Work participation of patients with musculoskeletal disorders: is this addressed in physical therapy practice?

A cross-sectional survey was conducted among PTs who treat working-age patients with MSDs. PTs in the Netherlands were contacted (during November–December 2016) for participation via calls in digital news-mails of the Royal Dutch Society for Physical Therapy (KNGF), the Dutch Institute of Allied Health Professions (NPi), and social media networks of the researchers (LinkedIn). Included for this survey were generalist PTs who treat working-age patients with MSDs, whereas OPTs and work-related physical therapists (WPTs) were excluded in order to get a clear view of the opinions of generalist PTs who have not specialized in occupational healthcare. The call in the news-mails explained the purpose of the study and the voluntary nature of participation. The PTs were asked to fill out an online survey, provided via Parantion Easion Survey version 3.63. A link to log on to the website anonymously was included in the digital newsletter. To encourage participation, all PTs who filled in the survey had the option to fill in their e-mail address (voluntary) in order to win a gift card of 60 euro.

Based on the results of our recent qualitative study [26], a survey was developed for the present investigation. The qualitative study investigated how PTs integrate occupational factors within their practice, what they need for a better cooperation with other occupational health professionals, and which factors can facilitate a better integration of occupational factors within physical therapy [26]. An overview of the main categories and underlying themes identified in the earlier qualitative study are presented in Additional file 1: Appendix 1. The survey was pretested by two generalist PTs and reviewed by the members of the research group. No major modifications of the survey were found to be necessary.

The first part of the survey assessed demographics of the participating PTs in terms of gender, age, years of experience as PT, and PTs’ specialization. With regard to specialization and referral to occupational health professionals, it was possible to choose more than one specialization. The survey consisted of questions on how PTs currently integrate occupational factors within their practice, and on their opinion on the integration of occupational factors within physical therapy. The PTs were also asked about their needs with regard to the integration of occupational factors (need of knowledge, skills and tools) and with regard to cooperation with WPTs, OPTs, and other occupational health professionals.

Part of the survey was based on the concepts awareness, attitude, social influences, and self-efficacy of the I-Change model [28]. Awareness of the importance of involving occupational factors in their practice was investigated (Table 2, question 1a–d). Attitude was assessed by asking the PTs whether they had a positive (Table 2, question 2a-e, 2k) or a negative attitude (Table 2, question 2f-g, 2i-j) towards involving occupational factors in their practice. Social influences were assessed in terms of norms, modeling, support, and pressure (Table 2, question 3a–e). Furthermore, self-efficacy was assessed (Table 2, question 4a–f). For all questions, unless stated otherwise, a 5-point Likert scale was used for response, ranging from strongly disagree to strongly agree, or ranging from never to always.

Demographics are presented as means and standard deviations (SDs), while gender and specialization are presented as number and percentage. All answers using Likert scales are presented as the number and the percentage of the respondents reporting that specific answer, whereas all other answers are presented as means and standard deviations (SDs).

The Statistical Package for the Social Science (SPSS, version 22) was used to analyze the data.

Most respondents were aware of the importance of involving occupational factors within their care. Most of the respondents had a positive attitude towards paying (more) attention to occupational factors. They found it important to address the patient’s work because it has a positive effect on the patient’s performance. This is consistent with findings from our recent qualitative research [26]. In general, the respondents had high self-efficacy (i.e. beliefs about their capabilities to produce designated levels of performance) with regard to integrating occupational factors within their practice. With regard to social support, the perceived support of colleagues and supervisors of the respondents was not clearly shown in this study. However, with regard to the social support of patients, most respondents received appreciation with regard to involving occupational factors within their care.

In this study, most respondents stated that they integrate occupational factors of patients in their care. Generally, respondents indicated that they regularly or always address occupational factors within their patient interview. However, almost a quarter of the respondents indicated that they only sometimes pay attention to work methods, the workplace, and absenteeism of their patients. Respondents had a positive attitude and experienced awareness, social support, and high self-efficacy with regard to integrating occupational factors within their practice. However, although these positive findings and the fact that most respondents stated that they involve the occupational factors of their patients within their practice, 64.1% indicated that occupational factors should be addressed to a greater extent. It seems that fulfilling the items mentioned in the I-Change model [28], does not necessarily lead to adequate behavior with regard to addressing occupational factors within generalist physical therapy. Thus, although respondents do address occupational factors, most respondents think that the patient’s work should be more extensively addressed.

With regard to working together with supervisor/colleagues, most respondents indicated that they rarely or only sometimes address this topic. Relationships at work is one important psychosocial factor and bad relationships at work are an important barrier for recovery for, e.g., chronic low back pain [29]. This is line with previous qualitative research in which participants emphasized that patients need to be questioned about their work, including all work features and psychosocial factors [26]. Another study showed that psychosocial factors are a major barrier for return to work [30]. Also, musculoskeletal PTs are aware of the potential benefits of incorporating psychological interventions within their practice, but feel insufficiently trained to use such interventions and do not sufficiently integrate these psychosocial factors within their practice [31, 32]. However, in the present study, work pressure (also a psychosocial factor) was addressed regularly or always by most respondents.

Addressing the patient’s work/work activities is done by the majority of respondents in all phases of care. However, during physical examination, 38.1% of the respondents stated that they never, rarely, or only sometimes pay attention to the work of their patients. Respondents indicated that they give advice to their patients about their workplace, and most respondents let the patient imitate/show their work activities. However, the majority of respondents do not use pictures/videos, nor do they visit the workplace, and 67.4% never or only rarely uses a work-related questionnaire. This indicates that the advice given by generalist PTs is mainly general advice and not based on the specific workplace/work situation of the patient.

In previous qualitative research in the Netherlands [26], lack of knowledge of generalist PTs was seen as a barrier for addressing work within PT practice. Participants felt particularly uncertain about what kind of advice they are ‘allowed’ to give patients, and about their knowledge related to workplace laws and regulations. Other topics requiring attention were: knowledge about work-related factors, how to address work-related factors, the workplace, workplace investigations, and knowledge about occupational healthcare providers [26]. In the present study, only 41.6% of the respondents agree or totally agree that, based on their current knowledge, they are optimally able to treat patients who work and to advise them about occupational factors. Of all respondents, 36.6% mentioned that they need more knowledge about work tasks/work activities, work methods/technique, workplace, working hours, and workload. Although most respondents indicated that they were able to address the patient’s work despite the ever-changing laws and regulations, half of the respondents indicated ‘more knowledge about occupational health-related laws and regulations’ as one of their needs.

About 36% of the respondents stated that they need more work-specific knowledge and skills to carry out a basic workplace assessment. Since 60.6% of the respondents indicated that they have a need for the possibility to bill for a workplace assessment, financial considerations might be an additional reason for the low percentage of workplace visits. However, in the Netherlands, from 2017 onwards several insurance companies provide billing opportunities for workplace visits, which meets the need of the respondents. Therefore, upgrading the knowledge and skills of generalist PTs who will carry out these workplace assessments seems necessary.

Other needs of over 50% of the respondents were: questionnaires about work participation and screening lists to assess to what extent the patient’s complaint is work related (this was also an outcome of the previous qualitative research) [26]. Almost 40% of the respondents stated that attention to occupational factors should play a greater role in the basic physical therapy educational programs and in physical therapy guidelines.

Our earlier qualitative study revealed that a major issue to be addressed is the lack of cooperation between the PT and (other) occupational healthcare providers, especially between the generalist PT and the WPT/OPT and the occupational health physician [26]. Moreover, the difference between generalist physical therapy and work-related physical therapy/occupational physical therapy was unclear. It was emphasized by the participating PTs and WPTs/OPTs that WPTs/OPTs have specific knowledge and that WPT/OPT is a valuable specialization. However, some respondents mentioned that they were able to address most of the work-related factors themselves [26]. In the present survey, for most of the respondents the difference in competences and responsibilities between generalist PT and OPT was unclear but 77.5% of the respondents do see a role for themselves within the domain of ‘work’. However, for at least part of the respondents, the specific knowledge that is required in the field occupational health is not sufficiently accessible to the generalist PT. Also, more than 40% of the respondents also stated that they need more knowledge about the domain and position of WPTs and other occupational health professionals.

Generalist PTs do refer patients to an occupational health professional. However, this referral process could be improved, especially after the patient interview and in case of a disappointing recovery. Another question is: to which occupational health professional should patients be referred to. It seems that generalist PTs mostly communicate about the patient with the occupational health physician/insurance physician and the occupational therapist. Only 14.8% of the respondents indicated that they communicate with or consult a WPT. If generalist PTs have a colleague WPT within their practice they often do work together. However, if no WPT is present within their practice, only 12.7% of the PTs sometimes/regularly refer patients to a WPT. Only 35.9% of the respondents answered that they had a need for more intensive cooperation with the WPT, whereas 46.5% had a need for a more intensive cooperation with the OPT. Based on the results of qualitative research it was concluded that the cooperation/networking between PTs and WPTs, and knowledge about the WPT, should be enhanced [26]. However, based on the present survey, it seems that although there is little cooperation between generalist PTs and OPTs/WPTs, generalist PTs do not feel the need to work more closely together. Moreover, since almost 50% of the respondents indicated that they have sufficient knowledge of the domain of the WPT to refer patients, they do not see a need for cooperation or have insufficient insight into the additional value of the WPT. In the earlier qualitative study [26], the interaction between participants (WPTs, OPTs and PTs) during the focus group meetings might have contributed to a better perspective with regard to cooperation with the generalist PT and the OPT/WPT.

Although some studies have evaluated the experiences/perspectives of PTs with regard to RTW [19, 30] or managing a condition in the context of work [33], to our knowledge this is the first study to use a survey to investigate how generalist PTs currently integrate work participation within their practice, and to evaluate their opinions/needs with regard to enhancing the integration of the patient’s work within physical therapy. The developed survey was based on our earlier qualitative research [26], which ensured that a variety of clinically important topics was included in the survey. Moreover, this survey provides a triangulation of the results of the previous qualitative study and evaluated the results of the qualitative study on a broader scale in a group of generalist PTs. Thus, the present study contributes to the body of knowledge with regard to addressing occupational factors within physical therapy practice.

This study also has some limitations. Although the use of digital news-mails and social media increased the chance of reaching almost all PTs in the Netherlands, it was still difficult to find respondents for this study. This was also the case in previous qualitative research, probably indicating that the relevance of this topic was judged as low by PTs [26]. Since potential respondents were recruited by news-mails and announcements, this implies that mainly PTs already interested in work/occupation filled in the survey, which could have led to selection bias and influenced our results. Also, in this study, 23.2% of the respondents had a WPT within their practice. From a total of 19,557 PTs in the Netherlands who are a member of the Royal Dutch Society for Physical Therapy, only 169 are registered with the professional Dutch OPT/WPT association. Therefore, in this study, a relatively large number of respondents had a WPT in their practice, which may have led to more knowledge about occupational factors and a more pronounced positive attitude with regard to the WPT.

It is also possible that some respondents gave wished-for answers on some of the questions in the survey. This could be possible in most of the questions, because we assume that the ideal answers are known by the respondents. In addition, respondents can also have insufficient insight in their own knowledge and skills and overestimate their actual knowledge and skills, which could lead to too positive results of the survey.

Due to the varying background, age, gender and specializations of the respondents, it is a representative sample of generalist PTs. However, the 142 respondents represent only a small proportion of the Dutch PTs, which limits the generalizability of the results. Therefore, the results of this study should be interpreted with caution. Nevertheless, we think that this study is a valuable addition to our previous qualitative research, in which 21 generalist PTs and 9 WPTs/OPTs participated in the focus groups [26].

Although most respondents were aware of the importance of integrating occupational factors and perceived that they addressed occupational factors within their practice, it seems that the patient interview and clinical reasoning process were based on subjective procedures and impressions. It seems that a more systematic approach to obtain insight into occupational factors by means of questionnaires, observations, and workplace visits could increase effectiveness. This was also supported by the respondents, as the majority indicated that occupational factors should be more extensively addressed within physical therapy. Therefore, it seems valuable to support and facilitate generalist PTs in addressing these factors, i.e. by providing more information about work-related factors, laws and regulations, questionnaires and screening lists, and by incorporating work-related factors in guidelines. This can be done by developing (online) courses and integration of these factors within physical therapy educational programs. Moreover, an easy-to-use guideline to address occupational factors could be developed and it seems valuable to provide an overview of all these topics (e.g. via an online toolbox) [26]. Also, facilitating a systematic approach for addressing work participation within PT practice seems valuable. There is also a lack of knowledge about the domain and added value of the WPT and OPT, and a lack of cooperation. Although enhancing the cooperation with the WPT was not a specific need of most of the respondents (only 35.9% mentioned they want more intensive cooperation with a WPT), cooperation between generalist PTs and WPT should be enhanced [17, 26]. To achieve this, an overview or decision tree could be useful. To facilitate cooperation, a role might be played by the professional associations and the individual therapists [26].

It is also recommended to investigate the actual situation in practice by observations or investigation of the medical files. This would allow to explore areas in which generalist PTs might be unaware of missing competences and knowledge. In addition, it would be interesting to examine how generalist PTs in other countries integrate occupational factors within their practice.