Featured article from DMEC: Employers Can Help Employees with Traumatic Brain Injuries Return to Work

MDGuidelines experts were featured in a recent article on traumatic brain injuries in the DMEC (Disability Management Employer Coalition) publication. The authors were Kerri Wizner, MPH, Assistant Director of Epidemiology, MDGuidelines; Justine Ahle, MS, Senior Analyst, MDGuidelines; and Keemia Vaghef, PhD, Director of Analytic Consulting, Leave Solutions, Alight.

Publication date: September 18, 2023

More than 27 million cases of traumatic brain injury (TBI), a category that includes falls, motor vehicle crashes, and sports injuries, occur globally every year.1 Described as a silent epidemic, the injuries can be difficult to manage due to complex coding that affects claims and an outdated approach that may delay an employee’s return to work.

While the data is daunting, there are things employers can do to prevent TBIs and support employees.

In the U.S., an estimated 18% of TBI cases (out of an estimated 350,000 per year) are work-related and commonly caused by falls, being struck, vehicle crashes, and assaults.2 Workers’ compensation programs show that 60% of work-related TBI injuries resulted in disability or death, and cost on average more than $150,000; one-third of severe work-related injuries involve TBI.3,4 Research indicates that upwards of 80% of injured workers may consider their TBI to have been preventable if there were more supervision or safety trainings. In other words, more investment in trainings could help avoid TBIs, and considering that 20% to 50% of these employees experience limitations three to 12 months after the injury, this is something to consider.5–8

From a non-occupational perspective, an estimated 5.3 million Americans live with disabilities related to TBIs. A recent article also notes that the highest rate of injury occurs between the ages of 15 and 24 years old.9

The most common TBI symptoms include headache, nausea, fatigue, speech issues, dizziness, sensitivity to light or sound, memory or concentration problems, and mood swings. Employees with more severe cases may also experience seizures; fluids draining from the nose or ears; or unusual behavior, such as combativeness.10 Most people with concussions can go back to work in about two weeks, while people with more severe TBI may not be able to return to work for four months if ever.11

Nonmedical factors can affect if and when a person returns to the job after an injury. For example, people in professional and managerial positions more often return to work — and more quickly — after a TBI than those in manual labor jobs.12, 13 This response may be due to a higher educational level, early use of return-to-work supports, and more flexibility by employers that are interested in keeping the in-demand skill set of a manager. TBI is unique from other workplace disabilities because it combines physical and mental care and may become chronic.

despite the fact that it is not categorized as a musculoskeletal, mental, or long-term disability. You may see national headlines about sports concussions, but it has not been a focus of short-term disability (STD) discussions despite increasing prevalence.

Additionally, work satisfaction, future vocational outlook, and quality of life can affect time frames for someone who has a TBI and returns to work.14 However, it is difficult to predict who will go back to work because of individual characteristics such as personality, pain tolerance, and support systems, as well as TBI severity, impairments, and environmental factors like access to care.15

Returning to the job

Resuming normal activities after an injury or illness can help mental, physical, and financial health. Going back to work is a major step toward employee recovery even if it is at a modified capacity.16 The Job Accommodation Network recommends that employees who have TBIs work closely with management to identify job modifications and consistently evaluate what is and is not working.17 The World Health Organization emphasizes a model of work rehabilitation that considers the following elements when designing a return-to-work plan for employees who have a TBI: job development, job task analysis, testing, job coach, community manager, work trial, and monitoring or follow-up.18 A job coach is a one-on-one supervisor who teaches the job in small portions and directly follows up with the employee. The coach can work with employers to set expectations as well as observe the successes and failures of the employee at work.

An Americans with Disabilities Act (ADA) assessment should include evaluating job requirements and linking them to reasonable accommodations. These may include modifications to physical workspace, adjustments to workload or schedule, and assistive technologies or support personnel, as needed. Going a step further, receiving input from vocational rehabilitation teams, physical therapy and occupational therapy professionals, or ergonomics experts can ensure a comprehensive accommodation plan.

An example of ADA accommodations for an employee with TBI includes workspace modifications that reduce sensory distractions and a flexible work schedule to accommodate therapy appointments and fluctuations in energy levels due to fatigue. Employees can be offered speech recognition software and ergonomic tools to support cognitive and physical abilities that are affected by a TBI. Researchers have highlighted the most valuable cognitive accommodations for TBI to be adapting shifts, increasing the number of breaks, reducing the number of digital meetings, and limiting light exposure in work areas.19 Additionally, the future of cognitive accommodations may lead employers to regularly assess workplace flexibility and accessibility to encourage employees to voice their needs as they evolve.

Case managers who excel at implementing a comprehensive return-to-work plan that includes an ADA-compliant process as outlined above support a safe and timely reintegration to the workforce.

Predicting Recovery

Physical demand level (i.e., the amount of lifting required) has been the cornerstone of disability determination for decades. However, research studies find that cognitive demands play an important role in worker well-being and should be considered when devising a return-to-work strategy20 though measuring cognitive demand and systemic application is still in its infancy.

One resource to consider is the Occupational Information Network (www.onetonline.org), which scores job-specific verbal abilities, idea generation, and reasoning, as well as quantitative abilities, memory, perceptual abilities, special abilities, and attentiveness.21

These types of research survey tools may also be used to predict resiliency after an injury or illness. For example, the General Self-Efficacy Scale measures a person’s ability to cope with adversity.21 While using this tool, employees are asked to rank how much they identify with the following statements:

  • It is easy for me to stick to my aims and accomplish my goals.
  • I am confident that I could deal efficiently with unexpected events.
  • I can solve most problems if I invest the necessary effort.

People who get a low resiliency score should be flagged for more assistance, especially those with TBI who are likely to have inconsistent recovery, with some good days and some bad days even after they have returned to the office.

Currently, each TBI case needs hands-on management to account for the wide variety of symptoms and individual levels of resiliency. However, new tools (and research in progress) could help assess capabilities and enable employees to go back to work sooner. Systemic improvements to ensure the correct diagnostic code is used, employing some creativity to offer employee-specific accommodations, and widening the types of data collected can help people return to their jobs and set benchmarks to measure change.



  1. Brazinova A, Renzaho A. Global, Regional, and National Burden of TBI and Spinal Cord Injury, 1990-2016. Lancet Neurol. Retrieved from https://www.thelancet.com/journals/laneur/article/PIIS1474-4422(18)30415-0/fulltext
  2. Toccalino D, Colantonio A, Chan V. Update on the Epidemiology of Work — TBI: A Systematic Review and Meta- Analysis. Occup Environ Med. 2021;78(10):769-776. Retrieved from https://pubmed.ncbi.nlm.nih.gov/33380517/
  3. Wrona R. The Use of State Workers’ Compensation Administrative Data to Identify Injury Scenarios and Quantify Costs of Work-Related TBI. J Safety Res. 2006;37(1):75-81. Retrieved from https://pubmed.ncbi.nlm.nih.gov/16519901/
  4. Occupational Public Health Program. Work-Related TBI in Oregon: Trauma Registry Data and Deaths, 2009- 2014. 2017. Retrieved from https://sharedsystems.dhsoha.state.or.us/DHSForms/Served/le9401.pdf
  5. Sharma B, Nowrouzi-Kia B, Mollayeva T, et al. Work-Related TBI: A Brief Report on Workers Perspective on Job and Health and Safety Training, Supervision, and Injury Preventability. Work. 2019;62(2):319-325. Retrieved from https://bit.ly/3LxzmvZ
  6. Nelson LD, Temkin NR, Dikmen S, et al. Recovery After Mild TBI in Patients Presenting to US Level 1 Trauma Centers. JAMA Neurol. 2019;76(9):1049-1059. Retrieved from https://pubmed.ncbi.nlm.nih.gov/31157856/
  7. Cooksley R, Maguire E, Lannin NA, et al. Persistent Symptoms and Activity Changes Three Months After Mild TBI. Aust Occup Ther J. 2018;65(3):168-175. Retrieved from https://pubmed.ncbi.nlm.nih.gov/29498077/
  8. Benedictus MR, Spikman JM, Van Der Naalt J. Cognitive and Behavioral Impairment in TBI Related to Outcome and Return to Work. Arch Phys Med Rehabil. 2010;91(9):1436-1441. Retrieved from https://pubmed.ncbi.nlm.nih.gov/20801264/
  9. International Brain Injury Association. Brain Injury Facts. Retrieved from https://bit.ly/3ZoxThlP
  10. Proprietary TBI data. Retrieved from https://app.mdguidelines.com/health- advisor/mda%2Ftraumatic-brain-injuryW
  11. Walker WC, Marwitz JH, Kreutzer JS, et al. Occupational Categories and RTW After TBI: A Multicenter Study. Arch Phys Med Rehabil. 2006;87(12):1576-1582. Retrieved from https://www.archives-pmr.org/article/S0003- 9993(06)01317-7/fulltext
  12. Spitz G, Mahmooei BH, Ross P, et al. Characterizing Early and Late RTW after TBI. J Neurotrauma. 2019;36(17):2533-2540. Retrieved from https://www.liebertpub.com/doi/10.1089/neu.2018.5850
  13. Libeson L, Downing M, Ross P, Ponsford J. The Experience of RTW in Individuals with TBI: A Qualitative Study. Neuropsychol Rehabil. 2020;30(3):412-429. Retrieved from https://www.tandfonline.com/doi/full/10.1080/09602011.2018.1470987
  14. Shames J, Treger I, Ring H, Giaquinto S. RTW Following TBI: Trends and Challenges. Disability and Rehab. 2009;29(17):1387-1395. Retrieved from https://www.tandfonline.com/doi/abs/10.1080/09638280701315011? journalCode=idre20
  15. Military Health Systems. TBI Center of Excellence. 2023. Retrieved from https://health.mil/Military-Health- Topics/Centers-of-Excellence/Traumatic-Brain-Injury-Center-of-Excellence
  16. Ask Jan Network. Brain Injury. 2023. Retrieved from https://askjan.org/disabilities/Brain-Injury.cfm
  17. World Health Organization. Rehabilitation for Persons with Traumatic Brain Injury. 2004. Retrieved from https://www.who.int/publications/i/item/rehabilitation-for-persons-with-traumatic-brain-injury
  18. Spjelkavik Ø, Enehaug H, Klethagen P, et al. Workplace Accommodation in RTW After Mild TBI. Work. 2023;74(3). Retrieved from https://content.iospress.com/articles/work/wor211440
  19. Meyer SC, Hünefeld L. Challenging Cognitive Demands at Work, Related Working Conditions, and Employee Well-Being. Int J Environ Res Public Health. 2018;15(12). Retrieved from https://www.mdpi.com/1660- 4601/15/12/2911
  20. O*NET. Published 2023. Retrieved from https://www.onetcenter.org/

Sign Up Email Subscription