What Comes First: Return to School or Return to Activity for Youth After Concussion? Maybe We Don't Have to Choose

Abstract

Objectives: Return to School (RTS) and Return to Activity/Play (RTA) protocols are important in concussion management. Minimal evidence exists as to sequence and whether progression can occur simultaneously. Experts recommend that children/youth fully return to school before beginning RTA protocols. This study investigates recovery trajectories of children/youth while following RTA and RTS protocols simultaneously, with the following objectives: (1) to compare rates and patterns of progression through the stages of both protocols; (2) to evaluate symptom trajectories of youth post-concussion while progressing through stages of RTS and RTA; and (3) to propose a new model for concussion management in youth that involves the integration of Return to Activity and Return to School protocols. Methods: In a 3-year prospective-cohort study of 139 children/youth aged 5–18 years with concussive injury, self-reported symptoms using PCSS and stage of protocols were evaluated every 48 h using electronic surveys until full return to school and activity/sport were attained. Information regarding school accommodation and achievement was collected. Results: Sample mean age is 13 years, 46% male. Youth are returning to school with accommodations significantly quicker than RTA ( p = 0.001). Significant negative correlations between total PCSS score and stage of RTS protocol were found at: 1-week ( r = −0.376, p < 0.0001; r = −0.317, p = 0.0003), 1-month ( r = −0.483, p < 0.0001; r = −0.555, p < 0.0001), and 3-months ( r = −0.598, p < 0.0001; r = −0.617, p < 0.0001); indicating lower symptom scores correlated with higher guideline stages. Median full return to school time is 35 days with 21% of youth symptomatic at full return. Median return time to full sport competition is 38 days with 15% still symptomatic. Sixty-four percent of youth reported experiencing school problems during recovery and 30% at symptom resolution, with 31% reporting a drop in their grades during recovery and 18% at study completion. Conclusions: Children/youth return to school faster than they return to play in spite of the self-reported, school-related symptoms they experience while moving through the protocols. Youth can progress simultaneously through the RTS and RTA protocols during stages 1–3. Considering the numbers of youth having school difficulties post-concussion, full contact sport, stage 6, of RTA, should be delayed until full and successful reintegration back to school has been achieved. In light of the huge variability in recovery, determining how to resume participation in activities despite ongoing symptoms is still the challenge for each individual child. Ther...

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

“…Recent evidence recommends that youth progress through the initial stages of RTA and RTS protocols simultaneously, but the priority should be on their complete and successful RTS before returning to full contact sport 34. CanChild Pediatric Concussion Guidelines now recommend that children complete stages 1–3 of the RTA and RTS protocols together and then fully RTS before revisiting the last stages of the RTA protocol 34…”

Concussion Management for Children Has Changed: New Pediatric Protocols Using the Latest Evidence

“…Further evidence for the shortened rest period comes from parents in the Back to Play study, who reported the greatest difficulties with the rest period, given the extensive restrictions associated with this stage. 11 The recent adherence study confirmed that the lowest rates of compliance corresponded to Stages 1 and 2, suggesting that the recommendations for these stages needed to be adapted to make them more realistic and achievable, allowing children to return to their regular activities gradually and safely. 14 Research supports these findings, with 2 studies demonstrating that nearly half (40% to 48%) of concussed participants completed RTA and/or RTS prematurely.…”

“…Data collected from the aforementioned longitudinal study by DeMatteo et al 11 also examined adherence to the 2015 protocols 4,5 in individuals with concussion aged 5 to 18 years. 14 Both RTA and RTS protocols prescribe/recommend a certain level of time or activity intensity for each stage, increasing accordingly.…”

“…Most of the information available on websites is a reproduction of the Berlin Consensus guidelines, and as such it is classified as evidence level C. 2 The protocol development team had to deduce from the biomedical research and adult consensus conclusions to make decisions suitable for children and youth, although there has been an increase in publications on the research topics since the previous guideline publications. 4,5 Furthermore, including evidence from additional studies and incorporating adherence data 12 and stakeholder feedback 11 may have added some empirical data that was lacking from the 2015 protocols. 4…”

“…There has been a complete lack of protocols that integrate the processes of RTS and RTA. 11 Research in the field of pediatric concussion has increased significantly over the past 5 years as education and awareness have become a public health priority among stakeholders. It is important that protocols be updated and revised to reflect the current best evidence regarding the needs of children and youth with concussive injury and the unique management of pediatric concussion.…”