Return-to-Activity / Work / School Considerations

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Current evidence indicates graded resumption of regular pre-injury activities as tolerated (i.e., in a manner that does not result in a significant or prolonged exacerbation of symptoms), within the first few days to weeks post-injury should be encouraged because, regardless of symptomatic status, activity is more likely to speed up rather than delay recovery. For workers, the literature demonstrates patients with brain injury who are employed report better health status, improved sense of well-being, greater social integration within the community, less usage of health services and a better quality of life than do those who are not employed.1 In order to facilitate early and safe resumption of activities following concussion, healthcare professionals should advise patients on appropriate restrictions and limitations and then focus on abilities to ensure the optimal timing and nature of return-to-work and school activities.

General Considerations Regarding Rest and Return-to-Activity

Determining the optimal timing and nature of return-to-activity for patients with concussion must carefully consider the risks and benefits of activity resumption. While a short period of physical and cognitive rest may be beneficial, particularly to limit symptom aggravation, evidence suggests prolonged rest and/or avoidance of activities may worsen outcomes. Evidence indicates complete bed rest in excess of 3 days should be avoided 2,3 and gradual resumption of pre-injury activities should begin as soon as tolerated.2,4-7 Activities with high concussion/ exposure risk should be avoided in the first 7-10 days.

When advising patients on return-to-activity, it is important to consider both physical and cognitive activities because both have the potential to exacerbate symptoms 8,9 Cognitive load refers to mental activities requiring attention, concentration and problem solving. Patients should be educated on the concept of cognitive load and advised on how to go about minimizing cognitive load in circumstances where cognitively demanding activities are aggravating symptoms.

General Considerations Regarding Return-to-work (RTW)

Medically unnecessary delays in RTW must be avoided because employment is an important determinant of health and unsuccessful RTW can have profound negative economic and psychosocial consequences for affected individuals.10,11 Therefore, remaining at or promptly returning to some form of productive work, provided it does not pose risk of re-injury, should be encouraged. 

The healthcare provider should communicate the specific medical restrictions, limitations and abilities to the employer and other stakeholders, with appropriate consents, to facilitate temporary accommodations where necessary.13 

While it is the responsibility of the healthcare practitioner to provide information on a patient’s restrictions, limitations and abilities, it is the responsibly and role of the employer, based on the information provided by the healthcare practitioner, to determine the type of work available and whether the patient can be accommodated.13,14 

There is no common RTW template that fits the needs of all individuals in all circumstances; in some instances workers may return to work regular duties, while in others accommodation with temporary workload restrictions or placement in a completely different job function may be necessary.15,16 Therefore, each program should be individually prescribed and should support the reintegration and rehabilitation of the person with the injury or disability back into the workplace.

General Consideration Regarding Return-to-school (Post-Secondary)

There has been an increasing appreciation of the impact that concussion symptoms have on the ability for students to manage their academic programs. Resuming academic activity requires students to manage work in the classroom that includes listening, note-taking, presentations, homework, assignments and examinations, as well as managing additional volunteer activities and memberships in school-based clubs. It must be acknowledged that program requirements differ at the post-secondary level, and the nature of the accommodations available also differ between institutions. 

The essential premise of managing cognitive exertion is that cognitive activity must be paced in order to avoid exceeding the threshold at which concussion symptoms are exacerbated. The cognitive demands therefore span activities that would be conducted at school, and also at home and in the community. It is recommended that the management plans that are implemented should be individualized to student needs. Other people who might be involved in the management plan may include academic support staff, team physician, course instructors and disabilities services.17 

References supporting introduction:

  1. Cancelliere C, Kristman VL, Cassidy JD, et al. Systematic review of return to work after mild traumatic brain injury: results of the International Collaboration on Mild Traumatic Brain Injury Prognosis. Arch Phys Med Rehabil. 2014;95(3 Suppl):S201-209.
  2. Silverberg ND, Iverson GL. Is rest after concussion “the best medicine?”: recommendations for activity resumption following concussion in athletes, civilians, and military service members. J Head Trauma Rehabil. 2013;28(4):250-259.
  3. McCrory P, Meeuwisse W, Dvořák J, et al. Consensus statement on concussion in sport. Br J Sports Med. 2017; 51:838-847
  4. Willer B, Leddy JJ. Management of concussion and post-concussion syndrome. Curr Treat Options Neurol. 2006;8(5):415-426.
  5. Snell DL, Surgenor LJ, Hay-Smith EJ, Siegert RJ. A systematic review of psychological treatments for mild traumatic brain injury: an update on the evidence. J Clin Exp Neuropsychol. 2009;31(1):20-38.
  6. Berrigan L, J B, P F, L L, JA S. Concussion Management Guidelines for Certified Athletic Therapists in Quebec. In: Corporation des Thérapeutes du Sport du Québec, Quebec Corporation of Athletic Therapists; 2014.
  7. Leddy JJ, Baker JG, Willer B. Active Rehabilitation of Concussion and Post-concussion Syndrome. Phys Med Rehabil Clin N Am. 2016;27(2):437-454.
  8. Valovich McLeod T, Gioia G. Cognitive rest: the often neglected aspect of concussion management. Athletic Therapy Today. 2010;15:1-3.
  9. Wales MaANS. Guidelines for Mild Traumatic Brain Injury following closed head injury. In. Sydney Australia: Motor Accidents Authority; 2008.
  10. Waddell G BK. IS WORK GOOD FOR YOUR HEALTH AND WELL-BEING? In: Work and Pensions HG, ed. Norwich: The Stationery Office; 2006.
  11. Committee SaWaRtWPI. Preventing needless work disability by helping people stay employed. J Occup Environ Med. 2006;48(9):972-987
  12. Vanderploeg RD, Curtiss G, Duchnick JJ, Luis CA. Demographic, medical, and psychiatric factors in work and marital status after mild head injury. J Head Trauma Rehabil. 2003;18(2):148-163.
  13. Practice OMACoMCa. Ontario Medical Association Committee on Medical Care and Practice. The role of the primary care physician in timely return-to-work programs. Ont Med Rev. 1994;61(10):19-22.
  14. Association CM. THE TREATING PHYSICIAN’S ROLE IN HELPING PATIENTS RETURN TO WORK AFTER AN ILLNESS OR INJURY. CMA Policy. 2013.
  15. Colantonio A, Salehi S, Kristman V, et al. Return to work after work-related traumatic brain injury. NeuroRehabilitation. 2016;39(3):389-399.
  16. Martinez K, Small J. Addressing Work Performance After Mild Brain Injury. OT Practice. 2014;19(9).
  17. Hall EE, Ketcham CJ, Crenshaw CR, Baker MH, McConnell JM, Patel K. Concussion management in collegiate student athletes: return-to-academics recommendations. Clin J Sport Med. 2015;25(3):291-296.
Rest and Return to Activity
12.1

Immediately following a concussion, patients should be provided with recommendations to avoid a second concussion, particularly during the first 7-10 days post-injury.

Adapted from the VA/DoD Management of Concussion/Mild Traumatic Brain Injury Clinical Practice Guideline (VA/DoD, 2009).

There is evidence suggesting that there is an elevated risk for re-injury during the first 7-10 days post-concussion (the acute recovery phase), which can significantly impact a patient’s recovery and compound an existing concussion injury.

References supporting context:

  1. Dessy AM, Rasouli J, Choudhri TF. . Second Impact Syndrome. Neurosurgery Quarterly. 2015; 25 (3): 423-426.
  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. British Journal of Sports Medicine 2017;51:838-847.
Level of Evidence C
Last updated  
12.2a

After a brief period of rest during the acute phase (24-48 hours) after injury, patients with concussion should be encouraged to gradually resume normal activity (activities of daily living, work, school, duty, leisure) based upon their tolerance, as long as the activity does not pose a risk for concussion.

REPEAT OF 4.5

Evidence suggests that while an initial period of rest following injury (24-48 hours) may be of benefit, there is currently insufficient evidence that prescribing complete rest may ease discomfort or promote recovery during the post-acute period. Prolonged inactivity during the post-acute period following injury has been shown to slow recovery, while a progressive and gradual return to normal activity promotes recovery.

References supporting context:

  1. Buckley TA, Munkasy BA, Clouse BP. Acute Cognitive and Physical Rest May Not Improve Concussion Recovery Time. J Head Trauma Rehabil. 2016;31(4):233-241.
  2. Nygren-de Boussard C, Holm LW, Cancelliere C, et al. Nonsurgical interventions after mild traumatic brain injury: a systematic review. Results of the International Collaboration on Mild Traumatic Brain Injury Prognosis. Arch Phys Med Rehabil. 2014;95(3 Suppl):S257-264.
  3. Schneider KJ, Iverson GL, Emery CA, McCrory P, Herring SA, Meeuwisse WH. The effects of rest and treatment following sport-related concussion: a systematic review of the literature. Br J Sports Med. 2013;47(5):304-307.
  4. Schneider KJ, Leddy JJ, Guskiewicz KM, et al. Rest and treatment/rehabilitation following sport-related concussion: a systematic review. Br J Sports Med. 2017;51(12):930-934.
Level of Evidence A
Last updated  
12.2b

Explain to patients that transient symptom worsening with increased activity is common. If symptom worsening is significant or prolonged then a monitored, slower progressive return to normal activity should be implemented.

Evidence suggests that patients with concussion can safely and gradually resume normal activity (activities of daily living, work, school, duty, leisure) based upon their tolerance. Transient symptoms refer to a temporal onset of symptoms related to activity that typically resolve or improve in less than 24 hours. Exacerbation of symptoms greater than 24 hours indicate that tolerance thresholds have been exceeded, and activity should be adjusted
accordingly. The onset of transient symptoms during a gradual return to activity is common and safe so long as these do not impair functional abilities beyond a short time frame and no new or further injury is caused.

Analogy: A patient who has an ankle injury is encouraged to walk or jog lightly to promote recovery. This benefits the patient by maintaining mobility in the joint. However, the patient should avoid activities that exceed his tolerance threshold, such as intense or long runs. Any activity carried out by the patient should not impair his ability to walk again the next day.

References supporting context:

  1. Maerlender A, Rieman W, Lichtenstein J, Condiracci C. Programmed Physical Exertion in Recovery From Sports-Related Concussion: A Randomized Pilot Study. Dev Neuropsychol. 2015;40(5):273-278.
  2. Remigio-Baker, R., Bailie, J., Gregory, E., Cole, W., McCulloch, K., Cecchini, A., Stuessi, K., Andrews, T., Mullins, L., & Ettenhofer, M. (2020). Activity Level During Acute Concussion May Predict Symptom Recovery Within an Active Duty Military Population. Journal of Head Trauma Rehabilitation, 35(2), 92-
    103.
Level of Evidence B
Last updated  
Vocational Screening and Evaluation
12.3

Return to work: Encourage patients to return to some form of work, so long as work does not place the person at risk of reinjury. Facilitate identification of necessary restrictions (where there is risk of reinjury) and appropriate accommodations by clearly identifying patient symptoms and functional limitations (physical, cognitive and emotional).

Evidence indicates that encouraging patients to gradually and progressively (hours and duties) return to some form of meaningful work provides the opportunity for the individual to establish and maintain routine and structure to their day and their sleep schedule, to gradually build tolerance to environmental stimuli, to gradually build tolerance for physical and/or cognitive activities, and to provide a purpose for the day. Returning to meaningful activities earlier helps to promote both physical and mental recovery and results in higher likelihood of
success.

References supporting context:

  1. Cancelliere et al. Systematic review of return to work after mild traumatic brain injury: results of the International Collaboration on Mild Traumatic Brain Injury Prognosis. Arch Phys Med Rehabil. 2014;95(3Suppl):S201-209.
  2. Thompson, A. (2021). Framework for Return to Work (RTW) Recommendations [PowerPoint Slides].
Level of Evidence B
Last updated  
12.4

For patients experiencing prolonged symptoms, compensatory cognitive training with supportive employment interventions is recommended to help patients return to employment.

Compensatory cognitive training aims to teach patients strategies to manage their prolonged symptoms. Examples of compensatory strategies include:

  • Planning (keeping lists and notes of forthcoming tasks)
  • Prioritizing (use colour coding or numbers with lists to choose tasks that need to be done immediately versus ones that can be done later)
  • Pacing (use a timer to take set breaks, finish one task and take a break, alternate high-demand and low-demand cognitive tasks throughout a day)
  • Working as a team with co-workers (e.g., asking for assistance)
  • De-cluttering the workspace (e.g., ensure only items required for accomplishing work tasks are on a desk)

Supportive employment interventions may include:

  1. Workplace accommodations (e.g., flexible work hours, working from home) to help patients to gradually increase their workload. 
  2. Individual placement and support (IPS) which involves actively facilitating job acquisition and provides ongoing support once the client is employed. Some examples of IPS services include paying attention to patient preferences for jobs, providing a rapid job search for the patient, provision of personalized benefits counselling, and individualized support on the job for as long as the patient requires it. Please see Fure et al (2021; the primary supporting article for this recommendation) or Sveinsdottir et al. (2014) for more detail. 

References supporting context:

  1. Fure SCR, Howe EI, Andelic N, et al. Cognitive and vocational rehabilitation after mild-to-moderate traumatic brain injury: A randomised controlled trial. Ann Phys Rehabil Med. 2021;64(5):101538.
  2. Sveinsdottir V, Løvvik C, Fyhn T, et al. Protocol for the effect evaluation of Individual Placement and Support (IPS): a randomized controlled multicenter trial of IPS versus treatment as usual for patients with moderate to severe mental illness in Norway. BMC Psychiatry. 2014;14:307.
Level of Evidence A
Last updated  
Community Re-Integration and Future Vocational Planning
12.5

When prolonged post-concussive symptoms pose a barrier to return to pre-injury employment, introduction of other meaningful activities that facilitate recovery should be considered. Other employment (full-time or part-time), educational activities, community roles, and activities that promote community integration (e.g. volunteer work) may be considered as an alternative focus for meaningful activities.

In situations where persistent symptoms were not successfully managed with an individualized treatment or rehabilitation plan, a broad variety of meaningful activities that promote recovery or provide a sense of purpose should be considered.

References supporting context:

  1. Varner CE, McLeod S, Nahiddi N, Lougheed RE, Dear TE, Borgundvaag B. Cognitive Rest and Graduated Return to Usual Activities Versus Usual Care for Mild Traumatic Brain Injury: A Randomized Controlled Trial of Emergency Department Discharge Instructions. Acad Emerg Med. 2017;24(1):75-82.
Level of Evidence C
( For other employment )
Level of Evidence C
( For remaining )
Last updated  
Return-to-School (Post-Secondary) Considerations
12.6

Return to School: Immediately after concussion, the student should rest for 24-48 hours and not participate in any sport or academic activities. After 24-48 hours, an individualized return to school/studies strategy should be established with the aim of progressing activity without provoking significant symptom exacerbation.

Immediately after concussion, the student should rest for 24-48 hours and not participate in any sport or academic activities. After 24-48 hours, if symptoms are improving, the student can attend school as tolerated but should avoid evaluations (e.g., exams) or do them with appropriate accommodations (e.g., more time provided). If the student is experiencing symptoms and cannot tolerate a return to in-class learning, the student should receive education on symptom management and modified at-home study tasks.

After 2 weeks postinjury, students can gradually resume normal activities but should be monitored for symptoms. Reintegration should occur progressively, and specific accommodations should match the student’s residual symptoms.

If re-integration into school is ineffective at 4 weeks (i.e., symptoms plateau/continue to worsen), specialized clinical assessment(s) should be considered through an interdisciplinary concussion clinic or specialized assessment, particularly when confounding conditions are present (including learning disabilities, ADHD, anxiety, depression, neuropsychological). A review should be done as to whether the student should continue in the program for that term if there will be substantially negative consequences to their grades and program participation.

References supporting context:

  1. André-Morin, D., Caron, J. G., & Bloom, G. A. (2017). Exploring the unique challenges faced by female university athletes experiencing prolonged concussion symptoms. Sport, Exercise, and Performance Psychology, 6(3), 289-303.
Level of Evidence A
( For first 24-48 hours )
Level of Evidence C
( For individualized return )
Last updated  
Return To Activity
CATT Online Return to Activity Tool
Return To Work (Table 12.2)
Identifying Work Restrictions
Return To Work (Table 12.3)
Return to Work Accommodation List
Return To Work (Table 12.4)
Identifying Work Limitations
Return To Work
Return to Work Brain Injury Algorithm
Return To School
CATT Online Return to School Tool
Return To School
Certificate of Disability (University of Toronto)
Return To School (Table 12.5)
Return to School Accommodation Plan
Return to School
CATT Online Learning Accommodations and Modifications
To learn more about strengths and limitations of the evidence informing each recommendation, click here.

André-Morin, D., Caron, J. G., & Bloom, G. A. Exploring the unique challenges faced by female university athletes experiencing prolonged concussion symptoms. Sport, Exercise, and Performance Psychology. 2017; 6(3), 289-303.
CASP: 8/9
Associated with recommendation 12.6 (individualized return)

Bailie, J. M., Remigio-Baker, R. A., Cole, W. R., McCulloch, K. L., Ettenhofer, M. L., West, T., Ahrens, A., Sargent, P., Cecchini, A., Malik, S., Mullins, L., Stuessi, K., Qashu, F. M., & Gregory, E. Use of the progressive return to activity guidelines may expedite symptom resolution after concussion for active duty military. The American Journal of Sports Medicine. 2019; 47(14), 3505–3513.
Downs and Black: 14/28
Associated with recommendations 12.2a and 12.6 (first 24-48 hours)

Gourdeau, J., Fingold, A., Colantonio, A., Mansfield, E., & Stergiou-Kita, M. Workplace accommodations following work-related mild traumatic brain injury: What works? Disability and Rehabilitation. 2018; 42(4), 552–561.
CASP: 8/9
Associated with recommendations 12.3, 12.4, and 12.5 (other employment)

Graff, H. J., Deleu, N. W., Christiansen, P., & Rytter, H. M. Facilitators of and barriers to return to work after mild traumatic brain injury: A thematic analysis. Neuropsychological Rehabilitation. 2020; 31(9), 1349–1373.
CASP: 6/9
Associated with recommendations 12.3 and 12.5 (other employment)

Howell, D. R., Brilliant, A. N., Oldham, J. R., Berkstresser, B., Wang, F., & Meehan, W. P. Exercise in the first week following concussion among collegiate athletes: Preliminary findings. Journal of Science and Medicine in Sport. 2020; 23(2), 112–117.
Downs and Black: 18/28
Associated with recommendation 12.2a

Maerlender A, Rieman W, Lichtenstein J, Condiracci C. Programmed Physical Exertion in Recovery From Sports-Related Concussion: A Randomized Pilot Study. Dev Neuropsychol. 2015;40(5):273-278.
PEDro: 6/11
Associated with recommendation 12.2b

Nygren-de Boussard C, Holm LW, Cancelliere C, et al. Nonsurgical interventions after mild traumatic brain injury: a systematic review. Results of the International Collaboration on Mild Traumatic Brain Injury Prognosis. Arch Phys Med Rehabil. 2014;95(3 Suppl):S257-264.
PRISMA: 17/27
Associated with recommendation 12.2a

Remigio-Baker, R. , Bailie, J. , Gregory, E. , Cole, W. , McCulloch, K. , Cecchini, A. , Stuessi, K. , Andrews, T. , Mullins, L. & Ettenhofer, M. Activity Level During Acute Concussion May Predict Symptom Recovery Within an Active Duty Military Population. Journal of Head Trauma Rehabilitation. 2020; 35 (2), 92-103.
STROBE: 19/23
Associated with recommendation 12.2b

Schneider KJ, Iverson GL, Emery CA, McCrory P, Herring SA, Meeuwisse WH. The effects of rest and treatment following sport-related concussion: a systematic review of the literature. Br J Sports Med. 2013;47(5):304-307.
PRISMA: 10/27
Associated with recommendations 12.2a and 12.6 (first 24-48 hours)

Schneider KJ, Leddy JJ, Guskiewicz KM, et al. Rest and treatment/rehabilitation following sport-related concussion: a systematic review. Br J Sports Med. 2017;51(12):930-934.
PRISMA: 18/27
Associated with recommendations 12.2a and 12.6 (first 24-48 hours)

Silverberg, N. D., & Otamendi, T. Advice to rest for more than 2 days after mild traumatic brain injury is associated with delayed return to productivity: A case-control study. Frontiers in Neurology. 2019; 10.
Downs and Black: 18/28
Associated with recommendations 12.2a and 12.6 (first 24-48 hours)

Varner CE, McLeod S, Nahiddi N, Lougheed RE, Dear TE, Borgundvaag B. Cognitive Rest and Graduated Return to Usual Activities Versus Usual Care for Mild Traumatic Brain Injury: A Randomized Controlled Trial of Emergency Department Discharge Instructions. Acad Emerg Med. 2017;24(1):75-82.
PEDro: 8/11
Associated with recommendation 12.2a

Brett BL, Breedlove K, McAllister TW, et al. Investigating the Range of Symptom Endorsement at Initiation of a Graduated Return-to-Play Protocol After Concussion and Duration of the Protocol: A Study From the National Collegiate Athletic Association-Department of Defense Concussion, Assessment, Research, and Education (CARE) Consortium. Am J Sports Med. 2020;48(6):1476-1484.

STROBE: 18/23

Associated with recommendations 12.2a and 12.2b

Howe EI, Fure SCR, Løvstad M, et al. Effectiveness of Combining Compensatory Cognitive Training and Vocational Intervention vs. Treatment as Usual on Return to Work Following Mild-to-Moderate Traumatic Brain Injury: Interim Analysis at 3 and 6 Month Follow-Up. Front Neurol. 2020;11:561400.
Downs and Black: 23/28

Associated with recommendation 12.3

O'Brien KH, Wallace T, Kemp A. Student Perspectives on the Role of Peer Support Following Concussion: Development of the SUCCESS Peer Mentoring Program. Am J Speech Lang Pathol. 2021;30(2S):933-948. 
CASP: 5/9

Associated with recommendation 12.6 (individualized return)

Fure SCR, Howe EI, Andelic N, et al. Cognitive and vocational rehabilitation after mild-to-moderate traumatic brain injury: A randomised controlled trial. Ann Phys Rehabil Med. 2021;64(5):101538.
Downs and Black: 26/28

Associated with recommendation 12.4

Gaudette É, Seabury SA, Temkin N, et al. Employment and Economic Outcomes of Participants With Mild Traumatic Brain Injury in the TRACK-TBI Study. JAMA Netw Open. 2022;5(6):e2219444.
JBI: 14/16

Associated with recommendation 12.4

Karmali S, Beaton MD, Babul S. Outlining the Invisible: Experiences and Perspectives Regarding Concussion Recovery, Return-to-Work, and Resource Gaps. Int J Environ Res Public Health. 2022;19(13):8204.
CASP: 7/9

Associated with recommendation 12.4

Pinnow D, Causey-Upton R, Meulenbroek P. Navigating the impact of workplace distractions for persons with TBI: a qualitative descriptive study. Sci Rep. 2022;12(1):15881.
CASP: 9/9

Associated with recommendation 12.4

Howe EI, Fure SCR, Løvstad M, et al. Effectiveness of Combining Compensatory Cognitive Training and Vocational Intervention vs. Treatment as Usual on Return to Work Following Mild-to-Moderate Traumatic Brain Injury: Interim Analysis at 3 and 6 Month Follow-Up. Front Neurol. 2020;11:561400. 
Downs and Black: 23/28

Associated with recommendation 12.4