Concussions and the Nervous System: When Head Injuries Affect Breathing

Breathing is typically automatic—until it’s not. 

For many patients recovering from a concussion, especially those with persistent symptoms, this foundational function can suddenly become labored, irregular, or anxiety-inducing. Although breathing problems are not often the first symptom associated with a concussion, disruptions to respiratory rhythm and control can be traced back to the injury's impact on the autonomic nervous system (ANS).

As clinicians and athletic trainers, understanding the neurophysiological connection between head trauma and respiratory symptoms is crucial. These changes can directly affect recovery trajectories, athletic performance, and quality of life. Let’s examine the emerging evidence, explore the clinical implications, and consider therapeutic strategies rooted in neurological regulation and respiratory training.

How Concussions Disrupt the Nervous System’s Control of Breathing

At the center of this issue is the autonomic nervous system, a branch of the peripheral nervous system responsible for involuntary body functions—heart rate, digestion, blood pressure, and, notably, breathing. The ANS operates through two main branches: sympathetic (fight-or-flight) and parasympathetic (rest-and-digest). These systems are tightly regulated by brainstem structures such as the medulla oblongata and pons, as well as higher centers like the hypothalamus.

Concussions can interfere with this delicate balance. Even without structural brain damage visible on imaging, functional impairments in the brainstem or cortical-autonomic pathways can occur, disrupting normal autonomic responses. This dysregulation is commonly referred to as "autonomic dysfunction" or "dysautonomia," and one of its lesser-known manifestations is irregular or restricted breathing.

Research detailed concussion patients with impaired breathing patterns, particularly in military trauma cases. These individuals presented with "unstable respiration," heightened anxiety, and a sense of air hunger, even in the absence of pulmonary pathology (source). The findings reinforce a clinical reality: when the nervous system loses its rhythm, so can the breath.

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Symptomatology: When Breathing Becomes a Post-Concussion Concern

Respiratory complaints may emerge days or even weeks after the initial concussion. Athletes, in particular, may report:

  • Shortness of breath during minimal exertion
  • A sensation of not being able to take a full breath
  • Frequent sighing or chest tightness
  • Heightened sensitivity to CO₂ buildup, triggering anxiety
  • Dizziness linked to changes in posture or breathing effort

These symptoms are often accompanied by other signs of autonomic imbalance—orthostatic intolerance, lightheadedness, exercise intolerance, and persistent fatigue.

A 2023 study published in Physiological Reports highlights that adolescent concussion patients exhibited irregularities in heart rate and blood pressure regulation—clear indicators of ANS dysfunction (source). These same neural circuits control respiratory rhythm. When affected, even a simple cardiovascular warm-up or breathing through a mouthguard during practice may provoke symptoms.

Clinical Scenario: The Overlooked Link Between Breath and Brain

Consider a 17-year-old soccer player with a diagnosed concussion two weeks prior. She’s cleared of acute symptoms like headaches and visual strain, but reports "can’t catch my breath" during warm-ups. Spirometry is normal. The pulmonary exam is unremarkable. Her O₂ saturation is stable. Yet, her breathing is shallow, chest-dominant, and rapid.

A closer look reveals elevated resting heart rate and difficulty regulating breath with exertion—both pointing to autonomic imbalance. Her physical therapist evaluates diaphragmatic recruitment and thoracoabdominal synchrony. With HRV (heart rate variability) biofeedback, they discover reduced vagal tone—confirming parasympathetic suppression and sympathetic dominance.

In this case, it’s not a respiratory issue in the lungs—it’s a neurological issue in the brain-body connection.

The Science of Breath Retraining After Concussion

Recent studies support the use of breath retraining to help regulate autonomic function in patients with persistent concussion symptoms. 

One clinical pilot study published in the International Journal of Therapeutic Massage & Bodywork examined the effects of abdominal and pursed-lip breathing in individuals with ongoing post-concussive complaints. The result? Reduced symptoms and improved mental clarity through targeted respiratory control and HRV modulation (source).

Paced breathing—specifically at a rhythm of six breaths per minute—has also shown promise. In a thesis conducted at the University of Manitoba, post-concussion athletes participating in guided breathing with biofeedback demonstrated enhanced sleep quality, symptom control, and reduced physiological reactivity to stressors (source).

These studies emphasize that breathing is more than just air exchange. It’s a regulator of neurochemical balance, vagal tone, and emotional stability.

Why Breathing Training Should Be Part of Post-Concussion Rehab

Integrating breathwork into concussion rehabilitation isn’t just about relaxation—it’s about restoring neurological control. For physical therapists and athletic trainers, particularly those working with adolescents and competitive athletes, respiratory evaluation should be part of the return-to-activity decision tree. This is especially relevant in light of the Consensus Statement on Concussion in Sport (Amsterdam, 2022), which underscores the need for individualized, symptom-guided return-to-play strategies.

Practical steps for integration include:

Diaphragmatic Breathing Assessment: Evaluate whether the athlete is belly-breathing versus relying heavily on accessory chest muscles.

HRV Monitoring: Use devices or applications that provide real-time biofeedback to detect autonomic imbalances.

Paced Breathing Protocols: Implement structured breathing sessions (e.g., 6 breaths/min for 10 minutes/day), ideally in conjunction with mindfulness or guided relaxation.

Symptom Tracking: Align changes in breathing quality with improvements in fatigue, sleep, and mood.

This isn’t a “nice-to-have” component. For many athletes, regulating the breath may be key to regulating the nervous system.

Athletic Trainers and Sports Medicine Teams: Recognizing the Red Flags

Athletic trainers are often the first to hear about breathing complaints. 

These conversations may be brushed off as anxiety or conditioning issues. However, understanding that respiratory irregularities could be neurological helps shift the response from referral to pulmonology to collaboration with concussion-trained clinicians.

Be aware of athletes who:

  • Report feeling winded unusually early in workouts
  • Use frequent sighing or mouth breathing at rest
  • Express “air hunger” with no exertion
  • Have visible changes in posture linked to chest tightness
  • Report dizziness that worsens with exertional breathing

In such cases, consider involving a physical therapist with experience in neuro-concussive recovery or a specialist in vestibular/autonomic dysfunction.

As concussion care continues to evolve, so must our awareness of the body’s subtle distress signals. Disordered breathing post-concussion is more than a secondary complaint—it is a physiological manifestation of disrupted neural regulation. It affects recovery timelines, emotional stability, and athletic performance.

By recognizing these patterns and applying evidence-backed interventions like paced breathing, HRV biofeedback, and diaphragmatic retraining, we can better serve our patients—not just in healing their brains, but in restoring balance to their entire system.

Athletes, especially adolescents, often don’t have the language to articulate neurological discomfort. But they do understand when they feel “off.” Paying attention to the breath might just be the breakthrough their recovery needs.

For clinicians and athletic trainers alike, the breath is not an afterthought. It’s part of the rehabilitation roadmap.