Research in Focus | Returning to Work After Concussion: Beyond Symptom Resolution

Return to work (RTW) is often regarded as one of the most important markers of recovery following concussion. Yet despite increasing advances in concussion assessment and management, many individuals continue to experience challenges when attempting to resume employment. While much of the concussion literature has traditionally focused on symptom burden, prognostic factors and clinical recovery, a recent scoping review in the Journal of Head Trauma Rehabilitation by Shahzad and colleagues in Toronto, Canada, reminds us that successful return to work is influenced by far more than the injury itself.

The authors reviewed 20 studies exploring factors that facilitate or hinder return to work following concussion. Their findings were organised into four broad domains:

• the person affected by concussion,
• the medical system,
• funders and insurers, and
• the workplace.

Collectively, these findings highlight the complex interaction between individual, clinical, organisational and societal factors that shape recovery and work participation.

A Shift Away from the Biomedical Model

Historically, concussion management has been heavily influenced by a biomedical model that emphasises symptom resolution and impairment-based assessment. However, as Shahzad et al. note, many of the commonly cited prognostic factors for prolonged recovery—including sex, age and pre-existing mental health conditions—are largely non-modifiable.

In contrast, the current review highlights the importance of modifiable psychosocial and environmental influences. Factors such as personal agency, self-advocacy, social support, workplace flexibility and access to appropriate rehabilitation services emerged as important facilitators of successful work reintegration.

This aligns with a growing body of literature suggesting that concussion recovery should be viewed through a biopsychosocial lens, recognising that symptoms occur within the context of an individual’s work demands, social environment, psychological state and access to healthcare.

The Importance of Personal Agency

One of the more interesting findings was the role of personal agency in the return-to-work process. Several studies reported that successful work reintegration was facilitated when individuals were actively involved in decision-making regarding their recovery and work schedule. Self-awareness, self-advocacy and the ability to establish appropriate boundaries between work and personal life were repeatedly identified as important factors.

The authors suggest that return to work should not be viewed simply as a clinical outcome but rather as a behavioural and adaptive process. Individuals often need to adjust expectations, develop coping strategies and establish a new understanding of their abilities during recovery.

This observation is particularly relevant for clinicians. Successful rehabilitation may require not only symptom management but also supporting patients to develop confidence, self-management skills and realistic expectations regarding recovery.

The Critical Role of Healthcare Systems

The review also highlights several healthcare-related factors associated with improved RTW outcomes. Tailored rehabilitation programs, interdisciplinary care, concussion-specific services and vocational rehabilitation were all identified as beneficial.

Conversely, delays in diagnosis, mistimed and inappropriate referrals, poor follow-up and insufficient mental health support were consistently identified as barriers.

Notably, the findings reinforce contemporary concussion management principles that emphasise active rehabilitation and gradual progression rather than prolonged rest. One study included in the review found that individuals advised to rest for more than two days were less likely to have resumed work or study within one to two months of injury.

These findings support current international concussion recommendations advocating early education, symptom-guided activity and targeted rehabilitation interventions.

Workplace Culture Matters

Perhaps unsurprisingly, workplace factors emerged as one of the strongest influences on RTW outcomes. Supportive employers, flexible scheduling, graduated duties, environmental modifications and positive workplace relationships were consistently associated with successful work reintegration.

In contrast, poor concussion awareness, stigma, discrimination and a lack of meaningful accommodations were commonly reported barriers.

A particularly important observation was that accommodations are not universally beneficial. Some individuals reported that workplace modifications inadvertently increased social isolation or failed to align with their actual post-injury capabilities. This highlights the importance of individualised workplace planning rather than relying on generic return-to-work recommendations.

Implications for Future Research

One of the most striking findings from the review is the relative absence of research examining the role of funding systems and insurers. While several studies identified administrative burden, adversarial interactions and poor continuity of case management as barriers, no studies identified funder-related facilitators.

This represents an important gap in the literature. Given the significant influence that compensation systems, insurers and workplace injury schemes can have on access to treatment and vocational rehabilitation, future research should seek to better understand how these systems can either facilitate or hinder recovery.

The review also highlights the need for more longitudinal data examining how individuals transition back into work over time. Return to work is not a single event but a dynamic process that may involve fluctuations in symptoms, multiple domains of brain functions, changing workplace demands and evolving rehabilitation needs. Understanding these trajectories may help inform more personalised approaches to concussion management.

Conclusion

The review by Shahzad and colleagues provides a timely reminder that return to work after concussion is influenced by far more than symptom resolution alone. Recovery occurs within a broader ecosystem that includes healthcare providers, workplaces, family supports, funding systems and the individual themselves.

As concussion management continues to mature, there is increasing recognition that successful outcomes require more than accurate diagnosis and symptom monitoring. Supporting sustainable participation in work demands an integrated approach that considers the biological, psychological and social dimensions of recovery.

For clinicians, researchers and policymakers alike, the challenge moving forward will be developing and utilising streamlined systems that support not only recovery from concussion, but successful reintegration into meaningful work and daily life.