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Updated: Dec 26, 2025
A Multi-Modal Approach to Assessing Recovery in Youth Athletes Following Concussion
Published on: September 25, 2014
Effectiveness of return to activity and return to school protocols for children postconcussion: a systematic review
Carol DeMatteo1,2, E Dimitra Bednar2,3, Sarah Randall2
1School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada.
Insights
Limited evidence supports return to activity (RTA) and return to school (RTS) protocols for pediatric concussion. Short rest periods (1-2 days) are recommended, but more research is needed to confirm protocol efficacy.
Area of Science:
- Pediatric neurology
- Sports medicine
- Rehabilitation science
Background:
- Concussion management in children often involves structured return to activity (RTA) and return to school (RTS) protocols.
- The efficacy of these protocols in the pediatric population remains incompletely understood.
Purpose of the Study:
- To evaluate the effectiveness of RTA and RTS protocols on clinical outcomes for children diagnosed with concussion.
- To examine the evidence supporting the components of these protocols, including rest, exercise, and school accommodations.
Main Methods:
- A systematic review was conducted, searching multiple databases (PubMed, MEDLINE, EMBASE, CINAHL, ERIC) and reference lists.
- Studies evaluating RTA or RTS protocols in children aged 5-18 with concussion were included, along with rigorous studies providing evidence for recommendations.
- Original research and systematic reviews were included; articles lacking methodology or involving participants with comorbidities were excluded.
Main Results:
- The search identified 198 articles, with 13 ultimately included in the review.
- Despite widespread clinical adoption, there is a paucity of evidence demonstrating the efficacy of current RTA and RTS protocols in pediatric concussion.
Conclusions:
- Current data suggest that 1-2 days of physical and cognitive rest is advisable in the acute phase post-concussion, followed by a graduated approach to RTA/RTS.
- Prolonged rest may negatively impact symptom reporting and recovery time.
- Further interventional studies are essential to rigorously assess the effectiveness of RTA/RTS protocols in youth concussion management.
Objective:
To determine the effects of following return to activity (RTA) and return to school (RTS) protocols on clinical outcomes for children with concussion. The 12 subquestions of this review focus on the effectiveness of protocols, guidelines and recommendations, and the evidence supporting content of the protocols including rest, exercise and school accommodations.
Design:
Systematic review.
Data Sources:
PubMed, MEDLINE, EMBASE, CINAHL, ERIC and manual reference list check.
Eligibility Criteria For Selecting Studies:
Studies were included if they evaluated RTA or RTS protocols in children aged 5-18 years with a concussion or if they reported a rigorous study design that provided evidence for the recommendations. Included studies were original research or systematic reviews. Articles were excluded if they did not report on their methodology or included participants with significant neurological comorbidities.
Results:
The literature search retrieved 198 non-duplicate articles and a total of 13 articles were included in this review. Despite the adoption of several RTS and RTA protocols in clinical practice there is little evidence to determine their efficacy in the paediatric population.
Summary:
The current data support the recommendation that children in the acute stage postconcussion should undergo 1-2 days physical and cognitive rest as they initiate graduated RTA/RTS protocols. Prolonged rest may increase reported symptoms and time to recovery. Further interventional studies are needed to evaluate the effectiveness of RTA/RTS protocols in youth with concussion.
