Feature Providing Onsite Physical Therapist Services These PTs work everywhere their patients are, from industrial sites and touring shows to naval ships and universities. By Keith Loria | July 2019 Not too long ago, physical therapists (PTs) largely were constrained to their workplace—their practice, clinic, hospital, or anywhere patients came for treatment. But today's PT has evolved, taking the action outside the designated physical therapy "office" and bringing care to patients wherever they may be. One significant result of this transformation is that many physical therapy clinics, hospitals, and other health care providers have teamed up with businesses and employers to provide onsite health care and rehabilitation services. Examples include setting up company- specific ergonomics programs, identifying and advising on ways to eliminate dangerous working conditions, and enhancing health clinics to address issues ranging from obesity to dizziness. The profession is becoming more dynamic and diversified in its approach and finding more ways to provide effective care to consumers. Josh D'Angelo, PT, DPT, is cofounder and chief operating officer of Move Together, based in Fairfax, Virginia. (See related article on page 28.) He's also cofounder of MovementX, whose mission is "to help people move their best, so they can live their best." "We use precision care to deliver high-quality services," explains D'Angelo, a board-certified clinical specialist in orthopaedic physical therapy. "If patients are having pain at their home work station, we are able to treat them in their home, analyze their ergonomics, and recommend changes. If a patient is having pain running outside, we can take him to the local track to conduct a running analysis. If a patient has pain that started during a fitness studio workout, our team can treat her directly before or after her workout, and observe her in-workout movement." Moving its activities outside the clinic walls enables the company to provide further education, create greater awareness of services, and, ultimately, deliver more precise care, D'Angelo says. The model is built on flexibility, autonomy, and innovation. "One of the beautiful parts of physical therapy is that it can be done anywhere—all you need is your hands, your heart, and your mind," D'Angelo says. "I've seen physical therapist services delivered in hotel rooms, fitness studios, parks, gyms, and online." The founding team of MovementX came together in 2018 when they noticed providers who were frustrated with being told how many patients they needed to see, how much they needed to bill, and who was or was not eligible for care. The frustration wasn't limited to providers. "We saw patients who were frustrated with receiving surprise bills, being placed on long wait lists, and receiving inconsistent quality of care," D'Angelo says. "Our team came to a collective realization: If patients want better care and providers want to deliver better care, we needed to launch a movement to make it happen. MovementX was born as a better way to care." The site of the service is only one element of the process, but it's a significant one, as its website explains: "When providers are not focused on productivity requirements, cancels, and no-shows," much more can be accomplished, the site notes. Another variation of traveling to the patient is offered by Onsite Physio of Jacksonville, Florida. The practice offers what it calls "therapy on demand," in which a PT goes to an injured person's worksite—or home, in some cases—sets up equipment (if it's not already onsite), and focuses solely on the single injured employee. "It's the same methodology you might use to treat an injured athlete," he says. "You treat the individual to help him or her specifically get back to work. I couldn't understand why we weren't doing it for occupations such as firefighting and sanitation work—or any other lines of work," says Daniel Sanchez, PT, OnSite Physio's vice president of operations. Among the industries it works with is education (going to schools to treat teachers); hospitality (treating hotel workers and banquet servers); and entertainment (formerly partnering with Feld Entertainment, which produced Ringling Brothers and Barnum & Bailey Circus and Disney on Ice). Sanchez often will visit a job site, determine what caused the injury, and help the patient better determine how to do the job without risking further injury. "The 1-on-1 care is the biggest benefit," Sanchez says. Plus, the workers have to be at their jobs, so adherence is 100%. You're eliminating the obstacle of someone cancelling a visit because ‘something came up.'" The "Arts" of Being Onsite Carolyn M. Lawson, PT, is owner and chief executive officer (CEO) of Neuro Tour Physical Therapy Inc, which provides PTs to touring performing arts companies around the country. She started the business in 2000 when she identified that many people in the arts community needed care but didn't have the time or weren't in a location long enough to receive appropriate treatment. "We specialize in performing arts medicine. We treat backstage and in rehearsal studios, or conduct concierge visits to homes," she says. "This allows for 1-on-1 treatment sessions, better clinical decision-making skills, and more autonomy." For instance, Neuro Tour's Cody Gardner, PT, DPT, travels with a national tour of The Lion King. His job allows for exposure and opportunities for advocacy, as well as plenty of chances to help those who need physical therapist services. "Teaching the cast and crew just what and how much I can do with my doctoral degree in physical therapy is probably half of what I do. Treatment is important, but it's meaningless without buy-in and understanding," Gardner says. "Many dancers don't realize the effects of prolonged knee hyperextension on their back pain, for example, until I tell them to unlock their knees and do a quick soft-tissue workup. Today's entertainment professionals are tired, burnt out, and have unhealthful behaviors. What we do has the potential to alleviate those stresses." Additionally, he says, most of the performers with whom he works feel better to have someone "in their corner" and a safe space to share their experiences. "My presence has meant a greater voice for the health of the cast and crew, whether it's mitigating an unstable step down from the stage, poor footwear, or risky choreography," Gardner says. "Most artists don't have the resources to seek out health care, and when they do, they frequently are met with ignorance about the lifestyle, mismatching of goals, and orders to stop doing what they love. Like elite athletes," Gardner observes, "they rely on their bodies for their livelihood, and craft and push them to the limits. I empathize with this, and I wanted to change the status quo by improving education, health literacy, and access to care for artists, as well as advocate for this amazing group of individuals." Welcome Aboard Gregg Ziemke, PT, MS, MHA, with the Naval Medical Center Portsmouth in Virginia, is a retired captain in the US Navy. He was one of the first PTs to serve aboard a ship when the Navy's physical therapy program began in 1998. In a little more than 20 years, the effort has grown to feature PTs aboard all carriers. "I was very interested in having PTs on Navy ships," Ziemke says. "I first started working toward that end in the mid-1990s. While a US Navy ship is deployed, not all medical specialties are available quickly—or even at all. Having PTs on board a ship gives the medical staff and patients quick and easy access to physical therapy care, which is important." Ziemke was 1 of 4 authors of "Physical Therapists Forward Deployed on Aircraft Carriers: A Retrospective Look at a Decade of Service," a 10-year study that appeared in Military Medicine last year.1 It was a 10-year retrospective evaluation of the types of services provided, volume of workload, value of services provided, and impact of PTs on the operational readiness of personnel on Naval aircraft carriers. Data revealed that during that decade, there were 144,211 PT encounters. That worked out to about 1,448 per therapist per assigned tour. The average number of follow-up appointments performed by the PT per tour was 1,440. The average number of treatment appointments per tour provided by the PT and physical therapy technician combined was 1,888. "Some of the problems we saw and treated were acute low back pain and shoulder, hand, and arm injuries," Ziemke says. "Often the types of injuries were defined by what the ship's company was doing on that particular day. For example, during onloading of fuel and supplies, we may have had more hand injuries." The study found multiple benefits of having PTs on board. One advantage—similar to Ziemke's observation—was faster access to care. The study noted, "Prior to the PT pilot studies in 1996 and 1997, sailors' access to care for specialty musculoskeletal services (ie, occupational therapy, orthopedic surgeon, physical therapy, or sports medicine physician) most often required referral and transit to a fixed Medical Treatment Facility (MTF) and could take days or weeks until care was initiated. Full-time assignment of PTs to the aircraft carrier enabled same-day access to care regardless of ship's location." Another benefit of onboard PTs is that more sailors can deploy with the ship. The study explains, "Numerous reports also indicated examples of services members…that were allowed to deploy based upon the availability of physical therapy services, that would have been placed on limited duty were such services not available." Even when the injury or condition was beyond the PT's scope of practice, there was value in having the PT onsite. "There were multiple reports of sailors with non-musculoskeletal conditions being initially evaluated by the PT and subsequently referred to carrier medical staff (ie, physicians, physician assistant, clinical psychologist) for further work-up. Such conditions included pyelonephritis/nephrolithiasis, myocardial infarction, transient ischemic attack, and multiple sclerosis," the study reported. Manufacturing Patients Kim Smith, PT, DPT, owns Onsite Work Solutions, which provides injury prevention and management services primarily in manufacturing settings. The company's therapists work with employers who manufacture everything from furniture to footwear and automotive and aerospace components to fiber optics and electronics. "Different services are provided to different employers, depending on their needs and wants," Smith says. "Services we provide include early intervention for musculoskeletal issues, post-offer testing, job matching, job function analysis and creation of job function descriptions, ergonomic job and task assessment, return-to-work consulting, and injury-prevention consulting and education. We also can provide limited physical therapy and occupational therapy services onsite upon request." Smith first began visiting worksites in the early 1990s while she was in private practice. She saw that many of her patients had work-related orthopedic injuries. "During treatment, most of the patients with work-related injuries had work restrictions, but frequently their symptoms recurred upon returning to full-duty work," she recalls. "To determine why this was happening, I wanted to see their workplaces. After visiting a manufacturing plant for the first time and seeing the nature of the work, I was challenged and excited by what I saw. I remember watching employees repetitively handling products with awkward wrist and back positions, and reaching into high bins with awkward shoulder postures to access and lift materials." If ergonomic improvements and job-specific injury-prevention education for employees had been provided, she realized, recurrences after treatment's end might have been prevented or reduced. Likewise, had those interventions been provided before rather than after the onset of symptoms, the injuries might not have occurred at all. Shortly after that realization, Smith says she began working onsite for the first time, providing employers with ergonomics consulting, and offering employees first aid care and work-method education to keep early musculoskeletal symptoms from becoming injuries. "That visit also affected my clinic practice," she adds, "because I realized that following a rehab protocol was no guarantee that a patient would be able to transition safely back to an industrial work setting. So, in addition, I worked on improving rehab goal- setting and functional testing for patients in the clinic." Eventually, Smith felt she could help employees and employers more by practicing onsite than by remaining in the clinic. She made the decision to practice only at worksites. Over the years, she has seen an increase in PTs consulting with employers to practice onsite at workplaces—although until the past few years, she adds, it was atypical to find a PT in an industrial setting. "While it still is not common, the number of manufacturing employers hiring PTs and OTs [occupational therapists] to consult at job sites to help reduce the incidence and cost of musculoskeletal injuries in the workplace is rising," she says. "More PTs and OTs are practicing or consulting at worksites for employers each year because it reduces the incidence and cost of employee injuries." Higher Learning Fran McDonald, PT, DPT, president and CEO of McDonald Physical Therapy in South Bend, Indiana, has operated a private practice for 30 years. A dozen years ago, Notre Dame University came calling to ask if he would open a site in its health center. The university's goal: to make it easier for everyone to access care. Now, his practice treats faculty, graduate and undergraduate students, and workers' compensation patients. "Our therapists love working on a university campus. We deal mostly with students aged 18 to 28, and it's enjoyable and rewarding," says McDonald, a board-certified clinical specialist in orthopaedic physical therapy. "Calling and speaking with specialists all over the country—orthopedists, neurosurgeons, and so forth—and hearing their protocols for the same surgeries teaches us that most surgeons are not well-informed regarding rehabilitation and that PTs are the true experts." Benefits for All The benefits to both employers and employees of offering services onsite are many, starting with providing access to new populations. Gardner knew he wanted to pursue performing arts medicine before he graduated from school. He also values his broadened opportunities to work with and interact with patients. "My company regularly hosts injury-prevention workshops in addition to providing daily maintenance and prevention services," he says. "This environment invites a very open relationship with my patients, and I am proud that they feel like they can discuss whatever health concerns are on their mind." Both employers and employees appreciate the fact that less time needs to be taken away from work, D'Angelo says. "On the employer side, our presence leads to greater employee productivity. On the employee side, the convenience of care leads to greater satisfaction," he says. "Additionally, seeing the physical therapist first for many conditions results in reducing overall health care costs." Being onsite thus can offer cost savings to both employers and employees. For PTs, meanwhile, it provides a glimpse into the environment, culture, and physical setup of the employee—which in turn enables more-precise care delivery. Smith says the benefits she offers employers include saving money by reducing work-related injuries. This can be accomplished in different ways: by making sure that new hires can safely handle the physical demands of the job they are hired to do, by addressing ergonomic challenges before they cause injuries, and by providing first aid care that includes job-specific ergonomic education. "Employers also benefit from safe, early transitioning of employees back to work after injury," she adds. "Those transitions can be facilitated at the worksite or in a clinic setting by making sure that an employee's physical abilities match the demands of the job, and by communicating with the employer to see if any needed work modifications are feasible." Meanwhile, employees benefit from having a health professional available at work to teach them how to address early musculoskeletal symptoms and to counsel them on how to prevent musculoskeletal injuries. They also benefit and feel valued when their employer works with a consultant, such as a PT, to identify and address ergonomic causes of work injury. Working in Traditional Settings Opportunities to expand into "nontraditional" settings occur when PTs strive to provide the best care for their patients and see a need that can't be met any other way, the PTs interviewed for this article say. Therefore, even PTs and physical therapist assistants (PTAs) in more-traditional settings can benefit from the trend and move interventions away from traditional settings. Clinic-based PTs and PTAs can use PTs who practice at workplaces as resources. Smith explains: "When a clinic-based PT or PTA treats a patient whose employer has a PT working onsite, the onsite PT can provide specific information about the patient's job to help set rehab goals, Also, the onsite PT can follow up to see if there are any ergonomic issues that should be addressed prior to the patient's transition back to work, and assist the clinic PT by supporting the patient's transition back to work." Lawson suggests that this may impose an additional responsibility on PTs. "Most people are convinced that health care is [time-consuming] and costly—and for the most part, they are right," she says, adding, "Accessing these non-traditional environments improves our ability to change the perception of what physical therapy is, and its applicability to everyday life." Ziemke suggests that most PTs can find ways to think unconventionally and move some care to a different setting. "I hope that those in more-traditional practice settings will continue to look for opportunities to collaborate with other medical colleagues, especially physicians," he says. "I worry a bit that we may be isolating ourselves. A physical therapist is a highly trained medical professional, but other practitioners don't always know that." Gardner says that onsite arrangements, when properly structured, also may attack another serious problem: burnout. "My job allows me to be closely involved in the lives of my patients, improving care and trust. I also don't feel overworked," he says. "I treat and document just as does everyone else in the profession, but these cash-based contracts from larger corporations and businesses mean that we can provide the 1-on-1, high-quality care we crave without the barriers of having to meet productivity standards. I love what I do." To succeed in this realm, McDonald says PTs must establish themselves as the undisputed, recognized experts in their field. "When PTs achieve positive results and educate physicians and patients at a level that exceeds their expectations, PTs will be noticed." He advises PTs: "Dare to excel in your examination, rehab, and ability to help those in need in a way that each patient, physician, and caregiver will recognize as exceptional." Similarly, D'Angelo says onsite services offer PTs a great opportunity to better define physical therapy to the public. "Most of the locations in which we provide services initially are unaware of what quality physical therapy looks like, when it's appropriate to see a physical therapist, and how we can help," he says. "Stronger consumer awareness of the benefits of physical therapy services will create a stronger profession." Additionally, say the PTs interviewed for this article, clinicians who seek to diversify their careers have the opportunity to explore innovative models of care and provide it in unique settings and many meaningful ways. Meeting the Needs of Today's Patients and Clients D'Angelo says the biggest lessons are those learned from patients: They want the ear and undivided attention of their health professional. They want their health care provider to understand their job and life commitments. They're looking for compassion, and for timely access to understand what's happening with their bodies. They want to be empowered, and to have someone fighting for them. "We are selling them short if we don't deliver on patient desires, because it is possible," Gardner says. "This is a perfect addendum to our profession." He suggests that a number of social and economic changes will lead to more innovative models of care, starting with the public becoming more aware of the importance of the movement system and demanding solutions. "Services such as ‘stretch studios' and cryotherapy are accessible, convenient, and attractive options for consumers," Gardner says. "Copays, deductibles, and cost-sharing are on the rise, so consumers are willing to try new solutions when care otherwise is no longer covered. The gig/job-sharing economy is growing, and a new generation of providers is demanding more flexibility and autonomy. We can no longer stay in traditional settings, expect to passively receive patients, and stay relevant. It will be up to us to evolve, survive, thrive, and create our future." Keith Loria is a freelance writer.