Most outcomes-based research has been conducted outside of the U.S. — primarily in Australia, Canada, New Zealand, and the U.K. — where emergency physical therapy is more widely practiced and accepted. Heath systems in these countries differ from those in the U.S., often making direct comparisons challenging. However, their favorable outcomes help demonstrate why this practice should expand and evolve in the U.S.

APTA has compiled a summary of relevant research, grouped by the following categories:

• Wait and throughput time.
• Hospital admissions.
• Emergency department readmissions.
• Patient satisfaction.
• Patient outcomes.
• Physician acceptance of PTs in the ED.
• Physical therapist management of musculoskeletal conditions.
• Evidence-informed care.
• Medication.
• Use of imaging.
• Cost.

Wait and Throughput Time

Time spent waiting to be seen by a provider in the emergency department (wait time) and time from patient arrival to departure (throughput) are efficiency metrics that correlate with patient satisfaction (Sonis, 2018) and quality of care (Sayah, 2014). Thus, administrators often have a keen interest in streamlining ED processes and may be reluctant to add services that are perceived to increase length of stay.

The 15 articles that explored this topic had similar findings. The time waiting to be seen by an ED provider (Pugh, 2020; Alkhouri, 2020; Bird, 2016; Salt, 2016; Sayer, 2018) and total length of stay (Pugh, 2020; Alkhouri, 2020; Bird, 2016; Salt, 2016; Sayer, 2018; Stewart, 2022) were consistently shorter when patients were managed by a PT rather than by other health care professionals. In one U.S. study (Pugh, 2020), researchers reported a time savings of more than two hours when a PT was involved in care versus management solely by ED physicians.

Several articles that originated outside the U.S. found that when patients with non-urgent conditions were managed by PTs as the primary provider, length of stay was decreased and patients demonstrated similar outcomes compared with being seen by other health care professionals (Alkhouri, 2020; Gill, 2013; Morris, 2015) In a direct comparison, overall length of stay was reported to be 130 minutes (+/- 76) when a PT was in the primary care role versus 240 minutes (+/-115) when the PT was in a secondary role (Henderson, 2020).

Despite findings that independent patient management by PT can reduce both wait times and throughput, existing U.S. practice in requires that patients be evaluated by an approved medical provider while in the ED (CMS, 2003). Adding on the PT evaluation and treatment to the time required for medical assessment makes reduction in wait and/or throughput time challenging in our current health care system. 

Hospital Admissions

Avoiding unnecessary hospital admissions can have a substantial impact on individuals’ health as well as reducing financial costs. Several studies indicate that PT management of patients in the emergency department reduces hospital admission rates (Gurley, 2020; Cassarino, 2021; Kesteloot, 2012; Sayer, 2018). In the only known U.S.-based study to explore the effect of ED PT management on hospital admissions (Gurley, 2020) reported that PT management in the ED of patients with falls and/or safety and mobility issues substantially decreased hospital admissions and showed potential to reduce resource use, length of hospital stay, and cost both to patients and the health care system.

Emergency Department Readmissions

PTs practicing in the emergency department and observation unit often evaluate and treat patients who present after a fall or with a musculoskeletal disorder (Plummer, 2015). Implementation of PT services in the ED for patients presenting with a fall has been shown to significantly reduce the risk of readmission to the ED for a subsequent fall (Lesser, 2018; Goldberg, 2020). Lesser found this to be true for older adult patients receiving independent PT services, and Goldberg found this to be true for older adult patients receiving a tailored fall-prevention intervention administered collaboratively by pharmacists and PTs. Other studies (Gagnon, 2021; McDonough, 2022) showed that patients with musculoskeletal disorders who were managed by a PT or advanced practice PT in the ED also had significantly fewer return visits to the ED compared to the traditionally managed group.

Patient Satisfaction

High patient satisfaction with care provided by PTs in the ED is one of the most consistent findings across numerous studies both in and outside the U.S. (Farrell, 2014; Fruth, 2013; Guengerich, 2013; Kesteloot, 2012; Matifat, 2019; Schulz, 2016). In most reports, patient satisfaction rates were higher when comparing ratings for PTs involved in care management compared to that of other ED providers. Patients reported valuing the level of care and concern offered by PTs and the education provided by PTs related to the patient’s condition and information provided about how the condition could be managed.

Patient Outcomes

Research is limited on patient outcomes when PTs are involved in care management of patients in emergency departments. Reasons include the one-episode nature of ED care, difficulty with patient follow-up after ED discharge, and challenges related to downstream tracking for longer-term data collection.

A U.S. based study used pain interference and disability outcome measures to compare standard ED care with ED physical therapy care specifically involving low back pain (Kim, 2021). For both outcome measures, the physical therapy group began with higher scores (worse functioning) than the usual care group, but scores were equal between groups at three months. In addition, change scores from week one post-ED visit to months two and three were significant in the physical therapy care group.

A study out of Canada explored the benefit of PT-initiated ED care for older individuals at risk for immobilization syndrome (Tousignant-Laflamme, 2015). Of the 20 patients assessed by a PT in the ED, nine received PT intervention; none of them developed immobilization syndrome. Of the 11 individuals who did not receive PT intervention, two developed the complication. Results from another study showed that patients with musculoskeletal disorders managed independently by ED PTs had significantly greater reduction in pain and pain interference at discharge and at a one- and three-month follow-ups compared with similar patients who received traditional ED management (Gagnon, 2021). The patients seen directly by a PT also used fewer prescription medications and had significantly fewer return visits to the ED than did those in the traditionally managed group. Finally, an Australian study demonstrated no adverse events and improved return to function at 30-day follow-up for older adult patients who saw a dedicated vestibular physiotherapist in the ED versus traditional care (Lloyd, 2020).

Physician Acceptance of PT in the ED

Medical staff acceptance of and satisfaction with PT practice in the ED environment is shown to be favorable in several studies.

Two U.S.-based studies contributed to these findings: A qualitative study reported that ED physicians found value in the services the PT offered to patients and the department as a whole, with indications that PT consultations enhanced emergency care provided to patients (Lebec, 2010); and a prospective study found highly favorable physician impressions of PT practice in the ED that remained consistent over an eight-year period (Fruth, 2016). These physicians specifically valued the PT's extensive patient education, safety and injury prevention, gait training, discharge planning, and providing interventions as alternatives to pain medication. They also reported moderate to strong support for implementing standing PT orders for patients with various musculoskeletal conditions. 

Studies originating from Australia and Canada have reported similar results: Medical staff had high satisfaction with PT expertise and patient management (Morris, 2015; Matifat, 2021). Another report describes PT behaviors and actions that facilitate acceptance by other ED staff. Key themes include trust, knowledge and skills, and complementing (not competing with) ED practices.

Physical Therapist Management of Musculoskeletal Conditions

Research is increasingly demonstrating that PTs are capable of independent, safe, and effective management of low-urgent musculoskeletal conditions in the emergency department.

In terms of primary management of a low-urgency musculoskeletal caseload, one study found that PTs are as effective as other ED practitioners (Ferreira, 2019), while another observed that PTs were more time-efficient than ED physicians managing the same population (deGruchy, 2015). Elsewhere, diagnostic concordance between PTs and ED physicians for patients with musculoskeletal-related diagnoses was found to be nearly perfect (Gagnon, 2020). A study of PTs providing primary patient management for after-hours care demonstrated shorter overall length of stay, decreased referrals to orthopedic specialists, reduced analgesic prescriptions, and no adverse events (Henderson, 2018). Further, advance practice physiotherapists were found to be to able to assess, treat, discharge, and appropriately refer patients in an urgent care setting (McDonough, 2022), while other study found very good interrater agreement between physicians and PTs for patient diagnosis, and moderate interrater agreement for discharge plans for patients with non-complex musculoskeletal conditions (Matifat, 2019). Additional studies further demonstrate the contribution and safety of PTs in the ED (Farrell, 2014; Sutton, 2015).

Evidence-Informed Care

National and international guidelines on management of conditions such as low back pain, musculoskeletal injuries, and persistent pain consistently recommend judicious use of imaging, caution in prescribing potentially addictive medications, and the value of early mobilization. While trends are moving in that direction, these goals have met challenges in the emergency department environment. Multiple studies conducted in and outside of the U.S. (identified in the list below) indicate that PTs practicing in the ED have a higher concordance with guideline-recommended care; primarily, reduction in medications prescribed, fewer diagnostic imaging studies, and encouragement to resume function as early as possible.

Medication

Emergency physicians have limited options available to provide pain relief while patients are in the emergency department, and the opioid crisis has highlighted the need for alternative interventions for pain relief. Multiple guidelines have been published over the past several years that include physical therapy as a viable alternative and recommended non-pharmacologic intervention for pain relief (Dowell, 2016; Sun, 2018).

More research is needed on this topic in the U.S., as the results are currently inconsistent. For example, one study reported that patients with back pain seen by PT in the ED were no less likely to receive an opioid prescription but were more likely to receive a benzodiazepine prescription (Kim, 2019), while another reported a small but significant reduction of opioid prescription and a dramatic reduction of benzodiazepine use when patients were managed by a PT during their stay (Pugh, 2020). 

In studies of PTs functioning in primary contact roles (primarily from Australia, where PTs are afforded greater independence and intervention privileges than their counterparts in the U.S.), PTs typically prescribed fewer medications (Ferreira, 2019: Schulz, 2016). And a 2021 study out of Canada reported that patients directly managed by PTs used significantly less prescription pain medication in the ED than did those under traditionally managed care (Gagnon, 2021).

Use of Diagnostic Imaging

In the only U.S.-based study that explored frequency of diagnostic imaging, researchers conducted a subgroup analysis of patients with low back pain and reported reduced imaging with PT patient management (25%) compared with medical management (57%) (Pugh, 2020).

Similarly, studies out of Australia and Canada have shown that PTs practicing in primary contact roles ordered fewer diagnostic images yet obtained similar or better outcomes and patient satisfaction when compared with other ED providers (Gagnon, 2021; Matifat, 2019; Schulz, 2106; Sutton, 2015).

Cost

Findings regarding cost of care are inconsistent to date, and findings from outside the U.S. do not readily translate to U.S. practices due to the vast differences in how service costs are covered. It is also important to recognize that the cost of PT services in the ED will almost always make the ED visit more expensive because physical therapy care is added to medical services care, rather than replacing it, as can happen in other countries. While authors of one study reported that ED PT services are indirectly related to decreased costs, as they allow for decreased time spent in the ED and less imaging (Pugh, 2020), a systematic review found two studies of moderate to high quality that showed no significant differences in costs between ED care with and without implementation of PT services (Matifat, 2019). Based on the current operational and billing systems in the U.S., it may be more beneficial for studies to evaluate longer-term downstream costs to determine if physical therapy care in the ED will lead to reduced costs downstream, such as avoiding referrals to specialists when unwarranted, avoiding or decreasing medication costs, and reducing time required to return to work and other functional activity.  

Author: Stacie Fruth, PT, DHSc, Board-Certified Clinical Specialist in Orthopaedic Physical Therapy

Reviewers:  Lisa Tenbarge, PT, DPT; Kyle Strickland, PT, DPT, Board-Certified Clinical Specialist in Geriatric Physical Therapy