Physical Therapy for Sport-Related Concussion: A Network Meta-analysis and Systematic Review

Context: The effectiveness and optimal exercise-based physical therapy interventions for sport-related concussion (SRC) remain controversial, and a systematic synthesis of the evidence is lacking. Objective: To conduct a network meta-analysis (NMA) of randomized controlled trials (RCTs) evaluating exercise-based physical therapy interventions for SRC recovery and provide best-practice recommendations. Data Sources: MEDLINE (PubMed), Web of Science, and Cochrane databases were searched from inception through December 2024. Study Selection: RCTs assessing exercise-based physical therapy interventions for SRC that reported symptom or recovery outcomes were included. Animal studies, observational studies, and studies with nonextractable data were excluded. All records were screened independently and blindly by 2 reviewers. Study Design: NMA using a random-effects model. Study quality was assessed with the Cochrane Risk of Bias tool (PROSPERO registration: CRD420251011941). Level of Evidence: Level 1. Data Extraction: Two reviewers independently extracted data. Outcomes included clinical recovery time and symptom- or scale-based measures. Results: A total of 20 RCTs with 1320 participants (age, 12 to 60 years; 57% female) reporting acute or persistent SRC were included; details on sport types and levels were limited. Interventions comprised subthreshold aerobic exercise protocol (SAEP), usual care exercise protocol (UCEP), multidisciplinary interventions, stretching, strict rest, vestibular rehabilitation therapy (VRT), and combined VRT plus SAEP. Multidisciplinary interventions achieved the greatest improvements (standardized mean difference [SMD] = –2.06; P = 0.002), followed by combined VRT plus SAEP and VRT alone. Subgroup analyses showed similar patterns: multidisciplinary interventions were most effective in participants <30 years old (SMD = –2.42) and in patients with persistent symptoms (SMD = –2.999). Risk of bias was low in 13 studies, moderate in 3, and high in 4. Conclusion: Multidisciplinary interventions and the combination of VBT and SAEP are the most effective treatments for SRC recovery, particularly for patients with persistent symptoms and for those <30 years.