Most clients with a concussion or mild traumatic brain injury recover and return to work. The ones who don’t are often the ones whose plan was either too cautious (weeks of rest, then a sudden full return) or too vague (“back to work as tolerated”) for anyone to follow.
A good graduated return-to-work (RTW) plan is specific about three things: which demands the client returns to first, how you’ll decide to step up, and what evidence you’ll show the case manager at each step.
This guide is written for OTs working with adults in Canada, including clients with WSIB or other insurer involvement. It is not a substitute for current clinical guidelines or the treating team’s judgment.
Start From the Guideline, Not From Scratch
In Ontario and much of Canada, the reference point is the Ontario Neurotrauma Foundation’s Guideline for Concussion/Mild Traumatic Brain Injury & Persistent Symptoms (3rd edition, now maintained as a living guideline), which has a dedicated section on returning to work. Its broad direction is consistent with what OTs see in practice:
- Avoid prolonged rest. After a short initial period, clients should become gradually more active rather than waiting until symptoms are gone.
- Use symptoms as a guide. Activity is increased in steps, and a step is held or eased back if it clearly worsens symptoms.
- Plan for cognitive load, not just physical load. Sustained concentration, reading, screen work and demanding conversations are as relevant as lifting or standing.
- Accommodate. Shorter days, a gradual re-entry, extra time, quieter workspaces and modified tasks are expected tools, and there is no single template that fits every client and job.
- Escalate when it isn’t working. Clients who haven’t resumed their usual work should be considered for a more detailed interdisciplinary or vocational evaluation.
Check the guideline itself for the current wording before you cite it in a report.
Step 1: Map the Job’s Cognitive Demands
A plan built on “office job” or “labourer” will miss the demands that actually trip clients up. Spend part of your first session listing them.
| Demand | Questions to ask |
|---|---|
| Sustained attention | How long does the client focus on one task without a break? |
| Working memory | How many requests or instructions do they hold at once? |
| Task-switching | How often do priorities change or interruptions happen? |
| Processing speed | Is the pace set by the client, by a machine, or by customers? |
| Screen and reading load | How many hours a day on screens or documents? |
| Sensory environment | Noise, lighting, open-plan office, driving? |
| Safety-critical tasks | Machinery, driving, working at heights, medication handling? |
The highest-load items usually return last. Safety-critical tasks need explicit clearance, not just “symptoms improving”.
Step 2: Set a Baseline You Can Repeat
Case managers act on change over time. A single assessment says where the client is. Repeated measures show whether the plan is working.
At baseline, record:
- Symptoms with a standard checklist, and what makes them worse
- Tolerance: how long the client can do focused cognitive work before symptoms rise
- Cognitive performance on short, repeatable tasks for attention, working memory, task-switching and processing speed
- Function on a job-like task (for example, an inbox exercise or following a multi-step work instruction)
Pick measures you can repeat weekly in a few minutes. Brief digital tasks work well here because they record accuracy and response time the same way every time, and clients can complete them at home between visits.
Step 3: Build the Steps
A graduated plan usually moves through stages like these. Timelines vary widely; set each step by the client’s response, not the calendar.
| Stage | Hours and duties | Cognitive load | Move on when |
|---|---|---|---|
| 1. Activity at home | Structured routine, light activity, short cognitive tasks | Low, with breaks | Symptoms stable with daily structured activity |
| 2. Work-like tasks at home | Job-simulated tasks in short blocks | Low to moderate | Can sustain task blocks without a lasting symptom increase |
| 3. Part-time, modified duties | Reduced hours, quieter space, fewer simultaneous demands | Moderate | Completes modified shifts without a lasting symptom increase; performance measures steady or improving |
| 4. Increasing hours and duties | Hours and task complexity rise in steps | Moderate to high | Tolerates near-full hours; job-specific demands reintroduced |
| 5. Full duties | Pre-injury role, safety-critical tasks cleared | Full | Sustained over an agreed review period |
At each stage, agree with the client and employer on what “a lasting symptom increase” means and what happens if it occurs (usually: hold or step back, not stop).
Step 4: Grade Cognitive Load Deliberately
Grading cognitive work is where many plans stay vague. Make it concrete:
- Duration: 20-minute focused blocks with breaks, then 30, then 45
- Complexity: single tasks before multi-step tasks; familiar before novel
- Interruptions: protected time before open-door time
- Pace: self-paced before deadline-driven
- Environment: quiet room before open office; reduced screen time before full
Home practice between sessions keeps progress moving when clinic visits are weekly or less. Short, assigned cognitive activities with automatic tracking let you see tolerance and performance trends before the client walks in.
Step 5: Document for the Case Manager
Insurers and employers need to know three things at each review: where the client is now, what changed, and what happens next. A one-page update works better than a long narrative.
Include:
- Current stage and hours and duties
- Trend in objective measures since baseline (a small table or chart)
- Symptoms and tolerance at the current stage
- Barriers and the accommodations in place
- Next step, the criteria for it, and the review date
For more on which cognitive domains to measure and why standard screening misses RTW readiness, see Cognitive Assessment for Return to Work and The Return-to-Work Failures Your Clinical Assessment Is Missing. Progress report structure is covered in our OT progress report template guide.
Red Flags That Change the Plan
Stop stepping up and discuss with the treating physician or team if the client shows:
- Worsening symptoms that don’t settle with rest or step-back
- New neurological signs
- Significant mood changes, anxiety or sleep disruption limiting progress
- No meaningful progress over several weeks at the same stage
These are also the points at which a broader interdisciplinary or vocational assessment is usually warranted.
How Neurofit Helps
Neurofit lets you assign short cognitive activities for clients to complete at home, with accuracy and response time recorded on every attempt. You get a repeatable baseline, weekly trends across attention, working memory, task-switching and processing speed, and reports you can attach to case manager updates.
See pricing or book a walkthrough to see a return-to-work caseload in Neurofit.