Vocational rehabilitation for people with multiple sclerosis: A systematic scoping review of international evidence

Figures Abstract Introduction People with multiple sclerosis (pwMS) may encounter challenges in their professional lives, due to a combination of environmental and individual factors. According to Escorpizo et al., 2011 framework, Vocational rehabilitation (VR) aims to optimise job participation, providing support in the job access, retention and in the return to work for people with disability. However, the corpus of research on VR for pwMS is poor. This scoping review aims to map the available literature on VR interventions for pwMS, summarising their characteristics, study designs, implementation features, feasibility, and stakeholders’ perspectives. Methods Following the Joanna Briggs Institute (JBI) and the PRISMA-ScR guidelines, seven databases were searched up to October 2025: PubMed, SCOPUS, PsycInfo, CINAHL, Google Scholar, OT Seeker (University of Queensland), and the Physiotherapy Evidence Database (PEDro). Studies were eligible if they were related to VR interventions for pwMS, focused on job access, return, or retention and if they were primary articles. Data were extracted and synthesised following the Population–Concept–Context (PCC) framework. Results Out of 2,360 records, 28 articles describing 28 distinct VR interventions were included. Studies were published between 1996 and 2025, mostly from Western countries. Designs ranged from descriptive to randomized trials, with an increasing number of interventional and feasibility studies in recent years. The 61% of the interventions were multi-dimensional delivering a combination of rehabilitation, educational, and reasonable accommodation services. PwMS highlighted the importance of empathetic and individualized approaches, symptom management, and legal counselling as key elements in VR interventions, while logistical, personal and health issues were barriers to participation. Overall, interventions were considered feasible and acceptable. Conclusions This is the first comprehensive overview of VR interventions for pwMS, outlining a progressive shift toward multidisciplinary and goal-oriented approaches over time. Despite promising feasibility and stakeholder satisfaction, further rigorous trials are needed to evaluate effectiveness and inform evidence-based implementation of VR programmes in diverse contexts. Citation: Gualco C, Grange E, Rotondi F, Salivetto M, Pignattelli E, Manacorda T, et al. (2026) Vocational rehabilitation for people with multiple sclerosis: A systematic scoping review of international evidence. PLoS One 21(5): e0350122. https://doi.org/10.1371/journal.pone.0350122 Editor: Karlo Toljan, Cleveland Clinic Abu Dhabi, UNITED ARAB EMIRATES Received: February 6, 2026; Accepted: May 9, 2026; Published: May 27, 2026 Copyright: © 2026 Gualco et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability: All relevant data are within the manuscript and its Supporting information files. Funding: This study was funded by the Italian Workers’ Compensation Authority (INAIL), in the framework of the BRIC 2022: “RiaL SM” project (Bando BRIC 2022_ID 31). However, the funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing interests: The authors have declared that no competing interests exist. Abbreviations: MS, Multiple Sclerosis; pwMS, people with Multiple Sclerosis; VR, Vocational Rehabilitation; RCT, Randomized Controlled Trial; OSF, Open Science Framework; EDSS, Expanded Disability Status Scale; PRISMA-ScR, Preferred Reporting Items for Systematic Reviews and Meta-analyses extensions for Scoping review; JBI, Joanna Briggs Institute; RA, Reasonable accomodations; RR, Relapsing-Remitting; NA, Not applicable; NR, Not reported; OT, Occupational therapist Introduction Multiple sclerosis (MS) is a chronic disease of the central nervous system characterised by autoimmune and neurodegenerative processes [1]. MS presents a wide range of physical, cognitive and psychological symptoms that may have a detrimental effect on an individual’s work capacity [2–4]. This may lead to challenges in accessing employment, returning to work after diagnosis, and job retention [5,6]. As a result, the 36% of people with MS (pwMS) are unemployed, and 17% of workers with MS are forced into early retirement [6]. The premature job loss produces a financial burden for pwMS and their families [7,8], affecting individuals in the early stages of their professional careers [9]. In this context, work is also widely recognised as a pivotal social determinant of health, and an essential means of achieving self-determination and psychological well-being [10,11]. Ensuring that pwMS can access and retain their jobs is crucial not only to limit the economic burden but also to promote improved health management [10]. The diverse symptoms experienced by pwMS can result in a corresponding array of obstacles when attempting to access and maintain employment [12]. Architectural barriers in the workplace can impede the movement of workers with MS, both during the commute to and within the work environment and long consecutive working hours can lead to cognitive overload and extreme fatigue [12–14]. Administrative barriers, such as a lack of clarity regarding rights, have been shown to hinder access to social policies designed to support people with disabilities [15,16]. Furthermore, social barriers, such as judgemental work environments that demonstrate a lack of sensitivity to MS, have been demonstrated to engender severe stress and feelings of isolation [16]. Therefore, interventions aimed at facilitating the return to work, or job placement require a multidisciplinary and person-centred approach to support pwMS facing the range of work-related difficulties they may experience [17–19]. According to Escorpizo et al., 2011, Vocational rehabilitation (VR) aims to optimise job participation in individuals with disability [20], and it has emerged as a promising method for delivering employment support services to individuals with different conditions [21]. In this framework, VR is conceptualised as an intervention capable of supporting people with disabilities at all stages of their working life, facilitating access in the workforce and job retention, as well as in the return to work [20]. VR interventions typically combine medical and rehabilitative components with strategies aimed at adapting the work environment to individual needs. In addition, these interventions may provide practical information and support to help individuals navigate administrative procedures and address barriers related to employment and social policies [12,22]. However, VR for pwMS is still an emerging field [22,23], and evidence regarding the efficacy of VR for pwMS is still limited, as highlighted in the Cochrane review by Khan et al., 2009, [3]. According to Munn et al., 2018 [24], we conducted a scoping review in order to identify the types of available evidence of VR for pwMS, examining how research is conducted, and to assess the need for a systematic review, highlighting possible barriers and facilitators that may arise in the delivery of VR interventions for pwMS. To this purpose, in addition to identifying the state of the art and characteristics of VR interventions, particular attention will be paid to feasibility studies and to stakeholders’ opinions. Indeed, these two dimensions are now widely acknowledged as fundamental components in the definition of rehabilitation interventions, tailored to individuals’ needs, and in the evaluation of VR interventions effectiveness [25,26]. Aim and research questions Specifically, we aim to summarise the main components of VR intervention, the professionals involved, the settings in which they are mainly conducted, the opinions of pwMS and the healthcare and social care professionals who participated in the VR interventions highlighting barriers associated with intervention delivery. For this purpose, we formulated the following research questions: - 1. What is the state of the art in vocational rehabilitation for pwMS? - a. Where, when and how have vocational interventions been implemented and studied? - b. What are the sociodemographic, clinical and occupational characteristics of the samples? - c. What types of VR interventions are delivered, and which professionals are more likely to be involved in delivering vocational interventions? - 2. What type of study designs are available in the literature? - 3. What are the strengths and limitations highlighted so far in conducting vocational interventions for pwMS? - a. What are the stakeholders’ opinions (clients and health providers)? - b. are the barriers and facilitators to implement a vocational intervention for pwMS? Scoping review methods This scoping review was conducted following the Joanna Briggs Institute (JBI) recommendations for scoping reviews [27] and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extensions for Scoping Review (PRISMA-ScR) [28]. The protocol describing the scoping review process was previously registered on the Open Science Framework (OSF): 10.17605/OSF.IO/E3UF7 Sources and search strategy In order to identify articles, the following databases and registers were consulted: PubMed, SCOPUS, PsycINFO, CINAHL, Google Scholar, OT Seeker (University of Queensland), and the Physiotherapy Evidence Database (PEDro). An ad hoc search strategy was developed for these sources, using two primary domains in accordance with the Population, Concept and Context (PCC) framework: one pertaining to the population of pwMS, and the other relating to the conceptual framework of the study, namely vocational rehabilitation. An iterative process was employed to optimise the search sensitivity, and the effectiveness of this process was tested multiple times to ensure its correct functioning. The selection of keywords and MeSH terms was informed by a comprehensive review of extant literature in the field and through deliberations with a multidisciplinary team with experience in VR and members of the Italian Multiple Sclerosis Society (AISM). Subsequently, according to Pollock et al., 2023 [29], the search strategy was adapted to align with the particular functionalities of each database and register that was consulted. A comprehensive search was conducted up to 6 October 2024. The records extracted were subsequently managed on Rayyan for title and abstract screening, as well as for the assessment of eligibility. Since 100% of the studies included were available on PubMed or Google Scholar, we re-ran the search on these two databases to identify any articles published while the review was in progress between 6 October 2024 and the end of the literature review phase on 22 October 2025. The list of keywords and Mesh used in PubMed is reported in the S1 Table. Eligibility criteria We included articles related to or derived from VR interventions in pwMS aged 18 years or older. In line with the definition proposed by Escorpizo et al. 2011, we included all types of VR interventions aimed at supporting pwMS in access to, retention in, and return to work. We included only peer-reviewed articles Grey literature was not explored. Only articles in English or Italian were considered as eligible. No filters related to the year of publication or study design were applied. No time limitation was set for the literature search. Exclusion criteria We excluded articles that did not report separate data for pwMS or articles not related to VR interventions. We excluded articles generally focused on work and MS (e.g., barriers, risk factors) and articles related to VR interventions as main topic, but which do not follow the delivery of a VR intervention. Moreover, we excluded secondary sources (e.g., reviews) and articles published in language other than English or Italian. Study inclusion process After consulting the databases and uploading the records obtained from the literature search, we eliminated duplicates. Once the final pool of articles had been identified, two independent reviewers (CG, FR) carried out the initial screening by consulting the title and abstract of each article. This phase was conducted according to the rule of “in case of doubt, keep it”. Following the initial screening phases, a full-text inspection was conducted to ascertain their eligibility. The eligibility assessment was conducted by two independent reviewers (CG, FR). This phase was also conducted on Rayyan in order to facilitate the identification of conflicts between the two reviewers. Furthermore, a checklist developed specifically for the study in Excel was used to assess eligibility criteria and to track the reasons for exclusion for each article. Its appropriateness was tested by the research team conducting a pilot phase. In case of disagreement between the reviewers, a third reviewer inspected the full-text and resolved the conflicts (EG). Moreover, references of relevant articles and reviews were inspected to identify additional articles as well as a consultation with experts in the field. According to Munn and co-workers [24], no quality assessment was conducted. Data extraction Data from the included studies were extracted by two reviewers (CG, FR) and reported in an Excel sheet. This file had been developed ad hoc for the purposes of this review. The appropriateness of the worksheet was evaluated during a pilot phase, with adjustments being made as necessary. According to Pollock et al. (2023) [29], a guideline related to the data extraction sheet was created to standardise the process between the two reviewers. If available, the following information was extracted from articles, based on the PCC framework: - Population: age, gender, education level, clinical status, marital status, EDSS and occupational status of individuals receiving intervention; - Concept and context: the geographic locations of the interventions, the professionals who provided the intervention [e.g., occupational therapist, physiotherapist, neuropsychologist], the length of interventions, and the setting where it has been conducted. In addition, data on the study design and the methods employed to evaluate VR were extracted as well as a description of the VR programmes. If one article was related to a wider population including different diseases, we extracted only information and data related to pwMS. If articles described multiple interventions, we extracted separately information for each work-related intervention. Information on the implementation of VR interventions, including any barriers and facilitators, as well as stakeholder opinions was extracted, if available. In addition, other information on the feasibility of VR interventions for pwMS was extracted. Furthermore, the year of publication and the first author were documented. Data synthesis The extracted data were summarised by one reviewer (CG) and reviewed by EG and FR. In accordance with Munn et al., 2018 [24] and Peters et al., 2021 [27], the extracted data were summarised qualitatively, without using qualitative data analysis methods such as thematic analysis. However, in order to provide an overview of the main characteristics of VR interventions, a classification of the main variables has been undertaken, according to the model described in Escorpizo et al., 2011 [20]. These variables include the type of intervention, the aim, the settings and the professionals involved. To classify VR programmes, the following macro areas of intervention were used as labels: rehabilitation, reasonable accommodation and education. According to Negrini et al., 2022 [30] and Escorpizo et al. 2011 [20], the label ‘rehabilitation’ was used for all interventions involving programmes of any kind of rehabilitation, such as occupational therapy, physiotherapy, neuropsychological therapy and psychological support, as well as courses for managing symptoms at work, peer-support and stress management interventions, support in communication and training of vocational skills. Those involving adjustments to workstations and/or working methods (e.g., smart working) were considered ‘reasonable accommodation’ (RA). Finally, VR interventions aimed at raising awareness and providing information to workers with MS about their rights and the difficulties they may experience in the workplace were categorised as “educational”. Subsequently, interventions were classified as uni-dimensional if they encompassed only one of the three macro areas, or multi-dimensional if they involved at least two of the areas of intervention. In order to classify the aim of the intervention, we encompassed three distinct categories. First, interventions that support pwMS in seeking a job were classified as ‘job access’. Second, interventions that offered assistance in returning to work following a diagnosis or hospitalisation were designated as ‘job return’. Third, interventions aimed at maintaining the employment of already employed pwMS, enhancing work skills, and/or facilitating and optimising work participation were categorised as ‘job retention’. Furthermore, we have distinguished the following settings: interventions conducted online, within vocational agencies, in inpatient or outpatient clinics. Results were grouped and reported qualitatively in tables, according to the design employed in the studies that evaluated VR. This was done in order to follow the pyramid of scientific evidence, to highlight the level of evidence for VR that has been achieved to date. In instances where the same intervention was described in more than one article, we elected to include only one of the articles in order to calculate the frequency of key intervention characteristics (professionals involved, intervention components, settings). When more than one article was available for a given intervention, the most recent publication was included. Conversely, in instances where an article reported information pertaining to multiple interventions, the characteristics of each intervention were considered independently in the summary. Finally, opinions among stakeholders were divided between feedback reported by pwMS and feedback from healthcare and social care professionals. Additionally, we distinguished the reported strengths from the perceived limitations. All descriptive analyses were performed using jamovi (version 2.6; The jamovi project, 2025). Results The literature search identified 2,360 articles. After removing duplicates and screening, we included a total of 28 articles [16,31–57 35–42]. Details of the article inclusion process with reasons for exclusion are shown in Fig 1 according to PRISMA guidelines. When multiple exclusion criteria were met, all reasons for exclusion were recorded for each article at the eligibility stage. Flowchart according to PRISMA-ScR guidelines of the literature review process. We reported all the reasons for exclusion of each article evaluated in the eligibility phase. Characteristics of the included articles The articles included were published between 1996 and 2025, covering approximately 30 years of research into interventions to support work activities for pwMS. The majority of the articles were conducted in Western countries, with a particular focus on United States (N = 10; 36%) [33,34,42,47–52,54] and on Europe, with studies conducted in Norway (N = 2; 7%) [32,44], Germany (N = 2; 7%) [38,45] Netherlands (N = 1; 4%) [31], Sweden [N = 1; 4%] [57] and Belgium (N = 1; 4%) [56]. The remain articles were conducted in the United Kingdom (N = 6; 21%) [16,35–37,43,53] and Australia (N = 4; 14%) [39–41,55]. A single study was conducted in Iran (N = 1; 4%) [46]. The designs adopted varied considerably between articles, but there has been an increase in interventional studies over the last 10 years of research. Five studies utilised a randomised (or quasi) controlled trial design, three of which assessed feasibility and acceptability of VR interventions (11%) [32,39,51] while two studies (7%) evaluated the efficacy of VR interventions [40,50]. The remaining articles utilised the following designs: non-RCT pilot study (N = 1; 4%) [41], observational (N = 6; 21%) [33,34,38,42,54,57], protocols (N = 5; 18%) [31,36,37,45,55], semi-experimental (N = 2; 7%) [46,48], mixed-methods (N = 4, 14%) [16,36,47,56], qualitative (N = 2; 7%) [43,44], case studies (N = 2; 7%) [52,53] and comparative (N = 1; 4%) [49]. Of the ten RCTs conducted or described within protocols, six (60%) adopted usual care as control group [31,32,36,50,51,55] while four (40%) reported waitlist control [39–41,45]. Characteristics of the population The majority of studies included pwMS without specifying eligibility criteria related to clinical status, MS phenotypes or age. However, a proportion of studies included participants with low or moderate levels of disability, while Aarts et al., 2024 [31] targeted pwMS with mild cognitive impairment and an EDSS < 6. One study included people with other neurological conditions [49]. Furthermore, two studies specifically targeted women with MS [50,51]. Four studies also included health professionals and mentors involved in the delivery of the intervention [16,35,37,39], and four studies included participants’ employers [16,35–37]. All participants were over 18 years of age and under 64 years of age. The clinical, sociodemographic, and occupational characteristics of participants involved in VR programmes were reported heterogeneously across studies. Geographical origins or ethnicity of the samples were reported in eight articles [16,33–35,47,48,51,54]. In all of the eight studies, the samples predominantly comprised participants of European/Caucasian origin. Eleven articles reported the level of education of the sample [16,34,35,39–41,43,47,48,50,57]. In all of the eleven articles, the majority of participants held either a diploma or a university degree. Occupational status was reported in thirteen studies [16,32,33,35,38–41,47,50,53,56,57]. Most participants included in the studies were employed, with the exception of Chiu et al., 2015 [33] that included more unemployed participants. Marital status was reported in eight studies [16,35,39–41,47,50,51]. The majority of participants included were married or in a relationship. Disability levels were reported in five studies and measured with the Expanded Disability Status Scale (EDSS) [32,35,38,44,57], while MS phenotype was reported in eleven articles and disease duration in eight articles [16,32,35,38–41,43,53,57]. The samples consisted mainly of people with a relapsing-remitting (RR) MS phenotype, with low levels of disability. Specific sociodemographic, clinical and occupational data related to the samples of the included articles are reported in Tables 1 and in S2. In cases where more than one cohort was present within an article, we reported the data separately. Characteristics of the vocational rehabilitation intervention included The twenty-eight included articles documented a total of twenty-eight VR different interventions [31, 32, 33, 34, 38, 35, 36, 37, 16, 40, 39, 42, 43, 45, 46, 47, 48, 49_a, 49_b, 9_c, 50, 52; 53; 54, 55, 56, 57_a, 57_b]. Several articles reported more than one intervention, but the same intervention was reported in more than one article. Therefore, as detailed in the Methods section, only one study per intervention was included in this summary in order to avoid double counting the same intervention in the characteristics of the VR studies. In cases where multiple studies were available, the most recent study was selected. Wickstorm et al., 2017 [57] reported data from two interventions [57_a, 57_b], while Rumrill et al., 1996 [49] described four VR interventions: “The MS back to work”, “the job raising program”, “The return-to-work program” and “the career and possibilities project”. However, one of the interventions reported in Rumrill et al., 1996, “the career and possibilities project”, was also described in Rumrill et al., 1998. Harvedt et al., [2024] [44] reported the qualitative results of the coreDIST intervention, while Arntzen et al., [2023] [32] assessed its feasibility. Furthermore, Dorstyn et al. [2017] [41] and Dorstyn et al. [2018] [40] reported the results of the feasibility and effectiveness of the Work and MS package, respectively. VR interventions described by De Dios Perez and co-workers differ for the professional involved, the setting or the delivery methods, thus we consider them separately in the data synthesis [16,35–37]. Most of the VR programmes 61% [N = 17] were multi-dimensional in nature [34, 35, 36, 37, 16, 39, 42, 43, 45, 48, 49_a, 49_b; 49_c, 52, 53, 54, 55], with support being offered in more than one domains including rehabilitation, educational interventions and reasonable accommodation. The remaining studies comprised uni-dimensional interventions [N = 11; 39%] [31, 32, 33, 38, 40, 46, 47, 50, 56, 57_a, 57_b] encompassing a single category of intervention among the three aforementioned categories. The most prevalent components within the VR intervention reported across the twenty-eight interventions were rehabilitation [N = 21; 75%] [31, 32, 34, 35_a, 36_b, 37, 15, 42, 43, 45, 46, 49_b, 49_c, 50, 52, 53, 54, 55, 57_a] and education (N = 19; 68%) [34, 35_a, 36_b, 37, 16, 40, 39, 42, 43, 45, 48, 49_a, 49_b, 49_c, 52, 54, 57_b], while reasonable accommodation was present in thirteen interventions (46%) [34, 33, 35_a, 36_b, 37, 16, 42, 43, 47, 48, 52, 53, 54]. The setting was documented in twenty-six of the interventions. The largest proportion of interventions were conducted in outpatient clinics (N = 11; 42%) [31, 32, 45, 48, 49_a, 49_b, 49_c, 50, 53, 57_a, 57_b] followed by seven studies that were conducted online (27%) [39, 40, 36_b, 37, 16, 55, 56], five within vocational agencies (19%) [33,34,42,47,54] and two (8%) in inpatient clinics [38,43]. Finally, De Dios Perez et al., 2025_a [35] conducted the intervention in a hybrid format (online and face to face) (N = 1; 4%) at the clinical rehabilitation centre according to the participant’s preference. The professionals involved were reported in nineteen interventions. The professional figure with the highest level of involvement was the psychologist, who was present in eight of the interventions described (42%) [16,37,39,40,43,45,50,55], followed by the occupational therapist (N = 4; 21%) [35,37,43,53] and the physiotherapist (N = 3; 16%) [32,43,46]. Other professionals involved in the VR programmes were: vocational agency professionals (N = 5; 26%) [33,34,42,47,54] specialist doctors (N = 2; 11%) [32,45] and MS nurses (N = 1; 5%) [32]. In addition, other non-health professionals such as MS charities employees or social insurance suppliers and mentors (peer-support) (N = 4; 21%) were reported [31,36,39,45]. The interventions implemented were predominantly focused on job retention (N = 13; 46%) [31, 32, 35, 36, 37, 16, 45, 46, 50, 52, 55, 57_a, 57_b], while nine (32%) interventions were also directed towards job access or return to work following a prolonged absence [34, 54, 38, 42, 43, 47, 49_b, 54, 56]. The proportion of interventions that were directed exclusively towards job seekers, whether employed or unemployed, was found to be 14% (N = 4) [39, 40, 48, 49_a]. Finally, Sweetland et al., 2014 [53] intervention was directed towards both the reintegration into work and the job maintenance [N = 1; 4%]. Finally, 7 out of 28 (25%) interventions adopted a goal-oriented approach [16,31,35–37,43,48], and fourteen (46%) interventions reported an individualised programme [16,31–37,42,43,45,48,53,54]. Rehabilitation programmes Across the twenty-one rehabilitation programmes, we identified seven types of intervention: symptom management, functional rehabilitation, stress management, work–life balance, support in communicating the diagnosis, assertive communication training, peer support, and vocational skills training. Below, we report the frequency of each of these seven interventions within the twenty-one rehabilitation programmes identified. Each rehabilitation programme included one or more of these seven types of intervention. Of the twenty-one rehabilitation components of VR intervention, twelve interventions were aimed at supporting pwMS in managing their symptoms in the workplace (N = 12; 57%) [31, 34, 35, 36, 37, 16, 42, 45, 49_c, 50, 54, 55]. These interventions provided strategies to overcome symptom-related difficulties in the workplace and enhance awareness of the impact of MS on work ability. The rehabilitation of functions, encompassing physiotherapy, occupational therapy, neuropsychological rehabilitation and psychological support, was documented in eight out of twenty-one of the included VR interventions (38%). Two of these interventions provided physical activity [32] and aerobic training in water [46]. The other interventions provided rehabilitation based on individual needs, without starting from a predefined programme or protocol [34, 42, 43, 45, 54, 57_a]. The remaining interventions were targeted towards the facilitation of communication in the workplace (N = 9; 43%) [34, 42, 43, 45, 54, 57_a], the disclosure of the diagnosis (N = 10; 48%) [34, 35, 36, 37,16, 42, 49_b, 53, 54, 55] and in the vocational skills training (N = 9; 43%) [32, 34, 16, 35, 36, 37, 42, 49_b, 54]. Finally, a number of interventions were designed to assist pwMS in the alleviation of stress and mood difficulties, or the enhancement of coping mechanisms (N = 6; 29%) [35, 36, 37, 16, 49_b, 52], in achieving a balance between professional engagements and their daily lives (N = 5; 24%) [31, 34, 42, 54, 55], or were grounded in the concept of peer support (N = 3; 14%) [31, 39, 49_c]. Reasonable accomodations (RA) programmes We identified two different types of RA interventions within the thirteen VR intervention that comprised RA: interventions aimed at providing advice on workplace adaptations and interventions aimed at providing accommodation. These two different types of RA may coexist within the same VR interventions, or they may be present individually. Of the thirteen VR programmes which included a RA interventions, all studies provided an evaluation of the workplace or a consultations for adjustments and specific aids (100%) [16,33–37,42,43,47,48,52–54], while five (39%) directly provided the accommodation needed by the participant [33,34,42,47,48,54]. RA were mainly evaluated from VR agency databases, especially the studies in which RA has been fully provided [33,34,42,47,54]. VR agency provides the following kinds of RA schedule modification: equipment/assistive technology (e.g., enlarged computer screen, scooter, voice activated software), climate control/Air conditioning, reassignment, reduction of hours, physical accessibility [47]. Educational programmes Within the educational programmes, we have identified the following four areas of intervention: legal support, information on the labour market, referral to other sources of information, and career development support. Each educational intervention may contain more than one of these components. Of the nineteen educational programmes, the majority were aimed at providing information on legal rights (N = 11; 58%) [35; 36; 37; 16; 40; 39; 43; 45; 52; 55; 57_b]. Ten interventions (53%) were aimed at supporting pwMS in defining their career [35, 36, 37, 16, 40, 39, 48, 49_a, 49_c, 55] and nine interventions (47%) referred to other resources to support people with disability experiencing work-related difficulties [35_a, 36_b, 37, 16, 40, 39, 49_a, 52, 56]. Finally, six educational programmes (31%) provided information on the job market to support pwMS in access to new job position [40, 39, 48, 49_a, 49_b, 57_b]. The main findings and intervention features are reported in Table 2. Fig 2 shows the main interventions for each of the VR dimensions for pwMS. The figure summarizes the principal domains of VR interventions identified in the scoping review. Interventions were grouped into three main areas: Rehabilitation, reasonable accommodations, and educational. Stakeholder opinion: Perceived barriers and facilitators to the intervention The opinions of stakeholders were reported in seven articles [16,35,41,43,44,48,51]. We summarised the main aspects in Table 4. All studies focused on the perspective of pwMS, while the opinion of professionals was only investigated by De Dios Perez et al., 2023 [16] and De Dios Perez et al., 2025 [35], who also included the opinion of employers within the VR intervention. All seven studies reported positive aspects and strengths of VR programmes, as well as some limitations. PwMS reported that the adoption of an open-minded and sensitive approach by healthcare providers was paramount. This approach allows engendering a sense of understanding and acknowledgement [16,35,43]. The most beneficial initiatives in pwMS’s opinion also included awareness courses on the rights of workers with disability, information regarding the management of symptoms, empowerment, and guidance on entering the job market [16,43,51]. Similar results were also reported by Dorstyn et al., 2017 [41], where the provision of bespoke multimedia content, customised to individual case narratives and accompanied by guidelines on the disclosure of illness within the workplace, the provision of generic information on job-seeking and the employment market was found to be very helpful. Furthermore, Jellie et al., 2014 [43] also highlighted the importance of the support in the management of coping mechanisms for anxiety and loss of confidence. Stimmel et al., 2020 [51], where personalised guidance concerning cognitive functioning and in-person feedback following neuropsychological assessments were pivotal to the VR intervention. De Dios Perez et al.,2025 [35] highlights a strong acceptance of remote vocational support, valued for its flexibility, personalisation, and clinical relevance. Benefits were greatest when the intervention was timely and delivered within supportive organisational environments. In Hartvedt et al., 2024 [44] physical activity (PA) was perceived to improve work capacity, performance, satisfaction and retention. PA was identified as a pivotal factor in the domains of identity, self-esteem and quality of life. It is evident that the psychological benefits of PA, including enhanced tolerance and strength, have contributed to the ability of individuals to manage mental challenges and stress. However, these strengths have been reported as a limitation by other participants, who perceive PA as an activity that consumes energy and difficult to integrate with work. Finally, in Rumrill et al., 1998 [48] pwMS reported that the professional suggestions received, the identification of accommodation needs, and the support in the accommodation assessment with employers were central in their VR programmes. In terms of limitations, pwMS reported a preference for in-person meetings as opposed to online meetings, in instances where the subject matter pertains to emotionally sensitive aspects of their work. As Dorstyn et al. [2022] [39] asserted, the online format has also been identified as a potential barrier to participation. However, in contrast to these findings, Stimmel et al. [2020] [51] reported that pwMS cited travelling to the clinic as a barrier to programme participation, and in most cases, a reason for withdrawal. Furthermore, in Dorstyn et al., 2017 [41], pwMS reported a lack of provision of information regarding legal issues, strategies for maintaining a healthy work-life balance, but also the need for an effective method to interact with employers. Finally, the involvement of employers could prove invaluable; however, this must be approached with the utmost caution by the participants [16]. Healthcare professionals believed that there is a need to provide VR to PwMS, while employers reported an increased understanding of the needs of their employees with MS [16]. Although integration into NHS pathways was considered valuable, several practical and financial constraints were identified [35]. Feasibility of interventions Six interventional studies investigated the feasibility of the interventions [16,32,35,39,41,51]. Feasibility was assessed differently across the five studies, but all reported data on enrolment and subject retention in the study. In general, the included articles highlighted a good recruitment capacity and a variable adherence to the proposed activities. Only Stimmel et al., [2020] [51] contacted a large number of eligible participants, but included only a small percentage of them. Participation was occasionally constrained by logistical, motivational or health-related impediments, but drop-outs were minimal and predominantly ascribed to personal or medical justifications [32,35,39,41]. Although certain authors documented response rates that fell below the anticipated figures, the general feasibility of the programmes was deemed sufficient, with the potential for future implementation in larger settings [16,32,35,39,41,51]. We have summarised the main results for the reported variables of the workflow of the intervention in Table 4. Discussion To our knowledge, this is the first comprehensive scoping review aiming to identify the entire body of literature related to VR interventions to support pwMS to access, return to or to maintain job position. Previous systematic and scoping reviews aimed to assess the efficacy of the intervention, including only a few articles and without providing a landscape of the VR programmes for pwMS worldwide [3,22,23]. Thus, this is the first scoping review to encompass both qualitative and feasibility data related to the implementation of VR for pwMS. Our results suggest that a substantial corpus of research has been undertaken over time, highlighting VR as a highly sensitive issue for pwMS. However, at this juncture, the timing is not conducive to undertaking a systematic review, since high-quality RCTs are still lacking. However, the presence of several interventional protocols with randomization and control group has been reported recently and herald the arrival of highly scientific results [31,36,45,55]. The included studies were mainly conducted in Western countries. Nevertheless, the increasing prevalence of MS in non-Western countries emphasises the importance of conducting these studies worldwide [58,59]. Furthermore, the scoping review evidenced considerable heterogeneity in the reporting of sociodemographic and occupational characteristics of study samples, as well as in the description of work-related outcomes, across studies on VR in multiple sclerosis. In line with previous recommendations [60], we call for established guidelines to assist authors in the reporting of sociodemographic and occupational data, to enhance the representation of this population within research and to allow the stratification of clinical studies results based on these characteristics as well. This is particularly crucial to facilitate meta-analyses that encompass factors impacting the efficacy of VR intervention and to inform a systematic review [24]. The present review, in accordance with Escorpizo and colleagues’[20] definition, identified studies aimed at supporting pwMS throughout all stages of working life, conducted not solely by vocational agencies but also in outpatient or inpatient settings. Furthermore, Escorpizo et al., [2011] [20] emphasise the importance of addressing individual factors hindering participation in work, together with environmental factors. In accordance with this definition, the articles included pertained to multi-dimensional interventions that addressed work-related difficulties from multiple perspectives. We identified three main categories of VR intervention: rehabilitation, reasonable accommodation and educational interventions. Rehabilitation was the most prevalent component within VR interventions. In the VR context, rehabilitation aimed at assisting individuals in managing symptoms in the workplace and in identifying effective strategies to overcome work-related challenges. Furthermore, programmes that focus on enhancing communication skills, particularly in the context of disclosing diagnoses, are essential components of VR programmes [43,61,62]. Indeed, the process of diagnosis has been shown to engender a range of psychological effects in pwMS, including the questioning of professional capabilities and the development of persistent negative thought patterns and maladaptive coping strategies [11,52,62,63]. Consequently, recent studies have identified the importance of timely intervention following diagnosis as a means of mitigating the impact on vocational identity, self-esteem and self-efficacy [53,62,64]. Timing is crucial: premature intervention can be overwhelming, whereas intervention initiated at a later stage may become ineffective, due to the exacerbation of work-related difficulties [35]. In this regard, the most suitable figures to promptly identify work-related needs are primary care professionals, such as general practitioners or specialist nurses. Addressing work-related difficulties within primary care settings enables pwMS to engage with these issues when they feel ready, in a trusted environment, thereby reducing the risk of delayed intervention. In this light, the provision of bespoke training for professionals in the workplace is indispensable, a necessity that is not only expressed by professionals involved in VR programmes but is also a key demand [65,66]. Furthermore, the presence of communication difficulties is indicative not only of impaired psychological functioning and reduced well-being, but also of concomitant common symptoms such as cognitive impairment and dysarthria [67]. This underscores the multidisciplinary nature of VR interventions which is characterised by the diversity of intervention domains within VR, and by multidisciplinary intricacies inherent within these domains. Collaborative efforts to effectively address the multifaceted challenges posed by work-related difficulties are needed [18,64], and this is reflected in the significant involvement of psychologists and occupational therapists in the VR programmes reported in the included studies. A distinctive feature of VR interventions is the general absence of eligibility restrictions based on disease phenotype, disease duration or level of disability across the included studies. In this review, only two VR interventions selected participants with an average level of disability: the CoreDist participation [32,44] and the Strengthening the Mind [31]. While these findings should be interpreted with caution, they indicate that VR interventions have been applied in heterogeneous pwMS populations. In line with previous literature [13,68], work-related difficulties may occur across different forms and stages of multiple sclerosis, suggesting that individuals may benefit from VR interventions regardless of their clinical profile or level of disability. The inclusion of diverse clinical profiles may also reflect an underlying reliance on bio-psycho-social frameworks, which conceptualise work-related functioning as the result of interacting physical, cognitive, and contextual factors rather than disease severity alone [64,69]. Despite goal-oriented interventions being widely adopted in MS rehabilitation [70], our review identified only a few studies with a collaborative approach aimed at tackling specific work-related objectives [16,31,35,36,43,48]. De Dios Pérez et al., [2023] [16] highlighted the difficulty that pwMS experience in recognising the impact of their illness on their ability to work, and the subsequent challenge of accepting this impact. Conversely, a person-centred approach involving the development of personalised rehabilitation plans is more commonly adopted in VR for pwMS [16,33,34,37,42,43,45,48,53,54,64]. In this context, we believe that a person-centred approach and goal-oriented interventions, combined with individualised rehabilitation plans, are the most effective tools for addressing the variety of work-related difficulties and clinical characteristics experienced by people with MS [13,35–37,64]. Educational interventions are also frequently used, either as a standalone program or in combination with rehabilitation and reasonable accommodation. Indeed, the complexity of administrative procedures governing access rights for persons with disabilities has been demonstrated to act as a significant impediment to employment [13,15] for both those seeking to maintain their current position and those aspiring to transition to a new role [39–41]. In this particular context, the review identified several interventions that resulted in the creation of information packages with references to existing employment support resources [39,40,55,56]. Reasonable accommodation (RA) was the least frequent component within VR programmes. Nevertheless, the necessity to intervene at an environmental level is recognised as an essential element in ensuring that individuals with MS remain in work [12,13,47]. Furthermore, VR interventions that directly provided accommodation were primarily conducted using data from the databases of US vocational agencies [33,42,47,54]. Consequently, there is a paucity of evidence of effectiveness conducted outside the US and within healthcare settings. Research conducted outside vocational agencies has provided advice on accommodations, but there has been no subsequent follow-up on the provision of accommodations by employers. Further studies are needed to assess the effectiveness of RA, as well as their feasibility. Thus, this review reveals that the social context of work and relationships with employers can hinder the direct implementation of RA [35,37]. Without a supportive environment, accepting aids and adjustments can be challenging as it necessitates making one’s disability visible, exacerbating social isolation. In these contexts, pwMS may refuse the intervention, in order to avoid the deterioration of their relationships with colleagues and employers [17,35,37]. VR interventions included in our review were assessed as feasible and acceptable [16,32,39,41,51]. However, the reasons for ineligibility or withdrawal from the study were not systematically reported across studies and several barriers have been highlighted within this scoping review such as: proximity to the centre providing the service, lack of time due to excessive workload [51]; lack of time for personal reasons [44] and, in interventions aimed at changing job position or to enter the workforce, pwMS may change work position, or find the new job prior to receiving or completing the intervention or due to health issues [39,41]. These results highlight the need to design interventions that can be easily adapted to personal needs in terms of delivery methods and timing, adapting service schedules as far as possible outside peak working hours in order to facilitate participation, especially for those who are already employed and face work-related difficulties [61]. Furthermore, we did not identify studies evaluating the cost-effectiveness of VR interventions, which is a key aspect for the implementation of the service within the NHS. No cross-cutting preference for online interventions emerged: in De Dios Perez et al., 2023 [16], participants reported that addressing sensitive issues in person would have been more satisfactory for them, and in Dorstyn et al., 2017 [41], online intervention proved difficult for older people. PwMS recognised the importance of specific interventions aimed at tackling work-related difficulties, and evaluated an empathetic, non-judgemental and welcoming approach as essential to support them in accessing employment [16,43]. However, more studies are needed to frame stakeholder opinions, especially with regard to professionals and employers, who were only included in the study by De Dios Perez et al. (2023) [16]. Conclusions We have mapped the existing literature on VR for pwMS who need to enter, return to or remain in employment. Further high-quality scientific studies are needed in order to identify the most effective interventions and ensure a pathway that meets the real needs of workers. The implementation of VR interventions at both the environmental and individual levels introduce a heightened level of complexity, necessitating a more sophisticated scientific evaluation. However, these interventions possess the capacity to address authentic needs and are evaluated as acceptable and feasible. Strengths and limitations This is the first comprehensive scoping review of VR interventions for pwMS. This study examined the implementation process and considered the opinions of the relevant stakeholders, which is an innovation in the field of scoping review. A plethora of databases was consulted to include all the relevant publications; nevertheless, we refrained from utilising more extensive keywords associated with VR, such as “work,” in order to circumvent literature that encompasses work-related challenges without offering any insights pertaining to VR. Furthermore, we did not request the full texts from the authors of the articles if they were not available elsewhere. This may have excluded some articles of possible interest. Finally, the data on the study populations were characterised by a high degree of heterogeneity, thus we were not able to provide percentages related to the sample characteristics. Supporting information S1 Table. Search Strategy. Search strings used for each electronic database, including MeSH terms and free-text keywords. https://doi.org/10.1371/journal.pone.0350122.s001 (DOCX) S2 Table. Sociodemographic, clinical and occupational data. Detailed characteristics of participants across the included studies, including, geographical origins, marital and occupational status, MS type, EDSS and disease duration. https://doi.org/10.1371/journal.pone.0350122.s002 (DOCX) S3 Table. Data extraction. Full data extraction form including articles information, population and intervention characteristics, and stakeholder opinions. https://doi.org/10.1371/journal.pone.0350122.s003 (XLSX) S4 Prisma-ScR Checklist. PRISMA-ScR Checklist. 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