BLOG: Returning to school after concussion may help speed recovery in children
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The conventional wisdom that children who suffer a concussion should have total physical and cognitive rest until their symptoms resolve is increasingly being proven inaccurate.
In fact, several studies have already confirmed that light activity can speed recovery (Leddy et al; Ledoux et al).
In a study of 1,630 Canadian children with concussion, my colleagues and I demonstrated that an earlier return to school (ie, fewer days of missed school) may reduce the symptom burden 2 weeks after injury (Vaughan et al).
Our study was a planned secondary analysis of a prospective, multicenter, observational cohort of children aged 5 to 18 years who presented to a pediatric emergency department within 48 hours of sustaining a concussion. According to our results, the mean number of school days missed was 3.74 days, and, on average, teenagers missed more days of school than cohorts of children aged 5 to 7 years or 8 to 12 years.
More than half the children (53.7%) were classified as having an early return to school, meaning they only missed 1 or 2 days. Weekend days when school would not have been in session were not counted, so some of these children could also have been recovering for an additional 1 to 2 days without missing school, depending on the timing of their injury.
We also reported that missing fewer days of school was associated with a lower symptom burden, measured with the Post-Concussion Symptom Inventory, at 14 days after injury. This supports the growing belief that prolonged rest and cessation of normal activities does not necessarily facilitate recovery and may even worsen symptoms.
It is important to note, however, that our findings do not mean that children should be pushed to ignore symptoms or engage in activities that are too difficult during their recovery. Education around the strategic use of symptom management strategies, such as rest breaks, is important. The nature of support provided by schools is also likely to be an important factor in the successful return to school after a concussion. Prevention of reinjury before the concussion has healed remains a critical safety step to help avoid complicated and prolonged recovery.
We used a statistical method of propensity-score matching to account for injury characteristics, symptoms, and personal and family history variables known to affect concussion severity and recovery. The presence or severity of visual or oculomotor symptoms (other than balance) was not specifically evaluated in this study.
Given the nature of the dataset, we do not know what guidance children and their families were given by emergency room personnel, whether they attended full days of school when they returned, or what interventions and support might have been provided by the schools during their recovery. In other words, just because children returned to school early, we cannot say that their school days were the same as they had been before concussion.
We know that social connectedness, physical movement and anxiety reduction are helpful. It is entirely possible that some of the early returnees benefitted from these factors by being in school while still avoiding, for example, tasks that significantly provoked symptoms. More research remains to be done to understand the most effective protocols for a healthy return to school.
One very surprising finding was that children with a higher symptom burden at the time of injury benefited the most from an early return to school. We might have expected that more symptomatic patients had more severe concussions and would benefit from rest more than their peers, but the opposite was true. We do not fully understand this finding, and it warrants further research.
Concussions in children should be taken seriously. But parents and doctors do not need to overly restrict children from returning to school or from light activity. As concussion guidance evolves, children should:
- be strategic about getting good sleep and rest for the first 24 to 48 hours following concussion if symptoms are significant;
- engage in safe activities as soon as they can handle light physical activity;
- avoid activities that could cause a second concussion (ie, those with a risk for contact, falls or collisions) until fully recovered and cleared by a medical provider with expertise in concussion; and
- return to school as soon as they feel well enough, seeking accommodations or support as needed.
References:
- Leddy JJ, et al. Lancet Child Adolesc Health. 2021;doi:10.1016/S2352-4642(21)00267-4.
- Ledoux A-A, et al. Br J Sports Med. 2022;doi:10.1136/bjsports-2021-105030.
- Vaughan CG, et al. JAMA Netw Open. 2023;doi:10.1001/jamanetworkopen.2022.51839.
For More Information:
Christopher G. Vaughan, PsyD, is a pediatric neuropsychologist at Children’s National Hospital in Washington and assistant professor in the departments of psychiatry and behavioral sciences and pediatrics at George Washington University School of Medicine. He also is assistant director of the Safe Concussion Outcome, Recovery and Education (SCORE) Program, where he evaluates and treats children and adolescents with concussion. He serves as treasurer of the Sports Neuropsychology Society (SNS) and is a consultant with the National Hockey League’s concussion program.
Vaughan has published in multiple scholarly journals and has a specific interest in test and measure development for improving assessment and treatment of youths with concussion.
Disclaimer: The views and opinions expressed in this blog are those of the authors and do not necessarily reflect the official policy or position of the Neuro-Optometric Rehabilitation Association unless otherwise noted. This blog is for informational purposes only and is not a substitute for the professional medical advice of a physician. NORA does not recommend or endorse any specific tests, physicians, products or procedures. For more on our website and online content, visit noravisionrehab.org.
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