The practice of physiotherapists certifying capacity for work is not yet widely prevalent worldwide. In the UK, physiotherapists have been able to issue fitness for work certificates since July 2022. Alberta, Canada and Norway have also granted physiotherapists the authority to assess fitness for work. 

In Australia, physiotherapists can only write certificates in New South Wales (since 2020) and Victoria (since 1987). However, it wasn't until fairly recently that physiotherapy certification rates saw a significant increase, and this was because from about 2006 Victoria undertook a series of initiatives to encourage physiotherapists to do so.

At the Research to Real World for Compensable Injury Symposium, Paul Coburn, a pioneer in the field of physiotherapy and return to work, shared his insights on the emerging role of physiotherapists in certifying work capacity and the initiatives undertaken in Victoria to support this change. This is a summary of Paul’s presentation.

The benefits of physiotherapist certification

Physiotherapists often see patients more often than GPs, especially in rural areas where access to GPs may be limited. 

Physios conducting rehabilitation typically see patients once or twice a week, which means they may have up to 8 sessions with a patient in 4 weeks. While this frequency gives them lots of opportunities to write certificates, the real benefit lies in the regular contact that enables physiotherapists to:

• reinforce patient confidence and address their concerns or fears about returning to work
• closely assess a patient's physical capabilities through rehabilitation, leading to better-informed certification decisions
• discover that patients can often do more than initially expected, and
• identify instances where patients may not be able to perform all the tasks they believe they can do to RTW.

In other words, this frequent contact provides physios with valuable insights into a patient's true physical capacity, fears and concerns, which enables them to make appropriate certification decisions based on their observations and assessments.

The Victorian initiatives

In a pilot program to encourage more physios to certify, Victoria trained 200 physiotherapists in certification and RTW. The program showed improved patient outcomes and a higher likelihood of returning to work when treated by trained physiotherapists. 

To increase the certification rate further, in 2013 WorkSafe Victoria introduced the Early Intervention Physiotherapy Framework, which provides online training for all physiotherapists. As a result, physiotherapy certification rates rose from 5% in 2014 to nearly 18% in October 2022.

Issues that emerged from this work

What experience and expertise do physiotherapists need to write certificates? 

Some jurisdictions believe that physios must have experience, expertise and specific training in occupational health before they can write certificates. However, the Victorian experience suggests that:

• because the return to activity, function and participation are core competencies in the rehabilitation process, physiotherapists have the necessary skills and expertise to make informed decisions when issuing certificates of capacity for work
• requiring expertise and experience would create unnecessary obstacles and limit the number of physios who certify.

Also, the focus of certification should be on the patient's capacity, not the job itself. Once that's been determined there are lots of people who can support return to work — including employers, injury management advisors and occupational rehab providers.

What, how much, and what type of training do they need?

Training programs in Victoria have evolved from lengthy in-person sessions to online modules under the Early Intervention physiotherapy framework, which takes 90 minutes to 2.5 hours to complete.

That training is complemented by peer-to-peer discussions with clinicians on the management of their patients through the Clinical Panel. A team of 15 highly skilled physiotherapists review the certificates issued by community physiotherapists involved in helping patients return to work. If a certificate seems incorrect or inconsistent, they contact the physiotherapist who wrote it to discuss the certificate. This helps to ensure that physios in the community are consistently issuing appropriate certificates.

Acceptance by medical practitioners

Acceptance by medical practitioners can be a barrier to physios being able to write certificates. In Victoria, physios have enjoyed a good relationship with local GPs. Over the past 5 years, many GPs have opted out of certification, leading to a gradual reduction in GP-written certificates and a corresponding increase in those written by physiotherapists. 

However, physiotherapists should not certify in these situations:

• When the GP prefers to manage the certification process, often due to their long-term relationship with the patient and their family. In such cases, physiotherapists should communicate with the GP about the patient's capacity limitations.
• When the patient has non-musculoskeletal conditions, including mental health issues like depression, anxiety or trauma, which affect their capacity to RTW. In these situations, physiotherapists should refer the patient back to the GP for certification.
• When patients are taking medications such as opioids that can affect their ability to operate machinery, concentrate or maintain the safety of themselves and others. 

The takeaway messages

The Victorian experience shows that physiotherapists, regardless of their experience level, can be trained and supported to certify work capacity. 

While GPs should certify when clinically appropriate, rehabilitation requires continuous assessment of functional capacity, which supports the certification by physiotherapists. 

As more jurisdictions consider expanding the role of physiotherapists in work capacity certification, the Victorian model offers valuable insights and lessons.