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A systematic review of criteria used to define recovery from sport-related concussion in youth athletes
  1. Mohammad Nadir Haider1,
  2. John J Leddy2,
  3. Sonja Pavlesen2,
  4. Melissa Kluczynski2,
  5. John G Baker2,3,
  6. Jeffrey C Miecznikowski4,
  7. Barry S Willer1
  1. 1 Department of Psychiatry, SUNY Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
  2. 2 Department of Orthopaedics and Sports Medicine, SUNY Buffalo Jacobs School of Medicine and Biomedical Sciences, UBMB, Buffalo, New York, USA
  3. 3 Department of Nuclear Medicine, SUNY Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
  4. 4 Department of Biostatistics, SUNY Buffalo School of Public Health and Health Professions, Buffalo, New York, USA
  1. Correspondence to Dr Mohammad Nadir Haider, 160 Farber Hall, 3435 Main Street, Buffalo, NY 14214 ; haider_nadir{at}, haider{at}


Objective The Concussion in Sport Group guidelines recommend a multifaceted approach to help clinicians make return to sport decisions. The purpose of this study was to identify the most common multifaceted measures used to define clinical recovery from sport-related concussion in young athletes (high school and/or college level) and to summarise existing knowledge of criteria used to make return to sport decisions.

Design Systematic review.

Data sources The PubMed (MEDLINE), SPORTDiscus and Embase electronic databases were searched from 1 January 2000 to 1 March 2017 by three independent reviewers.

Eligibility criteria Inclusion criteria: elementary, high school and college age groups, and a specific definition of clinical recovery that required two or more measures. Exclusion criteria: review articles, articles using the same sample population, case studies, non-English language and those that used one measure only or did not specify the recovery measures used.

Study quality Study quality was assessed using the Downs and Black Criteria.

Results Of 2023 publications, 43 met inclusion criteria. Included articles reported the following measures of recovery: somatic symptom resolution or return to baseline (100%), cognitive recovery or return to baseline (86%), no exacerbation of symptoms on physical exertion (49%), normalisation of balance (30%), normal special physical examination (12%), successful return to school (5%), no exacerbation of symptoms with cognitive exertion (2%) and normalisation of cerebral blood flow (2%). Follow-up to validate the return to sport decision was reported in eight (19%) articles. Most studies were case–control or cohort (level of evidence 4) and had significant risk of bias.

Conclusion All studies of sport-related concussion use symptom reports to define recovery. A minority of studies used multiple measures of outcome or had clearly defined recovery criteria, the most common being a combination of a self-reported symptom checklist and a computerised neurocognitive test. Future studies ideally should define recovery a priori using objective physiological measures in addition to symptom reports.

  • sport-related concussion
  • recovery
  • mild traumatic brain injury
  • student athlete
  • return to play

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  • Contributors MNH, JJL, JGB, SP, MK and BSW contributed to the conception and design of the research, collection of data and writing, editing and approval of the manuscript. JCM contributed to analysis and editing and approval of the manuscript

  • Funding Research reported in this publication was supported by the National Institute of Neurological Disorders and Stroke of the National Institutes of Health under award number 1R01NS094444. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Funding was also provided by the Ralph and Mary Wilson Foundation and the Robert Rich Family Foundation.

  • Competing interests None declared.

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

  • Data sharing statement Additional data can be requested from Dr Mohammad Haider at