Every Concussion Includes a Cervical Injury The force that concusses the brain simultaneously injuries the cervical spine. Concussion requires rapid acceleration-deceleration of the head. This same force produces whiplash: strain of the cervical joints, muscles, and ligaments. The cervical injury occurs in 100% of concussions because the mechanism is identical. The brain injury receives attention. The cervical injury often does not (Marshall et al., 2015). The upper cervical spine (C1-C3) produces symptoms identical to brain-based PCS. The trigeminocervical nucleus, where cervical afferents converge with the trigeminal nerve, produces headache that is indistinguishable from post-traumatic migraine. Cervical proprioceptive dysfunction produces dizziness that is clinically similar to vestibular dysfunction. Cervical arterial compression or irritation produces brain fog through reduced posterior brain blood flow. These cervical mechanisms produce the "big four" PCS symptoms (headache, dizziness, brain fog, fatigue) without any ongoing brain dysfunction. Cervical-driven PCS is the most common form of persistent PCS. Studies of patients with PCS beyond 3 months show cervical dysfunction contributing to symptoms in 60-70% of cases. In many of these patients, the cervical spine is the primary or sole symptom generator. The brain injury resolved within the expected timeframe, but the cervical injury was never addressed, producing persistent symptoms attributed to the brain. How to Identify Cervical-Driven PCS Clinical signs that suggest cervical contribution: Headache that worsens with sustained head positions (looking down, turning) Dizziness triggered by head movement rather than visual stimulation Neck pain or stiffness (present in most cases but sometimes absent) Headache that starts at the base of the skull and radiates forward Symptoms that improve with manual cervical treatment Brain fog that correlates with neck position or cervical loading Diagnostic tests a physiotherapist uses: Flexion-rotation test: Tests C1-C2 rotation. Restriction greater than 10 degrees compared to the other side indicates upper cervical dysfunction with 91% sensitivity for cervicogenic headache. Manual palpation of C1-C3: Tenderness and stiffness at the upper cervical segments indicates local dysfunction. Reproduction of the patient's headache pattern during palpation confirms the cervicogenic source. Cervical proprioception testing: Head repositioning accuracy test. Error greater than 4.5 degrees indicates proprioceptive dysfunction consistent with cervicogenic dizziness. Smooth pursuit neck torsion test: Compares eye tracking with the trunk straight versus rotated. Increased eye tracking errors with trunk rotation indicates cervical contribution to oculomotor symptoms. The diagnostic challenge: cervical and brain-based symptoms coexist. Most PCS patients have both cervical and brain-based contributors. The clinical task is determining the relative contribution of each. Cervical treatment trial is the most practical diagnostic approach: if symptoms improve with 2-4 weeks of cervical rehabilitation, the cervical contribution is confirmed. Cervical Rehabilitation Exercises JME 14 Chin tucks are the foundational exercise for cervical-driven PCS. Deep cervical flexor retraining addresses the primary muscle dysfunction in upper cervical injury. The deep cervical flexors (longus colli, longus capitis) stabilize the upper cervical segments. When weak, the superficial muscles (sternocleidomastoid, upper trapezius) compensate, producing compression and irritation at C1-C3. Chin tucks retrain deep flexors and reduce superficial compensation. 10 repetitions with 5-second holds, 3-4 times daily. JME 1 Cervical rotation directly addresses the upper cervical joint stiffness and proprioceptive dysfunction central to cervical-driven PCS. Controlled rotation within the pain-free range provides proprioceptive input that recalibrates the cervical position sense. Each repetition teaches the brain to integrate cervical movement with spatial orientation, reducing cervicogenic dizziness. 10 repetitions each direction, 3 seconds per direction. JME 155 Diaphragmatic breathing supports cervical rehabilitation by reducing the sympathetic activation that maintains cervical muscle guarding. Sympathetic overdrive produces sustained contraction of the superficial cervical muscles, perpetuating the compression and irritation that drives cervicogenic symptoms. Parasympathetic activation through breathing releases this guarding and creates the conditions for cervical rehabilitation to work. 10 breaths, 4-5 times daily. JME 150 Thoracic rotation is essential for cervical-driven PCS because thoracic stiffness directly increases cervical load. When the thoracic spine does not rotate, the cervical spine must provide compensatory rotation. This compensation loads the already-injured upper cervical segments. Restoring thoracic mobility reduces the mechanical demand on the cervical spine, allowing cervical healing. 8 repetitions per direction. Start your 3-day free trial for cervical-focused concussion recovery programming. Progressive Cervical Rehabilitation JME 3 Lateral cervical flexion addresses the scalene and upper trapezius tightness that compresses the upper cervical spine. In cervical-driven PCS, these muscles are chronically shortened from protective guarding. The tightness maintains the joint compression that produces headache and dizziness. Regular stretching reduces compression and allows the deep cervical flexors to function. 8 repetitions per side, 15-20 second holds. JME 15 Cervical extension restores the posterior cervical mobility that cervical-driven PCS restricts. Extension is often the most restricted and feared movement after cervical injury. Progressive, gentle extension work restores the mobility needed for daily function (looking up, checking blind spots) and improves vertebral artery blood flow. Start with small range and increase gradually. 8 repetitions. JME 42 Shoulder circles release the shoulder girdle tension that loads the cervical spine. The upper trapezius connects the shoulder girdle to the cervical spine. Elevated, tense shoulders transmit force directly to the upper cervical segments. Shoulder mobility work reduces this force transmission. 10 repetitions each direction. JME 151 Lateral side bends with breathing combine thoracic mobility and autonomic regulation. For cervical-driven PCS, the thoracic mobility component is the priority: maintaining trunk mobility that prevents cervical compensation. The breathing component supports the nervous system regulation that allows muscle guarding to release. 8 repetitions per side. Address the cervical source of your persistent symptoms with simplmobility. Treatment Timeline and Expectations Cervical-driven PCS responds faster than brain-based PCS. Because the cervical spine is a musculoskeletal structure (unlike the brain), it responds to direct manual and exercise treatment. Most patients with cervical-driven PCS see meaningful symptom improvement within 2-4 weeks of targeted cervical rehabilitation. Complete resolution typically occurs within 8-12 weeks. Manual therapy combined with exercise produces the best outcomes. A trained physiotherapist provides manual joint mobilization of the stiff upper cervical segments combined with the exercise program above. Manual therapy provides immediate joint mobility improvements. Exercise maintains those improvements and retrains the neuromuscular system. Neither alone is as effective as the combination. If you have been told "the brain takes time to heal" while having persistent symptoms beyond 3 months, request cervical assessment. The brain does take time to heal, but that time is typically 14-30 days. Symptoms persisting beyond 3 months with no objective cognitive deficits on neuropsychological testing strongly suggest non-brain contributors, with the cervical spine being the most common. How do I know if my PCS is cervical-driven versus brain-based? A cervical-trained physiotherapist performing the flexion-rotation test, cervical palpation, and proprioception testing provides the most reliable assessment. Practically, if symptoms worsen with head/neck positions, improve with cervical treatment, and persist beyond 3 months without objective cognitive deficits, cervical contribution is highly likely. Why did my doctor not check my cervical spine? Most physicians receive minimal training in cervical musculoskeletal assessment during medical school and residency. The concussion diagnosis focuses attention on the brain, and cervical assessment is not part of standard concussion protocols. This is changing as research increasingly identifies cervical contributions, but the gap between evidence and practice remains significant. Does cervical-driven PCS mean my concussion was not real? No. The concussion was real and the brain was injured. Cervical-driven PCS means the brain injury has healed but the concurrent cervical injury has not. Both injuries occurred simultaneously from the same force. The brain healed on its typical timeline. The cervical spine needs targeted rehabilitation that it did not receive. References Marshall, C. M., et al. (2015). The role of the cervical spine in post-concussion syndrome. The Physician and Sportsmedicine, 43(3), 274-284. PubMed 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