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

JAMA Netw Open. 2023 Jan 3;6(1):e2251839. doi: 10.1001/jamanetworkopen.2022.51839.


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.

Publication types

  • Observational Study
  • Multicenter Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adolescent
  • Brain Concussion* / complications
  • Brain Concussion* / diagnosis
  • Canada / epidemiology
  • Child
  • Child, Preschool
  • Cohort Studies
  • Female
  • Humans
  • Male
  • Prospective Studies
  • Return to School*
  • Schools

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