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Targeted interventions and their effect on recovery in children, adolescents and adults who have sustained a sport-related concussion: a systematic review
  1. Kathryn J Schneider1,2,3,
  2. Meghan L Critchley4,
  3. Vicki Anderson5,6,
  4. Gavin A Davis7,8,
  5. Chantel T Debert9,
  6. Nina Feddermann-Demont10,
  7. Isabelle Gagnon11,
  8. Kevin M Guskiewicz12,
  9. K Alix Hayden13,
  10. Stanley Herring14,
  11. Corson Johnstone4,
  12. Michael Makdissi15,16,
  13. Christina L Master17,
  14. Rosemarie Scolaro Moser18,
  15. Jon S Patricios19,
  16. Johna K Register-Mihalik20,
  17. Paul E Ronksley21,
  18. Noah D Silverberg22,
  19. Keith Owen Yeates2,3,23
  1. 1 Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
  2. 2 Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
  3. 3 Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
  4. 4 University of Calgary, Calgary, Alberta, Canada
  5. 5 Child Neuropsychology, Murdoch Childrens Research Institute, Parkville, Victoria, Australia
  6. 6 Psychology, University of Melbourne, Parkville, Victoria, Australia
  7. 7 Murdoch Children's Research Institute, Parkville, Victoria, Australia
  8. 8 Cabrini Health, Malvern, Victoria, Australia
  9. 9 Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
  10. 10 Department of Neurology, University Hospital Zurich, Zurich Switzerland Sports Neuroscience, University of Zurich, Zurich, Switzerland
  11. 11 School of Physical and Occupational Therapy, Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
  12. 12 Sports Medicine Research Laboratory, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
  13. 13 Libraries and Cultural Resources, University of Calgary, Calgary, Alberta, Canada
  14. 14 Departments of Rehabilitation Medicine, Orthopaedics and Sports Medicine and Neurological Surgery, University of Washington, Seattle, Washington, USA
  15. 15 Florey Institute of Neuroscience and Mental Health - Austin Campus, Heidelberg, Victoria, Australia
  16. 16 Australian Football League, Melbourne, Victoria, Australia
  17. 17 Pediatrics and Sports Medicine, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
  18. 18 Sports Concussion Center of New Jersey, Princeton, New Jersey, USA
  19. 19 Wits Sport and Health (WiSH), School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
  20. 20 Exercise and Sport Science, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
  21. 21 Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
  22. 22 Department of Psychology, University of British Columbia, Vancouver, British Columbia, Canada
  23. 23 Psychology, University of Calgary, Calgary, Alberta, Canada
  1. Correspondence to Dr Kathryn J Schneider, University of Calgary, Calgary, Alberta, T2N1N4, Canada; kjschnei{at}


Objectives We evaluated interventions to facilitate recovery in children, adolescents and adults with a sport-related concussion (SRC).

Design Systematic review including risk of bias (modified Scottish Intercollegiate Guidelines Network tool).

Data sources MEDLINE(R) and Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Embase, APA PsycINFO, Cochrane Central Register of Controlled Trials, CINAHL Plus with Full Text, SPORTDiscus and Scopus searched until March 2022.

Study eligibility criteria (1) Original research including randomised controlled trials (RCTs), quasi-experimental designs, cohort, comparative effectiveness studies; (2) focus on SRC; (3) English; (4) peer-reviewed and (5) evaluated treatment.

Results 6533 studies were screened, 154 full texts reviewed and 13 met inclusion (10 RCTs, 1 quasi-experimental and 2 cohort studies; 1 high-quality study, 7 acceptable and 5 at high risk of bias). Interventions, comparisons, timing and outcomes varied, precluding meta-analysis. For adolescents and adults with dizziness, neck pain and/or headaches >10 days following concussion, individualised cervicovestibular rehabilitation may decrease time to return to sport compared with rest followed by gradual exertion (HR 3.91 (95% CI 1.34 to 11.34)) and when compared with a subtherapeutic intervention (HR 2.91 (95% CI 1.01 to 8.43)). For adolescents with vestibular symptoms/impairments, vestibular rehabilitation may decrease time to medical clearance (vestibular rehab group 50.2 days (95% CI 39.9 to 60.4) compared with control 58.4 (95% CI 41.7 to 75.3) days). For adolescents with persisting symptoms >30 days, active rehabilitation and collaborative care may decrease symptoms.

Conclusions Cervicovestibular rehabilitation is recommended for adolescents and adults with dizziness, neck pain and/or headaches for >10 days. Vestibular rehabilitation (for adolescents with dizziness/vestibular impairments >5 days) and active rehabilitation and/or collaborative care (for adolescents with persisting symptoms >30 days) may be of benefit.

  • Recovery
  • Brain Concussion
  • Rehabilitation
  • Sport

Data availability statement

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

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Data availability statement

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

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  • Twitter @Kat_Schneider7, @VickiAn28323584, @drtinamaster, @sccnj, @jonpatricios

  • Contributors All authors participated in the development and review of the search terms and strategy for rehabilitation, data base selection, inclusion/exclusion criteria, data extraction table and PROSPERO protocol development. KJS is the guarantor for the work and accepts full responsibility for the work and/or the conduct of the study, had access to the data, and controlled the decision to publish. KAH developed the search strategies and ran the searches in all databases. MC, CJ and KJS acted as methods authors and VA, GAD, CD, IG, CLM, JP, JKR-M, RSM, KOY participated in screening, data extraction and risk of bias. PER, MC and KJS designed and completed the results section. All authors participated in the writing, critical reviewing and final approval of the manuscript.

  • Funding Educational grant from the Concussion in Sport International Consensus Conference Organising Committee through Publi Creations for partial administrative and operational costs associated with the writing of the systematic reviews.

  • Competing interests VA Financial: Australian National Health and Medical Research Council and Medical Research Future fund: research grants. Royalties: Pearson Publishing (Test of Everyday Attention) Collaboration: Australian Football League (Partnership agreement to fund research—funds go to my institute) Boards: Editorship: Journal of Neuropsychology, Neuropsychology, Journal of Clinical & Experimental Neuropsychology. GAD is a member of the Scientific Committee of the 6th International Consensus Conference on Concussion in Sport; an honorary member of the AFL Concussion Scientific Committee; Section Editor, Sport and Rehabilitation, NEUROSURGERY; and has attended meetings organised by sporting organisations including the NFL, NRL, IIHF, IOC and FIFA; however, has not received any payment, research funding or other monies from these groups other than for travel costs. CTD Pharmaceutical:-2021 pharmaceutical funded invited expert panelist (Teva) for CGRP monoclonal antibody treatment in chronic migraine-2022 pharmaceutical funded grant for growth hormone deficiency following concussion Grants/Research Support: Canadian Department of National Defense, HBI, CIHR, Tri-council funding New Frontiers, Alberta Provincial government, Foundations for PMR Patents: urine metabolites diagnosis of concussion. NF International independent FIFA Concussion Advisory Group GOTS Concussion Committee Innovation and Technology Panel, UK Department for Digital, Culture, Media and SportInternational Consensus Group on Concussion in Sports (CISG), NINDSCDE Sports Concussion CDE Subacute Subgroup (National Institute of Health) IFAB Concussion Expert Group Member: Swiss Neurology Society, Swiss Society for Clinical Neurophysiology, European Neuro-Ophthalmology Society, Concussion in Sport Group (CISG) Editorial Board Member: Journal of Concussion, Journal of Science and Medicine in Football. IG has paid employment relationships with McGill University and the McGill University Health CenterI have received grants in the last 3 years from: Canadian Institutes of Health Research, Fonds de recherche du Québec—Santé, Research Institute of the McGill University Health Center, McGill University, Institut National du Sport du QuébecI have no conflicts of interest with regards to the material being presented or discussed at the conference. KMG has received grant funding from NFL for the NFL LONG study. He also serves on the NCAA Scientific Advisory Board in an unpaid capacity. KAH has nothing to disclose. SAH is co-founder and senior advisor, The Sports Institute at UW Medicine (unpaid), Centers for Disease Control and Prevention and National Center for Injury Prevention and Control Board Pediatric Mild Traumatic Brain Injury Guideline Workgroup (unpaid), Concussion in Sport Group (Travel support), NCAA Concussion Safety Advisory Group (unpaid), Team Physician, Seattle Mariners; Former Team Physician, Seattle Seahawks; occasional payment for expert travel testimony, support for professional meetings. Mr CJ has nothing to declare. MM is a sport and exercise medicine physician working in private consulting practice and is the Chief Medical Officer at the Australian Football League. Shareholder of Olympic Park Sports Medicine Centre in Melbourne. Ex-senior physician at the Hawthorn Football Club (AFL) Ex-Chief Executive Officer of the AFL Doctors Association. Research grants received from the Australian Football League, outside the submitted work.Travel support received from the Australian Football League, FIFA and the International Olympic Committee to attend and present at international conferences. Member of the Scientific Committee for the 6th International Consensus Conference on Concussion in Sport. Honorary member of the International Concussion in Sport Group. Honorary member of the Australian Rugby Union Concussion Advisory Group.Independent Concussion Consultant for World Rugby. CLM reports no financial COI Volunteer positions: Concussion team physician, Shipley School Board of Trustees, American College of Sports Medicine Board of Directors, American Medical Society for Sports Medicine Board of Directors, Pediatric Research in Sports Medicine Executive Committee, Council on Sports Medicine and Fitness, American Academy of Pediatrics Advisory Board, Untold Foundation, Pink Concussions, Headway Foundation Editorial Board, Journal of Adolescent Health, Frontiers in Neuroergonomics, Exercise, Sport and Movement. JP is Editor BJSM (honorarium), Member of World Rugby Concussion Advisory Group (unpaid), Independent Concussion Consultant for World Rugby (fee per consultation), Medical consultant to South African Rugby (unpaid), Co-chair of the Scientific Committee, 6th International Conference on Concussion in Sport (unpaid), Board member of the Concussion in Sport Group (unpaid), Scientific Board member, EyeGuideTM (unpaid). JKR-M has current or past research funding from the Centers for Disease Control and Prevention; Department of Defense—USA Medical Research Acquisition Activity, National Collegiate Athletic Association-Department of Defense Mind Matters Challenge; National Athletic Trainers’ Association Foundation; National Football League; and National Operating Committee on Standards for Athletic Equipment. She has consulted for Allied Health Education (paid) and received speaker honorarium and travel reimbursements for talks given. She is on the editorial boards (all unpaid) for Journal of Athletic Training, Journal of Sport Rehabilitation and Frontiers in Sports and Active Living. Previously she served on the editorial board for the International Journal of Athletic Training and Therapy (paid). She served previously (unpaid) on USA Football’s Football Development Council and is currently on USA Football’s Girls Football Council. She is also a member of several committees or the National Athletic Trainers’ Association and the North Carolina High School Athletic Association’s Sports Medicine Advisory Committee. PER has nothing to declare. KJS has received grant funding from the Canadian Institutes of Health Research, National Football League Scientific Advisory Board, International Olympic Committee Medical and Scientific Research Fund, World Rugby, Mitacs Accelerate, University of Calgary) with funds paid to her institution and not to her personally. 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 AFL Concussion Scientific Committee (unpaid position) and Brain Canada (unpaid positions). She works as a physiotherapy consultant and treats athletes of all levels of sport from grass roots to professional. NDS: Employee salary from the University of British Columbia, Research grants from the Canadian Institutes of Health Research, Canada Foundation for Innovation, WorkSafeBC and the US Department of Defense (no salary contributions), Research salary support from the Michael Smith Foundation for Health Research, Editorial board member for Neuropsychology and the Journal of Head Trauma Rehabilitation (unpaid), Chair of the American Congress of Rehabilitation Medicine Mild TBI Task Force (unpaid), Member of the Scientific Advisory Committee, Brain Injury Canada (unpaid), Clinical neuropsychological consulting fees from the National Hockey League, Major League Soccer, and NDS Inc (<10% of total income). KOY: is editor-in-chief of the journal Neuropsychology and receives an editorial stipend from the American Psychological Association. He is an unpaid consulting editor for the journals Archives of Clinical Neuropsychology and Journal of Head Trauma Rehabilitation. He is an unpaid member of the Scientific Advisory Committee for Brain Injury Canada. He is the chair of the Canadian Concussion Network, which is funded by a grant from Canadian Institutes of Health Research (CIHR) to his institution; He is the principal applicant on the grant but receives no income from it. He is a principal investigator on another grant from CIHR from which he derives no income. He is a coinvestigator on research grants from CIHR, the US National Institutes of Health (NIH), Brain Canada Foundation and National Football League Scientific Advisory Board; He derives income only from the grant from NIH. He serves as a member of a CIHR grant review panel for which he receive a small honorarium. He receives book royalties from Guilford Press and Cambridge University Press. He has received travel support and honorarium for presentations to multiple organisations. He has served or serves on the following committees/boards for which I receives honorarium: 1. Independent Data Monitoring Committee (IDMC), Care for Post-Concussive Symptoms Effectiveness (CARE4PCS-2) Trial, National Institute for Child Health and Human Development 2. Observational Study Monitoring Board (OSMB), Approaches and Decisions in Acute Pediatric TBI (ADAPT) Trial, National Institute of Neurological Disorders and Stroke National Research Advisory Council, National Pediatric Rehabilitation Resource Center, Center for Pediatric Rehabilitation: Growing Research, Education, and Sharing Science (C-PROGRESS), Virginia Tech University.

  • 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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