Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Observational Study
. 2023 Jan 3;6(1):e2251839.
doi: 10.1001/jamanetworkopen.2022.51839.

Association Between Early Return to School Following Acute Concussion and Symptom Burden at 2 Weeks Postinjury

Christopher G Vaughan  1 , Andrée-Anne Ledoux  2   3 , Maegan D Sady  1 , Ken Tang  4 , Keith Owen Yeates  5 , Gurinder Sangha  6 , Martin H Osmond  7 , Stephen B Freedman  8 , Jocelyn Gravel  9 , Isabelle Gagnon  10   11 , William Craig  12 , Emma Burns  13 , Kathy Boutis  14 , Darcy Beer  15 , Gerard Gioia  1 , Roger Zemek  2   7 ; PERC 5P Concussion Team
Collaborators, Affiliations
Observational Study

Association Between Early Return to School Following Acute Concussion and Symptom Burden at 2 Weeks Postinjury

Christopher G Vaughan et al. JAMA Netw Open. .

Abstract

Importance: Determining how the timing of return to school is related to later symptom burden is important for early postinjury management recommendations.

Objective: To examine the typical time to return to school after a concussion and evaluate whether an earlier return to school is associated with symptom burden 14 days postinjury.

Design, setting, and participants: Planned secondary analysis of a prospective, multicenter observational cohort study from August 2013 to September 2014. Participants aged 5 to 18 years with an acute (<48 hours) concussion were recruited from 9 Canadian pediatric emergency departments in the Pediatric Emergency Research Canada Network.

Exposure: The independent variable was the number of days of school missed. Missing fewer than 3 days after concussion was defined as an early return to school.

Main outcomes and measures: The primary outcome was symptom burden at 14 days, measured with the Post-Concussion Symptom Inventory (PCSI). Symptom burden was defined as symptoms status at 14 days minus preinjury symptoms. Propensity score analyses applying inverse probability of treatment weighting were performed to estimate the relationship between the timing of return to school and symptom burden.

Results: This cohort study examined data for 1630 children (mean age [SD] 11.8 [3.4]; 624 [38%] female). Of these children, 875 (53.7%) were classified as having an early return to school. The mean (SD) number of days missed increased across age groups (5-7 years, 2.61 [5.2]; 8-12 years, 3.26 [4.9]; 13-18 years, 4.71 [6.1]). An early return to school was associated with a lower symptom burden 14 days postinjury in the 8 to 12-year and 13 to 18-year age groups, but not in the 5 to 7-year age group. The association between early return and lower symptom burden was stronger in individuals with a higher symptom burden at the time of injury, except those aged 5 to 7 years.

Conclusions and relevance: In this cohort study of youth aged 5 to 18 years, these results supported the growing belief that prolonged absences from school and other life activities after a concussion may be detrimental to recovery. An early return to school may be associated with a lower symptom burden and, ultimately, faster recovery.

PubMed Disclaimer

Conflict of interest statement

Conflict of Interest Disclosures: Drs. Sady, Vaughan, and Gioia reported being the authors of the Postconcussion Symptom Inventory (PCSI) outside of the submitted work. Dr Sady reported receiving personal fees from PAR during the conduct of the study. Dr Tang reported receiving personal fees from Children’s Hospital of Eastern Ontario (CHEO) Research Institute during the conduct of the study. Dr Yeates reported receiving financial support as the Ronald and Irene Ward Chair in Pediatric Brain Injury from the Alberta Children’s Hospital Foundation outside the submitted work. Dr Gagnon reported grants from the Canadian Institutes of Health Research and Fonds de Recherche du Québec outside the submitted work. Dr Zemek reported receiving grants from the Ontario Neurotrauma Foundation, Physician Services Incorporated Foundation, CHEO Foundation, Ontario Brain Institute, and Ontario SPOR Support Unit and serving on the National Football League scientific advisory board and the concussion advisory board for Parachute Canada. He reported being the clinical research chair in pediatric concussion from University of Ottawa and the cofounder, scientific director, and a minority shareholder in 360 Concussion Care outside the submitted work. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Participant Enrollment Flowchart
Illustrates the number of eligible observations from the original 5P (Predicting and Preventing Postconcussive Problems in Pediatrics) study participants after applying exclusion criteria for the current substudy, the number of observations with Post-Concussion Symptom Inventory (PCSI) score at 2 weeks (primary study outcome), and number of observations included in the final propensity score models (ie, have complete data on primary outcome and all model covariates), stratified by age groups (5-7, 8-12, and 13-18 year olds).
Figure 2.
Figure 2.. Number of Missed School Days by Age Group
Missed school days by age group. Distribution of the number of missed school days following concussion is presented for each of 3 age groups (5-7, 8-12, and 13-18 year olds). The y-axis depicts the percentage of participants within each specific age group.
Figure 3.
Figure 3.. Association Between Early School Return and Symptom Level at 2 Weeks Postinjury by Initial Symptom Quintiles
Estimated association of early return-to-school on the primary study outcome at different baseline symptom severity. The x-axis represents baseline symptom severity quantified by the Post-Concussion Symptom Inventory (PCSI) summed score at the initial emergency department visit (baseline). The y-axis represents the estimated mean difference in PCSI summed score at 2 weeks between early and late return-to-school groups. A positive value indicates early return-to-school is associated with an increase in PCSI summed score at 2 weeks (more symptoms). A negative value indicates early return-to-school is associated with an decrease in PCSI summed score at 2 weeks (fewer symptoms). These estimates are derived from the final propensity score models fitted separately for each of 3 age groups (5-7, 8-12, and 13-18 year olds), where an interaction between timing of return-to-school and PCSI summed score at the initial emergency department visit was specified.
See this image and copyright information in PMC

References

    1. Lumba-Brown A, Yeates KO, Sarmiento K, et al. . Centers for Disease Control and Prevention guideline on the diagnosis and management of mild traumatic brain injury among children. JAMA Pediatr. 2018;172(11):e182853. doi:10.1001/JAMAPEDIATRICS.2018.2853 - DOI - PMC - PubMed
    1. Davis GA, Anderson V, Babl FE, et al. . What is the difference in concussion management in children as compared with adults systematic review. Br J Sports Med. 2017;51(12):949-957. doi:10.1136/bjsports-2016-097415 - DOI - PubMed
    1. Purcell LK, Davis GA, Gioia GA. What factors must be considered in ‘return to school’ following concussion and what strategies or accommodations should be followed: a systematic review. Br J Sports Med. 2019;53(4):250. doi:10.1136/BJSPORTS-2017-097853 - DOI - PubMed
    1. Reed N, Zemek R, Dawson J, Ledoux AA, Provvidenza CPM. Living guideline for diagnosing and managing pediatric concussion. Accessed December 12, 2022. http://www.braininjuryguidelines.org
    1. Grubenhoff JA, Deakyne SJ, Comstock RD, Kirkwood MW, Bajaj L. Outpatient follow-up and return to school after emergency department evaluation among children with persistent post-concussion symptoms. Brain Inj. 2015;29(10):1186-1191. doi:10.3109/02699052.2015.1035325 - DOI - PMC - PubMed

Publication types

Grants and funding