What Persistent Concussion Symptoms May Be Telling Us – An Interview with Lindsay Marie Branton
Lindsay Marie Branton is a Registered Kinesiologist and Director of Brain Health and Concussion Care at EPIC Health and Movement, where she works with people experiencing persistent and complex concussion symptoms. Her approach looks beyond isolated deficits to understand how the brain and body have adapted after injury, and why those adaptations may continue to affect function long after the initial concussion.
In this interview, Lindsay explores why recovery can stall, how compensations and nervous system responses can contribute to persistent symptoms, and why a plateau in rehabilitation does not necessarily mean someone has reached the limit of their recovery.
Lindsay Marie Branton, Complex Concussion Clinician
You’ve experienced more than 14 concussions yourself. How did your own recovery experiences shape the clinician you became and the way you approach complex concussion cases today?
After my 14th or so concussion in 2014, my health began to decline gradually, but significantly. I developed symptoms I never would have associated with concussion: resting tremors, tachycardia, high blood pressure despite being very fit, persistent pain and injuries, an exaggerated fight-or-flight response, insomnia, gut issues and food intolerances. I was also struggling with more recognizable symptoms like memory and word-recall difficulties.
I felt like I was losing control of my health, but no one could tell me why. Neurologists found nothing pathological to explain what I was experiencing, and my family doctor didn’t know what was happening. That was incredibly scary.
Eventually, with the help of my colleague Dr. Mel, we began to recognize that my concussion history could be connecting many of these seemingly unrelated issues. I found a practitioner who completed a detailed assessment and, for the first time, could explain why I felt the way I did. I no longer felt crazy. There was an explanation, and then the hard work of rehabilitation began.
That experience fundamentally shaped how I work today. I understand firsthand both the gaps that can exist in our healthcare system and how broad the effects of concussion can be. A concussion is a brain injury, but its effects can extend throughout the body. Understanding those connections is critical when working with complex cases.
What tells you that a concussion case may require a more comprehensive approach than a typical recovery?
One of the first things I look at is how long symptoms have persisted. When someone is still struggling months or even years after a concussion, I'm no longer thinking only about the original injury. I'm thinking about how the nervous system and body have adapted in response to it. Compensations can be helpful initially, but over time, some may begin contributing to the person's ongoing difficulties.
Concussion history is also important. A particularly traumatic mechanism makes me think differently, but so does a history of multiple concussions that were never properly identified or rehabilitated. Interestingly, patients will sometimes tell me they've never had a concussion before, but as we go through their history, we uncover accidents, sports injuries or other events that sound very consistent with concussions that were simply missed at the time.
I also look closely at the symptom pattern and how much it affects function. Unexplained tremors, tachycardia, fainting, significant anxiety or difficulty tolerating exercise, screens, driving or busy environments tell me there may be more going on than an isolated deficit.
The more systems, environments and activities involved, the more important it becomes to step back and look at the whole picture.
What can testing multiple systems together reveal that isolated vision, balance, or cognitive tests may miss?
Testing multiple systems together gives us insight into what is actually happening during activities of daily living. Having one system perform normally in isolation, for a short period of time, in a quiet and controlled environment isn't necessarily reflective of the demands of real life.
This becomes especially important when someone is further out from their concussion or has already completed rehabilitation. Their vision, balance or cognitive testing may look relatively normal when assessed individually. But real life rarely asks us to use one system at a time.
Think about walking through a busy grocery store while looking for a specific item. Your brain is simultaneously processing visual information, controlling eye and head movements, maintaining balance, navigating around people and objects, filtering noise and making decisions. Someone may perform each of those tasks well individually but struggle when they're combined.
Endurance matters too. A patient might perform well during a brief assessment but be unable to tolerate screens or noise by the end of a workday, with fatigue becoming overwhelming.
A detailed history is often where this investigation starts. Listening carefully to what a patient can and cannot do helps me determine which systems need to be challenged together and where we may find weaknesses that isolated testing hasn't captured.
How do compensations develop after concussion, and when can they start limiting recovery rather than helping it?
Compensation is actually a very normal and useful response to injury. When one system becomes less reliable, the brain will often rely more heavily on another system to help us continue functioning.
For example, after a concussion, someone may have impaired oculomotor function, while an associated whiplash injury may alter proprioceptive information coming from the neck. If vestibular information also becomes less reliable, the brain may begin weighting vision more heavily to understand where the body is in space.
Initially, that's helpful. The brain is finding another way to accomplish the task. The problem is when that strategy persists long after the acute injury.
If someone becomes overly visually dependent, for example, environments with large amounts of visual information – grocery stores, crowds, scrolling screens or driving – can become overwhelming. That altered sensory weighting may contribute to symptoms like dizziness, disorientation or visual motion sensitivity.
This is why, in persistent concussion, I'm not only asking, “What isn't working?” I'm also asking, “What has the nervous system learned to do instead?”
Sometimes the thing that helped someone function early in recovery becomes part of what is limiting them later.
What role can the nervous system’s stress response play when concussion symptoms persist, even after some of the original deficits have improved?
After a concussion, sympathetic activation is appropriate and protective. This is part of what we commonly call the fight-or-flight response – the body enters a heightened state of awareness following an injury. Most people gradually settle back toward normal regulation, but in some persistent or complex cases, the nervous system can remain biased toward that heightened state. I find this is an often-overlooked part of rehabilitation.
For example, a patient may initially have oculomotor deficits that make reading difficult. They eventually complete rehabilitation and those measurable deficits improve, but reading still provokes symptoms. I see this particularly in people who went months or years before the original problem was identified and treated.
By that point, the nervous system may have developed a strong association between reading and threat or symptom production. The original deficit has improved, but the response to the activity hasn't fully changed with it.
This can be a point where patients feel dismissed or are told this is simply their new normal. Instead, we may need to work on recalibrating that response – gradually teaching the nervous system that the activity is safe again.
It's nuanced work, but I think it's an incredibly important part of complex concussion rehabilitation.
Where do you see the biggest gaps in concussion care, particularly for people whose symptoms have persisted despite seeing multiple providers or trying different forms of rehabilitation?
I think it can be very difficult within our standard healthcare model for people with persistent concussion symptoms to get the kind of care they need. That's not necessarily because anyone is doing something wrong. It's partly the reality of an overburdened system and a condition that often doesn't present with a clear structural abnormality or disease process that explains why someone is still struggling.
Physicians and neurologists play an important role in ruling out serious pathology and managing medical concerns. But when a patient says, “I've done the rehabilitation, my imaging is normal, but something is still wrong,” the next question is often much more functional: What isn't working well together, under what conditions, and why?
Even within rehabilitation, we can become very focused on individual systems – vision, vestibular function, the neck, exercise tolerance – without always stepping back to see how they interact.
Complex concussion care takes time. It requires a detailed history, assessment, problem-solving, rehabilitation, reassessment and sometimes repeatedly changing the hypothesis as you learn more about the patient.
Our healthcare system isn't really structured to accommodate that kind of investigation. It's one of the reasons I developed my Complex Concussion Consultations: to create the time and space to step back, look beyond individual deficits, and understand why this particular person still can't function the way they need to.
What signs might tell someone with persistent concussion symptoms that it’s time for a fresh assessment or a different approach to rehabilitation?
One of the biggest signs is that you're no longer making meaningful progress – not only in your symptoms, but in your capacity.
I often say that people living with persistent concussion symptoms have made their lives small out of necessity. They've reduced their work hours, stopped exercising, limited social interactions, avoided busy environments or given up hobbies because those things make them feel worse. Good rehabilitation should gradually help you make your life bigger again.
If you've been consistently doing rehabilitation but that process has stopped, it may be time to ask why.
Another sign is when the deficits you've been working on appear to have improved – perhaps your eye movements, balance, vestibular function or neck function are testing well – but you're still significantly limited in everyday life. That doesn't necessarily mean the rehabilitation you've received wasn't valuable. It may mean there's another piece of the problem that hasn't yet been identified.
Broader changes in health can also warrant another look, including changes in heart rate or blood pressure, gastrointestinal symptoms, or hormonal and menstrual changes. These aren't specific to concussion and may require appropriate medical investigation, but they shouldn't simply be ignored.
If your testing is improving but your life isn't, that's a good reason to step back, reassess the bigger picture and potentially bring in a different perspective.
How do you decide when a patient is ready to increase complexity or challenge without pushing beyond their current capacity?
Symptoms are one of my biggest guides for progressing rehabilitation. The goal isn't necessarily to make rehab completely symptom-free – we often need to challenge the system—but the challenge needs to be tolerable.
I often use a green-light, yellow-light, red-light approach. Mild, temporary symptoms may be acceptable, particularly if they settle quickly after the exercise. If symptoms become more significant, continue building, or take a long time to return to baseline, that's a sign that the current challenge may be too much.
I'm also looking for change over time. If an exercise that initially caused noticeable symptoms is now producing very little response and the patient is recovering well, that's a good indication that we may be ready to increase the complexity.
Importantly, I don't progress based on performance alone. Someone may look like they're performing a task perfectly while their nervous system is still responding as though the task is highly threatening. Increasing the difficulty too quickly in that situation may continue to reinforce that response rather than improving tolerance.
Capacity can also fluctuate with sleep, stress, workload and environment, so individual sessions will vary. What matters most is the overall trajectory: over time, can we safely challenge more, recover more quickly and tolerate increasingly complex demands?
What do you want someone with persistent symptoms to understand when you say, “Persistent doesn’t mean permanent”?
I want people to understand that just because their symptoms have lasted a long time does not automatically mean they are permanent – even if they've been told, “This is just how you are now.”
I've worked with numerous patients who came to me after being symptomatic for months or years and having been given that message. I've watched people continue to make meaningful improvements, return to work, tolerate activities they had avoided for years and gradually make their lives bigger again.
This isn't just something I see clinically. Current concussion guidelines emphasize that even among people whose symptoms persist beyond the expected recovery period, the majority can still achieve symptom resolution, particularly when treatment is targeted toward the specific factors contributing to their symptoms.
In persistent concussion, ongoing symptoms aren't necessarily evidence that the brain has been damaged in some permanent, irreparable way. Sometimes symptoms are being maintained or influenced by the compensations and adaptations the nervous system developed in response to the original injury.
Those patterns can change. The brain is plastic. It can learn and adapt throughout our lives. That doesn't mean every person will recover completely, or that recovery follows a predictable timeline. But the passage of time alone shouldn't be used to decide that someone has reached the limit of their recovery.
Persistent describes how long symptoms have lasted. It doesn't tell us what someone is still capable of changing.
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