What are the guidelines for assessing return to work after a concussion?

Return to Work Assessment After Concussion

Individuals recovering from concussion should begin a gradual, stepwise return to work protocol after 24-48 hours of initial rest, with progressive increases in cognitive demands while monitoring for symptom recurrence, and should not wait until completely asymptomatic to start this process. 1

Initial Assessment (First Few Weeks Post-Injury)

Symptom Evaluation

• Use standardized symptom checklists (SCAT-5 Symptom Evaluation, Rivermead Post-Concussion Symptom Questionnaire) to objectively track symptom number and severity 2, 3
• Assess cognitive symptoms specifically: concentration difficulties, memory problems, mental fogginess, and processing speed 1
• Screen for mood disturbances using GAD-7 and PHQ-8/9, as anxiety and depression complicate recovery and affect work capacity 2, 3
• Evaluate symptom exacerbation with cognitive activity, as this predicts work readiness 2

Cognitive Function Testing

• Perform cognitive evaluation including orientation, immediate and past memory, new learning, and concentration 3
• Consider neuropsychological testing for patients with persistent cognitive symptoms beyond 10 days, though this should supplement rather than replace clinical assessment 1, 3
• Assess multitasking ability and work speed, as these are commonly impaired and critical for work function 4

Work-Specific Assessment

• Document pre-injury work hours, job demands (cognitive load, physical requirements, multitasking needs), and work environment 4
• Identify specific job tasks that may be problematic: sustained attention, computer work, meetings, noise tolerance, and deadline pressures 4
• Evaluate current work status: completely off work, partial return, or full return with accommodations 4

Timing Considerations

Early evaluation (within 30 days post-injury) is critical, as delayed assessment is associated with more severe persisting symptoms at 3 months and worse functional outcomes. 2

• Avoid advising rest for more than 2 days, as prolonged rest advice (>2 days) is associated with delayed return to productivity and worse outcomes 5
• Begin gradual cognitive activity reintroduction after the initial 24-48 hour rest period 1, 5
• Recognize that 15-20% of patients develop persistent post-concussion syndrome requiring specialized management 1

Stepwise Return to Work Protocol

Stage 1: Initial Cognitive Activity (Days 3-7)

• Start with 15-30 minute periods of light cognitive work at home 1
• Activities should not exacerbate symptoms beyond mild, temporary increases 6, 1
• If symptoms worsen, return to previous level for 24 hours before attempting progression 6, 1

Stage 2: Gradual Work Reintegration (Week 2-4)

• Begin with reduced hours (typically 25-50% of normal schedule) 4
• Implement workplace accommodations: frequent breaks, reduced workload, extended deadlines, quiet workspace 1, 4
• Monitor symptom levels throughout the workday, not just at day's end 4
• Each increase in work duration/intensity should be maintained for minimum 24 hours before progression 6, 1

Stage 3: Progressive Increase (Weeks 4-8)

• Gradually increase working hours by 2-4 hours per week as tolerated 4
• Add complexity incrementally: single tasks → multitasking → deadline-driven work 4
• Continue accommodations until functioning approaches pre-injury levels 1

Stage 4: Full Return

• Resume full work hours and responsibilities only when symptom-free with increasing cognitive demands 1
• Maintain monitoring for symptom recurrence for several weeks after full return 4

Red Flags Requiring Specialist Referral

• Symptoms persisting beyond 10 days despite appropriate management 1
• Worsening symptoms with gradual activity progression 1
• Inability to tolerate any cognitive activity without significant symptom exacerbation 6
• Significant mood disturbance (moderate-severe depression or anxiety) 2
• Multiple failed return-to-work attempts 4

Management of Persistent Symptoms (>4 Weeks)

For symptoms lasting beyond 4 weeks, implement multidisciplinary coordinated rehabilitation including at least two interventions from different disciplines. 6

• Graded aerobic exercise below symptom-exacerbation threshold 6, 1
• Vestibular rehabilitation for balance/dizziness symptoms 6
• Oculomotor vision therapy for visual symptoms (vergence, accommodation, eye movement dysfunction) 6
• Psychological treatment (cognitive-behavioral therapy) for emotional symptoms and coping strategies 6
• Vocational rehabilitation support for workplace reintegration 7

Evidence-Based Interventions for Return to Work

The most promising interventions based on recent systematic review include 7:

• Instruction on specific behavioral strategies for managing symptoms at work
• Action planning with concrete steps for gradual work reintegration
• Problem-solving training to address workplace challenges
• Education about health consequences of premature return versus gradual progression
• Strategies to reduce negative emotions related to work performance concerns

Common Pitfalls to Avoid

• Advising complete rest beyond 48 hours - this delays recovery and return to productivity 1, 5
• Waiting for complete symptom resolution before starting return to work - gradual reintroduction while mildly symptomatic is appropriate 1, 5
• Inadequate workplace communication - both employees and managers struggle to estimate appropriate workload without guidance 4
• Lack of long-term support - most employees need ongoing adjustments for weeks to months, not just initial accommodations 4
• Ignoring mood symptoms - anxiety and depression significantly complicate recovery and must be addressed concurrently 2, 3
• Premature full return - only one-third of workers return to similar pre-injury conditions even after "returning to work" 4

Medication Considerations

• Limit medication to acetaminophen only, and only as recommended by a physician 1
• Patients should not return to full work duties while taking medications for concussion symptoms 1