Occupational therapy interventions for return to work after acquired brain injury: A scoping review

Protocol and registration

This scoping review adhered to the methodological standards of the Cochrane Collaboration (Higgins et al., 2023) and was reported in alignment with the PRISMA-ScR guidelines, incorporating the corresponding checklist and flow diagram (Tricco et al., 2018). The protocol was prospectively registered on the Open Science Framework (available at: https://doi.org/10.17605/OSF.IO/SU8Z3).

Eligibility criteria

This scoping review included peer-reviewed original research limited to randomized controlled trials (RCTs), without restrictions on language or publication date up to November 2025. Exclusion criteria encompassed non–peer-reviewed sources and non-RCT designs, including conference abstracts, books and book chapters, editorials, letters, protocols, reviews, case reports, and other non-randomized studies. Study selection followed the Population, Intervention, Comparator, Outcome, Study design (PICOS) framework, as summarized in Table 1.

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Table 1.

Selection criteria used in the scoping review.

Criteria	Inclusion criteria	Exclusion criteria
Population	Studies were included if they involved people with acquired brain injury, either with a mean age of 18 years or older.	Pathologies other than acquired brain injury, including neurodegenerative diseases, dementias, and similar conditions.
Intervention	Studies involving OT interventions for return-to-work interventions lasting four weeks or more.	Studies that include other types of complementary interventions, not related to OT interventions for return-to-work.
Comparison	Interventions with active or inactive control groups.	Lack of baseline and/or follow-up data. Absence of control group.
Outcomes	Types of OT interventions for return to work (i.e., ESSVR, RETAKE, CCT-SE).	Lack of baseline data and/or follow-ups.
Study design	RCTs with pre- and post-assessment.	Controlled, retrospective, prospective and cross-sectional, non-randomized studies.
Level of evidence	1a	1b, 2a, 2b, 3a, 3b, 4, and 5

CCT-SE: combined compensatory cognitive training and supported employment; ESSVR: early stroke specialist vocational rehabilitation; OT: occupational therapy; RCTs: randomized controlled trials; RETAKE: return to work after stroke.

Information and database search process

An electronic search was performed across four databases: Scopus, Web of Science (Core Collection), MEDLINE/PubMed, and OTseeker. Using a strategy that integrated Medical Subject Headings (MeSH) from the U.S. National Library of Medicine with relevant keywords describing OT interventions aimed at facilitating return to work after ABI: (“stroke” OR “stroke” OR “cerebrovascular accident” OR “cerebral infarction” OR “brain ischemia” OR “ischemic stroke” OR “hemorrhagic stroke” OR “cerebral hemorrhage” OR “acquired brain injury” OR “acquired brain damage” OR “brain injury” OR “traumatic brain injury” OR “traumatic brain injury” OR “non-traumatic brain injury” OR “anoxic brain injury” OR “hypoxic brain injury” OR “encephalitis”) AND (“return to work” OR “return to work” OR “work reintegration” OR “vocational rehabilitation” OR “job reintegration” OR “occupational reintegration” OR “workforce reentry” OR “employment outcomes”) AND (“middle aged” OR “middle-aged adults” OR “middle age” OR “working-age adults” OR “midlife adults”). Two independent experts evaluated the articles for eligibility based on the predefined inclusion and exclusion criteria. Both reviewers held a Ph.D. in health sciences and had published in Journal Citation Reports^® indexed journals. To reduce bias, they were not given access to the search strategy. A final search was conducted on November 30, 2025, to identify any errata or retractions associated with the included studies.

Study selection and data collection process

All studies were imported into Zotero Reference Manager (Version 7.0.30, Roy Rosenzweig Center for History and New Media, George Mason University), and the selection process is depicted in the PRISMA flow diagram. Four researchers (M.M., V.O., K.R., and M.R.) and a field expert (E.V.-C.) independently screened the records. Duplicate entries were removed in Zotero. The screening proceeded in two stages: an initial review of titles and abstracts, followed by full-text evaluation based on the predefined inclusion criteria. Studies that met the eligibility criteria and achieved consensus among reviewers were included in the final analysis (Figure 1).

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Figure 1.

Flowchart of the scoping review (Page et al., 2021).

Methodological quality assessment

Methodological quality and evidence level were assessed using the Oxford Center for Evidence-Based Medicine criteria (Manterola and Zavando, 2009). Only Level 1a RCTs were included, while studies classified as levels 1b–5 were excluded. Trials were downgraded when issues related to bias, consistency, precision, or reporting transparency were identified.

Data synthesis

Data from the included studies were extracted into a standardized form using Microsoft Excel^® (version 16.81; Microsoft Corporation, Redmond, WA, USA), following Cochrane methodological guidance (Higgins et al., 2023). Four reviewers (M.M., V.O., K.R., and M.R.) independently conducted the extraction and cross-checked the results for consistency. The extracted information included (i) author and year, (ii) country, (iii) study design, (iv) intervention components, (v) sample size per group, (vi) intervention characteristics, and (vii) outcome measures.

Study selection

The database search yielded 1341 records, of which 87 were removed as duplicates. The remaining 1254 records underwent title and abstract screening, resulting in the exclusion of 1219 articles (798 based on title and 421 based on abstract relevance). Thirty-five full-text articles were assessed, and 28 were excluded for failing to meet the inclusion criteria, 10 due to insufficient methodological focus, 13 for addressing unrelated subject matter, and 5 for employing non-eligible study designs. Consequently, 7 studies met all criteria and were retained for the scoping review (Clarke et al., 2024; Craven et al., 2021; Fure et al., 2021; Pyne et al., 2024; Radford et al., 2018, 2024; Vikane et al., 2016).

Methodological quality

The methodological rigor of the studies included in this scoping review is considered high. All the investigations adopted RCT designs, ensuring a robust evidentiary foundation consistent with Level 1a standards of the Oxford Center for Evidence-Based Medicine (Clarke et al., 2024; Craven et al., 2021; Fure et al., 2021; Pyne et al., 2024; Radford et al., 2018, 2024; Vikane et al., 2016).

Characteristics of the studies

Seven RCTs were conducted in adult populations who had been employed prior to experiencing a stroke or traumatic brain injury. The study populations comprised individuals returning to work following stroke, adults with traumatic brain injury, and therapists involved in vocational rehabilitation. Participant ages ranged from 32 to 56.4 years. All the trials were conducted in two countries: the United Kingdom and Norway (Table 2).

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Table 2.

Selected studies on occupational therapy interventions for return to work after acquired brain injury.

References	Country	Study design	Initial sample	Mean age (years)	Type of intervention	Training volume			Main results
						Weeks	Frequency	Session duration
Clarke et al. (2024)	United Kingdom	RCT	People who had been working before the stroke	56.4	ESSVR	10 sessions	1 session, every 2 or 3 weeks	40–60 minutes	↑ Impact of the stroke on the individual and their work ↑ Continuous monitoring of the reintegration process ↑ Coordination with employers for reasonable adjustments and support during reintegration into the workforce ↑ Preparation for return to work ⇔ Education for patients, families, and employers about stroke and coping strategies
Craven et al. (2021)	United Kingdom	RCT	Adults with stroke	NR	Mentoring for occupational therapists implementing ESSVR after stroke	March 2018–April 2020	Monthly mentoring sessions	60 minutes	↑ Fidelity and adherence to the intervention ↑ The experiences of therapists and mentors during mentoring, and the time and modality of support provided, in order to identify facilitators and barriers in its implementation
Fure et al. (2021)	Norway	RCT	People with traumatic brain injury	43	CCT-SE	10 weeks	1 session/week	2 hours	↑ Proportion of patients who returned to work ⇔ Weekly working hours and percentage of work ⇔Days to pre-injury work levels ↑ Job stability
Pyne et al. (2024)	United Kingdom	RCT	Adults with stroke	54	Early individualized intervention, plus usual care alone	Start at 8 weeks post stroke, up to 12 months	Frequency varies according to the patient’s needs	Duration varies depending on the patient’s needs	↑ Disease-specific resource use data and EQ-5D-5L ↑ QALYs
Radford et al. (2018)	United Kingdom	RCT	Adults who suffered a brain injury	40.4	ESTVR focused on job retention	Start at 8 weeks post stroke, up to 12 months	Frequency varies, depending on the patient’s needs	Duration varies depending on the patient's needs	↑ Mood (HADs) ⇔ Activities of daily living (NEADL) ↑ Social participation (CIQ) ↑ Quality of life (EQ-5D-3L) ↑ Work self-efficacy ↑ Caregiver burden index (CSI)
Radford et al. (2024)	United Kingdom	RCT	Adults with stroke	54	Individualized intervention led by occupational therapists (ESSVR), delivered in the context of community care	7 weeks	Frequency varies, depending on the patient's needs	Individualized intervention, in-person and remote modality	↑ Mood (HADs) Functionality (NEADL) ↑ Social Participation (CIQ) ↑ Work Self-Efficacy (WAI) Post-Stroke Confidence (CASM) ↑ Caregiver Burden (MSCI)
Vikane et al. (2016)	Norway	RCT	Adults with traumatic brain injury	32	Multidisciplinary intervention versus usual care (CG with general indications)	4 weeks	4 group sessions over 4 weeks	Duration varies depending on the patient’s needs	↑ RTW ⇔ HADs ↑ PTSS-10 ⇔ GOSE ↓ Pain

CASM: confidence after stroke measure; CCT-SE: combined compensatory cognitive training and supported employment; CG: control group; CIQ: community integration questionnaire; CSI: caregiver strain index; EQ-5D-3L: EuroQol 5 dimensions, 3 levels; EQ-5D-5L: EuroQol 5 dimensions, 5 levels; ESSVR: early stroke specialist vocational rehabilitation; ESTVR: early specialist traumatic brain injury vocational rehabilitation; GOSE: Glasgow outcome scale – extended; HADS: hospital anxiety and depression scale; MSCI: modified caregiver strain index; NEADL: Nottingham extended activities of daily living; NR: not reported; PTSS-10: post-traumatic stress symptoms 10-item scale; QALYs: quality-adjusted life years; RCT: randomized controlled trial; RTW: return to work; WAI: work ability index.

Overview of included studies and thematic mapping of occupational therapy interventions for return to work after acquired brain injury

All included studies evaluated OT interventions for return to work after ABI. The evidence, comprising RCTs and pilot studies published between 1979 and 2025, reflects the current relevance and development of this research area. The database with the largest number of records was Scopus. A thematic map was generated using VOSviewer (Version 1.6.20, Center for Science and Technology Studies, Leiden University) to represent the conceptual structure of OT interventions for return to work after ABI. Figure 2 presents the general thematic organization of these interventions, while Figure 3 illustrates the grouping of specific intervention types (e.g., early stroke specialist vocational rehabilitation (ESSVR), RETurn to work After stroKE (RETAKE), and combined compensatory cognitive training and supported employment (CCT-SE)). Both figures were derived from the selected descriptors and their co-occurrence patterns.

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Figure 2.

Topical distribution of the literature on occupational therapy interventions for return to work after acquired brain injury.

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Figure 3.

The literature on specific intervention types (e.g., ESSVR, RETAKE mentorship, and CCT-SE).

Occupational therapy interventions in job reintegration for people with acquired brain injury

The studies analyzed indicate that OT interventions aimed at facilitating return to work following a stroke or traumatic brain injury are predominantly defined by specialized, sustained, and personalized approaches. Clarke et al. (2024) reported that participants enjoyed ESSVR, a form of job assistance that involves evaluating functional performance, collaborating with employers, and receiving individualized support from a therapist. This program helped people get back to their old jobs or find new ones when full reintegration was not possible. In the study by Craven et al. (2021), the RETAKE program, a training and mentoring framework designed to strengthen occupational therapists’ capacity to deliver complex vocational rehabilitation, was identified as a key component for supporting implementation in this field. Fure et al. (2021) demonstrated that CCT-SE a dual approach that integrates cognitive strategy training with individualized employment support promoted a faster return to competitive work, suggesting an accelerating effect on early vocational recovery. Conversely, Pyne et al. (2024) observed no significant differences between early vocational rehabilitation and usual care regarding return to work at 12 months and reported low cost-effectiveness for ESSVR. Findings from Radford et al. (2018) and Radford et al. (2024) similarly showed high return-to-work rates across both groups, with no evidence of superiority for specialized vocational rehabilitation over usual care, although certain subgroups such as older people or individuals with greater post-stroke impairment appeared to benefit more from the structured support characteristic of ESSVR. Lastly, Vikane et al. (2016) identified psychological distress and a history of prior work disability as negative predictors of job reintegration, while pain and neuroimaging findings did not demonstrate predictive value. The reviewed studies show that vocational rehabilitation programs based on specialized support, mentorship, and combined strategies (including ESSVR, RETAKE, and CCT-SE) can facilitate early return to work among individuals with neurological sequelae. However, more recent trials indicate that overall return-to-work rates are generally comparable to those achieved with usual care, with benefits mainly observed in specific subgroups. Additionally, psychological factors and a history of prior work disability emerge as negative predictors of successful return to work.

Effects adverse and adherence

Adherence reached 88% across the seven RCT with no harmful effects reported. These findings highlight the feasibility and tolerability of the interventions for adults returning to work after ABI, reinforcing their potential for broader clinical implementation.

Role of occupational therapy and effectiveness of early interventions

The findings of this review reinforce the central role of OT in early vocational rehabilitation programs following ABI, particularly when these include specialized support strategies, functional cognitive training, and systematic coordination with the workplace. Evidence consistently shows that the most effective interventions are those initiated early, tailored to job demands, and aligned with individual worker needs, incorporating mediation between the patient, family, and employers (Clarke et al., 2024). Nonetheless, some studies highlight the need to consider program efficiency and cost-effectiveness when implementing these approaches (Pyne et al., 2024). The review identified a comprehensive mapping of various Occupational Therapy interventions aimed at reintegration into the workforce, including the ESSVR and RETAKE models, and combined CCT-SE interventions. These strategies, while heterogeneous in structure, share a focus on addressing early on the functional, cognitive, and contextual barriers that limit the return to work after a stroke or ABI. Together, they constitute essential intervention processes that integrate functional assessment, individualized planning, ongoing support, and intersectoral coordination, allowing not only for optimized occupational recovery but also facilitating a sustainable reintegration adapted to the demands of the work environment.

Quality of evidence, intervention modalities, and qualitative contributions

The systematic review by Pearce et al. (2023) underscores the scarcity of high-quality studies on return to work after stroke, marked by methodological heterogeneity and a lack of standardized definitions for work reintegration. Still, individualized and multidisciplinary interventions led by occupational therapists such as environmental assessment, task adaptation, and employer coordination show promising but still inconclusive results. Studies on traumatic brain injury further reinforce this perspective: Mullins et al. (2025) demonstrate that combining cognitive rehabilitation, vocational training, and workplace adaptations supports safer and more sustainable work reintegration, with occupational therapists playing a central role in planning and monitoring the process. Additionally, Powers et al. (2022) highlight the importance of implementation fidelity within ESSVR programs, while the qualitative insights of Kurihara et al. (2024) identify six key domains of OT support from work performance to compensatory strategies illustrating therapists’ multifaceted role as guides, mediators, and facilitators of social and occupational participation. Importantly, the studies suggesting greater benefit in specific subgroups, such as older adults or individuals with greater post-stroke impairment, involved interventions of varying duration, ranging from short, structured programs of 4–10 weeks to individualized vocational rehabilitation delivered over several months and up to 12 months. Therefore, the current evidence does not allow firm conclusions regarding an optimal intervention duration for these populations; rather, benefit appears to depend on a combination of early initiation, individualized support, and coordination with workplace demands.

Psychosocial factors and needs for a sustainable practice

A recurring theme across studies is the relevance of psychosocial and emotional factors in determining return-to-work outcomes (Morris et al., 2012). Self-efficacy, social participation, and reconstruction of occupational identity emerge as facilitators, while psychological distress, global disability, and prolonged sick leave act as barriers (Matos et al., 2024). These findings highlight the need for comprehensive interventions that integrate physical, cognitive, and emotional dimensions, addressing stress regulation and beliefs about work ability (La Torre et al., 2022). Finally, the evidence emphasizes the importance of ongoing professional development, mentorship, and clinical supervision for occupational therapists to ensure the quality and fidelity of interventions. Together, these elements point to a person-centered, integrated, and sustained approach that optimizes return-to-work outcomes and reduces persistent barriers following ABI.

Limitations and strengths

This review has several limitations. Heterogeneity in intervention characteristics, outcomes, and patient profiles limits direct comparison across studies and prevents firm conclusions regarding the superiority of any single vocational rehabilitation model. In addition, all included studies were conducted in the United Kingdom and Norway, which may reflect country-specific rehabilitation systems and labor contexts, thereby limiting the transferability of the findings to other settings. Nevertheless, the inclusion of randomized controlled trials, together with the consistent reporting of good adherence and the absence of adverse effects, supports the feasibility of occupational therapy-based vocational rehabilitation after ABI. Therefore, the evidence should be interpreted as supportive, but not definitive, particularly with regard to the optimal intervention format, duration, and subgroup-specific effects.

Practical applications

From an OT perspective, the findings of this scoping review emphasize the importance of early, individualized, and contextually grounded vocational rehabilitation for adults recovering from stroke or traumatic brain injury. Programs such as ESSVR and ESTVR reported that structured interventions integrating workplace assessment, employer coordination, cognitive strategy training, and patient-family education can facilitate a safer and more efficient transition back to employment. The results also support the value of mentorship frameworks like RETAKE, which strengthen therapist competencies and ensure fidelity in the delivery of complex vocational intervention. Furthermore, interdisciplinary collaboration particularly among occupational therapists, employers, case managers, and mental health professionals emerges as a key component for addressing the psychosocial, cognitive, and environmental barriers that commonly hinder return-to-work trajectories. These interventions can be adapted to community-based, hybrid, or remote formats, allowing flexible implementation according to patient needs and service availability. Importantly, the evidence highlights the relevance of addressing emotional well-being, self-efficacy, and occupational identity reconstruction, all of which contribute to sustainable work participation ABI.

Research and policy implications

At the research level, this review highlights the need for larger, methodologically consistent trials that employ standardized definitions of return-to-work and long-term follow-up beyond 12 months. Future studies should explore subgroup effects, as evidence suggests that older people and individuals with higher post-stroke impairment may derive particular benefit from structured vocational rehabilitation. Incorporating mixed-methods approaches and implementation research such as fidelity evaluations like those conducted in the RETAKE trial will be essential to understanding how vocational interventions function in real-world contexts.

At the policy level, these findings underscore the importance of integrating OT interventions and vocational rehabilitation services into standard care pathways for individuals recovering from stroke and traumatic brain injury. Given the comparable return-to-work rates between specialized and usual care observed in more recent trials, policymakers should prioritize identifying which subpopulations benefit most and ensure equitable access to tailored services. Additionally, early coordination with employers, financial support systems, and community resources should be embedded into national return-to-work frameworks. Investment in cost-effectiveness studies is also needed to determine the economic sustainability of large-scale implementation of interventions such as ESSVR and CCT-SE within healthcare and social security systems.