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Bringing Prevention into the Workplace with On-Site Therapy
(Part 1 of 2)

After (and before) my last column on “practicing prevention aggressively,” I received a number of e-mails and other communications from some medical and risk management people telling me of frustrating experiences they have had in trying to implement prevention programs in the workplace. They asked for some clues on “how to do it.” One said that she was pleased that her company had a “so-called” wellness program in place for a long time, but that little was done to measure its results. She said that it consisted of little more than handing out health education pamphlets “on subjects most people already knew about.” A nurse expressed her frustrations with the large number of people she saw regularly who complained of aches and pains, who wanted to “go home” because of their inability to work. All she could do was to give them aspirin, Tylenol, or ibuprofen and hope they would feel better.

What is On-Site Therapy?

It occurred to me that there is a practice that has been around for a good while that is still unknown to a lot of people. Providing routine therapeutic services to workers in the workplace to relieve the symptoms of musculoskeletal discomfort and pain is a sensible, practical, convenient, economical, and feasible preventive activity. On-site therapy, as it is called by ArgosyHealth (a provider of such services), is classical secondary prevention in practice. Its presence in the same facility in which workers work and develop their aches and pains allows them to get palliative relief reasonably quickly and prevents their pains and spasms from getting worse. Most importantly, on-site therapy facilitates their remaining at work, which is almost always better treatment than going home, and, more often than not, it is better than going to a doctor’s office, where the treatment tends to be considerably less definitive.

I'm not suggesting that medical evaluation should be skirted, but it is not always necessary when the symptoms of musculoskeletal dysfunction first rear their ugly heads. The mere fact that patients with musculoskeletal pain almost always have to leave the workplace if the physician is to be the immediate, first line of defense is, in and of itself, one of the main reasons that they end up losing significant time from work. Also, patients who leave the workplace to see a physician take significantly longer to enter appropriate therapy than those who receive initial assessment and are symptomatic in close proximity to the job site.

If it were shown that a medical referral and the visit it entails, in and of itself, had a positive and expeditious impact on relieving the worker of his or her distress, on-site therapy would have significantly less comparative beneficial value. The positive impact of on-site therapy is based on the place in which it is carried out, the workplace orientation of the therapist who does it, and, invariably, the therapist’s sensitivity to the value of the workplace in the performance of his or her therapy.

For years, therapists have touted the value of work itself and the place in which it takes place as a part of the worker’s therapy. In advocating continued meaningful activity as a means of preventing early debilitation, therapists, in effect, laid the groundwork for on-site care. On-site treatment includes that same workplace in the worker’s treatment and transition back to work.

The American Academy of Orthopedic Surgeons (AAOS) has taken the position that “accommodated activities” should be a part of the therapeutic process. This gives even more credibility to the concept of on-site therapy, especially if one of the main goals of on-site therapy is to assist workers, when appropriate, to remain on the job.

Orthopedists refer to premature “rest,” with accompanying medication as primary treatment for musculoskeletal pain, as deconditioning. The AAOS said that “accommodated activities can be better than rest and can distract workers from pain.” Professional athletes who get hurt on the court or in the field almost always are given immediate and continuing physical therapy after developing muscle or joint pains. While the diagnosis of an injury should be made by a licensed health practitioner as expeditiously as possible, the treatment, short of the rare need for surgery, is almost invariably administered by a therapist on prescriptive orders from a doctor. Organized athletic teams almost always have such therapists available to use appropriate physical methods of treatment when pains and spasms occur, to delimit the degree of deconditioning that can take place. X-rays, CTs, MRIs, and EMGs all have their place in the scheme of things, but there is nothing like an experienced therapist to assist a worker in pain to get through his or her bout with momentary disability and prevent that short-term problem from turning into a chronic one.

Advantages to On-Site Therapy

For the average, reasonably healthy worker, there are probably very few contraindications to on-site therapy, as long as the therapist follows appropriate legal and ethical protocols. As a matter of fact, compared to the relatively cumbersome system of having an injured worker travel to a remote facility for the same type of treatment, there are the following advantages to carrying out the treatment in the workplace:

• the psychosocioeconomic benefits of getting remedial measures under way as soon as possible;
• the convenience of having approved treatments during breaks from work;
• the assurance of compliance since many workers fail to keep appointments when they have to travel to a therapist’s office for treatment;
• maintaining continuity of the worker’s job responsibilities with adjustments as recommended by the therapist;
• combining the treatments, if desirable, with the supervised activity of work;
• the avoidance of lost time from the workplace;
• discouraging the worker from developing an absentee, off-the-job mentality;
• having a therapist on-site who is familiar with the employee’s work, who can accompany the employee to his or her workplace to help the employee adjust to his or her limitations, who has immediate access to, and an understanding of, his or her written job description, and who can make recommendations about adjusting the workplace to accommodate the employee’s needs;
• having a therapist on-site who understands the culture of the particular company, and who knows its practices and attitudes towards return-to-work issues. (The best therapists and health-care practitioners invariably run into trouble when they treat all patients the same, without an understanding of the policies and mission of their employers.);
• having a therapist on-site who knows the personnel in the individual workplace, who knows how to reach them and who can call supervisors and discuss absences with people with whom he or she has a first-name relationship. (This is particularly important in situations where workers have psychosocial and “stress” reasons for being, or wanting to be, out of work; e.g., if they have stressful relationships with their supervisors. This is known to be one of the most prevalent, and unspoken reasons, for absences from work.); and
• having a therapist on-site can bridge the communication gap between the injured or pained worker and supervisor as to work limitations. (It is not unusual for a supervisor or other person with authority or influence over the worker to say, “Wouldn’t it be better if he were at home resting or in bed?” That is rarely necessary; if it is, a qualified therapist can recommend that to the worker. To those who ask, “Shouldn’t the worker be seen by a physician before the therapist renders care?” my answer is, “That depends upon the circumstances and the locale.”).

The Laws Governing the Practices of Physical and Occupational Therapy

Every state has laws governing the practices of physical and occupational therapy. By and large, they are very similar. The major difference from state to state relates to the relationship between the therapist and the licensed health-care provider who may or may not have primary responsibility for an injured worker’s treatment.

In most states, therapists are required to have a prescription for treatment after a licensed practitioner makes a diagnosis. In those instances where the therapist sees the injured worker before a physician, there are often acceptable systems of communication for complying with the law and treating the worker’s symptoms in a relatively convenient fashion, including in the workplace. There are some states where physical therapists can actually practice their professions without medical referral, prescription, or input.

The provider-therapist relationship should be viewed realistically. Even though the implications of the law are that a diagnosis should be made and treatment prescribed by a licensed health-care practitioner, more often than not, the so-called prescription simply reads “evaluate and treat,” with the modalities of treatment left up to the therapist. The diagnosis is often missing or vague, so most therapists become skilled at evaluating their own patients, proceeding at least with initial treatment, and then following through with the legal requirement of appropriate communication with the provider.

While no ethical issues can transcend the law, in most circumstances, therapists and doctors work out arrangements where they get to know each other’s needs and demands very well. The chances of such a system working well are enhanced considerably when the therapist is on-site.

Read Bringing Prevention into the Workplace with On-Site Therapy (Part 2)

ABOUT THE AUTHOR

The Journal of Workers Compensation is a quarterly review of risk management and cost containment strategies published by Standard Publishing in Boston, Massachusetts. For more information, please visit our web site, www.standardpublishingcorp.com, or contact the editor at 800-682-5759, extension 222, or subscription services at extension 228.

riskVue | The webzine for risk management profesionals
November 2001