Etiology — what causes it

Multifactorial — primary neurometabolic and brain network dysfunction, plus secondary contributors (cervical, vestibular, ocular, autonomic, psychological). Sub-typing identifies the dominant drivers.

Epidemiology — who gets it

Roughly 10–15% of concussions in adults and up to 30% in youth experience persistent symptoms (Patricios et al., BJSM 2023). Risk factors include initial symptom severity, prior concussion, female sex (youth), and pre-existing migraine, mood, or sleep disorders.

Clinical signs

Comprehensive assessment including VOMS for vestibular/ocular, cervical assessment for whiplash-type contributors, Buffalo Concussion Treadmill Test for exertional component, and screening for sleep and mood.

Symptoms

Variable — headache, dizziness, visual disturbance, fatigue, brain fog, sleep and mood changes. Pattern depends on which sub-types predominate.

Best evidence for chiropractic treatment

The Ellis sub-typing model (Ellis et al.) and Amsterdam consensus support targeted treatment based on dominant sub-type — vestibular rehab, ocular rehab, cervical rehab, sub-symptom-threshold aerobic exercise, sleep and mood support. Each sub-type has its own targeted treatment with growing evidence base.

Subtypes

  • Vestibular. Dizziness, motion sensitivity — vestibular rehabilitation.
  • Ocular. Convergence/accommodation deficits — ocular motor therapy.
  • Cervical. Cervicogenic headache and dizziness — cervical rehab.
  • Exertional/autonomic. Symptom return with exertion — sub-symptom-threshold aerobic progression.
  • Migraine/headache. Often pre-existing; managed with combined approach.
  • Mood/cognitive. Anxiety, depression, sleep — appropriate co-management.

When to seek emergency care

Some symptoms need urgent medical attention — not a chiropractic visit. Call 911 or go to the nearest emergency department for: progressive limb weakness, loss of bowel or bladder control, saddle anesthesia (numbness in the groin/inner thighs), severe unrelenting pain unrelieved by position, signs of fracture after significant trauma, chest pain, stroke-like symptoms (face drooping, arm weakness, speech changes), or any rapidly worsening or unusual symptom.

Bottom line

Persistent symptoms aren't a single thing — they're sub-types. Identifying the dominant drivers and treating each specifically is what moves recovery forward.