The contribution of physiotherapy to the employment of workers with a chronic musculoskeletal disorder: a focus group study*

The contribution of physiotherapy to the employment of workers with a chronic musculoskeletal disorder: a focus group study N. Hutting, W. Oswald, J. B. Staal, J. A. Engels, E. Nouwens, M. W. G. Nijhuis-van der Sanden and Y. F. Heerkens Research Group Occupation & Health, HAN University of Applied Sciences, Nijmegen, Netherlands; Department of Physiotherapy, HAN University of Applied Sciences, Nijmegen, Netherlands; Faculty of Health and Social Studies, Research Group Musculoskeletal Rehabilitation, HAN University of Applied Sciences, Nijmegen, Netherlands; Radboud Institute for Health Sciences, IQ Healthcare, Radboud University Medical Center, Nijmegen, Netherlands


Background
Musculoskeletal disorders are a major health problem resulting in negative effects on wellbeing and substantial costs to society. Work participation is associated with positive benefits for both mental and physical health, but work and return to work are insufficiently addresses in regular healthcare in the Netherlands. Insufficient knowledge about work-related factors within regular healthcare might lead to a longer duration of both diagnosis and treatment of complaints, and longer absenteeism than necessary. Potentially, generalist physiotherapists (GPTs) can play an important role in reducing absenteeism, presenteeism and associated costs in patients with musculoskeletal disorders. However, it seems that work participation is often insufficiently addressed within generalist physiotherapy practice.

Purpose
The purpose of this study was to evaluate whether generalist physiotherapists GPTs take work participation into account as a determining factor in patients with musculoskeletal disorders, and how this might be improved.

Methods
A qualitative study consisting of seven focus groups involving 30 participants in total (GPTs and occupational health physiotherapists [OPTs]) was conducted. Based on an interview guide, participants were asked about their experiences, opinions and needs with regard to the integration of work in their physiotherapy practice (history taking, physical examination, treatment, and evaluation, working together with (other) occupational healthcare providers).

Results
A total of 30 physiotherapists, distributed over seven focus groups participated in this study. Of the 30 participants, 9 had a specialisation in occupational health physiotherapy and 21 were GPTs. The mean age of the participants was 37.5 (range 22-65) years and mean experience as a GPT was 14.3 (range 1-35) years.

Importance of addressing work
In general, participants found it important to consider and address the patient's work within physiotherapy practice. One participant said: I agree that it should be part of it … work is part of the patient's life. And people have to work till the age of 67 and can be hindered in their work. (GPT) In case of absenteeism, reintegration should also be within the scope of generalist physiotherapy practice. It should be realised that work often represents much more than merely an income; work also provides a type of satisfaction and can make life meaningful. Absenteeism can have a considerable impact on a person's life. Participants also mentioned that work can be a barrier for recovery, which should be addressed during generalist physiotherapy.

Lack of addressing work
Although all the participants agreed that the patient's work should be a part of therapy, they also mentioned that work is generally not adequately addressed by GPTs and should be more systematically addressed within the clinical reasoning process. Participants emphasised that work is a difficult topic to address for many GPTs, particularly when they lack specific knowledge. One participant said: I think that if you have insufficient knowledge of occupational factors, or you don't have affinity with the subject, you won't address these factors sufficiently. (OPT)

Addressing work within physiotherapy practice
Participants mentioned that the patient's work should be a part of history taking. It was considered important to investigate whether or not work is involved as a causal factor or a barrier for recovery. Participants emphasised to focus not only on physical and environmental factors, but also to consider behavioural and psychosocial factors. Participants mentioned that asking about work-related factors is of no use unless these factors are addressed in the subsequent goals and treatment.
In addition to questions in the history taking, some participants did ask their patients to describe their working activities to gain insight into their daily work. Patients could be asked to bring work equipment (if possible) to the GPT practice, or were asked to demonstrate their activities.
OPTs have experience with workplace investigations, whereas GPTs have limited experience with this. Participants agreed that having the possibilities and skills to perform a workplace investigation is a great advantage. For GPTs it is difficult to perform a workplace investigation because they lack the time and skills for this, and it is not covered by the patient's health insurance. Some participants made use of pictures and (video) movies; this could be done by the patients themselves, or by colleagues, even at an unexpected moment.
Providing advice and information was considered an important part of generalist physiotherapy practice. Advice/ providing information was even considered as important as other forms of therapy, such as massage, mobilisation, or exercises. It was also considered important to provide insight into the relationship between work and complaints, and to create awareness with regard to possible risk factors and solutions. The level of confidence in providing good advice varied between the participants.

Cooperation between GPT and OPT
Cooperation between GPT and OPT was considered important. After evaluating the factor work as a cause of the complaints and as a barrier for recovery, the problem could be addressed by the GPT, or the patient was referred to an OPT. Most participants mentioned that cooperation between OPT and GPT could be valuable. However, most GPTs found it difficult to establish collaboration with an OPT. It was easier to cooperate if an OPT is available in the practice location. However, one participant who had an OPT in her practice never referred her patients to this colleague. Moreover, one OPT said: In our practice, my qualities are almost never used … (OPT) Participants mentioned that, if a patient is referred to an OPT, this often takes place when therapy is not successful, but not in an early stage of the treatment. GPTs generally agreed that they were often too late in referring their patients. Patients should not only be referred after recurring problems or disappointing treatment results, but also (if indicated) at the beginning of an episode.

Knowledge about the OPT
For most participants the borderline between GPT and OPT was unclear. Participants mentioned, for instance, that GPTs lack knowledge about OPTs. For GPTs it is often unknown what the scope of the OPT is. One participant stated:

I have no idea what an OPT does that differs from a GPT in private practice … (GPT)
For both GPTs and OPTs it was considered important that they cooperate with other professionals and that each professional focus on his/her own area of expertise. It was also necessary to have sufficient knowledge about the expertise of other (occupational health) professionals.
Most GPTs (and OPTs) agreed that, because GPTs know little about the specific knowledge of the OPT, they might think that they can address work-related issues themselves. The OPT can act on a broader spectrum; they are also skilled with regard to the organisation of work, work tasks, work hours/duration, and work pressure. The following quote from a GPT reflects the generally shared desired situation: On the one hand, you want the GPT to be able to notice and address work-related factors, certainly more than is done at the moment. I think we have the possibilities to address these workrelated factors to a greater extent within GPT practice. On the other hand, you need to clearly realize your own boundariesand at what moment do I need to refer to the specialist? (GPT)

Lack of knowledge/skills of GPTs
In the opinion of the participants, GPTs generally have insufficient specific knowledge to address the patient's work. GPTs should pay attention to work-related factors and have basic knowledge/skills with regard to addressing these factors.
Knowledge about the possible relationship between work and complaints, and how that can be evaluated, was considered important. Participants mentioned that GPTs need knowledge on the following areas: work content (e.g. work analysis, work tasks, posture, lifting, work load, time management), physical and psychosocial working conditions (e.g. working atmosphere, stress management), terms of employment (e.g. working hours, absenteeism), and social relationships at work (e.g. personal factors, communication skills). Moreover, knowledge about other healthcare providers, laws and regulations, and the occupational language was considered important.
Participants mentioned that they never choose courses with regard to work; also, only a limited number of courses were available. Also, participants mentioned that in their GPT education, work was either not addressed or not addressed extensively; this applied to both older and younger GPTs.

Cooperation with other occupational health physicians
Most GPTs had limited contact with occupational health physicians. On the other hand, cooperation between the occupational health physician and OPTs was much better, especially with OPTs working within a company. The accessibility to, and communication and cooperation with occupational health physicians was considered far from optimal. However, participants said that cooperation between occupational health physicians and GPTs is essential, e.g. to assess the patient's functional capacity. The information collected by both professions was considered important for the other profession.

Conclusions
Although a patient's work is important, GPTs take insufficient account of work participation as a determining factor in the treatment of patients with musculoskeletal disorders. GPTs often lack specific knowledge about work-related factors such as workplace laws and regulations, work-related factors, addressing work-related factors, the workplace, workplace investigations, and occupational healthcare providers. Moreover, there is insufficient cooperation between GPTs and other occupational healthcare providers. The integration of work participation within generalist physiotherapy practice, and the cooperation between GPTs and other occupational healthcare providers, show room for improvement.

Implications
The results of this study will be used to investigate (on a broader scale) how GPTs in the Netherlands currently integrate their patients' work within generalist physiotherapy and what their needs are. Moreover, the results of this study can be used to make adaptations in physiotherapy educational programmes and to develop specific (online) courses. Moreover, it is recommended to develop an overview of work-related factors and tools which can be used by GPTs.
Such an overview can be provided by an online toolbox. Also, facilitating a systematic approach for addressing work participation within generalist physiotherapy practice seems valuable. In addition, the cooperation/networking between GPTs and OPTs, and knowledge about the OPT, should be enhanced. For this, a role might be played by the professional associations as well the individual therapists.

Ethics approval
Medical ethical approval was necessary for his study (HAN UAS, number registration: ACPO 09.01/16).

Disclosure statement
No potential conflict of interest was reported by the authors.

Funding
This study was funded by the Scientific College Physical Therapy (WCF) of the Royal Dutch Society for Physical Therapy (KNGF).