Introduction 

Concussions are defined as a form of mild traumatic brain injury (mTBI) that can result from minor blows or impacts to the head. Concussions are common and are most likely to happen when participating in sports or other physical hobbies; however, concussions can also occur due to simple accidents in your everyday life. 

If you are concussed, the immediate symptoms you may experience will typically include headaches, dizziness, and confusion, however, these are often resolved within a few weeks. Unfortunately, some patients can experience long-term symptoms that persist beyond the initial phase. Persistent balance impairment is a notable long-term symptom that can seriously impact the quality of life.

Your sense of balance is the result of multiple complex systems working holistically. Your vision, vestibular (inner ear), and proprioceptive (sense of body position in space) systems all integrate to give you balance. 

A concussion can interfere with these systems, impairing your balance and increasing the chance of subsequent injury, as well as significantly disrupting your day-to-day life. 

Mechanisms of balance impairment post-concussion 

Located within the inner ear, the vestibular system and its functionality has a strong impact on your sense of balance and spatial orientation. Vestibular dysfunction is likely to result in balance impairment and can be a consequence of concussion. 

As well as physically disrupting the vestibular system, a concussion can impair your brain's ability to process sensory information, such as visual, vestibular, and proprioception stimuli, additionally contributing to the potential for long-term balance impairment post-concussion. 

The dysfunction of your balance will likely manifest as dizziness, vertigo, unsteady walking, and an inability to complete balance-based tasks, such as standing on one leg. 

The reported likelihood of experiencing balance issues post-concussion varies widely. Short-term balance impairment is experienced in 23% to 81% of concussion patients. Estimates of long-term balance impairment also have a large variance, affecting 1.2% of patients for 6 months to 32.5% for 5 years post-concussion.¹ 

Unfortunately, the effects of balance impairment aren’t limited to just physical dysfunction. The discomfort of dizziness and vertigo, as well as the brain's reduced ability to process sensory stimuli, can affect cognitive function, manifesting as difficulty concentrating, fatigue, and anxiety. 

Assessment of balance post-concussion

It is important to accurately assess your balance and the severity of any impairment to develop an effective rehabilitation plan. This can be achieved through the use of standardised physical tests administered by a healthcare professional. 

The balance error scoring system (BESS) is widely adopted and assesses your postural stability by having you complete a series of balance tasks.²

Tests that target the functionality of the vestibular system include the head impulse test (HIT) and the dynamic visual acuity (DVA) test. These tests will look at your ability to maintain visual focus while moving your head. They can identify disruption to a reflex, known as the vestibulo-ocular reflex, which can indicate vestibular impairment. 

Another option is the sensory organization test (SOT), which focuses on assessing how your ability to process visual and proprioceptive stimuli affects your balance. Using tests such as these in conjunction with each other can help to identify specific individualised causes of balance impairment post-concussion and guide the development of your rehabilitation.³

Rehabilitation strategies for balance problems 

Rehabilitation of balance impairment often requires a holistic approach integrating multiple disciplines such as physical therapy, vestibular rehabilitation therapy (VRT), and cognitive behavioural therapy. Ultimately, the end goal is quality of life improvement through treatment and management of symptoms, and restoring balance function.

Vestibular rehabilitation therapy (VRT)

If your balance impairment is a consequence of vestibular dysfunction, VRT will be fundamental in your treatment. It involves performing exercises that allow your vestibular system to adapt and compensate for its dysfunction. Examples include gaze stabilisation exercises, which can induce repair of the vestibulo-ocular reflex, and habituation exercises, to increase tolerance to sensitivity of motion, which in turn triggers dizziness and vertigo.⁴

Gaze stabilisation exercises will have you attempt to focus on still objects while moving your head in various patterns. The aim is to induce adaptation of your vestibulo-ocular reflex and effectively retrain it so that you can maintain visual focus, which is necessary for balance. 

The clue to habituation exercises is in the name, they aim to habituate and desensitise you to movement or environments that trigger balance impairment via recurrent exposure. 

There is evidence that VRT is effective in treating balance impairment and reducing symptoms such as dizziness and vertigo. Patients who undergo VRT are more likely to see quality-of-life improvements than those who don’t. However, there is evidence that treatment does not result in permanent or long-term rehabilitation, with benefits dissipating months after treatment, suggesting consistent long-term treatment may be necessary.^5,6

Balance training 

Balance training can also play an integral role in rehabilitation. It involves undertaking exercises that increasingly and progressively challenge your balance system, with the aim of improving your overall balance over time. Examples can include standing on one leg, walking on uneven surfaces, or performing certain movements or tasks with limited eyesight. The idea is to actively improve your balance, postural control, and associated vestibular, proprioceptive, and visual systems. 

Over time the exercises should become more difficult, starting at an appropriate level for your current ability and becoming more complex as your balance improves. An example of progression may be to begin by standing on a firm, flat surface with your eyes open, and then gradually progress to standing on an uneven surface with your eyes closed. It is fundamentally about progressively challenging your sense of balance so that it can continually adapt and improve.

Sensory integration therapy 

Sensory integration therapy (SIT) is designed to ameliorate the brain's capacity to process sensory information from multiple sources. SIT can be beneficial if the root cause of a patient's post-concussion long-term balance impairment is caused by an inability to process visual, proprioceptive, or vestibular stimuli. 

Similar to other therapies, SIT involves performing physical exercises and tasks. Examples include walking in a dark room, forcing reliance on proprioceptive stimuli and, hopefully, improving the ability to process the stimuli. Another example may be to stand on a balance board whilst performing a simple mental challenge, such as counting backwards. 

Unfortunately, research on SIT in the context of treating long-term post-concussion symptoms is limited. However, there is evidence that SIT is beneficial in treating sensory integration deficits in other contexts or patient groups. For instance, SIT has been shown to improve balance and coordination in autistic individuals with sensory processing disorder symptoms.⁷ 

Theoretically, we may be able to extrapolate that SIT can work for treating post-concussion-associated sensory processing disorders. However, it is important to understand that there is a lack of scientific research to confirm this.

Cognitive behavioural therapy

Cognitive behavioural therapy (CBT) can be used in conjunction with physical rehabilitation therapies, especially if anxiety or other psychological issues are exacerbated by impaired balance and the associated effects on a patient's quality of life. For instance, it is relatively common for patients with long-term impaired balance to have anxiety over falling, which can hamper rehabilitation. 

CBT attempts to identify negative thought patterns and challenge them by developing healthy coping strategies to manage anxiety. If a patient has anxiety regarding situations that are likely to trigger dizziness, CBT may attempt to expose them to those situations whilst using techniques to increase resilience and reduce anxiety. 

There is currently little evidence to suggest CBT is effective in reducing the physical symptoms associated with post-concussion balance impairment.⁸ However, it may have the potential to help patients cope with any negative psychological aspects.

Exercise and physical activity

There is evidence that aerobic exercise, including walking, cycling, swimming, and jogging, can improve cognitive function and reduce balance impairment in post-concussion patients. An individualised exercise program built to suit a patient’s physical background can be effective in reducing post-concussion-associated symptoms and can increase the rate of recovery.⁹ 

It is important that the exercise program is closely monitored by a healthcare professional to ensure it is appropriately suited to the individual and progresses safely. 

Summary

Balance impairment can be a serious long-term post-concussion symptom with large quality-of-life implications. Thorough, careful assessment and an individualised rehabilitation treatment plan are required to achieve the best patient outcomes. 

Vestibular rehabilitation therapy, balance training, sensory integration therapy, cognitive-behavioural therapy, and carefully managed physical activity can, depending on the individual, be integrated and contribute to recovery. A holistic approach to balancing physical and psychological therapies should be considered. 

If you ever suffer from a concussion and are concerned about your symptoms, do not hesitate to contact a healthcare professional.