Millions of children and adolescents experience concussion annually, but fewer than 50% present for medical assessment.1 The general practitioner (GP) is often the first point of care in local clinics, urgent care centres and Aboriginal medical services or, particularly in regional and rural Australia, via emergency departments.2 One in five adolescents sustains a concussion prior to completing high school; this is most commonly sport related.3–5 For younger children, most concussions occur at home or school.
Concussion occurs when an injury to the head or body results in an impulsive force being transmitted to the brain, triggering a cascade of cerebral cellular processes.6,7 Symptoms occur either immediately post-injury or evolve within hours or days and are not accounted for by other factors. Acute signs are transient and may include seizure activity, unresponsiveness, tonic posturing, ataxia, poor balance, confusion, behavioural changes and amnesia.6 Symptoms vary and can be classified into clusters: somatic/physical, cognitive, emotional or sleep related.
For most children and adolescents who seek medical attention, symptoms will resolve within 4 weeks; however, approximately 30% experience prolonged symptoms.8 These are referred to as persistent post-concussion symptoms (PPCS).5 Symptom severity is the most consistent predictor of delayed recovery, whereas preinjury migraine and neurodevelopmental or mental health concerns are additional risk factors for PPCS,5,9 as is parental anxiety.10
The GP’s role is crucial in managing safe return to activities of daily living, but this is challenging as knowledge surrounding concussion diagnosis, management and guidelines varies significantly, and diagnostic confidence relates to exposure to patients with concussion.11 We present a summary of a GP model of care (Table 1).
| Table 1. Summary of the general practitioner (GP) model of care of paediatric concussion |
| If initial presentation within first 14 days of concussion |
| Visit 1 |
Recognition of concussion and identification of red flags for escalation, use of symptom checklist, education and general activity advice. |
| Visit 2 (within weeks 1–3) |
Symptom monitoring, further education, progression of activity, possible multidisciplinary referral if symptoms are not improving or are increasing. |
| If initial presentation beyond first 14 days of concussion |
| Visit 1 |
Recognition of concussion and analysis of activity levels and symptoms. Consider multidisciplinary referral. |
| Subsequent management for all patients |
| Ongoing visits |
Symptom monitoring and management in conjunction with other practitioners, including allied health and other medical specialists. Patient education is ongoing. |
| Final visit |
Once symptoms have fully resolved (back to baseline) at rest and post-exertion, clearance for return to high-risk activities is addressed. If required, return-to-play clearance is provided. If concerns persist regarding individual risk for return to play, non-GP specialist referral may be required. |
| Considerations: |
Consider multidisciplinary team early management as required particularly if there is:
- slow return to activity
- increased or new symptoms
- presentation of migraine, mood disturbance/post-traumatic stress disorder
- comorbid diagnoses.
Given GP time constraints, consider using practice nurses to administer symptom checklists prior to the GP consultation. Other elements of concussion management may also be delegated. |
Diagnosis: Recognition and assessment
Concussion diagnosis requires clinical assessment, including a detailed history (including a parent, carer and/or witness) confirming a plausible mechanism of injury and post-concussion symptoms.7 Symptoms of concussion can include headaches, dizziness, cognitive issues and emotional liability. Younger children (ie under 8 years of age) may be unable to report their symptoms, and therefore behavioural or physical observations – such as social withdrawal, clinginess, excessive fatigue or the child holding their head or stomach – provided by parents/carers will help guide clinical management. Understanding of a child’s development and current learning history as well as other comorbidities such as attention deficit hyperactivity disorder is important; any pre-existing conditions may be amplified post-concussion. In infants and young children, changes in sleep patterns, behaviour and interest levels may also assist with diagnosis.
Physical examination should: (1) identify any focal neurological signs or indicators of possible cervical pathology; and (2) assess for common signs (eg impaired cognition and/or recall, vestibular and/or oculo-motor disturbance, impaired balance, orthostatic changes or altered mental state), while taking into account pre-existing conditions that may complicate assessment (eg astigmatism or need for corrective glasses). Initial signs and symptoms should be documented and monitored over time.7
Use of validated symptom checklists or questionnaires at the initial assessment and while monitoring recovery can be valuable for management (Table 2).
| Table 2. Tools to assist with concussion recognition and recovery |
| Name of tool |
Function |
Where to access |
| Concussion Recognition Tool 6 (CRT6) |
Community tool – for non-medical people to recognise possible concussion and to safely remove an athlete from the field of play.27 |
https://bjsm.bmj.com |
| HeadCheck app |
Community-facing digital health application.
Includes the CRT6 sideline concussion check, monitoring symptoms and uses Concussion in Sport Group guidelines to provide management and recovery education to 4 weeks post-injury.28
This was developed for the paediatric population. Once the age of the individual is identified, guidance is tailored to this age. |
www.headcheck.com.au |
Sport Concussion Assessment Tool-6 (SCAT6) and Child SCAT6
|
For use by medical practitioners:
- SCAT6: for ages 13+ years
- Child SCAT6: for ages 8–12 years
Best used in the acute period (first 72 hours).29,30 |
SCAT6: https://bjsm.bmj.com
Child SCAT6: https://bjsm.bmj.com |
| SCOAT6, Child SCOAT6 |
Used during subacute period (>72 hours).7,31
For multidisciplinary assessment. The general practitioner delegates some components to allied health practitioners. |
SCOAT6: https://bjsm.bmj.com
Child SCOAT6: https://bjsm.bmj.com |
| Melbourne Paediatric Concussion Scale (MPCS) |
Validated symptom questionnaire modified from the Post Concussion Symptom Inventory (PCSI) checklist.32 |
https://concussion.scholasticahq.com |
Initial management
Community knowledge regarding concussion is poor, with 34% of parents having no or very limited knowledge about concussion.
4 During the acute period, education and reassurance regarding the transient nature of concussion, typical recovery and expected trajectory of symptoms are key. Lack of knowledge and understanding around concussion increases parental anxiety, which affects the child’s recovery.
10 GPs play a prominent role in primary provision of concussion education, with their holistic patient knowledge being key to understanding the unique needs of each child/family. Initial education should also include explanation that current evidence does not support the routine use of intracranial imaging or blood tests in the diagnostic work-up.
7
Following concussion, current guidelines recommend relative rest (a period of reduced activity but not strict bed rest) during the first 24–48 hours.
12 Importantly, previous recommendations for prolonged rest have been shown to delay recovery.
13,14 In the acute recovery period, the focus should be to support the individual to return to their usual physical and cognitive activities in a graded way. In most instances, school return should be prioritised prior to extracurricular activities. It is a parent’s responsibility to inform the school of a concussion, and the family and the school should communicate regularly during the child’s recovery regarding recommended accommodations, which need to be appropriate to the child’s symptoms and will evolve with stage of recovery.
There are currently no validated concussion-modifying pharmacological agents for use acutely. Treatment should focus largely on child and parent psychoeducation, with individualised treatment aimed at restoring pre-injury sleep patterns and a graded return to the individual’s normal activity levels.
15 Parents can be advised that simple analgesia (paracetamol or ibuprofen) may be helpful in the short term for relief of physical symptoms (eg headache) but should be avoided over extended periods. Avoidance of opioid medication and benzodiazepines is advised.
Sleep management
Sleep disturbance and associated fatigue are common following paediatric concussion and recognised as modifying factors that can lead to persisting symptoms if not addressed acutely.
16 Evidence suggests a bidirectional relationship between other concussion symptoms and sleep disturbance, with cognitive symptoms, headache, mood disturbance and fatigue being examples of symptoms commonly exacerbated by sleep disturbance.
17 GPs are skilled in evaluating sleep and providing appropriate initial sleep hygiene advice to the parents and the child. Pre-existing sleep difficulties may vary depending on a child’s age, and an understanding of pre-existing sleep routines and how they have changed post-concussion is crucial. Adolescents may have pre-existing poor sleep hygiene, and sleep hygiene advice should generally aim to keep sleep schedules as close to normal as possible. Reducing the use of screens, especially prior to bedtime, should be encouraged.
Return to learn
For children and adolescents, returning to school and learning is a vital part of recovery and involves a stepwise process, gradually increasing cognitive load and allowing for mild, brief symptom provocation. Most students achieve a full return to school and learning without accommodations. Those with PPCS may require modifications including curriculum, environmental, physical and testing accommodations (Figure 1). For a small proportion of children and adolescents with PPCS, cognitive testing may be helpful, but it is not recommended while significant symptoms persist, as these will limit participation and tolerance. Best practice involves a coordinated approach with liaison between the GP, other healthcare providers, child and family and school. Emphasis should initially be placed on returning a child to the school environment for social purposes rather than emphasising returning to learn. Often older children experience a significant pressure to perform academically in their final years. During recovery, it should be emphasised that this is not the focus, and appropriate accommodations should be enlisted (Figure 1).
Figure 1. Return to learn strategy.7 Click here to enlarge
Reproduced with permission of Professor Jon Patricios on behalf of Concussion in Sport Group and British Journal of Sports Medicine.
Return to physical activity/sport
Stepwise return to physical activity assists with managing post-concussion symptoms. It is safe and beneficial to commence light physical activity within 24–48 hours of a concussion.12 This helps manage fatigue, sleep, mood and physical symptoms. This process occurs in tandem with returning to daily activities and learning (Figure 2).
The first stages of return to sport include symptom-limited activity with light-moderate aerobic exercise prior to commencing sport-specific drills. Mild symptom exacerbation is accepted during the first three stages, and individuals will progress through these at different rates.7 If there is minimal progression, consider early referral to a physiotherapist experienced in concussion management. It is recommended that children and adolescents participate in exercise daily for 20–30 minutes post-concussion, which can include playing with friends, participating in more structured cardiovascular programs or attending non-contact training. Benefits of participation in regular exercise and return to sport include positive effects on mental health and social participation.
An individual must be symptom free at rest and post-exertion and have returned to other cognitive and physical activities prior to obtaining medical clearance from their GP for return to contact sport practice and unrestricted play.7,17
Figure 2. Return to sport strategy.7 Click here to enlarge
Reproduced with permission of Professor Jon Patricios on behalf of Concussion in Sport Group and British Journal of Sports Medicine.
The role of multidisciplinary management for paediatric PPCS
Many symptoms of concussion are non-specific and common in the general population (eg headache). Such symptoms can be exacerbated post-concussion because of biopsychosocial factors (eg anxiety, stress),18 where symptoms arise from complex dynamic physiological, environmental, psychosocial and contextual factors, with pre-injury illness, family interactions and experiences all playing roles.7,19 Given parental anxiety has been identified as a contributing factor for development of PPCS, caregivers must be involved early and throughout concussion recovery. The GP is well placed to identify individuals who may be experiencing symptoms unrelated to their concussion but attributing these to their injury. The differentiation of such symptoms is crucial to the provision of appropriate care.
When symptoms persist, biopsychosocial management with a multidisciplinary team (in person or using telehealth) is recommended.7 However, these resources are scarce in the community. At a minimum, GP-led multidisciplinary care coordination involving concussion-trained allied health practitioners is crucial, and it is recommended that GPs familiarise themselves with such practitioners available locally and via telehealth. It is also beneficial for GPs to familiarise themselves with available resources and guidelines (Table 3).
Physical symptoms are often driven by visual, vestibular, cervical or autonomic system dysfunction or sensitivities. If symptoms such as headache and or/neck pain or dizziness persist after 10 days, referral to a physiotherapist with expertise in concussion assessment and management and/or additional vestibular training for systematic assessment and treatment should be considered.7,20 Systematic physiotherapy assessment can guide targeted treatment, including oculomotor function, habituation exercises or cervical treatment.21 With suspected autonomic dysfunction, a submaximal exertion test may be completed, and individualised heart rate–based sub-symptom threshold aerobic exercises provided.12 Physical therapy can guide graduated return to leisure and sport activities including high-risk activities such as contact sport, cycling or equestrian sports, where sport-specific drills incorporating dual tasking and decision making are completed to ensure readiness for medical clearance prior to returning to (contact) training and playing.7
Physical and cognitive symptoms of concussion can lead to low mood and high levels of anxiety.22 In turn, these psychological symptoms can compound the physical symptoms.23,24 This bi-directional relationship can lead to a self-perpetuating cycle. In adolescents and children who are going through several pertinent developmental changes, concerns about self-identity, school performance and social changes can exacerbate symptom persistence. Recent evidence has described the effectiveness of early psychological intervention in breaking this cycle.25,26 The mechanisms by which these modalities assist in treatment for PPCS include addressing unhelpful thinking patterns, such as catastrophising, and promoting graded return to meaningful activity. GP concern that maladaptive thinking styles or avoidance behaviours may be delaying recovery warrants referral to a psychologist.
In conclusion, paediatric concussion management is multifaceted, requiring a comprehensive biopsychosocial approach. A detailed history of the individual’s symptom trajectories, relevant medical history, current activity levels, sleep patterns and psychosocial history is required to guide clinical decisions. GPs are well placed to lead this approach, as they have an understanding of each individual paediatric patient’s pre-concussion history and the health beliefs of their family/caregivers. GP-led skilled coordination of complex multidisciplinary concussion care will result in optimisation of outcomes in paediatric concussion.
Key points
- Paediatric concussion is a common presentation to emergency departments and primary care settings.
- Following diagnosis, the initial management should include psychoeducation, return-to-activity advice (including learning and sport) and sleep hygiene (if appropriate).
- Occurrence of PPCS is common, affecting one in four paediatric patients with concussion, who will benefit from multidisciplinary management.
- Multidisciplinary management should involve a team of practitioners coordinated by the GP and may include paediatric medical specialists, physiotherapists, other allied health and mental health clinicians.
- Early referral is recommended if there is a lack of progress with returning to activities, if patients are not responding to treatment or if symptoms persist or worsen.