Second-Order Peer Reviews of Clinically Relevant Articles for the Physiatrist: Workplace Accommodations for Returning to Work After Mild Traumatic Brain Injury : American Journal of Physical Medicine & Rehabilitation

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Physiatry Reviews for Evidence in Practice

Second-Order Peer Reviews of Clinically Relevant Articles for the Physiatrist

Workplace Accommodations for Returning to Work After Mild Traumatic Brain Injury

Slayter, Jeremy BSc; Journeay, W. Shane PhD, MD, MPH, FRCPC, DABPMR, BC-OccMed

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American Journal of Physical Medicine & Rehabilitation 102(6):p e76-e78, June 2023. | DOI: 10.1097/PHM.0000000000002217
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Traumatic brain injury (TBI) is a lifelong condition which has a wide spectrum of short- and long-term potential impairments. Globally, between 64 and 74 million individuals will experience a TBI every year.1 Traumatic brain injury occurs across the lifespan with different causes attributing to the injury. The most frequent cause of TBI worldwide is road traffic collisions.1 In Canadian young adults, the most common causes of TBI are related to sports, motor vehicles, and recreational activities, while in persons older than 40 years falls become the predominant cause of TBI.2 Moreover, work-related TBI is becoming an increasingly common area of research interest.3

One manner to classify TBI severity is based on the highest Glasgow Coma Scale (GCS) after the initial resuscitation within 48 hrs of injury.1,4–6 The most common classification system breaks TBI into three categories based on the initial GCS score. It is estimated that of all TBIs worldwide, 81% are mild (GCS 13–15), 11% are moderate (GCS 9–12), and 8% are severe (GCS 3–8) injuries.1

Physiatrists are integral to the rehabilitation management of mild TBI (mTBI) in the subacute and chronic time periods since injury. During this phase of recovery, there can be a wide range of treatment goals and patient expectations. The broad spectrum of symptoms and recovery expectations can be challenging for physiatrists because many factors can influence recovery from mTBI. Regardless of whether the mTBI is work- or nonwork-related in etiology, return to work (RTW) is often a goal of both patients and treatment providers. Moreover, RTW is a commonly used outcome measure as an indicator of overall recovery4,7–11 as it is an indicator of global function given its demands on social, cognitive, physical, and executive functional domains.7 Return to work and employment, in general, are also linked to increased life satisfaction with several psychological, physiological, and financial benefits.12

Mild TBI is very common in occupational settings across a range of industries3 and in a variety of nonoccupational settings.1 As physiatrists often play a central role in supporting occupational function after mTBI, it is imperative that they know how RTW is achieved and what occupational and patient factors vary among patients after an mTBI. Furthermore, with an improved understanding of the functional demands of a worker, appropriate supports, modifications, and accommodations can be put in place to improve workforce participation in the mTBI population. Specifically, accommodations and work modifications are one of the most impactful recommendations made by physicians and often in concert with occupational therapy, to allow for the initiation of a graduated RTW plan. This article by Spjelkavik et al.13 identifies accommodations in the workplace that influence the RTW process after mTBI. Given the incidence of mTBI among those in the working population, physiatrists should have a general understanding of how workplace accommodations can impact patients in their RTW.


The focus of this PREP review is a recently published article by Spjelkavik et al.,13 which sought to better understand workplace processes for accommodation during RTW after mTBI. The authors accomplished this with a qualitative case study of 38 participants with mTBI, interviewing employees with mild-to-moderate TBI and their workplace managers across eastern Norway between 2017 and 2020. Both employees and managers were interviewed at two time points with the first being 1 to 3 mos after RTW post-mTBI and 12–16 mos later.

The interviews were semi-structured and developed based on the Copenhagen Psychosocial Questionnaire, which characterized workplace environment, conflicts, social support, and management.14 Additional questions included the present work situation and any changes due to mTBI, work accommodations, challenges in work accommodation, and overall knowledge of mTBI. The qualitative analysis used a comparative case study approach and codes were developed by the researchers using both previous knowledge and data derived from the interviews.

A total of 109 interviews were completed. The patient sample was overrepresented by “white-collar” work across several industries when compared with other work types. The total dropout rate for interviews was 28%, driven primarily by managers in 72% of those dropout cases. Manager dropouts were most often due to declining to be interviewed, or employees declining their manager to be interviewed.


Spjelkavik et al.13 have added to the body of evidence that RTW is a nonlinear process where outcomes are highly dependent upon a person’s intrinsic characteristics as well as the institutional regulations, workplace policies and practices, and ability of a workplace to customize accommodation. Most employees used a graduated RTW program, with 19 of 38 employees achieving full-time work by the end of the study. At 12–18 mos, some participants continued to require accommodation, and some needed more intensive accommodations than at the first interview. Twelve employees who had achieved full-time work continued to require accommodation at the second interview.

Both psychosocial and physical/organizational accommodations are frequently used conjointly to achieve successful RTW post-mTBI. Poor psychosocial support results in worse outcomes requiring additional support and higher reported stress rates during RTW. Examples of poor psychosocial support included managers who were uncertain of how to emotionally or psychologically support employees with mTBI during the RTW process or having unsupportive coworkers. Modification of responsibilities, position, working hours, and work demands were the most frequent accommodations to implement for employees with mTBI. Despite accommodations being common, the majority focused on optimizing employee productivity in the workplace rather than seeking to achieve a balance of the needs of the employee with mTBI and the workplace to optimize the person-environment fit.

Spjelkavik et al.13 argue that to optimize RTW post-mTBI, the goal of accommodations should seek to achieve a balance of the needs of employees with mTBI and of the workplace, using a combination of psychosocial and organizational changes, which should be reassessed as needed during the first 12–16 mos, or until a stable RTW outcome has been achieved. To facilitate this goal, closer integration between treating providers and workplaces should occur, to ensure adequate transfer of knowledge and expectations and provide a mediating body to achieve the needed balance. A possible approach could be the use of RTW case managers who have been shown to increase employee and workplace satisfaction, while also increasing the number of accommodations.15


This study used a qualitative approach to understand current processes for RTW and workplace accommodation post-mTBI. The qualitative approach provided a rich data set, which carefully describes a heterogeneous and complex environment in each participant case. This data set provides opportunities for further evaluation and recognition of successful approaches while providing opportunities for future hypothesis generation. Interviews at two time points are another unique strength, which provides knowledge of the challenges and variability of the RTW process over the first 12–16 mos.

A limitation of this study includes the high dropout rate, particularly among managers, which may limit the generalizability or bias the sample in an unknown direction. Despite the dropout rate, the high sample size was felt by the authors to counteract the incomplete data. A second limitation of this study is reduced generalizability due to including only mild-to-moderate TBI, although mTBI is the most common form of TBI.1,2 Another factor limiting the generalizability of this study is the national regulatory frameworks which are unique to each country and will modify RTW incentives for employees with mTBI, managers, and healthcare providers. The varied regulatory frameworks will alter the attitudes, accommodations, and outcomes of RTW post-mTBI meaning physiatrists should aim to become familiar with the RTW regulations applicable to their patients.

Given the design of this study, the intention was not to compare accommodations among jobs. Thus, the article is limited in that the patients may have required various accommodations depending on the nature of their work (e.g., seated cognitive work vs. physically demanding work). Furthermore, we do not know the post-mTBI sequelae of these patients. Specifically, in the mTBI category, there may be associated mood disturbances and symptom misattribution, which needs to be managed accordingly.16 Conversely, vertigo and neck pain often seen after mTBI may be more limiting to workers with higher physical demands classifications.

Furthermore, this study seems to include all mTBI patients rather than a specific focus on work-related mTBI. Injuries associated with workers’ compensation may open additional resources and pathways to support recovery and RTW in patients with mTBI. In addition, work-related mTBI because of assault17 or unique physical jobs (e.g., working at heights) may pose additional barriers in the RTW process such as mental health related features of the injury or unique physical requirements to perform one’s occupation.


Spjelkavik et al.13 provide unique insights into common challenges experienced by employees attempting to RTW after an mTBI. The authors provided evidence that RTW is a nonlinear, fluid process and should be followed by the healthcare team until the patient has consistently been stable in their RTW process. In the early stages of RTW, managers and coworkers were more supportive of the person with mTBI; however, the support decreases by 12–16 mos with reduced optimism and support, particularly if accommodation continues to be required and limited the employee’s duties. By 12 mos of RTW, a more durable evaluation of the RTW outcome can be made.

Knowledge of the medical and occupational barriers to RTW is important to employees, workplaces, and physiatrists in achieving RTW. The findings of Spjelkavik et al.13 suggest that an opportunity exists to advocate for improved mechanisms to support RTW after mTBI. Specifically, to implement case managers who are knowledgeable about mTBI and can guide beneficial workplace accommodations while acting as a mediator between the employee and the workplace.15,18 It is important to note that within the workers’ compensation system, many of these supports are in place but the communication between providers, patients, and employers is often complicated in the setting of mTBI and other specialized occupations.

Mild TBI recovery and RTW are complex, particularly in the presence of subacute and chronic symptoms. Physiatrists should consider RTW, because of the benefits that employment can provide. This is important regardless of whether the patient’s injury was work related or occurred outside of the workplace. To support the prediction of RTW, physiatrists should consider patient demographics, preinjury employment type, injury features, and postinjury variables when exploring patient goals and expectations.6 Furthermore, based on the current reviewed article, the physiatrist should understand the nature of accommodations to support RTW and the often nonlinear nature of this process. Individuals at risk of being less likely to achieve RTW should be identified as they may benefit from additional vocational rehabilitation and other supports to achieve RTW in a suitable occupation.

Finally, an understanding of the unique aspects of occupational cognitive and physical functions would help prevent a mismatch between the patient’s function and their occupational functional demands. It can also assist in the provision of appropriate recommendations for job modifications and accommodations for a safe, supported, and successful RTW. Collaborators in this process may also include our colleagues in occupational medicine, occupational therapy, and others with vocational and employment expertise.

Physiatrists can use the evidence from this study to inform patients about the possible accommodation strategies available and how they support rehabilitation, recovery, and RTW after mTBI. This may minimize the long-term impacts of the mTBI experience for some patients and better support the reintegration of individuals back into the workforce.


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Mild Traumatic Brain Injury; Return to Work; Occupational Medicine; Rehabilitation; Employment; Concussion; Workplace Accommodation

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