Effectiveness of return to activity and return to school protocols for children postconcussion: a systematic review

Abstract

Objective To determine the effects of following return to activity (RTA) and return to school (RTS) protocols on clinical outcomes for children with concussion. The 12 subquestions of this review focus on the effectiveness of protocols, guidelines and recommendations, and the evidence supporting content of the protocols including rest, exercise and school accommodations.Design Systematic review. Data sources PubMed, MEDLINE, EMBASE, CINAHL, ERIC and manual reference list check.Eligibility criteria for selecting studies Studies were included if they evaluated RTA or RTS protocols in children aged 5-18 years with a concussion or if they reported a rigorous study design that provided evidence for the recommendations. Included studies were original research or systematic reviews. Articles were excluded if they did not report on their methodology or included participants with significant neurological comorbidities. ResultsThe literature search retrieved 198 nonduplicate articles and a total of 13 articles were included in this review. Despite the adoption of several RTS and RTA protocols in clinical practice there is little evidence to determine their efficacy in the paediatric population.

Management of sport-related concussion in emergency departments in England: a multi-center study

“…The results also show inconsistency in the amount of cognitive rest advised, with most selecting either 48 hours or until symptoms-free. The current guidelines and a recent systematic review (27) suggest that 48 hours rest should be recommended and that, for children, a graduated return-to-school protocol be followed post-SRC. Whilst further research is required, data from Thomas et al (28) suggested that a rest period of 5 days compared to the recommend 24-48 hours resulted in a greater post-concussion symptom scale score and time until symptom-free.…”

Effect of Collaborative Care for Persistent Postconcussive Symptoms on Academic Function: A Randomized Clinical Trial

“…Various return to school protocols have been utilized post‐concussion, but evidence for their effectiveness is limited 21 . The amount of accommodation and the optimal degree of restriction from school is unknown.…”

The Nocebo Effect and Pediatric Concussion

“…The nocebo effect often results from well-meaning practitioners who simply continue to make recommendations grounded in outdated knowledge or reflect reports they have heard in the lay media as opposed to the medical literature. As mentioned, there was never evidence for "absolute" or "prolonged" physical rest, 59,60 yet this recommendation is still frequently encountered in clinical settings. All health care providers caring for youth with mild TBI should practice within their areas of competence, take accredited continuing education courses within the broad field of concussion, critically read research literature on concussion outcomes and treatment, and rely heavily on evidence-based reviews and recommendations.…”