Return to Work After Brain Injury: Six Occupational Therapy Support Pillars That Transform Recovery

A qualitative study published in the Hong Kong Journal of Occupational Therapy (Kurihara et al., 2024) has clarified how occupational therapists systematically guide clients through return-to-work rehabilitation. By conducting in-depth interviews with 20 experienced occupational therapists in Japan, the researchers identified six interconnected support pillars that form the foundation of effective return-to-work (RTW) outcomes. Understanding these pillars helps patients, families, and employers recognise what comprehensive work rehabilitation should include—and what gaps may exist in current support.

Here’s what the research demonstrates—and how these insights translate into effective clinical practice.

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Why Occupational Therapists Are Essential for Return to Work

Before diving into the six pillars, it’s worth understanding why OTs lead this space. Unlike traditional rehabilitation that focuses on regaining physical function or basic daily activities, occupational therapy approaches work holistically: it addresses the person’s entire life context, not just their functional deficits.

The Kurihara study found that OTs recognise a critical truth that many healthcare systems miss: disruption of life rhythms due to cognitive dysfunction is a major barrier to work. An individual might regain hand strength or walking ability, yet still struggle to maintain a consistent sleep schedule, manage energy levels, or navigate social dynamics at work. Occupational therapists address both.

This research builds on the established hierarchical model of vocational readiness developed by Matsui & Kikuchi (2006)—a framework widely used in Japanese vocational rehabilitation. The model conceptualises an individual’s work capacity across four interconnected layers, from foundational life skills to specific job duties. The Kurihara study uses this framework to clarify which occupational therapy techniques specifically address each layer, making the OT role in vocational rehabilitation more transparent and replicable.

Hospital-based rehabilitation, whilst valuable, typically emphasises physical function recovery and daily living skills rather than vocational readiness. This creates a gap that community-based occupational therapy work support aims to address. As the study notes, “hospital rehabilitation focuses on return to physical function and daily activities rather than RTW,” leaving the transition to employment often underspecified. Evidence-based rehabilitation programmes aimed specifically at successful RTW have historically been scarce (Donker-Cools et al., 2016; Van Deynse et al., 2022)—which is precisely the gap the Kurihara study addresses.

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The Six Pillars of Occupational Therapy Work Support

The Kurihara et al. research identifies six interconnected concepts that structure effective OT work support. These are not sequential steps; they overlap and inform one another throughout the rehabilitation journey.

1. Support for Vocational Life: The Foundation of Work Readiness (14 of 20 OTs)

Before anyone can succeed in a job, their basic life rhythms must stabilise. This pillar focuses on what seems deceptively simple but is often the biggest obstacle: managing sleep, meal intake, activity levels, and fatigue.

OTs working in this domain use tools like daily activity charts and apps to help clients notice disruptions to their rhythm. A client might record sleep hours, meals consumed, and energy levels to identify patterns. Research on long-term work sustainability identifies fatigue management, rest, and sleep as key factors for those who maintain employment successfully (Karcz et al., 2022)—which is why OTs treat life rhythm as a clinical priority, not a lifestyle suggestion.

Support includes:

• Life rhythm management: Using apps or notebooks to track sleep, meals, and activity
• Environmental adjustment: Modifying work schedules, rest periods, and commute times
• ADL and IADL support: Direct training in personal care, grooming, and instrumental activities (using public transport, shopping, managing finances)
• Family engagement: Discussions and problem-solving with carers to sustain lifestyle changes
  
  

As one therapist in the study noted, they had a client with acquired brain injury who was eating excessively. Rather than lecturing about diet, the OT asked the client to record daily intake in a notebook—shifting responsibility and awareness to the client themselves.

2. Support for Interpersonal Skills: The Social Dimension of Work (9 of 20 OTs)

Cognitive deficits are only half the barrier to employment. Many individuals with acquired brain injuries struggle with communication, cooperation, and workplace social navigation—even if their physical abilities have recovered.

This pillar includes:

• Group training: Creating structured environments where clients practise working alongside others, learning to express ideas, and understand different perspectives
• Communication coaching: Encouraging clear reporting, active listening, and appropriate self-disclosure through simulated work scenarios
• Aphasia support: For those with speech difficulties, using aids like text messaging, memory notebooks, and communication boards
  
  

One therapist described implementing weekly group recreation sessions where clients plan and execute activities together. Through this process, individuals learn cooperation, task delegation, and how to balance their own needs with group goals—exactly what workplace collaboration requires.

3. Support for Work: The Direct Skills and Employer Bridge (All 20 OTs)

This pillar is where the practical work preparation happens. Unlike the previous two pillars (life rhythm and social skills), this one directly addresses job-specific training, employer coordination, and interdisciplinary collaboration.

Support includes:

• Work assessment and training within the facility: Using simulated work tasks, mock job interviews, and vocational assessment tools to evaluate readiness
• Community-based work experience: Real placements outside the facility, allowing clients to test capabilities in actual work environments
• Job search assistance: Helping clients identify suitable roles and navigate application processes
• Employer education: Explaining the client’s disability characteristics, necessary workplace adjustments, and how to provide effective support
• Work environment adjustment: Modifying job tasks, quantity of work, or the human environment (identifying a supportive supervisor as a “key person”)
• Interdisciplinary coordination: Collaborating with job coaches, vocational counsellors, work support workers, and welfare professionals. The study emphasises that “it is important to cooperate with vocational rehabilitation professionals” and “to support the employers.” In the Japanese context specifically, vocational rehabilitation professionals often serve as the bridge to the workplace, meaning OTs frequently coordinate indirectly through these specialists. The extent of direct vs. indirect OT involvement varies by country and healthcare system; in some regions, OTs engage more directly with employers and job tasks.
  
  

One therapist explained that when a client needed specific computer settings for work, she provided detailed explanations to the employer and then asked the supervisor to observe the client’s behaviour to ensure the setup was effective. This blend of education and practical support prevents misunderstandings and builds employer confidence.

The research underscores that OTs do not work in isolation. Supporting sustainable employment requires coordination across multiple professionals—each contributing specific expertise—with the OT serving as the central coordinator of the whole-person rehabilitation process.

4. Support for Illness, Disability, and Awareness: The Therapist Role (All 20 OTs)

This pillar addresses what might be the most challenging barrier: the person’s own understanding of their disability. Many individuals in the acute phase of brain injury believe they are unaffected, minimising the real impacts of cognitive impairment.

OTs working in this domain:

• Build awareness of cognitive changes: Through feedback, neuropsychological test results, and real-world activity results, helping clients recognise specific deficits (e.g., “I notice you forget verbal instructions; let’s develop a written checklist system”)
• Provide function-specific training: Cognitive rehabilitation, physical conditioning, and endurance-building exercises adapted to the individual’s profile
• Establish safe, trusting environments: Creating relationships and group settings where individuals feel secure exploring their limitations
• Coordinate medical support: Consulting with doctors, nurses, and other professionals about daytime sleepiness, concentration issues, or other symptoms affecting work capacity
• Manage emotional responses: Supporting clients who struggle to accept their disabilities through patience, non-judgmental feedback, and repeated exposure to successful experiences

This pillar is where OTs operate as therapists, not just trainers. The goal is intrinsic change in how the client perceives themselves and their potential.

5. Support for Utilisation of Compensation Measures: Practical Problem-Solving (15 of 20 OTs)

A person with cognitive impairment might never “overcome” their memory deficit. But they can use a digital calendar, checklist app, or alarm system to compensate. This pillar is about identifying and implementing these practical supports.

The process includes three steps:

1. Building awareness of the need: Group discussions and goal-setting help clients understand why compensation measures matter. A therapist might ask, “You want to be independent at work, but you’re forgetting verbal instructions. What tool could help you capture those instructions?”
2. Introducing compensation measures thoughtfully: OTs assess the client’s characteristics, timing of awareness, and readiness. They never force adoption; if a client resists, the therapist adjusts the approach rather than pushing compliance.
3. Training and adaptation: Ongoing practice ensures the client can use the tool reliably, and adjustments are made as needed. Importantly, OTs avoid changing compensation methods frequently—consistency is key to habit formation.

The research emphasises that compensation measures are not crutches; they are tools that allow people with disability to function independently and perform at work.

6. Support for Goal Setting: Direction and Motivation (13 of 20 OTs)

Without clear, achievable goals, rehabilitation can feel aimless. This pillar ensures that OTs and clients work together to define what success looks like.

Goal-setting includes:

• Joint planning: Reviewing the client’s needs, assessment results, living situation, and financial circumstances to identify realistic targets
• Starting small: Focusing on specific, concrete goals (e.g., “Maintain a 10 pm bedtime three nights per week” rather than “fix your sleep”)
• Regular reflection: Reviewing progress through daily activity logs and adjusting goals as the client demonstrates capability
  
  

One therapist noted the importance of helping acute brain injury survivors think beyond just employment: “What do you want your life to look like when you return to work? What problems do you need to solve beyond the job itself?” This holistic perspective prevents narrow goal-setting that overlooks quality of life.

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How These Six Pillars Work Together: The Integrated Model

The Kurihara study presents these pillars not as isolated interventions but as an integrated system. Here’s how they interconnect:

The Journey Begins:

• Vocational life support forms the foundation. Without stable sleep, nutrition, and activity levels, everything else fails.
• Interpersonal skills support builds alongside vocational life. Even clients with mild functional deficits need strong social foundations before job-specific training.
  
  

The Middle Phases:

• Work support is provided once life rhythms and interpersonal skills are stabilised. This prevents clients from being placed in jobs they’re not yet ready for.
• Compensation measures and illness/disability awareness run parallel to all other support. Clients learn why they need tools and how to use them, whilst simultaneously building understanding of their own disability.
  
  

The Ongoing Element:

• Goal setting threads throughout the entire process, providing direction and motivation at every stage.
  
  

After Employment:

• Once a client secures a job, the focus shifts to work settlement support: maintaining employment, building habits, and preventing relapse into unemployment. OTs continue communication with the employer, family, and rehabilitation specialists to ensure sustainability.

 

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Why This Framework Matters for Private Healthcare Decisions

For families, carers, and individuals considering rehabilitation options, the Kurihara framework offers a clear rubric: does the provider address all six pillars, or only some?

Some rehabilitation programmes focus heavily on physical recovery (pillar 4) but neglect vocational life management (pillar 1). Others provide excellent employer liaison (pillar 3) but minimal goal-setting support (pillar 6). The research is clear that each pillar influences the others—gaps don’t stay contained; they compound.

A provider genuinely committed to this framework assesses not just physical function or cognitive scores, but the full picture: whether daily life rhythms support work capacity, whether social confidence matches job demands, how well the client understands their own disability, what compensatory systems will enable independence, and whether stated goals are realistic given current capabilities. The integration of all six is what separates rehabilitation that results in lasting employment from rehabilitation that results in placement alone.

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Comparison Table: The Six OT Work Support Pillars

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Frequently Asked Questions

Q: How long does return-to-work rehabilitation typically take?

A: Timeline varies significantly based on injury severity, the individual’s baseline health, and support availability. The Kurihara study does not specify fixed durations for individual client rehabilitation, but it emphasises that work-readiness support is a longitudinal process. Some clients secure employment within months; others require sustained support over 1–2 years. What matters is that progress is steady across all six pillars, not adherence to a fixed timeline. Work settlement (maintaining employment post-placement) often requires ongoing occupational therapy coordination beyond the formal rehabilitation phase.

Q: Can someone return to the same job after brain injury?

A: This depends on the nature and severity of the injury, the person’s recovery trajectory, and the demands of the specific job. Whilst some individuals regain capacity for their previous role, others require modifications—reduced hours, adjusted tasks, or workplace accommodations such as a quieter environment or flexible schedule. The Kurihara study emphasises that occupational therapists help determine what’s realistic for each individual and coordinate with employers to make necessary adjustments. The key is a thorough assessment of both the person’s capabilities and the job’s requirements.

Q: What if someone doesn’t have access to an occupational therapist?

A: Ideally, return-to-work support should be led by an occupational therapist who can coordinate the six pillars in an integrated way. Without OT coordination, support becomes fragmented and less effective. Other healthcare professionals—physiotherapists, speech-language pathologists, psychologists—and community support workers can contribute to individual pillars (e.g., physical conditioning, communication support, social reintegration). However, the Kurihara study makes clear that the depth of clinical reasoning required to implement all six pillars simultaneously, adjust sequencing based on recovery stage, and coordinate with employers is what distinguishes comprehensive OT work-readiness support. If access to an experienced OT is not possible, seek providers who explicitly coordinate across vocational life, interpersonal skills, work training, disability awareness, compensation strategies, and goal-setting.

Q: How important is employer involvement?

A: Crucial. The Kurihara research emphasises that OTs don’t simply prepare individuals in isolation; they educate employers, coordinate workplace adjustments, and identify “key persons” (supportive supervisors or colleagues) who can sustain support after formal rehabilitation ends. Employers who understand the disability and feel equipped to support the individual are far more likely to retain the worker long-term.

Q: What’s the difference between “return to work” and “work settlement”?

A: Return to work (RTW) is the phase of preparing for and securing a job. Work settlement is the phase after employment begins, focusing on maintaining the role, building work habits, preventing relapse into unemployment, and ensuring long-term sustainability. The Kurihara study emphasises that both phases require ongoing occupational therapy support, though work settlement may involve less intensive intervention as individuals stabilise in their roles. The study notes that OTs provide “work settlement support” with the aim that “clients are able to maintain and become habituated to their work.”

Q: Can these six pillars be applied to other health conditions besides brain injury?

A: The Kurihara et al. (2024) framework was developed specifically for acquired brain injury, based on analysis of OT practice with ABI clients. The study does not examine application to other conditions. However, the underlying principles—supporting life rhythms, interpersonal skills, direct work training, awareness of disability, use of compensatory strategies, and goal-setting—are likely relevant to return-to-work support across acquired conditions such as stroke, spinal cord injury, and severe musculoskeletal injury. The particular emphasis on cognitive awareness and compensation measures is especially pertinent to brain injury because cognitive deficits are often invisible and misunderstood by the person and their environment. Any application of this framework to other conditions would require evaluation to ensure relevance and appropriateness.

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The Evidence: Why This Matters Now

The Kurihara et al. (2024) study is timely because despite clear evidence of the importance of return-to-work support following brain injury, the specific occupational therapy techniques used to facilitate RTW have not been well-articulated in the literature. As the study notes in its introduction: “techniques of occupational therapy support for return to work remain relatively unelucidated.”

The study addresses this gap by describing the current practices of experienced occupational therapists in Japan who specialise in work support. The research provides:

• A shared language for OTs, employers, and healthcare systems to discuss work support
• A framework for assessment to identify gaps in current rehabilitation provision
• Evidence of current best practice from experienced practitioners that can inform programme development in other regions
• Confidence for families that there is a systematic, evidence-based approach to returning to work after brain injury—not guesswork or trial-and-error
  
  

Important context: This qualitative study describes current practice approaches used by experienced Japanese OTs (10+ years in practice, with work-support experience ranging 1.5–29 years). The findings reflect best-practice approaches from this experienced cohort and are not necessarily generalisable across all OT experience levels or all countries’ healthcare systems. Regional and international variations in vocational rehabilitation policy, employment law, and healthcare structure mean that the extent and method of OT involvement in work support varies by location.

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Study Limitations: What This Research Does—and Doesn’t—Tell Us

Why experience matters. The study recruited 20 OTs with 10+ years of occupational therapy experience; most had 10+ years of work-support experience specifically. The researchers made this a deliberate criterion because, as they note: “more experienced OTs might have offered clients a clearer perspective on disability compared to younger OTs who may still be in the process of fine-tuning their skills.”

This is not a limitation to dismiss; it’s a critical insight for clients and families choosing a provider. The six pillars described here represent the practice of veteran practitioners. Younger or less experienced OTs may use different techniques, lack the nuance for employer coordination, or struggle to help clients develop realistic disability awareness. The depth of clinical reasoning required to implement all six pillars simultaneously—adjusting intensity, sequencing, and individualisation based on the client’s stage of recovery—requires years of experience.

Selection bias and geographic context. The study recruited OTs through snowball sampling (recommendations from existing participants) and purposive selection, rather than random sampling. This means the 20 therapists likely represent highly engaged, experienced practitioners active in work-support networks. Additionally, the study describes Japanese OT practice within Japan’s vocational rehabilitation system, which includes specific employment policies for persons with disabilities. Whilst the underlying principles are likely applicable across contexts, implementation will differ depending on local employment law, disability policy, and available resources.

What this means for your decision: When selecting a return-to-work rehabilitation provider, the evidence points clearly to experience as a non-negotiable criterion. Prioritise clinicians with substantial years in both occupational therapy and specifically in work support. Look for practitioners who can coordinate across all six pillars, not just one or two. It is worth asking any prospective provider directly where their occupational therapists sit on the experience spectrum—and whether those years include sustained, dedicated work in employment rehabilitation, not just general rehabilitation settings. The difference is not marginal; it directly affects how well clients understand their disability, whether they adopt compensatory strategies, and ultimately whether employment is sustained long-term.

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What Next? If You or Your Family Member Is Navigating Return to Work

If you’re considering rehabilitation options after acquired brain injury, ask providers these questions:

1. What is your team’s experience in occupational therapy and specifically in work support? Look for practitioners with 10+ years in the field, including sustained work in return-to-work rehabilitation. Experience directly affects clinical reasoning, disability awareness support, and the ability to coordinate across all six pillars effectively.
2. Do you address all six pillars, or only some? A comprehensive programme should include life rhythm support, social skills, direct work training, awareness-building, compensation measures, and goal-setting. Providers focusing on only one or two pillars may miss critical barriers to sustained employment.
3. How do you coordinate with employers? Look for providers who actively educate employers, identify workplace accommodations, and maintain contact throughout the employment settlement phase—not just at job placement. Employer confidence and understanding significantly improve long-term employment outcomes.
4. What’s your track record with work settlement—not just job placement? Securing a job is one milestone; sustaining employment for 6–12 months and beyond is the real measure of success. Ask how the provider supports clients after employment begins.
5. How do you involve the family? Family understanding and support significantly improve outcomes. Providers should offer family education alongside individual rehabilitation.
   
   

These questions are not just due diligence—they are the difference between a provider who offers rehabilitation and one who delivers sustained employment outcomes. An initial consultation with an experienced occupational therapist is the most direct way to assess which pillars need the most attention, what realistic timelines look like, and whether the provider’s approach matches the full scope of what the research shows is necessary.

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Key Takeaways

• Return to work after acquired brain injury requires integrated, multi-pillar support. The Kurihara study identifies six interconnected pillars—vocational life, interpersonal skills, work, awareness, compensation measures, and goal-setting—that experienced OTs address simultaneously or sequentially.
• Occupational therapists are well-positioned to lead this work because they assess the whole person: physical function, cognitive ability, life rhythms, social confidence, and work-specific skills, rather than addressing these in isolation.
• The six pillars are interconnected, not sequential. Experienced OTs provide support across multiple pillars concurrently, with emphasis shifting as the client progresses through work readiness, job placement, and work settlement.
• Employer involvement is essential. OTs bridge the gap between individual readiness and workplace reality, educating employers and coordinating sustainable workplace adjustments.
• Sustaining employment requires ongoing coordination. Success is not achieving job placement; it is maintaining employment whilst supporting quality of life across all six pillars over time.