EPIC Environmental physiotherapy in the clinic

Como tornar a sua clínica de fisioterapia mais ambientalmente sustentável

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On this page, you will find relevant literature, background information and further details expanding on the different action-points suggested on the EPIC poster: ‘How to make your physiotherapy clinic more environmentally sustainable’. Under each point you will find:

(1) Action points for the implementation of each individual point. All of the proposed measures are exemplary because there are always other options and significant inter/national, regional and local differences that will need to be accounted for and adjusted to. People’s living environments are also different and we recommend that everyone assesses which measures are most effective for their own living and working environment

(2) Reasons for why and how the suggested measures contribute to environmental sustainability

(3) Literature and pointers to reputable sources. Here, we consider authors who rely on recognised scientific knowledge and who can be proven to act independently (e.g. independently of companies or their interest groups) to be reputable sources. Commercial providers are not excluded in principle, as long as they work independently. In principle, despite the great care taken in our research, we cannot assume any liability for the correctness of the information provided by third parties. If in doubt, we hope you will research further yourself and inform us how we might improve what we are presenting here.

The ‘How to make your physiotherapy clinic more environmentally sustainable’ poster and the additional information provided on this page were developed as a collaboration between the Physiotherapists for Planetary Health organised under Health for Future in Germany and the Environmental Physiotherapy Association.

The examples and explanations we have collected here are meant to help you implement targeted measures in your practice (and private life) to improve the environmental sustainability of your physiotherapy clinic and practice. The need to address the current climate and ecological crises quickly and consistently requires action from all people, institutions and organisations, as outlined in the UN Agenda 2030 Sustainable Development Goals. Making physiotherapy more environmentally sustainable is critical for economic, social and environmental sustainability alike. To help us further develop and improve our EPIC posters and associated background information please see the information provided at the bottom of this page.

1. Assessing your emissions and potential to reduce them

At the beginning of the path to a sustainable, climate-neutral clinic is the analysis of its ecological footprint, that is, its status quo. Based on the identification of its current ecological footprint, potential savings can be identified that will come with an implementation of the following action points suggested here (2-8). In the first instance, we particular on the CO2 equivalent, or carbon footprint, a measure of the emissions from a product, person, company, or else, in which the various climate-damaging substances (e.g. methane, etc.) are converted to the damage potential of CO2.

 

Action points

To calculate the current emissions of your physiotherapy clinic you can use a variety of platforms, including for example:

  1. Carbon Footprint calculator by Carbon Footprint Ltd.
  2. Carbon footprint calculator by The Nature Conservancy
  3. World Wide Fund footprint calculator by WWF
  4. Ecological Footprint calculator by the Global Footprint Network

Rationale

With an analysis of the status quo of your clinic emissions, the following measures can be planned in a targeted and efficient manner (TARGET determination, “therapy goal”) and, above all, the results of the efforts can be proven (reassessment, TARGET-ACTUAL comparison). However, it is not entirely possible without emissions. The remaining emissions can be compensated with appropriate measures, like e.g. tree-planting schemes (50 trees = approximately 1 tonne CO2), rewetting of bogs and other wetlands, or industry certificates (e.g. https://www.compensators.org/).

Sources und additional information (Currently all in German. Get in touch and help us add English-language resources here!)

Three steps to calculate the CO2 emissions of your business: https://plant-values.de/3-schritte-zu-einer-co2-bilanz-im-unternehmen/8085/ 

Carbon footprint for business explained: https://dfge.de/carbon-footprint-fuer-unternehmen/

Additional CO2 calculator: https://utopia.de/ratgeber/co2-rechner-5-webseiten-mit-denen-du-deine-klimabilanz-errechnen-kannst/

2. Saving energy: electricity, water, heating

Saving energy also means saving money and is therefore also economically advantageous for your clinic. Measures for this can range from small changes (at the behavioural level) to larger changes (such as replacing an existing system with a more sustainable system). Finally, you can also optimise an existing system in order to achieve a reduction in emissions (the middle path, so to speak). One way or another, you can already achieve savings with some fairly small changes! An average household in Germany consumes energy in the form of around 71% heating, 15% hot water, and 14% other electricity and 71% space heating. In the following, we describe energy saving measures for clinics in these three main areas of electricity, water and heating.

 

Action points

Electricity

    • Daylight instead of artificial light
    • Switch off devices (e.g. PC, printer,…) instead of keeping them on standby mode
    • Invest in socket strips that can be switched off in the evening
    • Use energy efficient devices

Water

    • Be mindful of water consumption, especially hot water (the manufacture of other products, e.g. clothing, food also uses a lot of “invisible” water)

Heating

    • Ventilate the room vigorously 3-4 times a day for 5 minutes instead of keeping the windows open slightly all day

Rationale

Electricity: Although LED light bulbs can be more expensive, they last about 25 times longer than incandescent bulbs and use significantly less energy. Energy-efficient labels for electronic devices, such as the EU energy consumer label, provide information about energy consumption, among other things. For example, a refrigerator with energy efficiency class A+++ consumes around 100 kilowatt hours (kWh) less per year than a refrigerator with energy efficiency class A+, which is around 40kg less CO2/year.

Water: Hot water consumption requires the most CO2, because the water has to be heated first, which in turn consumes energy and can therefore be up to 4.5 times more expensive than cold water. You can reduce about 50% of the water consumption by using water saving shower heads. Flush volume regulators on toilets also lead to savings.

Heating: Often people overheat or forget to turn off the heating, so temperature control is useful. In German households, 500kg CO2 (about 150 Euros) can be saved per year for heating alone! Natural gas or district heating is more climate-friendly than oil heating. But even better are ‘heating communities’ with heat pumps and the use of solar thermal or geothermal energy.

 

Sources and additional information

LED vs. standard light bulb (point 16): https://news.climate.columbia.edu/2018/12/27/35-ways-reduce-carbon-footprint/

EU-Energy labels

How much electricity does my refrigerator use? https://www.directenergy.com/learning-center/how-much-electricity-does-my-refrigerator-use

Water-saving for businesses: https://www.waterwise.org.uk/save-water/ 

How much water does an average UK household use per day: https://www.ccwater.org.uk/households/using-water-wisely/averagewateruse/ 

Heating properly and environmentally-friendly heating systems: https://friendsoftheearth.uk/climate/eco-heating-what-are-options 

    3. Reducing waste: saving, reusing and recycling

    Similar to the process for reducing CO2 emissions, it is advisable to first determine where savings in waste production are feasible. The next step would then consist in getting an overview of which resources could be used more often, for example through upcycling or second-hand. If you do end up producing waste, make sure you separate your waste and dispose of hazardous waste correctly. The following lists provide some examples and should be supplemented individually by each clinic.

     

    Action points

    Reduce

      • Plastics should be avoided wherever possible, both in products and packaging. Saving paper (e.g. through digitalisation) also helps the environment, simplifies processes and saves money. For more information, see points 7 and 8.

    Reuse

      • Reusable instead of disposable and/or refill packs
      • Buy recycled bottles for employees or drink tap water where possible
      • Use washable protective gowns when treating high-risk patients
      • Patients bring their own towels/sheets and are advised to use them more often
      • Alternatives to paper towels: electric hand dryers, recycled paper towels, cloth towel rolls in the towel dispenser or, best of all, jet streams
      • Use paper that has already been printed (while respecting data protection) as scrap paper
      • Use glasses instead of paper cups in the waiting room
      • Laminate, sign, scan, wipe, and reuse your privacy policy and similar documentation

    Recycle

      • Provide several labeled bins for separating plastic, paper and general waste, as well as a separate collection point for hazardous waste such as batteries or light bulbs.

    Rationale

    The German testing agency Brunnen eG (2008) showed that returnable PET bottles, closely followed by returnable glass bottles, are more environmentally friendly than disposable PET bottles.

    Larger refills mean you need fewer disposables while saving money.

    In 2014, the German Environment Agency conducted a study comparing hand drying systems from an ecological perspective. The result showed that jet streams show the lowest impact on the environment.

    By correctly separating waste, materials can be better recycled and waste reduced. Glass and paper are easier to recycle than plastic. For example, magazines, office supplies, cardboard boxes, sanitary paper, etc. could be produced from recycled paper. Plastic waste can only be recycled by around 16% in Germany, and even less worldwide. Plastic waste in particular should therefore be reduced.

     

    Sources and additional information

    Reduce, Reuse, Recycle: The Three R’s: https://www.greenandgrowing.org/reduce-reuse-recycle-information/

    Plastic waste worldwide – statistics & facts: https://www.statista.com/topics/5401/global-plastic-waste/#dossierKeyfigures

    74 recycling facts + statistics for 2021: https://www.rts.com/blog/recycling-facts-statistics/

    4. Environmentally friendly transport: commutes, home visits, professional education, conferences

    Using the example of Germany, the transport sector contributes around 20% (2019) to greenhouse gas emissions. Mobility still largely takes place with one’s own car.

    • Only 11% of trips in Germany are made by bike
    • On average, bicycles are used for only 7.4% of journeys in Europe
    • 57% of journeys in Germany are made by car
    • Up to 50% of car journeys in Germany are shorter than 5 km and are therefore within a range that can often be reached fastest by bicycle or on foot.

    Another argument for environmentally friendly mobility is the associated reduction in noise and air pollution. Both of these are environmental risk factors for cardiopulmonary mortality (contribution to 43,500 premature deaths in Germany in 2013). Adding to the other points explicated on this page, an immediate and drastic reduction in greenhouse gas emissions in traffic is necessary to protect public health despite existing environmental and climate changes.

     

    Action points

    • Promotion of active mobility for the way to work and for home visits, for example, via
    • Employee incentives such as subsidies for public transport or bicycle wear-and-tear, company bicycles
    • Cycling together for the climate as a team-building activity (see e.g. projekt.klimaretter-lebensretter.de)
    • Motivating patients to use active transport in everyday life and on the way to the practice

     

    Rationale

    Active transportation modes like cycling and walking can, in combination with the use of public transport, save millions of tons of CO2. Regular outdoor activity, for example in the form of endurance training, has a cardioprotective effect and increases general health. Cycling increases life expectancy by 3-14 months and contributes to mental health. In this manner, active transport could help reduce premature mortality from chronic diseases (so-called common diseases) such as cardiovascular diseases, type II diabetes mellitus, osteoporosis or obesity while reducing noise and air pollution caused by traffic.

    Air pollution and particulate matter are classified as carcinogenic and the leading risk factor for heart and lung diseases worldwide: Dust particles can penetrate the respiratory tract and bloodstream and cause changes in the activation of the autonomic nervous system, the dampening of endothelial vasomotor function as well as systemic inflammation and oxidative stress trigger. Depending on short-term (several hours to days) or long-term exposure (more than one day), there is an increased risk of bronchitis symptoms in children, chronic bronchitis in adults, asthma attacks and cardiovascular problems. In the worst case, a hospital admission to the intensive care unit could follow.

     

    Sources and additional information

    Global Mobility Report 2017: https://openknowledge.worldbank.org/bitstream/handle/10986/28542/120500.pdf?sequence=6

    5. Sustainable work clothes, clinic and therapy equipment

    For new purchases, you should give priority to fair-trade products or choose companies that produce in an environmentally friendly manner. We recommend regional shopping to reduce transport distances.

     

    Action points

    • Look for sustainable product labels and seals when shopping.
    • Agree to wear plastic-free clothing as a team (instead of so-called functional clothing).
    • Don’t buy new tennis balls, but ask sports clubs for old/playful balls (they usually give them to you as a gift).
    • As much as possible, use therapy tools such as your own body, everyday objects or the environment
    • Look for durable products and products with recycled plastic or more sustainable raw materials (e.g. cork and wood) 
    • When choosing end-use devices, you can also consider a number of things (see point 8). Here you can also decide to buy a second-hand device.

    Rationale

    Since 2014, the Partnership for Sustainable Textiles has been pursuing the goal of improving textile production in terms of both social and ecological conditions. The German government is working together with companies, non-governmental organisations and trade unions to achieve sustainable production. This means production without child labour, without exploitation of workers and without the use of environmentally harmful chemicals.

    Product labels and seals have been developed to identify sustainable textiles, for example:

    If you work more without therapy equipment, it enables your patients to do exercises at home without having to buy equipment (e.g. elastic bands).

    In addition to the environmental aspect, furniture and furnishings have an influence on the indoor air and thus also on the health of employees and patients.  Symptoms such as tiredness, fatigue and headaches or eye irritation can occur as a result of insufficient indoor air quality. In Germany, there is a special “Golden M” seal for furniture. Furniture with this seal is subject to quality assurance for health compatibility and must be safe, stable and well-made: www.dgm-moebel.de/das-goldene-m.html 

    Sources and additional information (Currently all in German. Get in touch and help us add English-language resources here!)

    6. Working with partners in sustainability: insurance companies, banks, electricity providers, and others

    Because of the immense role of the energy sector and other large industries in today’s social and environmental crises, and their links to the banking, insurance and similar sectors, divestment and working with partners in sustainability is a critical measure to make physiotherapy clinics more sustainable.

    Action points

    • Select electricity suppliers according to sustainability criteria
    • Work with insurance companies and banks that prioritise sustainability

    Rationale

    Energy providers and other partners

    In addition to insurance companies and banks, there are other partners to consider to increase sustainability. These partners can be, for example, billing services, tax consultants, suppliers or electricity providers. In order to also check new partners or companies for sustainability, it is generally helpful to find out whether the company takes into account the “three pillars” of sustainability (ecology + social + economic) in their corporate policies and culture or whether its corporate management is oriented towards the 17 UN Sustainable Development Goals. Example green-electricity: The use of green electricity in hospitals can save up to 72% of emissions. As the term “green electricity” is not protected, it is recommended to use electricity providers with certified labels (Eco Top Ten, Ok-Power-Label, Grüner-Strom-Label) or to carry out an assessment via Robin Wood/ wirklich-grün.de (in Germany) or at green-e.org (international).

    Sustainable insurance companies and banking

    Sustainable insurance companies and banks are characterised by the fact that they invest their capital according to ESG (Environmental Social Governance) criteria. This means that they invest their money exclusively in ethically and ecologically acceptable companies and thus promote sustainable development and social projects. They therefore do not invest in projects or companies that, for example, put the brakes on the energy transition, violate human rights, destroy the environment and carry out animal testing or genetic engineering. However, it should be noted that each bank has its own exclusion criteria for investments. These can be found on the respective company’s website. Examples of sustainable banks are GLS Bank, EthikBank, Triodos Bank and Tomorrow bank.

    Sources und additional information

    Green-e. (o.J). Find Green-e certified Energy providers. https://www.green-e.org/certified-resources 

    7. Being conscious around paper use

    Reducing paper use is still an important environmental measure for a variety of reasons, including the conservation of forests and reducing the overall footprint of the global paper industry. To get a general idea, it is worth noting that 10 sheets of plain paper consume 100g wood, 2.6 l water, 0.5 kW/h electricity and produce 100g CO2, and 10 sheets of recycled paper: 100g waste paper, 1.0 l water, 0.2 kW/h electricity, 80g CO2 (source: papiernetz.de)

     

    Action points

    Paper can be saved in many places. Basically, it’s simple: Whenever you see or pick up paper, ask yourself: “Is this necessary?” If there is a (more ecological) alternative: no! Today, an alternative can often lie in digital solutions. But here, too, caution is advised (see point 8 below). Some more specific ideas might include the following:

    • Digital appointment organisation (letting patients book their own appointments online)
    • Digital administration (no more paper and cardboard folders)
    • Only print out what is absolutely necessary
    • Use recycled paper (also in the toilet), avoid kitchen rolls (use rags)
    • Use paper printed on one side as scratch paper
    • Digital patient files
    • Use hot-air dryers instead of paper towels
    • More than 95% of flyers, brochures and direct mail end up in the rubbish unread. Use digital media for customer contact instead.
    • Use letter post only when absolutely necessary. Look for digital alternatives (e.g. contact with patients, business partners, doctors), including by e-mail or messenger.
    • Glasses and ceramics instead of cardboard dishes

    Rationale

    A paper-free practice might be the final goal, even if it will take a moment to get there. Ideas for this have been around for a long time and they even make the practice more efficient, because paper use often consumes more time than other solutions (DtschÄrztebl, 2011). If, for example, the digital appointment planner is linked to the patient’s email address, the patient automatically receives an appointment reminder by email (or alternatively on the mobile phone). Every online appointment booking at a hairdresser works like this. Why not let the patients book their appointments online themselves? Many doctors’ surgeries and some physio practices already offer this and non-digital solutions can still be offered to those patients that prefer not to use digital means.

    Sources and additional information (Currently all in German. Get in touch and help us add English-language resources here!)

    8. Digitalization: Sustainable use of hardware, software, digital patient files and communication

    Digitalisation offers opportunities and risks for the environment. It can help to conserve resources and make processes more effective and/or efficient. But digitalisation also consumes resources (e.g. rare earth metals), promotes exploitation and social inequality (e.g. working conditions in African, Asian and South American mines), pollutes the environment during production, operation and disposal and has a significant CO2-equivalent footprint.

     

    Action points

    1. Digital management of patient data and communication with patients and partners
    2. Sustainable hardware and software
    3. Sustainable browsers and search engines
    4. Sustainable Webhosting

    Rationale

    1. Digital management of patient data and communication with patients and partners

    An initially internal digital patient file for patient data, findings and therapy documentation as well as other documents (MRIs, therapy reports, etc.) saves space because filing cabinets are no longer needed, and is practical because everything can be found quickly, is easy to handle and can be linked to billing tools. This saves paper and “paperwork”.

    There are numerous providers of digital solutions that can easily be found via an internet search. Unfortunately, we could not find any information on sustainability in product development and operation during our research. Asking your own provider specifically can also make a difference.

    It is best if the patient data is backed up directly on a secure server at the facility and not in a cloud, e.g. at the provider as local storage is much more energy-efficient.

    In Germany, an electronic patient record (ePA) functions as an inter-institutional (external) interface for patient care according to the Appointment Care and Service Act (TVSG). What this means for physiotherapy has been summarised by the professional association VDB: https://vdb-physio.de/aus-der-therapie-und-praxis/die-elektronische-patientenakte/. Wherever possible, there should be a switch to digital communication. Digital solutions (e.g. mailing lists) are also available today for customer contact for marketing purposes.

    But be aware! Digital communication also pollutes the environment: e.g. between 4 and 50g CO2 per e-mail depending on the servers used, amount of data attachments, logos etc. (see e.g. https://oliverbrux.de/blog/der-co2-fussabdruck-von-e-mails). In general, the core principle applies here as well: Reducing overall use is the first choice! Everything that runs through the internet has an ecological footprint (e.g. clouds, streaming, mails, banking transactions, PC etc. use in general). The higher the data volume and security standards, the more energy is consumed.

    2. Sustainable hardware and software

    This is where it gets a bit difficult. Digital end devices consist of countless components that originate around the globe from the extraction of raw materials to final production, making sustainability almost impossible to control.

    Software also consumes a lot of energy during production, updates and use. Here, too, it is worthwhile to be smart, because there are often several software providers with solutions for one application.

    Despite the complexity, there are a few alternatives. For smartphones, you might want to look at options like Fairphone or Shiftphone. Second-hand devices might also be an option. These devices can be well refurbished, upgraded and, above all, cheap and they have a guarantee, thus saving money, resources, energy and waste at the same time. (e.g. www.refurbed.de/)

    3. Sustainable browsers and search engines

    Even when you search the internet, you can do something good for the environment, because every search query consumes considerable energy, as thousands of servers are active to deliver the results. The search results of search engines committed to sustainability are no worse than when you search on Google, and they often handle your personal data more responsibly. Examples for sustainable browsing:

    • Ecosia (green electricity, tree planting for CO2 compensation)
    • Ekoru (uses only hydroelectric energy and supports ocean clean-up)
    • Gexsi (green electricity, promotes social investments)
    • Lilo (climate compensation and support for social projects – freely selectable for customers).

    4. Sustainable Webhosting

    Having your own homepage can have a considerable ecological footprint but there is another way. There are sustainable providers who, for example, use the immense waste heat of the servers to heat water or to heat offices, flats, greenhouses or to recover electricity and also use green electricity and offset their own footprint. You can simply move with your homepage, and it’s much easier than moving to a new flat or physical clinic. To estimate the carbon emissions of your website you could check out https://www.websitecarbon.com/ or https://www.wholegraindigital.com/digitaldeclutter/.

    And finally

    Reducing your digital footprint not only protects your privacy and that of your family, friends, acquaintances, colleagues, etc., but also protects the environment. Data basically consumes electricity (for generation, storage, backup, transport). The less data you have “in the network”, the better. The most important thing here is to critically question your own digital consumption behaviour. And often it is a lack of knowledge about alternatives or how the internet works. There are quite a few things to become more sustainable in this area. For example, (a) allowing only the necessary cookies from websites saves energy. Every cookie sets servers in motion that consume electricity, (b) you can also use offline maps on your navigation system. Live routing, e.g. with Google Maps, consumes a lot of energy, (c) download instead of streaming: Streaming consumes a lot of energy!

    Sources and additional information (Currently all in German. Get in touch and help us add English-language resources here!)

    Have you tried any of these EPIC possibilities yet?

    Tell us about your experiences with making your physiotherapy clinic more sustainable!

    Because environmental physiotherapy is still a very young field of research, education, and practice, there is a lot that still needs to be tested, trialled and further developed. For this reason, we hope that you will support the ongoing refinement of our EPIC posters and other resources for clinical practice throughout the years. Several kinds of support are needed virtually immediately at this stage:

    1. We are in need of translations and contextual adaptations of existing posters and support materials into as many languages as possible. If you can volunteer your time and efforts for this purpose, please get in touch using the contact form below.

    2. We would appreciate your feedback on the existing posters to help us add new suggestions, improve existing ones, and further strengthen the evidence-base to support what we are suggesting. Let us know which suggestions make sense, which are difficult to put into practice, how we can better adjust the posters and other recommendations to your specific context and anything else that comes to mind using the contact form below.

    3. We are looking for a team of volunteers keen on creating another thematic EPIC poster. If this sounds like you, please get in touch using the contact form below.

    Thanks for your support!  🌍 🌏 🌎 🚑  #EnviroPT

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