Effectiveness of vocational rehabilitation intervention on the return to work and employment of persons with multiple sclerosis New search for studies and content updated (no change to conclusions)




Multiple sclerosis is a neurological disease that frequently affects adults of working age, resulting in a range of physical, cognitive and psychosocial deficits that impact on workforce participation. Although, the literature supports vocational rehabilitation (VR) approaches in persons with multiple sclerosis (pwMS), the evidence for its effectiveness is yet to be established.


To evaluate the effectiveness of VR programs compared to alternative programs or care as usual on return to work, workability and employment in pwMS; to evaluate the cost effectiveness of these programs.

Search methods 

We searched the Cochrane Multiple Sclerosis Group's Trials Register (February 2011), PEDro (1990‐2011), ISI Science Citation Index (1981‐2011) the Cochrane Rehabilitation and Related Therapies Field trials Register and the National Health Service National Research Register.

Selection criteria 

Randomized and controlled clinical trials, including before ‐ after controlled trials, that compare VR rehabilitation with alternative intervention such as standard or a lesser form of intervention or waitlist controls.

Data collection and analysis 

Two reviewers selected trials and rated their methodological quality independently. A 'best evidence' synthesis was performed, based on methodological quality. Trials were grouped in terms of type and setting of VR programs.

Main results 

Two trials (one RCT and one CCT) (total 80 participants) met the review criteria. Both trials scored poorly on the methodological quality assessment. There was 'insufficient evidence' for VR programs for (a)‘competitive employment’, in altering rates of job retention, changes in employment, improvement in rates of re‐entry into the labour force; (b) for altering ‘work ability' by improving participants’ confidence in the accommodation request process, or employability maturity or job seeking activity. No evidence could be assimilated for changes in proportions of persons in supported employment or on disability pensions, nor for cost‐effectiveness.

Authors' conclusions 

There was inconclusive evidence to support VR for pwMS. However, the review highlights some of the challenges in providing VR for pwMS. Clinicians need to be aware of vocational issues, and to understand and manage barriers for maintaining employment. Proactive and timely VR programs should incorporate practical solutions to deal with work disability, workplace accommodation and educate employers, and the wider community. Liaison with policy makers is imperative for government initiatives that encourage work focused VR programs. Future research in VR should focus on improving methodological and scientific rigour of clinical trials; on the development of appropriate and valid outcome measures; and on cost effectiveness of VR programs.


Fary Khan, Louisa Ng, Lynne Turner‐Stokes


Plain language summary 

Vocational Rehabilitation (VR) programs are used to support persons with multiple sclerosis (MS) on their entering or returning to work 

Major as well as minor disabilities, such as physical, psychosocial, environmental and memory/attention impairment, significantly affect the entering or the returning to work of persons with MS. The objective of this review was to assess the efficacy and to evaluate the cost effectiveness of VR programs compared to other types of programs.

Among the pertinent medical literature, only two studies, comprising a total of 80 participants, met the criteria of the methodological quality necessary for their inclusion in this review, although the subsequent quality assessment revealed they scored poorly. Furthermore, the two studies were carried out in USA, with limited generalisability in other geographical/cultural settings. The whole data neither supports nor refutes the effectiveness or cost‐effectiveness of VR programs for persons with MS.

The data also identified critical points worth of future attention: more awareness of vocational issues by professionals; putting in place practical solutions such as a proper workplace accommodations and employers' education; asking for political/governmental initiatives to really support disabled employees; taking into account that supported withdrawal from work at the proper time is as important as supported re‐entering to work. Further research are necessary also to improve the methodology of the researches and to identify those individuals most likely to benefit.


Fary Khan, Louisa Ng, Lynne Turner‐Stokes

Reviewer's Conclusions

Authors' conclusions 

Implications for practice 

  • VR interventions are multi‐faceted and include a range of different dimensions including job retention, work re‐training, work re‐entry/employment and work withdrawal at the appropriate time. Individuals may require one or more of these interventions at different stages of their condition.
  • Provision of VR for pwMS requires highly specialist knowledge. Treating health professionals need to be familiar with the complexity of MS; and the contextual and personal factors that may confound intervention if not appropriately addressed.
  • Cognitive issues in particular are frequently under‐estimated.
  • VR interventions should be proactive and timely, but at the same time they have the potential to leave pwMS unsupported if not adequately followed through – a holistic multi‐disciplinary/multi‐agency approach is required. 
  • Liaison with policy makers is imperative for government initiatives that encourage work focused VR programs.

Implications for research 

  • Further research to evaluate VR programs is required, ideally in across international and boundaries so that the results reflect the effectiveness of interventions in a variety of different political and social contexts, with varied employment rates and social welfare systems.
  • Trials should involve robust methodology in a range of different study designs as appropriate to the research question.
  • Future studies should address not only the effectiveness, but also cost effectiveness of VR programs, as well as the impact of return to work on mental and social outcomes need exploration.
  • Further research is required to develop appropriate outcome measures to evaluate work ability.
  • The ICF model of disability can be used to explore interactions of intrinsic and extrinsic factors on return to work and VR programs.

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