Vocational rehabilitation and return to work: integrative review

ABSTRACT |

Analysis of population growth trends and aging—which is associated with occurrence of chronic diseases, in addition to (work-related or not) diseases and accidents in general—points to an increasing need to implement rehabilitation services worldwide. Rehabilitation comprises three aspects: medical, vocational and social. The aim of the present study was to describe the state of the art in vocational rehabilitation approaches in several countries, as well as vocational rehabilitation-based return-to-work strategies for individuals with restrictions due to diseases and accidents in general developed in the past 30 years. We performed an integrative review of studies located in databases Virtual Health Library-Regional Library of Medicine (VHL-BIREME), PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, Web of Science, Sociological Abstracts, Education Resources Information Center (ERIC) and SCOPUS. A total of 1,109 studies were initially retrieved, of which 12 were considered eligible on methodological assessment and included for review. The selected studies analyzed new approaches and the implementation of existing programs, new programs/projects, and educational measures for workers on sick leave. Most programs had multidisciplinary nature and included complementary educational approaches, early intervention, and possibility of workplace adjustments. The studies on new projects consisted in job retention and return-to-work programs for unemployed or temporary workers. The number of studies which describe occupational rehabilitation programs is small and evaluating their efficacy is difficult. Scientific research on this subject is still scarce vis-à-vis the current demands.

INTRODUCTION

According to the United Nations, understanding the demographic changes which will take place in the coming years, as well as challenges and opportunities to attain sustainable development is indispensable in the present time. The global population was 7.3 billions in mid-2015, with a growth of about 1 billion along the past 12 years. 901 millions were individuals aged 60 or over, corresponding to 12% of the global population, with a growth rate of 3.26%/year¹.

The number of older adults is estimated to reach 1.4 billion in 2030, 2.1 billions in 2050 and possibly 3.2 billions by 2100. While Europe exhibits the largest proportion of individuals aged 60 or over (24%), the population is aging quickly also in other parts of the world¹. Increased life expectancy and aging associated with low fecundity rates represent a call for specific public policies². By 2050, one-fourth of the population in the main global regions, except for Africa, will be of people aged 60 or over¹. These changes will have substantial impact on pension and social security systems worldwide.

According to a World Health Organization/World Bank report on disability,

more than 1 billion people, or about 15% of the world’s population, are estimated to be living with disability. Of these, 110–190 million adults have very significant difficulties in functioning. These numbers are expected to growth as a function of global population aging, increasing incidence of chronic diseases, and environmental factors, such as road traffic injuries, climate changes, natural disasters and conflict situations³.

Actions centered on disease prevention in and outside the workplace, through occupational health and safety and public health interventions, respectively, are essential. Measures focused on rehabilitation and return to work have paramount importance when disease does occur.

Work is considered a significant means for people to meet their basic needs. In addition, it is extremely relevant to their financial, psychological and emotional well-being, besides being crucial for the development of self-esteem, social status, feeling of personal accomplishment, independence, freedom and security⁴.

Return to work encompasses all procedures and initiatives to facilitate the reintegration to work of persons with reduced work capacity or capability, whether this is due to invalidity, illness or aging⁵. This notion is relevant within the present-day political context, in which the focus is on maintaining the sustainability of social security systems and reducing the economic impacts of sick leaves and improperly managed return to work, which lead to unemployment, disability pension or early retirement⁴.

In many countries, the entry point for the question of return to work at policy level is the lack of sustainability of social security systems and the need to reform the management of sickness absence and disability⁵. Sick leaves due to chronic diseases and early retirement result in salary losses and have physical and emotional consequences for workers. In turn, employers have to meet the additional costs of high employee turnover rates and the time lost in managing absenteeism, besides the overall costs to society at large.

Disability retirement poses a heavy burden to society, to be added to the challenges presented by workforce aging⁵. Disabled workers retire while they still are relatively young, which considerably reduces the overall effective age of retirement. In addition to the costs to society, early retirement has significant impact on the workers themselves, inasmuch as work is a relevant source of material and psychological well-being.

A study performed in the European Union affords a wider perspective of vocational rehabilitation. According to the authors, while many international organizations discuss rehabilitation within the context of individuals with disabilities, in this study the authors considered all workers who were potentially at risk of exclusion from the labor market because of a health problem, rather than only those with an officially recognized disability. This is to say, all previously healthy workers requiring medium- to long-term sick leaves or regular shorter sick leaves (due to chronic diseases) and who needed support to go back to work at their previous or a different workplace, even when not been formally recognized as disabled⁵.

The high risk of contracting a disease while employed influences the rates of labor market exit due to health problems. And while not all cases of early retirement are due to health problems, they do make a substantial contribution⁵.

According to the Organization for Economic Cooperation and Development (OECD) many individuals with work incapacity leave permanently the labor market and few are able to return or remain in it⁶. Therefore, fostering inclusion and enlarging the workforce is a relevant item in scientific and political agendas, and there is strong interest in encouraging people to work with their residual capacity and avoid leaving the labor market permanently⁷.

Rehabilitation services should be increased worldwide, particularly in medium- and low-income countries. Rehabilitation should be available to all workers who need it⁸.

Rehabilitation… consists of three different aspects. Medical rehabilitation aims to restore the functional or mental ability and the quality of life of people with physical or mental impairments or disabilities; vocational (or occupational) rehabilitation aims to enable persons with physical or mental impairments or disabilities to overcome barriers to accessing, maintaining or returning to employment or other useful occupation; and social rehabilitation aims to facilitate the participation of people with disabilities in social life⁸.

The aims of the present study were to describe the state of the art in vocational rehabilitation, with emphasis on return to work, in different countries, and to analyze return-to-work strategies based on vocational rehabilitation for individuals with restrictions due to diseases or accidents in general developed in the past 30 years.

METHODS

Integrative reviews summarize the available empirical or theoretical information on a given subject⁹ and contribute to theoretical developments, in addition to having direct applicability in practice and policies¹⁰. Integrative reviews seek to synthesize and develop new knowledge out of the results of previous studies^11-13. It is the single approach that allows combining different methods, and this methodological combination plays a significant role in evidence-based practice¹⁴.

In the present integrative review we followed the steps described by Whittemore and Knafl¹⁰. To ensure methodological rigor and enable reproducibility, we describe each individual step.

Searched databases were: Virtual Health Library – Regional Library of Medicine (VHL-BIREME), PubMed, MEDLINE, Embase, Latin American and Caribbean Health Sciences Literature (LILACS), Cumulative Index to Nursing and Allied Healthcare Literature (CINAHL), PsycINFO, Web of Science, Sociological Abstracts, Education Resources Information Center (ERIC) and SCOPUS. Controlled search terms were obtained from Health Sciences Descriptors (DeCS)–BVS-BIREME, Medical Subject Headings (MeSH)–MEDLINE/PubMed and Emtree–Embase, combined by means of Boolean operators (AND, OR, NOT). No filters were selected. We included qualitative and quantitative studies published in Portuguese, English, Spanish, Italian, French or German from 1 January 1988 through 5 April 2018 (past 30 years). We also included studies retrieved by handsearching in the aforementioned databases independently from the defined search strategy. Chart 1 describes the eligibility criteria (inclusion and exclusion).

Chart 1. Eligibility criteria.

Inclusion	Exclusion
Studies on vocational rehabilitation with focus on return to work	Studies which exclusively addressed medical/physical rehabilitation
Adult workers (18 to 79 years old)	Studies which analyzed congenital physical or mental disabilities
Workers with definitive restrictions/stable sequelae of diseases or accidents in general involving any organ system	Studies which analyzed vocational rehabilitation for war veterans
Published from 1 January 1988 through 5 April 2018 (past 30 years)	Studies without available abstract
Published in Portuguese, English, Spanish, Italian, French or German	Tests, retests or instrument evaluations
	Case reports
	Dissertations, protocols, presentations and pilot studies
	Studies which analyzed costs
	Studies which analyzed client perception

Article selection was independently performed by two reviewers (first and second authors). Duplicates were excluded using EndNote^® and manually when it failed to detect them due to differences in spelling or use of abbreviations. Studies were initially selected following analysis of titles and abstracts as per the inclusion and exclusion criteria. The thus selected articles were subjected to full-text analysis as per the exclusion criteria. The extracted information was summarized for later analysis.

Reporting was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) to improve its quality^15,16.

We applied two search strategies which combined the most frequently used search terms related to the subject of interest:

• simple •

  Search strategy #1: Return to Work AND Rehabilitation, Vocational;

• simple •

  Search strategy #2: Return to Work AND Rehabilitation, Vocational AND Social Security.

The search strategies were developed from headings representing the subject of interest, and a protocol was created to guide the review, which also included the results of cross-checking both strategies to broaden the scope of the search.

The strength of evidence of the selected studies was established following the Johns Hopkins Nursing Evidence-based Practice: Model and Guidelines¹⁷.

RESULTS

The selected search strategies allowed retrieving 2,642 studies. Duplicates were excluded using EndNote^® and manually. A total of 1,109 studies were selected for title and abstract analysis, of which 33 were subjected to full-text analysis. As a result, 11 studies were selected for integrative review. Through handsearching we located 5 further studies, one of which was selected for analysis. Therefore, 12 studies were finally included for integrative review.

Table 1 describes the results of the search strategies applied to the selected databases. Figure 1 consists in a flowchart representing article selection following PRISMA.

Table 1. Results of the application of the search strategies to databases.

Databases	Strategy	Number of selected studies
PubMed	1	528
	2	38
Virtual Health Library (VHL–BIREME)	1	455
	2	39
Cumulative Index to Nursing and Allied Healthcare Literature (CINAHL)	1	315
	2	31
Scopus	1	725
	2	52
Web of Science	1	136
	2	12
Embase	1	96
	2	4
PsycINFO	1	157
	2	9
Education Resources Information Center (ERIC)	1	8
	2	5
Sociological Abstracts	1	20
	2	12
Total (search data)		2,642
Duplicates removed with EndNote®		794
Manually removed duplicates		739
Articles selected for analysis		1,109

ERIC: Education Resources Information Center.

Figure 1.

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flowchart.

The vast majority of the 1,109 preselected studies following title and abstract analysis dealt with return to work and corresponding strategies, and many described medical rehabilitation. However, most did not describe or provide details on vocational rehabilitation, but merely cited this topic as part of a wider perspective on return to work.

The subjects most frequently addressed in the excluded studies were spinal cord injury, stroke, acute myocardial infarction and orthopedic conditions.

The analyzed studies were conducted in several countries: Germany (2), Norway, Netherlands, United Kingdom, France, Australia, Denmark, United States and China (1 each).

Two studies addressed rehabilitation programs for workers with musculoskeletal problems, 2 neurological problems, 1 mental disorders, 1 cancer and 2 diseases in general. Systematic reviews focused on return to work and chronic diseases, and 1 study analyzed educational “trainings.”

Chart 2 describes the studies included in the integrative review according to author, publication year, country, aims, sample, study design, type of analysis and results.

Chart 2. Summary of studies included in the integrative review (n=12).

Author, year, country, subject, strength of evidence	Aims and setting	Sample	Design	Analysis	Results
Arling et al.18 2016 Germany Implementation of rehabilitation program RehaFutuReal® within the organizational structure and counseling process Strength of evidence: III	Assessment of a new counseling concept (RehaFutuReal®) developed by Westphalia Pension Insurance, in which rehabilitation managers are the central protagonists in the counseling process Dortmund/Westphalia	10 rehabilitation managers 320 insurants	Non-experimental	Donabedian’s 3-stage concept (structure quality, process, results); summative (pre-post comparison) and formative (process-oriented) evaluation	Rehabilitation managers identified with the implementation process, and also the consultants. Also the employers rated the counseling performance positively
Böttcher et al.19 2013 Germany Evaluation of a vocationally oriented concept within inpatient oncological rehabilitation Strength of evidence: II	Evaluation of an occupation-related rehabilitation program to enhance the return to work of cancer patients Hamburg	309 patients (intervention and control groups)	Quasi-experimental	Non-parametric tests, Student’s t-test, χ2 test, analysis of variance, binary logistic regression	Intervention did not have significant impact on return-to-work rates. Positive effects of specific occupational orientation on group intervention, which reported positive self-evaluation of performance, which might be rated a partial success of intervention. Positive self-evaluation of performance as such favors reintegration. The occupation-related rehabilitation program enhanced subjective variables, as e.g. patient satisfaction with information and improved work capacity
Braathen et al.20 2007 Norway Effects of a multidisciplinary vocational rehabilitation program Strength of evidence: II	To evaluate a vocational multidisciplinary rehabilitation program for patients on long-term sick leave with respect to their work ability and return to work Oslo	Group intervention (GI): 183 patients (Rauland Vocational Rehabilitation Center) Control group (CG): 96 patients (national sickness insurance)	Clinical trial; GI non-randomized, CG randomized	Descriptive statistics, Student’s t-test, analysis of variance (ANOVA), Cohen statistic, χ2 test, logistic regression analysis	Work capacity and return to work improved in both groups, but work capacity improvement was significantly higher in GI. 80% of GI returned to work vs. 66% in CG after 4 months
Cameron et al.21 2012 United Kingdom Job retention project for workers with mental health problems Strength of evidence: III	To understand experiences and perspectives of job retention project users in relation to challenges faced and support received; to develop explanatory insights into effective interventions Brighton	14 job retention project users, with a range of mental health problems, including depression, bipolar disorder and schizoaffective disorder	Qualitative (semi-structured individual interviews)	Deductive and inductive thematic analysis, constant comparative analysis	Themes: difficulties in the workplace; support to gain self-confidence, communication skills and problem solving; analysis of work and identification of changes which might contribute to return to work; sharing job retention issues with the employer; feedback on skills and competences; impacts and outcomes in terms of job retention. 10/14 participants retained employment. This type of project should include support for workers to maintain their identity and vocational aspirations. Multi-faceted job retention interventions seem to have better results than individual approaches, such as cognitive behavioral therapy (CBT) alone
Cogné et al.22 2017 France Unités d’Êvaluation, de Reclassement et d’Orientation Socioprofessionnelle (UEROS) programme Strength of evidence: III	To evaluate the 5-year outcome of persons with brain injury included in 2008 in the Aquitaine Unit for Evaluation, Training and Social and Vocational Counseling Programme (UEROS) (focus on return to work, life satisfaction, psychosocial and community integration) Bordeaux	57 persons with brain injury who completed UEROS vs. 75 persons contacted 5 years after completing the 1997–1999 program	Observational Questionnaires: EBIS (European Brain Injury Society) and community integration	Descriptive statistics, χ2, test, Kruskal-Wallis test, Mann-Whitney test	The program had several strengths. The study describes the progression of a population with brain injury long time since injury, and assessed the management of a vocational and social rehabilitation program 5 years after admission. This was one among the few studies which analyzed psychosocial and community integration long time after brain injury among the individuals who completed a rehabilitation program. The program was effective in terms of return to work, autonomy and rehabilitation irrespective of the length of time since injury
Gensby et al.23 2014 Workplace disability management programs Strength of evidence: III	To analyze the nature and effectiveness of workplace disability management programs promoting return to work as implemented by employers	16,932 records identified on initial screening; 559 papers assessed for relevance; 12 articles included in review	Systematic review, Campbell Collaboration	Articles were independently analyzed by 2 reviewers	The efficacy of programs could not be assessed due to lack of evidence and high risk of bias. However, there were rich descriptions of implementation issues, program components, procedures and human resources. The authors encourage researchers to analyze the independent and synergic effects of program components to establish their most effective combination
Hilton et al.24 2017 Australia Early intervention vocational rehabilitation of patients with traumatic spinal cord injury Strength of evidence: II	To explore longitudinal outcomes for people who received early intervention vocational rehabilitation and examine the nature and extent of relationships between contextual factors and employment outcomes over time Victoria	97 patients with spinal cord injury upon admission to a spinal community integration service; 74 patients at second time point (12 months post discharge); 60 patients at third time point (2 or more years post discharge)	Longitudinal cohort	Descriptive statistics, χ2 test, regression and correlation analysis, Spearman’s correlation, Mann-Whitney test	Intervention showed promise in delivering similar return-to-work rates as those traditionally reported, but sooner. Many factors enhanced return to work: being in a relationship, subjective well-being and educational level before injury. The results reinforce the relevance of maintaining pre-injury relationships and subjective well-being to promote favorable occupational outcomes
Holm et al.25 2017 Denmark Effects of active labor market programs (educational measures) for sick-listed workers Strength of evidence: III	To analyze the effects of active labor market programs on the duration until returning to non-subsidized employment and the duration of this employment Denmark	Population-based data: 88,948 sick-listed workers in Denmark from 2008 to 2011 who received sick pay over more than 4 weeks	Follow-up of database data	Econometric model (multivariate mixed proportional hazard model)	2 of the 4 analyzed programs, to wit, ordinary education and subsidized job training, had significant positive employment effects. Ordinary education had positive effect on employment duration, and subsidized job training on the transition to employment. The other 2 programs—non-formal education and subsidized internships—had negative employment effects, mainly due to unfavorable impact on employment duration
Li-Tsang et al.26 2008 China Job placement and support program for workers with work-related musculoskeletal injuries Strength of evidence: I	To investigate the efficacy of a job placement and support program designed for workers with musculoskeletal injuries Hong Kong	63 workers, allocated to group PS (enrolled in program, n=32) and SP (control, self-placement, n=31)	Randomized clinical trial	Descriptive statistics, Student’s t-test, analysis of variance (ANOVA), χ2 test	The program seems to have enhanced return to work, reduced stress and promoted health self-perception. The authors further suggest that rehabilitation professionals should consider including support and placement programs in occupational training programs for injured workers, particularly those on long sick leave
Sabariego et al.27 2018 Work integration and reintegration strategies for persons with chronic diseases in Europe Strength of evidence: III	To summarize the evidence on the effectiveness of strategies for integration and reintegration to work for persons with chronic diseases or musculoskeletal disorders implemented in Europe in the past 5 years	11,961 records (11,947 retrieved from electronic databases, 13 from reference lists of included studies and 1 from relevant reviews) initially identified; 315 full-text publications assessed for eligibility; 101 selected publications; 21 included in review	Systematic review	Quality appraisal checklist for quantitative intervention studies by the national Institute for Health and Care Excellence (NICE)	Positive changes in employment status, return to work and sick leave outcomes for persons with chronic diseases or disabilities in general might be facilitated by graded sickness-absence certificates, part-time sick leave, early ergonomic interventions for back pain, disability evaluation followed by information and advice, and multidisciplinary, coordinated and tailored return-to-work interventions. There was positive association between coexistence of active labor market policies to promote employment and passive support measures (e.g. pension) and the probability of finding a job
Sears et al.28 2015 United States Innovative vocational self-directed retraining Strength of evidence: II	To describe how frequently the self-directed retraining was selected and by whom, the extent to which the workers who selected this option used their reserved retraining funds, and their degree of satisfaction compared to traditional vocational retraining Washington	Administrative data sample: 7,350 workers (number of workers who selected each option), 772 of whom were eligible for a retraining program, 361 interviews	Cohort	Descriptive statistics, Student’s t-test, logistic regression	A low proportion of workers selected traditional retraining, and many had difficult to select, start and manage their own training. Self-directed retraining affords opportunities to enhance independence and autonomy of choice, but failed to replace traditional vocational rehabilitation
Van Beurden et al.29 2012 Netherlands STEP-UP project–participatory return-to-work program for workers without an employment contract, sick-listed due to musculoskeletal disorders Strength of evidence: III	To describe the reach and extent of implementation of a participatory return-to-work program for workers without employment contract or with temporary jobs, sick-listed due to musculoskeletal disorders, the satisfaction and experiences of stakeholders, and the perceived barriers and facilitators for implementation in daily practice Amsterdam	30 workers were enrolled; 24 occupational health care professionals (7 insurance physicians, 8 labor experts, 9 trained return-to-work coordinators)	Experimental with qualitative approach	Descriptive statistics Two researchers independently rated obstacles and solutions	The results indicated overall feasibility of program implementation in daily practice. However, several aspects should be improved: timely offering of suitable temporary workplaces, more clear description of program and professionals’ roles, and additional support for workers with more complex health problems

Chart 3 describes the included studies according to sample, vocational rehabilitation program, multidisciplinary approach or not, complementary educational approaches, early intervention, and possibility of workplace adjustments.

Chart 3. Description of included studies: author, publication year, country, analyzed population, existing vocational rehabilitation program, multidisciplinary nature, complementary educational approach, early intervention, possibility of workplace/workstation adjustments.

Author and year	Country	Population	Vocational rehabilitation program	Multidisciplinary	Complementary educational approach	Early intervention	Workplace/workstation adjustments
Arling et al.18 2016	Germany	Rehabilitation managers and insurants	RehaFuturReal®	Y	Y	Y	Y
Böttcher et al.19 2013	Germany	Cancer patients requiring vocational rehabilitation	MBOR program (medical and vocational rehabilitation orientation)	Y	Y	Y	Y
Braathen et al.20 2007	Norway	Raulan Vocational Rehabilitation Center patients and insurants	Vocational rehabilitation program	Y	Y	Y	Y
Cameron et al.21 2012	United Kingdom	Employed workers with several mental health problems enrolled in a job retention program	Job retention program including vocational rehabilitation	Y	N	N	Y
Cogné et al.22 2017	France	Persons with brain injury	UEROS	Y	Y	Y	Y
Gensby et al.23 2013	Denmark, Canada, USA and Norway	Persons with acquired physical injury, mental health problems or other conditions causing job restrictions and sick leave	Several	Y	N	Y	Y
Hilton et al.24 2017	Australia	Patients with spinal cord injury	EIVR	Y	Y	Y	Y
Li-Tsang et al.26 2008	China	Workers with work-related musculoskeletal disorders	Job placement and support program	Y	N	Y	Y
Sabariego et al.27 2018	Germany, Austria, Italy, Greece and Slovenia	Persons with chronic diseases and musculoskeletal disorders	Several	Y	N	Y	Y
Sears et al.28 2015	USA	Workers requiring vocational rehabilitation (government funded and employer-paid insurance)	Traditional vocational rehabilitation program and Vocational Improvement Project (VIP)	Y	Y	Y	Y
Van Beurden et al.29 2012	Netherlands	Workers without or with temporary employment contract and musculoskeletal disorders; program staff (occupational physicians, labor experts and coordinators)	Participatory return-to-work program–STEP-UP	Y	N	N	N (temporary/therapeutic jobs)

Y: yes; N: no; MBOR: Medizinisch-Berufliche Orientierung in der Rehabilitation; UEROS: Unités d’Êvaluation, de Reclassement, et d’Orientation Socioprofessionnelle; EIVR: Early Intervention Vocational Rehabilitation; VIP: Vocational Improvement Project.

The systematic review performed in Denmark²⁵ was not included in Chart 3 because it exclusively dealt with educational trainings for return to work.

Analysis of Chart 3 shows that multidisciplinarity was a striking characteristic of all the selected studies, followed by early intervention and possibility of workplace adjustments. Complementary educational approaches were not mentioned in the studies performed in China²⁶, Netherlands²⁹ and the United Kingdom²¹.

In Table 2 the studies are categorized according to subject, whether there was an ongoing vocational rehabilitation program, whether program implementation was discussed, whether differential approaches were included in available programs, or the programs/project were new. Only 2 studies described new initiatives for employment retention and unemployed or temporary workers; all the other studies analyzed already implemented programs with new approaches or proposals for implementation

Table 2. Studies according to subject.

Subject	Number of studies	Country
Implementation of existing program	3	Germany18, China26 United States28
Assessment of existing program with novel approach	4	germany19, Norway20, France22, Australia24
New program/project	2	United Kingdom21, Netherlands29
General evaluation of vocational rehabilitation educational programs	1	Denmark25
Systematic review23,27	2
Total	12

DISCUSSION

We initially located a large number of studies, but most addressed return to work generically, without any description of implemented vocational programs. Only a small number of studies described implemented vocational rehabilitation programs.

Comparative analysis between countries was difficult due to variability in approach, in addition to cultural differences and in public policies. This difficulty to analyze the targeted programs was evidenced in a systematic review performed in 2014²³.

Many European countries developed an holistic view on the subject of interest and approach vocational rehabilitation in a broadly encompassing manner with individualized strategies, affording possibilities for reintegration to the labor market. The European Union is making further advances through discussions of safe and healthy work for workers of any age, in which a preventive culture of workplace health and safety is given the due value, while also taking the population aging into account. Disease-centered cultures hinder the overall development of rehabilitation programs, while broader scoped approaches which consider the residual capacity, skills and perceptions of workers yield better outcomes.

Analysis of the available literature evidenced an interest in the identification of return-to-work predictors, studies having been conducted in cardiology, orthopedics, neurology, oncology and mental health. Sex-related differences were considered by some authors.

Critical analysis of the selected studies enabled comparing the data to the available theoretical information. All 12 selected studies described positive strategies which facilitated return to work for workers on sick leave for variable reasons. The following stand out among the observed aspects: joint design of vocational rehabilitation programs with the targeted workers, with clear and well-defined goals and deadlines; coordination between the various actors involved; early intervention; individualized approach (case management); psychological support combined with multidisciplinary approaches; possibility of workplace/workstation adjustments as a function of the workers’ restrictions; vocational training; and part-time return to work.

Several studies and surveys were conducted in the European Union on rehabilitation systems for ill or injured workers, which are used to ground national policies on workforce aging. A study performed by the European Agency for Safety and Health at Work (EU-OSHA) made an inventory of rehabilitation and return-to-work systems in member countries. The results allowed establishing which factors may have a relevant role in the design and implementation of rehabilitation and return-to-work systems and may be considered as reasons for success⁵. The participating countries were categorized according to the following criteria: employers’ duties vis-à-vis rehabilitation and return to work, access to vocational rehabilitation, approaches to disability, length of intervention, focus on prevention, coordination of actors and/or multidisciplinary staffs involved in rehabilitation, and external support to employers⁵. Germany, Denmark, Austria, the Netherlands, Norway and Sweden stood out by their comprehensive and mature rehabilitation/return-to-work frameworks⁵.

The countries with comprehensive rehabilitation and return-to-work programs accounted for the largest scientific production on this subject, as was found in the present review: Germany, 2 studies, Norway, Denmark and Netherlands, 1 study each.

Germany developed a distinct vocational rehabilitation approach. The study from 2016¹⁸ shows that continuous improvement should be systematically anticipated. The authors describe the implementation of a new counseling and management concept, in which coordination among the various involved actors is a relevant part of the process. Adequate and early support during return-to-work-centered vocational rehabilitation behaves as a facilitator, as shown in the study performed in 2013 with cancer patients¹⁹.

The relevance of multidisciplinary approaches in rehabilitation programs was evidenced in the study conducted in Norway²⁰, which reported significant outcomes with direct impact on return to work.

Although rehabilitation programs established in the United Kingdom and France were not rated comprehensive or mature in the EU-OSHA report, several authors performed research on this subject and discussed new policies for return to work; two such studies^21,22 were included in the present review. One of them²¹ addresses employment retention, which is a challenge to be overcome by vocational rehabilitation programs, but is scarcely considered in those available. In turn, the study performed in France²² considered also social rehabilitation, thus broadening the scope of rehabilitation. It was conducted long time after the onset of the analyzed vocational rehabilitation program, and for this reason affords a wider view of its efficacy.

The included studies mentioned and described relevant aspects of the vocational rehabilitation process, such as adequate structure, strategies to integrate and reintegrate workers with chronic diseases, employment retention, placement for unemployed or temporary workers, autonomy to orient self-training, and educational programs.

The results indicate that the process of rehabilitation has many facets, which need to be continuously considered and implemented.

The relevance of early intervention was addressed in the study performed in Australia²⁴. Two studies^20,28 found that outcomes were better when structured vocational rehabilitation programs including worker autonomy to choose training modalities to improve their work capacity were implemented. These results suggest that a previously well-defined structure might lead to greater benefits for workers.

The systematic review performed in 2018²⁷ found positive and facilitating return-to-work strategies, such as early ergonomic interventions, counseling, coordinated multidisciplinary interventions centered on return to work, active labor market policies to enhance employment, and passive measures (as e.g. pension).

Given the broad scope of the present review, we were able to locate also strategies to reintegrate workers after sick leave due to diseases or accidents, and to identify the best practices available.

The one limitation of the present study derives from the choice of the language in which the eligible studies were published. Thus we excluded, for instance, studies performed in Japan and published in Japanese only.

CONCLUSION

In the present review we detected gaps in the divulgation of existing successful rehabilitation programs, notwithstanding the difficulties to evaluate the efficacy of this type of process. Despite problems inherent to the return to work process in different countries, scientific studies on this subject should be encouraged to contribute to the development of programs, particularly in countries with still precarious approaches. Once again, scientific studies are still scarce vis-à-vis the magnitude of the ongoing challenge. Such studies are necessary for the implementation of public policies to enhance the reintegration of workers to the labor market. Equally relevant is the challenge posed by the implementation of vocational rehabilitation programs for unemployed or temporary workers.

To conclude, studies on vocational rehabilitation should be encouraged to contribute to a wider discussion of this subject and raise awareness in several countries as to the urgent need to implement measures to enhance vocational rehabilitation and return to work based on the needs of workers, to thus improve their quality of life, reduce functional impairments related to aging and to sequelae of health problems, and ensure the sustainability of social security systems.