Returning to work after a concussion can be a considerable challenge. Many people return to work before their symptoms are fully resolved. This is often okay—it may even be beneficial—provided the appropriate protocol is followed.
If you have suffered a concussion, it is very important that you make your return to work a priority—and here’s why. Compared to those who are unemployed, those who remain employed after head injury report better health status, improved sense of wellbeing, greater social integration within the community, and less usage of health care services.
Furthermore, an early return to work is correlated with better outcomes.
Now, before we get into the specific elements of a sound return-to-work process, let’s take a moment for a brief refresher on the basics of concussion. These basics are important because they form the basis for the prescribed protocol.
A concussion (or mild traumatic brain injury) is an injury that results from a biomechanical impact to the head or the body resulting in a functional disruption in the brain. Being a functional injury rather than a structural one means that there are no perceivable changes to the architecture of the brain following concussion. This makes medical imaging like x-rays, MRI’s, or CT scans futile since they analyze the structures of the body. Concussion does not change the tissues of the brain in any discernible way so apart from ruling out something more serious like a fracture or brain bleed, imaging is not especially helpful.
There is also no current biomarker for concussion, so blood tests and urinalysis are also of no use.
Since the brain is something like a central processing unit of the body, an injury to the brain can affect various bodily systems. Your concussion symptoms will result from neurological dysfunction, but may also arise from dysfunction of the endocrine system, the visual system, and/or gut inflammation.
Concussion may also have a psychological impact on patients. Safely returning to work is one of the most important steps you can take in ensuring sound mental health as you recover. Without an appropriate step-by-step plan for returning to work, you may aggravate rather than relieve your symptoms and prolong the time to full recovery.
The return-to-work protocol is a process that unfolds gradually. Your initial return to the work place will be for a partial day only, and your activities will be modified appropriately. Over time as you proceed through the stages outlined below, you will progressively remove work restrictions and return to full days of work. But it doesn’t all happen at once.
The gradual nature of this protocol means that you may still be experiencing symptoms when you initially go back to work. The initial goal of the return-to-work protocol is not for you to work without symptoms (although that is ideal), but for you to remain for the prescribed duration without a significant increase in symptoms.
It is important to be realistic about your expectations when you begin the return to work process.
One common barrier is mental (cognitive) fatigue. The most common manifestations of mental fatigue in concussion patients are delayed memory and delayed processing of information. With mental fatigue, one may find it easier to forget appointments, meetings, or other important tasks. One may also find it difficult to keep up with conversations and follow along when multiple people are speaking at once.
To reduce the impact of mental fatigue on your return to work process, it’s important to have reasonable working hours and take frequent breaks throughout the day. This will help prevent overexertion and allow your brain time to rest and recover. All of these points were considerations in crafting the return to work protocol below.
Physical exertion can be another barrier for returning to work after a concussion. Some patients may experience symptoms like headaches, dizziness, or nausea with physical activity due to their injury. It is important to communicate these symptoms with your employer and discuss potential modifications
Like all symptoms of concussion, it is important to remember that mental fatigue is a treatable barrier.
Another symptom of concussion that can serve as a significant barrier in the return to work process is headache. It is no surprise that an intense headache can interfere with cognitive functioning. This outlines the tremendous, compounding effect that one symptom can have on your overall sense of well being. But inversely, it also highlights the fact that resolving one symptom may in turn result in a simultaneous decrease in other related symptoms (e.g., decrease in headache results in an increase in cognitive functioning).
Once again, these symptomatic barriers to return to work are treatable. Be sure to discuss your symptoms openly with your clinician and convey any anxieties you have about your return to work-related activities.
Like mental fatigue, physical fatigue is another possibility. When you are not feeling your best, you are less likely to stay active. Decreased activity levels lead to deconditioning, and as a result, upon return to work you may discover that you are not as easily able to accomplish your physical tasks in the way you could pre-injury.
The vulnerability to deconditioning after concussion highlights the need for cardiovascular exercise very early on post-injury. Ask your clinician to guide you in your return to physical activity. Using tools like the Buffalo Concussion Treadmill test, they will be able to give you specific guidelines (like max. heart rate) to facilitate your exercise regimen.
Another factor that may present as a challenge in your return to work is the fact that concussions are invisible injuries. Whereas an injury like a broken leg is very hard to hide during recovery, there are usually few if any visible signs of concussion.
And while the symptoms of a concussion can be at least equal to, if not more, intense and complex than the symptoms of other injuries, they often go unperceived by others. This can become a complicating factor as you may encounter people at work that have a hard time empathizing with your condition.
To overcome such an obstacle, consider requesting a letter from your clinician to your employer in order to communicate the nature of your condition and the return-to-work protocol. This will help to mitigate any misunderstandings or lack of awareness about the severity and complexity of your recovery process.
Having a well-informed employer means having a powerful advocate by your side as you face the challenges of returning to work following a concussion.
The fear and anxiety associated with returning to work after a concussion can also be significant barriers. You may experience worry about not being able to perform tasks as well as before, failing at work, or even re-injuring yourself.
It is important to address these fears and anxieties openly and honestly with your clinician. They can provide you with coping strategies, support, and reassurance throughout the return-to-work process. Additionally, consider reaching out to friends, family members, or a support group for further emotional support during the return to work process.
The majority of patients who undergo immediate assessment and treatment for their concussions within the first few days following injury will fully recover within four weeks. Those who do not present to a clinician for evaluation until a month or so after their concussion tend to have a much longer road to recovery, often taking months instead of weeks.
But initiating treatment late is always better than never! Indeed, it is never too late to be assessed and undergo a plan of mangement.
Because of the diverse physiological and psychological factors that may be causing symptoms, a concussion management plan for both acute and chronic concussion sufferers should include things like manual therapy, cardiovascular exercise, a healthy diet, adequate sleep, and steps for returning to sport, school, and work.
If indicated, plans of care should also include vestibular rehabilitation for symptoms related to inner ear dysfunction and vision rehabilitation for eye dysfunction.
But for every concussion patient—no matter the kind or severity of symptoms—it is absolutely critical that evaluation by a clinician is undergone as soon as possible. Research strongly indicates that early presentation to a clinic for postconcussion assessment is a strong indicator of a faster recovery time.
The bottom line: Delaying time to evaluation following a concussion can significantly prolong recovery from injury. Consider this “step number one” in making a successful return to work.
The return-to-work and return-to-school protocols are nearly identical (see below). They both take into account all of the details we have just discussed.
Remember: your first step is assessment by a trained clinician. After assessment, this protocol should be immediately implemented and will be a crucial part of achieving full recovery as fast as possible.
Patricios, J. S., Schneider, K. J., Dvorak, J., Ahmed, O. H., Blauwet, C., Cantu, R. C., … & Meeuwisse, W. (2023). Consensus statement on concussion in sport: the 6th International Conference on Concussion in Sport–Amsterdam, October 2022. British journal of sports medicine, 57(11), 695-711..
The Return to Work protocol includes five stages:
Old and outdated concussion management protocols included a relatively long period of “absolute rest.” Prolonged absolute rest is now known to be detrimental to recovery!
In this initial stage, your physical and cognitive activity levels should be decreased, but only enough to keep your symptoms from any significant increases. You may wish in this initial stage to stay home from work for a day or two.
Light-to-moderate cognitive activities may include things like conversing with friends and family, reading, or watching television—provided they do not cause a significant increase in your symptoms. Light-to-moderate physical activities may include going for walks or just spending time outside in your yard or neighborhood.
It is appropriate to get some additional sleep on these days but you should not be sleeping all day! Sleep is important here, but it is not more important than symptom-limited activity.
The golden rule of this step: stay as active as possible without increasing your symptoms.
You may proceed to Stage 2 once you have gone 24 hours without symptoms.
In this stage you can begin to increase your cognitive load. You may still wish to remain at home during this time, but if possible you can begin to work remotely.
Activites in Stage 2 may include answering emails, making phone calls, and completing computer or paper-based work duties. The goal is to complete these activities while keeping your symptoms to a minimum. If your symptoms increase during these kinds of activities, take a break and try again later in the day.
You should also increase your physical activity, choosing low-risk ways of getting cardiovascular exercise without signficantly increasing your symptoms. Your clinician may subject you to a specialized, in-clinic treadmill test in order to help you determine what level of cardiovascular exertion is appropriate at this stage of your recovery.
Once you can tolerate 45 minutes to one hour of light cognitive activity with minimal increase in your symptoms, you may proceed to Stage 3.
Once you have entered Stage 3, you may return to work for a half day. It may be for the morning or the afternoon.
Your work duties should remain restricted to low-risk work activities that are not likely to significantly increase your symptoms. Entering this stage will require careful planning with your employer. You may wish to get a letter from your clinician that outlines and explains the circumstances and the recommended modifications specific to your line of work.
Even if you complete your half day without any exacerbation of symptoms, you should still go home. In the event that you do experience a significant symptom increase, return to Stage 2.
Once you have completed a symptom-free half day at work, you may move on to Stage 4.
At this late stage of the return-to-work protocol, you should be able to complete a full work day without experiencing any significant increase in your symptoms. However, it is still important to have the same modifications and accommodations as Step 3 in place.
These modifications may include things like breaks throughout the day for rest or light physical activity, as well as limiting the amount of cognitive or physical exertion required for tasks. It is important to maintain open communication with your employer during this stage and adjust your workload if necessary.
Once you can successfully complete a full day at work without an increase of symptoms, you may begin to gradually lift restrictions until you can complete a full day of work with no work modifications and no increase in symptoms.
Stage 5 arises organically out of Stage 4. Once you have reached this final stage, you may be ready for discharge from your medical provider. Thus, once you have achieved an asymptomatic full day of work, it is important to see your clinician for final clearance.
If you are also an athlete, it is important to understand that your successful completion of the return-to-work protocol does not mean you are ready for a full return to your sport. Athletes will undergo a simultaneous return-to-play process, and may not progress at the same rate through the stages of the return-to-play protocol.
It is important to note that the return-to-work protocol may vary depending on individual factors such as severity of concussion symptoms and type of work. It is always best to follow the guidance of a medical professional in order to safely and effectively return to work after sustaining a concussion.
Additionally, modifying workplace environments and duties may also play a crucial role in promoting successful return to work for individuals recovering from concussions. Employers should be aware of these potential modifications and accommodate employees as needed during this delicate period of recovery.
Overall, with proper rest, symptom management, and gradual increases in cognitive and physical activity, individuals can successfully return to work after experiencing a concussion. So don’t rush your recovery process, take care of yourself and listen to your body. Remember, your health and well-being should always be the top priority. Keep following up with your medical provider as needed, and do not hesitate to ask for help from your employer or loved ones during this time. Recovery takes time, but with patience and determination, you will get there.
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