Early return to school reduces concussion symptoms

Early return to school reduces concussion symptoms

According to a recent study, prolonged absence from school and other life activities after concussion may impair recovery in pediatric patients ages 5 to 17.

Current guidelines recommend 24 to 48 hours of rest for students after a concussion before gradually returning to school (RTS). However, strong evidence of time spent outside of school is lacking. Studies have shown that 72% of children miss at least 1 day of school, many of them 2 to 5 days.

While longer periods of rest have been linked to potentially delayed recovery, one study showed higher levels of symptoms in students who spent more time in school. However, there is also evidence that an early return to physical activity improves symptom recovery.

Investigators conducted a study to determine the average length of time absent from school after concussion and the associations between RTS timing and symptom burden 14 days after injury. Data were collected from the Predicting Persistent Postconcussion Problems in Pediatrics study, which evaluated pediatric patients who had suffered a concussion.

Exclusion criteria for the original study included no traumatic injury, a Glasgow Coma Score of 13 or less, and the need for hospitalization for a multisystem injury or neurosurgical procedure. The recent study also required a valid and specific RTS date, excluding children whose injuries occurred during standard school closure hours.

Demographic, developmental, and psychiatric data were collected. Follow-ups took place at 7, 14, and 28 days after injury, where participants provided information on their RTS date and current symptom behavior. Patients aged 5 to 7 years received answers from their parents.

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

The final sample included 1630 participants, approximately 38% of whom were female. The mean age of the participants was 11.8 years and the subjects 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 school 3.74 days after a concussion. Older children often missed more days than younger children. About 54% of participants experienced early RTS and about 46% experienced late RTS. Late RTS was most common among 13-17 year olds, followed by 8-12 year olds and 5-7 year olds.

Overall, significant associations were found between early RTS and reduced average symptom levels at 14 days post-injury in subjects aged 8 to 12 years and subjects aged 13 to 17 years. This association was stronger in those with a greater symptom burden. However, it has not been detected in children aged 5 to 7 years.

These results suggest that younger children return to school earlier, on average, than older children, but early RTS could lead to lower 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 after acute concussion and symptom burden 2 weeks after injury. JAMA network open. 2023;6(1):e2251839. doi:10.1001/jamanetworkopen.2022.51839

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