INTRODUCTION: People with long-term conditions or recovering from serious injuries can struggle to return to work. The evidence for occupational therapy supporting return to work is limited. We aimed to identify and explain how occupational therapy interventions work. METHODS: Systematic review. Seven databases were searched between 1 January 1980 and 15 June 2022. Studies measuring work-related outcomes among individuals receiving occupational therapy during absence from paid work were included. Multiple reviewers independently contributed to screening, quality appraisal and data extraction processes. Data were analysed as a narrative. RESULTS: Twenty studies with 3866 participants were included; 17 were assessed as having high risk of bias. Occupational therapy was inconsistently acknowledged affecting study identification and occupational therapy components were poorly described. Meta-analysis was unfeasible due to outcome heterogeneity. Individually tailored occupational therapy focused on return to work in musculoskeletal conditions indicated the most promising outcomes. Key intervention components included vocational assessment, goal setting and self-management. Key mechanisms of action included early intervention, individualised support and being responsive to needs. CONCLUSIONS: Occupational therapists' contributions supporting return to work should be clearly attributed. Future effectiveness research should standardise the measurement of work outcomes to support meta-analysis. Developing a taxonomy for occupational therapy supporting return to work could facilitate comparisons across studies, highlighting occupational therapists' roles and facilitating training and benefits to patients.

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