The Short Answer Educational content only. Any suspected concussion warrants medical evaluation. Consult vestibular-trained physical therapist, neuro-optometrist, or concussion specialist for individualized guidance. Concussion causes central vestibular dysfunction through injury to brainstem, cerebellum, thalamus, and cortical vestibular processing centers (Silverberg et al., 2020). Central dysfunction differs from peripheral (inner ear) dysfunction in symptom pattern and rehabilitation approach. Central patterns include atypical nystagmus (vertical, direction-changing, gaze-evoked), saccadic pursuit, impaired vestibulo-ocular reflex (VOR) cancellation, dysmetric saccades, and impaired visual motion processing. Diagnosis includes VOMS (Vestibular/Ocular Motor Screening), videonystagmography (VNG), rotary chair testing, and neuroimaging when indicated. Rehabilitation requires central-focused approach including gaze stabilization, cortical integration, and cognitive-motor dual tasking. Vestibular-trained physical therapist with central dysfunction expertise essential. Concussion damages brainstem, cerebellum, cortical vestibular centers. Damages central vestibular centers. Central patterns differ from peripheral. Central patterns differ from peripheral. Central-focused rehabilitation required. Central-focused rehabilitation required. Central Vestibular Structures Affected Brainstem vestibular nuclei. Brainstem vestibular nuclei. Cerebellum (flocculus, nodulus, uvula). Cerebellum flocculus nodulus uvula. Thalamus vestibular relay. Thalamus vestibular relay. Parieto-insular vestibular cortex. Parieto-insular vestibular cortex. Vestibulo-ocular pathways. Vestibulo-ocular pathways. Vestibulo-spinal pathways. Vestibulo-spinal pathways. Vestibulo-cortical pathways. Vestibulo-cortical pathways. Central Dysfunction Signs Vertical nystagmus (downbeat or upbeat). Vertical nystagmus. Gaze-evoked nystagmus. Gaze-evoked nystagmus. Direction-changing nystagmus. Direction-changing nystagmus. Saccadic pursuit. Saccadic pursuit. Impaired VOR cancellation. Impaired VOR cancellation. Dysmetric saccades. Dysmetric saccades. Impaired visual motion processing. Impaired visual motion processing. Abnormal head impulse test on multiple planes. Abnormal head impulse test multiple planes. Skew deviation. Skew deviation. Ocular tilt reaction. Ocular tilt reaction. Symptoms Distinguishing Central from Peripheral Continuous dizziness (vs episodic peripheral). Continuous dizziness central. Non-fatiguing nystagmus (vs fatiguing peripheral). Non-fatiguing nystagmus central. Vertical or direction-changing nystagmus. Vertical or direction-changing. Impaired VOR cancellation. Impaired VOR cancellation. Coexisting neurological symptoms. Coexisting neurological symptoms. Slower recovery. Slower recovery. Complex rehabilitation needs. Complex rehabilitation needs. Diagnostic Testing VOMS (Vestibular/Ocular Motor Screening). VOMS. Videonystagmography (VNG). Videonystagmography VNG. Video head impulse test (vHIT). Video head impulse test vHIT. Rotary chair testing. Rotary chair testing. Dynamic visual acuity. Dynamic visual acuity. Computerized dynamic posturography. Computerized dynamic posturography. MRI brain when indicated. MRI brain when indicated. Neurological examination. Neurological examination. Post-Concussion Central Dysfunction Patterns Vestibulo-ocular dysfunction most common. Vestibulo-ocular dysfunction most common. Saccadic dysfunction 50-70%. Saccadic dysfunction 50-70%. Smooth pursuit dysfunction 40-60%. Smooth pursuit dysfunction 40-60%. VOR gain reduction. VOR gain reduction. Impaired gaze stability. Impaired gaze stability. Motion sensitivity. Motion sensitivity. Visual motion sensitivity. Visual motion sensitivity. Rehabilitation Approach Gaze stabilization exercises. Gaze stabilization exercises. VOR adaptation exercises. VOR adaptation exercises. Habituation exercises. Habituation exercises. Cortical integration exercises. Cortical integration exercises. Cognitive-motor dual tasking. Cognitive-motor dual tasking. Balance retraining. Balance retraining. Visual motion desensitization. Visual motion desensitization. Sensory integration training. Sensory integration training. Prognosis Slower recovery than peripheral. Slower recovery than peripheral. 12-24 week rehabilitation common. 12-24 week rehabilitation common. Central-trained PT essential. Central-trained PT essential. Chronic residual symptoms possible. Chronic residual symptoms possible. Compensation over time. Compensation over time. Supporting Mobility Routine These exercises support central vestibular rehabilitation through cervical mobility and nervous system regulation. JME 155 Diaphragmatic breathing supports vagal tone and parasympathetic regulation during concussion recovery. 10 breaths every 60-90 minutes. JME 14 Chin tucks reduce upper cervical tension common in concussion injury. 10 repetitions with 5-second holds. JME 1 Cervical rotation supports cerebral blood flow and nervous system regulation. 10 repetitions each direction. JME 150 Thoracic rotation restores breathing depth shallow during concussion recovery. 8 repetitions per direction. Start your 3-day free trial for joint-specific mobility programs that support nervous system regulation through concussion recovery. How is central vestibular dysfunction different from peripheral? Central dysfunction involves brain (brainstem, cerebellum, cortex). Peripheral dysfunction involves inner ear (labyrinth, vestibular nerve). Central features vertical or direction-changing nystagmus, non-fatiguing nystagmus, impaired VOR cancellation, and often coexisting neurological symptoms. Peripheral features horizontal nystagmus, fatiguing nystagmus, and isolated vestibular symptoms. Both can occur after concussion. Why does concussion cause central vestibular dysfunction? Concussion causes diffuse axonal injury affecting brainstem, cerebellum, and cortical vestibular processing centers. Vestibular nuclei in brainstem particularly vulnerable. Cerebellar vermis and flocculus commonly affected. Cortical vestibular processing altered. Multiple vestibular pathways can be simultaneously affected creating complex dysfunction patterns. How long does central vestibular rehabilitation take? Central vestibular rehabilitation typically 12-24 weeks longer than peripheral (4-12 weeks). Complex dysfunction requires longer rehabilitation. Cortical integration exercises take longer to show benefit. Chronic residual symptoms possible. Combined with cognitive rehabilitation. Central-trained PT essential. Do I need brain MRI for central vestibular dysfunction after concussion? Brain MRI indicated for atypical presentations, focal neurological signs, prolonged symptoms, or diagnostic uncertainty. Standard MRI often normal in concussion-related central dysfunction. Diffusion tensor imaging and functional MRI may show abnormalities. Neuro-otologist evaluation supports imaging decision. Should I see a specialist for post-concussion central vestibular dysfunction? Yes. Neuro-otologist or vestibular neurologist supports diagnosis. Vestibular-trained physical therapist with central dysfunction expertise essential for rehabilitation. Neuropsychologist for cognitive-motor assessment. Concussion clinic coordinates multidisciplinary care. Not all vestibular therapists trained in central dysfunction. References Patricios, J. S., et al. (2023). Consensus statement on concussion in sport: the 6th International Conference on Concussion in Sport, Amsterdam, October 2022. British Journal of Sports Medicine, 57(11), 695-711. PubMed Silverberg, N. D., et al. (2020). Management of concussion and mild traumatic brain injury: a synthesis of practice guidelines. Archives of Physical Medicine and Rehabilitation, 101(2), 382-393. PubMed