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Do physical interventions improve outcomes following concussion: a systematic review and meta-analysis?
  1. Susan A Reid,
  2. Joshua Farbenblum,
  3. Shreya McLeod
  1. Discipline of Physiotherapy, Faculty of Health Sciences, School of Allied Health, Australian Catholic University, North Sydney, NSW, Australia
  1. Correspondence to Shreya McLeod, Discipline of Physiotherapy, Faculty of Health Sciences, School of Allied Health, Australian Catholic University, North Sydney, NSW 2060, Australia; shreya.mcleod{at}


Objective To investigate the effect of physical interventions (subthreshold aerobic exercise, cervical, vestibular and/or oculomotor therapies) on days to recovery and symptom scores in the management of concussion.

Design A systematic review and meta-analysis.

Data sources Medline, CINAHL, Embase, SportDiscus, Cochrane library, Scopus and PEDro.

Eligibility criteria Randomised controlled trials of participants with concussion that evaluated the effect of subthreshold aerobic exercise, cervical, vestibular and/or oculomotor therapies on days to recovery/return to activity, symptom scores, balance, gait and/or exercise capacity.

Results Twelve trials met the inclusion criteria: 7 on subthreshold aerobic exercise, 1 on vestibular therapy, 1 on cervical therapy and 3 on individually tailored multimodal interventions. The trials were of fair to excellent quality on the PEDro scale. Eight trials were included in the quantitative analysis. Subthreshold aerobic exercise had a significant small to moderate effect in improving symptom scores (standardised mean difference (SMD)=0.43, 95% CI 0.18 to 0.67, p=0.001, I2=0%) but not in reducing days to symptom recovery in both acutely concussed individuals and those with persistent symptoms (SMD=0.19, 95% CI −0.54 to 0.93, p=0.61, I2=52%). There was limited evidence for stand-alone cervical, vestibular and oculomotor therapies. Concussed individuals with persistent symptoms (>2 weeks) were approximately 3 times more likely to have returned to sport by 8 weeks (relative risk=3.29, 95% CI 0.30 to 35.69, p=0.33, I2=83%) if they received individually tailored, presentation-specific multimodal interventions (cervical, vestibular and oculo-motor therapy). In addition, the multimodal interventions had a moderate effect in improving symptom scores (SMD=0.63, 95% CI 0.11 to 1.15, p=0.02, I2=0%) when compared with control.

Conclusions Subthreshold aerobic exercise appears to lower symptom scores but not time to recovery in concussed individuals. Individually tailored multimodal interventions have a worthwhile effect in providing faster return to sport and clinical improvement, specifically in those with persistent symptoms.

PROSPERO registration number CRD42020108117.

  • brain concussion
  • exercise therapy
  • rehabilitation
  • physical therapy modalities

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  • Contributors All authors contributed to the development of the search strategy, writing and critical review of the manuscript. JF and SM undertook the process of inclusion/exclusion and independently assessed methodological quality. JF extracted all data from the included studies, SM and SAR confirmed the accuracy of this.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

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

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.