Early return to school reduces concussion symptoms


In a recent study, children returning to school earlier following a concussion experienced reduced symptom burdens at 14 days postinjury.

Prolonged absences from school and other life activities following a concussion may cause harm to recovery in pediatric patients aged 5 to 17 years, according to a recent study.

Current guidelines recommend 24 to 48 hours of rest for students following concussion, before a gradual return to school (RTS). However, strong evidence supporting the period spent away from school is lacking. Studies have found 72% of children will miss at least 1 day of school, with many absent for 2 to 5 days.

While prolonged rest has been associated with a potential delayed recovery, 1 study showed higher symptom levels in students spending more time at school. However, there is also evidence that early return to physical activity improves symptom recovery.

Investigators conducted a study to determine the average duration of absence from school following concussion and the associations between RTS timing and symptom burden 14 days postinjury. Data was gathered from the Predicting Persistent Postconcussion Problems in Pediatrics study, examining pediatric patients following concussion.

Exclusion criteria for the original study included not having an injury based on trauma, having a Glasgow Coma Score of 13 or less, and requiring hospital admission for multisystemic injury or neurosurgical intervention. The recent study also required a valid and specific RTS date, with children whose injury occurred during common school closure periods excluded.

Demographic, developmental, and psychiatric data were gathered. Follow-ups occurred at 7, 14, and 28 days postinjury, where participants provided information on their RTS date and current symptom behavior. Patients aged 5 to 7 years had responses given for them by their parents. 

The Post-Concussion Symptom Inventory (PCSI) was used to report symptom severity. Symptom burden, the primary outcome of the study, was measured by PCSI score at 14 days postinjury. The number of school days missed was assessed, with 0 to 2 days missed considered early RTS and 3 or more days missed considered late RTS.

There were 1630 participants included in the final sample, about 38% of which were female. The average age of participants was 11.8 years, and individuals were divided into 3 age groups: 5 to 7.9 years, 8 to 12.9 years, and 13 to 17.9 years.

On average, students missed 3.74 school days following a concussion. Older children often missed more days than younger children. About 54% of participants experienced an early RTS, and about 46% experienced a late RTS. Those aged 13 to 17 years most often experienced a late RTS, followed by those aged 8 to 12 years, then those aged 5 to 7 years.

Overall, significant associations between early RTS and reduced average symptom levels 14 days postinjury were recorded in individuals aged 8 to 12 years and those aged 13 to 17 years. This association was stronger in individuals with a greater symptom burden. However, it was not recorded in children aged 5 to 7 years.

These results indicated younger children return to school sooner than older children on average, but early RTS could lead to reduced symptom burden and faster recovery.


Vaughan CG, Ledoux A, Sady MD, Tang K, Yeates KO, Sangha G, et al. Association between early return to school following acute concussion and symptom burden at 2 weeks postinjury. JAMA Netw Open. 2023;6(1):e2251839. doi:10.1001/jamanetworkopen.2022.51839

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