18 “if in doubt, sit them out” department if they develop any of the following clinical features: > > neck pain > > increasing confusion, agitation or irritability > > repeated vomiting > > seizure or convulsion > > weakness or tingling/burning in the arms or legs > > deteriorating conscious state > > severe or increasing headache > > unusual behavioural change > > double vision. The current principles of concussion management involve rest during the acute period post-injury followed by a gradual increase in cognitive activity and then physical activity5 . The optimal duration of the period of rest is not clear, but the most current evidence supports rest during the acute period (24 – 48 h post-injury)18,43 . Strict rest beyond the initial period is not recommended based on recent studies, including a randomised clinical trial showing that subjects who were prescribed strict rest reported more symptoms and recovered more slowly than those who engaged in some physical activity43 . Patients with symptoms persisting greater than 14 days for adults or 4 weeks for children require careful reassessment. Persisting symptoms can be due to a range of pre-existing confounding issues. The specific contributors to symptom persistence may be difficult to identify. Every effort should be made to structure a treatment program which addresses any medical, physical or psychosocial factors identified on assessment. Those who can tolerate short duration of light exercise may benefit from a closely monitored and graduated aerobic rehabilitation program3,44 . When there is any evidence of cervical spinal vestibular dysfunction, referral to a physiotherapist with specific skills in cervical/vestibular rehabilitation is appropriate. Mood or behavioural issues may respond to cognitive behavioural therapy5 . Children and adolescents Sport concussions are common in children and adolescents45 . Concussion warrants special consideration in this age group and a more conservative approach to diagnosis and management is recommended17,19 . The physical, cognitive and emotional characteristics of young children require that assessment tools be targeted to this population46 . The child Sport Concussion Assessment Tool (Child SCAT5) by the Concussion in Sport Group for children aged 5 – 12 years intends to address these concerns46 . Children and adolescents may be more susceptible to concussion due to a variety of factors including decreased myelination, poor cervical musculature, and increased head to neck ratio, but the evidence for this remains inconclusive and inconsistent. The role of cerebral blood flow alterations in the pathophysiology of concussion may be more significant in children than in adults47 . A growing amount of evidence suggests that adolescents in particular may experience longer recovery times16,17 . The implications of this are not clear and further studies are required to confirm or refute these data. The guidelines surrounding management of concussion from the Concussion in Sport Group Consensus Statement 2016 include prioritising return to school and learning before commencing return to physical activity3 . Modification of school attendance and activities may be required. An increased asymptomatic period should be allowed before full return to sport and the graduated return to sport protocol should be extended. A more cautious return to sport protocol is recommended when factors associated with slower recovery are evident3,16 . World Rugby recommend that children and adolescents 18 years or younger not return to contact training or competitive sport for at least two weeks after resolution of concussion symptoms48 .