Concussions and return-to-work considerations

To better understand concussion and optimize care of concussion patients injured at work, there are two valuable resources: the Concussion in Sport Group consensus statement that arose from the Berlin Conference of October 2016;[1,2] and the Ontario Neurotrauma Foundation’s Guidelines for Concussion and Minor Traumatic Brain Injury and Persistent Symptoms,[3] which includes advice for returning to work after concussion and many helpful algorithms for the management of common symptoms. The following concepts are emphasized in these documents.

Rest is no longer recommended for an indefinite period of time.[4] After an initial 24 to 48 hours of rest, the worker should be activated. Activation begins using a concept of symptom threshold wherein key symptoms are provoked at certain levels of aggravation. Producing a slight aggravation of symptoms is not harmful and is thought that, over time, will set the threshold higher and higher until normal activities both in and out of work are no longer symptom provoking.

Individuals should gradually resume normal physical and cognitive work-related activities. While this is sometimes difficult to initiate and understand, a rule of thumb that I have incorporated into my practice is to begin with the 10-20-30 rule. Cognitive activity can be initiated in 10-minute periods followed by 30-minute rest periods. If doing this three successive times does not exacerbate the symptoms, progress to 20-minute activity periods followed by 30-minute rest periods, three times. Once the 30-minute level is reached without symptom exacerbation, the injured worker can consider returning to work part-time, with adaptations to the work environment (sunglasses, earplugs, quieter workspace, area with less movement) for specific symptoms.

Early introduction of aerobic physical activity is a major factor in rapid recovery. Lawrence and colleagues reported that, “for each successive day in delay to initiation of aerobic exercise, individuals had a less favorable recovery trajectory.”[5] Dr John Leddy of the University of Buffalo Concussion Clinic pioneered the concept of subsymptom exercise threshold rehabilitation.[6] Patients can be exercise-challenged to determine the level, duration, and intensity of activity at which symptoms appear and peak no more than 2 out of 10 above their baseline symptoms. The doctor can then prescribe an individualized exercise regimen, gradually increasing intensity and duration to the endpoint of submaximal heart rate exercise for 30 minutes without symptom exacerbation. This has been shown to accelerate recovery.

Interventions that are associated with better outcomes include early education and early psychological and physical support.[7,8] Setting a patient’s expectations of recovery and reentry into the workplace and establishing a goal of returning to their previous job early in the course of treatment and management is recommended. Occupational therapists have a 4-P strategy for assisting return to work: prioritize, pace, plan, and position (that is, change positions frequently and switch up activities).[9] This approach can be initiated by the patient’s primary care physician and supported by allied health care professionals such as physiotherapists or occupational therapists.

Primary care physicians can play a significant role in identifying injured workers with significant multiple risk modifiers who should be considered for early referral to a multidisciplinary clinic, such as WorkSafeBC’s Head Injury Assessment and Treatment Service (HIATS). Significant modifiers include a history of prior concussions or migraine headaches, and patients for whom headache is the predominant symptom.

For more information or assistance with treatment of work-related concussion in a worker patient, or to discuss referral to HIATS, please contact a medical advisor in your nearest WorkSafeBC office.
—David J. Rhine, MD, FRCPC
WorkSafeBC Medical Advisor and HIATS Medical Consultant

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This article is the opinion of WorkSafeBC and has not been peer reviewed by the BCMJ Editorial Board.

References

1.    Gerschman T. Canada advances concussion education. BCMJ 2017;59:325-355.

2.    McCrory P, Meeuwisse W, Dvorak J, et al. Consensus statement on concussion in sport – the 5th international conference on concussion in sport held in Berlin, October 2016. Br J Sports Med 2017;51:838-847.

3.    Ontario Neurotrauma Foundation. Guideline for concussion/mild traumatic brain injury & persistent symptoms. 3rd edition, for adults over 18 years of age. Accessed 26 October 2018. https://braininjuryguidelines.org/concussion.

4.    Howard A, Schwaiger T, Silverberg N, Paneka W. This Changed My Practice (UBC CPD). Concussion management: Time to give “brain rest” a rest. Accessed 22 October 2018. http://thischangedmypractice.com/concussions-and-rest.

5.    Lawrence DW, Richards D, Comper P, Hutchison MG. Earlier time to aerobic exercise is associated with faster recovery following acute sport concussion. PLoS One 2018;13:e0196062.

6.    Leddy JJ, Haider MN, Ellis M, Willer B. Exercise is medicine for concussion. Curr Sports Med Rep 2018;17:262-270.

7.    Grabowski P, Wilson J, Walker A, et al. Multimodal impairment-based physical therapy for the treatment of patients with post-concussion syndrome: A retrospective analysis on safety and feasibility. Phys Ther Sport 2017;23:22-30.

8.    Putukian M, Kutcher J. Current concepts in the treatment of sports concussions. Neurosurgery 2014;75(Suppl 4):S64-S70.

9.    InMotion Health Centre Inc. Return to work after a concussion. Accessed 26 October 2018. www.inmotionhealthcentre.ca/returning-work-concussion.