Return to School, Work, and Sport after Sport-Related Concussion

Sport-related concussion (SRC) is a form of mild traumatic brain injury characterized by rapid onset of impaired neurologic function usually followed by spontaneous resolution.¹ Concussions represent 9% to 12% of sport-related injuries in high school athletes,² and although most athletes return to sport within weeks (adults) to a month (adolescents),¹ at least 30% of untreated adolescents experience persisting symptoms beyond 1 month.³ Concussion management traditionally has focused on return to sport, but return to school and learning is important for children and adolescents, because school is their primary work.⁴ SRC traditionally has been treated with strict cognitive and physical rest until complete symptom resolution occurs.¹ Recent evidence, however, shows that prolonged strict rest is not effective for SRC,⁵ can delay return to sport and education,^5,6 and that controlled cognitive activity and physical activity in the first days after injury can facilitate recovery.^5,6

Return to School and Work

Adolescents (13 to 17 years of age) report more difficulty with returning to school than children (5 to 12 years of age) or adults (≥18 years of age),⁷ especially students with greater initial symptom burden, persisting symptoms, or specific symptoms such as difficulty concentrating, headaches, dizziness, or fatigue.⁷ Physical examination signs and symptom exacerbation indicative of visual and vestibulo-ocular dysfunction (eg, abnormal smooth pursuits, repetitive saccades, vestibulo-ocular reflex) are very common after concussion⁸ and can cause persisting symptoms,⁹ impairing return to education. Whereas excessive cognitive activity very early after SRC, such as immediate school attendance, may exacerbate symptoms and delay return to education,⁷ extreme or prolonged activity restriction increases symptoms and delays recovery.⁵ Clinicians therefore must consider the risk of substantial symptom exacerbation upon too rapid a return to school versus the risk of delayed return to education from a prolonged absence.

It has been reported that up to 45% of students may have exacerbation or recurrence of symptoms upon resuming their education⁷ and that 17% to 73% of students receive academic support or experience difficulty upon returning to school.^7,10 Nevertheless, most students are able to resume school within 2 to 5 days after SRC.⁷ Academic support, which is important for limiting symptom exacerbation and easing the transition back to school, is more likely to be initiated in schools with formal concussion management policies.¹⁰ Early¹¹ and regular medical follow-up (eg, weekly)^12,13 appears to facilitate recovery, and students who receive a return-to-school letter from their health care provider are more likely to receive academic support.¹⁴ Purcell et al⁷ include a sample health care provider letter in their supplemental material. There is little information on return to work for adults after concussion. A systematic review of mild traumatic brain injury¹⁵ reported that >50% of adults had returned to work by 1 month and >80% by 6 months after injury.

Strategies for Return to School

In the initial days following SRC, strict physical and cognitive rest (ie, cocooning) should be avoided,¹ although students may need to stay home from school for a day or two with relative restriction of physical and cognitive activities to allow acute symptoms to stabilize. One randomized controlled trial showed that limiting screen use during the first 48 hours after concussion facilitated recovery,¹⁶ although this strategy likely is not effective beyond 48 hours.¹⁷ Another study¹⁸ reported that symptom spikes were associated with abruptly increased mental activity, such as school attendance and extracurricular activities, but that most children were nevertheless able to resume their education without experiencing a symptom spike. This study reported that most symptom spikes were transient, were not preceded by mental or physical exertion, and that other factors such as stress and sleep problems appeared to contribute more to symptom fluctuations.¹⁸ Recent consensus guidelines recommend minimizing school absences to avoid secondary problems of social isolation, depression, and anxiety about mounting schoolwork.⁷ It is important for clinicians to realize that students do not need to be symptom-free to go back to school⁷ and that mild, transient symptom exacerbation is not harmful.^12,13 A consensus-based recommendation is that once students can tolerate 30 minutes of cognitive activity at home with no more than mild symptom exacerbation, they can return to school, with academic support if needed.⁷ Returning to school may be facilitated by following a stepwise, symptom-limited program, as outlined by the Concussion in Sport Group (Figure 1).¹ Some symptom-specific strategies and supports⁷ are listed in Table 1. Effective communication among the support network, including the medical team, school personnel, student, and parents or caregivers, helps reduce anxiety about missing school, allows students to focus on recovery, and facilitates successful return to school.⁷

Return to Sport

The time for clinical recovery and return to sport increased from a mean of 3 days to 15.43 days in collegiate American football athletes between 2003 and 2020, which has reduced same-season repeat concussions.¹⁹ The risk of delayed recovery (symptoms >1 month) and delayed return to sport increases in those with concussion symptoms who continue to play sport²⁰ as well as in those who do not seek medical attention within 1 week of injury.¹¹ In a recent study of collegiate athletes after SRC, approximately two-thirds returned to academics and exertion within 14 days and to unrestricted return to sport within 28 days.²¹

Recovery and return to sport after SRC typically follow a graduated stepwise strategy (Figure 2).¹ The 2017 Concussion in Sport Group consensus statement recommended that, after 24 to 48 hours of relative rest, symptom-limited light aerobic activity could begin, with the athlete proceeding to each subsequent step if remaining symptom-free, with each step expected to take 24 hours.¹ The athlete was advised to return to the previous step in case of any symptom exacerbation. Evidence published since 2017, however, shows that light spontaneous physical activity (eg, walking) within 24 to 48 hours of SRC safely facilitates recovery,²² and that brief, mild symptom exacerbation (defined as no more than a 2-point increase in symptoms or appearance of new symptoms when compared with the preactivity value on a 0- to 10-point scale) does not delay recovery.^12,13 Moreover, recent randomized controlled trials confirm that sub-symptom threshold aerobic exercise treatment prescribed within 2 to 10 days of SRC, based on systematic determination of the individual’s level of exercise tolerance on exertion testing, safely facilitates recovery¹² and significantly reduces the incidence of symptoms persisting beyond 1 month.¹³ This is crucial because persisting concussion symptoms impair adolescent participation in school, physical activity, and overall quality of life.^23,24 Whereas athletes, regardless of age or sex, can be managed using the same general approach, clinicians should account for individual premorbid and postmorbid factors (eg, depression or anxiety and migraine history) that may affect SRC recovery and which may benefit from a multidisciplinary treatment approach.¹ Clinicians should consider a shared decision-making model to support psychological readiness of athletes to return to sport.²⁵ A full resumption of education without the need for ongoing academic support should always precede unrestricted return to sport, especially for activities that pose a risk for contact, collision, or fall.¹

The reader is advised that a new graduated stepwise return to sport strategy will soon be forthcoming from the 6th CISG International Consensus Conference that was held in October-November of 2022 in Amsterdam, The Netherlands.

Conclusions

Whereas some students seamlessly return to school after SRC, many benefit from a brief absence from school and academic support to facilitate the resumption of their education. If instituted immediately after SRC, the majority of athletes return to school successfully within days to a week. Schools with a formal concussion policy offer more academic support, and a return-to-school letter from the clinician helps students receive support. Early and regular medical follow-up, spontaneous light physical activity within the first 2 days of SRC, and sub-symptom threshold aerobic exercise treatment prescribed as soon as 2 days after SRC facilitate recovery. Early exercise treatment reduces the risk of symptoms persisting beyond 1 month in adolescents. Unrestricted return to sport follows a graduated stepwise strategy and typically is accomplished within a month after SRC. SRC should be managed individually, accounting for the athlete’s clinical presentation, premorbid and postmorbid medical conditions, recovery trajectory, and psychological readiness to return to sport. Full school reintegration should always precede unrestricted return to sport, especially for sports that pose a risk for contact, collision, or fall.