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Review
Predictors of clinical recovery from concussion: a systematic review
  1. Grant L Iverson1,2,
  2. Andrew J Gardner3,
  3. Douglas P Terry1,2,
  4. Jennie L Ponsford4,
  5. Allen K Sills5,
  6. Donna K Broshek6,
  7. Gary S Solomon7
  1. 1 Department of Physical Medicine and Rehabilitation, Harvard Medical School, Charlestown, Massachusetts, USA
  2. 2 Sport Concussion Program, MassGeneral Hospital for Children, Boston, Massachusetts, USA
  3. 3 Centre for Stroke and Brain Injury, School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia
  4. 4 School of Psychological Sciences, Monash University, Melbourne, Australia
  5. 5 Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
  6. 6 Department of Psychiatry & Neurobehavioral Sciences, University of Virginia, Charlottesville, Virginia, USA
  7. 7 Departments of Neurological Surgery, Orthopaedic Surgery & Rehabilitation, and Psychiatry & Behavioral Sciences, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
  1. Correspondence to Dr Grant L Iverson, Center for Health and Rehabilitation Research, Department of Physical Medicine and Rehabilitation, 79/96 Thirteenth Street, Charlestown Navy Yard, Charlestown, MA, 02129, USA; giverson{at}mgh.harvard.edu

Abstract

Objective A systematic review of factors that might be associated with, or influence, clinical recovery from sport-related concussion. Clinical recovery was defined functionally as a return to normal activities, including school and sports, following injury.

Design Systematic review.

Data sources PubMed, PsycINFO, MEDLINE, CINAHL, Cochrane Library, EMBASE, SPORTDiscus, Scopus and Web of Science.

Eligibility criteria for selecting studies Studies published by June of 2016 that addressed clinical recovery from concussion.

Results A total of 7617 articles were identified using the search strategy, and 101 articles were included. There are major methodological differences across the studies. Many different clinical outcomes were measured, such as symptoms, cognition, balance, return to school and return to sports, although symptom outcomes were the most frequently measured. The most consistent predictor of slower recovery from concussion is the severity of a person’s acute and subacute symptoms. The development of subacute problems with headaches or depression is likely a risk factor for persistent symptoms lasting greater than a month. Those with a preinjury history of mental health problems appear to be at greater risk for having persistent symptoms. Those with attention deficit hyperactivity disorder (ADHD) or learning disabilities do not appear to be at substantially greater risk. There is some evidence that the teenage years, particularly high school, might be the most vulnerable time period for having persistent symptoms—with greater risk for girls than boys.

Conclusion The literature on clinical recovery from sport-related concussion has grown dramatically, is mostly mixed, but some factors have emerged as being related to outcome.

  • Concussion
  • sex differences
  • outcome
  • moderators
  • age
  • sports

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

https://doi.org/10.1136/bjsports-2017-097729

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    Footnotes

    • Contributors GLI and AJG wrote the first draft of the review. All authors participated in conceptualising the review, designing the search terms, reviewing the literature and extracting data from articles, reviewing drafts of the manuscript and approving the final draft for submission.

    • Competing interests GLI has been reimbursed by the government, professional scientific bodies and commercial organisations for discussing or presenting research relating to mild TBI and sport-related concussion at meetings, scientific conferences and symposiums. He has a clinical and consulting practice in forensic neuropsychology involving individuals who have sustained mild TBIs (including professional athletes). He has been a principal investigator and coinvestigator on federal and industry grants on topics relating to mild traumatic brain injury, neuropsychological assessment and depression. He has received consulting fees from pharmaceutical companies. He receives royalties for books and one neuropsychological test. He has received research funding from several test publishing companies, including ImPACT Applications, Inc., CNS Vital Signs and Psychological Assessment Resources (PAR, Inc.). He acknowledges unrestricted philanthropic support from the Mooney-Reed Charitable Foundation and ImPACT Applications, Inc. He previously served as a contractor in the area of TBI research through General Dynamics for the Defense and Veterans Brain Injury Center within the US Department of Defense. He receives salary support for chairing the Brain and Behavior committee for the Harvard Integrated Program to Protect and Improve the Health of NFLPA Members. AJG has a clinical practice in neuropsychology involving individuals who have sustained sport-related concussion (including current and former athletes). He has operated as a contracted concussion consultant to the Australian Rugby Union (ARU) from July 2016. He has received travel funding from the Australian Football League (AFL) to present at the Concussion in Football Conference in 2013. Previous grant funding includes the NSW Sporting Injuries Committee, the Brain Foundation (Australia), and the Hunter Medical Research Institute (HMRI), supported by Jennie Thomas. He is currently funded through the HMRI, supported by Anne Greaves, and the University of Newcastle’s Priority Research Centre for Stroke and Brain Injury. JLP is an employee of Monash University and Epworth Healthcare and conducts a private practice conducting assessments for forensic purposes. She has received funding from the Rehaklinik Bellikon and Suvacare to present on the management of concussion in Zurich in 2013. She frequently presents on TBI-related topics at brain injury conferences and has received funding from the International Neuropsychological Society, the International Brain Injury Association and World Federation of NeuroRehabilitation, Federation of European Neuropsychological Societies, British Psychological Society, Norwegian Neuropsychological Society and various hospitals to do this. She has received grant support from the National Health and Medical Research Council, Institute for Safety Compensation and Recovery Research, Victorian Neurotrauma Initiative, the Australian Research Council, the William Buckland Foundation, Epworth Research Institute and Monash University for studies involving people with traumatic brain injury. AKS is a full-time employee of the Vanderbilt University Medical Center. He is an unpaid consulting neurosurgeon to the NHL Nashville Predators, the MiLB Nashville Sounds, Vanderbilt University athletics and Mississippi State University athletics. He serves as unpaid member of the Medical Committee for the International Equestrian Foundation (FEI) and on the NCAA Concussion Protocol Committee. He is section editor (unpaid) for Sports and Rehabilitation for the journal Neurosurgery. He also receives compensation to serve as Unaffiliated Neurotrauma Consultant for the National Football League. He receives no direct grant or research support for concussion research. DKB is a full-time employee of the University of Virginia School of Medicine. Clinically, she evaluates primarily high school and collegiate athletes who have sustained sports concussions. She is a member of the Concussion Committee for the National/Women’s Basketball Association (NBA/WNBA) and is president of the Sports Neuropsychology Society, but receives no compensation for either activity. She has received grant support towards her salary on sports concussion-related research from the US Department of Defense, NIH/NHLBI and the National Athletic Trainers Association Research and Education Foundation. She has received speaking honoraria for scientific presentations on sports concussion. GSS is a full-time employee of the Vanderbilt University Medical Center. He is a consulting neuropsychologist for the NHL Nashville Predators, NFL Tennessee Titans, University of Tennessee Athletics and Tennessee Tech Athletics, with all fees paid to institution. He is also a member of the ImPACT Scientific Advisory Board and receives expense reimbursements for attendance at board meetings. He has received speaking honoraria for presentations at scientific meetings related to concussion in sports. He receives some grant support from the Department of Defense (non-TBI related).

    • Provenance and peer review Not commissioned; externally peer reviewed.