Sustainable Healthcare and Environmental Physiotherapy

Introduction[edit | edit source]

UN Sustainable Development Goals

Climate change and sustainability are at the forefront of current events.  The UK hosted the 26th UN Climate Change Conference of the Parties (COP26) in Glasgow in 2021 with the aim to accelerate action toward the goals of the Paris Agreement and the UN Framework Convention on Climate Change.[1]

  • According to the UN, we are experiencing accelerated global warming due to human activities, primarily the burning of fossil fuels, that generate greenhouse gas emissions. 
  • Increased concentration of greenhouse gases such as carbon dioxide and methane in our atmosphere insulates the earth, trapping the sun’s heat and raising average global temperatures.[2] Click here to learn more about climate change.

The UN Agenda 2030 Sustainable Development Goals (SDG) call for the “mobilisation of all available resources, participation of all countries, all stakeholders and all people” to work toward more sustainable futures. For healthcare professions, including physiotherapists, this is a call for the inclusion of sustainability considerations into daily routines and practices.[3]

Sustainable Healthcare[edit | edit source]

“A system that improves, maintains, or restores health while minimizing negative impacts on the environment and leveraging opportunities to restore and improve it and to benefit the health and well-being of current and future generations.” -WHO definition of sustainable healthcare

It is the role of the practitioner to do the following when providing sustainable healthcare:

  • Prescribe therapeutic or diagnostic interventions while balancing environmental health while providing needed care for an individual’s health.
  • Gauge if an intervention is sustainable or not by measuring its carbon footprint.[4]

Healthcare's Carbon Footprint[edit | edit source]

According to the UN, a carbon footprint is determined by the amount of carbon-containing greenhouse gases (GHG), most notably carbon dioxide and methane, released into the environment by an activity, process, individual, or group, usually expressed as the equivalent in kilograms of carbon dioxide. GHG can be emitted through the burning of fossil fuels, land clearance and the production and consumption of food, manufactured goods, materials, wood, roads, buildings, transportation and other services.[2]

What exactly is a carbon footprint? The following 2 minute video gives a simple explanation.


Sources of Healthcare’s Carbon Footprint[edit | edit source]

  1. Direct emissions
    • Energy consumption: use of electricity in hospitals and clinics, to power diagnostic equipment
    • Transportation: of a patient via ambulance or helicopter, of medical equipment, linens, pharmaceuticals, etc.
    • Product manufacture: making of all the products needed in healthcare.
    • Product use and disposal: food preparation in hospitals, surgical procedures, monitoring devices used during a patient’s hospital stay or outpatient procedure. Disposal of medical waste either into landfills or incinerators; each has a carbon price tag of its own.
  2. Indirect emissions: from electricity, steam, cooling and heating systems[4]

How are an organisations' GHG emissions tracked and measured? This 5 minute video explains how this is done in the business world but the information can be applied to healthcare.


Threats to Sustainability by Healthcare[edit | edit source]

  1. Pollution caused by plastic waste disposal
  2. Inadequate biomedical waste disposal, especially when it reaches our waterways
  3. Excessive use of pharmaceuticals and their polluting effect on our aquatic environments by means of sewage water[4]

Physiotherapy as a Sustainable Alternative[edit | edit source]

Physiotherapy is unique in healthcare systems; it uses patient communication, palpation, physical special tests, and movement assessment for impairment diagnosis and treatment. Physiotherapy relies less on the use of diagnostic testing or energy-consuming equipment and its associated carbon footprint.[4]

To illustrate how physiotherapy can be a successful sustainable alternative to current health systems, we will examine two topics in greater detail: how pre-operative physiotherapy can reduce the carbon footprint of hospitals, and how physiotherapy can be an alternative to Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) for pain management.

Hospital’s Carbon Footprint and Pre-operative Physiotherapy[edit | edit source]

Emerging studies suggest that the global healthcare system has a carbon footprint that is about 4.4% of the global net GHG emissions, which is up to two gigatons of carbon dioxide.[4] A 2020 study by Karliner et al stated that “if the global health care were a country, it would be the fifth-largest emitter of greenhouse gas emissions of the world.”[7]

How much is a ton of carbon dioxide? How are GHG emissions calculated? Watch this less than 2 minute video to see an example of how this is done in Canada:


A hospital’s basic infrastructure can create a large carbon footprint. This infrastructure includes power and durable medical goods used every day and include:

  • Electricity: used to power everything from basic needs such as lighting, computers, cooling and heating, to more complex medical devices and monitoring systems.
  • Medical diagnostics: includes medical equipment such as imaging devices. The carbon footprint of these devices includes the power to run them, the energy and resources needed to build and manufacture them, and the sometimes global transportation to deliver them to the hospital.
  • Surgical procedures: includes the electricity to run the suite and instrumentation and diagnostics, the autoclave to prepare the surgical setup, the footprint of all the single-use sterile supplies, and the footprint of transporting all the surgical and support staff.
  • Patient’s postoperative hospital stay: includes all the electricity needed to run the hospital and monitoring equipment, prepare meals, launder linens, transport staff.[4]

Considering the existing literature, it is important to consider the potential of preoperative physiotherapy in reducing hospitals' carbon footprint. Even with the advent of renewable resources, such as solar energy, hospitals’ high demand for energy will keep them dependent on fossil fuel consumption, upping their carbon footprint. [9][10] Physiotherapy can be used to shorten a patient’s hospital length of stay (LOS) by participating in preoperative therapy interventions for planned surgeries. Preoperative physiotherapy aids in early recovery, therefore shorter hospital stays. A shorter LOS will decrease a patient’s overall carbon footprint while in the hospital. Examples from the literature include:

  1. The use of preoperative multidisciplinary rehabilitation to improve a patient’s functional capacity, provide education in-hospital expectations, and early discharge planning has been shown to reduce a hospital LOS following a knee or hip arthroplasty from 10.5 to 6.5 days.[11]
  2. Patients participating in preoperative respiratory exercises under the guidance of a physiotherapist were found to have fewer respiratory complications and had an overall shorter LOS, 9.6±3.2 days compared to 13±5 days, following a Coronary Artery Bypass Graft (CABG).[12]

NSAIDs and Physiotherapy Pain Management[edit | edit source]

NSAIDs are prescribed to treat mild to moderate pain. They are among the most commonly prescribed medications in the world because of their strong efficacy and low abuse potential.[13] The most commonly prescribed NSAIDs include diclofenac, ibuprofen, and naproxen, which are among the ten most persistent pharmacological pollutants, accounting for more than 15% of all pharmaceuticals detected in aquatic environments. As orally consumed pharmaceuticals, NSAIDS are ingested, metabolised, and excreted from the human body before arriving in sewage plants and eventually into rivers, lakes, and oceans. [4]

The following 4 minute video discusses how pharmaceuticals travel through the planet's water cycle, it is startling how often they can affect human's quality of life.


NSAIDs have toxic effects on a variety of aquatic life, including fish, molluscs, and crustaceans. These drugs disrupt the metabolic homeostasis of targeted animals, which in turn disrupt the greater ecosystem. NSAIDs induce oxidative stress in aquatic life which causes alterations in enzymatic activity and changes in gene transcription.

  • Diclofenac: modulates fish genes which affect the kidney’s ability to repair and regenerate, affects gill and liver function, alters feeding behaviour, and affects gametogenesis which limits the species ability to reproduce. Diclofenac also causes developmental disorders and deformities in fish.
  • Naproxen: affects antioxidant gene expression in the intestines of fish.
  • Ibuprofen: affects fish egg production and their ability to hatch.
  • Acetaminophen: has an immunosuppressive effect on fish immune systems.[4] [15]

Physiotherapy can be a sustainable alternative for pain management. It is possible to improve subjective complaints of pain without the use of NSAIDs with physiotherapy interventions. Oral NSAIDs are known to have a wide range of direct negative side-effects on human health, including increasing the risk of adverse events in the gastrointestinal tract (perforation, ulcers, bleeding), the cardiovascular system (myocardial infarction, heart failure, hypertension), liver and kidneys.[4]

NSAIDs’ limited pain reduction effects and their diverse negative effects on human, aquatic, and ecosystems health make evident the need for sustainable alternatives for reducing mild to moderate musculoskeletal pain. Though further research is needed in this regard, growing evidence is suggesting that physiotherapy is better tolerated and at least as effective as NSAIDs in the treatment of mild to moderate musculoskeletal pain for a variety of conditions.[4] The following physiotherapy treatment interventions have growing evidence to support their use in musculoskeletal pain management:

Conclusion[edit | edit source]

Everyday research is showing how interconnected all life on Earth is, and how human beings are altering our planet’s delicate balance through pollution and global warming. By working toward the UN’s SDGs it is possible to improve life on this planet for all living things. The healthcare system must work to decrease its carbon footprint by turning to renewable resources when able and improve patient care efficiency to decrease the need for hospital admission and average patient LOS. In addition, the healthcare system must re-evaluate its dependence on the use of pain medications for pain management, and turn to more sustainable options.  Physiotherapy can help meet both these needs. More research is needed to strengthen physiotherapy’s role as a sustainable alternative to NSAIDs.

Resources[edit | edit source]

Related articles:

Additional Viewing:

  • For deeper discussion on environmental physiotherapy, please view this webinar by Dr. Filip Maric, PT.[22]

References[edit | edit source]

  1. United Nations. UN Climate Change Conference UK 2021.  Available from: (accessed 15/11/2021).
  2. 2.0 2.1 United Nations. Global Issues, Climate Change.  Available from: (accessed 15/11/2021).
  3. Maric, F., Groven, K.S., Banerjee, S. & Dahl-Michelsen, T. (2021). Essentials for sustainable physiotherapy: Introducing environmental reasoning into physiotherapy clinical decision-making. Fysioterapeuten, 4/21.
  4. 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 4.09 4.10 Banerjee, S, Sustainable Healthcare. Sustainable Healthcare and Environmental Physiotherapy.  Plus. November 2021.
  5. Youtube. Simpleshow Explains the Carbon Footprint. Available from: (accessed 18/11/2021).
  6. Youtube. Scope of GHG emissions Explained. Available from: (accessed 20/11/2021).
  7. Karliner J, Slotterback S, Boyd R, Ashby B, Steele K, Wang J. Health care’s climate footprint: the health sector contribution and opportunities for action. European Journal of Public Health. 2020;30(Supplement_5).
  8. Youtube. How We Measure Greenhouse Gas Emissions. Available from: (accessed 19/11/2021).
  9. González González, A., García-Sanz-Calcedo, J., Salgado, D.R. A quantitative analysis of final energy consumption in hospitals in Spain. Sustainable Cities and Society, 2018;36: 169-175.
  10. Environmental Physiotherapy Association. Can pre-operative physiotherapy reduce the carbon footprint of hospitals?. Available from: (accessed 16/11/2021).
  11. Crowe, J., Henderson, J. Pre-Arthroplasty Rehabilitation is Effective in Reducing Hospital Stay. Canadian Journal of Occupational Therapy, 2003;70(2):88-96.
  12. Sobrinho, M.T., Guirado, G.N., Silva, M. Preoperative therapy restores ventilatory parameters and reduces length of stay in patients undergoing myocardial revascularization. Brazilian Journal of Cardiovascular Surgery, 2014;29(2), 221-228.
  13. Kim SY, Chang YJ, Cho HM, at al. Non-steroidal anti-inflammatory drugs for the common cold.  Cochrane Database Syst Rev. 9, CD006362. 2015
  14. Youtube. Safer Pharma | Pharmaceuticals in the environment. Available from: (accessed 20/11/2021).
  15. Świacka, K., Michnowska, A., Maculewicz, J., Caban, M., Smolarz, K., Toxic effects of NSAIDs in non-target species: a review from the perspective of the aquatic environment, Environmental Pollution, 2021;273.
  16. Devereaux M, Velanoski KQ, Pennings A, Elmaraghy A. Short-Term Effectiveness of Precut Kinesiology Tape Versus an NSAID as Adjuvant Treatment to Exercise for Subacromial Impingement: A Randomized Controlled Trial. Clin J Sport Med. 2016 Jan;26(1):24-32.
  17. Mansiz-Kaplan B, Pervane-Vural S, Celik O, Genc H. Comparison of the effects of using non-steroidal anti-inflammatory drugs with or without kinesio taping on the radial nerve in lateral epicondylitis: A randomized-single blind study, EXPLORE. 2021 July-August;17(4):327-333.
  18. Hayati M, Yazdi Z, Abbasi M. Comparison of Non-steroidal Anti-inflammatory Drugs and Knee Kinesio Taping in Early Osteoarthritis Pain: A Randomized Controlled Trial, Journal of Bodywork & Movement Therapies. 2019 July;23(3):666-670.
  19. Sanz D R, Solano F U, López D L, Corbalan I S, Morales C R, Lobo C C. Effectiveness of Median Nerve Neural Mobilization Versus Oral Ibuprofen Treatment in Subjects Who Suffer From Cervicobrachial Pain: a Randomized Clinical Trial. Archives of Medical Science. 2018;14(4):871-879.
  20. 20.0 20.1 20.2 20.3 Bendtsen L. Drug and Nondrug Treatment in Tension-type Headache. Therapeutic Advances in Neurological Disorders. 2009 May;2(3):155-61.
  21. 21.0 21.1 van Driel M, Anderson E, McGuire T, Stark R. Medication Overuse Headache: Strategies for Prevention and Treatment Using a Multidisciplinary Approach. Hong Kong Med J 2018;24:617–22.
  22. Youtube.Environmental Physiotherapy by Dr. Filip Maric. Available from: (accessed 19/11/2021).