The impact of fear avoidance on return to work outcomes after mild traumatic brain injury

Research Objectives: We investigated whether fear avoidance was associated with return to work-related activity (RTW) after mild traumatic brain injury (mTBI). Fear avoidance has been associated with persisting symptoms but the potential links with return to work remain unexplored.

Design: Secondary analyses of two prospective observational cohorts, with follow up assessments conducted six-nine months after mTBI.

Setting: Outpatient concussion services.

Participants: Adult participants (n=175), were included if they were aged 16 or over, were within three months of injury and engaged in work-related activity at time of injury.

Interventions: N/a

Main Outcome Measures: The primary outcome was return to usual levels of work-related activity six-nine months after mTBI. Participants completed the Fear Avoidance Behavior after Traumatic Brain Injury (FAB-TBI) questionnaire at enrolment and six months later.

Results: Overall, 53% of participants had returned to usual work levels by six-nine months after mTBI. While early fear avoidance was weakly associated with RTW outcome, persistent high fear avoidance between study assessments or increasing avoidance over time were associated with greater odds of still being off work six-nine months after injury.

Conclusions: Pervasive and increasing avoidance of symptom triggers after mTBI were associated with lower rates of RTW six-nine months after mTBI. Work place accommodations and pacing interventions can be useful early after mTBI, but potentially unhelpful for those who are highly fear avoidant. For this group, interventions encouraging pacing and symptom avoidance may reinforce dangerousness beliefs. High or increasing levels of fear avoidance behavior should flag to clinicians that alternative treatment approaches are indicated. Further research is needed to better understand transition points along the recovery trajectory where fear avoidance behaviors fade or increase.

Author(s) Disclosures: This research was supported by grants from the Health Research Council of NZ (Study 1: ref 18/046 (Dr Snell); Study 2: ref 20/041 (Dr Faulkner)). Professor Alice Theadom is supported by a Rutherford Discovery Fellowship, administered by The Royal Society–Te Aparangi.
Professor Surgenor receives book royalties from Thomson Reuters. The authors report no other declarations of interest.