Included articles that addressed questions of this systematic review
| Question | Included articles | Objective | Design | Results | Level of evidence |
| What are the effects of following RTA guidelines/protocols? | Darling et al20 | Evaluated the Zurich Consensus Guidelines for RTA in adolescents with concussion after they successfully completed the BCTT. | Retrospective chart review with 2-month follow-up | Completing the Zurich RTA guidelines facilitated successful return to sport without symptom exacerbation; 100% of participants returned to sport successfully. | Level 4 |
| Do children who follow RTA/RTS protocols have decreased symptom time compared with children who do not follow guidelines? | Moor et al21 | Determined adherence tendencies of adolescents to concussion management strategies and if adherence influenced recovery time. | Descriptive case series | Participants reporting greater adherence to protocols had a slower recovery time when compared with participants reporting lower adherence to the management recommendations. | Level 4 |
| What is the effect of physical rest postconcussion on outcomes including symptom, emotions, recovery time, academic success and participation? | Thomas et al22 | Determined if prolonged physical rest for 5 days compared with usual care (1–2 days physical rest) improved concussion recovery time and symptoms. | RCT | Prolonged rest group reported a greater mean PCSS score and had a longer time to symptom resolution than the usual care group. Both groups reported a similar decrease in physical activity. | Level 1 |
| Taubman et al23 | Determined the effect of delayed physical rest on recovery time in children with concussion. | Prospective cohort | Immediate rest group had a shorter time to clinical recovery compared with the delayed rest group. | Level 4 | |
| Moser et al24 | Examined the effects of prescribed rest in adolescent athletes with persistent concussive symptoms. | Prospective cohort | Symptoms improved following rest for a majority of participants. A significant effect of rest on neurocognitive and total symptom scores was found. | Level 4 | |
| How much physical rest is recommended/what is the recommended duration of physical rest and what is the supporting evidence behind these recommendations? How much physical rest is recommended/what is the recommended duration of physical rest and what is the supporting evidence behind these recommendations? | DeMatteo et al (2015)8 | Developed a protocol for paediatric population’s RTA. | Protocol developed and modified from the Zurich guidelines | Conservative protocol included a series of six steps with the goal of resuming all activity. Physical rest was recommended for 1 week after being symptom free. | Level 2 |
| Lumba-Brown et al1 | Developed recommendations for the management of children with concussion. | Guidelines created based on systematic review | Recommended patients rest 1–2 days postconcussion before beginning a gradual schedule of subthreshold activity. Graduated introduction to non-contact and contact activity is permitted so long as they remain symptom-free. | Level 1 | |
| Halstead et al25 | Provided education on current management of children and adolescents with concussion. | Clinical report created by expert consensus | Athletes with concussion should be removed from play immediately and undergo 1–2 days physical rest before completing a stepwise return-to sport programme. | Level 4 | |
| McCrory et al4 | Provided evidence-based recommendations to guide clinical practice of sport-related concussion management. | Consensus statement based on systematic review | After 1–2 days physical rest, patients are encouraged to become more active while staying below their symptom exacerbation threshold. | Level 1 | |
| What is the effect of cognitive rest postconcussion on outcomes including symptom, emotions, recovery time, academic success and participation? | Thomas et al22 | Determined if prolonged cognitive rest for 5 days compared with usual care (1–2 days cognitive rest) improved concussion recovery time and symptoms. | RCT | Prolonged rest group reported a greater mean PCSS score and longer time to symptom resolution than usual care group. The usual care group reported more school time than the prolonged rest group. | Level 1 |
| Taubman et al23 | Determined the effect of delayed cognitive rest compared with immediate cognitive rest on recovery time in children with concussion. | Prospective cohort | Immediate rest group had a shorter time to clinical recovery compared with the delayed rest group. | Level 4 | |
| How much cognitive rest is recommended/what is the recommended duration of cognitive rest and what is the supporting evidence behind these recommendations? | McCrory et al4 | Provided evidence-based recommendations to guide clinical practice of sport-related concussion management. | Consensus statement based on systematic review | Complete cognitive rest is recommended for 1–2 days postconcussion before patients are encouraged to become more mentally active while remaining below their cognitive symptom exacerbation threshold. | Level 1 |
| Brown et al28 | Examined the effect of cognitive activity level on duration of postconcussion symptoms. | Prospective cohort | On univariate modelling, participants in the highest quartile of cognitive activity days took longer to recover than those in the first-third quartiles of cognitive activity. | Level 4 | |
| What is the recommended time to progress through the stages of RTA/RTS protocols? | McKeon et al30 | Developed probability estimates for the time until return to play after concussion in high school athletes. | Descriptive epidemiology study | Probability of Return to Play was 2.5% 1–2 days postconcussion; raised to 71.3% 7–9 days postconcussion. | Level 4 |
| McCrory et al4 | Provided evidence-based recommendations to guide clinical practice of sport-related concussion management. | Consensus statement based on systematic review | The time between stages in graduated protocols should be a minimum of 24 hours. | Level 1 | |
| O’Neill et al29 | Conducted a comprehensive review of the return to learn literature. | Narrative review | The average time to fully return to learn varies across populations; age and gender are important predictors. | Level 4 | |
| Is graded exercise of benefit in achieving a faster RTA? | Leddy et al33 | Investigated the effect of subsymptom threshold aerobic exercise compared with rest. | Quasiexperimental | Recovery time was significantly lower in the exercise group than the rest group. Exercise may reduce the risk of delayed recovery. | Level 2 |
| Leddy et al32 | Assessed the effectiveness of subthreshold aerobic exercise compared with stretching. | RCT | Exercise group recovered in a median of 13 days while stretching group recovered in 17 days. | Level 1 |
BCTT, Buffalo Concussion Treadmill Test; PCSS, Postconcussion Symptom Scale; RCT, randomised controlled trial; RTA, return to activity; RTS, return to school.