5 “if in doubt, sit them out” Once the diagnosis of concussion has been made, immediate management is physical and cognitive rest5 . This may include time off school or work and relative rest from cognitive activity. Having rested for 24 – 48 hours after sustaining a concussion, the patient can commence a return to moderate intensity physical activity as long as such activity does not cause a significant and sustained deterioration in symptoms18 . The majority of concussive symptoms should resolve in 10 – 14 days3 . The activity phase should then proceed as outlined below with a minimum of 24 hours spent at each level. The activity should only be upgraded if there has been no recurrence of symptoms during that time. If there is a recurrence of symptoms, there should be a ‘step down’ to the previous level for at least 24 hours (after symptoms have resolved)3 . The steps in the activity phase are: > > return to daily activities (including school/work) that do not provoke symptoms > > light aerobic activity (at an intensity that can easily be maintained whilst having a conversation) until symptom-free > > basic sport-specific drills which are non-contact and with no head impact > > more complex sport-specific drills without contact (may add resistance training) > > full contact practice following medical review > > normal competitive sporting activity. Sporting organisations need to continually review their policies for best practice concussion diagnosis and management. High-risk sports such as professional collision sports need to ensure that medical personnel are appropriately trained in the detection and management of concussion. See diagram 1 on page 8. Children and adolescents A consistent and growing body of evidence supports a slower rate of recovery in children and adolescents aged 18 and under16,17,19-21 . A more conservative approach to concussion is recommended, and return to learn should take priority over return to sport. School programs may need to be modified to include more regular breaks, rests and increased time to complete tasks. The graduated return to sport protocol should be extended such that the child does not return to contact/collision activities less than 14 days from the resolution of all symptoms. See diagram 2 on page 9. Long-term consequences There is concern about potential long-term consequences of concussion or an accumulation of subconcussive head impacts resulting from ongoing participation in contact, collision and combat sports22-24 . There is some association between a history of multiple concussions and cognitive deficits later on in life25 . However, there is currently no reliable evidence clearly linking sport-related concussion with chronic traumatic encephalopathy (CTE), a condition with yet unclear clinical diagnostic criteria22 . The evidence purporting to show a link between sport-related concussion and CTE consists of case reports, case series, and retrospective and post-mortem analyses. Due to the nature of the studies, and the reliance on retired athletes volunteering for an autopsy diagnosis, there is significant selection bias in many of the reports23 . The studies to date have not adequately controlled for the potential contribution of confounding variables such as alcohol abuse, drug abuse, genetic predisposition and psychiatric illness22 . Given that concussion is very common and the number of cases of CTE reported is extremely small, the link between sport-related concussion and CTE remains tenuous. The potential link between concussion and CTE is of concern however and there is need for well-designed prospective epidemiological studies, which take into account the potential confounding variables.