Management of sport-related concussion: a review

To systematically review the evidence for rest, treatment, and rehabilitation after sport-related concussion.

Nine databases including PubMed, Cochrane Central Register of Controlled Trials, Sport Discus, and Web of Science were searched for studies that evaluated the effect of rest separately from the effects of treatment and/or rehabilitation, using words related to concussion, mild traumatic brain injury, rest, treatment outcome, and therapy.

Inclusion criteria were published reports (either articles or abstracts) of original peer-reviewed research that investigated sport-related concussions and evaluated the effects of rest or treatment on the symptoms. One investigator performed the searches. From 749 articles evaluating rest and 1175 evaluating treatment, 2 studies met criteria for the effect of rest and 10 abstracts met criteria for treatment. Three further treatment articles were identified by the authors.

Details of study design, samples, type and duration of treatment, outcome measures, and main results, with effect sizes, were extracted. Confidence intervals (CI) were extracted or calculated where possible. Level of evidence was graded (1-5; best to poorest) using Downs and Black criteria to assess study quality.

The 3 studies that investigated rest after concussion were all retrospective case series. The studies were too heterogeneous for a clear assessment of the benefits of rest. Other treatments (evaluated by case studies, retrospective case series, or other level 4 or 5 studies) were subcutaneous sumatriptan, hyperbaric oxygen therapy, amantadine, ibuprofen, and various hormonal treatments. Light exercise, or daily exercise after a 2-week baseline period, appeared to encourage return to physical activity in children and adults. The only randomized controlled trial (with blinded assessment) investigated individualized treatment of 31 participants with symptoms from sport-related concussion that persisted for 12 to 30 months. Interventions included manual spinal therapy, physiotherapy, and neuromotor and sensorimotor retraining compared with rest and graduated exercise, for up to 8 weeks. More participants in the intervention group were medically cleared to return to sport within 8 weeks of initiating treatment (risk ratio 10.3; 95% CI, 1.51-69.6).

Studies of management of concussion were so poor that conclusions that rest was not helpful or that exercise might be beneficial are premature. Better evidence showed that individualized treatment of long-standing symptoms may allow earlier return to sport than rest and exercise alone.