A GP guide to concussion in children
- Up to one in five adolescents will sustain a concussion before completing high school.
- Post-concussion symptoms may persist for weeks to months in 20-30% of young people. These may include physical, cognitive, emotional and social symptoms, which can interfere with quality of life and level of function.
- Community education for adults and supervisors of child sports is important to ensure appropriate removal from play in the event of a concussive event.
- Detailed clinical assessment using widely available tools is recommended as soon as practicable after a concussion. Routinely allocate longer appointments for post-concussion assessments as the use of tools or questionnaires is likely to take longer than the average standard consultation.
- Evidence-based clinical guidelines do not support the use of intracranial imaging such as CT or MRI as standard following a concussion. Imaging may be indicated if a more serious injury is suspected, or if symptoms worsen over time.
- Clear guidelines are readily available to inform clinicians when advising patients about a suitable stepwise progression back to learning and sport after concussion.
- Referral to a multidisciplinary team for targeted and specific assessment and management may be indicated for patients with persisting post-concussion symptoms. This team may include a specialist paediatrician, sports physician, neurologist, physiotherapist, psychologist and neuropsychologist.
In Australia, concussion is a frequent presentation among children and adolescents in both emergency and primary care settings.
Diagnosis requires a plausible mechanism of injury and the presence of clinical symptoms and/or signs that cannot be explained by other confounding factors or other injuries.1-3
In younger children, the majority of concussions occur at home, while sport-related concussion makes up a large proportion of emergency presentations in older children and adolescents.4,5 It is estimated that up to one in five adolescents will sustain a concussion before completing high school.6
Increasing media attention on concussion has been associated with a rise in healthcare-seeking behaviour from parents following paediatric head injury, as well as hesitancy regarding children’s participation in contact sports, and other physical activities such as bike riding or playing in the park.5
Concussive symptoms can occur immediately post-injury or evolve over the following hours or days. Acute signs of concussion can include loss of consciousness, seizure activity, tonic posturing, ataxia, poor balance, confusion, behavioural changes, and amnesia.1,3
The concussion-induced cerebral pathophysiological processes are thought to include induction of a cascade of effects through neurotransmitter and metabolic pathways, with possible axonal injury, blood flow change and inflammation affecting the brain.1,3
While most patients demonstrate rapid clinical and physiological recovery post-concussion, approximately one-third demonstrate more generalised symptoms that can last days to months (persisting post-concussion symptoms [pPCS]). These symptoms typically fall into four categories, shown in table 1.
| Table 1. Categories of persisting post-concussion symptoms | |
| Physical | Headache Nausea Visual disturbances Dizziness Sensitivity to light or noise |
| Cognitive | Poor concentration Memory difficulties Slowed thinking |
| Emotional | Anxiety Irritability Low mood |
| Sleep | Insomnia or hypersomnia Fatigue |
The impact of concussion on young people can be wide-ranging and disruptive. Common consequences include difficulties returning to school, disrupted sleep, heightened irritability or anxiety, and reduced participation in physical and social activities. These disruptions are particularly problematic during critical stages of academic and psychosocial development.7
The symptoms of pPCS often interfere with quality of life and longer-term daily functioning in the 20-30% of young people with concussion who experience them.8,9 The constellation of symptoms involved in pPCS often requires a more targeted, multidisciplinary approach to care.7 It is important for GPs to be familiar with the assessment and management options, both for acute concussion and pPCS.
| Resources: |
| • Concussion Recognition Tool 6 • HeadCheck app • Sport Concussion Assessment Tool 6 (SCAT6) • Child SCAT6 • Sport Concussion Office Assessment Tool 6 (SCOAT6) • Child SCOAT6 |
Education
GPs play a key role in patient education and the diagnosis and management of concussion in the community. The most critical step is the initial recognition of injury, and in the context of sport, removal from play.
The Concussion in Sport Group (CISG) published the sixth edition of the Concussion Recognition Tool (CRT6), which is for non-medical professionals to recognise possible concussion and to safely remove the athlete from the field of play.10 Provision of CRT6 (see resources) to all teachers, parents, team trainers and other supervising adults is an important component of community education.
Another valuable tool to assist with concussion recognition is HeadCheck: a community-facing digital health application that assists with sideline concussion checks, symptom monitoring, and commencement of management with psycho-education (see resources).11
Clinical assessment
Following a suspected concussion, standard acute post-head/neck injury assessment is required. In a patient with a Glasgow Coma Scale score of 15 and normal cervical spine assessment, clinical assessment includes a detailed history, including the mechanism of injury, the patient’s concussion history (including the management and recovery trajectory/time frame of each of these), concurrent or previous medical history (such as migraine/headache disorders, anxiety, depression or neurodiversity) and medication history.2
Detailed symptom evaluation is vitally important and is best accomplished with the use of a symptom checklist, such as those published by the CISG in the Sport Concussion Assessment Tool 6 (SCAT6, for ages 13+) and Child SCAT6 (for ages 8-12) (see resources).12,13
These tools assist the medical practitioner in the diagnosis and management of concussion. These are multimodal tools that take 10-15 minutes to perform. They are best used in the acute period (first 72 hours) after a suspected concussion.
During the sub-acute period (>72 hours) it is recommended that the Sport Concussion Office Assessment Tool 6 (SCOAT6, Child SCOAT6) is used (see resources).14,15
The SCOAT6/Child SCOAT6 have been developed to allow for easy transition from acute (SCAT6/Child SCAT6) to sub-acute assessment and further multimodality evaluation.
The SCOAT6/Child SCOAT6 tools are designed for symptom-directed assessment, and include detailed symptom checklists, tests of memory and concentration, autonomic function, cervical spine evaluation, neurological examination, formal balance testing, simple and complex timed tandem gait, vestibulo-ocular assessment, mental health screen and sleep screen checklists.14,15 These tools were developed for use in the evaluation of concussion in a controlled office environment by healthcare professionals.
The Melbourne Paediatric Concussion Scale is a symptom questionnaire that can also assist with classifying symptoms into various domains.16 This is a valuable questionnaire to be aware of, and it can also be used to screen for concussion symptoms, especially during the sub-acute period.
It is advisable to routinely allocate a longer appointment time for the assessment of patients after concussion, as a comprehensive clinical assessment and application of an appropriate tool or questionnaire will take longer than an average standard consultation.
Evidence-based clinical guidelines do not support the use of intracranial imaging such as CT or MRI as standard following a concussion. However, these should be performed when a more serious injury is suspected, or where symptoms increase in the days post-injury.
Decision-making around imaging and management in a hospital setting are detailed in the PREDICT and PECARN ED Guidelines.17,18 Currently, advanced neuroimaging, fluid-based biomarkers and genetic testing are being investigated in the research setting for diagnosis, prognosis and recovery, but are not currently indicated for use in standard clinical practice.19
Management
In the first 48 hours following concussion, relative rest is important.20 Relative rest can be defined as a period of reduced activity as opposed to strict bed rest. Strict rest in bed or in a darkened room is not advised and is associated with worse outcomes compared with relative rest.
It is important that individuals gradually return to their normal activities. Light physical activity is recommended in the acute stages post-injury (eg, 2-14 days).2,20 If concussion symptoms are triggered or worsened by physical or cognitive activity, the activity may be continued, provided the symptoms are mild and resolve within an hour. However, if symptoms persist beyond this time frame or intensify, it is advisable to discontinue the activity and allow for appropriate rest.2
Currently, there are no pharmacological agents that modify concussion recovery; however, simple analgesics (non-opioid) may be used sparingly in the acute period for somatic symptom management (eg, headache). The recommended use of simple analgesia is limited to short-term relief and is to be avoided over extended periods.
Hypnotic and sedative medications should be avoided post-concussion. Poor sleep in the acute phase following a concussion (<10 days) is associated with increased risk of persisting symptoms. Evaluating and providing appropriate management of sleep hygiene is vital for optimal recovery.21
Further psycho-education regarding typical concussion recovery and the process of returning to activities (such as return to learning, sport and other activities) is highly valuable for concussed patients and their family members. A national child health poll conducted by the Royal Children’s Hospital Melbourne in 2023 showed that one in three (34%) parents had no or very limited knowledge about concussion.5 Lack of knowledge often increases parental anxiety, which itself has a significant impact on an individual’s recovery.22
Return to learn
Returning children and adolescents to school and learning is a primary goal in concussion management. GPs can help facilitate return to learn. A stepwise return-to-learn paradigm has been published by the CISG to guide this (see table 2).2
| Table 2. Return-to-learn algorithm | |||
| Step | Mental activity | Activity at each step | Goal |
| 1 | Daily activities that do not result in more than a mild exacerbation* of symptoms related to the current concussion. | Typical activities during the day (eg, reading) while minimising screen time. Start with 5-15 minutes at a time and increase gradually. | Gradual return to typical activities. |
| 2 | School activities. | Homework, reading or other cognitive activities outside of the classroom. | Increase tolerance to cognitive work. |
| 3 | Return to school part-time. | Gradual introduction of schoolwork. May need to start with a partial school day or with greater access to rest breaks during the day. | Increase academic activities. |
| 4 | Return to school full-time. | Gradually progress in school activities until a full day can be tolerated without more than mild* symptom exacerbation. | Return to full academic activities and catch up on missed work. |
| * Mild and brief exacerbation of symptoms is defined as an increase of no more than 2 points on a 0-10-point scale (with 0 representing no symptoms and 10 the worst symptoms imaginable) for less than an hour when compared with the baseline value reported prior to cognitive activity. | |||
| Reproduced with permission from the Concussion in Sport Group and the British Journal of Sports Medicine2 | |||
Return to learn is a gradual process that increases cognitive load and allows for mild, brief symptom provocation. The return-to-learn strategy takes priority over the return-to-play strategy, although both can usually be implemented simultaneously.
Most children and adolescents will progress through this process with little or no difficulty, however, if a child cannot progress through the stages in a timely manner, then referral to a specialist with expertise in concussion management is appropriate.
Return to sport
Similarly, a strategy for return to sport has also been published by the CISG (see table 3).2 During the initial 24-48 hours it is both safe and highly recommended to commence light physical activity. This forms the initial stage of the six-stage return-to-sport strategy. It is recommended to commence sub-symptom threshold aerobic exercise early.20
Individual children and adolescents will progress through the stages at different rates, depending on the rate of symptom resolution. Some key components of the current return-to-sport strategy include allowing mild and brief symptom exacerbation during stages 1-3, provision of heart-rate-guided aerobic exercise in stage 2, and the requirement for symptom resolution at rest and post-exertion before progressing to stage 4.
It must be emphasised that medical clearance from the treating physician is required before return-to-contact practice and unrestricted return to play.2,23
| Table 3. Return-to-sport strategy — each step typically takes a minimum of 24 hours | |||
| Step | Exercise strategy | Activity at each step | Goal |
| 1 | Symptom-limited activity. | Daily activities that do not exacerbate symptoms (eg, walking). | Gradual reintroduction of work/school. |
| 2 | Aerobic exercise: 2A — Light (up to approximately 55% maxHR) then 2B — Moderate (up to approximately 70% maxHR). | Stationary cycling or walking at slow to medium pace. May start light resistance training that does not result in more than mild and brief exacerbation* of concussion symptoms. | Increase heart rate. |
| 3 | Individual sport-specific exercise. Note: If sport-specific training involves any risk of inadvertent head impact, medical clearance should occur prior to step 3. | Sport-specific training away from the team environment (eg, running, change of direction and/or individual training drills away from the team environment). No activities at risk of head impact. | Add movement, change of direction. |
| Steps 4-6 should begin after the resolution of any symptoms, abnormalities in cognitive function and any other clinical findings related to the current concussion, including with and after physical exertion. | |||
| 4 | Non-contact training drills. | Exercise to high intensity including more challenging training drills (eg, passing drills, multiplayer training). Can integrate into a team environment. | Resume usual intensity of exercise, co-ordination and increased thinking. |
| 5 | Full-contact practice. | Participate in normal training activities. | Restore confidence and assess functional skills by coaching staff. |
| 6 | Return to sport. | Normal gameplay. | |
| *Mild and brief exacerbation of symptoms (ie, an increase of no more than 2 points on a 0-10-point scale for less than an hour when compared with the baseline value reported prior to physical activity). Athletes may begin step 1 (ie, symptom-limited activity) within 24 hours of injury, with progression through each subsequent step typically taking a minimum of 24 hours. If more than mild exacerbation of symptoms (ie, more than 2 points on a 0-10-point scale) occurs during steps 1-3, the athlete should stop and attempt to exercise the next day. Athletes experiencing concussion-related symptoms during steps 4-6 should return to step 3 to establish full resolution of symptoms with exertion before engaging in at-risk activities. Written determination of readiness to return to sport should be provided by a healthcare professional before unrestricted return to sport as directed by local laws and/or sporting regulations. MaxHR: predicted maximal heart rate according to age (ie, 220-age). | |||
| Reproduced with permission from the Concussion in Sport Group and the British Journal of Sports Medicine2 | |||
Management of persisting symptoms
Persisting concussive symptoms are those that have not resolved within 14 days of injury. Symptoms attributed to concussion are non-specific and can occur with conditions other than concussion.2 The GP plays a critical role in the early management of concussion and the identification of persisting symptoms that will require specialist intervention (eg, sports medicine, neurology, paediatrics, physiotherapy).
When managing a patient with persisting symptoms, consider possible biopsychosocial risk factors, such as pre-injury factors, personality traits, environmental stressors and social-psychological factors. These include patient and family mental health, ADHD, and other conditions, including cervical spine, oculovestibular, migraine, other headache disorders, sleep dysfunction, chronic pain conditions and autonomic dysfunction.2,24
It is important to recognise that symptoms often co-occur and may be sustained or intensified by various interacting factors that trigger, exacerbate or reinforce the persistence of symptoms.24,25
When necessary, refer for a multimodal and multidisciplinary approach to provide further targeted and specific assessment and management for pPCS.2 The multidisciplinary model of management commonly includes physical therapy (physiotherapy) and psychological management:
Physical therapy
If physical symptoms of dizziness, neck pain and/or headache persist for longer than 10 days, then referral for individualised, patient-centred treatment is appropriate. Somatic symptoms can be driven by visual, vestibular, cervical or autonomic system dysfunction or sensitivity and patients benefit from targeted physical treatment.2,26
Vestibular-trained physiotherapists provide systematic assessment and prescribe customised exercise programs, which often initially focus on oculomotor function or habituation exercises. At times, canalith repositioning manoeuvres for benign paroxysmal positional vertigo may be of benefit.26 Manual therapy or targeted exercises for the cervical spine to manage cervicogenic symptoms may be indicated.27,28
In adolescents with pPCS and autonomic dysfunction, individualised, heart rate-based, sub-symptom threshold aerobic exercise is effective at improving symptoms.20 Physical therapy should also consider rehabilitating the individual to return to their previous sport and leisure activities.
Once the physical subsystems have improved, the patient needs to be challenged through sport-specific drills at high speeds inclusive of dual tasks and decision-making to rehabilitate them back to return to play.
Psychological management
Symptoms such as headaches, dizziness and fatigue can lead to heightened anxiety and low mood, while psychological distress, in turn, can amplify the perception of physical symptoms, contributing to a self-perpetuating cycle.29
This bidirectional relationship is particularly relevant in paediatric populations, where concerns about school performance, identity, or re-injury can further exacerbate symptom persistence and functional impairment.
Early psychological intervention can help disrupt this cycle.30 Approaches such as CBT and acceptance and commitment therapy are evidence-based in this population and assist by addressing unhelpful beliefs (eg, catastrophising thoughts about brain damage), promoting gradual return to meaningful activities, and reducing avoidance behaviours.30,31
In cases involving non-accidental head trauma, a trauma-informed approach is essential, recognising the broader psychosocial context and prioritising immediate safety.
GPs play a critical role in identifying when symptoms extend beyond expected recovery timelines. Consider referral to a clinical psychologist where emotional distress, maladaptive thinking styles, school avoidance, or pre-existing mental health concerns are impacting recovery. When persisting cognitive concerns are evident, referral to a neuropsychologist is required.
Differential considerations
When concussion symptoms persist longer than the typical recovery period, consider a broad range of potential differential diagnoses and appropriate referral pathways (see table 4).
These include identification of mental health conditions (eg, anxiety or depression); learning or attention difficulties, which may predate the injury or be exacerbated by it; headache disorders, including migraine; autonomic dysfunction, such as orthostatic intolerance or postural orthostatic tachycardia syndrome; and functional neurological disorder, which can mimic or complicate post-concussive presentations.32-35
| Table 4. GP considerations for managing concussion in children and adolescents | ||
| Phase | GP role | Key actions |
| 0-14 days post-injury. | Confirm diagnosis of concussion and initiate management. | • Complete a clinical assessment (at a minimum consider using the Melbourne Paediatric Concussion Scale, if extended session, using elements of the Sport Concussion Assessment Tool 6 (SCAT6) within 72 hours or the Sport Concussion Office Assessment Tool 6 (SCOAT6) after 72 hours. A long appointment is required for completion of a SCAT6/SCOAT6. • Advise 24-48 hours relative rest, followed by a graded return to daily activity. • Provide broad education around concussion management — including return to learn and return to sport. • Brain/cervical imaging only if red flags. |
| >2 weeks post-injury (persisting post-concussion symptoms). Or Re-presentation (or increased symptoms, decreased activity). | Referral to clinicians specialised in managing persisting post-concussion symptoms. Identification of contributing factors to tailor referrals. | • Clinical assessment. Reassess symptom profile using a structured tool (as above). Refer to: • Physiotherapy for persisting headaches, dizziness, neck pain and other physical symptoms to clear physical systems. • Clinical psychologist if anxiety/low mood is evident or if persisting symptoms remain in the context of physical system clearance. • Consider sports medicine physician, neurologist, paediatrician or other medical professional with expertise in managing concussion. |
| Return-to-sport clearance. | Provide medical clearance (if appropriate). | Confirm the patient is symptom-free at rest and post-exertion, has completed a stepwise process of return to sport, including a week of training non-contact, and full-time school/extracurricular activity without symptoms. Check that the patient is confident to return to sport. Seek multidisciplinary team involvement if complex presentation (ie, multiple concussions, poor recovery etc). |
Conclusion
Concussion commonly occurs in children and adolescents. While most will recover rapidly and spontaneously, 20-30% do not.
The evidence for early intervention, including appropriate exercise, physical and psychological interventions, has emerged recently. If properly implemented, early intervention improves patient outcomes.
GP awareness of the current recommendations, published diagnostic and management tools, and referral pathways is essential in appropriate concussion management.
Bianca Charles is a physiotherapist at the Neurological Rehabilitation Group, and is involved in paediatric concussion research at the Murdoch Children’s Research Institute and adult concussion research at Monash University, Melbourne, Victoria.
Taylor Mills is a neuropsychology registrar at the Royal Children’s Hospital and a research psychologist at the Murdoch Children’s Research Institute, with an interest in concussion, cognitive rehabilitation and neurodevelopment, in Melbourne, Victoria.
Professor Gavin A Davis is a neurosurgeon at Cabrini Health and Austin Health, an honorary professor at the Murdoch Children’s Research Institute, an adjunct professor at the University of Notre Dame Australia, an adjunct clinical professor at Monash University and a member of the Concussion in Sport Group, in Melbourne, Victoria.
Katie Davies is the principal physiotherapist at the Neurological Rehabilitation Group, and is involved in paediatric concussion research at the Murdoch Children’s Research Institute and adult concussion research at Monash University, Melbourne, Victoria.
Vanessa C Rausa is a clinical neuropsychologist at the Murdoch Children’s Research Institute and a PhD candidate in the department of paediatrics at the University of Melbourne, Victoria.
Professor Vicki Anderson is a paediatric neuropsychologist, director of clinical sciences research at the Murdoch Children’s Research Institute, and professorial fellow in the school of psychological sciences and department of paediatrics at the University of Melbourne, Victoria.
- References on request from Dr Kate Kelso.
