Post-Concussion Syndrome (PCS)

Post-concussion syndrome (PCS), also known as postconcussion syndrome, post concussive syndrome and persistent post concussive syndrome, is a common complication of concussion. Post concussive symptoms are typically similar to those of the initial concussion, but last longer than usual.

A concussion is a mild form of traumatic brain injury (MTBI) or mild head injury (MIH), which can result from a blow or bump to the head for example from a fall or a sports injury.

Post-concussion syndrome is most likely to affect a person soon after sustaining their minor head injury.

• Around 50 percent of people who have sustained a concussion will experience symptoms of PCS at one month after the initial injury
• Around 15 percent of people who have sustained a concussion will continue to experience symptoms of PCS for one year after the initial injury

PCS can affect both males and females and can develop following a concussion at any age. When babies, toddlers and older children develop PCS, the range of possible symptoms is slightly different to those experienced by adults. The symptoms of PCS are age-range specific and relate to a person’s stage of brain development. See the sections on PCS in babies and PCS in toddlers and older children for more information.

At any age, post-concussive symptoms usually resolve hours or days after the primary injury – i.e. the incident that caused the concussion – with appropriate rest and aftercare. Those who go on to develop PCS will experience similar symptoms to those present in the immediate two-week period following their head injury, such as headaches, dizziness and fatigue. However, in PCS, post-concussive symptoms may persist for weeks, months or even years after the primary injury. 2

Although medical supervision should be sought in all cases, PCS sometimes resolves without the need for specific treatment. 3 If treatment is needed, it typically involves a tailored care plan to address the particular symptoms that a person is experiencing, which may vary considerably between people. A treatment plan for PCS may feature medications and/or psychotherapeutic treatments, such as cognitive behavioural therapy (CBT).

Most people recover fully from PCS, after around three months of effective treatment. However, recovery can take months or years, depending on the number and severity of a person’s symptoms. Research indicates that the fewer symptoms of PCS a person presents with, the shorter their total recovery time is likely to be. 4

Good to know: This resource specifically provides information on PCS stemming from a regular concussion or mild head injury (MIH), and does not cover the treatment or prognosis for any other forms of traumatic brain injury (TBI). It is important to note that post concussive symptoms may also manifest following other, more serious kinds of TBI than a concussion.

If a person has been affected by a TBI that is different from a concussion ‒ even if they experience symptoms that can be present in the immediate aftermath of a concussion and/or can persist on a more long-term basis, as in PCS ‒ they will need treatment suited to their specific injury. This is because, when these symptoms manifest due to other forms of TBI, their associated health implications, recovery times and treatment recommendations may be different to those of PCS.

For information on other forms of traumatic brain injury, see these fact-sheets from Headway: the Brain Injury Association.

When post-concussion syndrome develops, at least three of the following cognitive, physical, emotional and behavioural symptoms will be present: 5 6 7

• Vestibular symptoms, including dizziness, vertigo, ringing in the ears (tinnitus), nausea and/or balance problems
• Vision problems, often involving blurred vision, difficulty moving one or both eyes as normal and/or difficulties with focussing or sustaining focus, which can impede activities such as reading
• Headache, and/or a sense of pressure in the head
• Hypersensitivity, or exquisite sensitivity; to light (photophobia), noise (phonophobia) and/or other external stimuli, including factors which would not bother a person normally, such as sunlight or background chatter
• Trouble sleeping, most commonly resulting in insomnia, circadian rhythm sleep wake disorder and/or sleep apnea
• Fatigue
• Cognitive difficulties, such as feeling as though one is in a blur or fog, difficulty concentrating, impaired memory, particularly surrounding the circumstances of the primary injury and/or confusion
• Psychological symptoms, including intolerance to stress, emotion or alcohol, irritable mood and changes in personality, emotional blunting or apathy, and/or disinclination towards activities which they would normally enjoy, including socialising and sexual activity
• Severe symptoms of concussion in the immediate aftermath of the primary injury can be predictors for developing PCS, but may also indicate that a person has actually sustained a more serious form of TBI requiring specialized aftercare.

It is important to monitor anyone who has sustained a blow to the head vigilantly for signs of concussion, which can appear within minutes, hours or days of the causal injury. Seek immediate medical attention in all cases where temporary loss of consciousness is experienced and/or the symptoms of concussion are severe.

In adults and teenagers, the symptoms of PCS are similar to those that may be experienced in the hours or days following an MTBI, other than that they have a longer duration, remaining present for over two weeks after the primary injury.

One person with PCS may experience an entirely different combination of symptoms to those that affect another. In PCS, it is common to develop symptoms of related psychological conditions, due to the impact of PCS on a person’s quality of life, possibly including:

• Depression
• Anxiety
• Panic attacks or limited-symptom panic attacks
• Hypochondrial fear of having incurred permanent or severe brain damage
• A combination of two or more of these findings

If you think that you, or a loved one, may be affected by symptoms of any of these conditions, you can get a free assessment at any time by downloading the Ada app.

Good to know: It is not uncommon for people affected by PCS to downplay the extent of their symptoms, in particular changes to personality and cognitive defects, such as vision problems, which may be interfering with their ability to go about their daily routine. 5 In some cases, a person may avoid acknowledging these symptoms altogether in order to ignore their impact. This can result in attempting to perform professional and personal obligations despite the problems posed by their symptoms, which can prolong and worsen PCS.

It is always recommended that anyone experiencing symptoms of concussion, that persist beyond their expected recovery time, discuss their symptoms with a doctor, even if a person genuinely feels their symptoms to be slight or insignificant. The symptoms that they are experiencing may turn out to relate to a more serious TBI requiring treatment, or to another condition, which can then be diagnosed. Furthermore, if a person’s symptoms are found to relate to PCS, treatments can then be recommended to help a person regain their pre-injury capabilities and quality of life.

The reasons why some people develop post-concussion syndrome following a concussion and others do not, is currently not fully medically understood. However, certain factors are believed to contribute to developing the condition. These include:

Structural damage to the brain. This will be due to the primary brain injury healing more slowly than in cases of regular concussion. A person’s neurotransmitter systems may be disrupted during this time, causing their symptoms of concussion to persist.

Psychological factors. In people with a predisposition towards certain other psychological conditions such as depression or anxiety, or who have a pre-existing diagnosis of these conditions, the brain may take longer than normal to recover from concussion, resulting in PCS.

Good to know: A certain proportion of cases of PCS are diagnosed due to misattribution. It is normally expected to experience symptoms of PCS following a minor head injury, and it is likely for people and their doctors to believe that any symptoms of PCS experienced following a minor TBI are linked to the injury. In fact, research suggests that some of the symptoms of PCS are almost equally likely to affect people who have not sustained a head injury, due to a wide range of other possible causes. A person who has sustained an injury to the head may therefore be diagnosed with PCS, when the development of their symptoms is, in fact, unrelated to their head injury.

Several medical theories could explain the presence of psychological symptoms, such as depression and anxiety, which may accompany PCS:

1. On a psychological level, symptoms of PCS can interfere with a person’s ability to go about their day-to-day routine as normal, causing distress and having a negative impact on their quality of life.
2. On a physiological level, the damage to neurons that may be causing PCS is believed to result in a person processing external stimuli differently from normal. 8

Whereas a healthy brain processes out the irrelevant aspects of their visual landscape and chooses what to focus on, a person with PCS may experience a sensory overload. This can trigger a primal stress response.

A person with PCS may take undue notice of elements of their surroundings, such as objects in their peripheral vision. 8 The confusion that this results in can be distressing and make it difficult to perform everyday activities such as driving or grocery shopping. The distress experienced can lead to a stress response, and, for some people, a full or limited-symptom panic attack. See this resource for more information on panic attacks.

When a person is treated effectively for PCS, associated symptoms such as the stress response, depression and anxiety will improve too. To treat the psychological symptoms associated with PCS, specific psychological therapies such as cognitive behavioural therapy (CBT) may be needed.

Certain population groups are at greater risk of developing PCS from a concussion than the general population, including:

• Elderly people
• Women

A concussed person is considered to be at greater risk of developing PCS if:

• They have a history of prior concussion
• They are affected by severe symptoms of concussion in the hours or days after the causal injury
• They are not resting the injury appropriately by following their recommended recovery plan

A person’s recovery can be compromised and their risk of PCS increased if they do not rest as instructed by their doctor following the primary injury.

Not resting the injury appropriately can:

• Delay the healing process relating to the primary injury
• Thereby increase the likelihood of developing a secondary TBI, if the person receives another knock to the head whilst the internal damage from the first TBI is still healing

Resting appropriately following the injury usually involves avoiding certain activities, such as looking at computer screens and smartphones for prolonged periods, driving or playing certain sports.

Research indicates that non-compliance with a do-not-return-to-play recommendation is a primary factor, among those who play sports, in persistent PCS.

Persistent PCS is post-concussion syndrome which does not get better fully with treatment, after one year or more. Always follow medical advice fully in order to maximise the likelihood of making a full recovery from PCS. 9 Furthermore, repeated head injuries leave a person vulnerable to developing other, more serious conditions, such as chronic traumatic encephalopathy (CTE), in which the function of the brain deteriorates.

With a view to identifying and diagnosing PCS promptly, the number and intensity of a person’s concussive symptoms should be monitored closely over their recovery period from the initial concussion. Seek medical attention if any symptoms remain present after two weeks. 10 This is the normal timeframe in which people who are not affected by PCS feel themselves to be fully recovered after a concussion. The presence of any symptoms beyond this point may indicate post-concussion syndrome.

Diagnosis of post-concussion syndrome will be made by assessing a person’s symptoms on a case-by-case basis. There are no standard diagnostic tests for PCS.

Before making a diagnosis of PCS, a doctor will usually perform brain imaging tests, such as a to rule out the possibility that a more serious complication has developed from the concussion. This may include a secondary brain injury, for instance, an intracranial hemorrhage (bleeding in the brain) resulting from the body’s inflammatory response to the primary injury. 11

Good to know: Brain imaging tests will also usually be performed when a concussion is initially diagnosed to rule out the possibility that a person is affected by a more serious form of TBI. Most often, PCS develops after a mild TBI, but it is also possible to develop symptoms of the condition after a moderate or severe TBI, or following a whiplash injury. A different treatment approach will be needed if a person’s symptoms are found to result from any cause other than a prolonged recovery from concussion.

Differential diagnoses which may be made instead of a diagnosis of PCS include:

• Major depressive disorder
• Post traumatic headache. Read more about headaches »
• Chronic pain syndrome
• Cervical strain/whiplash associated disorder
• Generalized anxiety disorder
• Post traumatic stress disorder (PTSD)
• Substance abuse or polypharmacy, i.e. symptoms resulting from adverse reactions to or cross reactivity between medications
• Somatoform disorder,i.e. psychological symptoms that cannot be fully explained by any underlying general medical or neurological condition
• Factitious disorder, in which a person convinces themselves that they are experiencing their symptoms
• Primary sleep disorder: e.g. adjustment insomnia, or chronic insomnia

On diagnosing PCS, the doctor may provide patient handouts in order to help educate a person about the condition and to provide information about recovery and the various treatment options available.

Due to the fact that there are no diagnostic tests to help doctors establish a diagnosis of PCS, a doctor may draw on the guidelines suggested by the ICD-10, The International Statistical Classification of Diseases and Regulated Health Problems, Tenth Revision. The ICD-10 arranges the symptoms of PCS into the following six categories: 13

• Headache, dizziness, malaise, fatigue, noise intolerance (phonophobia)
• Irritability, depression, anxiety, emotional lability, i.e.rapid shifts between emotions and/or a lack of ability to control emotions and/or expressing emotions differently from normal
• Subjective concentration, memory or intellectual difficulties, without neurophysiological evidence of marked impairment
• Insomnia
• Reduced alcohol tolerance
• Preoccupation with the above symptoms and/or fear of brain damage with hypochondriacal concern (irrational fear of brain damage) and/or unwillingness to attempt work or social activities as normal, due to the perceived impact of PCS

To meet the ICD-10 criteria for diagnosis with PCS, a person must have symptoms which fall into at least three of the above categories.

Good to know: The relevance of these guidelines is debated among doctors, and some doctors will diagnose PCS without drawing on the ICD-10 criteria. This is, in part, because they also stipulate that a person must have sustained the primary injury a maximum of four weeks before the diagnosis is made. Cases of PCS may last weeks, months or years, and it is not uncommon for a person to visit their doctor over four weeks after the primary injury took place. Many doctors therefore find a person’s history of traumatic brain injury and their symptoms, if appropriate, sufficient to make a diagnosis of PCS. If you think you may be affected by PCS, you can get a free symptom assessment at any time, by downloading the Ada app.

Treatment for PCS usually involves a combination of therapies, targeting the specific symptoms that a person experiences. Each individual symptom may require a different targeted treatment approach, although some types of treatment for PCS, for example vestibular rehabilitation therapy, may provide relief from multiple symptoms, including impaired balance, dizziness, vertigo and vision problems.

Due to the fact that the symptoms of PCS vary between people, possible combinations of therapies and medications that may be recommended for treating PCS vary greatly between people, too. Doctors will help devise a care plan that targets all of a person’s symptoms. The simple reassurance physicians can provide can be very helpful in the immediate time period following a TBI, as, in most cases, symptoms improve within three months.

Doctors will provide education on PCS and on symptoms that a person might expect or experience following their head injury. This education has two important effects:

• The severity and duration of PCS symptoms may be lessened. Research suggests that people who are well-informed about the condition recover from it more quickly than people without a solid understanding of what to expect.
• The inherent anxiety associated with experiencing PCS can be reduced, if the affected person and their family, friends and coworkers are informed about PCS. Education helps the affected person and their support network to understand that PCS is a recognized medical condition and is a relatively common consequence of sustaining a TBI rather than an unusual problem.

Good to know:* All or part of a person’s initial treatment plan for PCS may need to be adjusted, depending on whether the treatment(s) that are initially recommended prove effective. Periodic follow-up sessions will be scheduled while a person is undergoing treatment for PCS in order to monitor a person’s recovery acutely and make adjustments to their treatment plan as needed.

Treatments for PCS may include:

Vision therapy, or vision rehabilitation therapy, has been found to be very effective at treating the vision problems associated with PCS. This treatment will usually be supervised by a doctor specializing in problems related to the eyes, an optometrist, or a behavioural optometrist, who focuses on the intersection between vision problems and behaviour.

For example, a behavioural optometrist can help a person with PCS overcome difficulties in concentrating that stem from vision problems and that interfere with their ability to perform everyday activities such as reading.

For more information, see the question, What does vision therapy (VT) for PCS involve?, in the FAQs.

Vestibular rehabilitation therapy can help a person overcome temporary or permanent changes to the vestibular apparatus in the inner ear, which controls sensory information about balance, motion and spatial orientation. This type of therapy consists of specialized exercises, which can help treat impaired balance, dizziness, vertigo and some vision problems in those affected by PCS.

Good to know: It may not be possible to restore the previous function of the vestibular apparatus. VRT therefore focuses primarily on helping a person develop ways of using their other senses, in order to overcome the difficulties posed by vestibular damage. The process of developing these new techniques is called compensation. 14 (For more information, see the FAQs.)

Treatment for headaches depends on the type of headaches experienced. Tricyclic antidepressants are often prescribed. These can also work to lessen depressive symptoms. For severe headaches, medications used to treat migraine headaches, such as triptan medications, may be recommended.

Read more about migraine headaches »

Reducing the use of painkillers/analgesics may be helpful for some people in treating headaches. Headaches in PCS are often caused by the overuse of painkillers. Where this is the case, cutting down on or discontinuing the use of the analgesic that is causing the headaches, can be sufficient to allow PCS-related headaches to improve.

Lifestyle adaptations such as establishing regular meal times and rest times, and practising relaxation techniques, such as breathing exercises can help to reduce the number and severity of headache attacks. Low-intensity exercise, such as walking, gentle cycling on an exercise (stationary) bicycle or swimming may be helpful.

However, all forms of exercise undertaken during recovery from PCS should be discussed in full with a doctor to ensure they pose no risk of prolonging PCS.

Psychotherapy may be recommended to address emotional and behavioural changes associated with PCS, such as irritability and apathy, as well as to treat psychological problems such as anxiety and depression that may accompany or arise from, PCS.

The psychotherapeutic technique most commonly employed in the treatment of PCS is cognitive behavioural therapy (CBT), a type of talking therapy led by a cognitive behavioural therapist. CBT aims to provide a person with new techniques for processing their thoughts, which can help alter their emotional responses and behaviour. 15 Mindfulness-based CBT therapy may be recommended to treat anxiety and depression.

CBT can also be helpful in addressing other symptoms of PCS; it is often recommended to help a person overcome tinnitus (ringing in the ears) and difficulty sleeping.

Also known as cognitive remediation, cognitive rehabilitation therapy (CRT) is a combination of techniques that, together, can be used to improve behavioural, emotional and cognitive symptoms of PCS, including improving a person’s attention, memory and cognitive processing speed, as well s recovering lost functions.

Certain treatments used in CRT may be the same or similar to those used in vision therapy (VT) and vestibular rehabilitation therapy (VRT), if a person’s symptoms include problems with hand-eye coordination and balance, or vision problems. (For more information, see the FAQs.)

Also known as EEG biofeedback and neurotherapy, neurofeedback is a relatively new treatment for cognitive impairment in PCS. Using a special headset linked to a screen, a person performs activities designed to strengthen or develop particular neural connections. This allows them to regain cognitive abilities lost due to their concussion. 16

As they do the tasks, the person can see on the screen which regions of their brain are struggling. Their activity plan is adapted to target and treat problem areas. 17 The length of a course of neurotherapy will depend on a person’s specific symptoms.

When PCS is diagnosed, the doctor will ask about the affected person’s sleeping experiences, to screen for sleep disturbances. They will ask about:

• Difficulties falling or staying asleep, i.e. short-term or chronic insomnia (persists beyond two months)
• Unusual events during sleep, such as nightmares or unusual bodily functions such as gasping or choking. This may, but will not necessarily, indicate that the person is affected by obstructive sleep apnea (OSA).
• Daytime tiredness, which can, but will not necessarily, indicate that the person is affected by circadian rhythm sleep wake disorder (CRSWD)

If a person is affected by difficulties relating to sleep, the appropriate treatment plan will depend on the particular nature of their problem(s). A focussed sleep assessment will be conducted, in which the doctor will ask many questions to establish the exact circumstances surrounding a person’s sleep routine, the effects of their sleep-related problems on their quality of life and will ascertain if a person is affected by any comorbid conditions, such as headaches or tinnitus (ringing in the ears), which may interrelate with their sleep problems, and may need additional treatment.

People undergoing treatment for sleep-related problems are recommended to keep a sleep diary, recording their sleep and wake times and any problems encountered during sleep, as well as any tiredness experienced during the day. This will help to demonstrate the effectiveness of the treatment, which can be adjusted as needed.

Treatment for sleep disturbances may involve:

Practicing good sleep hygiene. Avoid stimulants, such as caffeine and nicotine in the hours before bed, create a calm and relaxed sleeping space with a cool temperature and minimal light and noise, make efforts to go to bed and get up at the same time each day.

Managing exposure to stimuli. Remove electronic devices from the bedroom, avoid looking at computers, television screens and smartphones before going to sleep, engage in relaxing activities in the evening; rather than ones which may be very stimulating, or intellectually or emotionally charged.

Medications. Non-benzodiazepine sedative-hypnotic drugs may be prescribed to promote sleepiness at night time, for a course of between two weeks and one month. Antihistamines, antipsychotics and melatonin receptor agonists are not usually recommended to treat short-term insomnia.

Good to know: Activities which require full alertness, such as driving, should be avoided the day after taking non-benzodiazepine sedative-hypnotic medications. This is because the number of hours that they take to wear off varies between people.

PCS can significantly impact upon a person’s quality of life, their ability to do day-to-day activities as normal and their work and personal relationships. This is due to the range of cognitive, behavioural and emotional difficulties that it presents. Stress, overuse of certain parts of the brain and physical activities which risk further impact to the head are all considered to aggravate the risk of persistent PCS and slow down a person’s recovery.

There are some steps that a person can make in order to create the best conditions for their treatment to be effective. These include:

Seeking help from a medical professional to educate friends and family about PCS and what to expect. This will help to minimise the affected person’s feelings of stress in situations where their cognitive, behavioural and/or emotional changes are evident.

Informing school teachers or colleagues following a diagnosis of PCS; certain activities such as looking at computer screens for long periods are not recommended or may be challenging, especially during the early stages of recovery. Lifestyle adaptations, such as working from home or taking some time off, may be necessary.

Lifestyle adaptations that may be recommended during recovery from PCS include:

• Giving the damaged parts of the brain a chance to heal and rest, by avoiding looking at smartphones and/or screens for long periods of time
• Avoiding situations which foreground cognitive difficulties, such as driving and grocery shopping, until treatment such as vestibular rehabilitation therapy has been effective
• Practicing mindfulness-based meditation, as an adjunct to CBT therapy in order to overcome the psychological symptoms of PCS
• Practicing low-intensity exercise such as yoga, rather than high-intensity sports and contact sports, which are not recommended whilst in recovery from PCS. Gentle exercise promotes feelings of calm and relaxation, and may help improve problems with balance and coordination.

Most people who are affected by a concussion ‒ those who do not go on to develop post-concussion syndrome ‒ feel themselves to be fully recovered after around two weeks. However, to prevent PCS, a person may be advised by their doctor to continue refraining from certain activities for a longer period of time, such as high-intensity or contact sports, and activities which are compromised by their PCS symptoms. The purpose of this is to promote the full healing of any internal bruising and bleeding related to the causal injury.

Diagnosing and treating the possible symptoms of PCS as early as possible can prevent PCS from developing and/or lessen its extent. For this reason, it is always recommended to seek medical attention after two weeks, if any symptoms of concussion remain present.

What are the signs of PCS in children?
A: When toddlers and older children develop PCS from a concussion, the possible symptoms that they may experience are broadly the same as adults may experience. These persist for, or develop after, more than two weeks following the primary injury.

Children, especially toddlers, may lack the language to communicate how they are feeling. Therefore, it is especially important that they are closely monitored for symptoms of PCS during the two-week period after the initial injury and beyond. Common post-concussive symptoms in children include nausea and sleeping more than usual. These should get better in the initial two-week period following their head injury when post-concussion syndrome is not present.

In spotting PCS, it can be particularly helpful to look out for the child encountering problems completing activities as normal at school: these may be signs of cognitive impairment related to PCS. In children younger than 6 or 7, signs such as difficulty remembering words and lack of concentration may not be a cause for concern or indicate PCS. In older children, where these abilities will be more developed, beginning to experience such problems may indicate PCS, and a medical opinion should be sought. 18

Read more about signs of concussion in children »

Immediate medical attention should be sought in all cases where a toddler or child has sustained a head injury, followed by regular medical check-ups to monitor for the development of PCS.

Q: What factors make it more likely that children will develop PCS?
A: Research indicates that children are at increased risk of developing PCS following an MTBI if: 19

• They experience loss of consciousness immediately after the primary injury
• The primary injury resulted from a motor-vehicle accident
• The brain imaging scan taken immediately following the primary injury reveals abnormalities
• Hospitalization is required to supervise their initial rest and recovery following the primary injury

Q: What are the signs of PCS in babies?
A: Signs of concussion in babies may include:

• A bump or bruise to the head
• Changed sleeping habits; sleeping more or less can both be indicators of concussion
• Crying when the head is moved
• Vomiting
• Changes in mood, especially increased irritability
• Difficulty feeding

In all cases where a baby has sustained an injury to the head, immediate medical attention should be sought. The baby should be monitored closely after the injury, and their symptoms should get better within two weeks of the primary injury, where PCS is not present. In babies, PCS may be indicated by the loss of newly-learned skills, such as babbling, sitting up or pointing. A baby may also cry more than normal or become a pickier eater. Usually, these symptoms resolve of their own accord within weeks or months; lost skills will return, and a baby will not be affected by any ongoing problems. 18

Good to know: After a baby has been affected by an MTBI, there should be no changes to the shape of the head, other than the possibility of slight swelling related to bruising, at the site of the injury. If the baby’s head appears to stop growing in the days or weeks following the injury or there is any bulging of the anterior fontanelle (the soft spot on top of the baby’s head), this may indicate a more serious type of injury and a medical opinion should be sought. 20

Q: Is an affected person usually entitled to workers’ compensation, following a diagnosis of PCS?
A: A person who has sustained a concussion and is experiencing long-lasting post concussive symptoms may be entitled to workers’ compensation, particularly if the primary injury was work-related. However, due to the fact that many of the symptoms of PCS are self-reported rather than demonstrable in diagnostic tests, it is not uncommon for people affected by the condition to encounter difficulties in gaining adequate compensation and support from their workplace, especially if the primary injury occurred elsewhere. Many people seek legal advice in order to ensure the best possible outcome when negotiating the terms of their recovery period from PCS with their workplace.

Q: When can I resume playing sports after a diagnosis of PCS?
A: A graded exercise assessment will be taken periodically in order to monitor a person’s recovery from PCS; this will feature activities designed to reveal the impact of a person’s symptoms on their ability to complete various movements and tasks. People who are considered to have made a full recovery by the medical professionals involved in treating their condition can be granted permission to return to play. 21

However, in cases where symptoms of PCS have been severe, a person may be discouraged from returning to playing contact sports, particularly of the type that caused the initial concussion. This is because the risk of developing PCS following a sports-related head injury is heightened in people who have already been concussed and/or been affected by PCS.

Good to know: Return-to-play permissions cannot legally be granted without a person completing a graded exercise assessment and/or other tests to establish the extent of their recovery. It is considered gross negligence to grant someone permission to return to play after PCS on the sole basis of their self-reported loss of symptoms. 22

Q: What is the Post-concussion Symptom Scale (PCSS)?
A: Although there are no standard diagnostic tests for PCS, the Post-concussion Symptom Scale (PCSS) may sometimes be used. This is a self-assessment questionnaire, which requires the affected person to give their symptoms a numerical rating, resulting in a total score.

The PCSS questionnaire is usually filled out several times in the two-week period following a person’s primary injury, often with the objective of determining when they will be ready to return to playing sports. While its results can provide useful information about a person’s perception of their persisting or diminishing symptoms, its medical validity as a diagnostic test for PCS is contested. This is because the information it provides is subjective, revealing only the viewpoint of the affected person and no new neurological or physiological information. 23

Q: What does vision therapy (VT) for PCS involve?
A: Although the term exercise is usually associated with strengthening muscles, the aim of vision therapy exercises is different: the purpose of VT activities is to help a person develop new neural connections, in order to overcome the vision problems associated with PCS. Common vision problems associated with PCS which can be treated with vision therapy include:

• Convergence insufficiency: difficulty focussing at close range, with a tendency to exophoria, i.e. the visual axes of the eyes diverge away from one another, rather than working together
• Accommodative insufficiency: difficulty focussing or sustaining focus at close range
• Saccadic dysfunction: difficulty shifting the eyes from one point to another

A visual rehabilitation programme will then be devised, often consisting of sessions with the optometrist, combined with regular practice of certain vision exercises at home. 24 Due to the great variability between recovery times from PCS, one person may need a longer treatment programme of vision therapy than another. On average, a complete course of treatment includes 15 sessions. 25

Q: What does vestibular rehabilitation therapy (VRT) for PCS involve?
A: When a person undergoes VRT, an exercise routine will be devised by a doctor specializing in vestibular disorders, which a person can practice daily at home. This will primarily consist of exercises including:

Habituation. Movement exercises, often focussed on transitioning between sitting, standing and lying down. These exercises are designed to treat symptoms of dizziness that occur due to motion and/or visual stimuli.

Gaze stabilization. There are two possible aims of gaze stabilization exercises. They can be used to reduce vision problems related to head movement, such as the view appearing to bounce around when a person turns, sits or stands. Gaze exercises can also be used to help a person develop visual capabilities, as compensation for damage to the vestibular system.

Balance training. These exercises help a person regain their steadiness and/or overcome dizziness and vertigo associated with PCS. They may involve performing tasks while balancing, practicing movement routines and/or moving in response to visual or sound cues.

Many people affected by vestibular symptoms of PCS recover within a few months of undergoing VRT, with daily practice. Due to the variable nature of PCS, the length and intensity of a person’s treatment programme will depend on their specific symptoms.

Q: What does cognitive rehabilitation therapy (CRT) for PCS involve?
A: CRT aims to create new neural pathways and connections which can help a person overcome the difficulties posed by their symptoms of PCS. 26 A team of healthcare professionals with different neurological and psychological specialisms will usually be involved in delivering CRT, as this treatment is based on acknowledging the overlap between the cognitive, psychological and physical factors that contribute to PCS symptoms. 27 For example, the emotional distress that may be experienced as a result of failing to carry out an everyday task as normal, such as reading a map or book, can further impact upon their ability to do so by raising the level of activity in the brain.

To discern the correct CRT treatment approach for a person, diagnostic tests such as a neurological exam and neuropsychological exam will be carried out, in some cases accompanied by imaging tests such as a CT scan of the head.

A programme will then be devised which aims to build a person’s visual and auditory skills through exercises completed in CRT sessions, with a focus on restoring a person’s abilities to complete day-to-day tasks as normal. A CRT treatment plan may require certain lifestyle adaptations, including avoiding certain activities such as looking at computer screens or smartphones. These will be strategically reintroduced as a person responds to their CRT treatment.