Five systems to assess after a concussion

Cervical, visual, vestibular, autonomic, and psychological. Any one of them can be the reason a patient isn't recovering, and they can coexist in the same patient. Below is how each one presents, what to assess, and how to treat it.

This is a clinical framework, not a set of discrete diagnoses. The systems overlap, the picture changes over the course of recovery, and post-traumatic headache can cut across several of them and may need medical co-management. Cervical injury and peripheral vestibular dysfunction can also be separate injuries that happen alongside the concussion rather than part of it.

Cervical

The same forces that injure the brain often go through the neck too. Cervical dysfunction can produce headache and dizziness that look vestibular, and it's easy to miss once the chart already says concussion.

What you'll see

  • Neck pain and suboccipital or unilateral headache, often provoked by sustained postures
  • Dizziness or unsteadiness linked to neck movement or position rather than head movement alone

What to assess

  • Active range, segmental mobility, and the craniocervical flexion test
  • Cervical joint position error, smooth pursuit neck torsion, and eye-head coordination

How to treat

  • Manual therapy, deep neck flexor and postural endurance, and proprioceptive retraining
  • Treat cervicogenic dizziness as a contributor, since the diagnosis still rests on excluding other causes

Visual

Oculomotor and binocular vision problems can explain screen, reading, and busy-environment complaints that get put down to general concussion symptoms.

What you'll see

  • Eye strain, blur or intermittent diplopia, losing place while reading, and headache with near work
  • Discomfort in visually busy settings like grocery stores and scrolling screens

What to assess

  • Near point of convergence, accommodation, saccades, and smooth pursuit
  • VOMS as a vestibular and oculomotor screen, with referral to optometry when binocular vision needs a full workup

How to treat

  • Saccade, pursuit, and vergence training with graded near-work tolerance
  • Co-management with optometry for lenses, prisms, or vision therapy

Vestibular

Peripheral and central vestibular deficits both show up after concussion, and post-traumatic BPPV is worth ruling out early because it's quick to treat.

What you'll see

  • Dizziness with head movement, blurred vision during head turns, and imbalance
  • Brief positional vertigo when rolling in bed or looking up

What to assess

  • Positional testing, head impulse test, dynamic visual acuity, and VOR cancellation
  • Balance across sensory conditions, and gait under dual-task conditions
  • Persistent postural-perceptual dizziness, a functional vestibular disorder that requires at least three months of symptoms and all five Bárány criteria

How to treat

  • Repositioning manoeuvres for BPPV, and gaze stabilization progressing from VORx1 to VORx2
  • Habituation, plus balance and gait training with added sensory and cognitive demands
  • Keep an eye on the neck during gaze and habituation work, since repeated head movement can aggravate cervical impairments

Autonomic

Exercise intolerance is common after concussion. Autonomic dysregulation is the leading proposed explanation, though the mechanism isn't settled. A symptom-limited exercise test tells you where the threshold is. Resting symptom scores don't give you that.

What you'll see

  • Symptoms that climb with exertion and stop exercise at a lower heart rate than expected
  • Light-headedness or palpitations on standing

What to assess

  • Buffalo Concussion Treadmill Test or Bike Test to find the symptom-limited heart rate threshold, using the bike when cervical or vestibulo-oculomotor impairments are present
  • Heart rate and blood pressure supine, sitting, and standing, with referral to medicine when orthostatic intolerance needs a full workup

How to treat

  • Sub-symptom-threshold aerobic exercise, prescribed and progressed from the test result
  • Attention to hydration, sleep, and graded return to daily activity

Psychological

Anxiety, low mood, and fear of provoking symptoms can shape how the other systems recover.

What you'll see

  • Worry about symptoms, irritability, low mood, and disrupted sleep
  • Avoidance of activities or environments that have provoked symptoms before

What to assess

  • Screen with general tools like the GAD-7 and PHQ-9
  • Ask directly about avoidance and fear of provoking symptoms

How to treat

  • Clear explanation of symptoms, graded exposure, and a plan the patient understands and agrees with
  • Referral to psychology when screens are positive or mood is driving disability

The Dizzy Brain: Evaluation and Treatment of Vestibular Dysfunctions Following Concussion

Continuing education for clinicians working with dizzy and post-concussion patients. The course focuses on oculomotor screening and vestibular assessment and treatment. It also covers how cervical, autonomic, and psychological problems overlap with a dizzy presentation, and how to work through the differential.

In person: Sunday, October 18, 2026, 9 am to 4 pm, Richmond Hill

  • One self-paced module to complete before the live day
  • Oculomotor screening, plus vestibular assessment and treatment
  • Differential diagnosis across the other systems
  • An interactive workbook
  • PDF resources
  • An assessment and exercise video library
Register for the course

References

Collins, M. W., Kontos, A. P., Okonkwo, D. O., Almquist, J., Bailes, J., Barisa, M., Bazarian, J., Bloom, O. J., Brody, D. L., Cantu, R., Cardenas, J., Clugston, J., Cohen, R., Echemendia, R., Elbin, R. J., Ellenbogen, R., Fonseca, J., Gioia, G., Guskiewicz, K., … Zafonte, R. (2016). Statements of agreement from the Targeted Evaluation and Active Management (TEAM) approaches to treating concussion meeting held in Pittsburgh, October 15–16, 2015. Neurosurgery, 79(6), 912–929. https://doi.org/10.1227/NEU.0000000000001447

Collins, M. W., Kontos, A. P., Reynolds, E., Murawski, C. D., & Fu, F. H. (2014). A comprehensive, targeted approach to the clinical care of athletes following sport-related concussion. Knee Surgery, Sports Traumatology, Arthroscopy, 22(2), 235–246. https://doi.org/10.1007/s00167-013-2791-6

Leddy, J. J., Haider, M. N., Ellis, M. J., Mannix, R., Darling, S. R., Freitas, M. S., Suffoletto, H. N., Leiter, J., Cordingley, D. M., & Willer, B. (2019). Early subthreshold aerobic exercise for sport-related concussion: A randomized clinical trial. JAMA Pediatrics, 173(4), 319–325. https://doi.org/10.1001/jamapediatrics.2018.4397

Mucha, A., Collins, M. W., Elbin, R. J., Furman, J. M., Troutman-Enseki, C., DeWolf, R. M., Marchetti, G., & Kontos, A. P. (2014). A brief Vestibular/Ocular Motor Screening (VOMS) assessment to evaluate concussions: Preliminary findings. American Journal of Sports Medicine, 42(10), 2479–2486. https://doi.org/10.1177/0363546514543775

Patricios, J. S., Schneider, K. J., Dvorak, J., Ahmed, O. H., Blauwet, C., Cantu, R. C., Davis, G. A., Echemendia, R. J., Makdissi, M., McNamee, M., Broglio, S., Emery, C. A., Feddermann-Demont, N., Fuller, G. W., Giza, C. C., Guskiewicz, K. M., Hainline, B., Iverson, G. L., Kutcher, J. S., … Meeuwisse, W. (2023). Consensus statement on concussion in sport: The 6th International Conference on Concussion in Sport–Amsterdam, October 2022. British Journal of Sports Medicine, 57(11), 695–711. https://doi.org/10.1136/bjsports-2023-106898

Quatman-Yates, C. C., Hunter-Giordano, A., Shimamura, K. K., Landel, R., Alsalaheen, B. A., Hanke, T. A., & McCulloch, K. L. (2020). Physical therapy evaluation and treatment after concussion/mild traumatic brain injury. Journal of Orthopaedic and Sports Physical Therapy, 50(4), CPG1–CPG73. https://doi.org/10.2519/jospt.2020.0301

Schneider, K. J., Meeuwisse, W. H., Nettel-Aguirre, A., Barlow, K., Boyd, L., Kang, J., & Emery, C. A. (2014). Cervicovestibular rehabilitation in sport-related concussion: A randomised controlled trial. British Journal of Sports Medicine, 48(17), 1294–1298. https://doi.org/10.1136/bjsports-2013-093267

Staab, J. P., Eckhardt-Henn, A., Horii, A., Jacob, R., Strupp, M., Brandt, T., & Bronstein, A. (2017). Diagnostic criteria for persistent postural-perceptual dizziness (PPPD): Consensus document of the committee for the Classification of Vestibular Disorders of the Bárány Society. Journal of Vestibular Research, 27(4), 191–208. https://doi.org/10.3233/VES-170622