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Primary Prevention Programs for Business and
Industry: Role of Physical Therapists
Robert R Huhn and Robert V Volski
PHYS THER. 1985; 65:1840-1844.
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Primary Prevention Programs for Business and Industry
Role of Physical Therapists
ROBERT R. HUHN
and ROBERT V. VOLSKI
Business and industry are interested in reducing their direct and indirect costs
of health services. The answer to reducing these costs for many companies has
been to shift their emphasis from subsidizing sickness to promoting health and
welfare in wellness, prevention, or fitness programs. Basic certification courses
have been developed at a graduate level for fitness instructors, exercise test
technologists, exercise leaders, and directors of preventive programs. These
courses are open to a broad range of disciplines, including physical therapy.
Physical therapists can perform different roles in industrial preventive programs
to prevent on-the-job injuries and improve physical fitness. Physical therapists
have both the education and the clinical experience to be effective in planning
preventive programs. We have divided the comprehensive preventive exercise
program into five phases: history questionnaire, evaluation, consultation, performance, and progress assessment. These phases, especially the evaluation of the
patient, are discussed from the perspective of the contribution the physical
therapist can make. The characteristics of successful company-sponsored exercise programs also are discussed.
Key Words: Exercise therapy, Heart diseases, Industry, Physical therapy, Preventive
health.
General Motors in 1976 made headlines by spending more
money on employee health benefits than on steel. Over the
last decade, business and industry have given increasing attention to these rising health care costs. Estimates published in
1982 have placed the national price tag on health care at $470
billion. Of this, business annually pays approximately $170
billion, or about one third.1
Coronary heart disease and back pain create an appalling
cost in lives, lost wages, disability, and lost productivity. Xerox
Corporation estimates that its replacement costs for high level
executives who have heart disease range from $500,000 to
$ 1,000,000 a person in compensation and training costs. Back
pain affects 75 million workers and accounts for $1 billion in
lost output and $250 million in workmen's compensation
claims annually.2
Business and industry, therefore, are interested in reducing
their direct and indirect costs of health services. Direct costs
include health, workmen's compensation, disability, and life
insurance premiums. Indirect costs that are less noticeable
and more difficult to quantify include absenteeism, lost productivity, poor job performance, employee turnover, and poor
morale.
The answer to reducing these costs for many companies
has been to shift their emphasis from subsidizing sickness to
promoting health and welfare in wellness, prevention, or
fitness programs. In theory, some differences exist between
the concepts of prevention, wellness, and fitness. Prevention
deals with discouraging negative behavior such as smoking,
poor eating habits, and lack of exercise. Wellness stresses the
positive aspects of life style change, including the joy of living.
Fitness programs emphasize exercise participation and the
Mr. Huhn owns and directs Human Performance Center, 411 W Pueblo St,
Santa Barbara, CA 93105 (USA).
Mr. Volski is President, Florida Health Fitness Consultants, Inc, 1546 Venera
Ave, Coral Gables, FL 33146.
dynamic aspect of behavioral change. All concepts, however,
deal with improved health through self-responsibility.
BUSINESS AND INDUSTRY PREVENTIVE
SERVICES
Many different health services are used by business and
industry. Johnston and Blakney presented a diagram of their
concept of both the "preventive health phase" and "rapid
response phase" of a comprehensive industrial health program.3 Jacobs and Chovil have developed a framework to
assess the role of company medical programs and company
operations.4
These preventive services can be placed in the broad categories of 1) medical examinations, 2) medical fitness screening, 3) exercise programs, 4) health education and change in
life style courses, and 5) safety activities. Medical examinations and screening may include health risk appraisals; questionnaires regarding musculoskeletal problems; and evaluations of cardiovascular endurance,flexibility,muscle strength,
body composition, pulmonary function, and blood chemistries. Health action programs include a variety of exercise
programs that usually emphasize cardiovascular endurance.
Health education programs often emphasize cessation of
smoking, control of hypertension, positive eating habits, management of stress, abstinence from alcohol and drugs, and
proper lifting and moving techniques. Throughout these
courses, the positive and joyful aspects of work usually are
emphasized.
In 1973, only 75 major corporations had physical fitness
programs. Now the Fortune 500 companies comprise a major
share of the 750 companies that have physical fitness programs. More than 400 major corporations such as Xerox,
Johnson and Johnson, IBM, Prudential Insurance, Control
Data, Kimberly Clark, Century Insurance, Ryder Systems,
and General Foods offer some type offitnessprogram.5
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PHYSICAL THERAPY
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Although large corporations have established comprehensive programs, including instructor-led in-house exercise programs, smaller corporations and businesses face financial
constraints for their fitness programs. The products most
readily marketable to these smaller companies are health risk
profiles and educational packages. These lack the employee
participation that gives increased impetus to positive life style
changes. Several alternatives exist and will be discussed.
Studies
Several definitive studies have researched the long-term
benefits of corporate wellness programs. A study of 600
employees who received a comprehensive preventive health
and activity program over a five-year period showed a significant reduction in the risk of coronary artery disease, amelioration of a wide range of health problems, and a large
reduction in employee absenteeism.6
Shephard et al studied 234 men and 300 women who
participated in a three session a week company fitness program for one year.7 They noted the following results: significant reduction in medical reimbursement costs, decrease in
absenteeism of 1.3 days for each employee, 13.5% decrease
in employee turnover, and 50% reduction in employee hospitalizations.
Cox et al reported the results of a Canadian Life Assurance
study.8 This controlled trial measured the effects of a wellregulated employee fitness program on physiological "fitness"
scores and job satisfaction, productivity, and absenteeism.
The results of these studies included the following: Turnover
decreased from 15% to a rate of 1.5% for a 10-month period,
productivity rose 31.3% in three departments with zero turnover, average monthly absenteeism figures decreased 20% in
both the test and control companies, and net maximum
benefit savings accounted for approximately 1 % of the company's payroll costs, or $231,000 annually.
Metropolitan Life found that 100 employees who participated in a fitness program averaged 4.8 sick days a year
compared with 6.2 days a year for the members of a control
group who did not exercise (Wall Street Journal, September
15, 1981, p 56). Shephard summarized the results of many
programs that have looked at cost-benefit and cost-effectiveness.9 He found promising benefits to the company and the
employee, including an increase in worker satisfaction, an
increase in productivity, and a decrease in absenteeism and
turnover.
Despite these encouraging reports, sound scientific data
relative to these effects have been sparse.10 In general, most
employee fitness research lacks reliable control groups and
leaves open the question of self-selection because this research
is predominantly cross-sectional in nature. Thus, the actual
value of implementing physical activity and life style programs
in business and industry is yet to be established scientifically.
This same question haunts the advocates of the benefits of
cardiac rehabilitation programs.
Wright, of the Xerox Corporation, agrees on the lack of
scientific proof.11 He points out, however, that far more
important justification for physical fitness programs is the
multiple informal indicators. Participants and nonparticipants at all levels of the company believe that the Xerox
program is cost-effective and contributes greatly to employee
job satisfaction, company loyalty, and productivity.
Personnel
Individuals with many different backgrounds, such as exercise physiologists, physical educators, nurses, and physical
therapists, are being used by business and industry to carry
out roles in prevention programs.
To respond to the increasing demand for personnel, major
universities have developed many preventive and rehabilitative programs at the graduate level during the last five years.
The American College of Sports Medicine (ACSM), Preventive and Rehabilitative Exercise Committee, has developed a
directory of these programs.12 This directory presents a description of 29 programs given by the faculty members at the
respective institutions.
The ACSM also has developed basic certification courses
for fitness instructors, exercise test technologists, exercise leaders, and program directors.13 Educational courses are held
separately from the certification. The process is designed to
certify basic knowledge and skills in each category. The
courses are open to a broad range of disciplines, including
physical therapy. The ACSM certification is required or preferred for positions in many programs.
Role of Physical Therapists
Physical therapists have unique professional qualities to
contribute to business and industrial preventive programs.
Entry-level professional education prepares physical therapists
not only in normal anatomy and physiology but also emphasizes pathology and health problems. During clinical practice,
these professionals commonly treat injuries and problems
that could have been prevented. Exercise programs are designed and modified for problems such as sprains, strains,
arthritis, bronchitis, and myocardial infarction.
For individuals to use preventive techniques effectively,
they must have experience with the problems they are attempting to prevent. Textbook knowledge alone is insufficient. Physical therapists have both the education and clinical
experience to be effective in dealing with prevention.
Preventive programs must consider both the cardiopulmonary and neuromusculoskeletal areas. Physical therapists have
tended to develop expertise in specific areas. More individuals
have advanced knowledge and skills in dealing with neuromusculoskeletal problems than with cardiopulmonary problems. To deal with cardiopulmonary problems effectively, an
individual must have knowledge of cardiopulmonary pathology, exercise physiology, and in some cases electrocardiography. Physical therapists have sought out postgraduate educational opportunities to upgrade their proficiency. They have
gained an additional knowledge base and skills in groupexercise leadership and planning exercise programs. The certified cardiopulmonary physical therapists have demonstrated
a very high level of competence in all of these areas.14 Overall,
physical therapists need broad backgrounds in dealing with
cardiopulmonary and neuromusculoskeletal problems, or
they need to pool their skills with others.
Physical therapists can be used for many different roles in
industrial preventive programs. Two broad areas are preventing on-the-job injuries and, therefore, workmen's compensation claims and improving physical fitness and possibly
preventing disease. Their roles in either program can be
categorized as consultants, educators, exercise leaders, or program directors.
Volume 65 / Number 12, December 1985
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Some physical therapists are currently working with business and industry in preventing on-the-job injuries. As consultants, they have developed injury profiles on a specific
business's workers. They have prepared profiles of the physical
demands and biomechanics of specific jobs. This information
has been used to develop educational presentations on injury
prevention. They have also used this to train safety personnel.
Other physical therapists have been involved directly as
exercise leaders or program directors of company fitness
programs. The role of these individuals will be described in
the remainder of this article.
COMPANY FITNESS PROGRAM ELEMENTS
Previous discussion of the needs and benefits of preventive
exercise programs left open the questions of hard scientific
data. Therefore, for a preventive exercise program to be
successful, upper management and the company medical
director must be convinced of its value, endorse the program,
and participate in it.10 Other elements that lead to a successful
program include employee involvement in program planning,
promotional planning, convenience, conducive environment,
professional leadership, and management information systems to provide data for program evaluations. Comprehensive
preventive exercise programs can be divided into five phases:
history questionnaire, evaluation, consultation, performance,
and progress assessment.
History Questionnaire
The history questionnaire ideally would contain questions
regarding general health, musculoskeletal problems, exercise
and physical activity, weight and eating habits, and a cardiovascular risk factor analysis, which includes stress. A health
hazard appraisal questionnaire can be a part of this or a
separate entity.15 This tool compares individual responders to
a data base of national norms and statistical data.
Medical Screening and Evaluation
An evaluation is helpful to establish a baseline. A physician's physical examination may include some of the items
that will be discussed. The purpose of this separate evaluation,
however, is to establish a baseline of fitness, assist in planning
an exercise program, and recommend corrective measures or
further testing for problems observed.
A number of decisions must be made to determine the
most appropriate type of evaluation. The location of the
evaluation can be a fitness facility, professional office, hospital, school, work site, or mobile van. The comprehensiveness
of the testing and the number of tests administered will
determine how many individuals can be tested at one time.
For example, if maximal stress testing is done on a treadmill
with a 12-lead ECG, more time and personnel will be required
than for submaximal testing with telemetry monitoring on a
bicycle ergometer. Specific tests must vary and match the
group to be tested. For example, strength testing of shoulders
may not be necessary for women interested in fat loss but, for
a fireman, such a test would be mandatory. A group of 25year-old highway patrolmen would not benefit as much from
12-lead ECG monitoring as a group of 50-year-old executives.
Comprehensiveness of the testing may also come down to
finances. Compromises may be necessary to reduce costs of
administration—specifically personnel and equipment. Because some of the tests can be carried out by relatively
inexperienced personnel, a clinician can use those being tested
to monitor testing stations.
Another consideration is work specificity. Is the test designed to be relevant to job requirements or is it for healthrelated components of fitness? If work-related testing is a
factor in hiring or firing, then all tests must be shown to
represent abilities required for functioning successfully on the
job. Can a highway patrolman of 26% body fat be shown to
be less capable of handling his job than one of 15%? Such a
test may not be used to hire or fire even though it may be
linked to optimal health.
Classification of test results poses a problem. Most individuals are motivated by a comparison of their specific results
with others of similar age and sex. The comparison standards
are difficult, however, because of the high variability of testing
procedures, variability of the test itself, or lack of adequate
sampling for noncollege age groups and different sports. Establishing what is an optimal result for many tests is also
difficult. For example, what is optimal flexibility of the hamstring muscles—90 degrees or 110 degrees? Will a more
flexible individual have fewer injuries? Should 90 degrees be
classified as fair, good, excellent, or optimal? However testing
standards have been developed, care must be given to select
standards of the highest reliability.
Components that may be tested are cardiovascular endurance, joint screening, body composition, muscle strength,
flexibility, pulmonary function, and blood chemistry. These
evaluation procedures are in addition to the examination
done by a physician.
Cardiovascular endurance. The evaluator may choose from
a variety of tests including measured oxygen consumption
testing with full 12-lead ECG, maximal treadmill testing
estimating the oxygen consumption (Vo2), submaximal bicycle testing estimates of Vo2 with or without ECG monitoring,
step tests with heart rate recovery, or field tests.16 Decisions
must be made on the importance of physiological and metabolic components or ECG results. Physician supervision and
interpretation may be mandatory for some tests, and others
may be done without the physician present.
Body composition. Testing choices are underwater weighing, impedence testing, skin fold measurements, and girth
measurements.16 Each test has its advantages and disadvantages. Underwater weighing with measured residual volume
(not estimates by vital capacity) still is considered to be the
best of these methods. Impedence testing is much faster, but
it has not been proved with many types of patients. Skin fold
measurements vary according to the tester's capabilities and
the specific formula that is used. Girth measurements are
helpful to show local changes and may be better used as a
motivator for those who have higher percentages of body fat.
Joint screening. Many physical fitness evaluations do not
include joint screening because, either the clinicians lack expertise or do not recognize its value. Joint screening is certainly an important measure because abnormalities of the
musculoskeletal system may require modifying the type of
cardiovascular exercise one performs. The joints most important to be screened are the shoulders, low back, knees, feet,
and ankles. Screening procedures include postural evaluation
of anatomical abnormalities, range of motion and strength,
ligamentous stability, and dynamic biomechanical evaluation
PHYSICAL THERAPY
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that may include videotape analysis. Corrective recommendations, such as strengthening, range-of-motion, or proprioceptive exercises; foot orthotics; or improved or modified
body mechanics, enhance a patient's abilities to continue
exercise indefinitely.
Muscle strength. An evaluator has multiple choices for
testing this component. Consideration must be given to the
muscle groups most important for the group being tested.
Testing can be done by using Cybex®* or isokinetic devices,
isotonic devices, isometric devices, tests done against an individual's body weight, or manual muscle testing. The best
approach may be to rule out pathological conditions first with
manual muscle tests and then to test specific muscle groups
that correlate with functional activities. Areas of the body to
be tested include the upper extremities, lower extremities,
abdominal muscles, and back extensor muscles. Explanatory
statements should emphasize the specificity of strength measurements. Testing procedures should be similar to the most
appropriate method of carrying out remedial exercises. For
example, in place of performing a timed, bent knee sit-up
with the knees held as a test of abdominal endurance, a more
appropriate test might be the absolute number of abdominal
curls performed by the patient with the legs over a chair. Care
must also be used in selecting one-maximum repetition tests
because of their injury potential.
Flexibility. Often, the evaluator administers the sit and
reach test and draws general conclusions from it as to total
body flexibility. Flexibility is specific to the muscle group
being tested. Comprehensive lower extremity testing may be
appropriate for athletes. Measurements can be made objectively by goniometer or estimated visually. The latter testing
can be graded as hypermobile (4), normal (3), tight (2), or
very tight (1). Comprehensive testing might include hamstring, gastrocnemius, soleus, quadriceps femoris, hip flexor,
hip adductor, low back, tensor fascia lata, hip external rotator,
and hip internal rotator muscles.17 Differentiation must be
made between capsular and muscle tightness.
Pulmonary function. Forced vital capacity and forced expiratory volume in one second (FEVi) are the most important
screening procedures. Another important test is FEV25-75.
Residual volume testing can be done if precise underwater
weighing body composition results are desired.
Blood chemistry. A lipid panel with determinations of total
cholesterol, high density lipoprotein (HDL), low density lipoprotein, very low density lipoprotein, total cholesterol to
HDL ratio, and triglycerides may be very important, especially for men who are over 40 years of age. Many other blood
chemistry panels can be done at relatively little expense.
Consultation
Consultation may include a description of the tests, individual specific results, a categorization of the results by comparison with similar age and sex groups, and a presentation
of an individualized exercise plan. The plan is based on the
history questionnaire, individual goals, and results of the
screening evaluation. Computerization of these results is possible and may enhance acceptability by those tested. The
computer also provides group summaries that would be help-
* Cybex, Div of Lumex, Inc, 2100 Smithtown Ave, Ronkonkoma, NY 11779.
ful to management. A consultation may be given individually
or in a group. Further comprehensive testing may be indicated
by the screening testing results. Referral may be made to other
health professionals.
Exercise recommendations should be given for cardiovascular endurance activities, strengthening, and flexibility. The
therapist should give specifics for frequency, duration, and
intensity for each type of exercise; progression; short- and
long-range goals; and appropriate recreational activities and
activities of daily living.
Exercise Performance
If we examine the types of programs that are provided at
this time, we see a great variation in application and style.
We can, however, basically classify all programs into four
categories: 1) home programs or individually carried-out programs; 2) company-sponsored programs that may include
partial payment of memberships in YMCAs or YWCAs,
racquetball centers, or health spas; 3) company-sponsored
programs outside of the work place (eg, softball program at a
county recreational facility or aerobic dancing at a nearby
gymnasium); and 4) company-sponsored and organized programs at in-house facilities. Each of these programs has specific advantages and can be used depending on company
resources and commitment. Company-sponsored programs
outside of the work environment relieve the company of some
administration and planning. The employer does have some
control over the content of the program and may choose a
specific program for a target health problem (eg, hypertension,
obesity, or diabetes). Company-sponsored in-house programs
offer greater potential for long-term adherence because the
employees have the greatest opportunity to participate in these
programs. An in-house program also gives the employer the
opportunity to research cost-effectiveness.
Successful company fitness programs have the following
characteristics10:
1. Top level management participates.
2. Dynamic professional leadership is employed or contracted.
3. The program emphasizes endurance exercise with adjunctive strengthening and flexibility programs and also
includes recreational activities and sports.
4. Participants join with a partner of similar ability at least
one time a week for exercise.
5. Performance agreements may be exchanged among the
partners.
6. Exercise logs are completed and turned in to the program
director monthly. Comments from the director are resubmitted to the participant.
7. Exercise clubs are formed such as bicycling, swimming,
and jogging.
8. Safe competition is built in for interested participants
after baseline level of fitness has been achieved.
9. A logo, T-shirts, and awards are used.
Progress Reassessment
Periodic reassessment is done to determine progress and
maintain motivation. Complete reevaluations may be done
on an annual basis with similar interim evaluations every two
to three months.
Volume 65 / Number 12, December 1985
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1843
SUMMARY
Preventive programs for business and industry are being
established with increasing frequency. Economic motivation,
either directly or indirectly, is the major reason for implementation. Personnel with many backgrounds have contributed
to these programs. Physical therapists can play a major role
because of their musculoskeletal expertise. Those with cardiopulmonary backgrounds in electrocardiography, cardiopulmonary pathology, and exercise physiology are even more
valuable to the programs.
REFERENCES
1. Baumann JR: Healthy, wealthy and wise. Management Focus 29:6,1982
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3. Johnston B, Blakney MG: Industrial health program: Alternative or obligation? Clinical Management in Physical Therapy 2(4):18-22,1982
4. Jacobs P, Chovil A: Economic evaluation of corporate medical programs.
J Occup Med 25:4, 1983
5. Levy R: Fitness fever, Everybody into the company gym. Dun's Review
Nov, 1980, pp 115-118
6. Bjurstrom LA: A program of heart disease intervention for public employees. J Occup Med 20:521-531, 1978
7. Shephard RJ, Corey P, Rinzlaird P, et al: The influence of an employee
fitness and lifestyle modification program upon medical care costs. Can J
Public Health 73:259, 1982
8. Cox M, Shephard RJ, Corey P: Influence of an employee programme upon
fitness, productivity and absenteeism. Ergonomics 24:10, 1981
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10. Cox MH: Fitness and lifestyle programs for business and industry: Problems in recruitment and retention. Journal of Cardiac Rehabilitation 4:136142,1985
11. Wright CL: Cost containment through health promotion programs. J Occup
Med 24:12, 1982
12. American College of Sports Medicine: Directory of Preventive and Rehabilitation Programs of Graduate Study, 1983
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Testing, ed 2. Philadelphia, PA, Lea & Febiger, 1980
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Chapel Hill, NC, Cardiopulmonary Specialty Council, American Board of
Physical Therapy Specialties, 1984
15. Healthfinder: Health risk appraisals. Washington, DC, Office of Disease
Prevention and Health Promotion, Public Health Service, US Dept of Health
and Human Services, June 1985 (Copies may be obtained from National
Health Information Clearing House, PO Box 1133, Washington, DC 20013)
16. Pollack M, Wilmore J, Fox S: Exercise in Health and Disease. Philadelphia,
PA, WB Saunders Co, 1984
17. Guidelines for Pre-Season Athletic Participation Evaluation, ed 2. Alexandria, VA, Sports Physical Therapy Section, American Physical Therapy
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Manuscript Reviewers
The Associate Editors and the Editor of PHYSICAL THERAPY wish to thank the following
individuals for their dedicated and valuable services a s manuscript reviewers during 1985.
Diane Aitken
Louis R. Amundsen, PhD
Rosemary Archambault
Joseph Asturias
Susan Attermeier
Jean Barr, PhD
John Barr
Patricia Belson
Sue Bemis
Donna Bernhardt
Stuart A. Binder-Macleod
Richard W. Bohannon
Barbara Bourbon
Jeri Boyd-Walton
Suzann K. Campbell, PhD
Janet M. Caston
Polly Cerasoli
Kay Cerny
Catherine M. Certo
Shelby Clayson
Tali A. Conine, HSD
Barbara H. Connolly, EdD
Janet Cookson
Mark Cornwall
Jane Coryell, PhD
Rebecca L. Craik, PhD
Linda Crane
Charles L. Curry
Jerome V. Danoff, PhD
Carol M. Davis, EdD
Jody Delehanty
Robert H. Deusinger
Pam W. Duncan
Jeffrey Dwyer
John L. Echternach, EdD
Sally C. Edelsberg
Joan E. Edelstein
Susan Effgen
Corinne C. Ellingham
Carolyn Erickson
Betsy J. Fallon
Francis Finney
Joan Flynn
Russell A. Foley
Maj. Ronald J. Franklin
Richard J. Gajdosik
Meryl Roth Gersh
Joan Gertz
Diana N. Goldstein
Marilyn Gossman, PhD
Maureen Gribben
Andrew A. Guccione
Susan Haberkorn
Steve Haley, PhD
Willy E. Hammon III
Susan Harris, PhD
Susan J. Herdman, PhD
Jane Hill, PhD
Fay B. Horak, PhD
Bette Horstman
Damien Howell
D. LaVonne Jaeger
Gail M. Jensen
Geneva Johnson, PhD
Colleen M. Kigin
Karen Kirkman
Harry G. Knecht, EdD
Marie Louise Koch
Rhonda Kotarinos
David Krebs
Carl Kukulka, PhD
Nick Laubenthal
Don Lehmkuhl, PhD
Carole B. Lewis, PhD
Elizabeth H. Littell, PhD
Rosalie Lopopolo
Joyce MacKinnon
Jeffrey Mannheimer
Winifred W. Mauser
Bella J. May, EdD
Claire P. McCarthy
John Medeiros, PhD
Sue Michlovitz
Scott D. Minor
Ruth U. Mitchell, PhD
Mike Mueller
Rose Sgarlat Myers, PhD
Roger M. Nelson, PhD
Roberta A. Newton, PhD
Garvice Nicholson
David H. Nielsen, PhD
Arthur J. Nitz, PhD
Michael Nolan, PhD
Barbara Norton
Rex Nutt
Carol A. Oatis, PhD
Linda O'Connor
Nancy Patton, PhD
Leslie Gross Portney
Mary B. Proctor
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Ruth B. Purtilo, PhD
Lt. William S. Quillen
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Mary Rodgers
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PHYSICAL THERAPY
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Primary Prevention Programs for Business and
Industry: Role of Physical Therapists
Robert R Huhn and Robert V Volski
PHYS THER. 1985; 65:1840-1844.
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