Current Clinical Concepts: A Framework for Concussion Management Strategies in Law Enforcement Officers

The first step in concussion management is concussion education. Research examining different athletic and military populations suggests that not knowing their head injury was a concussion or not thinking it was serious enough are among the top reasons for not seeking appropriate care.^33–37  As in these other populations, LEOs may not seek appropriate care without awareness of the signs and symptoms of concussion and their potential consequences. Concussion education should start in the training academy, which often involves defensive tactics training with the potential for concussion.³⁸  Many LEOs also undergo an annual in-service training, which may provide a venue for continued concussion education. Because there may be a reluctance to report concussions, concussion education should focus on the importance of immediate reporting and removal from duty by stressing the potentially negative outcomes associated with delayed reporting and removal from duty. For example, research in athletes indicates that delayed concussion reporting leads to longer recovery times and increased symptoms.³⁹ 

Concussion education should extend beyond LEOs themselves to other stakeholders, such as supervisors, on-site medical providers (eg, physicians, emergency medical technicians), and medical providers affiliated with the Bureau of Workers’ Compensation, who may be responsible for concussion recognition and removal from duty in LEOs. Beyond recognizing signs and symptoms of concussion, this training could also include how to initiate a concussion RTD protocol and best practices for recovery, LEO-specific safety concerns, such as driving at high speeds and weapons fire, and the potential for persisting symptoms and prolonged recovery if appropriate management is not initiated. All stakeholders should document their concussion education and training through an annual acknowledgement, similar to the requirements for athletes, parents, and coaches in many sporting organizations. Finally, it is important to make educational resources for both LEOs and other stakeholders available in an easily accessible location. Possible solutions include an organization’s intranet or mobile applications (eg, custom or commercial smartphone applications), where LEOs can easily reference them when needed.

Despite a robust body of literature suggesting better concussion outcomes following a graduated return to activity protocol in athletes and military personnel, to our knowledge, few law enforcement organizations have established concussion RTD protocols.^10,11,40,41  Implementing such a protocol in this population may be highly important due to job requirements, including high-speed driving, marksmanship, stress, critical decision-making, and irregular sleep/shift work. Here, we propose a graduated concussion RTD protocol for LEOs (Table). Although this framework is flexible enough to fit the needs of various roles (eg, SWAT, patrol, and criminal) and law enforcement organizations (eg, sheriff’s office, police department), it may require careful consideration for how to implement based on the specific needs of each role/organization.

The protocol, based on the US Department of Defense’s concussion RTD protocol with modifications based on the most recent Consensus Statement on Concussion in Sport, consists of 6 stages, progressing from relative rest to full duty.^2,42  Each step of the protocol should allow for a minimum of 24 hours, and if symptoms worsen, LEOs should return to the previous stage. At stage 3, LEOs may transition to return to work with symptom-based work limitations (eg, light duties). Although there is insufficient evidence to make recommendations for a particular timeframe from concussion to return to driving, LEOs should abstain from any type of driving until dizziness or visual symptoms have resolved.^43–47  Additionally, because a robust body of literature suggests that sleep disturbances and clinical sleep and circadian disorders are common after concussion and lead to worse outcomes, alternating shift work or shifts exceeding 8 hours could worsen symptoms or impede recovery and should be avoided.⁴⁸  Further, activities that may lead to additional head impacts or injuries (eg, defensive tactics training, weapons fire) may also worsen symptoms or impede recovery and should be avoided until LEOs can undergo an RTD screening with a medical provider. Consistent with recommendations by the Concussion in Sport Group, when concussion-related symptoms persist for more than 2 to 4 weeks after injury, LEOs should be referred to a medical provider with expertise in concussion management.^2,49,50  These medical providers can recommend targeted treatment for specific symptoms (eg, vestibular therapy for persisting dizziness, vision training for persisting visual symptoms).

Implementing a concussion RTD protocol within a law enforcement organization will require the support of multiple key individuals (eg, sheriff or chief) and groups (eg, unions, human resources, legal department). When beginning the process of establishing an RTD protocol, clear goals must be outlined. These goals should be presented in a multifaceted way that addresses the needs and concerns of LEOs in various roles. For example, an LEO on patrol may be more interested in faster symptom reduction, whereas a state commission member may be more interested in a reduction of potential accidents. Mandating a concussion RTD protocol may also be met with resistance by the unions; however, unions should consider advocating for change in this area to protect the health of officers. Identifying specific interests of different law enforcement groups requires open and transparent dialogs at every career stage and experience level. Goal setting and process evaluation can be more precise if an implementation team is formed of motivated individuals with experience in different stakeholder groups. The implementation team will play a pivotal role in establishing the requisite trust between LEOs and any RTD protocol efforts.

In implementing a concussion RTD protocol, determining the roles and responsibilities of stakeholders will be crucial.³⁰  Regarding removal from duty, LEOs can either self-report symptoms to supervisors or supervisors can recognize signs and symptoms in their LEOs and take them off duty. If available, on-site medical providers (eg, at jails) or emergency medical technicians (eg, at the scene of motor vehicle accidents) can also assist in identifying concussion signs and symptoms and removing LEOs with suspected concussions from duty. Without on-site medical care, such as ATs, LEOs themselves may need to implement the concussion RTD protocol, which would require additional tools and training. Organizations or medical providers can offer suggested physical activities and light duties for each stage to facilitate this process. Whenever feasible, law enforcement organizations should provide on-site access to medical providers with experience and expertise in concussion management and RTD progressions, such as ATs, to reduce medical costs and enhance injury recovery.⁵¹  For full RTD, LEOs should obtain medical clearance from a physician or other licensed medical provider. Lastly, evaluating the impact of implementing a concussion RTD protocol is important.³⁰  Collaborating with researchers can enable law enforcement organizations to test and refine their concussion RTD protocol and prove efficacy in LEOs as done previously by the Department of Defense.¹⁰ 

Documentation of the concussion or potentially concussive event will be crucial for Bureau of Workers’ Compensation reimbursements. At a minimum, the documentation should include a description of the event, any alteration of consciousness or memory, and the presenting symptoms. Organizations can refer to The American Congress of Rehabilitation Medicine diagnostic criteria for mild traumatic brain injury to obtain detailed information about potential mechanisms of injury, clinical signs and symptoms, and findings from clinical examinations.⁵² 

Here, we present a framework for concussion management in LEOs, including concussion education and RTD protocol implementation. Implementing an athlete-healthcare model for LEOs and other public safety personnel in various injury management contexts stands the potential to enhance their performance and health throughout their careers and lifetime, which will improve retention rates and extend career longevity. It is evident that LEOs often experience inadequate or delayed access to medical care, resulting in prolonged recovery and unfavorable long-term outcomes. By raising awareness and advocating for initiatives, such as on-site ATs, we may be able to mitigate the serious long-term consequences of injury for these individuals. As alluded to throughout this clinical commentary, having an AT on-site offers numerous advantages for law enforcement organizations. ATs have expertise in injury risk reduction, rehabilitation, and return-to-play/activity protocols, allowing them to provide education and immediate care and management of injuries, including concussions, ultimately reducing recovery times and improving outcomes.

It is important to note that the proposed protocol will require careful consideration for how to implement based on the specific needs of each role/organization. For example, organizations must consider how to implement work limitations based on symptoms, such as what light duties are feasible as LEOs transition to return to work, and how to facilitate training activities within a supervised environment, such as training on driving courses and in shooting simulators. Law enforcement organizations will also need to consider how to schedule RTD evaluations promptly and establish a referral process for cases requiring additional concussion management. When available, ATs can assist in concussion management planning and implementation.

The primary focus of this clinical commentary was to provide a comprehensive framework for ATs to contribute to concussion management in LEOs and to identify LEO-specific considerations for concussion management. Although this is a first step in improving concussion management in LEOs, there is much room for future research. For example, we must assess the impact of implementing a concussion RTD protocol. This evaluation can be conducted using quantitative data, which includes analyzing the number of concussions and recurrent concussions, measuring time loss and medical costs, tracking symptoms and other health outcomes, identifying complications arising from unreported or undiagnosed concussions, and assessing knowledge, attitudes, or behaviors surrounding concussions. Correct expectations must be set about the result of a successful implementation. There is the potential that implementing an RTD protocol will increase the number of concussions detected because of increased reporting. This possibility must be clearly articulated to law enforcement organizations before the collection of any concussion metrics. The purpose of an RTD protocol is to improve the overall health of LEOs after a concussion. Clearly articulating this goal and vision to all LEOs within an agency is important to successful implementation.

Additionally, qualitative data gathered through interviews and focus groups can provide valuable insights into the experiences of LEOs with concussions before and after concussion RTD protocol implementation. We also need additional data on the value of baseline data in this population and specific protocols for return to driving and return to shooting. To address these important questions, researchers must work collaboratively with law enforcement organizations to advance the field of concussion management for LEOs and enhance their overall well-being.

Concussions can significantly impact LEO performance and well-being. Implementing a concussion RTD protocol, like those used in sporting and military contexts, may aid LEOs in achieving a faster recovery and a safer RTD. We have proposed such a protocol, but it is important to adapt it to the specific requirements of different law enforcement roles and organizations and to test its effectiveness during implementation. The fundamental principles of current concussion management involve promptly removing individuals from activity upon suspicion of a concussion and obtaining medical clearance from a physician or other licensed medical provider before resuming activity. Comprehensive concussion education and training for all stakeholders is crucial in recognizing, diagnosing, and managing concussions effectively. We strongly believe that implementing a concussion RTD protocol, along with a comprehensive education and training plan, will facilitate quicker recovery, yield better short- and long-term outcomes, and ultimately improve readiness and career longevity for LEOs.

We would like to acknowledge the Franklin County Sheriff’s Office for partnering with our research group on this important and impactful work.

This work was supported by the Assistant Secretary of Defense for Health Affairs endorsed by the Department of Defense through the Traumatic Brain Injury and Psychological Health Research Program under Awards HT9425-23-1-0520 and HT9425-23-1-0521 and by Ohio State’s Chronic Brain Injury Pilot Award Program. Opinions, interpretations, conclusions and recommendations are those of the authors and are not necessarily endorsed by the Department of Defense or by Ohio State’s Chronic Brain Injury Program.