Supportive Elements and Challenges to Return to Work Following a Concussion: A Scoping Review

Abstract

Objective:

This scoping review aims to comprehensively explore the facilitators and barriers influencing the return to work (RTW) process following a concussion, with a focus on the person impacted by concussion, medical system, funder, and workplace domains.

Design:

A scoping review of electronic databases, including CINAHL, Embase, MEDLINE, PsycINFO and Web of Science, was conducted to identify relevant studies published up to April 6, 2024. Studies were included if they examined factors influencing RTW following a concussion and were available in English. Data extraction, numerical analysis and deductive content analysis were performed to determine key themes from the data. Reporting guidelines provided by the PRISMA-ScR were adhered to, and the protocol has been registered and can be accessed at the Open Science Framework.

Results:

Twenty studies met the inclusion criteria and were included in the review. Findings were organized into 4 main themes influencing the RTW process: the person impacted by concussion, medical system, funder, and workplace. These were further categorized into 2 subthemes: supportive elements and challenges. Various supportive elements within each theme were identified, such as individualized rehabilitation services, graduated return to work, and developing personal agency in the individual impacted by concussion. Challenges such as lack of patient education, delayed access to services, and isolating workplace accommodations were highlighted. These findings underscore the complex interplay of factors shaping the RTW trajectory post-concussion.

Conclusion:

This scoping review provides a detailed examination of supportive elements and challenges in the RTW process following a concussion. The identified themes offer valuable insights for clinicians and researchers seeking to optimize RTW outcomes and support individuals re-entering the workforce after a concussion. Future research should prioritize an examination of relevant policies and practices, assessing long-term outcomes, and explore strategies to integrate support systems to enhance the RTW experience.

CONCUSSIONS, OR MILD traumatic brain injury (mTBI), affect 200 000 individuals in Canada annually,1 posing a significant concern due to their high prevalence, and potential for long-term consequences. Literature suggests that 15% of individuals experience persistent symptoms,2 with some studies reporting 50% face physical, cognitive, and/or psychosocial issues at 1-year.3 Prolonged recovery is linked to work disability, which is characterized by limitations in performing job duties,4 and has a significant impact on quality of life, as well as economic and social costs.4,5 Although return to work (RTW) is a key indicator of concussion recovery, there is limited research examining the multifaceted experiences of individuals navigating the process. Much of the current evidence on adult concussions focuses on prognostic indicators, such as female sex and pre-injury mental health issues which are predictive of prolonged symptoms.6 While this empirical work informs concussion management, these factors are often non-modifiable and framed through a biomedical lens.7 RTW processes are greatly shaped by socioenvironmental factors such as the medical system, workplace, and funding sources. Despite this, there is a notable gap in primary studies and knowledge syntheses addressing these broader influences. As this is an emerging area, a scoping review was conducted to explore the facilitators and barriers to RTW following a concussion.

METHODOLOGY

Published guidance on scoping review methodology was used to inform our study approach and reporting, with key articles serving as foundational resources.8-11 The review stages included: (1) identifying the research question, (2) identifying relevant studies, (3) study selection, (4) charting the data, and (5) collating, summarizing, and reporting results.11 The protocol registration can be accessed at Open Science Framework (10.17605/OSF.IO/RMKU2).

Identifying the research question

The following question was addressed: What is known in the literature about the facilitators and barriers to RTW following a concussion, particularly in relation to the person impacted by concussion and socio-environmental factors? We hypothesized that RTW is shaped by individual factors, such as motivation and readiness, and socio-environmental factors, such as workplace culture and social support.

Identifying relevant studies

A preliminary search was conducted on MEDLINE and PsycINFO to develop the search. Initial search string included “concussion,” “RTW,” “facilitators,” and “barriers” as key concepts. Facilitators were conditions that supported, enabled or positively influenced RTW. Barriers were conditions that delayed, constrained, prevented, or created challenges to RTW. Two authors independently screened the first 30 results and created a list of key concepts, text words, and controlled vocabulary. Preliminary searches yielded insufficient results and excluded relevant studies prompting a broadening of the search. A combination of controlled vocabulary terms (eg, MeSH) and keywords related to the concepts of “concussion” and “RTW” were used. A sample search strategy for MEDLINE is provided in the Appendix. Translated search were completed on CINAHL, Embase, MEDLINE, PsycINFO, and Web of Science. Databases were searched from inception to April 10, 2023, and updated searches ran from April 11, 2023, until April 6, 2024. Although concussion care has evolved in past decades, no clear temporal markers for these changes exist, as such, date range restrictions were not applied. Grey literature and hand searches were excluded due to feasibility considerations.

Study selection

Covidence was used to efficiently manage study selection. The eligibility criterion for inclusion were studies: (1) with a focus on adults (age 18 and older) who have sustained a concussion and/or mTBI, (2) extractable data pertaining to RTW (recommendations, facilitators, and barriers), (3) published in English, and (4) available on peer-reviewed platforms. Exclusion criteria were: (1) pediatric concussion studies (participants less than 18 years old), (2) mixed age categories, and (3) military veteran studies. Veteran studies were excluded due to their unique injury mechanisms, presence of complex comorbidities and specialized care streams.12

Charting the data

An extraction form was developed to capture characteristics (eg, authorship, publication year), design, participant demographics, and facilitators and barriers. Two reviewers completed a calibration exercise by independently extracting data from 5 studies and resolving discrepancies, then proceeded to full text extraction. One reviewer verified the charted data to ensure it accurately reflected the original studies.

Collating, summarizing, and reporting results

Basic numerical analysis including frequency counts was conducted to quantify study characteristics. Following JBI scoping review guidance, a deductive content analysis approach was applied, suitable for various study designs.13,14 The analysis proceeded through 3 stages: preparation, organization, and deductive analysis. In preparation, a framework was developed, guided by the study’s theoretical orientation, objectives and key literature. Grounded in critical realism, the analysis examined the role of intrinsic factors (eg, person-level), and extrinsic systems (eg, socioenvironmental context).15 Insights from RTW literature and key papers16 emphasized the role of stakeholders like the medical system, workplace and funder. During organization, studies were reviewed for relevance to objectives and framework. In deductive analysis, data was categorized into: “person impacted by concussion,” “medical system,” “workplace,” and “funder”, with an “other” category to capture emergent data not in alignment with the predefined framework. Category definitions were developed in advance and provided in results. Throughout analysis, reviewers remained open to shifting to inductive analysis if needed, but the deductive approach remained suitable.14 Both reviewers verified the data to ensure proper categorization and analysis.

RESULTS

Study characteristics

The initial search yielded n = 1189 studies, of which 544 duplicates were removed. Two reviewers screened 645 titles and abstracts, of which 596 were deemed irrelevant. The reviewers then analyzed 49 full-texts, and 29 were excluded. Twenty studies were included after full-text analysis. Figure 1 presents a flow diagram (PRISMA), which reports decisions at each stage.

Figure 1.

PRISMA flow diagram.

Among the 20 studies, research from Canada was predominant (n = 9),17-25 followed by Norway (n = 5).26-30 Countries with less than 3 studies include: United States (n = 2),31,32 Denmark (n = 2),33,34 Netherlands (n = 1)35 and Finland (n = 1).36 Most of the study designs employed qualitative design (n = 8),17,18,20,25,28-30,34 followed by prospective cohort (n = 5),21,31,32,35,36 randomized controlled trials (n = 2),26,27 retrospective cohort (n = 2),19,33 retrospective chart review (n = 2),22,23 case-control (n = 1)24 and other types of quantitative studies (n = 1).37 The majority of the studies were published in the 2020s (n = 10),17,18,23,26-29,31,32,34 and the 2010s (n = 9)19,20,22,24,25,30,33,35,36 while only one study was published in the late 1990s.21 Findings were organized into 4 themes in alignment with the analysis framework: Person impacted by concussion, medical system, workplace and funder, with subthemes of supportive elements and challenges within each. Frequency counts were completed per theme and subtheme, summarized in Table 1. The characteristics of studies are summarized in Table 2. The key findings are organized by theme in Table 3.

TABLE 1.

Frequency counts of studies in each theme and subtheme (n = 20)

Theme	Supportive elements		Challenges
	n	%	n	%
Person impacted by concussion	6	30%	7	35%
Medical system	7	35%	4	20%
Funder	0	0%	5	25%
Workplace	917,18,29-31,34	45%	9	45%

TABLE 2.

Key characteristics of included studies

Author (year)	Country	Study design	Aim	n	Key findings
De Koning et al (2017)35	Netherlands	Prospective cohort	To study RTW after mTBI at different intervals following injury and identify relevant predictors.	319	Rates of complete RTW increased from 34% at 2 weeks after injury to 77% at 12 months after injury. Occupational factors influenced work resumption after 6 months. Workload (hours worked per week) was predictive of RTW at 6 months, with 32 hours being associated with the lowest odds of RTW, and less than 25 hours per week related to highest odds of RTW, suggesting a balance between work and rest. Psychological distress and posttraumatic complaints were identified as barriers to RTW.
Dornonville de la Cour et al (2019)33	Denmark	Retrospective cohort	To explore employment outcomes during a multidisciplinary and holistic vocational rehabilitation program for individuals with mTBI.	32	During vocational rehabilitation (VR), hours at work and RTW-status improved as 97% returned to work after VR.
Fure et al (2021)27	Norway	Randomized controlled trial	To examine the effect of compensatory cognitive training and supported employment (CCT-SE) on vocational outcomes following mTBI	116	No difference in RTWk between CCT-SE and treatment as usual (TAU) group at 12 months, however a significantly higher proportion of the CCT-SE group had resumed work at 3 months. Findings suggest an early effect of cognitive and vocational rehabilitation specific intervention.
Fure et al (2023)26	Norway	Secondary analysis of data from a previous randomized controlled trial	To examine work-related predictors of RTW 6 months and 12 months after mTBI.	113	Key factors predicting RTW work participation included job predictability (eg, in work tasks), quantitative demands (medium to high workload), workplace recognition, type of employment (private or public), initial symptom severity, and sex.
Gaudette et al (2022)31	United States	Prospective cohort	To examine the employment and economic status of individuals with mTBI, and the association between work status and employer assistance at several intervals.	435	Participants that were provided support by employers at 3 months were more likely to report working post injury at 6 months and 12 months. Notably, modified scheduling, reduced hours, part-time work, or alternative position (different tasks) were associated with higher probability of working at 12 months post injury.
Gourdeau et al (2020)17	Canada	Qualitative, secondary analysis of 12 interviews	To explore workplace accommodations received by individuals with mTBI, specifically how they are provided and to whom.	12	The following themes were identified: Formal and informal accommodations, workplace social and structural elements, personal factors and occupational factors. Formal accommodations (eg, modified scheduling, breaks, and alternative tasks, environmental changes) were explicitly outlined with relevant stakeholders (eg, funder, healthcare team). Meanwhile, informal accommodations were implemented by the participant (employee). Some participants identified challenges if alternative tasks or roles were assigned, that were a poor fit with their post-injury abilities. Workplace social and structural elements, such as the relationship between the employee and employer, in addition to financial and job security were identified. Personal factors included insight, the ability to self-advocate and the invisible nature of concussions. Occupational factors included the nature of work (eg, physical and mental demands) and control/autonomy over the job and duties.
Graff et al (2021)34	Denmark	Qualitative, semi-structured interviews	To explore RTW among individuals with persistent concussion symptoms and identify relevant facilitators and barriers.	22	The following themes were identified: Worker-employer relationship, the role of the general practitioner (GP) and municipal case management. Modified work conditions, and the relationship with coworkers were relevant factors. Additionally, appropriate referrals from the GP and adequate guidance emerged as relevant elements. Finally, within the theme of municipal case management, frequent follow-ups, unspecific treatment, lack of continuity in care, lack of mTBI knowledge among case workers were presenting issues in the RTW process.
Karmali et al (2022)18	Canada	Qualitative, semi-structured interviews	To explore barriers, facilitators and resource gaps to RTW following a concussion.	31	Participants who experienced a concussion reported that receiving resources (eg, recovery guidelines) involvement of specific clinicians (eg, physiotherapists and occupational therapists), and support from family, friend and the employer facilitated their RTW. Further, symptom coping strategies (eg, taking breaks) were beneficial. Lack of concussion information and follow-up care, insufficient mental health resources, poor support from friends, family, insurers and employers hindered RTW.
Leblanc and McLachlan (2010)19	Canada	Retrospective cohort	Examine the effectiveness of individualized education and treatment (IET) and compare efficacy of a group treatment to IET.	49	IET resulted in 78% of individuals returning to competitive employment, while 46% of individuals in group treatment returned. There is potential effectiveness of early, individualized, educational, and abilities focused approaches to concussion management.
Mansfield et al (2015)20	Canada	Qualitative, in-depth interviews	To explore the RTW experience of individuals with work-related mTBI as they return to the same workplace where the injury occurred.	12	Employer and workers’ compensation factors influenced the RTW experience. Participants reported inadequate understanding of mTBI recovery and trajectory affected their experience.
Ruffolo et al (1999)21	Canada	Prospective cohort	To describe the RTW experience for individuals with MVA-related mTBI, and examine the relationship between RTW and various factors (eg, sociodemographic, injury severity, cognitive impairment).	50	Significant relationships were found between RTW and social interaction, jobs with more decision-making latitude, and discharge home rather than a rehabilitation facility.
Sagstad et al (2023)28	Norway	Qualitative, Semi-structured interviews	To explore the experience of RTW following mTBI related sick leave.	6	The following 3 phased themes emerged: starting work, increased workload and reintegrating into work. The starting work phase was further grouped into the following: the crisis (challenges related to RTW), the decision to RTW (personal agency) and being physically present in the workplace. Increased workload was grouped into the following: time perception (expectations and plans around time), being seen, valued and included, and capacity (to engage in daily tasks). Reintegrated into work was grouped in the following: Setting priorities (boundary setting) and revaluing work and priorities (attitudes and goals regarding professional life).
Sekely et al (2023)23	Canada	Retrospective chart review	To examine RTW rates following mTBI in a litigating sample.	125	Participants that had not returned to work reported the most depressive symptoms and had the greatest attentional deficits.
Sekely and Zakzanis (2019)22	Canada	Retrospective chart review	To explore the prevalence of post-traumatic growth (PTG) after mTBI, and the relationship between PTG and vocational status.	74	31% of the sample presented moderate levels of PTG. Growth was most evident in the appreciation of life, relating to others and personal strength domains. Personal strength and new possibilities were associated with RTW.
Silverberg and Otamendi (2019)24	Canada	Case-control	(1) To examine the degree to which prolonged rest is advised to patients with mTBI. (2) Explore patient characteristics that are associated with receiving prolonged rest advice (eg, health history, gender). (3) Compare symptomatic and functional recovery of patients who were exposed to versus not exposed to prolonged rest advice.	146	82.9% of participants reported being advised to rest for more than 2 days. Advice to rest was not associated with any patient characteristics, including gender, race, age, history of prior mTBI(s), psychiatric problems, loss of consciousness, and access to financial compensation. Patients that were advised to rest for more than 2 days were less likely to have resumed work or school 1 to 2 months following injury.
Spjelkavik et al (2023)29	Norway	Qualitative, multiple case study	To explore workplace accommodations implemented in the workplace context following mTBI.	109	Accommodations were captured as belonging to the organizational work environment or the psychosocial work environment. The organizational work environment included work tasks, position, hours, organization of work, job demands and physical arrangements. The psychosocial work environment included social support and supportive management.
Stergiou-Kita et al (2016)25	Canada	Qualitative, in-depth interviews	To examine the influence of gender on RTW processes for individuals with a work-related mTBI.	12	Women were more proactive in help-seeking. Individuals who worked in nurturing (feminine) workplaces, reported more positive RTW experiences compared to individuals in more masculine work environments. Workplace culture and social relations were significant to RTW outcomes.
Sveen et al (2016)30	Norway	Qualitative, focus groups	To explore mTBI as a biographical disruption and examine the reconstruction of occupations (including RTW) for individuals with mTBI.	20	The following 4 themes emerged: disruption of occupational capacity and balance; changes in self-perceptions; experience of time; and occupational adjustment and reconstruction.
Waljas et al (2014)36	Finland	Prospective cohort	To examine factors related to RTW after mTBI.	109	Age, multiple bodily injuries, intracranial abnormality the day of injury, and fatigue were predictors of the number of days to RTW.
Yue et al (2021)32	United States	Prospective cohort pilot	To evaluate the associations between baseline clinical variables, 3-month RTW and post-concussional symptoms, and 6-month RTW.	152	PCS symptoms at 3 months predicted delayed RTW at 6 months, with emotional symptoms (eg, sadness, irritability) being most predictive of delayed RTW.

TABLE 3.

Key findings organized by theme

Factors	Description	Supportive elements	Challenges
Person impacted by concussion	Person-level characteristics that may affect RTW.	Personal agency21,28	Inadequate concussion knowledge17,18,30
		Self-advocacy17
			Lack of family support18
		Insight and awareness22
			Specific symptom presentation22,26,30,32,36
		Social support18
		Occupational values30	Poor psychosocial adjustment30
		Post-traumatic growth (specifically, new possibilities and personal strength)22	Invisible nature of disability17
Medical system	Medical system characteristics encompassing the healthcare and rehabilitation system and services intended to reduce disability and improve function.	Professional advice28	Lack of appropriate referrals33,34
		Iterative RTW planning28
		Specific rehabilitation interventions18,27,30	Poor follow-up18
		Interdisciplinary rehabilitation team18,33	Recommendation for prolonged rest24
		Individualized and tailored approaches19	Lack of diagnosis or misdiagnosis18
		Concussion clinic18	Lack of mental health supports and resources18
		Provision of concussion education and resources18,34
		Abilities-focused (rather than deficit)19
Funder	Funder of injury-related services which may include public, private, or a combination.	None identified	Adversarial relations18,20
			Administrative and procedural concerns17,36
			Threat of claim dismissal20
			Concussion knowledge gap within the funding system and its representatives18,20,34
			Poor continuity in care and follow-up34
Workplace	Workplace characteristics encompassing physical, social and psychological domains.	Social supports17,18,28,30,34 Independence and decision-making latitude21,28	Lack of understanding, and potential stigma and/or discrimination18,20,28-30,34
		Balance between work and rest28,35	Isolating job accommodations and modifications28
		Formal and informal accommodations and modifications17,18,29-31,34	Physical work and manual labour17,35
			Poor fit between accommodations and post-injury abilities17
			Absence of accommodations17,34
			Administrative barriers18
			Lack of autonomy17,21

Theme 1: Person impacted by concussion

This theme centered on individuals impacted by concussion, covering their personal experiences, skills, abilities, and physical, cognitive and psychosocial factors.

Supportive elements

Personal agency emerged as a supportive element, particularly when individuals impacted by concussion were empowered through active involvement in decision-making, such as collaborating to determine work schedule.21,28 The active decision to RTW, independent of influence from clinicians, coworkers, or family, was seen as a pivotal step.28 Gordeau et al noted self-advocacy as a key trait, as it enabled individuals to assert their needs and share in the decision-making process.17 The person’s physical presence in the workplace was important as it provided a means of feeling “useful” and encouraging individuals to leave the home.28 Additionally, establishing clear boundaries between work and personal life emerged as a facilitator, with participants in one study emphasizing the importance of limiting work-related tasks to work hours,28 enabling balance and well-being. Social support from family and friends played an instrumental role, with participants noting the value of help with daily tasks and companionship.18 In another study, participants reported feeling empowered as they re-evaluated their priorities, personal and professional goals.30 Sekely et al expanded on the concept of empowerment, by highlighting the importance of post-traumatic growth, specifically focusing on personal strengths and new possibilities.22 Self-awareness regarding symptoms and abilities also contributed to improved navigation of physical, cognitive and psychosocial challenges, and facilitated work reintegration.17

Challenges

Three studies found that participants struggled with limited understanding of the injury, including symptoms and recovery timeline.17,18,30 This lack of knowledge not only affected the injured individuals, but at times extended to their families/caregivers, whose insufficient understanding and/or assistance complicated recovery.18 Specific symptoms including fatigue,26,30,36 cognitive23,26 and affective symptoms23,32 such as emotional distress35 were related to poor RTW outcomes. Poor psychosocial adjustment was a hindrance, defined as difficulty adapting to life changes. Adapting to a new normal, redefining goals, and reconciling with potential limitations were examples of adjustments.30 Gourdeau et al also identified difficulties associated with the invisible nature of symptoms (eg, headaches) which could lead to unrealistic recovery expectations and dismissal of ongoing symptoms, hindering workplace and other supports.17

Theme 2: Medical system

This theme encompassed the healthcare services and professionals involved in the recovery process, addressing the quality, timing, and accessibility of medical care, rehabilitation and vocational services.

Supportive elements

The literature indicated that optimal recovery outcomes were achieved through individualized, flexible and tailored approaches that catered to the injured individual’s needs. Given the myriad of factors contributing to concussion symptoms and prognosis, a multifaceted approach is necessary to address these variables effectively.18,19 Additionally, studies suggested that tailored vocational rehabilitation and concussion management programs were preferred over more general treatment or rehabilitation approaches. These programs offer tailored interventions that consider the individual’s career, skills, interests, and abilities, aimed at achieving meaningful employment.33 Positive professional guidance played a key role in promoting RTW, underscoring importance of supportive and informative interactions with healthcare providers.28

Among the range of concussion symptoms, studies emphasized the significant impact of psychosocial symptoms and encouraged healthcare providers to be more aware and responsive to the psychological well-being of the injured person, particularly to mitigate the risk of long-term sequelae.32 One study highlighted the importance of collaborating with injured individuals to develop coping strategies for daily life such as keeping lists and pacing.18 Several studies highlighted the effectiveness of specific interventions and RTW approaches in supporting outcomes. For instance, cognitive training, supported employment,18,27,30 and a strengths-based approach, focused on abilities rather than deficits, were found to be beneficial.19 In addition, the role of healthcare providers in facilitating adjustment and reconstruction of daily activities following injury was discussed as significant to RTW.30 For example, working with the injured person to create a routine and facilitate engagement in daily tasks. Finally, in supporting a gradual return to work, clinicians used a trial-and-error approach as an effective method to navigate the transition. The use of an iterative approach allowed for refinement of hours and duties in an incremental manner to ensure alignment with evolving abilities.28

Challenges

Several hindrances in the RTW process were identified, primarily revolving around education, referrals, monitoring and recovery management. Educational and referral barriers included poor psychoeducation, involving insufficient knowledge about concussion recovery and the RTW process among both individuals and healthcare providers.18,34 Graff et al identified that the lack of appropriate referrals was a notable barrier,34 with studies adding that absence of timely and suitable referrals for specialized services (e.g. vocational rehabilitation) impeded recovery.18,33 Karmali et al identified that lack of diagnosis or misdiagnosis could also result in improper referrals and treatment. Monitoring and support challenges were also an issue, with insufficient monitoring of injured individuals, and poor follow-up care indicated.18 Additionally, the absence of support specifically for mental and/or emotional health was problematic, as it left the individual without essential support for full recovery.18 Finally, management of rest and recovery posted its own challenge, with one study noting that the advice for prolonged rest was related to reduced likeliness to return to pre-injury work.24

Theme 3: Funder

This theme referred to the financial entities funding the individual’s recovery, which may include insurance companies (eg, disability or health insurers), government programs, workplace safety and insurance boards, and not-for-profits. Notably, none of the studies included in this review reported on funder level supportive elements.

Challenges

An adversarial relationship between the injured person and the funding system and/or representatives emerged as a barrier due to multiple reasons. One study reported tension between all injured individuals in the sample and their workers’ compensation representatives,20 emphasizing the consistency of this experience. Another study highlighted the absence of empathy from insurance representatives was a key factor in creating contention and distrust.18 This could be due to and aggravated by poor continuity in care such as frequent changes in the representative overseeing the case.20,34 Participants reported having to repeatedly explain their medical history, creating a disruptive experience, impairing rapport with their representative and impeding RTW. Furthermore, administrative tasks were perceived as burdens particularly due to executive functioning challenges during recovery from injury. For example, complex forms and unclear processes often exacerbated the difficulties faced during an already demanding period.20,34 Frequent follow-up assessments further compound this issue, with one study noting that participants felt they were being “chased” with assessments that felt unnecessary and not injury-focused.34 Another study identified that participants felt their injury claims were at risk of dismissal based on pre-existing medical history, creating concerns that the injury won’t be fully acknowledged or compensated, adding stressors for the injured person.20 Three studies identified a lack of concussion knowledge among funders and their representatives as a hindrance to work reintegration. Due to the non-visible nature of concussion symptoms (eg, headaches and dizziness), misunderstandings regarding severity and impacts of concussion were common, detracting from RTW progress.18,20,34

Theme 4: Workplace

This theme referred to the employer, encompassing policies, organizational culture, accommodations and interpersonal relations.

Supportive elements

The essential role of social support within the workplace was identified in many studies.17,18,28,30,34 Participants expressed the importance of being included and valued by colleagues and superiors, particularly for their current work, rather than in comparison to pre-injury performance.28 An open dialogue and effective communication between the person and their employer also fostered understanding and inclusion.30 Further, having an advocate in the workplace, in the form of a colleague or supervisor was a form of social support identified as beneficial.17,21,28 Additionally, a gradual increase in work hours and duties, allowed individuals to slowly build abilities and tolerances, without overexerting themselves, supporting a sustainable RTW,30 maintaining a balance between rest and work during this process was an essential facilitator, with one study highlighting a workload of less than 25 hours per week as optimal.35

Formal and informal accommodations facilitate RTW, highlighted across various studies.17,18,26,29-31,34 Several strategies were discussed, such as modified duties and expectations,17,31 including reducing memory and concentration tasks, extended deadlines,18,29,31 and flexible work hours/adjusted schedules.29-31 In addition, self-modifications such as coping and compensatory strategies (eg, deep breathing) were identified as helpful in managing symptoms while at work.17,30 Furthermore, physical and environmental modifications were noted, for example the use of private rooms to minimize stimulation.18,29,31 Psychosocial accommodations involved creating a supportive environment where open communication was encouraged.17,29 It was specifically noted that having an employer demonstrate willingness to implement accommodations was a positive factor.30 Additionally, it was reported that quantitative rewards, like recognition for effort helped foster a psychologically supportive RTW atmosphere.26 Finally, Spjelkavik et al, underscored the importance of recognizing the complexity of workplace accommodations and the possibility of changing accommodation needs.29

Challenges

A primary RTW challenge was lack of understanding among employers and coworkers, leading to stigmatization and discrimination.17,18,28-30,34 Examples included perception of reduced productivity, concerns about injury-related costs, and time lost to attending medical appointments.20 Furthermore, while intended to aid recovery, some accommodations paradoxically contributed to increased isolation, such as private offices and remote work.28 It was also identified that alternative duties were often assigned and, in some cases, there was a poor fit between post-injury abilities and recommended duties.17 Studies also indicate that occupations involving manual labor and/or physical work present the greatest hurdles for RTW, with individuals encountering difficulties seeking job modification and accommodations.17,35 The absence of accommodations and administrative barriers are another commonly cited challenge in literature.17,34

DISCUSSION

A substantial body of existing literature focuses on concussion prognostic factors (e.g. age and sex), which have been associated with both functional and symptom-based outcomes.16,38 The “Person Impacted by Concussion” theme expands the field by synthesizing literature on modifiable elements and provides avenues for targeted support based on unique needs and circumstances. Key findings included the central role of personal agency,21,28 self-advocacy,17 boundary setting,30 insight,22 and social support,18 which aligns with extant research supporting the importance of autonomy and empowerment.39-41 Interestingly, the active decision to RTW was a critical step in the RTW process28 and may be linked to the stages of change model, which, by considering a person’s readiness for behavioral change could create tailored RTW strategies.42 Challenges include inadequate concussion knowledge,17,18,30 lack of family support,18 and poor psychosocial adjustment.30 Prior research on concussion management has noted the importance of mental health interventions such as self-advocacy43 and resiliency training,44 and coping strategies.45 The current study further supports consideration of psychosocial factors for overall concussion management, and RTW44 Family and friends also play a role in offering emotional reassurance and daily assistance, however, limited injury knowledge among them may make RTW more difficult.18 Strengthening family and social relations and providing family education are potential approaches to improve RTW outcomes.

The “Medical System” theme emphasized the importance of individualized, timely and appropriate referrals/services. Interdisciplinary teams and concussion-specific clinics18,33 were valued aligning with existing literature on the importance of interdisciplinary management in pediatrics,46 sports,47 and persistent concussion populations.48,49 Barriers include lack of appropriate referrals,34 poor follow-up,18 lack of diagnosis/misdiagnosis, and insufficient mental health support.18 Medical systems may address access and integration barriers by establishing coordination protocols among providers (eg, family physician, rehabilitation team) to address gaps in referrals to specialized services (eg, vocational rehabilitation).18,33 Additionally, it is known that psychological factors contribute to poor concussion outcomes, and inadequate mental health treatment remains a concern, as identified in the review. Addressing this requires both individual-level and systemic changes. On a medical system level, proactive mental health screening and early intervention, as supported by existing literature,50 could be integrated into protocols to support the provision of comprehensive care.

The “Funder” theme revealed several challenges, with no studies reporting on supportive elements. This gap may arise from a scientific emphasis on identifying barriers, as research is often problem-oriented and aims to improve practices. Additionally, facilitators, such as timely access to services, may go unnoticed when functioning effectively, while barriers like adversarial relations are more readily identified. Specific obstacles noted included adversarial relationships,18,20 poor continuity in care,34 burden of administrative tasks,17,36 and lack of concussion knowledge.18,20,34 The results align with extant literature that indicates complex paperwork, and frequent assessments create additional challenges for injured workers.20,51,52 This suggests a need to establish more consistent care for injured individuals, promote mutual understanding between injured individuals and funders, address the concussion knowledge gap, and simplify administrative processes. Lastly, the studies included varied funding sources, with some studies reporting care through mixed funding systems, and others lacking clear identification. This variation makes it difficult to draw clear distinctions, and a more detailed examination of different systems is warranted.

In the “Workplace” theme, social support, formal and informal accommodations, and being valued were critical supportive factors, resonating with prior research, which underscores the importance of workplace culture and environments in shaping RTW success.25,53,54 Some challenges included lack of knowledge with the potential for stigma/discrimination,17,18,20,28-30,34 and poor fit between accommodations and post-injury abilities.17 The studies included in the review lack clarity regarding roles and responsibilities in recommending, implementing and monitoring accommodations, leaving a critical gap in practical guidance, particularly when multiple parties are involved in RTW. Previous studies have similarly noted that employees and employers can be unclear about their roles in the accommodation process,55 with this ambiguity more pronounced for individuals returning to work with non-visible disabilities.56,57 There may be some benefit from professional mediation to bridge the gap.55 Findings also support the value of addressing issues of stigma and discrimination in the workplace. This study’s broad search strategy aimed to capture a breadth of literature but may have sacrificed depth. Gaps in findings may be due to diverse participant characteristics, geographic regions, and funding systems. Despite efforts to mitigate the risk of rigidity in the deductive content analysis approach, the possibility remains. The date range of included studies (1999 to 2024) presents a potential concern as the approach to concussion diagnosis and management has evolved. Despite this, our findings revealed consistent themes across studies, such as avoiding prolonged rest, workplace accommodations, social support, and personal agency. A temporal examination of concussion management is needed to explore the evolving history of the field.

CONCLUSION

This scoping review explored the factors influencing RTW after a concussion. Applications of this review span numerous areas, including clinical practice, workplace interventions, and patient advocacy. Findings may be applied strategically to enhance vocational, and concussion supports by focusing on fostering personal agency, strengthening social supports, and integrating mental health considerations at both individual and systems levels. Increasing concussion knowledge among stakeholders, and streamlining administrative procedures are also key to facilitating work reintegration. These results inform evidence-based concussion management approaches that can enhance RTW experiences and outcomes.

Appendix. Full electronic search of Ovid MEDLINE: April 10, 2023.

1. brain concussion/ or post-concussion syndrome/11991

2. concuss*.tw,kf.12693

3. mTBI.tw,kf.3938

4. mild traumatic brain injur*.tw,kf.6316

5. Return to Work/3582

6. Rehabilitation, Vocational/9736

7. return to work.tw,kf.11358

8. vocation*.tw,kf.14204

9. 1 or 2 or 3 or 419465

10. 5 or 6 or 7 or 832046

11. 9 and 10215