Table 2

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

ArticleStudy design, duration, countryParticipants (n, age, sex)Exposure/intervention (Definition)Outcome (Definition)Results (including statistical outcomes)Main limitationsStudy quality assessment (DB score)Level of evidence
Carson et al 34 Retrospective EMR review
April 2006 to March 2011
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 concussionPremature RTP/RTL defined as recurrence or worsening of symptoms on RTL or RTP using SCAT and self-reportSymptom 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

Corwin et al 35 Retrospective EMR review
July 2010 to December 2011
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 ClinicIdentify 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

Glang et al 36 RCT
August to November 2011
(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

Grubenhoff et al 37 Secondary analysis of a prospective longitudinal cohort observational study
October 2010 to March 2013
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

Thomas et al 38 Prospective RCT
Urban paediatric ED
May 2010 to December 2012
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

Zuckerbraun et al 39 Preimplementation and postimplementation design in 2 urban paediatric EDs
Pre-February to July 2009
Post-December 2009 to June 2010
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 patientsImpact of ACE-ED tools on patient follow-up and postinjury behaviourAfter 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

  • 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.