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Rest and exercise early after sport-related concussion: a systematic review and meta-analysis
  1. John J Leddy1,
  2. Joel S Burma2,
  3. Clodagh M Toomey3,
  4. Alix Hayden4,
  5. Gavin A Davis5,
  6. Franz E Babl6,
  7. Isabelle Gagnon7,8,
  8. Christopher C Giza9,10,
  9. Brad G Kurowski11,
  10. Noah D Silverberg12,
  11. Barry Willer13,
  12. Paul E Ronksley14,
  13. Kathryn J Schneider15
  1. 1 UBMD Department of Orthopaedics and Sports Medicine, SUNY Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, USA
  2. 2 Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
  3. 3 School of Allied Health, Faculty of Education and Health Sciences, University of Limerick, Limerick, Ireland
  4. 4 Libraries and Cultural Resources, University of Calgary, Calgary, Alberta, Canada
  5. 5 Murdoch Children’s Research Institute, Melbourne, Victoria, Australia
  6. 6 Emergency Department, Royal Children's Hospital, Melbourne, Victoria, Australia
  7. 7 School of Physical and Occupational Therapy, McGill University, Montreal, Quebec, Canada
  8. 8 Trauma Center and Pediatric Emergency Medicine, Montreal Children’s Hospital- McGill University Health Center, Montreal, Quebec, Canada
  9. 9 Neurosurgery, UCLA Steve Tisch BrainSPORT Program, Los Angeles, California, USA
  10. 10 Pediatrics/Pediatric Neurology, UCLA Mattel Children's Hospital, Los Angeles, California, USA
  11. 11 Departments of Pediatrics, Neurology and Rehabilitation Medicine, Cincinnati Children’s Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
  12. 12 Department of Psychology, University of British Columbia, Voncouver, BC, Canada
  13. 13 Department of Psychiatry, SUNY Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, USA
  14. 14 Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
  15. 15 Sport Injury Prevention Research Centre, Faculty of Kinesiology; Hotchkiss Brain Institute, Alberta Children’s Hospital Research Institute, Sport Medicine Centre, University of Calgary, Calgary, Alberta, Canada
  1. Correspondence to Dr John J Leddy, UBMD Orthopaedics and Sports Medicine, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY 14203, USA; leddy{at}


Objective To synthesise the evidence regarding the risks and benefits of physical activity (PA), prescribed aerobic exercise treatment, rest, cognitive activity and sleep during the first 14 days after sport-related concussion (SRC).

Design Meta-analysis was performed for PA/prescribed exercise interventions and a narrative synthesis for rest, cognitive activity and sleep. Risk of bias (ROB) was determined using the Scottish Intercollegiate Guidelines Network and quality assessed using Grading of Recommendations, Assessment, Development and Evaluations.

Data sources MEDLINE, Embase, APA PsycInfo, Cochrane Central Register of Controlled Trials, CINAHL Plus and SPORTDiscus. Searches were conducted in October 2019 and updated in March 2022.

Eligibility criteria Original research articles with sport-related mechanism of injury in >50% of study sample and that evaluated how PA, prescribed exercise, rest, cognitive activity and/or sleep impact recovery following SRC. Reviews, conference proceedings, commentaries, editorials, case series, animal studies and articles published before 1 January 2001 were excluded.

Results 46 studies were included and 34 had acceptable/low ROB. Prescribed exercise was assessed in 21 studies, PA in 15 studies (6 PA/exercise studies also assessed cognitive activity), 2 assessed cognitive activity only and 9 assessed sleep. In a meta-analysis of seven studies, PA and prescribed exercise improved recovery by a mean of −4.64 days (95% CI −6.69, –2.59). After SRC, early return to light PA (initial 2 days), prescribed aerobic exercise treatment (days 2–14) and reduced screen use (initial 2 days) safely facilitate recovery. Early prescribed aerobic exercise also reduces delayed recovery, and sleep disturbance is associated with slower recovery.

Conclusion Early PA, prescribed aerobic exercise and reduced screen time are beneficial following SRC. Strict physical rest until symptom resolution is not effective, and sleep disturbance impairs recovery after SRC.

PROSPERO registration number CRD42020158928.

  • athletes
  • brain concussion
  • exercise
  • meta-analysis
  • rest

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

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Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

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  • Twitter @clo2me, @griz1, @#bswiller, @Kat_Schneider7

  • Contributors JJL is the author acting as guarantor. JJL and KJS participated in the conception or design of the work. JJL, JSB, CMT, AH, GAD, FEB, IG, CCG, BGK, NDS, BW, PER and KJS participated in the acquisition, analysis and interpretation of data for the work, and drafting the work and revising it critically for important intellectual content. All authors gave final approval of the version to be published.

  • 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 JJL receives grant/research support from NIH, DoD and AMSSM. He is a member of the Scientific Advisory Boards for Neuronasal, Highmark Innovations and Quadrant Biosciences; has minority stock options in Highmark Innovations and 360 Concussion Care; is an expert consultant to NCAA; consults with NFL and NHL teams on athlete care but does not receive any compensation from these organisations. GAD is an honorary member of the AFL Concussion Scientific Committee and has attended meetings organised by sporting organisations including the NFL, NRL, IIHF and FIFA; however, he has not received any payment, research funding or other monies from these groups other than for travel costs. BW receives grant/research support from NIH, DoD and AMSSM. NDS receives clinical consulting fees from the National Hockey League and Major League Soccer. BGK receives grant support from NIH. IG receives funding from Fonds de la recherche du Québec–Santé; Canadian Institutes of Health Research; Research Institute of the McGill University Health Center; School of Physical and Occupational Therapy, McGill University. CCG receives grant/research support from Hit-IQ (2022–2023); NIH NINDS (R01 NS110757 2019–2024); NINDS (U54 NS121688 2021–2026); UCLA Brain Injury Research Center, UCLA Steve Tisch BrainSPORT Program, Easton Clinic for Brain Health; a clinical consultant (provides clinical care to athletes) for NBA, NFL-Neurological Care Program, NHL/NHLPA, Los Angeles Lakers; a member of the Advisory Boards (non-compensated) for Major League Soccer, National Basketball Association and US Soccer Federation, as well as Advisory Boards (stock shareholder) for Highmark Interactive; other financial or material support: book royalties—Blackwell/Wiley Publishing: prioritised neurological differential diagnosis. KJS is a lead and coinvestigator on grants related to concussion and traumatic brain injury funded by several governments or other organisations (including but not limited to the Canadian Institutes of Health Research, Canadian Academy of Sport and Exercise Medicine, National Football League Scientific Advisory Board, Public Health Agency of Canada/Parachute Canada, Hotchkiss Brain Institute, Wellcome Trust, International Olympic Committee, Highmark Innovations, Mitacs Accelerate, University of Calgary), with funds paid to her institution and not to her personally. She is an associate professor and clinician scientist at the University of Calgary in the Sport Injury Prevention Research Centre and is a physiotherapy consultant, primarily working with patients with concussion and traumatic brain injuries. She is an associate editor of BJSM (unpaid) and has received travel and accommodation support for meetings where she has presented. She is coordinating the writing of the systematic reviews that will inform the 6th International Consensus on Concussion in Sport, for which she has received an educational grant to assist with the administrative costs associated with the writing of the reviews. She is a member of the Scientific Advisory Board for Eye Guide (share options), and member of the AFL Concussion Scientific Committee (unpaid position) and Brain Canada (unpaid position).

  • 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.

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