Concussion Protocol for Return to School
Students should follow a stepwise return-to-school protocol after a concussion, beginning with 24-48 hours of relative rest followed by a gradual reintroduction of cognitive activities based on symptom tolerance. 1
Initial Management (First 24-48 Hours)
- A period of relative rest for 24-48 hours immediately following concussion is recommended 1
- During this period:
- Limit screen time (phones, computers, TV)
- Permit light activities of daily living as tolerated
- Avoid activities that worsen symptoms
- Walking and other symptom-limited physical and cognitive activities are permitted as tolerated 1
Return-to-School Protocol
Step 1: Initial Rest Period (24-48 hours)
- Limited cognitive activity
- Brief mental activities (5-15 minutes) that don't worsen symptoms
- No school attendance
Step 2: Gradual Return to Cognitive Activity
- Start with homework at home for short periods (15-30 minutes)
- Increase duration as tolerated
- Avoid activities that trigger symptoms
Step 3: Part-time School Attendance
- Begin with half-days or selected classes
- Take breaks as needed in a quiet area
- No standardized testing, music class, physical education, or assemblies
- Modify assignments and reduce workload
Step 4: Full-day Attendance with Accommodations
- Attend most or all classes with minimal breaks
- Gradually increase workload
- Begin to catch up on essential missed work
- Limited testing with accommodations
Step 5: Full Return to Academic Activities
- Full school day without accommodations
- Normal testing and workload
- Resume all academic activities
Important Considerations
- If symptoms worsen during any stage, the student should return to the previous asymptomatic stage 1
- Students should not take medications that mask concussion symptoms when beginning the return-to-school protocol 1
- Medical clearance from a healthcare provider trained in concussion management is essential before returning to full academic and physical activities 1
Academic Accommodations
Timing considerations:
Recommended accommodations:
- Extended time for assignments and tests
- Reduced homework load
- Provision of class notes
- Rest breaks during the day
- Excused absence from physical education
- Quiet environment for testing
- Avoidance of noisy environments (cafeteria, assemblies)
Return to Physical Activity
- Students should complete the return-to-school protocol before beginning the return-to-play protocol 1
- The American Academy of Pediatrics recommends a minimum of 24 hours for each step of the return-to-play protocol, requiring at least 5 days after becoming asymptomatic 1
- Each step of physical activity progression requires 24 hours without symptom recurrence 1
Warning Signs Requiring Immediate Medical Attention
- Worsening headache
- Repeated vomiting
- Increased confusion
- Seizures
- Difficulty waking up
- Slurred speech
- Weakness or numbness in arms/legs
- Unusual behavior changes 1
Common Pitfalls to Avoid
- Rushing the process: Research shows that complete rest exceeding 3 days is probably not helpful 3, but returning to full cognitive load too quickly can prolong recovery 2
- Inconsistent implementation: Studies show significant variability in compliance with recommended return-to-activity guidelines 4
- Ignoring symptom recurrence: Any symptom exacerbation should trigger a return to the previous step 1
- Failing to communicate with school personnel: Ensure teachers, school nurses, and administrators understand the student's accommodations
Remember that younger students typically require longer recovery periods compared to college-aged or professional athletes 1. The goal is to support the student's recovery while minimizing the impact on academic progress.