Table 2

Articles examining strategies or provision/receipt of accommodations on return to school

Article	Study design, duration, country	Participants (n, age, sex)	Exposure/intervention (Definition)	Outcome (Definition)	Results (including statistical outcomes)	Main limitations	Study quality assessment (DB score)	Level of evidence
Carson et al 34	Retrospective EMR review April 2006 to March 2011 Canada	n=159 elementary (24.1%), secondary (55.9%), college/university (20.0%) Ages not specified 170 concussions 61.8% male	SRC student-athletes assessed by same family and sport medicine physician who gave advice regarding cognitive and physical rest after concussion	Premature RTP/RTL defined as recurrence or worsening of symptoms on RTL or RTP using SCAT and self-report	Symptom recurrence with RTP=43.5% and RTL=44.7% Prior concussion associated with more rest days before return to activity (RTA) (P<0.001) Elementary school patients required fewer rest days to RTA (11.6 days) versus high school (25.1) versus college/university (23.6) (P=0.0163)	Did not state reasons for going back too soon Mixed age cohort (20% college/university students) Ages not specified No definition of injury characteristics; no mention of when seen in postinjury clinic	17	4
Corwin et al 35	Retrospective EMR review July 2010 to December 2011 USA	Convenience sample (n=247 selected from 3740) (same data set as ref 24) Median age 14 (7–18) years 58% male	Patients with concussion seen at a tertiary paediatric hospital-affiliated Sports Medicine Clinic	Identify pre-existing characteristics associated with prolonged recovery	RTS (median) part-time=12 days (IQR 6–21); full-time without accommodations=35 days (IQR 11–105); symptom-free 64 days (IQR 18–119); full RTP 76 days (IQR 30–153) 73% symptomatic >4 weeks; 73% prescribed school accommodations; 61% had decline in grades Pre-existing characteristics associated with prolonged recovery: depression/anxiety, dizziness at time of injury, abnormal convergence or symptom provocation on oculomotor exam, prior concussion Symptom provocation with eye exam more likely to have accommodations (P=0.0001), take longer to RTS full-time (P=0.050), be symptom-free (P=0.048), to have decline in grades (P=0.035) Patients with abnormal convergence more likely to have accommodations (P=0.038) RTS full-time compared with ages 17–18 years: 13–14 years=1.8 times, 15–16 years=1.6 times Age <12 years: almost 2× longer to be symptom-free History ≥2 concussions more than twice as long to become symptom-free (P=0.039)	Relatively small sample size External validity: referral of more severe concussions Delayed presentation Retrospective review 23% non-SRC	18	4
Glang et al 36	RCT August to November 2011 USA (knowledge transfer)	High schools in Oregon (n=25) (13 intervention, 12 control)	Brain 101 website (intervention), CDC material on safety (not concussion) Pretest and post-test	Effect on parents and athletes’ concussion knowledge, behavioural intention and concussion management	Pretest/post-test intervention group outperformed controls on sports concussion knowledge (P<0.0001) No significant difference in number of school days missed or whether accommodations provided More intervention schools implemented best practice guidelines More test schools formed a CMT (P=0.007) with a coordinator (P=0.005) More students in test schools received a variety of accommodations compared with controls (not statistically significant)	Did not assess other groups (teachers, coaches, and so on). Outcome primarily RTA, not specifically RTS Lack of control for other sources of concussion knowledge	19	2
Grubenhoff et al 37	Secondary analysis of a prospective longitudinal cohort observational study October 2010 to March 2013 USA	n=234 Aged 8–18 years enrolled, 179 completed follow-up 70% male (no PPCS) 66% male (PPCS)	Concussed patients seen in urban ED with and without prolonged symptoms (≥3 new symptoms >1 month after injury)	Number of follow-up visits after ED visit; number of school days missed; receipt of academic accommodations	No significant differences in demographic or injury characteristics between no PPCS and PPCS PPCS occurred in 21% Only 45% of patients had follow-up appointments after ED visit Children with PPCS missed twice as many school days (P<0.0001) but did not differ in academic accommodations Outpatient follow-up associated with receiving academic accommodations 72% missed at least 1 day of school 40% received academic accommodations; only 53% of patients with PPCS received accommodations	Secondary data analysis External validity: urban ED may not represent community Urban population only Short follow-up of only 30 days Low prevalence of PPCS (21%) Did not account for reasons for school days missed 51% non-SRC	20	4
Thomas et al 38	Prospective RCT Urban paediatric ED May 2010 to December 2012 USA	n=99 11–22 years of age (median 13.7 years) One-third female 71% SRC	Concussed patients randomised to strict rest (intervention) versus usual care (control) Patients completed a diary to record physical and mental activity level, calculate energy exertion and record daily PCS	Concussion recovery and outcome	After discharge, both groups reported a 20% decrease in energy exertion and physical activity levels Intervention group reported less school and after-school attendance for days 2–5 after concussion (3.8 vs 6.7 hours total, P<0.05) No clinically significant difference in neurocognitive or balance outcomes Intervention group reported more daily postconcussive symptoms (total symptom score over 10 days, 187.9 vs 131.9, P<0.03) and slower symptom resolution	Only 71% SRC Included adults Urban ED setting may not be generalisable to community Strict rest group older Selection bias: convenience sample (patients may have been more motivated to participate) Diary report subject to recall bias Looked only at short-term outcomes (first 7–10 days) Did not assess long-term outcomes Not blinded	21	2
Zuckerbraun et al 39	Preimplementation and postimplementation design in 2 urban paediatric EDs Pre-February to July 2009 Post-December 2009 to June 2010 USA	164 participants pre 190 participants post Mean age 10.6 years (SD 3.7) 65% male 27% SRC	Use of modified ACE tools in concussed patients	Impact of ACE-ED tools on patient follow-up and postinjury behaviour	After implementation, 58% of patients received ACE-ED and 84% received ACE-ED DI Follow-up improved at all time points (32% vs 61% at week 4; P<0.001) After implementation, parental recall of discharge instructions significantly increased, patient’s mean total PCSS was significantly higher, and report of return to normal activity was significantly longer Largest improvement was in recall of instructions for school restrictions After implementation, children reported to receive greater support than those before implementation (17% vs 4%, P<0.001) Two-thirds of parents reported using ACE-ED DI ‘Return to School’ form	ED setting may not be generalisable to other settings Only 27% SRC Did not control for other sources of concussion knowledge Differences between groups may be related to time differences between each phase of the study, not just the intervention Possible overdiagnosis of concussion given the definition used (diagnosis could be made with only one sign/symptom) Possible underdiagnosis of concussion given that mechanism of injury had to be blunt force trauma to head Self-report bias for patient outcomes	20	3

ACE-ED, Acute Concussion Evaluation-Emergency Department; ACE-ED DI, Acute Concussion Evaluation-Emergency Department Discharge Instruction; CMT, concussion management team; CDC, Centers for Disease Control; DB, Downs and Black checklist; ED, emergency department; EMR, electronic medical record; PCS, postconcussion symptoms; PCSS, Post-Concussion Symptom Score; PPCS, persistent postconcussive symptoms; RCT, randomised controlled trial; RTA, return to activity; RTL, return to learn; RTP, return to play; RTS, return to school; SCAT, Sports Concussion Assessment Tool; SRC, sport-related concussion.