A summary of the first Australian and Aotearoa New Zealand Clinical Practice Guideline for the management of mild traumatic brain injury/concussion and persisting post-concussion symptoms

Case

Miss LC, aged 28 years, is a female executive who works at a law firm and practices martial arts in her spare time. She has a past medical history of infrequent migraine and mild anxiety. She presents to her general practitioner (GP) after sustaining a head injury when she tripped and struck her head on gym equipment during a fitness training session 4 days earlier. She did not lose consciousness at the time but since has had a bad headache, nausea and dizziness, and she is finding it difficult to concentrate at work. She wonders if she needs a brain scan. She also wants to know if she will recover faster if she stays at home and rests, as she has an important martial arts tournament this weekend that she wants to be ready for.

Mild traumatic brain injury (mTBI), often referred to as a concussion, affects over 220,000 people in Australia and Aotearoa New Zealand (ANZ) annually, with 25–30% of people experiencing persisting symptoms for months or longer.¹ Concussion occurs in all age groups, with children, young adults and older adults having the highest incidence. Major causes of concussion include falls, sports-related concussion, motor vehicle crashes, assaults and blast-related incidents.² Patient recovery is highly variable. A significant proportion of children and adults experience ongoing symptoms that impair function and quality of life, yet local clinical resources remain limited, and management is inconsistent.³ The GP plays a crucial part in management, yet up to 40% of Australian GPs report limited confidence in managing mTBI, especially persisting post-concussion symptoms (PPCS).² Low patient volumes (40% of GPs report seeing fewer than five concussion cases per year) contribute to this lack of confidence, but a major factor is uncertainty in making evidence-based decisions.² Although several evidence-based guidelines exist internationally for managing mTBI/concussion in specific populations,⁴ such as children,^5–7 sports-related concussion⁸ or in particular settings such as emergency departments,^4,5 none provide comprehensive guidance across management from injury to recovery, nor are they tailored to the ANZ healthcare systems.

To address this gap, a multidisciplinary group of researchers, clinicians and consumers with lived experience has collaboratively developed the first ‘Australian and Aotearoa New Zealand Clinical Practice Guideline for the management of mild traumatic brain injury/concussion and persisting post-concussion symptoms in adults and children’ (hereafter the ANZCPG).⁹ Figure 1 summarises the methodology for the development of the guidelines and the accompanying website (https://anzconcussionguidelines.com). A total of 119 recommendations (61 evidence-based, 58 consensus-based) and 27 practice points were developed. Refer to Table 1 for the types of recommendations in the ANZCPG and Appendix 1 for the recommendations (available online only). The full guideline document and a summary document are available on the website, providing comprehensive details about the rationale, methodology and background information on the recommendations.

The new ANZCPG provides the first binational guideline to address the full scope of mTBI/concussion management from injury to recovery, co-designed with consumers and experts to support the ANZ healthcare systems.^4,10-11 The ANZCPG recommendations are divided into six sections to reflect the patient journey: (1) recognition and assessment; (2) initial management; (3) return to activity, (4) assessment and management of specific symptoms; (5) assessment and management of persisting symptoms; and (6) repeated concussion and long-term effects; refer to Figure 2. All recommendations have been adapted to be consistent with resources generally available to ANZ populations across all aetiologies and age ranges.

The ANZ Concussion Guidelines website (www.anzconcussionguidelines.com) has an online toolbox and quick access tabs corresponding to each stage of the patient journey, which can direct GPs to information and resources required to assist in identifying, assessing and managing concussion presentations; refer to Figure 3. For example, the ‘Recognise and assess’ tab leads to further information boxes relating to initial identification and assessment of concussion, including tools such as the Concussion Recognition Tool and the Sport Concussion Assessment Tool. There are specific subheadings with guidance on how to identify red flags at ‘When to send to hospital’ and ‘Neuroimaging’ indications. All quick access tabs in the case study that link to recommendations referenced from the website are marked with an asterisk ‘*’.

Figure 1. Methodology for the development of the ‘Australian and Aotearoa New Zealand Clinical Practice Guideline for the management of mild traumatic brain injury/concussion and persisting post-concussion symptoms in adults and children’ and website. Click here to enlarge 

ANZCPG, ‘Australian and Aotearoa New Zealand Clinical Practice Guideline for the management of mild traumatic brain injury/concussion and persisting post-concussion symptoms in adults and children’.

Figure 2. The ‘Australian and Aotearoa New Zealand Clinical Practice Guideline for the management of mild traumatic brain injury/concussion and persisting post-concussion symptoms in adults and children’ is organised to reflect the patient journey across six key stages from initial assessment through recovery. Each website section provides an overview of important considerations at that stage as well as recommendation tabs with accordions to provide increased detail. The website has a clinical toolbox to aid assessment and management with useful questionnaires, templates, links and flow charts corresponding to each stage.

Figure 3. Screenshots of the Guidelines Outline and Toolbox pages of the ANZ Concussion Guidelines website (www.anzconcussionguidelines.com), with examples of tools that can be accessed for different stages of the patient journey. If you have suggestions for what you would like to see in the toolbox, you can share your ideas through the ‘Contact Us’ page on the website. Click here to enlarge  

Adapted with permission from the ANZ Concussion Guidelines website (www.anzconcussionguidelines.com).

Case continued

From taking a thorough history, Miss LC’s GP identifies that the headaches have migrainous features. Miss LC’s examination is unremarkable except for non-focal tenderness of the cervical paraspinal muscles. Her Rivermead Post Concussion Symptom Questionnaire score is 26, suggesting moderate-to-severe level symptoms (*Recognise and assess: Assessment). The GP and Miss LC discuss concussion and her symptoms (*Initial management: Education and advice). The GP advises Miss LC that she does not require neuroimaging, discusses the importance of sleep and recommends that she use paracetamol and ibuprofen for milder headaches and her usual triptan for severe headache over the next 2 weeks. She is further advised to limit analgesic use to 2–3 times per week after this because of the risk of medication-associated headache (*Headaches). Her GP also provides advice regarding activity, recommending she start light exercise and gradually increase intensity and time over the next 2 weeks (*Return to activity). She should be guided by her symptoms; a mild increase in symptoms during or after exercise is acceptable. When compared with baseline, if symptoms increase by 3 points or more on a 10-point scale lasting longer than an hour, then she should stop the exercise and try again the next day. She should be able to exercise at her previous levels of intensity for 1–2 days (*Return to activity) before progressing to non-contact martial art drills (*Return to sport strategy: Stage 4). Miss LC and her GP discuss the potential benefit of physiotherapy for further management of her dizziness, for treatment of her paraspinal cervical tenderness and to assist with a graduated exercise program, and Miss LC says she will consider this (*Management of specific symptoms: Balance, dizziness and visual dysfunction). The GP recommends that Miss LC continue normal household activities, taking breaks as needed (*Return to activity), and they agree that it is reasonable for Miss LC to return to work gradually over the next 2 weeks (*Return to activity: Return to work). The GP provides her with a letter for work and advises that formulation of a return-to-work plan with her employer is often helpful, sometimes with advice from an occupation therapist. She should expect these symptoms to resolve within a few weeks but is warned that it can take 1–3 months. Miss LC is advised not to return to sport, including martial arts, until her symptoms have resolved, she is back to her baseline level of function and at least 21 days have passed since the concussion. She is asked to return for follow-up in 2–4 weeks, or earlier if required.

Recognition, assessment and initial management

Through the ANZ Concussion Guidelines website, the ‘Initial management’ and ‘Return to activity’ tabs would be appropriate for use by Miss LC’s GP, with ‘Initial management’ information including subheadings of ‘Education and advice’, ‘Early symptom management’ and ‘Prognosis’. In the case of Miss LC, the ‘Return to activity’ tab is particularly important, as it explains the evidence for gradual resumption of normal activity and confirms that strict rest is not effective. It also includes a detailed section on the ‘Return to sport’, with a table outlining the six progressive steps to safely return to playing sports.

Case continued: Follow-up

Miss LC returns to the GP 5 weeks post-injury because her headache and ‘brain fog’ are not improving. She has difficulty getting to sleep and worries that her work performance is suffering, and she is struggling to meet important deadlines. However, her physical activity levels have improved (*Return to sport strategy: Stage 3), and her symptoms score has decreased to 19. She wants to know what else can be done to help her recover.

Persisting symptoms

Concussion symptoms usually resolve within a few weeks of injury. If symptoms continue for longer than 4 weeks, they are considered ‘persisting symptoms’, which occur in 30–40% of children and 20–50% of adults.^12,13 The ANZ Concussion Guidelines website provides advice about the assessment and management of ‘Persisting symptoms’, as well as management of the most common acute and persistent symptoms: ‘Headaches’, ‘Cognitive difficulties’, ‘Sleep disturbance and fatigue’, ‘Mental health’, ‘Balance, dizziness and visual disturbances’ and ‘Autonomic nervous system’. In addition to the concussion itself, pre-existing conditions often contribute to the prevalence and severity of persisting symptoms, making management more complex.¹⁴ In some PPCS cases, especially where symptoms show little improvement or comorbidities are complex, a coordinated approach is required to facilitate recovery. Ideally this involves referral to a multidisciplinary concussion team or service; these typically use shared-care models including the patient’s GP and community clinicians. However, there is geographical variation in the availability of such services, with many regions in Australia being under-resourced and significant travel often involved. The ANZCPG provides useful advice about symptom management, rehabilitation and the engagement of local allied health professionals while such services are awaited, or in the absence of such services to assist the GP in coordinating multidisciplinary care with available resources.

Case continued: Management

The GP reassures Miss LC that she is improving and provides further guidance on strategies to address her persisting symptoms: a 2-week trial of melatonin to improve sleep, information about amitriptyline for headaches, and the usefulness of mindfulness for stress reduction (*Persisting symptoms; Management; Headaches; Mental health). They agree that if her symptoms have not improved in 2 weeks, the GP will refer her to a multidisciplinary concussion service (*Persisting symptoms: Follow-up and referral).

Implementation of the ANZCPG

To be useful, all clinical practice guidelines require active implementation strategies to increase their uptake and usefulness. Implementation strategies for the ANZCPG will unfold over the next 2 years. These include the development of resources to increase public education about concussion, app development (eg HeadCheck), tele-rehabilitation and patient-driven models of care. Further, a GP education course based on the ANZCPG is currently in development with Connectivity Traumatic Brain Injury Australia and is anticipated to be available through The Royal Australian College of General Practitioners in 2026. By embedding guideline use into professional learning, we aim to enhance GPs’ confidence in managing concussion and thereby improve patient outcomes.

Conclusion

The ANZCPG and its accompanying website and toolbox provide high-level evidence and practical advice for GPs and other clinicians across the life span. The successful implementation of guidelines will not only increase knowledge across health professionals but ultimately result in standardised practice across ANZ. Hence, we encourage GPs to refer to the guidelines to receive an up-to-date management recommendation with key tools to support care.

Key points

• mTBI and concussion are often overlooked and undermanaged across healthcare settings.
• The ANZCPG bridges gaps in concussion care through evidence-based and locally relevant recommendations.
• GPs play a crucial part in managing mTBI/concussion but report a lack of confidence in managing PPCS.
• The ANZ Concussion Guideline website offers practical resources to aid in decision making and patient education.
• Consistent application of the ANZCPG can improve GPs’ confidence and knowledge.