Managing Concussion: Understanding and Treating Persistent Dizziness
Managing Concussion: Understanding and Treating Persistent Dizziness
Concussion is a common form of mild traumatic brain injury (mTBI), affecting approximately 170,000 Australians annually. While many recover within weeks, up to 15% experience persistent symptoms at one year, with dizziness being the second most common complaint. For therapists, understanding the mechanisms behind post-concussion dizziness is essential for effective concussion rehab.
Symptom Subgroups After Concussion
Patients may present with a variety of overlapping symptoms, often classified into subgroups such as:
- Cognitive/fatigue-related: difficulties with memory, attention, and mental endurance
- Vestibular: dizziness, balance issues, motion sensitivity
- Ocular: blurred or double vision, difficulty with eye movements
- Migraine-related
- Cervical-related: neck pain or proprioceptive disturbances
- Mood/anxiety-related
Dizziness often predicts a longer recovery and may indicate involvement of vestibular, cervical, or autonomic systems.
Mechanisms Behind Post-Concussion Dizziness
Persistent dizziness can arise from multiple sources:
- Peripheral vestibular dysfunction – e.g., benign paroxysmal positional vertigo (BPPV), affecting 10–57% of patients.
- Autonomic dysfunction – light-headedness when moving from sitting to standing, often seen in adolescents.
- Central vestibular dysfunction – ocular motor changes, motion sensitivity, impaired vestibulo-ocular reflex (VOR).
- Cervicogenic dizziness – injury to the neck during impact, affecting proprioception and postural control.
Additional contributors include biochemical changes, inflammation, and disrupted integration of visual, vestibular, and proprioceptive inputs.
Key Outcome Measures
To assess concussion and dizziness, therapists commonly use:
- Rivermead Post-Concussion Symptom Questionnaire (RPQ) – evaluates severity of 16 symptoms including dizziness and balance problems.
- SCAT-5 (Sideline Concussion Assessment Tool) – useful both on the field and in follow-up, including red flags, memory, balance, and cognitive assessment.
- Buffalo Concussion Treadmill Test (BCTT) – identifies exercise tolerance and autonomic dysfunction, guiding graded return-to-activity.
- Vestibular Ocular Motor Screen (VOMS) – assesses smooth pursuits, saccades, VOR, and visual motion sensitivity.
- Balance Error Scoring System (BESS) – evaluates postural stability on firm and foam surfaces.
- Dizziness Handicap Inventory (DHI) – quantifies physical, emotional, and functional impact of dizziness.
- Motion Sensitivity Quotient & Visual Vertigo Analogue Scale – identifies triggers for visual motion sensitivity and informs habituation exercises.
- Functional Gait Assessment – measures dynamic balance during walking tasks, predicting fall risk.
Treatment Approaches
Treatment is tailored to the identified subtype(s) of dizziness:
- Autonomic dysfunction: graded aerobic exercise based on BCTT results
- BPPV: repositioning manoeuvres and balance training
- Central vestibular dysfunction: VOR and gaze stability retraining
- Motion sensitivity: habituation exercises guided by MSQ or VVAS scores
- Cervicogenic dizziness: musculoskeletal rehabilitation and proprioceptive retraining
Visual retraining techniques include binasal occlusion, convergence exercises (Bronx strings/pencil push-ups), saccade training, and dynamic visual tracking. Advanced interventions may involve collaboration with neuro-opticians or behavioural optometrists.
Reflection Questions for Clinicians
- How do you differentiate between peripheral, central, and cervicogenic dizziness in your assessment?
- Which outcome measures do you routinely use to guide treatment decisions for post-concussion dizziness?
- How can graded exercise and visual habituation be integrated to support faster recovery in your patients?
Responses