Concussion series, Part 3: Post Concussive Syndrome, Second Impact Syndrome, and Treatment Strategies

Parts 1 and 2 discussed the pathophysiology and return to play guidelines for a concussed athlete. But what happens if the athlete’s symptoms don’t go away, and it’s been a month or more? The ICD-10 definition of Post Concussive Syndrome (PCS) states that in order to be diagnosed with PCS, the athlete must experience at least 2 or more symptoms for a span of at least 4 weeks (i.e. headaches, dizziness, nausea etc…).

Post concussive syndrome can be tricky because most often times, you will need to not just treat the physical symptoms of the athlete, but you have to address the psychosocial aspect as well. While many studies have shown that while physically an athlete can show no signs or symptoms as soon as a week (some recover as fast as 8 -15days), through magnetic resonance spectroscopy we’ve found that metabolically, it could take up to 30 days to fully recover. In many cases the athlete will have been told by someone, prior to seeing you, that they should rest until they are symptom free because it could further damage their brain. In Part 2, you’ll remember that in return to play/work/life guidelines, step 1 is brain rest and step 2 is light activity. Under most usual circumstances you need to be in a stage for 24 hours symptom free before progressing. However I did place an asterisk  next to step 1 because you do not want your athlete in this stage of more than 3-4 days, though sometimes up to 14 days max.


If an athlete comes to your clinic 3-4 weeks out from their concussion still symptomatic, and they’ve been on brain rest for this entire time, you’ll want to start them on some light activity to increase their hear rate.Aerobic exercise via bike and treadmill have been proven to help PCS athletes and non-athletes recover and become symptom free. Prolonged rest for an athlete can lead to deconditioning and metabolic deficits: which from Part 1 you’ll remember that a concussion is ultimately a mismatch in energy and is a metabolic syndrome of the brain. You do not want your athlete to become anxious and fear that looking at a screen will cause more damage (especially since they are a few weeks out from the initial injury) – fear avoidance behavior should be avoidedConsistently reassure the athlete and provide a timeline of how they’re improving towards their goals. Utilize positive language. If you haven’t please check out my interview with Dr. Ramez Antoun, PT, DPT who explains why language is so important and why it is often overlooked.

It is also interesting that studies have shown that if you exercise too soon (within the first week of recovery) you run the risk of doing more harm than good, but aerobic exercise starting between 14-21 days after injury has shown to improve cognitive function.

Aside from the physical symptoms similar to whiplash (suboccipital/upper trap/levator/SCM tightness, hypomobility in cervical spine etc…) you will want to also address any visual tracking/vestibular deficits they may still have. Think back to your Neurorehabilitation courses in PT school (shout out to all of the wonderful neuro inpatient rehab therapists out there). You will want to assess for any nystagmus and saccadic eye movement, re-train smooth pursuit, as well as use X1 and X2 activities to retrain the VOR. Dix-Hall pike and CRT roll maneuvers are examples of great for assessing and treating any vestibular deficits that made still be lingering (assess properly for specific vestibular deficits so that you can pick the correct treatment approach). Many outpatient PTs will often forget about the vestibular/visual tracking systems due to focus on manual therapy any joint/soft tissue restrictions, but these systems can ALSO contribute to any lingering symptoms.

Another very important topic, when discussing concussions, is Second Impact Syndrome. Second impact syndrome is when an athlete, prior to full metabolic AND physical recovery of a previous concussion, sustains a second concussion. In an athlete recovering from a concussion, there is metabolic deficits in the brain, disruption of the blood brain barrier, as well as diffuse axonal injuries that contribute to their symptoms. However, if an athlete recovers physically (but has not fully healed metabolically), they will run the risk of serious damage if a second hit is sustained. There will be an additive effect in second impact syndrome and can lead to increased intracranial pressure and decrease cerebral perfusion, leading to increased edema and swelling of the white matter.

Many athletes will argue they feel better and unless you have objective tests to run, you will have nothing prevent the athlete from going back in. This is why baseline testing is so crucial and important in contact sports. Having objective data to compare before and after injury will allow you as the clinician/therapist to make a better judgement on whether or not the athlete should be allowed to return to play. Asymmetries or cognitive scores lower than their baseline could indicate delayed metabolic healing. However, it’s better to be on the conservative side if you are unsure – athletes have died in the past due to Second Impact Syndrome (google Rowan’s Law, an athlete in Canada who died after sustaining a second hit prior to full recovery. Now, in Canada, you must be cleared by a trained medical professional in order to return to play to prevent Second Impact Syndrome).

While sometimes I think that the media can go a bit crazy and over report certain things, concussions are to be taken very seriously. This is not to say that you have to suspect that every little hit is a concussion, but you need to be vigilant if you’re covering a sport on the sidelines as well as if an athlete comes to your clinic. There is not enough education to the public at this moment about the severity of concussions and parents and athletes need to be informed. Concussions should not be brushed off as something minor, they are a form of brain injury and you only get 1 brain – make sure to take care of it!

'I don't think it's a concussion . . . although the smoke has me concerned.'


Leddy, J. J., MD et al Rehabilitation of concussion and post concussion syndrome. Sports Health. 4(2) 2012





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