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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 returnto-contact practice and unrestricted return to play. 2, 23

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

24, 25 persistence of symptoms.

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

Table 3. Return-to-sport strategy— each step typically takes a minimum of 24 hours Step Exercise strategy Activity at each step Goal

2 Aerobic exercise: 2A— Light( up to approximately 55 % maxHR) then 2B— Moderate( up to approximately 70 % maxHR).

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.

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

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.

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.

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

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

Increase heart rate.

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.

Resume usual intensity of exercise, co-ordination and increased thinking.

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 Medicine 2

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.

> 2 weeks post-injury( persisting postconcussion symptoms).

Or

Re-presentation( or increased symptoms, decreased activity).

Return-to-sport clearance.

Referral to clinicians specialised in managing persisting post-concussion symptoms.

Identification of contributing factors to tailor referrals.

Provide medical clearance( if appropriate).

• 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.

• 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.

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).

diagnostic and management tools, and referral pathways is essential in appropriate concussion management.

References on request from kate. kelso @ adg. com. au

Online resources

• Concussion Recognition Tool 6 bit. ly / 45Vuyf1

• HeadCheck app bit. ly / 3TuDj8l

• Sport Concussion Assessment Tool 6( SCAT6) bit. ly / 46vKq86

• Child SCAT6 bit. ly / 4lJeelZ

• Sport Concussion Office Assessment Tool 6( SCOAT6) bit. ly / 4kvjpFl

• Child SCOAT6 bit. ly / 4kqm4jH