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Approach to investigation and treatment of persistent symptoms following sport-related concussion: a systematic review
  1. Michael Makdissi1,2,3,
  2. Kathryn J Schneider4,5,6,
  3. Nina Feddermann-Demont7,8,
  4. Kevin M Guskiewicz9,
  5. Sidney Hinds10,
  6. John J Leddy11,
  7. Michael McCrea12,
  8. Michael Turner13,14,
  9. Karen M Johnston15
  1. 1 Melbourne Brain Centre, Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia
  2. 2 La Trobe Sport and Exercise Medicine Research Centre, La Trobe University, Bundoora, Victoria, Australia
  3. 3 Olympic Park Sports Medicine Centre, Melbourne, Victoria, Australia
  4. 4 Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
  5. 5 Alberta Children's Hospital Research Institute, University of Calgary, Calgary,, Alberta, Canada
  6. 6 Hotchkiss Brain Institute, Cummings School of Medicine, University of Calgary, Calgary, Alberta, Canada
  7. 7 Department of Neurology, University hospital Zurich, Zurich, Switzerland
  8. 8 Swiss Concussion Center, Zurich, Switzerland
  9. 9 Sports Medicine Research Laboratory, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
  10. 10 DoD Brain Health Research Program, Blast Injury Research Program Coordinating Office, United States Army Medical Research and Materiel Command, FT Detrick, Maryland, USA
  11. 11 Department of Orthopaedics, SUNY Buffalo, Buffalo, New York, USA
  12. 12 Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
  13. 13 Princess Grace Hospital, London, UK
  14. 14 The International Concussion and Head Injury Research Foundation, London, UK
  15. 15 Department of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
  1. Correspondence to Dr Michael Makdissi, Melbourne Brain Centre, Florey Institute of Neuroscience and Mental Health, Austin Campus, 245 Burgundy St. Heidelberg,3084 Victoria, Australia ; makdissi{at}


Objective To conduct a systematic review of the literature regarding assessment and treatment modalities in patients with persistent symptoms following sport-related concussion (SRC).

Data sources We searched Medline, Embase, SPORTSDiscus, PsycINFO, CINAHL, Cochrane library and ProQuest Dissertation & Theses Global electronic databases.

Study eligibility criteria Studies were included if they were original research, reported on SRC as the primary source of injury, included patients with persistent postconcussive symptoms (>10 days) and investigated the role of assessment or treatment modalities.

Results Of 3225 articles identified in the preliminary search, 25 articles met the inclusion criteria. 11 articles were concerned with assessment and 14 articles with treatment of persistent symptoms following SRC. There were three randomised control trials and one quasi-experimental study. The remainder consisting of cross-sectional studies, historical cohorts and case series.

Summary ‘Persistent symptoms’ following SRC can be defined as clinical recovery that falls outside expected time frames (ie, >10–14 days in adults and >4 weeks in children). It does not reflect a single pathophysiological entity, but describes a constellation of non-specific post-traumatic symptoms that may be linked to coexisting and/or confounding pathologies. A detailed multimodal clinical assessment is required to identify specific primary and secondary processes, and treatment should target specific pathologies identified. There is preliminary evidence supporting the use of symptom-limited aerobic exercise, targeted physical therapy and a collaborative approach that includes cognitive behavioural therapy. Management of patients with persistent symptoms is challenging and should occur in a multidisciplinary collaborative setting, with healthcare providers with experience in SRC.

  • concussion
  • sports
  • post-concussion syndrome
  • assessment
  • treatment

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  • Competing interests MM is a consultant sport and exercise medicine physician at Olympic Park Sports Medicine Centre and team physician for the Hawthorn Football Club (AFL). MM receives research funding from the AFL and non-financial support from CogState. He has attended meetings organised by the IOC, NFL (USA), National Rugby League (Australia) and FIFA (Switzerland), however has not received any payment, research funding or other monies from these groups other than for travel costs. He is an honorary member of concussion working/advisory groups for AFL, Australian Rugby Union and World Rugby.

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

  • Correction notice This paper has been amended since it was published Online First. Owing to a scripting error, some of the publisher names in the references were replaced with 'BMJ Publishing Group'. This only affected the full text version, not the PDF. We have since corrected these errors and the correct publishers have been inserted into the references.