Post-concussion syndrome (PCS) describes a constellation of potential symptoms that commonly occur after sustaining a mild traumatic brain injury. 

Signs of PCS can present as physical, cognitive and emotional disturbances (outlined in Table 1). 

Research indicates that when PCS is identified and managed early, the prognosis is favourable (Le Sage et al 2022) but when missed, symptoms can last for years and even become permanent (Ryan & Warden 2003). 

Unfortunately, it has also been well documented in the literature that PCS is often missed in the acute stages of injury for various reasons, including delayed onset of symptoms (Ryan & Warden 2003), inconsistencies in the patient history, lack of a ‘gold standard’ to distinguish PCS symptoms from those of another differential/concurrent diagnosis such as whiplashassociated disorder (WAD) and inconsistent implementation of guideline-based care across emergency departments and primary care facilities (Rebbeck et al 2019). 

A diagnosis of PCS is appropriate in the presence of significant cognitive impairments, a cluster of symptoms consistent with those described by either the International Classification of Diseases or the Diagnostic and statistical manual of mental disorders and an elevated Rivermead Post-Concussion Symptoms Questionnaire score (Boake et al 2005, Owen & Taylor 2005, Kessels et al 2000, American Psychiatric Association 2000). 

However, as shown in Table 1, the overlap between PCS and WAD symptoms presents a challenge in a definitive diagnosis of PCS (Kessels et al 2000). 

When PCS is a potential clinical diagnosis, minimum screening should consist of administering questionnaires and a cranial nerve assessment (Rebbeck et al 2019) as well as utilisation of a validated tool such as the Vestibular Ocular Motor Screening (VOMS) assessment (Mucha et al 2014). 

Once minimum screening suggests a PCS diagnosis, ensuring that a multidisciplinary team is in place to undertake relevant additional assessment and provide evidence-based, collaborative care is crucial for optimising a patient’s prognosis (Schneider 2019a, Schneider 2019b). 

The following case study describes a patient who experienced a delayed diagnosis of PCS and delayed care as a result. 

The patient’s history that led to this diagnosis being delayed will be explored, along with the factors that ultimately led to suspicion of and assessment for PCS.

Physiotherapy care that I provided over the course of the patient’s rehabilitation will also be reflected on, including ways in which my management could have been better and things I will be more considerate of in the future when assessing and managing patients with traumatic neck and head injuries

Initial assessment

Subjective findings

JV is a 56-year-old male heavy vehicle driver who experienced a work-related neck injury six months before my review. 

While he was helping to unload a trailer on his vehicle, a large tyre fell from the trailer and struck JV in the back of the head, fracturing his C1. 

There was no loss of consciousness reported and the initial subjective history and medical referral documentation focused on JV’s structural pathology.

He was managed in a cervical halo for 12 weeks. JV underwent an independent specialist physiotherapy review, which described a significant movement impairment, some general right shoulder restriction, neural sensitivity in the right shoulder and upper limb, and some fear-avoidant behaviours. He was on-referred to physiotherapy with a recommendation for hands-on treatment, mobility exercise, gradual return to gymbased activities and facilitation of confidence with movement. 

My review of JV was one month later. 

He reported a constant localised ache central to his upper cervical region. 

This pain was aggravated by prolonged postures and repetitive neck movements, which would then cause headaches behind both eyes, of equal intensity. 

He also described a persistent burning sensation in his upper trapezius and deltoid region as well as pins and needles in his dorsal wrist and proximal second and third digits, which he described as having worsened since he came out of the halo.

A subjective screen for vertebrobasilar insufficiency was unremarkable and at this stage JV reported no dizziness or double vision. 

JV was able to go on some light walks, do some beach fishing and perform some very light dumbbell activities but having been very active and disciplined with his exercise routine prior to his accident, he felt incredibly frustrated with his situation. 

At this stage, JV described his sleep as being quite impaired. He noted that he could fall asleep easily but would wake up through the night with an elevated heart rate and feeling anxious. 

He also described being irritable, which he attributed to lack of sleep, and scored 7/10 for anxiety on his initial SF Örebro, with an overall score of 56/100. 

The SF Örebro score was lower than the 75/100 described in the specialist physiotherapy report but still indicated a risk of delayed return to work (Beales et al 2021). 

No questioning with regards to individual Örebro question scores was completed. 

Figure 1 outlines JV’s distribution of symptoms.

Objective findings

Upon initial assessment, the immediate concern was of a developing C7 conduction loss. Initial management consisted of manual therapy to improve cervical range of motion and reduce headaches and shoulder/scapula exercises to strengthen the weakened and deconditioned muscles. 

The key findings from the initial assessment (outlined in Table 2) were communicated to the referring physiotherapist, treating GP and injury management adviser. 

JV was subsequently referred for an MRI, which confirmed a C7 nerve root compression. 

He was then referred for a review by a neurosurgeon, who recommended a C6–C7 decompression surgery. 

A recommendation for psychologist-led adjustment to injury counselling was also communicated to the insurance company and they organised this. 

Over the next four months, JV demonstrated modest improvement in his cervical mobility and overall shoulder strength. 

However, his neuropathic pain remained unchanged and his triceps, serratus anterior and rotator cuff external rotation strength did not improve. 

Coupled with a significant delay in surgery approval, this meant that physiotherapy remained focused on JV’s cervical and neurological impairments. 

Over this time, JV continued to report poor sleep and irritability, which remained unchanged. 

The recommended surgery eventually occurred seven months after his initial presentation to physiotherapy, after which time JV’s neurological symptoms significantly improved.

Assessment of post-concussion symptoms

Ten weeks following surgery (11 months post-injury), JV had started to significantly increase his cardiovascular and strength training. 

At this time, he reported an increase in dizziness, fatigue and concentration and memory issues as well as persistent tinnitus in his left ear. 

He also described getting double vision when going on brisk walks with his partner. 

He had commented on issues with dizziness and concentration in the previous months, but these were very mild and infrequent at the time and were overlooked due to increased focus on his neck and arm symptoms. 

When discussing any investigations that occurred after the initial injury, JV wasn’t sure if an MRI of the brain was completed at this stage. 

JV had shown consistent improvement with his rehabilitation and was confidently completing a lot of his daily activities at a high level, such as fishing, boating and heavy resistance training. 

However, his primary goals were returning to work and completing high-level cardiovascular exercise, which he felt his remaining symptoms were preventing. 

He also described wanting to be happier and more present in his home life, which he felt his irritability, concentration issues and sleep disturbance were impacting. 

Further questioning using the Diagnostic and statistical manual of mental disorders (American Psychiatric Association 2000) showed that JV met the subjective criteria for PCS, namely: 

• becoming fatigued easily
• disordered sleep
• headaches
• dizziness
• visual disturbance
• irritability on little provocation
• apathy/lack of spontaneity. 

The signs of exercise intolerance described earlier are also a common indication of PCS (Mucha & Trbovich 2019). 

A Rivermead Post-Concussion Symptoms Questionnaire (Balalla et al 2020) was administered, on which JV scored 39/64. 

Notably, JV had maximum scores for light sensitivity, double vision, irritability, sleep disturbance and memory. 

This indicated that PCS was likely a part of JV’s clinical presentation (King et al 1995). 

Further physical assessment was conducted. 

At this stage, JV’s upper cervical symptoms and headaches had improved; however, he still had significantly restricted upper cervical movements in all planes as well as mild tenderness over his suboccipital region that referred behind his eyes with increased pressure.

A cranial nerve assessment was completed. 

Dizziness and double vision were present, with eye depression and left abduction eye movements. 

The remaining cranial nerve tests were unremarkable. 

A Buffalo concussion bike test (Janssen et al 2022) was performed. JV started noticing blurred vision at the four-minute mark and the test was ceased five minutes into testing. 

A VOMS assessment (Mucha et al 2014) was completed and the results supported the preliminary diagnosis of PCS. 

The individual tests completed revealed the following: 

• smooth pursuit—JV had difficulty tracking an object in the left end range of his vision
• saccades—JV expressed difficulty with concentration in completing this test
• near point of convergence—JV experienced this at 20 centimetres, a greater distance than the usual cut-off of five centimetres (Heick & Bay 2021)
• head impulse test—saccade with left-sided testing
• visual motion sensitivity was not tested at this stage. 

A Dix-Hallpike test was also performed, which didn’t elicit any of JV’s symptoms. 

Given that dizziness symptoms are also often associated with cervical impairment following neck trauma (Treleaven 2017), additional testing was completed to gauge the presence of a cervicogenic influence on JV’s symptoms. 

Testing revealed the following: 

• joint position sense/error testing—significant deviations with leftsided testing
• standing balance—unable to hold left static balance for more than six seconds. With left cervical rotation, this test was unable to be completed
• smooth pursuit neck torsion—increased visual disturbance and dizziness with left cervical rotation. 

The patient’s sensitivity to light and noise, significant cognitive deficits, elevated Rivermead Post-Concussion Symptoms Questionnaire score and positive Buffalo concussion bike test strongly suggested the presence of PCS. 

However, the clinical history and prevailing literature also indicated WAD symptoms, which led to communication with other key stakeholders in JV’s treatment team. 

The treating neurosurgeon and injury management adviser were contacted to discuss the potential diagnosis and implications for care and recovery. 

The neurosurgeon referred for a brain MRI, which reported no abnormal findings. 

The insurer referred JV for a second opinion with a vestibular physiotherapist, who confirmed a diagnosis of ‘post-injury cognitive dysfunction’ and ‘post-injury vestibulo-ocular and balance dysfunction which may be driven by cervicogenic and/or post-concussion factors’.

Management

Once approval was gained from the workers compensation insurer, treatment commenced. 

There is recognition in the literature that rehabilitation expedites recovery for PCS symptoms with a strong vestibulo-ocular component (Gianoli 2022). 

Rehabilitation initially focused on exercises aimed at graded exposure to the uncovered vestibular and cervicogenic deficits, including: 

• smooth pursuit exercises in sitting and standing
• static single-leg balance exercises, first with head kept still, then adding head turning as this became easier
• dynamic balance exercises—starting with tandem walking and adding head turning as a progression
• joint proprioception training—using a target and laser to practise left rotation and a return to centre
• an interval program on a stationary bike to build up aerobic capacity. 

In collaboration with JV, a rehabilitation plan was developed to incorporate this evidence-based treatment and to set up a walking plan that progressively increased pace. 

JV would record this using a smartwatch, noting how long it took for his symptoms to come on. 

He started considering return-to-work options and a plan was developed in consultation with his treating physiotherapist and GP. 

JV also engaged with a psychologist as well as an occupational therapist with experience in PCS to assist with the cognitive aspects of his rehabilitation. 

Both new stakeholders were communicated with to outline treatment to date and to seek additional feedback on the physiotherapy treatment plan. 

JV continued with his strength and conditioning program, which had previously been set up over the course of physiotherapy for his neck and right upper quadrant and was now integrated into an independent gym program.

Results

Four months after initiation of treatment, JV reported a reduction in symptom frequency and duration, improvement in balance and increased tolerance to cardiovascular activity. 

He said that he was sleeping better and was a lot less irritable and that his home life and relationships had improved as a result. 

JV described being able to walk and cycle unrestricted and without symptoms, which allowed him to exercise regularly with his partner. 

JV had also fulfilled his return-to-work goal, resigning from his truck driving role and accepting a supervisor position on a mine site. 

JV was now quite independent with his rehabilitation, attending physiotherapy on a three-weekly basis. 

His program at this stage consisted of dynamic balance exercises, smooth pursuit in tandem stance and joint position training using complex patterns (eg, tracing non-symmetrical shapes) and in dynamic environments (eg, while walking, in a busy gym space). 

He was close to being discharged from physiotherapy care and closing his workers compensation claim. 

Despite these improvements, JV continued to have a significant cervical movement impairment, as shown in Table 3. 

He underwent an independent medical exam with a neurosurgeon, who attributed this to complications with the C1 healing process and was guarded with regards to how much further mobility JV would gain.

Discussion

This case study shows the importance of comprehensive assessment of post-concussion symptoms in guiding patient care. 

Through thorough testing of JV’s symptoms, a working diagnosis of PCS was reached, with an understanding that there was a potential overlap of WAD symptoms and a significant cervicogenic contribution to symptoms (Rebbeck et al 2019). 

Being able to articulate these findings to the insurance company enabled assessment in the form of a second opinion, which led to this condition being accepted as part of JV’s workers compensation claim and therefore improved access to appropriate multidisciplinary care. 

The comprehensive assessment also informed the management of JV’s specific impairments. 

The deficits in his balance and joint position sense were targeted with specific exercises as part of his overall management plan and this led to meaningful improvement over the course of his rehabilitation (Treleaven 2017). 

The specific rehabilitation program was accompanied by a more holistic management plan involving improved walking capacity, engagement in goal-setting activities, more collaborative multidisciplinary care and a deeper understanding of JV’s goal to increase cardiovascular capability and return to work. 

The case also highlights the importance of a physiotherapist’s role within a multidisciplinary team to proactively communicate with the relevant parties over the course of rehabilitation (Marwaa et al 2023). 

Initial written and verbal communication facilitated further investigation into JV’s worsening radicular symptoms, which led to appropriate medical intervention and ultimate improvement in JV’s symptoms. 

Once JV’s PCS symptoms were identified, communication with key stakeholders enabled further investigation and establishment of a multidisciplinary team to optimise JV’s management and recovery. 

While the overall outcome was positive, there were some notable areas in JV’s management that could have been improved. 

The clearest concern was the delay in recognising signs that could have led to an earlier diagnosis and earlier access to treatment.

One of the key challenges in diagnosing PCS is that symptoms can be subtle in the initial stages (Corwin et al 2020).

Given this and considering the time-sensitive issues of worsening radiculopathy and significant upper cervical impairments, it is understandable that these symptoms weren’t initially given priority. 

However, the way JV described his sleep disturbances, high anxiety and irritability in the early stages of his presentation should have provided sufficient information to screen for PCS at this stage, instead of simply arranging psychological review. 

It should also be noted that the care provided throughout was not as psychologically informed as evidence-based care would recommend (Lin et al 2020), even when the presence of psychosocial influences was identified. 

Upon reflection, more emphasis should have been put on integrating this into the patient’s care and collaborating with the treating psychologist and occupational therapist, rather than solely focusing on managing the patient’s physical impairments. 

A more detailed investigation to distinguish between postconcussion and other psychological influences on JV’s condition would have been very useful when recommending a referral to a psychology service. JV’s initial reporting of sleep disturbance may have been suggestive of post-traumatic stress disorder and an Impact of Event Scale would have been an appropriate tool to screen for this (Beck et al 2008). 

Another limiting factor in JV’s assessment was the lack of specific additional vestibular testing as part of the examination of JV’s dizziness symptoms. 

Vestibular impairments are observed frequently in conjunction with PCS (Broglio et al 2015) and given that cervicogenic dizziness is a diagnosis of exclusion, more consideration needed to be given and thorough testing completed before it was decided that JV’s symptoms had a strong cervicogenic component (Reiley et al 2017). 

Visual motion sensitivity—an important part of the VOMS assessment—was omitted due to physiotherapist error. 

Vestibular testing was more systematically conducted during the vestibular physiotherapist’s assessment, including a comprehensive VOMS assessment and use of the Modified Balance Error Scoring System (Iverson & Koehle 2013). 

She agreed that JV’s symptoms were most likely due to a combination of vestibulo-ocular and cervicogenic factors, which ensured that the rehabilitation JV was guided through was consistent with his presentation. 

Despite these limitations and the complexity of JV’s situation, JV’s care was ultimately quite successful and at the time of discharge, JV was independently managing his remaining symptoms, was exercising at his pre-injury levels and had taken a full-time position requiring significant levels of cognition and concentration. 

The management of his rehabilitation was a very steep but rewarding learning experience in the management of PCS.

Conclusion

As well as highlighting the complexity and challenge of identifying and managing PCS, this case study underscores the importance of identifying and addressing symptoms early, initiating management that targets a patient’s specific impairments and communicating with all key stakeholders to ensure that the patient receives appropriate multidisciplinary care. 

JV provided consent to use this information as part of the case study.

>>Aaron Peden MACP is an APA Titled Musculoskeletal Physiotherapist and a senior physiotherapist at Body Sense Physiotherapy in Perth, Western Australia. Aaron is a registrar of the Australian College of Physiotherapists.

• References