Why Concussion Symptoms Persist & How to Manage Them

Persistent Concussion Symptoms (PCS) are debilitating for patients and for many physios, very challenging to treat.

In his recent Case Study, expert in concussion and PCS, Cameron Marshall, explores not one but two complex PCS cases and explains how he applied a treatment algorithm to achieve meaningful outcomes for both patients. It’s a great reminder that even the most overwhelming presentations usually make more sense when we understand the underlying mechanisms and follow a clear clinical process. This blog highlights some key info Cameron covers in his Case Study.

If you want to see exactly how concussion expert Cameron Marshall manages real-life cases with PCS, check out his full Case Study HERE. With Case Studies you can step inside the minds of experts and apply their strategies to get better results with your patients. Learn more here.

What is concussion?

This is a good place to start. Once thought to be a coup–contrecoup injury, our understanding of concussion has shifted over the years. We now know it’s less about the brain bouncing around the skull and more about the stretching and shearing of axons in the white matter, leading to temporary changes in how the brain functions. That load on the system creates a cascade of metabolic and neurological changes.

But Cameron explains this far better, check out this clip from his Case Study:

What are persistent concussion symptoms?

Here’s the part that surprises and relieves a lot of patients: persistent symptoms aren’t due to ongoing brain damage. Most brains recover within three to four weeks. So why do symptoms drag on for months or even years in some cases?

Cameron outlines several leading theories, but the reality is that many patients have a mix of these rather than a single driver.

1 – Autonomic nervous system dysregulation:
Some patients get stuck in a persistent fight-or-flight state. This can mess with blood flow, digestion, sleep, stress levels, hormones, cognition, and can even show up as orthostatic intolerance.

2 – Neuroinflammation and hormone dysregulation:
Chronic inflammation can be tied to cognitive changes, fatigue, headaches, energy fluctuations, and even mood. Add to that the gut–brain axis and you have a system that’s sensitive to sleep, diet, stress, and exercise. These lifestyle factors become part of treatment, not afterthoughts.

3 – Visual and vestibular dysfunction:
Problems with eye movements, convergence, or the vestibular system can easily perpetuate dizziness, headaches, and fatigue.

4 – Cervical dysfunction:
Cervical issues can mimic or worsen concussion symptoms, especially headaches, dizziness, and brain fog. And because the mechanism of injury is often the same, it’s common for both cervical and concussion-related drivers to be at play.

5 – Psychological factors:
Rates of depression and anxiety are higher in people with PCS, but it’s still unclear whether this is caused by the neurophysiological effects of the concussion itself or by the impact of ongoing symptoms on function, stress, and quality of life. Anxiety or stress can exacerbate and perpetuate common problems such as decreased cognitive function and sleep disturbances.

How do you treat PCS?

As with many complex conditions, PCS almost always responds best to a multimodal, multidisciplinary approach.

No single treatment fixes everything, and most patients need input and support across several domains. The challenge for physios is figuring out where to start and how to pace exposure in a way that builds confidence instead of triggering flare-ups.

Cameron explains his PCS treatment algorithm in the below video from his Case Study:

The cases

Case 1 was a 27-year-old woman with six years of symptoms after a fall overseas. She was prescribed bed rest in the early stages, which we now know can be counterproductive, and had seen multiple specialists with little improvement. She presented with worsening symptoms whenever cognitive load increased and hadn’t been able to exercise since the fall. Neurologically, her exam was clear.

Case 2 was a 24-year-old education assistant with 7 months of symptoms. Her presentation was very different: gross motor dysfunction, visual disturbances, cerebellar involvement, and even aphasia – but only when reading aloud! A great example of how PCS can look completely different from one patient to the next.

Cameron demonstrates exactly how he applies the PCS algorithm in real time, what he prioritises first, and how he builds patient confidence in his Case Study, so make sure you check it out!

Wrapping up

Concussions can be overwhelming for both patients and clinicians – while PCS can be distressing for the patient, they’re far from hopeless.

When we understand the mechanisms that keep symptoms going, we’re much better placed to assess, explain, and guide patients through a structured plan. Cameron’s approach shows that even long-standing cases can improve with the right management combination.

If you want to see this process in action and get more comfortable managing PCS in your own clinic, be sure to watch Cameron’s full Case Study HERE.