The Role of Physical Therapists in Optimizing Return to Work

Physical therapists have routinely been involved in treating workplace injuries. Implementation of manual therapy, therapeutic exercise, and modalities have all served to resolve symptoms, improve function, and ultimately facilitate return to work (RTW). While therapists are typically quite successful at preparing injured workers for return to work, often treatment approaches have varied by clinician, by organization, and by region. As the profession of physical therapy continues to evolve and research continues to reshape and guide our interventions, best practices continue to take shape for many aspects of the profession; including optimizing return to work. Recently, in the August 2021 volume of the Journal of Orthopaedic & Sports Physical Therapy (JOSPT), an extensive Clinical Practice Guideline (CPG) was published, reviewing hundreds of research articles performed over several decades, to highlight current best evidence for how therapists can facilitate faster return to work, at a reduced cost to the system, while offering best-in-class treatment to injured workers.

Before diving into the specifics of the CPG, let’s first discuss the concept of a practice guideline. First and foremost, a CPG is NOT intended to serve as a standard of medical care. The recommendations listed within the CPG are provided to clinicians to serve as evidence-based guidelines only, and are to be used in conjunction with other published guidelines (related to diagnosis, treatment, examination, and patient management) and standards of care. Furthermore, adherence to the recommendations within the CPG will not ensure a successful outcome in every patient. Rather, the CPG is intended to synthesize years of research and provide therapists with an evidence-based framework to effectively manage injured workers and promote timely return to work.

In the current CPG published in JOSPT titled “Clinical Guidance to Optimize Work Participation After Injury or Illness: The Role of Physical Therapists,” the authors provide 26 total recommendations, split across 5 different aspects of physical therapy care: Diagnosis/Classification, Clinical Course, Risk Factors, Examination, and Interventions. In the interest of keeping this blog relatable and understandable, the following paragraphs will focus on relevant recommendations, while providing context and clarification as to how the recommendations can be easily applied to clinical practice and stakeholder interaction.

CPG Recommendation

Physical therapists should screen for risk factors associated with delayed RTW or work absence throughout the episode of care, using patient interviewing and validated tools. Risk factors include type of injury, previous injury episodes, extended work absence prior to referral, comorbidities, and the presence of psychosocial factors such as high levels of perceived or self-reported functional disability, severity of pain, pain behaviors, fear-avoidance beliefs, low recovery expectations, and low self-efficacy.

In summary, there is strong evidence that a patient’s beliefs, perceptions, and motivations regarding injury and RTW impact the course of recovery and time to RTW following a work-limiting injury. Therapists can serve as screeners, educators, and motivators throughout the course of treatment. By implementing proper screening questionnaires, performing a thorough evaluation, developing a therapeutic alliance, and maintaining continuity of care by seeing the same therapist with each visit, injured workers seen for therapy at providers Upstream Rehabilitation are continually being assessed for factors which may delay their return to work. By doing so, stakeholders can be made aware of risk factors as they are identified, and the necessary steps taken to mitigate their negative impacts.

CPG Recommendation

Physical therapists should develop a therapeutic alliance by including the worker in RTW planning and engaging in work-focused supportive behaviors throughout the episode of care, documenting and addressing worker goals, preferences, and concerns.

You likely noted the phrase “therapeutic alliance” in the prior paragraphs. This is described as “the social connection between therapist and patient,” and is made up of 3 components; Therapist-patient agreement on goals, therapist-patient agreement on interventions, the affective bond between the therapist and patient. While some may not consider this relationship between healthcare providers and the injured worker a top priority, there is actually moderate evidence that a worker’s rehabilitation experience with health providers (and potentially the health care system) can influence RTW trajectory of the worker.

Supportive worker interactions include respecting the worker and assuming legitimacy, ongoing communication/education throughout treatment, minimizing system intrusion on the provider-worker relationship, and avoiding bias, stigma, stereotyping, or hostility. In addition to facilitating return to work, when implemented by employers and worker’s compensation stakeholders, this empathetic and supportive approach has also been shown to decrease cost to claims, decrease absenteeism, and improve productivity.

CPG Recommendation

Physical Therapists should provide consultation and recommendations to patients, employers, and the health care team for graded, modified, or transitional duties that promote work reintegration, while taking contraindications and barriers into consideration.

Many of us know that good work is good for our health. That said, when an injured worker is faced with either continued work, or return to work, there is often an element of anxiety or skepticism. This is where development of a therapeutic alliance between injured worker and PT can be crucial. Therapists and healthcare providers must prioritize work reintegration as part of the rehabilitation process. As outlined by the CPG, there was moderate to strong evidence in favor of graded/modified work strategies reducing the duration of leave compared to usual care, along with improved worker coping. Therapists can and should provide clinical insights related to injured worker progression, and encourage modification of work restrictions when appropriate.

CPG Recommendation

Physical Therapy providers should not use light exercise as an isolated intervention to address RTW goals, except when there is an explicit reason documented, such as psychosocial or psychological involvement, catastrophic injury, and/or condition-specific or postsurgical guidelines.

Functional activities that mimic workplace essential job functions must be implemented into a rehabilitation program. Obviously, there are times (catastrophic injury, post-op, etc.) where simple movements and light exercise are the only treatment options, but for the majority of injured workers seeking care with a physical therapist, exercise prescription must be more robust. This is reflected in the recommendation listed above, as the literature outlines that light exercise as an isolated intervention does not appear to be effective in positively impacting RTW.

Therapists must look to progress to therapeutic activities, focusing on overload principles, specific work demands, and worksite integration. By addressing these activities in the clinic (which is a controlled setting), injured workers can build confidence that they truly are ready for return to work.

CPG Recommendation

Physical therapists should not rely solely on written material or group education to improve work abilities and limit time away from work.

As our recent blog posts have suggested, a biopsychosocial approach to patient interaction is extremely important. A significant portion of this approach is tethered to patient interaction and education. While education, discussion, and active listening to a patient is crucial to establishing a therapeutic alliance, it cannot be a standalone intervention. This CPG recommendation applies to both psychosocial and physical limitations. While addressing the person, their concerns, and their perception of their injury is important, there is strong evidence that education is not beneficial in terms of facilitating return to work when used exclusively. Therapists must implement other interventions (exercise, manual therapy, trigger point dry needling, modalities, etc.) in addition to education in order to expedite return to work.

While the list above is only a sampling of the 26 total recommendations, it aimed to address some of the most relevant. We also aimed to outline that, in keeping with our mission to offer world-class care to all of our patients, we at Upstream Rehabilitation are striving to adhere to the recommendations listed above. By doing so, we’ll continue to do what we’ve been doing for years; Help patients get better, faster.

For more information on how Physical Therapy can help you or your injured workers, contact Upstream Rehabilitation.

1. “Clinical Guidance to Optimize Work Participation After Injury or Illness: Using the Evidence to Guide Physical Therapist Practice.” Journal of Orthopaedic & Sports Physical Therapy, JOSPT, 31 July 2021, www.jospt.org/doi/abs/10.2519/jospt.2021.0505?journalCode=jospt.