The Role of Physical Therapists in Optimizing Return to Work: Part 2

In our most recent blog post, we began discussions on a recent Clinical Practice Guideline (CPG) published in the August 2021 volume of the Journal of Orthopaedic & Sports Physical Therapy (JOSPT). This CPG’s intent was to offer clinicians evidence-based guidelines to direct clinical practice and improve functional outcomes. This recent post focused on what a CPG is, while also summarizing several of the recommendations. For Part II of this discussion, we will expand on why the development of a CPG was warranted, as well as summarize several more of the 26 recommendations.

Unfortunately, workplace injuries are a relatively common occurrence. Data from the US Bureau of Labor Statistics identified more than 2.8 million nonfatal workplace injuries and illness in 2018. Of this 2.8 million, 1.6 million resulted in time away from work or job transfer/restrictions. The National Safety Council further analyzed 2018 data, and reported that workplace injuries accounted for 105 million lost work days that year! This resulted in an economic burden to the 2018 US economy of $170.8 billion. Considering the prevalence of injury, as well as the economic cost, best practices (in the form of a CPG) are crucial to providing a framework to therapists to aid in timely resolution of injury and facilitate return to work. In the paragraphs below, we’ll focus on the biopsychosocial and screening considerations provided within the CPG, and further discuss and expand upon how they can be applied

CPG Recommendation:

Physical therapists should, during the initial evaluation, use validated self-report measures, such as the WAI and DASH work subscale, which specifically address return to work (RTW) in order to estimate RTW-related outcomes and guide the course of treatment.

Research and literature continue to demonstrate the impact that a patient’s psyche can have on their healing and rehabilitation. As healthcare providers, it’s important that therapists screen for risk factors that may negatively impact progression. Self-report measures do appear to have predictive abilities related to likelihood for RTW. Therefore, physical therapists should be administering these questionnaires as part of an initial evaluation, and poor scores should be viewed as a complicating prognostic factor related to RTW. Noting this risk factor early in treatment can allow the therapist to implement strategies to mitigate and circumvent, as well as notify other stakeholders of potential delays in return to function.

CPG Recommendation:

Physical therapists should administer reliable and valid tools, as part of the evaluation and throughout treatment, to identify the presence of fear avoidance, psychosocial risk, or readiness for change, which impact RTW outcomes, to guide patient management.

In addition to functional scales like the DASH, psychosocial questionnaires like the Fear Avoidance Belief Questionnaire, Work and Health Questionnaire, and others allow therapists to identify workers whose prognosis may be negatively impacted by their beliefs, and therefore allow the provider to modify interactions to accommodate.

CPG Recommendation:

Physical therapists should communicate and coordinate services with the employer, the employee, case managers, and health care providers in the presence of an estimated high risk for delayed RTW.

This recommendation confirms and expands upon content already addressed in the paragraphs above. If a therapist identifies poor prognostic factors (based on elevated psychometrics and poor scoring on self-report measures), it becomes crucial that communication between stakeholders commence immediately, so that the interdisciplinary team can intervene. In a number of studies that assessed delayed RTW, communication and coordination of services between all providers improved RTW outcomes and lead to cost savings. It should also be noted that for injured workers with an estimated low risk for delayed RTW, multidisciplinary case management was not seen as beneficial in promoting RTW when reviewing the literature.

CPG Recommendation:

Physical therapists should incorporate psychologically informed practice, such as individual goal setting, motivational interviewing, education regarding activity pacing, problem solving, relaxation, and coping techniques into the plan of care when psychosocial barriers are identified during the episode of care.

As already discussed above, proper screening and communication with stakeholders allows the interdisciplinary team to modify treatment interventions based upon the absence or presence of certain risk factors. When therapists identify an injured worker with poor self-report measures and elevated psychometrics, the addition of interventions (like motivational interviewing, practical sessions in ergonomics, instruction in relaxation and coping technics, etc.) to address the injured workers concerns is warranted to facilitate RTW. The majority of research studies reviewed for the CPG show benefit following psychologically informed treatment in patients who present with risk factors. It should be noted that these interventions should be directed at the specific identified barrier for RTW.

CPG Recommendation:<

Physical therapists should assess work demands, work-related psychosocial factors, and workplace policies regarding the availability of transitional or modified work to identify potential RTW barriers and inform the treatment plan.

The most consistent work-related risk factor for delayed RTW was the physical demand/type of work that the injured worker would resume. Across multiple studies, work policy factors related to employer response following injury; specifically the availability of RTW programs, modified duties, or ergonomic changes, were noted to serve as a facilitator of or a barrier to RTW outcomes. In short, how an employer responds to an injured worker, as well as the options made available regarding modified duty/transitional work, all factor in to improving outcomes. This topic was specifically addressed in another one of our recent blog posts, as we examined the evidence behind effective employer interactions following injury on the job. As therapists often partner with employers to reduce workplace injuries, it becomes crucial for therapists to educate employers on the benefits of RTW programs, modified duties, biopsychosocial interaction, and other ergonomic considerations to facilitate a more timely RTW.

More and more literature continues to stress the importance of evaluating the injured worker’s mental state in addition to their physical injury. While this topic has been addressed in other blog posts, this emphasis within the CPG further solidifies its importance. At Upstream Rehabilitation, we continue to pursue evidence-based approaches to patient care, including proper screening of injured workers during initial evaluation, subsequent communication with stakeholders when warranted, consideration of psychologically informed practice (when clinically appropriate), and focus on functional progression of therapy to facilitate RTW. By focusing on adherence to best practices, we strive to get injured workers better, faster.

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

“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.
“2.8 Million Nonfatal Workplace Injuries and Illnesses Occurred in Private Industry in 2019.” U.S. Bureau of Labor Statistics, U.S. Bureau of Labor Statistics, 6 Nov. 2020, https://www.bls.gov/opub/ted/2020/2-8-million-nonfatal-workplace-injuries-and-illnesses-occurred-in-private-industry-in-2019.htm#:~:text=There%20were%202.8%20million%20nonfatal,reported%20in%202018%20and%202017.