Work-Focused Health Care: The Role of Physical Therapists (2024)

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Musculoskeletal disorders (MSDs) are characterized by pain and reduced physical functioning that often results in decreased quality of life. Work-related MSDs are health problems in which working conditions (ie, physically demanding or repetitive activities or a poor work environment) significantly contribute to the onset or progression of the disorder but are not necessarily the sole cause. Even if work-related environmental factors do not directly cause MSDs, the symptoms can be work relevant (ie, the work can influence the symptoms, or the symptoms can affect the ability to work). Work-related MSDs are burdensome to patients, employers, and society, as they are associated with high rates of disability, absenteeism, presenteeism, loss of productivity, longer recovery timeframes, and workers’ compensation costs. In this Point of View, we argue that physical therapists treating patients with MSDs should adopt a work-focused approach. There is ample evidence showing that being employed is associated with better health.1 Physical therapists can improve the health-related quality of life for patients with MSDs through adopting a work-focused approach and promoting participation in work.

Work-Focused Physical Therapy

Several government policies have embedded work as a health outcome by encouraging health care professionals to participate in work-focused health conversations and tackle obstacles to work participation.2 These conversations may include work-related topics such as discussing barriers and facilitators for work, setting work-focused treatment goals, or updating relevant stakeholders such as employers, insurers, and other health care professionals.

The absence of work-focused health care often creates an obstacle to work participation due to the lack of consistent, supportive conversations about work and agreed therapeutic goals aimed at work participation.3 This suggests that conversations about work have not been clearly defined or embedded within clinical practice.2

Although most physical therapists acknowledge the importance of their patients’ work, occupation and the ability to work are often not sufficiently addressed within regular physical therapy.4^,5 In a recent narrative review,2 the barriers for work participation and positive work outcomes were highlighted. This review reported that professionals do not address work due to the belief this is not part of their scope of practice. Physical therapists may feel more comfortable focusing on other dimensions of function such as household tasks, hobbies, and sports rather than considering inquiries about work. Physical therapists may believe they lack sufficient knowledge regarding ergonomics, the return to work process, vocational rehabilitation, or insurance medicine issues. Other obstacles may include lack of time and insufficient communication between the treating physical therapist and occupational health care professionals (including physical therapists specialized in occupational health, where available).5^,6 On a more system-based level, a lack of funding to deliver work-focused care has been reported to be a barrier by some health care professionals.2 Another system-level obstacle could be the separation of occupational and primary health care professionals that exists in some countries7 or that the role of physical therapists in the workers’ compensation system is unclear.6 These obstacles have financial consequences and may limit cooperation between professionals.

A recent pilot study among 4 physical therapist professional education programs (from Australia, Brazil, Kenya, and Spain) focused on how these programs include work and work-related conditions in their curricula. It was found that program content differed regarding the extent to which topics such as work injury prevention, management, and return to work issues are addressed, indicating possibilities for improvement.8

Crucial Role of Physical Therapists

The longer a patient is away from work due to a MSD, the more difficult it is to return.9 Physical therapists can play an essential role in work-focused health care. They are often involved in the early management of MSDs and can deliver interventions as part of usual care. They are ideally situated and qualified to undertake these activities and include structured work-related assessments or interventions such as functional capacity evaluations, work conditioning, or graded activity programs.

To facilitate return to work or to stay at work, a structured approach that integrates medical and vocational interventions may be useful. Sennehed etal10 tested a structured workplace dialogue (convergence dialogue meeting; a physical therapist-led interview with the patient and an interview with the employer and, finally, a meeting between patient, employer, and physical therapist) in a randomized controlled trial among patients with acute and sub-acute low back and neck pain. They demonstrated that this cost-effective combined approach improved work ability at 12-month follow-up.10^,11

Physical therapists should apply a patient-centered approach, including shared decision-making, where both physical therapist and patient agree on treatment goals. Inherent in these goals are those relevant to work. Physical therapists should explore the impact of work-related factors on the patients’ work performance during the therapeutic consultation and support working patients with active management or return-to-work strategies. By adopting a work-focused approach, physical therapists can explore a variety of work-related factors acting as barriers or facilitators to work. These factors can then be used to provide active recovery and pain-coping strategies, to educate both the employee and the employer about the benefits of remaining in or returning to work, and to offer advice on work-rest schedules or pacing. When issues regarding work participation or barriers to return to work are present, physical therapists can formulate goals related to work participation and return to work, then address any identified issues during treatment. The physical therapist should promote worker self-management strategies to increase work tolerance and offer accommodations to allow for a gradual increase in work tolerance, both of which are aimed at reducing work disability.12 Examples of domains and questions that can be used by physical therapists in a work-focused approach are presented in Table 1.

Assessment of Barriers and Facilitators for Work

The International Classification of Functioning, Disability and Health (ICF) framework13 is a biopsychosocial model of disability, which can be used by physical therapists to guide the assessment of barriers and facilitators for work. Figure 1 contains a work-adapted ICF scheme14 that is illustrative of how work can be assessed using the ICF to guide a comprehensive examination. Functioning, including work participation, can be influenced positively or negatively by environmental and personal factors. Environmental factors make up the physical, social, and attitudinal environment in which people live13 and can be subdivided into work-related environmental factors (work tasks, work conditions, terms of employment, and social relationships at work) and other environmental factors (like living conditions). Work-related environmental factors can influence functioning positively (eg, employer support can stimulate return to work) or negatively (eg, working conditions can attribute to Work-related MSDs).

Personal factors are the particular background of a patients’ life and living.13 Personal factors can be subdivided into work-related personal factors (eg, job satisfaction, personal meaning of work, and work identity) and other personal factors (eg, age and level of education). Work-related personal factors can influence functioning positively (ie, when work identity is high, absenteeism is reduced) and negatively.

Work-related environmental and personal factors can also influence each other. Support by colleagues can lead to higher job satisfaction, while poor working conditions can result in job dissatisfaction.

Physical Therapists Specialized in Occupational Health

Physical therapists specialized in occupational health promote healthy work, endeavor to prevent injuries and illnesses, and manage work-related conditions. Undergraduate training related to the role of physical therapists in occupational health varies globally and in some countries occurs at a postgraduate level.8

Both Australia and the United Kingdom have professional practice standards for occupational health physical therapists.15 These standards may include legislative requirements, understanding how the workplace can influence health, implementation of interventions that may affect stakeholders (eg, employers, employees, and insurers), methods of evaluation, communication with stakeholders, and professional practice considerations (eg, ethics and confidentiality).

Physical therapists with the requisite skills can play an educative role, explaining the health benefits of work, and liaising with employers about suitable and/or modified duties for a gradual return to sustainable work. This may include conducting workplace visits and meeting various stakeholders to enhance communication. Physical therapists specializing in occupational health can share their findings with other physical therapy practitioners who may not be familiar with the nuances of the work involved or the work environment. It is essential to identify which countries do not provide occupational health pathways within their educational programs and establish a specialization route within physical therapist education.

A Multidisciplinary Approach

A multidisciplinary approach may be needed that involves physical therapists who specialize in occupational health and other occupational health care professionals (ie, occupational physicians, ergonomists, occupational therapists). It can be especially beneficial when workplace adjustments are needed or aspects of work require change, for example, if work-related cognitive demands require modification. Where available, we recommend that physical therapists closely collaborate with physical therapists who specialize in occupational health and other occupational health care professionals. The extent of this collaboration will be case specific depending on the environmental and personal factors. This cooperation could be an intraprofessional consultation (ie, a consultation with physical therapists specialized in occupational health) or an interprofessional consultation (ie, a consultation with other occupational health care professionals). It may also take the form of a referral for a work capacity evaluation, workplace analysis, or, in more complex situations, a referral for a more extensive work-related intervention performed by a physical therapist who specialize in occupational health or an entire multidisciplinary occupational health team. A guidance for cooperation/collaboration between treating physical therapists and physical therapists specialized in occupational health is presented in Figure 2. In most cases, this cooperation/collaboration with occupational health professionals is an addition to the individualized treatment. An overview of a guidance for cooperation/collaboration between the treating physical therapists and physical therapists who specialize in occupational health is presented in Figure 2.16

Recommendations

Physical therapists are ideally situated to provide work-focused care and to support employees with MSDs. Therefore, we recommend that:

1. Physical therapists should be aware of the health benefits of participating in work and the importance of adopting a work-focused approach in treatment.

2. Physical therapists should discuss work participation in patients with MSDs during the consultation. If the complaints are relevant to the performance of work, physical therapists should establish work-focused goals and address issues related to work participation during the consultation.

3. Physical therapists should collaborate with physical therapists who specialize in occupational health and other occupational health care professionals as part of a patient-centered approach.

To support physical therapists, readily available and easy-to-use tools that can guide and help physical therapists in handling work-related issues should be identified and/or developed. The utility and effectiveness of these tools is a topic for further research. It is also crucial to embed occupational health in all physical therapist undergraduate education programs and to provide professional training and courses about occupational health to physical therapists.

Author Contributions

Concept/idea/research design: N. Hutting, D.P. Gross, Y.F. Heerkens, V. Johnston, G. Skamagki, K. Stigmar

Writing: N. Hutting, R. Boucaut, D.P. Gross, Y.F. Heerkens, V. Johnston, G. Skamagki, K. Stigmar

Project management: N. Hutting

Consultation (including review of manuscript before submitting): N. Hutting, R. Boucaut, D.P. Gross, Y.F. Heerkens, V. Johnston, G. Skamagki, K. Stigmar

Disclosures

The authors completed the ICMJE Form for Disclosure of Potential Conflicts of Interest and reported no conflicts of interest.

References

© The Author(s) 2020. Published by Oxford University Press on behalf of the American Physical Therapy Association. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com

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