Adapting the dynamic, recursive model of sport injury to concussion: an individualized approach to concussion prevention, detection, assessment, and treatment

Key points

1. 01Previous concussion history, female sex, adolescent age, and pre-existing migraine or mental health problems are established risk factors for concussion and slower recovery.
2. 02Rule changes (e.g., removing body checking in youth ice hockey) achieved a 67% reduction in concussion risk, representing the strongest single prevention intervention reported.
3. 03Screening tools like the SCAT5 and CRT5 guide sideline detection; clinical utility of the SCAT5 diminishes after 3 to 5 days, but the symptom scale remains useful for tracking change.
4. 04Nine persistent symptom domains are addressed: headache, cervical spine pain, dizziness, vision problems, exertion intolerance, cognitive difficulties, mood and mental health, sleep problems, and neuroendocrine dysfunction.
5. 05Cervicovestibular physiotherapy and sub-symptom aerobic exercise are the rehabilitation approaches with the most supporting evidence for persistent symptoms.

How it was conducted

Design

Clinical commentary applying the dynamic, recursive model of sport injury (Meeuwisse et al. 2007) to sport-related concussion

Scope

Covers the full continuum of concussion care: prevention, detection, assessment, and rehabilitation

Population

Athletes of all ages with sport-related concussion, with emphasis on youth and adolescent populations

Framework

Dynamic, recursive model of sport injury etiology adapted to concussion; also incorporates the van Mechelen injury prevention model

Evidence base

Narrative synthesis of published literature across epidemiology, risk factors, screening tools, and rehabilitation interventions

What they found

• A neuromuscular training program performed at least three times weekly reduced overall risk of game-related concussion in youth rugby players.
• A vision training program may reduce the risk of concussion in collegiate football players.
• Rule changes to disallow body checking reduced concussion risk in youth ice hockey by 67%.
• Sub-symptom aerobic exercise at 80% of maximal heart rate achieved on the Buffalo Concussion Treadmill Test (BCTT), five days per week, demonstrated benefit for symptoms and function.
• Exercise at 60% of maximal heart rate for up to 15 minutes combined with guided imagery and sport-specific coordination exercises also showed benefit.
• Of children with convergence insufficiency post-concussion, 46% resolved within 4.5 weeks and another 41% recovered with vestibular rehabilitation including convergence training.
• Canalith repositioning maneuvers resolve up to 98% of BPPV cases within three treatments.
• Collaborative care including cognitive-behavioral therapy, care management, and psychopharmacological evaluation had positive effects on symptom reduction after six months.
• Among youth aged 5 to 18 presenting to an emergency department, female sex, age greater than 13 years, migraine history, previous concussion with symptoms for greater than one week, noise sensitivity, fatigue, headache, parent report of slow answers, and more than three errors on the Balance Error Scoring System tandem stance were predictors of longer recovery.

Limitations

• This is a clinical commentary, not a systematic review or meta-analysis; conclusions reflect expert synthesis rather than pooled quantitative evidence.
• Evidence for several rehabilitation domains (e.g., cognitive remediation, neuroendocrine management) is described as very limited or inconclusive.
• Optimal timing, order, frequency, and combination of rehabilitation interventions remain unclear and require further research.
• The commentary focuses on sport-related concussion in athletes; generalizability to non-sport or occupational concussion contexts may be limited.

Why it matters

For patients

Athletes and parents can use this framework to understand their individual risk factors, know when to seek care, and follow a stepwise return to school and sport plan tailored to their specific symptoms.

For clinicians

Clinicians are guided to use multifaceted, symptom-specific assessment at each stage of recovery and to apply targeted interventions (cervicovestibular physio, sub-symptom aerobic exercise, sleep hygiene, mental health referral) based on the individual presentation rather than a one-size-fits-all protocol.

For readers

This paper provides a comprehensive, organized clinical framework for concussion care that integrates current evidence on prevention, screening tools, and rehabilitation across nine symptom domains within a coherent theoretical model.