PROGRESSIVE CLINICAL PRACTICE

The Effectiveness of Early Educational

Interventions in the Emergency Department to
Reduce Incidence or Severity of
Postconcussion Syndrome Following a
Concussion: A Systematic Review
Leeor Eliyahu, Scott Kirkland, MSc, Sandy Campbell, MLS, and
Brian H. Rowe, MD, MSc, CCFP (EM)

Abstract
Objectives: Concussions or mild traumatic brain injury are a major public health concern accounting for
85% of all brain injuries. Postconcussion syndrome (PCS) has been found to affect between 15 and 25%
of patients with concussion 1 year after the initial injury. The goal of this review is to assess the
effectiveness of early educational information or interventions provided in the emergency department on
the onset and/or severity of PCS.
Methods: A comprehensive literature search strategy involving seven electronic databases was developed.
A grey literature search of Google Scholar, recent conference proceedings in emergency medicine,
bibliographies of included studies, and clinical trial registries was also performed. The citation list was
reviewed independently by two reviewers; no restrictions on publication status or language of publication
were applied. The Cochrane risk-of-bias tool and the Newcastle-Ottawa scale were used to assess quality.
Results: From 1,325 citations retrieved, four RCTs and one controlled clinical trial met inclusion criteria.
Interventions identified in these studies included: educational information sheets, with or without
telephone or in-person follow-up, and one study on bed rest. While rarely requested, one study offered
referrals and additional treatment, if needed. None of the studies were deemed to be high quality.
Heterogeneity among outcome reporting, follow-up dates and interventions used precluded a pooled
analysis. Overall, only two of the five included studies involving adult patients receiving early educational
interventions reported a significant improvement in PCS symptoms. No reduction in PCS symptoms was
found in the study on bed rest interventions.
Conclusion: Limited evidence exists regarding the effectiveness of early educational interventions
following concussion. Standardization of the interventions, outcome measures, and follow-up periods
would make quantitative comparisons more valid. Moreover, higher-quality research in the field of early
interventions for patients in the acute care setting is urgently required.
ACADEMIC EMERGENCY MEDICINE 2016;23:531–542 © 2016 by the Society for Academic Emergency
Medicine

From the Department of Emergency Medicine (LE, SK, BHR), the J. W. Scott Health Sciences Library (SC), and the School of
Public Health (LE, BHR), University of Alberta, Edmonton, Alberta, Canada.
Received August 11, 2015; revision received December 30, 2015; accepted January 4, 2016.
Presented in part at the Canadian Association of Emergency Physicians (CAEP) Annual Scientific Meeting, Edmonton, AB,
Canada, May 31–June 3, 2015
Ms. Eliyahu was supported by a Frederick Banting and Charles Best Canada Graduate Scholarship from the Canadian Institutes
of Health Research (CIHR; #274555), The Health Quality Council of Alberta (HQCA) Studentship, and the Walter H. Johns Gradu-
ate Fellowship from the University of Alberta. Mr. Kirkland is supported by the Emergency Strategic Clinical Network (Alberta
Health Services; Edmonton, AB) and the Emergency Medicine Research Group (EMeRG) at the University of Alberta. Dr. Rowe is
supported by a Tier I Canada Research Chair in Evidence-based Emergency Medicine from the Canadian Institutes of Health
Research (CIHR) through the Government of Canada (Ottawa, ON).
The authors have no potential conflicts to disclose.
Supervising Editor: Christopher R. Carpenter, MD, MSc.
Address for correspondence: Dr. Brian H. Rowe; e-mail: brian.rowe@ualberta.ca.

© 2016 by the Society for Academic Emergency Medicine ISSN 1069-6563 531
doi: 10.1111/acem.12924 PII ISSN 1069-6563583 531
532
M
ild traumatic brain injury (mTBI), also
referred to as concussion, is the most com-
mon type of brain injury presentation to the
emergency department (ED).1 Concussion/mTBI has
been defined as a “complex pathophysiological process
affecting the brain, induced by biomechanical forces”,2
and 3.8 million concussions are seen annually in the
United States.3 While it is estimated that most industri-
alized countries share similar incidence (100–300/
100,000), it is believed that there is significant underre-
porting and the true number of mTBI/concussion
(referred to as “concussion”) may be higher.4
Accounting for 85% of all brain injuries,1 concussion
has been found to leave 25%–35% of patients with lin-
gering symptoms 3 months after injury.5 These persis-
tent and often disabling symptoms have been labeled
postconcussion syndrome (PCS) by the International
Classification of Disease (Version 10; ICD-10).6 Symp-
toms vary widely and may include a variety of neuro-
logic deficits encompassing the emotional, cognitive,
and physical spectrums.7 There is similar variation with
respect to severity and duration.8 The ICD-10 describes
PCS as including “a number of disparate symptoms
such as headache, dizziness (usually lacking the features
of true vertigo), fatigue, irritability, difficulty in concen-
trating and performing mental tasks, impairment of
memory, insomnia, and reduced tolerance to stress,
emotional excitement, or alcohol.”6 PCS has been found
to affect between 15% and 25% of mTBI victims 1 year
after initial injury.9,10
Although much uncertainty exists about the etiology4
of concussion and PCS onset,4 there is little doubt that
PCS takes an emotional and physical toll on those suf-
fering from it.6–8 Despite its importance and frequency,
no clear and consistent interventions or standard man-
agement practice currently exists within the ED,11 even
though it is often the main or only point of contact with
the medical system for concussion patients.12 A system-
atic review from 2005 concluded that out of all treat-
ment modalities, early patient education had the
strongest evidence of support.13 Therefore, the objective
of this review was to identify the effectiveness of early
educational interventions for patients with concussion.
METHODS
Protocol
A study protocol was developed a priori to define the
objective, outline the search strategy, establish explicit
selection criteria, determine the primary outcome, guide
the data collection process, and define the analysis (see
Data Supplement S1, available as supporting informa-
tion in the online version of this paper). This review fol-
lows the PRISMA statement checklist of systematic
review reporting.14
Research Question
The research question addressed in this review was: In
patients diagnosed in the ED with a concussion, are
brief educational interventions, with or without follow-
up care, effective in reducing PCS compared to usual
care?
Eliyahu et al. • CONCUSSION REVIEW
Eligibility Criteria
Randomized controlled trials (RCT), quasi-RCTs, and
nonrandomized prospective observational studies with
comparison groups were eligible to be included. Retro-
spective studies, chart reviews, or studies with no com-
parison group were ineligible.
Types of Participants
Studies enrolling adult patients > 15 years presenting to
the ED or other acute care setting (urgent care or other
ambulatory care facilities) diagnosed with a simple con-
cussion were considered for inclusion. Concussion was
defined by each study’s criteria. Only studies in which
patients presented to the ED or acute care setting
within 72 hours of injury were eligible. Studies that
enrolled pediatric and adult patients were considered,
assuming that data on adults were available. Similarly,
studies that enrolled patients with any severity concus-
sion were considered, provided that a separate analysis
for discharged patients was reported.
Interventions
Eligible interventions included written, verbal, comput-
erized, and/or video advice from a physician or nurse;
pamphlets or information sheets on concussion; specific
discharge instructions, as well as instructions to follow
up with a primary care/family physician (e.g., appoint-
ments made, taxi voucher, written information to clini-
cian). To be included in the review, the intervention/
educational session had to be initiated within 10 days of
the initial visit to the ED or acute care setting. Given the
objective of this review, any studies in which the
intervention involved referrals to other health care
professionals (e.g., physiotherapists) or treatment with
pharmacotherapy or potential neuroprotective therapies
were excluded. Interventions using cognitive beha-
vioural therapy and other types of psychotherapy or
neuropsychology were also excluded.
Control
The control groups in the included studies were defined
as the comparison group not receiving the intervention
of interest within the given study. No studies were
excluded based on the type of care the control group
received which may have included no intervention,
usual standard care, generic discharge instructions, or a
less intense treatment option compared to the study
intervention (“enhanced care”).
Outcomes
All patient-oriented outcomes were considered; how-
ever, the primary outcome was the incidence of PCS
symptoms. Individual symptoms as well as symptom
composites were evaluated. All follow-up periods were
considered. Secondary outcomes included duration and/
or severity of PCS, quality-of-life assessments, reinjury,
noncompliance with advice, financial/economic burden
(i.e., days of work lost, employment), and return to ED.
Search Strategy
A comprehensive search strategy was developed with
the help of an experienced health librarian (SC). An
ACADEMIC EMERGENCY MEDICINE • May 2016, Vol. 23, No. 5 • www.aemj.org
electronic search without restrictions on language, pub-
lications status, or dates, was employed for seven data-
bases: Medline, EMBASE, CINAHL, Scopus, Proquest
Dissertation and Theses, SPORT Discus, and ERIC. The
searches encompassed the time from 1946 to August
2014. Google translate, which has been shown to be a
moderately effective translation tool for foreign-
language studies,15 was used to translate any foreign lan-
guage articles. Further evaluation was only conducted if
translation was able to produce a legible manuscript;
otherwise, a native speaking translator was be used to
translate. There were no restrictions based on language
or publication status. A complete search strategy can be
found in Data Supplement S2 (available as supporting
information in the online version of this paper).
Searching Grey Literature
Additional sources were searched for any potential stud-
ies including clinical trial registries (Cochrane Central
Register of Controlled Trials, controlled-trials.com, and
ClinicalTrials.gov), Google Scholar, and hand searching
through the most recent emergency medicine conference
abstracts from the following journals: Canadian Journal of
Emergency Medicine (2008–2014) and Academic Emer-
gency Medicine (2008–2014). Bibliographies from
included studies and reviews were searched for additional
citations.
Selection of Studies
Two authors (LE, SK) independently reviewed titles and
abstracts to identify potentially relevant trials for full-
text review and then independently identified articles
for inclusion using predefined inclusion/exclusion crite-
ria. Interobserver agreement was measured using
kappa statistics.16 Disagreement was resolved by third-
party adjudication (BHR); reasons for exclusion were
documented.
Protocol Amendments
The initial search excluded trials where the intervention
was applied from 10 to 30 days postinjury. We amended
the protocol to include this time frame and allow a com-
parison between early (≤10 days) and subacute (10–
30 days) interventions.
Data Extraction and Management
Data were extracted (LE) onto standardized forms with
information about patients, methods, interventions, and
outcomes (see Data Supplement S3, available as support-
ing information in the online version of this paper). The
data were independently verified by a second reviewer
(SK), and disagreements were resolved by consensus.
Descriptive results of the included studies were sum-
marized in evidence tables. Agreement was reported
using Kappa (k) statistics. For continuous data, mean
differences (MD) for individual studies were calculated.
For dichotomous data, odds ratios (OR) are reported.
All results are reported with 95% confidence intervals
(CI) using a random effects model.
Quality Assessment
Risk of Bias for RCTs. The methodologic quality of
the included RCTs was assessed by two independent
533
reviewers (LE, SK) using the risk-of-bias (RoB) assess-
ment tool.17 Disagreements were resolved by consensus
or third-party adjudication (BHR). RoB examines the
adequacy of sequence generation, allocation conceal-
ment, blinding of participants, personnel and outcome
assessors, addressing incomplete outcomes, freedom
from selective reporting, and freedom from any other
bias.
Newcastle-Ottawa Scale. The Newcastle-Ottawa scale
(NOS) was used to assess the quality of nonrandomized
studies17 by two independent reviewers (LE, SK). Dis-
agreements were resolved by consensus or third-party
adjudication (BHR).
RESULTS
Search Results
The systematic and grey literature search identified
1336 and 83 studies, respectively; a total of 1,419 unique
citations were identified. After title and abstract review,
40 studies were selected for full-text review. Of these, 35
were excluded, and the remaining five studies, involving
822 patients, were included. The reasons for exclusion
are shown in Figure 1. There was weak reviewer agree-
ment for identifying relevant studies (k = 0.4) and
included/excluded studies (k = 0.26).
Study Characteristics
Table 1 provides a summary of the characteristics of the
included studies. All of the included studies were pub-
lished, peer-reviewed articles. Four of the studies were
RCTs,18–21 while one used a cohort design.22 The studies
recruited patients presenting to the ED within 6–48
hours of injury. The most common cause of concussion
across the studies included falls,18–20,22 traffic/vehicular
collisions,18 horse riding,19 sports,22 and work-related
injuries.20
The definition of concussion varied across studies.
Loss of consciousness in patients was accepted in one
study20 for up to 15 minutes and in three studies for up
to 30 minutes.18,19,22 Posttraumatic amnesia following
injury was acceptable for up to 1 hour in two stud-
ies19,20 and up to 24 hours in two studies.18,22 One study
simply used the American College of Rehabilitation
Medicine’s definition of mTBI.21
Description of Intervention and Control Groups
A detailed description of each study’s intervention can
be found in Table 2. Interventions were implemented
between 1 and 10 days18,20–22 or 14–21 days following
ED discharge.19 The interventions varied widely. Bell
et al.18 provided patients with booklets on concussion at
discharge and provided five scheduled telephone fol-
low-up calls over 12 weeks to facilitate recovery.18 Both
control and intervention groups received a patient
instruction handout, separate from the CDC booklets.
Similarly, Ponsford et al.22 provided patients with an
information booklet outlining common symptoms asso-
ciated with mild head injury, likely time course, and
some suggested coping strategies. The control group
received standard ED care with no information booklet.
A novel approach in one study21 provided all patients
534
Figure 1. PRISMA chart of search results.
with a handout at discharge and sent three daily SMSs
(short-message service communications) where patients
scored their symptoms. The intervention group was
sent additional educational and reassuring messages
tailored to the symptom they reported most, while the
control group received no such messages. Another
study, studied the effects of 6 days of full bed rest, fol-
lowed by a gradual tapering to normal activity versus
limited bed rest.20 Finally, Matuseviciene et al.19 pro-
vided some written information about common symp-
toms and outcomes at ED discharge to both control and
intervention groups but provided an additional appoint-
ment at 14–21 days following discharge for the inter-
vention group. Recommendations for gradual return to
play, detailed interview, and other standard examina-
tions were provided at this time.
Outcomes
Follow-up timing and outcome assessments varied
across the studies. Outcome measurements in three
studies were performed at 2 weeks,21 3 months,19,22 and
6 months18 after discharge. One study assessed out-
comes at multiple periods of time, including 2 weeks,
3 months, and 6 months.20 Two studies reported PCS
symptoms as individual symptoms only20,22 and three
studies reported on composite symptoms.18–21 Individ-
ual symptoms were reported inconsistently across stud-
ies due to different surveys used to assess PCS (see
Data Supplement S4, available as supporting informa-
tion in the online version of this paper).
Quality of life was reported in one study18 and gen-
eral health status was reported in two studies.18,20
Another study21 screened subjects for the presence of
posttraumatic stress disorder (PTSD). One study evalu-
ated patient’s compliance with the advice provided to
them; however, the fidelity of the interventions was
rarely reported.20 Some proposed secondary outcome
Eliyahu et al. • CONCUSSION REVIEW
analyses could not be assessed as planned due to a lack
of reporting.
Study Quality
The overall RoB was considered high for all four RCT
studies (Figure 2).18–21 One study18 was deemed to have
a low RoB in all categories except blinding, as the
authors failed to blind participants or personnel. The
cohort study22 was found to be of moderate quality
using the NOS.
Heterogeneity
Clinical heterogeneity due to the variability of interven-
tions used, length of follow-up, and outcome reporting
precluded efforts to pool the results in a traditional
meta-analysis. Therefore, the studies will be summa-
rized based on outcomes below.
PCS Outcomes
Primary Measure. Table 3 presents the PCS results
identified across the five included studies. Briefly, Bell
et al. reported that patients receiving the intervention
were overall less likely to experience posttraumatic symp-
toms (MD = 6.6, 95% CI = 1.2 to 12.0; p = 0016). The lar-
ger the MD the bigger the difference between the
posttraumatic composite mean score for the intervention
and control groups. Suffoletto et al. failed to demonstrate
differences in headaches (odds ratio [OR] = 0.38, 95%
CI = 0.07 to 1.99) or concentration (OR = 0.32, 95%
CI = 0.04 to 2.24).
Secondary Measures (Severity). In Matuseviciene
et al.19 a mean score of symptoms from the Rivermead
Post-Concussion Questionnaire was reported on a 5-
point scale, where 0 = symptom not experienced at all
and 4 = severe symptoms. The mean score reduction
between baseline and follow-up symptoms was similar
Table 1
Summary of Findings from Included Studies

Author and Country Participant Characteris- No. of Sub- Follow-up Per- Quality of
Year of Study tics jects, % male iod (s) Follow-up Proportions Methods Main Results
Bell et al. United ≥16 y old Ctl: n = 195, 1: 6 mo Ctl: 85% High RoB Values presented as mean differences
200818 States ED admission within 64% male Int: 85% (95% CI):
48 h of injury Int: n = 171, Posttraumatic symptom composite: 6.6
LOC ≤ 30 min 66% male (1.2, 12) p = 0.016.
GCS 13–15 General health composite: 15 ( 2.2, 5.2)
PTA ≤ 24 h p = 0.417.
Home phone + address Individually significant symptoms:
No hx of neurologic or Fatigue, p = 0.042; trouble sleeping,
psych disease p = 0.002; sexual difficulties, p = 0.031;
No drug or EtOH use affected function at work, p = 0.024;
No other very severe during leisure or recreation, p = 0.027;
injuries with memory and concentration,
p = 0.011; and financial independence
p = 0.010
Subgroup analysis showed:
Males in the intervention group had a
lower symptom composite than their
male counterparts in the control group,
p = 0.008.
de Kruijk et al. Netherlands >15 y old Ctl: n = 54, 3: at 2 wk, 3 Ctl: 61% High RoB 6 full days of bed rest had no “beneficial
200220 Present to ED within 6 h 52% male mo, 6 mo Int: 87% effect on the severity of posttraumatic
of injury Int: n = 53, at 6 mo complaints or on general health status
LOC < 15 min 60% male (SF-36) at 6 mo after mTBI.”
ACADEMIC EMERGENCY MEDICINE • May 2016, Vol. 23, No. 5 • www.aemj.org

GCS 14–15 @ ED
presentation
PTA < 1 h
Absence of focal
neurologic signs
Lack of multiple trauma
Hx of TBI, EtOH abuse,
or psych problem were
excluded
Matuseviciene Sweden 16–70 y old Ctl: n = 49, 1: at 3 mo Ct: 84% High RoB No significant differences found between
et al. 201319 Present to ED within 47% male Int: 81% the groups as a mean RPCQ value or as
24 h of injury Int: n = 48, changes in individual symptoms at
LOC < 30 min 31% male follow up. The same was found with
GCS 14–15 depression and anxiety scores as
PTA < 1 h measured by HADS.
Included patients with
intracranial pathology
without need for
surgery

(Continued)
535
 536

Table 1 (continued)

Author and Country Participant Characteris- No. of Sub- Follow-up Per- Quality of
Year of Study tics jects, % male iod (s) Follow-up Proportions Methods Main Results
Ponsford et al. Australia ≥16 y old Ctl: n = 126 1: at 3 months Ctl: 98% Moderate RoB Those in the intervention group reported
200222 English speaker Int: n = 136 Int: 58% fewer symptoms 3 mo after injury: sleep
LOC < 30 min Note: %male **Note: This disturbances (p < 0.01), anxiety
GCS 13–15 not described rate excludes (p < 0.04), paranoia (p < 0.01), and
PTA < 24 h outliers who hostility (p < 0.01). On the global severity
Exclusion of patients completed index scale intervention group also
with focal neurologic follow-up. reported fewer symptoms with a
signs p < 0.01. They also showed lower levels
of psychological distress on the SCL
90-R.
Suffoletto United ≥18 y old Ctl: n = 25; 1: at 2 weeks Ctl: 88% High RoB No significant differences were found in
et al. 201321 States Speak English 32% male Int: 78% the median RPCQ scores or the PTSD,
Met the American Int: n = 18; anxiety, and depression screens between
College of 61% male the groups at 14-d f/u.
Rehabilitation Medicine Intervention participants had similar odds
definition of mTBI of headaches (OR = 0.38, 95% CI = 0.07–
No major confounding 1.99), concentration difficulty (OR = 0.32,
issues 95% CI = 0.04–2.24), and irritability
Has a cell phone with (OR = 0.33, 95% CI = 0.05–2.35).
SMS capability

Hx = history; PTA = posttraumatic amnesia; LOC = loss of consciousness; TBI = traumatic brain injury; GCS = Glasgow Coma Scale; Int = intervention; Ctl = Control; RoB = Risk
of Bias; EtOH = alcohol; SCL-90-R = Symptom Checklist-90 revised; SMS = short message service; RPCQ = Rivermead Post-Concussion Symptom Questionnaire; OR = odds
ratio.
Eliyahu et al. • CONCUSSION REVIEW
Table 2
Interventions Used by Included Studies

Intervention Components
Timing of ED Presenta-
tion Postinjury/First Con- Scheduled Telephone or Additional
Study Control Group tact Information Booklet SMS Follow-up(s) Bed Rest Treatment
Bell et al. Usual ED standard of Within 48 h of injury; Instruction handout + Scheduled telephone N/A N/A
200818 care—with patient first telephone follow- CDC booklet on mTBI contacts over first 3 mo
instruction handout. up at 2 d after provided at ED after injury to facilitate
discharge. discharge. symptom recovery.
Scheduled for 2 d and 2, 4,
8, and 12 wk postinjury.
de Kruijk et al. No bed rest; mobile Within 6 h of injury— N/A N/A Full bed rest during first N/A
200220 from the first day after intervention 6 days (12 h/d)
trauma with at most implemented the day postinjury and then
4 h of bed rest on day after injury. taper method on day 7,
1, 3 h on day 2, 2 h on as seen in control
day 3, and 1 h on day group.
4.
Matuseviciene Treatment as usual Within 24 h of injury— Written info at ED N/A N/A Identified problems
et al. 201319 including some written intervention discharge about mTBI, related to mTBI or
info about common implemented within 14– common symptoms, comorbidities were
symptoms and 21 d. and outcomes. At the provided as needed
outcomes at ED later appointment (n = 4).
discharge. recommendations for
gradual return to play,
detailed interview, and
other standard exams
were performed.
ACADEMIC EMERGENCY MEDICINE • May 2016, Vol. 23, No. 5 • www.aemj.org

Ponsford et al. Standard ED treatment Within 48 h of injury— Information booklet N/A N/A N/A
200222 with no information intervention outlining common
booklet. implemented within 5–7 symptoms associated
d with mTBI; likely time
course; suggested
coping strategies.
Suffoletto Patient instruction Within 24 h of injury. Patient instruction Patients received three daily N/A Outpatient referral if
et al. 201321 handout and outpatient Intervention handout. SMS messages asking prescribed.
referral if prescribed. implemented the day them to score their
Received three daily after discharge. symptoms. If responses
SMS messages asking indicated symptoms, a
them to score their follow-up message was
symptoms. sent designed to provide
symptom-specific
education, reassurance,
and management guidance
(one message for mild and
two for severe symptoms).

mTBI = mild traumatic brain injury; N/A = not applicable; SMS = short- message service; CDC = Center for Disease Control; ED = emergency department.
537
538
High
ADEQUATE SEQUENCE GENERATION
ALLOCATION CONCEALMENT
BLINDING OF PARTICIPANTS, PERSONNEL
BLINDING OF OUTCOME ASSESSORS
INCOMPLETE OUTCOMES ADDRESSED
FREE OF SELECTIVE REPORTING
FREE OF OTHER BIAS
OVERALL RISK OF BIAS
Figure 2. Risk of bias assessments for the four randomized controlled trials included.
in the treatment and control groups (0.54 vs. 0.34) and
was not considered clinically important.
Secondary Outcomes
Quality of Life. Two studies reported on general health
indicators.18,20 While Bell et al. reported that patients
receiving the intervention were less likely to report an
altered ability to work (MD = 11, 95% CI = 1 to 20),
reduced function in leisure or recreational activities
(MD = 10, 95% CI = 1 to 18), altered functioning in mem-
ory and concentration (MD = 12, 95% CI = 3 to 21), and
reduced financial independence (MD = 9, 95% CI = 2 to
16), general health composite scores were similar to con-
trols (DoM = 1.5, 95% CI = 2.2 to 5.2).17 Values above or
below 1 and not including 0 are considered statistically
significant. Ponsford et al. reported statistically signifi-
cant higher general health composite scores in the nonin-
tervention group (p < 0.001).19 de Kruijk et al. assessed
general health indicators from the overarching categories
present on the Short Form-36 questionnaire; however, no
significant differences between groups were found.21
Mental Health Outcomes. Bell et al. reported that
patients receiving the intervention were less likely to feel
fatigue (MD = 11, 95% CI = 0.4 to 21), difficulty sleeping
(MD = 17, 95% CI = 6 to 26), and sexual difficulties
(MD = 6, 95% CI = 1 to 10).17 Ponsford et al. reported a
statistically significant reduction in anxiety (p < 0.04), dif-
ficulty sleeping (p < 0.01), paranoia, (p < 0.01), and hostil-
ity (p < 0.01) in those receiving the intervention.21
Proportions of patients with anxiety and depression were
found to be similar among intervention and control
patients in the study by Matuseviciene et al.19 Finally, no
statistically significant differences were seen in depres-
sion, anxiety, PTSD, or pain medication use in the study
by Suffoletto et al.21
Subgroup Analysis
The influence of age, sex, and race on concussion out-
comes could not be fully examined due to incomplete
outcome reporting.
Eliyahu et al. • CONCUSSION REVIEW
Low Unclear
2 2
1 3
2 2
2 2
2 1 1
2 2
3 1
4
NUMBER OF ARTICLES (#)
DISCUSSION
The goal of this review was to provide ED clinicians
with an up-to-date synthesis of evidence of the effective-
ness of advice and simple “at-home” (including brief fol-
low-up with a case manager) interventions that the
majority of patients seen in an ED could employ. Using
a comprehensive search and high quality methods, this
review identified five studies that involved early inter-
ventions to treat concussions in the ED. Even with a
focused research question, comprehensive search, and
efforts to avoid publication and selection bias, outcomes
were too heterogeneous to pool. Overall, the evidence
in this review is limited and the studies are generally of
low quality.
Only two of the five included studies reported a sig-
nificant improvement in PCS symptoms. Using a booklet
and telephone follow-up, researchers reduced the com-
posite score for the PCS symptoms compared to a stan-
dard care group.18 Another study found that
information booklet alone achieved some statistically
significant reductions in some individual PCS symp-
toms.22 On the other hand, one study failed to identify
any significant change in PCS symptoms among
patients receiving an information booklet coupled with
daily educational information and reassurance delivered
by text messaging follow-up.21 In addition, written
information and follow-up was insufficient to produce
significant differences in PCS symptoms from control
patients.19 Finally, advising concussion patients to
remain in bed for 6 days following injury20 failed to
improve outcomes.
Previous systematic reviews on interventions for con-
cussion have assessed the efficiency of all nonsurgical
interventions, including cognitive and physiotherapy
and pharmacologic interventions (summarized in Data
Supplement S5, available as supporting information in
the online version of this paper).13,23,24 In contrast, the
aim of this review was to assess whether early educa-
tional interventions improved outcomes for patients
presenting to the ED with mTBI or concussion shortly
Table 3
Individual PCS Symptoms That Were Consistently Measured Across All Five Included Studies

Symptom Headache Dizziness Trouble Concentrating Difficulty Sleeping Memory Difficulty

Bell et al.18 5 7 6 17 7
Difference in percentage points at (95% CI = 5 to 16) (95% CI = 1 to 15) (95% CI = 3 to 16) (95% CI = 6 to 26) (95% CI = 3 to 17)
6-mo F/U p = 0.301 p = 0.088 p = 0.195 p = 0.002* p = 0.156
de Kruijk et al.20 1.51 1.38 0.75 1.02 0.91
Reported as the log (95% CI = 0.66 to 2.37) (95% CI = 0.72 to (95% CI = 0.35 to 1.55) (95% CI = 0.50 to (95% CI = 0.42 to
transformation of exponential b 2.63) 2.07) 1.88)
coefficient at 3-mo F/U
Matuseviciene et al.19 Baseline: F/U: Baseline: F/U: Baseline: F/U: Baseline: F/U: Baseline: F/U:
4-point scale (0–3) comparisons Int: 1.51 Int: 0.48 Int: 1.24 Int: 0.53 Int: 1.20 Int: 0.73 Int: 0.89 Int: 0.66 Int: 1.32 Int: 0.71
between end points only at 3-mo Ctl: 1.55 Ctl: 0.63 Ctl: 1.05 Ctl: 0.54 Ctl: 1.12 Ctl: 0.38 Ctl: 0.74 Ctl: 0.48 Ctl: 0.89 Ctl: 0.44
F/U (no reported variance
measures)
Ponsford et al.22 Baseline: F/U: Baseline: F/U: Baseline: F/U: Baseline: F/U: Baseline: F/U:
5-point scale (1–5); comparisons N/A Int: 2.04 N/A Int: 1.48 N/A Int: 1.96 N/A Int: 1.72 N/A Int: 1.79
between end points only at 3-mo Ctl: 2.37 Ctl: 1.56 Ctl: 2.09 Ctl: 2.21 Ctl: 1.97
ACADEMIC EMERGENCY MEDICINE • May 2016, Vol. 23, No. 5 • www.aemj.org

F/U (no reported variance p < 0.01*

measures)
Suffoletto et al.21 Baseline: F/U: N/A Baseline: F/U: N/A N/A
Symptoms reported as mean (SD) N/A Int: 0.99 (0.98) N/A Int: 0.88 (0.93)
at day 14 F/U Ctl: 1.19 (0.89) Ctl: 1.23 (1.1)
p = 0.5 p = 0.2

N/A = no values reported; Int = intervention group; Ctl = control group; F/U = follow-up.
*Significant.
539
540
after injury. The previous reviews did not attempt to
identify studies focusing on early presentations to the
ED, even though most patients recover from symptoms
within 1–2 weeks following injury.11,25
While previous reviews on the topic have suggested a
possible benefit of early educational interventions to
patients with concussion,23,24 these findings, however,
have been disputed. A study by Al Sayegh et al.4 claimed
that these benefits may be overstated, while another
review focused its discussion on the lack of quality
research in the literature.26 To determine whether the
perceived health benefit of educational interventions is
valid, this review narrowed that search to only those
interventions identified as “early.” Our current review
has shown that although meta-analysis was not feasible,
three of the five studies found early educational/advice
interventions reduced the frequency of either composite
or individual PCS in adults. Few comparative effective-
ness studies were identified, and the relative effective-
ness of the individual interventions is unclear at this
time.
There are widespread variability and inconsistencies
among definitions,27,28 guidelines and outcome mea-
sures/reporting in the literature. Considerable ambigu-
ity in the literature exists when describing the time
frame for concussion symptoms and when these
become PCS. Some studies enrolled patients and
started the intervention within days to a week of the
injury,18–20,22,29–31 while others enrolled patients pre-
senting within a few weeks of the injury occurring.32–39
It would be beneficial to standardize or effectively
define the early intervention period and encourage
future studies to follow similar standards of early
enrollment. At this time, there are insufficient published
papers on interventions to be able to recommend a cut-
point for intervention timing.
Variability among outcome measures among the
included studies was widespread (Data Supplement S4).
In the four studies included in this review, only five PCS
symptoms were consistently assessed across all four
studies. An even greater variety exists with secondary
outcome reporting including social and quality-of-life
outcomes. A standardized, validated, and widely
accepted concussion outcome form would greatly aid in
the ability to compare studies or pool results to deter-
mine effectiveness of interventions.
LIMITATIONS
Several limitations exist in this review. First, hetero-
geneity precluded pooling and limited this review to
descriptive analyses. Second, the small number of
included trials, while surprising, limits the compar-
isons and recommendations. Third, while it is possi-
ble that some studies could have been missed,
comprehensive searches of published and grey litera-
ture were performed without restriction on language,
dates, or publication status to decrease the potential
for publication bias. Fourth, to mitigate selection
bias, two independent reviewers were used in all
stages of the review and third-party adjudication was
used to correct for low agreement. Fifth, the control
groups in this review varied and some controls could
Eliyahu et al. • CONCUSSION REVIEW
be considered to have received “enhanced care” (in-
formation/handouts). The only study to compare
information to no care failed to detect a difference in
outcomes, reflecting the need to further explore the
effectiveness of the components of current informa-
tion handouts.
CONCLUSION
There is insufficient high-quality evidence to provide
clear recommendations about early interventions
designed to decrease the severity of postconcussion
syndrom following a concussion. Despite the multiple
comparisons reported in the included studies, signifi-
cant results in favor of the interventions were infre-
quent. None of the interventions appeared to influence
the primary outcomes of the systematic review. Given
this limited evidence regarding the effectiveness of early
interventions including written information, with or
without reminders to reduce postconcussion symp-
toms,18,22 the comparative effectiveness of different
strategies is unknown. Research is urgently needed on
the value of information booklets and/or teaching of
coping strategies to patients with concussion presenting
to acute care settings in order to inform evidence-based
guidelines and improve outcomes.
This review was unfunded. The authors thank Drs. Jennie Pons-
ford, Giedre Matuseviciene, and Derick Wade for responding to
requests for additional information.
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moderate head injury. Scand J Trauma Resusc Data Supplement S2. Comparison between recent
Emerg Med 2010;18:10. systematic reviews on concussion literature.
Data Supplement S3. Data extraction form.
Data Supplement S4. Variation in questionnaires
Supporting Information
used in included studies.
The following supporting information is available in the Data Supplement S5. Comparison between recent
online version of this paper: systematic reviews on concussion literature.
Data Supplement S1. Protocol for a systematic
review.