and patient-specific. A patient who hikes may practice uneven surfaces, head turns, and scanning. A parent who navigates playgrounds may practice quick direction changes while tracking a moving object. Rather than performing novel circus tricks, good balance rehab recreates the contexts that provoke symptoms, then breaks them down into tolerable parts. Progress often feels too easy at first, which is exactly the point. Consistency at low irritation levels builds confidence and capacity.
Aerobic reconditioning and autonomic regulation
Many with post-concussion syndrome have a narrow window for exertion. Heart rate climbs too quickly. Symptoms flare unpredictably. A sub-symptom aerobic program can widen that window.
A typical plan starts with a treadmill or bike at a heart rate set about 10 beats below the symptom threshold found in testing. Sessions run 15 to 20 minutes initially, five to seven days per week, with gradual weekly increases in duration or intensity. Over several weeks, the threshold often rises. Patients notice less fatigue with daily tasks and better sleep quality. The work is not glamorous, but it is one of the most reliable levers for recovery.
Hydration, salt intake, and compression garments sometimes help those with orthostatic intolerance or POTS-like symptoms. These recommendations should be coordinated with the medical team. A physical therapist can track responses, but medication and diagnostic decisions belong with the physician.
Headaches, light sensitivity, and screen tolerance
Headaches are not one thing after concussion. Migrainous features respond to paced activity, regular meals, hydration, sleep hygiene, and sometimes medication prescribed by the physician. Cervicogenic headaches improve with neck treatment and postural endurance. Visual trigger headaches often yield to targeted oculomotor work and environmental adjustments.
Light sensitivity can be stubborn. Tinted lenses or gradual light exposure protocols help some, hinder others. Rather than chasing a single fix, therapists often pair short, structured screen sessions with breaks and visual rest strategies. High-contrast screens, larger fonts, matte screen protectors, and steps to reduce flicker or glare can make a https://blogfreely.net/comyazwapv/how-pain-management-practices-use-imaging-to-guide-post-crash-care practical difference. The rule of thumb is to change one variable at a time and record the impact.
Daily rhythms, sleep, and the cognitive load problem
Rehabilitation does not happen only in the clinic. The day’s rhythm either supports or undermines the process. Patients who push hard when they feel good, then crash for two days, tend to progress unevenly. A steadier approach works better: consistent wake and sleep times, planned activity blocks with short breaks, and limits on high-demand cognitive work until tolerance grows.
The best programs include brief education about cognitive load. For example, a 30-minute phone meeting with multitasking might count as a high-physiologic load if it also requires visual tracking and quick decision making. Recognizing these invisible loads helps patients plan their day and prevent setbacks.
Progress markers that matter
Numbers guide the process. Reliable changes look like this: the near point of convergence moves closer by a few centimeters across weeks, dynamic visual acuity improves by a line or two, the sub-symptom heart rate threshold rises by 5 to 15 beats per minute, and balance becomes steadier in previously provocative positions. Subjectively, grocery shopping feels tolerable, driving provokes less dizziness, and reading endurance expands from 5 minutes to 15, then to 30.
Setbacks will happen. They rarely mean the plan failed. Most are explained by life events, poor sleep, unplanned stress, illness, or an enthusiastic leap in activity. The response is straightforward: dial back to the last tolerable level for a few days, then resume progression.
The role of interdisciplinary care
A doctor of physical therapy is a key part of the team, not the whole team. Primary care or sports medicine physicians oversee the medical side, rule out red flags, and address headaches, mood, and sleep medically when needed. Neuro-optometrists assist when visual deficits are pronounced or stubborn. Psychologists or counselors help with anxiety, depression, or the stress that often accompanies long recoveries. Occupational therapy becomes relevant when return to work requires task-specific cognitive strategies.
Good communication among providers shortens recovery. A simple shared plan, even if only a one-page summary, prevents mixed messages and keeps progression consistent across domains.
Return to school, work, and sport
Graduated return is more art than script. With students, the plan might start with partial days, limited screens, and printed materials, then expand as tolerance increases. For desk workers, small shifts can help: scheduled visual breaks, headset use to reduce auditory load, lower brightness settings, or rearranged meeting times. Employers usually accept a clear, time-limited plan signed by the healthcare team.
Athletes follow staged progression that respects exertion tolerance and symptom response. Light aerobic work comes first, then sport-specific drills without contact, then controlled practice. Contact or high-risk activities only return when symptoms are absent at rest and with exertion, and when vestibular, oculomotor, and cervical assessments are stable. Coaches and trainers appreciate clear guardrails and objective checkpoints, such as symptom logs and heart rate targets.
Edge cases and pitfalls that complicate recovery
Not every case fits neatly into the typical pattern. Consider a patient with a pre-existing migraine disorder. They may need slower progression and migraine-specific strategies alongside PT. Another patient with a history of neck hypermobility might worsen with aggressive manual therapy and instead respond to stabilization, proprioceptive training, and gentle mobility.
Sometimes anxiety becomes the dominant limiter. The fear of symptoms can tighten the nervous system and produce the very dizziness someone dreads. In these moments, the therapist’s job shifts toward pacing, reassurance grounded in data, and gradual exposure to feared movements. If rumination or panic makes progress impossible, referral for cognitive behavioral therapy is not a sign of failure, but a smart step.
There are also red flags that push the therapist to refer back to the physician promptly: progressive focal neurological deficits, severe worsening headaches, repeated vomiting, seizure activity, or sudden changes in mental status. Most patients do not show these signs, but vigilance protects the few who do.
What a typical week of therapy looks like
Frequency depends on needs. Many patients start with weekly sessions for four to six weeks, then taper. Home exercises, five to six days per week, drive most of the change. A session might include 10 minutes of cervical mobility and stabilization work, 10 to 15 minutes of gaze stability and saccade drills, a few minutes of balance challenges scaled to current tolerance, and updates to the aerobic plan. Education is threaded throughout: how to pace the day, what to do when a headache starts, when to stop an exercise and when to push through mild symptoms.
Time in the clinic is finite. The real gains come from consistent, correctly dosed practice at home. Patients who keep brief logs of symptoms and activity help the therapist fine-tune the plan quickly.
Measuring value and setting expectations
A fair question is how long this takes. Many patients with post-concussion syndrome who engage in targeted rehabilitation see meaningful improvement within 6 to 12 weeks. Some need only a handful of visits. Others, especially those with complex histories or strong migraine phenotypes, may work through cycles of progress and plateau over several months. The goal is not perfection on every test, but robust, predictable function in the settings that matter to the person.
Cost and access matter too. Not every clinic offers specialized concussion rehabilitation. When searching for physical therapy services, ask whether the clinic provides vestibular assessment, exertional testing, and oculomotor rehabilitation, not only general orthopedic care. A brief phone call can save weeks by getting the right fit from the start.
A brief checklist to bring to your first appointment
- A symptom diary from the past week, including triggers and what helps. A list of medications and supplements, plus any prior imaging or medical notes. A description of work or school tasks that feel hardest right now. Glasses or contacts, including readers, even if you do not use them all the time. Comfortable shoes and clothing for light exercise testing.
What experience has taught many clinicians
Recovery rarely moves in a straight line. Patients who do best show two traits: consistency and curiosity. They practice small amounts often and treat setbacks as information, not verdicts. Therapists who do best stay humble, test hypotheses, and change course when something does not work. The nervous system responds to clarity and safety. When the plan is clear and the loads are safe yet challenging, the system tends to recalibrate.
Cases that drag often share certain patterns. Home programs are too hard or too random. The aerobic base never develops because each effort is either all-out or abandoned. The neck remains reactive because it is loaded before it is calm. Visual drills feel like punishment because the room’s lighting is harsh and the fonts tiny. These are not failures of willpower, but mismatches of dose and environment. The fix is to simplify and rebuild the sequence.
Finding the right partner in care
A doctor of physical therapy with concussion and vestibular training brings a methodical approach to a messy problem. Look for a physical therapy clinic that can explain its evaluation process in plain language and outline a plan after the first visit. If the therapist listens carefully, tests thoroughly, and sets measurable goals, you are likely in good hands.
Post-concussion syndrome is disruptive but rarely permanent. With targeted rehabilitation, most people regain confidence in movement, ease with visual tasks, and capacity for daily life. The work is steady rather than heroic. Step by step, system by system, the body learns to trust itself again.