Disability and Rehabilitation, December 2006; 28(24): 1563 – 1566
CLINICAL COMMENTARY
Work physical therapy and rehabilitation ergonomics: A review and discussion of the scope of the areas
EDGAR RAMOS VIEIRA Ergonomics Research Laboratory, Faculty of Rehabilitation Medicine, Department of Physical Therapy, University of Alberta, Edmonton, Alberta, Canada Accepted February 2006
Abstract Purpose. There has been a recent development of the work physical therapy area in Brazil. The relationship between work physical therapy and rehabilitation ergonomics needs to be highlighted to avoid segregation and fragmentation of these complementary fields. For these reasons, the purpose of this article was to review and clarify the scope of the areas of work physical therapy and rehabilitation ergonomics. Method. The available literature discussing the roles of the areas of interest was critically reviewed. Results. Both areas are concerned with workers’ health and safety and they complement each other. Conclusions. Work physical therapy can be considered as rehabilitation ergonomics practiced by physical therapists with their specific interests. Hopefully, this paper will contribute to further interaction between the areas of work physical therapy and rehabilitation ergonomics not only in Brazil but worldwide. This may contribute to improved occupational disability prevention and rehabilitation.
Keywords: Physical therapy, ergonomics, work, WMSD, prevention, rehabilitation
Introduction Twenty-five years ago and again in 2001, prevention, rehabilitation, and equalization of opportunity for the handicapped were defined as the primary goals of The World Program of Action of the World Health Organization [1]. Work physical therapy and rehabilitation ergonomics are instrumental areas to the fulfilment of these goals because the main objectives of both areas are the prevention and rehabilitation of work-related musculoskeletal disorders (WMSD). Among the WMSD are the low back disorders, shoulder and wrist tendinitis, and carpal tunnel syndrome when these are work-related [2]. In Brazil, WMSD are among the most common work-related health problems whose frequency, causation, and/or severity is modified by the work [3]. To give an idea of the dimension of the problem in Brazil, in 2002 a total of 105,514 work-related
diseases were recorded by the Brazilian National Institute of Social Insurance (INSS). However, these figures are a gross underestimation of the problem because the information includes only the employed workers (75,471,556 in 2002, according to the Brazilian Institute of Geography and Statistics – IBGE) covered by the Work Accidents Insurance (SAT) from the INSS (n ¼ 22,903,311 in 2002, according to the IBGE). Thus, only one-third of the working population was included and the number of cases is likely to be higher. Actually, based on a survey (n ¼ 1072 workers) it was estimated that 310,000 workers (6.6% of the working population) suffered WMSD in 2001 in Sa˜o Paulo city alone [4]. Occupational health professionals and ergonomists need to work together to alleviate work-related problems [5]. The relationship between work physical therapy and rehabilitation ergonomics need to be highlighted to avoid segregation and fragmentation
Correspondence: Edgar R. Vieira, PhD student, Ergonomics Research Laboratory, Faculty of Rehabilitation Medicine, Department of Physical Therapy, 3 – 48 Corbett Hall (mailbox), University of Alberta, Edmonton, Alberta, Canada, T6G 2G4. Tel: þ1 780 492 7187. Fax: þ1 780 492 1626. E-mail:
[email protected]. Web site: http://myprofile.cos.com/evieira ISSN 0963-8288 print/ISSN 1464-5165 online ª 2006 Informa UK Ltd. DOI: 10.1080/09638280600638182
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of these complementary lines of work. The question is: Are these areas different or are these different names for the same discipline? The answer to this question is important and has repercussions for the practice, certification, and regulation of the areas. For this reasons, the objectives of this article were to review and clarify the scope of the work physical therapy and rehabilitation ergonomics areas. Work physical therapy A holistic rehabilitation that considers the need for economic independence through gainful employment is necessary [6]. Work physical therapy needs to go further than traditional physical therapy because while the latter is mainly concerned with the restoration of the functionality to the level of activities of daily living, the former deals with the restoration of functionality to the level of job requirements, and the prevention of work-related injuries and re-injuries. Work physical therapy deals not only with rehabilitation and secondary prevention, but also with the design and implementation of primary prevention programs. The prevention programs should focus on job evaluations and intervention programs, and should not focus only on compensatory exercises during the work shift. In the USA, there is not a separate association of work physical therapy. However, the Orthopaedic Section of the American Physical Therapy Association (APTA) has a special interest group in ‘occupational physical therapy’ (http://www.orthopt. org/sigs/occupational_health_sig/). According to the APTA ‘‘the role of the physical therapist in occupational health includes examination and evaluation of individuals with work-related risk factor(s), impairments, functional limitations, disabilities, or other health-related conditions which prevent individuals from performing their occupational pursuits in order to determine a diagnosis, prognosis, and implement intervention as necessary’’ [7]. The APTA have also published guidelines for physical therapy practice in different areas including guidelines for the physical therapists involved in occupational injury prevention/ ergonomics [8]. According to the Canadian Physiotherapy Association (www.physiotherapy.ca), physical therapists require a license from the college in their province in order to practice in Canada. The college of physical therapists in each province is the licensing and regulatory body for the profession. It is responsible for safeguarding the public interest in the delivery of physical therapy service. Thus, the primary role of the colleges is to protect the patient/public and their secondary role is to guide/direct the profession. Each college ensures that physical therapists practicing in a particular province are registered and have met
the provincial standards for entry and re-entry to practice regardless of their ‘work setting’. However, there are some organizations in Canada who deal specifically with occupation rehabilitation such as the workers compensation boards of Alberta (www. wcb.ab.ca) and British Columbia (www.worksafebc. com), and the Workers’ Safety and Insurance Board of Ontario (www.wsib.ca). These bodies act like insurance corporations and are funded entirely by the industry/employers. There are also private companies specialized in the evaluation of injured worker such as the Disability Assessment Centre (www. disability-assessment.com). During the late 1980s/early 1990s physical therapists started to participate in preventative programs on work-related injuries in Brazil [9]. However, prevention is part of the education and scope of the Brazilian physical therapists work since 1983 (Resoluc¸a˜o N.4, CFE). There has been a recent development of the work physical therapy area in Brazil. In 2004, there were two major events in this area in the country: the 1st International Congress of Work Physical Therapy and the International Congress of Work Physical Therapy of the Brazilian Society of Work Physical Therapy. Two professional organizations, the National Association of Work Physical Therapy – ANAFIT (created in 1998) and the Brazilian Society of Work Physical Therapy – SOBRAFIT (created in 2002), were formed and organized. Due to the duplication of functions, there has being discussions with respect to the integration of the organizations into the Brazilian Association of Work Physical Therapy – ABRAFIT. The future ABRAFIT roles should be to license and regulate physical therapists whose practice relates to occupational settings, including rehabilitation of injured workers and work interventions to prevent workrelated musculoskeletal disorders (physical demand analysis, ergonomic interventions, recommendations, and training programs). Also, the association should represent the interests of the ‘work physical therapists’ to the regulatory entities (labour and safety regulations boards). Finally, it should promote continuing education in the area (seminars, workshops, symposiums, and conferences). Rehabilitation ergonomics According to the International Ergonomics Association (IEA) (http://www.iea.cc), ergonomics is the science that studies the relationship between the man and work. Its objectives are to modify the work systems to better adjust it to the characteristics, capacities, and limitations of the workers. Ergonomics is used to maximize work performance (optimize function) without compromising workers comfort and health. In 1983, the Brazilian Ergonomics Association
Work physical therapy and rehabilitation ergonomics (ABERGO) (http://www.abergo.org.br) was created. Wisner [10] in the paper ‘In praise of Brazilian ergonomics’ stated that ‘‘Brazilian ergonomists are rightly concerned about the health of workers’’ (p. 417). According to O’Neill [5], ‘‘in industrially developing countries, the emphasis must be on prevention and should be a national developmental priority’’ (p. 636). The same author pointed out that the main ergonomic concerns in these countries are physical workload, physical environment, equipment design, health and safety. However, a review of the studies on ergonomic intervention in Latin America in the past 20 years, published by Coury, show that the more recent intervention studies are using more a participative approach and that the organizational aspects of the work are receiving increasing attention [11]. In 1978, Kumar introduced the term rehabilitation ergonomics for the area of interaction between the disciplines of rehabilitation and ergonomics [12]. In 1993, the IEA formed a scientific committee for the area, and in 1994, the International Symposium on Rehabilitation Ergonomics happened in Toronto as part of the 12th International Conference of the IEA [13]. The ABERGO has a technical group called Prevention of musculoskeletal disorders/Rehabilitation (http://www.simucad.dep. ufscar.br/projetos/gt_abergo/). This technical group is co-ordinated by and has many physical therapist members. The rehabilitation ergonomics area requires knowledge in anatomy, anthropometry, physiology, and biomechanics. All these are part of physical therapists’ undergrad program. Considering the physical therapists work in the ergonomics field, they are prepared to work in rehabilitation ergonomics. The philosophy shared by rehabilitation ergonomists and work physical therapists Many work-related musculoskeletal disorders can be prevented; preventative research is an effective therapy [14]. The disciplines of rehabilitation and ergonomics ‘have similar philosophies and goals’ [12]. The efforts (particularly in industrially developing countries) should be participatory in nature, involve multi-disciplinary teams, and employ a bottom-up approach (starting from the workers) [5]. When the work physical demands exceed the workers’ functional capacity the risk of WMSD is significantly increased [15]. The prevention and rehabilitation of the WMSD involve the work physical demands analysis (PDA) and the evaluation of the workers’/patients’ functional capacity (FCE). The PDA objectives are to measure the physical effort required by the job in relation to the postures, movements, repetitions, and duration of the work
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tasks. While the FCE objectives are to determine the performance level that the workers/patients are able to work at including the range of motion, strength, endurance, kinematics, kinetics, proprioception, and coordination. The FCE information can be used to assess if the subjects are fit for the job both at admission and when returning to work after an injury. The study of the patients/workers and jobs should be systematic and could use the percentages of the normal or maximal available and required motion, endurance, and force [16]. The relationship between job requirements and the workers’ resources is further explored by Kumar including the social and psychological dimensions, in addition to the physical demands of work [6,12]. Basically, these assessments (PDA and FCE) should be considered together for optimum outcomes. When a work-related injury happens (if not before that) a PDA should be performed. In addition, the injured worker should go through a FCE. The results can then be used to study the relationship between the injury and the work demands. They should also be used to design the rehabilitation program for the injured worker, and to plan work modifications to prevent similar injuries. After the rehab program is executed a second PDA and FCE should be performed to evaluate if the worker: (i) has gained or recovered the required physical capacity to perform his/her job; (ii) is fit to return to work; (iii) needs further rehab and its objectives; and (iv) needs to change jobs and what activities would he/she be able to perform. Similarly, after the modification plan is put in place a new PDA should be conducted to assess if: (i) the modifications were sufficient to adequate the physical demands and reduce the risk of new cases and reinjuries, or if (ii) further interventions are required and what they should be. In the long-term this procedure will result in an efficient surveillance system and pro-active management of work-related injuries. Conclusions Considering the discussion presented in this article, work physical therapy can be considered as rehabilitation ergonomics practiced by physical therapists with their specific interests. Thus, any discussions in relation to codes of practice, and certification of the Brazilian physical therapists working in the area should be held by the ABRAFIT in combination with the ABERGO. Hopefully, this paper will contribute to further interaction between the areas of work physical therapy and rehabilitation ergonomics not only in Brazil but worldwide. This may contribute to improved occupational disability prevention and rehabilitation.
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Acknowledgements The author would like to thank the valuable contributions of Dr Helenice J. C. G. Coury (Universidade Federal de Sa˜o Carlos, Departamento de Fisioterapia) and Dr Shrawan Kumar (University of Alberta, Physical Therapy Department) to this article. Funding was provided by the Caritas Health Group, the Alberta CIHR Training Program in Bone and Joint Health (Canadian Institutes of Health Research), and by the Education Ministry of the Brazilian Government (CAPES, proc. # 1340-01/8). References 1. World Health Organization (WHO). International classification of impairments, disabilities and handicaps 2001. 2nd ed. Available from: http://www3.who.int/icf/intros/ICF-Eng-Intro. pdf via the Internet. 2. Bureau of Labor Statistics (BLS). Lost-worktime injuries and illnesses: Characteristics and resulting days away from work 2001. Available from: http://www.bls.gov/iif/oshwc/osh/case/ ostb1177.pdf.2001 via the Internet. 3. Juca´ R, Costa H, Berzoini R. Texto base da minuta de polı´tica nacional de seguranc¸a e sau´de do trabalho. Imprensa oficial 05/05/2005;(85). 4. Ministe´rio da Sau´de. LER/DORT afeta 310 mil trabalhadores na cidade de Sa˜o Paulo. Folha de Sa˜o Paulo 07/10/2001. p C9. 5. O’Neill DH. Ergonomics in industrially developing countries: Does its application differ from that in industrially advanced countries? Appl Ergonom 2000;31:631 – 640.
6. Kumar S. Rehabilitation: An ergonomic dimension. Int J Ind Ergonom 1992;9(2):97 – 108. 7. American Physical Therapy Association (APTA). Occupational health physical therapy guidelines: The physical therapist in occupational health 2005. Available from: http://www.apta. org/Publications/occ_health/role_of_pt via the Internet. 8. American Physical Therapy Association (APTA). Occupational health physical therapy guidelines: Work-related injury/illness prevention and ergonomics 2005. Available from: http://www. apta.org/Publications/occ_health/workinjury_ergonomics via the Internet. 9. Rossi CN, Vieira ER. Historical perspective of work physical therapy in Brazil (in Portuguese). SAUT – Health at Work 2005;2(1):22 – 26. 10. Wisner A. In praise of Brazilian ergonomics. Int J Indust Ergonom 1998;21(5):415 – 419. 11. Coury HJCG. Time trends in ergonomic intervention research for improved musculoskeletal health and comfort in Latin America. Appl Ergonom 2005;36(2):249 – 252. 12. Kumar S. Rehabilitation and ergonomics: Complementary disciplines. Can J Rehab 1989;3(2):99 – 111. 13. Kumar S. Preface. Int J Indust Ergonom 1996;17(2):77 – 79. 14. Kumar S. Preventive research – an effective therapy. In: Mital A, Karwowski W, editors. Ergonomics in rehabilitation. London: Taylor and Francis; 1988. pp 183 – 197. 15. Vieira ER, Kumar S. Occupational physical effort and musculoskeletal health (in Portuguese). Proceedings of the XIII Brazilian Congress on Ergonomics; 2004; Fortaleza. Ceara´, BR. CD-Room. 16. Vieira ER, Kumar S. Occupational biomechanical demand evaluation. Proceedings of the 2nd Annual Regional National Occupational Research Agenda; 2004; University of Utah, Salt Lake City. Utah, USA. pp 171 – 180.
