Post-Concussion Dizziness in a Returning Athlete
A 19-year-old collegiate soccer player is 12 days post-concussion after a head-to-ball collision with brief loss of consciousness. She reports constant 'foggy' dizziness, worse with quick head turns and in busy visual environments like the cafeteria, plus headache and difficulty reading for more than 10 minutes. Her symptoms resolve at rest but return with exertion. She has no hearing loss, no true spinning vertigo, and no focal weakness. Her neurologist has cleared her for graded return-to-learn but not return-to-play. Today she asks whether she can 'just do the eye exercises' she saw online and get back on the field this weekend. Vitals are normal; she is on no medications.
1. How would you classify her dizziness, and what bedside findings would you expect versus fear on examination?
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Her presentation fits cervicogenic/visual-vestibular and autonomic subtypes of persistent post-concussive dizziness, not a peripheral vestibular lesion. The constant foggy sensation, visual motion sensitivity, and reading intolerance with normal hearing and no spinning point away from BPPV or vestibular neuritis.
Expect to find:
- Provocation with smooth pursuit and saccades in a busy visual field (visual motion sensitivity).
- Abnormal near-point convergence, often with a receded near point of convergence.
- Exaggerated symptoms with VOR cancellation and with rapid horizontal head turns, but a normal head impulse test bilaterally.
- Normal Dix-Hallpike and no positional nystagmus.
- Possibly symptom provocation on the Buffalo Concussion Treadmill Test at a low heart-rate threshold.
Fear to exclude:
- Central oculomotor signs (dysmetric saccades, impaired smooth pursuit, gaze-evoked nystagmus) suggesting more significant brain injury.
- Worsening headache with Valsalva or focal neurologic deficits.
- Orthostatic intolerance suggesting autonomic dysfunction.
Document baseline symptom scores so exercise dosing is titrated, not guessed.
2. She wants to return to play this weekend. What is your recommendation and how do you justify it?
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Do not clear her for return-to-play this weekend. She is 12 days post-injury, still symptomatic with cognitive and visual load, and has not completed a graded exertion protocol. Return-to-play requires being asymptomatic at rest, tolerating full school and cognitive load, passing a full exertional stepwise protocol, and medical clearance.
Reasoning:
- Early return increases risk of repeat injury, and repeat concussion during recovery carries risk of prolonged recovery and, rarely, catastrophic swelling.
- Her symptoms are provoked by exactly the tasks sport demands (rapid head turns, visual scanning, physical exertion).
- She has not yet demonstrated tolerance of full exertion without symptom recurrence.
Plan:
- Continue graded return-to-learn until she tolerates full cognitive load.
- Begin sub-symptom-threshold aerobic exercise (e.g., stationary bike at a heart rate below symptom provocation) 20–30 minutes daily.
- Add vestibular/oculomotor rehabilitation: convergence drills, gaze stabilization, and graded visual-motion exposure.
- Progress through a stepwise return-to-sport protocol only when each stage is symptom-free for 24 hours.
Frame this as a temporary restriction with a clear path forward, not a permanent prohibition.
3. How would you structure and dose her vestibular rehabilitation over the first two weeks?
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Goal: desensitize visual motion sensitivity, restore convergence, and build exercise tolerance without triggering symptom flares.
Dosing principle: use the '2-point rule' - mild symptoms (0–2/10) during exercise are acceptable and should settle quickly; if symptoms exceed 2–3/10 or persist more than a few minutes after stopping, the dose was too high. Start low and progress by increasing duration, then speed, then complexity.
Week 1 (daily, 2–3 short sessions):
- Gaze stabilization (VOR x1) horizontal and vertical, 1–2 minutes per direction, seated, plain background.
- Convergence: pencil push-ups or Brock string, 5 repetitions, several times daily.
- Graded optokinetic exposure: watching a moving target across a screen or walking through a quiet hallway, 2–3 minutes.
- Sub-threshold aerobic exercise on a bike, 20 minutes, heart rate kept below symptom threshold.
Week 2 (progress if tolerated):
- Add VOR x2 and standing balance with head turns.
- Increase visual-motion exposure to busier environments (grocery store, cafeteria) in short controlled bursts.
- Add sport-specific drills (ball tracking, light jogging with head turns) only if prior stages are symptom-free.
Monitor: daily symptom log, headache intensity, and sleep. Reassess near-point convergence and exercise heart-rate threshold weekly. Coordinate with her athletic trainer and physician before any contact activity.