Do physical interventions improve outcomes following concussion: a systematic review and meta-analysis?

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, I=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, I=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, I=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, I=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.