By Amish Patel, MD, MBA

Founder & CEO, Verity XR | Board-Certified Anesthesiologist and Pain Management Physician

Musculoskeletal conditions are often discussed as a healthcare-cost problem.

For self-insured employers, that description is incomplete.

A musculoskeletal condition can affect medical spending, but it can also affect whether an employee comes to work, how effectively that employee functions at work, how long disability lasts, and how quickly someone can return to meaningful activity after an injury or procedure.

That makes musculoskeletal care both a healthcare issue and a workforce issue.

Over the course of my career in pain medicine, I have treated thousands of patients with back pain, neck pain, joint disorders and other musculoskeletal conditions. One lesson has become increasingly clear to me:

Providing access to treatment is not the same as achieving recovery.

A patient can receive appropriate imaging, medication, injections, surgery and physical therapy, but recovery still depends heavily on what that individual does between those encounters.

They have to participate.

They have to move.

And they have to remain engaged long enough for rehabilitation to have an opportunity to work.

For self-insured employers searching for ways to improve the value of musculoskeletal care, I believe this represents an important and underappreciated opportunity.

The Employer Has a Different Economic Perspective

Traditional healthcare reimbursement tends to focus on individual encounters and services.

A self-insured employer can see a much broader picture.

The employer may ultimately bear the financial consequences of:

• medical and pharmacy spending;
• physical therapy;
• imaging and procedures;
• short- and long-term disability;
• absenteeism;
• lost work capacity;
• reduced productivity;
• workplace accommodations; and
• prolonged recovery.

That changes the definition of value.

A treatment that costs somewhat more but helps an employee recover function and return to work sooner may potentially create greater overall value than a less expensive intervention that does not meaningfully change the recovery trajectory.

This is one reason occupational medicine has historically focused not simply on pain, but on function and work participation.

Research supports that broader perspective.

A systematic review of return-to-work programs found that among workers with musculoskeletal disorders, rehabilitation interventions were associated with significantly earlier return to work than usual care. Across the studies included in that analysis, the pooled estimate suggested approximately 41 fewer days before return to work, with a hazard ratio for return to work of 1.58.

That does not mean any specific rehabilitation program will reproduce those results. It demonstrates that rehabilitation strategy can materially influence work participation.

The Cost of Musculoskeletal Problems Extends Beyond Claims

Health-related productivity losses are increasingly recognized as an important economic burden.

The CDC’s National Center for Health Statistics specifically tracks missed workdays caused by illness, injury and disability, reflecting the importance of absenteeism as a population health and workforce measure.

Musculoskeletal conditions are particularly relevant because they often affect activities essential to work:

• lifting;
• standing;
• sitting;
• walking;
• reaching;
• bending;
• carrying;
• and repetitive movement.

The consequences can therefore persist even after the acute medical event has passed.

For an employer, the important question isn’t simply:

“Did the employee receive care?”

It is:

“Did the employee recover enough function to resume normal life and work?”

Rehabilitation Is Essential—but Participation Is Not Guaranteed

Exercise and active rehabilitation are fundamental components of conservative musculoskeletal care.

Yet prescribing exercise does not guarantee that patients perform it.

A 2022 systematic review of randomized trials examining digital interventions added to home-exercise rehabilitation included 10 trials and 1,117 participants. Seven of the ten studies reported significantly greater adherence in the groups receiving an additional digital intervention. The authors concluded that digital interventions can likely improve exercise adherence in the short term, although longer-term effects remain less certain.

A separate systematic review and meta-analysis focused specifically on musculoskeletal conditions included 11 randomized trials and 1,144 participants. At intermediate follow-up, digital rehabilitation produced a standardized mean difference of 0.53 in adherence to prescribed exercise compared with nondigital rehabilitation. The benefit was not clearly maintained at long-term follow-up.

That nuance matters.

The evidence does not tell us that simply adding technology solves adherence.

It tells us that adherence is modifiable—and that digital delivery can influence it.

That is a very different, and much more useful, conclusion.

Why Patients Stop Participating

• Patients rarely stop rehabilitation because they consciously decide that recovery no longer matters.
• The barriers are usually more complex.
• Pain makes movement unpleasant.
• Fear creates avoidance.
• Exercises become repetitive.
• Progress is difficult to see.
• Patients become frustrated.
• Work and family responsibilities compete for time.

Some patients also develop beliefs that can unintentionally interfere with recovery:

If it hurts, I must be damaging myself.

I should wait until all of the pain disappears before I move.

My back is fragile.

I’m afraid I’ll reinjure myself.

This is especially important in persistent musculoskeletal pain.

The fear-avoidance model describes how pain-related fear can lead to avoidance, reduced activity and disability in susceptible patients. This relationship is one reason modern rehabilitation increasingly considers behavioral factors alongside physical impairment.

For employers, that matters because a purely transactional model—authorize PT visits and wait for recovery—may fail to address why some employees disengage.

Engagement Is the Link Between Access and Outcomes

I think of rehabilitation as a chain:

Access → Engagement → Participation → Repeated Movement → Functional Recovery

Healthcare spends substantial resources on the first step.

We make sure patients can see physicians and therapists.

But if engagement breaks down, the rest of the chain becomes much less reliable.

This is why I believe engagement deserves to become an explicit outcome in employer-sponsored musculoskeletal programs.

Employers should ask:

• How many prescribed sessions were completed?
• How frequently did the employee participate?
• How consistently was home rehabilitation performed?
• Did participation decline over time?
• Did the employee become more confident moving?
• Was objective function improving?

Those are actionable measures.

Return to Work Is Not Simply a Medical Outcome

The occupational-health literature also demonstrates that return to work is influenced by more than treatment of the affected body part.

An earlier systematic review of workplace-based return-to-work interventions found strong evidence that work disability duration was reduced when programs included workplace accommodations and communication between healthcare providers and the workplace. It found moderate evidence supporting strategies such as early employer contact, ergonomic worksite visits and return-to-work coordination.

Another systematic review and meta-analysis of early interventions for workers with regional musculoskeletal pain included 20 randomized trials and 16,319 participants. Programs using a stepped-care approach improved return to work at 12 months, with a pooled hazard ratio of 1.29, although effects across intervention types were heterogeneous.

The implication for employers is important:

Recovery is an ecosystem.

Clinical care matters.

Rehabilitation matters.

The workplace matters.

Behavior matters.

And employee participation matters.

There Can Be Significant Economic Value—But ROI Should Be Measured, Not Assumed

Employers understandably want to know whether interventions save money.

There are examples suggesting substantial potential.

In one prospective controlled workplace intervention involving employees absent because of musculoskeletal conditions, the intervention group averaged 144.9 sick days per person over 12 months compared with 197.9 days in the reference group. Employees receiving the intervention were also more likely to return to work, with an odds ratio of 2.5. The study reported direct savings of $1,195 per case and a benefit-to-cost ratio of 6.8.

Those findings are interesting, but they should not be generalized into a promise that every musculoskeletal program produces a 6.8× return.

In fact, a much more recent 2026 systematic review and meta-analysis examined occupational-health interventions across 68 studies in eight industries. Among the studies suitable for quantitative pooling, the estimated reduction in sick days was not statistically significant, and the pooled ROI estimate of 1.92 also had substantial statistical uncertainty.

That is precisely why I believe employer programs should be designed around measurement rather than marketing claims.

The right question isn’t:

“Does digital MSK care have ROI?”

It is:

“Can this specific intervention improve measurable outcomes in this specific workforce at a cost that creates value?”

That requires data.

What Should Employers Measure?

For a self-insured employer evaluating a new rehabilitation program, I would divide outcomes into four levels.

1. Engagement

This is the earliest and easiest signal.

Measure:

• activation rate;
• sessions completed;
• sessions per week;
• completion of prescribed programs;
• duration of participation;
• dropout;
• home-exercise adherence; and
• employee satisfaction.

If employees do not engage, downstream outcomes are unlikely to follow.

2. Functional Recovery

Measure what employees can actually do.

Depending on the condition, this could include:

• range of motion;
• walking tolerance;
• lifting capacity;
• functional outcome scores;
• pain interference;
• fear avoidance;
• movement confidence; and
• return to normal activity.

3. Work Outcomes

For employers, these are particularly important:

• days absent;
• short-term disability duration;
• modified-duty duration;return-to-work timing;
• recurrence;
• presenteeism; and
• sustained return to full duty.

4. Economic Outcomes

Only after those outcomes are understood should the organization calculate:

• healthcare utilization;
• medical spending;
• disability payments;
• productivity effects;
• cost per participant;
• cost per successful return to work; and
• overall program ROI.

That sequence prevents the common mistake of jumping directly from “patients liked the program” to “the program saves money.”

What Digital Rehabilitation Has Already Demonstrated

The overall digital rehabilitation evidence base is becoming substantial.

A systematic review and meta-analysis of digital healthcare rehabilitation for musculoskeletal disorders included 54 studies and 6,240 participants. Digital-health interventions included mobile applications, virtual or augmented reality and other approaches. Across 45 studies reporting pain outcomes, digital rehabilitation was associated with a greater reduction in pain than conventional rehabilitation, with a pooled standardized mean difference of −0.55.

That doesn’t mean every digital program is superior to traditional rehabilitation.

The interventions were heterogeneous.

But it does tell us something important:

Technology-enabled rehabilitation has moved beyond the proof-of-concept stage.

The next question is how to use technology intelligently to solve particular problems.

For Verity, the problem we are most interested in is engagement.

Why Immersion May Be Different

Many digital rehabilitation platforms deliver therapy through a phone, tablet or computer.

Immersive rehabilitation changes the environment itself.

The patient doesn’t simply watch someone perform an exercise.

They become part of an interactive experience in which therapeutic movement accomplishes a task.

Turning the neck can release an object.

Reaching can activate a target.

Squatting can progress a game.

Repeated movement can generate immediate feedback.

This does not change the fundamental biology of rehabilitation.

But it may change how the patient experiences it.

And that is precisely why immersion is interesting from an engagement perspective.

Rehabilitation Also Has a Behavioral Component

One of the lessons I’ve learned in pain medicine is that some patients need more than exercise instructions.

They need to understand why they hurt.

They need to regain confidence in movement.

They may need to overcome fear avoidance.

They may benefit from pacing.

Some benefit from learning strategies that reduce stress and physiologic arousal before movement.

This is why I don’t believe the ideal digital rehabilitation platform should simply replicate exercises in a virtual environment.

It should address the barriers that prevent patients from performing those exercises consistently.

Where Verity Fits

Verity XR was designed as an immersive, clinician-directed rehabilitation platform organized around three connected components.

Behavioral Rehabilitation

The platform incorporates pain neuroscience education and concepts including graded exposure, pacing and self-management.

The objective is to help patients better understand recovery and build confidence participating in movement.

Autonomic Regulation

Immersive breathing, mindfulness, meditation and relaxation experiences provide tools for managing stress and physiologic arousal that can accompany pain and rehabilitation.

Movement Rehabilitation

Movement remains the primary goal.

Verity’s immersive activities facilitate clinician-directed range of motion, functional movement, balance, coordination and progressive rehabilitation while collecting objective performance information.

The first two components support the third.

Ultimately, patients need to move.

What Verity Has—and Has Not—Proven

This distinction is important.

The broader scientific literature supports many of the rehabilitation principles incorporated into our platform.

Our own early work has focused primarily on usability, patient and clinician preference, feasibility and engagement.

We have not yet demonstrated that Verity reduces employer healthcare costs, disability duration or absenteeism.

Those are outcomes that require prospective evaluation.

I think saying that explicitly is important.

The scientific rationale is strong enough to justify testing.

It is not a substitute for testing.

What an Employer Pilot Could Look Like

Rather than asking an employer to deploy immersive rehabilitation across an entire workforce, I would start with a carefully defined pilot.

For example, identify employees who are already entering rehabilitation for:

• low-back pain;
• neck pain;
• shoulder conditions;
• knee conditions;
• post-operative orthopedic rehabilitation; or
• other appropriate musculoskeletal disorders.

The treating clinician directs the rehabilitation program.

Verity provides an additional home or clinic-based engagement layer.

Then establish the outcomes before the first patient enrolls.

A meaningful pilot could measure:

Engagement: activation, weekly sessions, completion and dropout.

Clinical/functional: patient-reported function, movement data, pain interference, fear avoidance and functional progression.

Experience: employee and clinician satisfaction.

Work: absence, modified duty and return-to-work timing.

Economics: utilization and total relevant episode costs.

That turns a technology pilot into an evidence-generation program.

Self-Insured Employers Have an Opportunity Healthcare Often Doesn’t

One of the largest problems in American healthcare is fragmentation.

One organization provides medical treatment.

Another pays for physical therapy.

Another manages disability.

Another deals with workplace accommodations.

The patient experiences all of it as one recovery.

Self-insured employers are in a unique position to look across those silos.

They can ask whether investments made early in rehabilitation create value later in the recovery journey.

That does not mean employers should practice medicine.

Clinical decisions should remain with clinicians.

But employers can create benefit structures and partnerships that reward participation, function and recovery rather than simply paying for disconnected services.

The Future of Employer Musculoskeletal Care

I believe the next generation of employer-sponsored musculoskeletal programs will be increasingly:

• active rather than passive;
• measurable rather than episodic;
• personalized rather than standardized;
• behaviorally informed rather than exercise-only;
• connected to work outcomes rather than medical claims alone.

Immersive rehabilitation may become one component of that ecosystem.

The opportunity is not to place VR headsets in every employee’s home.

The opportunity is to determine whether immersive technology can help appropriate patients participate more consistently in the rehabilitation clinicians already know they need.

If it can, we then ask the next question:

Does better engagement produce better recovery?

And if it does:

Does better recovery create economic value for employees and employers?

Those are questions worth answering.

For self-insured employers, rehabilitation engagement may represent one of the few opportunities where patient experience, clinical recovery and workforce economics are potentially aligned.

The goal shouldn’t simply be to spend less on musculoskeletal care.

It should be to help employees recover better—and determine whether better recovery ultimately costs less.

Selected References

1. Zhang ZY, Tian L, He K, et al. Digital Rehabilitation Programs Improve Therapeutic Exercise Adherence for Patients With Musculoskeletal Conditions: A Systematic Review With Meta-Analysis. J Orthop Sports Phys Ther. 2022;52(11):726-739. Eleven randomized trials involving 1,144 participants were included; digital rehabilitation improved adherence at intermediate follow-up.
2. Lang S, McLelland C, MacDonald D, Hamilton DF. Do digital interventions increase adherence to home exercise rehabilitation? A systematic review of randomised controlled trials. Arch Physiother. 2022;12:24. Ten RCTs involving 1,117 participants were included; seven favored the addition of a digital intervention for adherence.
3. Doki S, et al. Return-to-work support programs for workers on sick leave: a systematic review and meta-analysis. Sangyo Eiseigaku Zasshi. 2018;60(6):169-179. For musculoskeletal disorders, rehabilitation was associated with earlier return to work, including an estimated 40.7 fewer days compared with usual care.
4. Cullen KL, Irvin E, Collie A, et al. Effectiveness of Workplace Interventions in Return-to-Work for Musculoskeletal, Pain-Related and Mental Health Conditions. J Occup Rehabil. 2018;28:1-15. This systematic review evaluated workplace-based return-to-work and disability-management strategies.
5. Franche RL, Cullen K, Clarke J, et al. Workplace-based return-to-work interventions: a systematic review of the quantitative literature. J Occup Rehabil. 2005. The review found strong evidence for workplace accommodations and healthcare-provider/workplace contact in reducing work-disability duration.
6. Shiri R, et al. Early interventions to promote work participation in people with regional musculoskeletal pain: a systematic review and meta-analysis. Twenty RCTs involving 16,319 participants were included; stepped-care programs improved return to work at 12 months.
7. Abásolo L, et al. Early workplace intervention for employees with musculoskeletal-related absenteeism: a prospective controlled intervention study. The intervention was associated with fewer sick days, greater return-to-work probability and a reported benefit-to-cost ratio of 6.8 in that study population.
8. Backes J, Mueller SI, Geissler A, Ehlig D. Occupational health interventions’ impact on absenteeism and economic returns: a systematic review and meta-analysis. Scand J Work Environ Health. 2026;52(2):79-97. The review included 68 studies and found considerable uncertainty around pooled absenteeism and ROI effects, underscoring the importance of evaluating economic outcomes rather than assuming them.
9. Kim Y, et al. A Systematic Review and Meta-Analysis of the Effects of Rehabilitation Using Digital Healthcare on Musculoskeletal Pain and Quality of Life. The review included 54 studies and 6,240 participants and found a pooled improvement in pain associated with digital rehabilitation versus conventional rehabilitation.
10. CDC/NIOSH. Ergonomics and Musculoskeletal Disorders: Elements of Ergonomics Programs. NIOSH provides employer guidance for identifying and addressing work-related musculoskeletal risks.