Paeds · rheumatology-musculoskeletal-and-sports
Concussion and return to learn or play
Also known as sport-related concussion · mild traumatic brain injury · concussion · return to learn · return to sport · return to play · SCAT6 · Child SCAT6 · Amsterdam consensus · persistent post-concussive symptoms
A fellowship approach to sport-related concussion in the child and adolescent, anchored by the 2022 Amsterdam Consensus Statement and its tools — the SCAT6 for athletes thirteen years and older and the Child SCAT6 for children six to twelve — built around the two graduated pathways that decide safe recovery: return to learn first, then a six-stage return to sport, with twenty-four to forty-eight hours of relative rest, no prolonged cocoon therapy, and a red-flag screen that sends the deteriorating child to the emergency department.
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Target exams
Red flags
- A deteriorating level of consciousness, drowsiness that cannot be roused, or a blank or vacant look after a head knock is a red flag for an evolving intracranial injury and needs emergency assessment
- Repeated vomiting, a severe or worsening headache, a seizure, or a focal neurological deficit such as limb weakness or unequal pupils demands urgent imaging and neurosurgical review
- Neck pain or midline cervical tenderness after a head injury raises the possibility of a cervical spine injury and mandates spinal precautions before any further assessment
- Symptoms that persist or worsen beyond four weeks are persistent post-concussive symptoms and need a structured multidisciplinary review rather than further rest
- A second head impact before full recovery risks the rare but catastrophic second impact syndrome, so no athlete returns to contact sport the same day and not before medical clearance
Life stages
Care settings
Clinical exam formats
Board mappings
- Acute presentations - recognise the red flags after a paediatric head injury and arrange emergency assessment
- Musculoskeletal and sports medicine - diagnose sport-related concussion with the SCAT6 and Child SCAT6
- Child development and behaviour - guide a graduated return to learn and return to sport
- Neurology and sports medicine - apply the 2022 Amsterdam Consensus Statement and the six-stage return to sport
- Adolescent medicine - manage persistent post-concussive symptoms and the factors that prolong recovery
- Renewed curriculum for first-year trainees from 2027 - Learning goal 6: Clinical management - essential general paediatrics
- Neurology 10-12
- Injury prevention and safety 10-12
- Clinical Applications
- Short Cases
- Long Cases
- Communication scenarios
- 9. Neurology - the assessment and graduated management of concussion in the child and young person
- 1. Child development and behaviour - return to learn after a brain injury
- 4. Professional skills and knowledge: Patient management
- Foundation of Practice (FOP)
- Theory and Science (TAS)
- Applied Knowledge in Practice (AKP)
- Clinical
- History
- Communication
- Video
- General Pediatrics Content Outline - Neurologic disorders
- General Pediatrics Content Outline - Sports medicine and the injured athlete
- General Pediatrics Content Outline - Universal Task 5: Patient Management
- Patient Care 4: Clinical Reasoning
- Medical Knowledge 2: Conditions common in pediatric primary care
- Systems-Based Practice 2: Coordinated acute and chronic care
- Systems-Based Practice 1: Cost-conscious stewardship and avoidance of unproven interventions
- Medical Expert
- Pediatrics: Foundations EPA #5 - Performing a focused physical examination
- Pediatrics: Neurology and musculoskeletal applied domain
A fourteen-year-old rugby player is helped off the field after a tackle, dazed and slow to rise, with a headache and a feeling of being foggy — a textbook sport-related concussion recognised at the sideline. An eight-year-old falls from a trampoline and bumps her head, vomits twice on the way to the clinic, and the task is to run the red-flag screen and to decide whether this is an emergency or a graduated recovery. A sixteen-year-old netballer is back at school but still has headaches and poor concentration a month after her injury, and the task is to recognise persistent post-concussive symptoms and to build the multidisciplinary plan. The fellowship skill in each is to assess the child, to place them on the right ladder, and to keep them safe through the recovery. [1] [6]
Hold the recovery as two ladders climbed in order. The first ladder is return to learn — light activity, then schoolwork at home, then part-time school, then full school. The second ladder is return to sport — symptom-limited activity, light aerobic, sport-specific drill, non-contact training, full-contact practice, then return to play. The child always climbs the learn ladder before the sport ladder, and no child moves to full contact without a medical clearance. [4] [1]
Overview & Definition
Concussion is the commonest form of traumatic brain injury seen in children and adolescents, and it sits at the centre of paediatric sports medicine because the decisions made in the days after a head knock change the trajectory of recovery. The 2022 Amsterdam Consensus Statement defines a concussion as a traumatic brain injury caused by a direct or an indirect blow to the head, with a short-lived impairment of neurological function that resolves spontaneously, and with symptoms that may or may not involve loss of consciousness. [1] [6] The disturbance reflects a functional brain injury rather than a structural one, and standard structural neuroimaging is normal, which is why the diagnosis is clinical and the imaging is reserved for the red-flag presentation. [8]
The clinical importance comes from what the recognition unlocks. A child whose concussion is missed returns to play, takes a second impact, and risks the rare but catastrophic second impact syndrome, while a child whose concussion is recognised but managed with prolonged strict rest develops the isolation, the deconditioning, and the persistent symptoms that cocoon therapy produces. [12] [5] The fellowship answer holds both risks at once. The child is assessed with the age-appropriate tool, given twenty-four to forty-eight hours of relative rest, returned to learn before sport, and progressed through the six-stage return to sport with a red-flag screen that runs throughout. [1] [4]
References12ShowHide
- [1]Patricios JS, Schneider KJ, Dvorak J, et al. Consensus statement on concussion in sport: the 6th International Conference on Concussion in Sport-Amsterdam, October 2022. Br J Sports Med, 2023.PMID 37316210
- [2]Echemendia RJ, Brett BL, Broglio S, et al. Sport concussion assessment tool - 6 (SCAT6). Br J Sports Med, 2023.PMID 37316203
- [3]Davis GA, Echemendia RJ, Ahmed OH, et al. Introducing the Child Sport Concussion Assessment Tool 6 (Child SCAT6). Br J Sports Med, 2023.PMID 37316202
- [4]Putukian M, Purcell L, Schneider KJ, et al. Clinical recovery from concussion-return to school and sport: a systematic review and meta-analysis. Br J Sports Med, 2023.PMID 37316183
- [5]Schneider KJ, Critchley ML, Anderson V, et al. Targeted interventions and their effect on recovery in children, adolescents and adults who have sustained a sport-related concussion: a systematic review. Br J Sports Med, 2023.PMID 37316188
- [6]Davis GA, Schneider KJ, Anderson V, et al. Pediatric Sport-Related Concussion: Recommendations From the Amsterdam Consensus Statement 2023. Pediatrics, 2024.PMID 38044802
- [7]Halstead ME, Walter KD, Moffatt K, et al. Sport-Related Concussion in Children and Adolescents. Pediatrics, 2018.PMID 30420472
- [8]Lumba-Brown A, Yeates KO, Sarmiento K, et al. Centers for Disease Control and Prevention Guideline on the Diagnosis and Management of Mild Traumatic Brain Injury Among Children. JAMA Pediatr, 2018.PMID 30193284
- [9]Lumba-Brown A, Yeates KO, Sarmiento K, et al. Diagnosis and Management of Mild Traumatic Brain Injury in Children: A Systematic Review. JAMA Pediatr, 2018.PMID 30193325
- [10]Davis GA, Anderson V, Babl FE, et al. What is the difference in concussion management in children as compared with adults? A systematic review. Br J Sports Med, 2017.PMID 28455361
- [11]Chizuk HM, Willer BS, Cunningham A, et al. Adolescents with Sport-Related Concussion Who Adhere to Aerobic Exercise Prescriptions Recover Faster. Med Sci Sports Exerc, 2022.PMID 35482774
- [12]McCrory P. Does second impact syndrome exist? Clin J Sport Med, 2001.PMID 11495318