In March this year, Dame Carol Black, national director of health and work, recommended the adoption of a multidisciplinary approach to help improve the health and wellbeing of individuals.
In light of this, and given the increasing numbers of unemployed physiotherapists, it could be asked why more businesses are not recognising the advantages of using the skills that this group of professionals have to offer.
Most physiotherapists develop their skill in an NHS setting under guidance and supervision, giving them an invaluable basis for learning due to the wide range of conditions encountered in both an in-patient and out-patient environment. However, NHS cutbacks mean potential employers in the OH sector have the problem of an abundance of qualified professionals looking for work, but without the required skillset to work independently in the specialised OH setting.
Employers often lack knowledge of how occupational physiotherapists can be used to aid productivity. Poor support for those in the early stages of illness and a lack of communication between stakeholders may also exacerbate the problem of sickness absence and ill health.
Yet physiotherapists can help both the therapeutic aspects of treatment and the impact on psychosocial issues such as morale and anxiety, and there are cost benefits in relation to productivity and sickness absence.
Given the opportunity, physiotherapists can hold a central role within the occupational health team. They can help other health professionals to promote and challenge health attitudes and beliefs, as well as provide immediate assessment and treatment of musculoskeletal disorders. They can facilitate referral to other health professionals and can be used to carry out home visits along with OH advisers to discuss return-to-work strategies or to assess fitness for return to work.
Although some employers are now using these services to facilitate a holistic approach to health and wellbeing, it is far from common practice.
Adaptability
One of the advantages of using a physiotherapy service is its adaptability and flexibility. In practice this means that employers can consult physiotherapists on either an ad-hoc basis – for example for one-off advice on ergonomic issues or fitness for work assessments – or on a more regular basis, such as weekly clinics and ongoing advice on ergonomic issues.
Occupational physiotherapists are in an ideal position to work with OH advisers in educating and raising awareness regarding the prevention, time course and nature of injuries. The early detection and reporting of symptoms has been shown to play an important role in recovery and rehabilitation.
In addition, musculoskeletal disorders are considered to be multi-factorial in nature (Battevi, Menoni and Vimercati, 1998), with physical and psychosocial factors interacting (Devereux, Vlachonikolis and Buckle, 2002).
An individual employee’s health beliefs and behaviour can influence their perception of symptoms, their severity and expected recovery (Ogden, 2004). Symptoms may go unreported, possibly contributing to long-term problems, if the employee is unaware of risk factors and the nature of musculoskeletal conditions (Sprigg, Smith and Jackson, 2003).
Most occupational physiotherapists have ergonomic experience and can therefore play an active role in increasing awareness regarding such risks, encouraging their reporting and making recommendations to reduce them. This is a holistic approach and is also effective in improving awareness regarding risks and increasing employees’ responsibilities for their own health.
Occupational physiotherapists are ideally placed to educate individuals regarding musculoskeletal disorder risk factors and encourage the early reporting of symptoms. They can be the first contact person to identify that working practices may or may not have contributed to symptoms, and to suggest that continued work may support rehabilitation.
This is advantageous not only to the employee as changes can hopefully be made to work tasks to prevent sickness absence, but also to the employer in terms of risk assessment, preventative action and therefore productivity. Attitudes and beliefs towards work and health have been identified as one of the factors affecting absence and return to work (Black, 2008).
Recommendations can be made to reduce or eliminate risks and may include retraining, the provision of information, and minor adjustments at the workstation between the employee and their interface or environment, or a change in policies or procedures.
Forward-thinking employers such as Westminster City Council are quick to recognise and use such services for their employees. This helps to reduce levels of anxiety regarding aggravating factors and sends out a message to employees that the employer is willing to take any necessary steps to support them in the workplace. Once again, this supports the recommendations of Black’s report, combining a holistic approach, early intervention and managerial support.
Challenge
Physiotherapists can challenge unfounded beliefs about health and promote work as a positive factor by avoiding negative terms that suggest that work is the cause of injury and symptoms, such as ‘repetitive strain injury’ and ‘work-related musculoskeletal disorders’.
They can reduce employees’ fears about remaining in or returning to work by explaining alternative mechanisms of injury and their nature and promoting the positive effect of exercise, activity and work. This also helps employees to recognise their own responsibilities regarding unhealthy and risky behaviour both in and outside of work, and how this may contribute to their condition.
Physiotherapists can also play an active role within the OH team in health promotion, such as increasing exercise levels, stopping smoking and encouraging healthy eating. Manual handling training, back care and risk assessor training can simultaneously aid the prevention of musculoskeletal injuries in the workplace and raise awareness of the relevant risk factors.
Employees may avoid returning to work because they incorrectly believe this will exacerbate their symptoms. Such beliefs can occur as a result of operant conditioning and classical conditioning (Ogden, 2004), when a person’s perception of pain increases when they think about their work tasks or environment. This can lead to fear avoidance behaviour, which can be reinforced by sickness certificates (Black, 2008).
Well placed
Due to their distance from the workplace, GPs are frequently in a difficult position to judge whether or not an individual is actually fit to return to work. Physiotherapists are ideally placed to liaise with them about the exact role of an employee and how their tasks will affect recovery.
This can facilitate both the GP’s decisions regarding certification, and the advice they give to the employee regarding their work capabilities. The employee gets uniform advice regarding work and rehabilitation, serving to reinforce information supplied by OH advisers. This supports shared goal-setting between all parties, regarding healthy working and return-to-work programmes.
Many employers are unaware that physiotherapists may be happy to provide a service for their staff that is financed directly by the employee or through an individual’s health insurance.
This has very little financial implication for the employer, but is advantageous to them, especially small businesses without OH facilities. Using an occupational physiotherapist can facilitate links with other health professionals in mainstream healthcare, helping to provide a more holistic approach to care.
Alternatively, some employers often agree to directly fund the services themselves or to adopt a combined approach. One such employer is the Wellcome Trust, which uses an occupational physiotherapist on an ad-hoc basis to provide clinical treatments funded by the patient or their health insurance. It also uses an occupational physiotherapist to provide display screen equipment training alongside an OH nurse, reinforcing their online assessment process and reducing the need for more costly individual assessments.
On-site access to physiotherapy provides the advantages of less time away from work travelling to and from appointments, reduced waiting times and therefore improved access to diagnosis, treatment and further referral where needed. This has obvious advantages, including improved communication with on-site stakeholders, such as OH advisers, HR and line managers, improved levels of morale, and reduced anxiety about symptoms, hence positive effects on treatment outcomes.
All of these factors have obvious implications regarding the cost effectiveness of reducing sickness absence, and the Health and Safety Executive has recently published work supporting the evidence for on-site physiotherapy and its cost effectiveness.
Conclusion
In conclusion, occupational physiotherapists have several advantages on both an individual and more global level. For the individual employee, these encompass both physical health and psychological wellbeing. This benefits the employer in reduced sickness absence, increased productivity and financial savings. Case study
A 38-year-old factory worker, employed by Goodrich Power Systems, had been absent from work for three weeks. Sickness certificates issued by his GP stated that he was suffering with lower back pain. He had been prescribed anti-inflammatories and analgesics and been advised to rest.
The employee had a history of back pain, but had not previously been signed off work due to this condition. He was significantly overweight and took no exercise. His understanding of the nature of his condition was limited and he had been told in the past that he was suffering with back pain due to compressed lumbar discs.
He was anxious about returning to work in case his symptoms increased, particularly with regard to manual handling tasks. His role required him to sit at a raised bench for most of the day performing manual tasks. He was required to perform manual handling activities on a regular basis. Apart from his current condition, he was otherwise in good health.
Following his third week off, an invitation to see the occupational physiotherapist was sent to him by the OH department. It was stressed that attendance was voluntary and would in no way signify his agreement to return to work. The advantages of attending were identified. It would provide him with an assessment and any necessary treatment, free of charge, so facilitating his rehabilitation and return to work while allowing him to voice his concerns about doing so.
The GP was informed of the invitation and agreed that it would be beneficial to the employee to attend. This provided uniform advice regarding the assessment from an external, mainstream health professional, as well as the OH professional, embracing a holistic approach.
The invitation was accepted, and the physiotherapist was able to discuss the assessment findings with the employee, explaining the possible nature of symptoms and reducing his fear and anxieties. Together with the OH adviser, the physiotherapist encouraged him to return to work and discussed the benefits for his health and wellbeing. His duty of care to himself was discussed, along with the benefits of exercise and healthy eating. Correct manual handling techniques were reiterated to support advice provided by the OH adviser and health and safety manager.
An ergonomic assessment was performed, and some of the tasks involving manoeuvring awkward and heavy items were modified. This ensured that the employee’s responsibilities, and therefore autonomy, were not removed, but that risks were identified and reduced. The height of his bench was raised to improve his working posture, and he began a phased return to work. He was advised to take more frequent posture changes and his manager agreed to actively promote this to him to ensure he did so. Other team members were informed of this so that they too could support their colleague and avoid negative comments regarding breaks.
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The employee took up swimming and walking during his lunch break, which improved his psychological wellbeing, fitness levels and weight control. Treatment from the physiotherapist was continued on a weekly basis for four weeks, during which time goals regarding activity and tasks were discussed and set in conjunction with the OH adviser and line manager. The employee no longer complained of symptoms and gradually increased his working hours and duties to his full work role without any further sick leave.
References
Battevi, N, Menoni, O and Vimercati, C (1998). The occurrence of musculoskeletal alterations in worker populations not exposed to repetitive tasks of the upper limbs. Ergonomics, 41 (9),1340-1339.
Black, C (2008). Working for a healthier tomorrow
Devereux, JJ, Buckle, PW and Vlachonikolis, IG (1999). Interactions between physical and psychosocial risk factors at work increase the risk of back disorders: an epidemiological approach. Occupational and Environmental Medicine, 56 (5), 343-353.
European Agency for Safety and Health at Work (2000). Work-related neck and upper limb musculoskeletal disorders. IN-house physiotherapy saves money and reduces time off work.
Ogden, J (2004). Health psychology. England: Open University Press
Sprigg, CA, Smith, PR, and Jackson PR (2003). Using psychosocial risk factors in call centres: An evaluation of work design and wellbeing.
