A teenager comes off the football pitch after a head knock, gets checked, looks fine, and goes home. Three weeks later, they’re back in your ED – headaches, fogginess, irritability, missing school – and a parent asking why this isn’t over yet. Most kids recover from concussion on their own within a couple of weeks. But a meaningful minority don’t, and until now, we haven’t had much robust evidence to offer them beyond reassurance and time.
Why is this study needed?
Children’s emergency departments see head injury and concussion all the time. Most concussions resolve spontaneously or with early intervention (think ACoRN), but a significant proportion — around 30% — go on to develop persisting post-concussion syndrome (PPCS). We still don’t have much high-quality evidence on the best persisting post-concussion syndrome treatment for this group.
PPCS is a heterogeneous condition. Factors well outside the original injury — mental health, an evolving disease course over time — shape how it plays out, and it can seriously affect a child’s quality of life, schooling, and mental health.
Previous studies have largely focused on single-method treatment plans or have been limited by study design and size.
This study takes a different approach. It tests an individualised, symptom-targeted plan that draws on a multidisciplinary (MDT) framework — education, physiotherapy, and psychology together — to accelerate recovery. It also makes the case that identifying at-risk children early can drive earlier intervention and better outcomes.
Patients
This single-centre Australian study recruited 8–18-year-olds who presented to the ED at the Royal Children’s Hospital in Melbourne, or who were referred by community practitioners or themselves, with a concussion in the preceding 17 days. The study ran from August 2019 to July 2024. The treating emergency clinician assessed each patient and confirmed a diagnosis of PPCS based on evidence of a head injury, GCS 13–15, and clusters of physical, cognitive, emotional, or sleep/wake disturbance symptoms.
The team invited anyone showing features of PPCS back for repeat assessment at 3 weeks post-injury. If they remained symptomatic, they were randomised into the trial.
The team screened 3235 patients initially. Of these, 864 consented to 14-day screening, and 712 completed it. They excluded 272 as asymptomatic and 306 as declined or unreachable. That left 179 who completed baseline assessment, and the team randomised 158 in total – 78 to Concussion Essentials (CE) and 80 to Usual Care (UC).
Exclusion criteria ruled out structural brain abnormality, significant C-spine injury, multiple traumas, non-accidental injury, pre-existing neurological, vestibular, or significant psychiatric diagnoses, and anyone unable to complete or attend study requirements, including those with insufficient English.
The average age of participants was 13 years (SD = 2.5 years); 57.6% were male, and 64.6% had no prior concussion. Acute management, symptoms, and demographics were similar across both arms, but the CE group was slightly less likely to have had a CT/MRI (17.9% vs 23.8%) and slightly more likely to report neurodevelopmental or mental health diagnoses.
Intervention
The team randomised patients to one of two interventions, delivered between 4 and 12 weeks post-injury.
- Concussion Essentials (CE)
- Weekly, individual, symptom-tailored, clinician-delivered sessions for up to 8 weeks or until symptoms resolved.
- Sessions targeted all aspects of PPCS and aimed to minimise disruption to normal life, with a graded return to activities.
- Usual Care (UC)
- This arm acted as the control group. Participants could access routine concussion care, and the team encouraged them to seek routine health support (e.g. their GP) if symptoms worsened.
Of note, researchers stopped the trial early because changes in international guidance meant the UC arm had fallen below best-practice recommendations.
Comparison
Both groups used a questionnaire — the PCSI (Post-Concussion Symptom Inventory) — to monitor symptoms, completed by parents (PCSI-P). Children and young people also completed a self-report version (PCSI-SR) at the same time points, although this didn’t contribute to the primary outcome. The researchers preferred parental reports because the PCSI-P has a validated cut-off score that correlates highly with clinician diagnosis. Worth remembering, though: this may not capture every symptom, since the patients themselves weren’t completing the forms.
Participants completed questionnaires at screening (14 ± 3 days post-injury), baseline (3 weeks ± 4 days post-injury), weekly during the intervention, and at post-intervention (3 months post-injury).
Outcome
The primary outcome was full recovery at trial completion (3 months post-injury) — defined as ≤1 symptom with increased severity compared with pre-injury, and measured using the PCSI questionnaires.
The secondary outcomes were symptom severity and number of symptoms at trial completion.
The team also conducted a subgroup analysis by age and sex to assess whether these variables affected the results.
Result
Three months post-concussion, 62.5% of the Concussion Essentials group were symptom-free, compared with just 37% in usual care. The numbers back this up: an adjusted risk difference of 25% (CI 10–40%) suggests the CE group really does benefit over the UC group.
The secondary outcomes told the same story — fewer ongoing symptoms, less severity, in the CE group across the board.
But there’s a catch: researchers terminated the study early due to changes in international guidance, so it fell short of its planned 90% power. Keep that limitation in mind when weighing up these results.
The CASP checklist
Did the study address a clearly formulated research question?
Yes — how effective was their Concussion Essentials programme in treating persisting post-concussion symptoms.
Was the assignment of participants to interventions randomised?
Yes — an independent party randomised participants 1:1 by software, stratifying by age and sex to reduce confounding.
Were all participants who entered the study accounted for at its conclusion?
Most were. Both arms lost some participants to follow-up (11 in the CE arm, 7 in usual care), but the team included all of them in the intention-to-treat analysis.
Researchers stopped the study early due to lower-than-anticipated dropout rates and a change in international guidance — co-authored by investigators in this study — recommending MDT intervention.
Were the participants ‘blind’ to the intervention they were given?
No — the nature of the treatment made blinding impossible.
Were the investigators ‘blind’ to the intervention they were giving to participants?
Yes.
Were the people assessing/analysing the outcomes ‘blinded’?
Yes — the assessors running the baseline and post-intervention assessments didn’t know which treatment allocation each patient had received.
Were the study groups similar at the start of the trial?
Yes, and universal healthcare meant the study could include a wide range of participants. That said, the researchers acknowledge that the high time commitment the study demanded may have limited participation from lower socioeconomic groups, and they excluded participants with limited English.
Apart from the experimental intervention, did each study group receive the same level of care?
Yes — neither arm faced limitations on additional healthcare use, though that may have been hard to track consistently.
Were the effects of the intervention reported comprehensively?
Yes — the researchers clearly defined both primary and secondary outcome measures and used standardised scores.
Was the precision of the estimated treatment effect reported?
Yes — though early termination meant the analysed sample only had 80% power to detect a 22.1% increase in recovery in the CE group, below the planned 90%.
Do the benefits of the experimental intervention outweigh the harms and costs?
Yes — the trial demonstrated no harm. Cost may be an issue, particularly in the CE arm, given the likely healthcare burden of high appointment load and multidisciplinary involvement.
Can the results be applied to your local population/context?
Yes — this trial was conducted in a universal healthcare system similar to the UK’s, and head injury/concussion management remains a common presentation to PEM.
Would the experimental intervention provide greater value than existing interventions?
Yes — if feasible within NHS frameworks, the intervention shows real promise as a treatment for PPCS.
Strengths and weaknesses
Strengths
- A large-scale, randomised controlled trial.
- Considers diverse symptomatology and multimodal treatment strategies.
- Sheds new light on treatment strategies for a commonly occurring paediatric condition that can hugely affect children and young people’s quality of life.
- Recruited participants from a universal healthcare system.
- Used a very conservative definition of recovery — patients had to be essentially symptom-free. A less conservative definition might have produced even higher ‘recovery’ rates.
Weaknesses
- Relied on parent-reported data, which may have missed subtle or internalised symptoms.
- Resource-intensive, so it may be difficult to implement in lower-resource settings or across larger areas.
- The heavy appointment burden may have excluded families who lived in rural areas, came from lower socioeconomic backgrounds, or faced other stressors.
- Early termination meant the study didn’t reach its planned 90% power.
- Baseline differences between groups — imaging received, neurodevelopmental and mental health diagnoses — may have skewed results.
What can we take away from this study?
This study shows that personalised, symptom-targeted, multidisciplinary treatment for prolonged post-concussion syndrome holds real promise. By tackling multiple elements of treatment at once, the team improved outcomes for children and young people with PPCS.
We still need more research into potential confounders like age, sex, and neurodivergence. And the model itself — multiple appointments across many healthcare practitioners — raises a practical question: can the NHS afford the cost and time it demands? That deserves further thought, too.
Bottom line
A personalised, multidisciplinary programme (Concussion Essentials) helped more young people with persisting post-concussion syndrome fully recover than usual care — 62.5% vs 37% at 3 months.
The trial stopped early for guideline reasons, so it fell short of its planned statistical power — promising, but not yet definitive.
Resource and funding questions remain before this model could be adopted more widely, but earlier identification and a graded, symptom-led approach look like the right direction.
Next steps..
Results from this study seem promising, and it appears to have been conducted in a similarly resourced setting to that of the NHS. However, further thought would need to be given to local funding to assess the feasibility of such a resource-intensive treatment pathway for a common condition. Perhaps moving some assessments online could go some way toward mitigating this issue and easing the appointment burden for patients and their families?
References
1. Anderson, V., Davies, K., Rausa, V.C., Anderson, N., Barlow, K.M., Bray, K., Charles, B., Davis, G.A., Dunne, K., Fabiano, F. and Hearps, S. (2026) Multimodal symptom-targeted treatment for young people with persisting post-concussion symptoms: a randomised clinical trial. British Journal of Sports Medicine, 60(12), pp.856–864. Available at: https://bjsm.bmj.com/content/bjsports/60/12/856.full.pdf
2. NHS Greater Glasgow and Clyde (2021) After Concussion, Return to Normality (ACoRN): Guidance for Parents and Guardians. Glasgow: NHS Scotland. Available at: https://rhc.nhsggc.org.uk/media/1744/312409_2_1_a4-acorn_rhc_s.pdf (Accessed: 29 May 2026).
