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Concussion and Return to Work

By Claire Odd

Published 12 September 2023

Coloured Brain

Introduction

I was a high achieving professional, working as Group Health and Safety Manager for a large PLC. Also, an academic achiever, having recently completed an Executive MBA and was on course to commence a PhD. However, in 2017 I sustained a concussion in a mountain bike accident and within a split second my life turned upside down. Initially, I thought it was just a bump on the head, but it became so much more than that. For many people, me included, it is a life-changing experience, and not always a positive one.

What is a concussion?

There is an ongoing debate   about whether concussion should be renamed as a mild traumatic brain injury (mTBI). Literature uses the terms interchangeably (Clark and Guskiewicz, 2015, Graff, 2020).

Concussion is frequently described as a traumatic brain injury or functional injury, caused by a direct or indirect blow to the head, neck, or body (McCrory et al., 2017, Boshra et Al, 2020 and Patricious et al, 2023). An impulsive force is transmitted to the brain. It does not involve damage or change to the structure of the brain and is not visible on most readily available imaging in the emergency care setting (Lunkova et al., 2021, Pinky et al, 2022). Imaging is, however, important to rule out more serious traumatic brain injury (Pinky et al., 2022, Patricious et al, 2023).  

Typically, people with concussion will make a full recovery within 3 months; however, there are people (19%) whose symptoms still affected their work after this time; the most common symptoms in this group were workplace fatigue and an inability to maintain previous workload/standards (Cooksley, 2018).

Rehabilitation

There are 160,000 people who experience traumatic brain injuries each year in the UK (Radford, 2018). Concussion recovery is different for everyone, no two recoveries will be the same. (Karmali, 2022).

Much is still unknown about the whole-body impact of a concussion, and research is primarily undertaken with male elite athletes. Translating this to the general population, taking account of hormonal changes and physiological differences between genders is not easy. However, Patricious et al 2023, reports longer recovery times for females, due to the cyclical nature of female hormones and metabolic effects. Ongoing symptoms of concussion (or post-concussion syndrome (PCS)) may be non-specific and may be due to other exacerbating factors such as mental health issues, sleep disturbance, learning and attention difficulties, vestibular problems and even menopause (Patricious et al, 2023).

Figure 1 below, demonstrates the number of functions of the brain and therefore the challenges in recovering from concussion. Understanding the points of impact that led to the concussion can be helpful to understand where there are likely to be challenges with areas of executive function (Dooley, 2022). Previously, it was thought that the only recovery from concussion was protection and rest, sitting in a dark room and avoiding any kind of activity that would stimulate the brain, however, given the interconnectedness of the human body, rehabilitation should have a whole-person approach, especially with the metabolic effects reported by Patricious et al, 2023.

Figure 1. Brain anatomy and function

A holistic and targeted rehabilitation programme can be helpful. I personally found immense success working with a practitioner who used a

combination of Neuro Kinetic Therapy, Proprioceptive Deep Tendon Reflexes, and Cranio-Sacral Therapy.

Recovery and return to work (RTW)

There are still questions about how to optimise a return to work given the variation in mechanisms of injury, personal experience, and symptoms (Patricious et al 2023). 

Concussion has a complex pathophysiology that disrupts the normal neuro metabolic activities within the brain, causing an inflammation response. It may take up to 30 days to rebuild energy  stores (Sun et al., 2008, Concussion Alliance)

The Consensus Statement in Concussion in Sport advocates a brief period of rest, which includes a reduction in activities of daily living during the initial 24–48 hours following a concussion, then proposes a framework for returning to work/learn then progressing in more vigorous activities/sport (Schneider, 2023). 

Table 1 –  Return to work plan
(
Adapted from Return to Learn, Consensus statement in Concussion in Sport, 2022) 

Mental activity

Activity at each step

Goal

Daily activities that do not result in more than a mild exacerbation of symptoms related to the current concussion

Typical activities during the day (e.g., reading) while minimising screen time.

 

Start with 5–15 min at a time and increase gradually.

Gradual return to typical life management activities

Dedicated cognitive activities

Setting aside time to perform cognitive activities such as reading or completing puzzles, logic games, crosswords, or similar outside of the workplace place   

Increase tolerance to cognitive in readiness for work

Return to work part-time

A gradual introduction of work.

 

May need to start with a reduced day or with greater access to rest breaks during the day.

Increase cognitive load activities & re-introduction to workplace

Return to work full time

Gradually progress into full work activities until a full day can be tolerated without more than mild symptom exacerbation.

To return to full workload capacity

Individuals can then return to light-intensity physical activity, which does not more than mildly exacerbate symptoms, such as walking. Gentle exercise (without any risk of falls) is also great for regulating the nervous system and mobilising the lymphatic system to reduce inflammation. When I think about my own journey, it took some time to start normal daily living activities. Swimming was my saviour during most of my recovery, primarily as I did not have to worry about balance and coordinating my body.

Where there are cognitive difficulties, sleep disturbances, dizziness, headaches, and neck pain that persist for more than ten days, then further support should be gained from an appropriately trained and experienced physical therapist.   

Typical challenges in returning to work (RTW).

Persistent PCS can have long-term consequences for return to work (Cancelliere et al., 2014) and influence self-esteem and quality of life (Mani et al.,2017). This is something that was very much part of my own journey.

The one thing from my own journey that has really stood out, was that my recovery was anything but linear. This made it both frustrating and difficult to plan incremental milestones for both me and my employer. This is something that is repeated frequently by my clients and recalled anecdotally by my colleagues.  A typical example would be completing routine work tasks successfully for several consecutive days, but then producing lower quality work whilst not displaying an overt return of symptoms. Working through this requires patience from both sides. Table 2 details the challenges involved for both employers and employees in successfully navigating returning to work.

Table 2 – Concussion RTW challenges

Employee

Employer

· Understanding of concussion

· Understanding their own capability

· Dealing with non-linear recovery 

· Sensitivity to light and noise

· Visual and vestibular processing issues

· Reading comprehension

· Trouble finding words/word amnesia.

· Taking part in conversations with multiple people

· Insomnia

· Fatigue

· Tinnitus

· Headaches

· Attention span

· Anxiety & loss of confidence

· Emotional regulation

· Nausea

· Digestive issues and food sensitivities

· Balance and co-ordination issues

· Cognitive capacity and processing

· Personal Organisation

· Memory and recall

· Support from family and friends

· Support from an appropriately qualified and experienced rehabilitation team.

· Travelling for work – particularly at dawn/dusk or in rush hour

· Understanding of concussion

· Referral pathways and signposting

· Understanding the employee capabilities

· Dealing with non-linear recovery

· Adjusted working hours.

· Changes to shift pattern (such as not working nights)

· Flexible working

· Increased breaks

· Physical changes to the working environment (quiet room, reduced lighting, blinds, moving closer to entrance/exits, working on the ground floor, different lenses in safety specs)

· Temporary secondment

· Working from home

· Decreased workload

· Re-allocation of tasks

· Less complex work allocated.

· Non-computer-based work

· Using additional technology (dictation & transcript)

· Buddy system

· Support of employer & colleagues

 

I know that from my own experiences, my ability to self-organise and be in the right place at the right time was deeply affected – as someone who was always unflustered no matter what and never late, this was hard to comprehend and accept. Other areas that I struggled with were memory recall, being able to keep up with the flow of conversation in meetings and being able to multi-task (e.g., listening and note-taking). I still struggle with memory recall now and being able to call things the right name spontaneously. Through a mindset shift and reframing, I no longer see this as a weakness, stressful or embarrassing. It is about creativity and finding new ways to use language.

Learning more about concussion

Coming from a background in exercise rehabilitation, learning more about effective rehabilitation for concussion was key for me and my journey to where I am today. Even more so as the support and onward referral for specialist support from my GP was lacking. It consisted of you just need to rest, and that is as good as it’s going to get for you, so you need to accept it. I feel lucky to have learnt about concussion with some of the world’s leading educators.

  • Dr Kathy Dooley – Immaculate Dissection
  • Dr Ryan Foley and Dr Kyle Paxton – Integrated Kinetic Neurology
  • Dr Cameron Marshall – Complete Concussion
  • Dr Molly Parker – Concussion Compass
  • Carrick Institute
  • University of Calgary

PS I didn’t get to start my PhD, but I have accepted that my brain just does not work that way anymore and that I have gone a different but more fulfilling path.

 

Claire Odd Headshot

Claire is a Health Coach, Rehabilitation Therapist, Sports Scientist and Chartered Health & Safety Practitioner. Before moving to independent practice and consultancy she worked in senior leadership positions in high-profile safety-critical organisations leading their health, safety, and wellbeing programmes.

In her independent practice, she practices a whole-person approach, working with all aspects of women’s health, particularly perimenopause & post-operative recovery, and concussion rehabilitation, alongside supporting organisations with their workplace health and wellbeing programmes.

 www.restoring-balance.co.uk

 

OH Today Spring 2023
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