34 Post-Concussion Syndrome

Post-Concussion Syndrome

A concussion is a mild traumatic brain injury caused by a complex physical process affecting the brain, induced by biomechanical forces. The commonly reported symptoms are occipital headache, blurry vision, nausea, dizziness, balance problems, a “foggy feeling,” difficulty with concentration, difficulty with memory, fatigue, confusion, drowsiness, and irritability. Clinically these symptoms fall into four major categories:

  1. Somatic: Headaches, nausea, vomiting, balance and or visual problems, and sensitivity to light and noise
  2. Emotional: Sadness to the point of depression, nervousness, and irritability
  3. Sleep disturbance: Sleeping more or less than usual and having trouble falling asleep
  4. Cognitive: Difficulty concentrating, troubles with memory, feeling mentally slow or as if in a fog that will not lift


Persistent symptoms’ does not reflect a single pathophysiological entity, but describes a constellation of non-specific post-traumatic symptoms that may be linked to coexisting and/or confounding factors, which do not necessarily reflect ongoing physiological injury to the brain (McCrory et al., 2017).

Concussion is an injury that typically resolves relatively quickly in most people (symptoms generally disappear for 80-90% of patients within 7 to 10 days), however whiplash symptoms can linger for up to a year or more. Persistent symptoms after concussive injuries often include headaches and neck pain. Post-traumatic headache (PTH) is a highly disabling secondary headache disorder and one of the most common symptoms after a concussion (Ashina et al., 2019). In these demographics soft tissue irritation and subsequent nerve sensitization may be a major contributor to symptoms. With the high impact nature of most concussive injuries, the assessment and rehabilitation of cervical spine may decrease the likelihood that an individual will develop persistent headaches and neck pain (Kennedy et al., 2019).

Ted Ed: What Happens When You Have A Concussion?


A thorough health history intake can be done to gather information about patients’ limitations, course of pain, and prognostic factors for delayed recovery (e.g., low self-efficacy, fear of movement, ineffective coping strategies, fear-avoidance, pain catastrophizing) and answers to health-related questions. Screen patients to identify those with a higher likelihood of serious pathology/red flag conditions. Then undertake a physical examination: neurological screening test, assess mobility and/or muscle strength.

Incorporate one or more of the following outcome measurements when assessing and monitoring patient progress:

  • Self-Rated Recovery Question
  • Patient Specific Functional Scale
  • Sport Concussion Assessment Tool 5th Edition (SCAT5)
  • Headache Impact Test 6-item (HIT-6)
  • The Migraine Disability Assessment (MIDAS)
  • Post-Concussion Symptom Scale

Physical Examination

Incorporate one or more of the following physical examination tools to determine the likelihood of tension-type headache or migraine and interpret examination results in the context of all clinical exam findings.

  • Cervical Flexion-Rotation Test
  • Trigger point palpation of the cranio-cervical muscles
  • Manual screening of the cervical spine



Provide reassurance and patient education on condition and management options and encourage the use of active approaches (lifestyle, physical activity) to help manage symptoms. After an initial short rest period lasting 24-48 hours, the early introduction of light cognitive and physical activity can be initiated if the activity does not worsen symptoms (sub-threshold activities).

Manual Therapy

Post-concussion headaches are multifactorial with evidence for the contributions of muscles and other structures surrounding the cervical spine. A massage therapy treatment plan should be implemented based on patient-specific assessment findings and patient tolerance. Structures to keep in mind while assessing and treating patients suffering from cervicogenic headaches may include neurovascular structures and investing fascia of:

  • Upper Cervical Spine (suboccipitals, upper trapezius, splenius cervicis, splenius capitis)
  • Levator Scapula
  • Longus Colli & Capitis
  • Rhomboid Minor and Major
  • Occipitofrontalis
  • Corrugator Supercilii
  • Sternocleidomastoid
  • Scalene Muscle Group (anterior scalene, middle scalene, and posterior scalene)
  • Temporomandibular Joint
    • Medial Pterygoid
    • Temporalis
    • Masseter
    • Suprahyoid Muscle Group (digastric, stylohyoid, geniohyoid, and mylohyoid)
    • Infrahyoid Muscle Group (sternohyoid, sternothyroid, thyrohyoid, and omohyoid)

Self-Management Strategies

Massage therapists not only provide hands-on treatment they can also develop self-management programs to help patients manage symptoms. Simple home-care recommendations such as self-massage, and mindfulness-based stress reduction may help reduce symptoms.

Multidisciplinary Concussion Management

Multidisciplinary Concussion Management
Multidisciplinary Concussion Management (Credit Dr. Nikita Vizniak)


Persistent symptoms often reflect a constellation of symptoms that may be linked to coexisting and/or confounding factors. Early intervention reduces the risk of cervicogenic headaches developing into chronic post-concussion headaches, but do not attempt to treat the concussion directly, instead treat the impairments that may be related to or irritating, based on patient-specific assessment findings and patient tolerance.

Key Takeaways

Contemporary multimodal massage therapists are uniquely suited to incorporate a number of rehabilitation strategies for post-concussion syndrome based on patient-specific assessment findings including, but not limited to:

  • Manual Therapy (soft tissue massage, neural mobilization, joint mobilization)
  • Education that is Person-Centered (e.g., biopsychosocial model of health and disease, self-efficacy beliefs, active coping strategies)
  • Stretching & Loading Programs (e.g., concentric, eccentric, isometric exercises)
  • Hydrotherapy (hot & cold)
  • Self-Management Strategies (e.g., engaging in physical activity and exercise, social activities, and healthy sleep habits)

References and Sources

Ashina, H., Porreca, F., Anderson, T., Amin, F. M., Ashina, M., Schytz, H. W., & Dodick, D. W. (2019). Post-traumatic headache: epidemiology and pathophysiological insights. Nature reviews. Neurology, 15(10), 607–617. doi:10.1038/s41582-019-0243-8

Ellis, M. J., McDonald, P. J., Olson, A., Koenig, J., & Russell, K. (2019). Cervical Spine Dysfunction Following Pediatric Sports-Related Head Trauma. The Journal of head trauma rehabilitation, 34(2), 103–110. doi:10.1097/HTR.0000000000000411

Ellis, M. J., Leddy, J., Cordingley, D., & Willer, B. (2018). A Physiological Approach to Assessment and Rehabilitation of Acute Concussion in Collegiate and Professional Athletes. Frontiers in neurology, 9, 1115. doi:10.3389/fneur.2018.01115

Harmon, K. G., Clugston, J. R., Dec, K., Hainline, B., Herring, S. A., Kane, S., … Roberts, W. O. (2019). American Medical Society for Sports Medicine Position Statement on Concussion in Sport. Clinical journal of sport medicine, 29(2), 87–100. doi:10.1097/JSM.0000000000000720

Heneghan, N. R., Smith, R., Tyros, I., Falla, D., & Rushton, A. (2018). Thoracic dysfunction in whiplash associated disorders: A systematic review. PloS one13(3), e0194235. doi:10.1371/journal.pone.0194235

Kennedy, E., Quinn, D., Tumilty, S., & Chapple, C. M. (2017). Clinical characteristics and outcomes of treatment of the cervical spine in patients with persistent post-concussion symptoms: A retrospective analysis. Musculoskeletal science & practice, 29, 91–98. doi:10.1016/j.msksp.2017.03.002

Kennedy, E., Quinn, D., Chapple, C., & Tumilty, S. (2019). Can the Neck Contribute to Persistent Symptoms Post Concussion? A Prospective Descriptive Case Series. The Journal of orthopaedic and sports physical therapy, 49(11), 845–854. doi:10.2519/jospt.2019.8547

Lal, A., Kolakowsky-Hayner, S. A., Ghajar, J., & Balamane, M. (2018). The Effect of Physical Exercise After a Concussion: A Systematic Review and Meta-analysis. The American journal of sports medicine, 46(3), 743–752. doi:10.1177/0363546517706137

Leddy, J. J., Haider, M. N., Ellis, M. J., Mannix, R., Darling, S. R., Freitas, M. S., … Willer, B. (2019). Early Subthreshold Aerobic Exercise for Sport-Related Concussion: A Randomized Clinical Trial. JAMA pediatrics, 173(4), 319–325. doi:10.1001/jamapediatrics.2018.4397

Makdissi, M., Schneider, K. J., Feddermann-Demont, N., Guskiewicz, K. M., Hinds, S., Leddy, J. J., … Johnston, K. M. (2017). Approach to investigation and treatment of persistent symptoms following sport-related concussion: a systematic review. British journal of sports medicine, 51(12), 958–968. doi:10.1136/bjsports-2016-097470

Mares, C., Dagher, J. H., & Harissi-Dagher, M. (2019). Narrative Review of the Pathophysiology of Headaches and Photosensitivity in Mild Traumatic Brain Injury and Concussion. The Canadian journal of neurological sciences, 46(1), 14–22. doi:10.1017/cjn.2018.361

McCrory, P., Meeuwisse, W., Dvořák, J., Aubry, M., Bailes, J., Broglio, S., … Vos, P. E. (2017). Consensus statement on concussion in sport-the 5th international conference on concussion in sport held in Berlin, October 2016. British journal of sports medicine, 51(11), 838–847. doi:10.1136/bjsports-2017-097699

McIntyre, M., Kempenaar, A., Amiri, M., Alavinia, S. M., & Kumbhare, D. (2020). The Role of Subsymptom Threshold Aerobic Exercise for Persistent Concussion Symptoms in Patients With Postconcussion Syndrome: A Systematic Review. American journal of physical medicine & rehabilitation, 99(3), 257–264. https://doi.org/10.1097/PHM.0000000000001340

Quatman-Yates, C. C., Hunter-Giordano, A., Shimamura, K. K., Landel, R., Alsalaheen, B. A., Hanke, T. A., … Silverberg, N. (2020). Physical Therapy Evaluation and Treatment After Concussion/Mild Traumatic Brain Injury. The Journal of orthopaedic and sports physical therapy, 50(4), CPG1–CPG73. https://doi.org/10.2519/jospt.2020.0301

Schneider, K. J., Leddy, J. J., Guskiewicz, K. M., Seifert, T., McCrea, M., Silverberg, N. D., … Makdissi, M. (2017). Rest and treatment/rehabilitation following sport-related concussion: a systematic review. British journal of sports medicine, 51(12), 930–934. doi:10.1136/bjsports-2016-097475

Schneider K. J. (2019). Concussion – Part I: The need for a multifaceted assessment. Musculoskeletal science & practice, 42, 140–150. doi:10.1016/j.msksp.2019.05.007

Schneider K. J. (2019). Concussion Part II: Rehabilitation – The need for a multifaceted approach. Musculoskeletal science & practice, 42, 151–161. doi:10.1016/j.msksp.2019.01.006

Schneider, K. J., Emery, C. A., Black, A., Yeates, K. O., Debert, C. T., Lun, V., & Meeuwisse, W. H. (2019). Adapting the Dynamic, Recursive Model of Sport Injury to Concussion: An Individualized Approach to Concussion Prevention, Detection, Assessment, and Treatment. The Journal of orthopaedic and sports physical therapy, 49(11), 799–810. doi:10.2519/jospt.2019.8926

Schwedt, T. J. (2020). Post-traumatic headache due to mild traumatic brain injury: Current knowledge and future directions. Cephalalgia: an international journal of headache, 333102420970188. Advance online publication. https://doi.org/10.1177/0333102420970188

Silverberg, N. D., Iaccarino, M. A., Panenka, W. J., Iverson, G. L., McCulloch, K. L., Dams-O’Connor, K., Reed, N., McCrea, M., & American Congress of Rehabilitation Medicine Brain Injury Interdisciplinary Special Interest Group Mild TBI Task Force (2020). Management of Concussion and Mild Traumatic Brain Injury: A Synthesis of Practice Guidelines. Archives of physical medicine and rehabilitation, 101(2), 382–393. https://doi.org/10.1016/j.apmr.2019.10.179

Streifer, M., Brown, A. M., Porfido, T., Anderson, E. Z., Buckman, J. F., & Esopenko, C. (2019). The Potential Role of the Cervical Spine in Sports-Related Concussion: Clinical Perspectives and Considerations for Risk Reduction. The Journal of orthopaedic and sports physical therapy, 49(3), 202–208. doi:10.2519/jospt.2019.8582


Icon for the Creative Commons Attribution-NonCommercial 4.0 International License

Evidence-Based Massage Therapy by Richard Lebert is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License, except where otherwise noted.

Share This Book