[ clinical commentary ]

Michael T. Lebec, PT, PhD1 • Carleen E. Jogodka, PT, DPT, OCS2

The Physical Therapist as a

Musculoskeletal Specialist in the
Emergency Department

P
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atients with musculoskeletal complaints are increasingly a limited understanding of how physical
using the emergency department (ED) as their primary access therapists may be of benefit for the ED
patient population. Due to the complexi-
to healthcare.25,27,31,55,74 Considering emergency medicine
ties of healthcare delivery, establishing
physicians are skilled generalists who regularly utilize the value of any new service or interven-
Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

specialist consults,57,66 it is possible to envision how a practitioner tion is important. Thus, clinicians consid-
with musculoskeletal expertise might be beneficial in this practice ering implementing ED-based physical
setting. While orthopedic surgeons can provide this level of expertise, therapy need to provide justification for
consultation of these specialists is traditionally reserved for critical cases. introducing such a unique service.
The literature provides some perspec-
Specific situations cited as necessitating orthopedic consult include
tive on this matter. There is a substantial
patients with unstable fractures, complex that specialist intervention is a treat- and growing body of evidence support-
dislocations, circulatory compromise, ment adjunct that improves patient care ing the benefits of early physical therapy
or those in need of emergency surgical in the ED.57 Because physical therapists intervention21,28,32,47,48,68,70,76,80,83 as can be
Journal of Orthopaedic & Sports Physical Therapy®

intervention.50
This traditional pattern of orthope-
dist involvement creates a large subset of
less severely affected patients with mus-
culoskeletal problems who could ben-
efit from more specialized intervention.
Existing literature supports the concept
t SYNOPSIS: Because patients with musculo-
skeletal injuries commonly seek intervention in the
emergency department (ED), it has been proposed
that practitioners with expertise in musculoskeletal
practice can be of benefit in this setting. This
clinical commentary describes the rationale for
utilizing physical therapists as musculoskeletal
specialists in the ED. Evidence indicates that
physical therapists have the knowledge and skills
to provide such expertise. Literature describing
ED practice suggests that the management of
patients with musculoskeletal conditions would
be improved through the consistent integration of
evaluation and treatment principles associated
have specialized knowledge of musculo-
skeletal dysfunction,2,14 it is proposed that
their consultation would be beneficial for
patients receiving emergency care.
Currently, only a handful of EDs have
physical therapists as part of their person-
nel. One possible reason for this may be
with physical therapy practice. Furthermore, early
access to physical therapy, as can be provided in
the ED setting, has the potential to positively influ-
ence patient recovery. Based on prior research and
recent evolution of practice, further consideration
of physical therapists as consultants in the ED is
warranted, and, therefore, additional dialogue on
the subject should be encouraged. J Orthop Sports
Phys Ther 2009;39(3):221-229. doi:10.2519/
jospt.2009.2857
t KEY WORDS: consultant, direct access, emer-
gency medicine, emergency room
provided in the ED. Evidence suggests
that ED practice may be enhanced by
the physical therapist’s perspective on
education and prescriptive exercise for
patients with musculoskeletal impair-
ments.23,37,39,49 Though it may be argued
that patients presenting to the ED who
need therapy can simply be referred for
outpatient management, multiple barri-
ers complicate this process. Many of these
individuals are either not referred39,64 or
lack the resources or the resolve to pursue
additional treatment. 31,74 Thus, physical
therapy provided in the ED may be the
only opportunity for these patients to re-
ceive such care.
The purpose of this clinical com-
mentary is to describe physical therapist
practice in the ED setting. A literature
review provides a description of existing
ED physical therapy practice models. The

Assistant Professor of Physical Therapy, Northern Arizona University, Department of Physical Therapy and Athletic Training, Flagstaff, AZ. 2 Lead Emergency Physical Therapist,
1 

Carondelet St Joseph’s Hospital, Outpatient Rehabilitation, Tucson, AZ. Address correspondence to Michael T. Lebec, PO Box 15105, Flagstaff, AZ 86011. E-mail: mike.lebec@nau.edu

journal of orthopaedic & sports physical therapy | volume 39 | number 3 | march 2009 | 221
 [ CLINICAL COMMENTARY
pists in the United States Army is one
historical model upon which subsequent
Patient admitted to
ED physical therapy programs have been
emergency department
based. While these practitioners do not
function in a true ED environment, their
experience has been used to demonstrate
that physical therapists may provide ef-
Emergency physician (EP) fective neuromuscular evaluation and
contact initiated treatment at the patient’s point of entry
into the healthcare system.30 A veteran’s
healthcare system in Salt Lake City, Utah,
replicated and broadened this approach
Physical therapy (PT) consult by allocating a full-time physical thera-
request initiated pist for consult with patients seeking
both primary care and emergency treat-
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]
the role of an AE-based physiotherapist
in screening and managing knee injuries.
These authors highlighted the role that
ED-based therapists play in discharge
planning. Ball et al7 described prac-
tice trends among ED physiotherapists,
nurse practitioners, and physicians. As
compared to the other ED practitioners,
these physiotherapists were more likely
to give patients written instructions for
self-management, to provide structural
support, such as crutches, less often, and
to refer significantly more patients for
outpatient physical therapy. While the
authors do not elaborate on the circum-

ment.60 A nonprofit healthcare system in stances surrounding these outpatient

PT exam, clinical
intervention(s), and patient
instruction, as indicated
Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
Tucson, Arizona, however, was among the physical therapy referrals, this outcome
first facilities to provide full-time physical should be considered within the context
therapist consultation in the ED. In this of ethical referral patterns. That is, while
model (<?=KH;'), therapists are employed facilitating the provision of follow-up

solely for the purpose of providing ED
PT follow-up services during the majority of operating
recommendations discussed hours, 7 days a week.82 Emergency physi-
with EP cians at this hospital use a pager system
to notify the ED therapist of patients who
may benefit from consultation. When
finished working with a patient, the
Interdisciplinary collaboration therapist briefly confers with the refer-
on course of care ring physician, then immediately attends
Journal of Orthopaedic & Sports Physical Therapy®
services for patients in need of physical
therapy may enhance health outcomes
for these individuals, promotion of self-
referral for the purpose of financial gains
should be avoided.
Finally, a narrative review published
in 20075 attempted to summarize the
existing literature on physiotherapy ED
services within the UK and Australia.

Patient disposition
proceeds as indicated
<?=KH;'$Current emergency department physical
therapist consultation process.36
need for ED physical therapist consulta-
tion and the value of this intervention
approach will be established through a
discussion of the relevant evidence. And
finally, the recommended physical thera-
pist qualifications for providing expertise
in the ED will be considered.
;c[h][dYo:[fWhjc[djF^oi_YWbJ^[hWfo
Various models describing how physi-
cal therapists in the United States can
function in the ED setting have been
reported. The system utilized by thera-
to the next individual in need. Through
education of ED staff and continuing ex-
posure to therapists’ skills, requests for
consultations are now frequent and in
demand.36,46
Other literature describes internation-
al programs utilizing ED-based physical
therapists. Kempson40 illustrated the
role of a physiotherapist in an accident
and emergency (AE) department in the
United Kingdom. Therapists in this pro-
gram commonly provided education on
the nature of patients’ injuries and initial
advice on self-management. They also
stressed the importance of early exercise
and graded activity. A recent observa-
tional pilot study by Anaf and Sheppard4
described the ED-based physiotherapist
as a provider who primarily treats aged
individuals and patients with musculo-
skeletal deficits by addressing problems
of pain, decreased mobility, and limited
range of motion. Jibuike et al35 described
Findings were inclusive of and similar to
those described above. The authors re-
ported that the typical ED physiothera-
pist managed aging adult populations
with musculoskeletal injuries. Common
diagnoses included acute and subacute
lower extremity and spinal trauma.
Management frequently focused on as-
sessment of functional activities and dis-
charge planning.
Few authors have attempted to define
the value of these services by describ-
ing associated outcomes. Morris and
Hawes,58 for example, determined that
patients seen by a physiotherapist in an
AE department had shorter wait times
between referral for outpatient physical
therapy and their first therapy visit. An-
other study reported higher satisfaction
ratings when patients in the ED were
seen by a physiotherapist.56 The veter-
ans’ healthcare system in Salt Lake City
reported that their program reduced the

222 | march 2009 | volume 39 | number 3 | journal of orthopaedic & sports physical therapy
 amount of time patients waited to see
an orthopedic or neurological specialist
from 90 to 30 days.60
Investigations describing the relation-
ship between patient recovery and this
approach to care are notably lacking.
One study using a randomized design,
however, did analyze patient outcomes
associated with ED-based physical ther-
apy.67 This study reported no differences
in patient outcomes between individuals
receiving physical therapy intervention in
the ED and those who did not. Although
a good first step, the design of this study
places the findings in question. While
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participants were limited to those with
musculoskeletal problems, the diagno-
ses included injuries of the cervical, tho-
racic, and lumbar spine, shoulder, wrist,
hand, hip, knee, ankle, and foot. From a
Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
research design perspective, including
such a wide range of conditions creates a
nonhomogeneous population that can ex-
perience highly variable rates of recovery
based on the involved anatomical regions
as well as the severity of the injury.
Based on these examples, it seems that
a model for physical therapy ED services
exists, but evidence examining specific
Journal of Orthopaedic & Sports Physical Therapy®
outcomes is deficient. This necessitates
further exploration of the rationale for
implementing such a program. The fol-
lowing sections of this commentary will
therefore describe this rationale and
present relevant supporting literature.
GkWb_ÓYWj_edie\F^oi_YWbJ^[hWf_ijiWi
;:CkiYkbeia[b[jWbIf[Y_Wb_iji
A brief description of the emergency
medicine scope of practice provides
some perspective on how physical thera-
pists may bring expertise to this setting.
Physicians of emergency medicine screen
and provide initial treatment for condi-
tions affecting multiple physiologic sys-
tems.50 Because these doctors manage
patients presenting with disorders of the
nervous, cardiopulmonary, lymphatic,
digestive, genitourinary, integumentary,
musculoskeletal, as well as other physi-
ologic systems, their initial focus is often
on recognizing red-flag situations and
journal of orthopaedic & sports physical therapy | volume 39 | number 3 | march 2009 | 223
the presence of serious disorders.33 Thus,
these physicians may be described as
professionals with general knowledge of
all body systems and the skills to screen,
evaluate, and manage a diverse set of pa-
tients. With these extensive expectations,
it is difficult to expect these individuals to
possess advanced knowledge in a special-
ty area such as musculoskeletal practice.
The literature supports this challenge in
describing entry-level training in muscu-
loskeletal medicine and traditional mus-
culoskeletal practice in the ED as areas
with potential for improvement.25,64,66
Conversely, physical therapy practice
and entry-level educational content are
reflective of a comprehensive systems
approach, with a significant focus on the
basic and clinical sciences of musculosk-
eletal disorders. The Guide to Physical
Therapist Practice2 lists musculoskeletal
disorders as 1 of 4 primary practice pat-
terns that physical therapists are qualified
to evaluate and manage. The Normative
Model of Physical Therapy Professional
Education3 states that entry-level educa-
tion must be reflective of the principles
outlined in The Guide to Physical Thera-
pist Practice,2 thus programs must estab-
lish curricula proportionally reflective of
musculoskeletal content. Analysis of the
normative model indicates that required
curricular content includes multiple as-
pects of musculoskeletal management.
Examples of such required content in-
cludes a primary focus on physiology,
injury, and regeneration of muscle, skel-
etal, and connective tissue, as well as
examination, diagnosis, prognosis, and
management of musculoskeletal condi-
tions. The recommended curriculum is
multisystem in scope and includes the
differential diagnosis and pathophysiol-
ogy of neuromuscular, cardiopulmonary,
and integumentary disorders. Therefore,
professional degree physical therapy
training encompasses the management
of patients with these conditions, muscu-
loskeletal problems, or both. Ultimately,
physical therapy program accreditation
is dependent upon the didactic and clini-
cal experiences being both inclusive and
comprehensive of all of this content.18
Musculoskeletal competency is then fur-
ther assessed by the National Physical
Therapy Examination. Eighteen percent
of this licensure examination is specifical-
ly dedicated to musculoskeletal practice
with up to an additional 40% of the ex-
amination having the potential to further
assess this domain.41
Empirical data provide further sup-
port for the premise that physical thera-
pists have expertise in the management
of musculoskeletal conditions. Childs et
al14 designed a study in which a validated
musculoskeletal examination previously
administered to physicians of varying
backgrounds was also given to physical
therapists and physical therapy students.
In comparison to all groups of medical
practitioners, with the exception of or-
thopedic surgeons, physical therapists
achieved superior outcomes. While fu-
ture concomitant studies are needed
to confirm these findings, the current
evidence suggests that the baseline mus-
culoskeletal knowledge of practicing
therapists is at least comparable to, and
frequently exceeds, that of other medical
practitioners.
Oldmeadow et al63 described how
physiotherapists in the United Kingdom
were used to screen patients with mus-
culoskeletal complaints prior to having
them sent to orthopedic surgeons. They
found this to be a successful strategy,
because the majority of patients did not
need surgical management, and there
were high levels of diagnostic agreement
between therapists and orthopedists.
Furthermore, significant levels of patient
satisfaction for physiotherapy services
were achieved.
A final perspective on how physical
therapy musculoskeletal expertise may
be of benefit in the ED is with respect to
movement dysfunction. The classifica-
tion of a movement dysfunction is non-
traditional in comparison to the medical
pathology model, in that it considers
the manifestations of a patient’s injury
on mobility and function. The Guide to
Physical Therapist Practice2 outlines
 [ CLINICAL COMMENTARY
evaluation and intervention to improve
mobility and function as primary roles of
the physical therapist. Because such limi-
tations can directly impact patients’ lives,
this perspective should be addressed by
the providers most qualified to do so.
The notable absence of an expert in the
realm of exercise and mobility has been
reported in the literature, and physical
therapists have been identified as the
practitioners of choice to fill this void.60
Therefore, whether the problem is due to
musculoskeletal injury or impairment of
multiple systems, physical therapists are
the most qualified individuals to make
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recommendations regarding a patient’s
functional capacity and potential.
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J^[hWf_ij9edikbjWj_ed
Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
One reason some have difficulty envision-
ing ED-based physical therapy services
may be the stigma associated with this
treatment setting. For many, the ED sum-
mons images of life-or-death situations,
in which patients are transported by am-
bulance and then rushed via stretcher for
the purpose of treating extensive trauma.
In reality, the increasing majority of pa-
Journal of Orthopaedic & Sports Physical Therapy®
tients seen in the ED present with condi-
tions of minor trauma or lower levels of
urgency.27,31,54
This trend is largely affected by issues
of healthcare access. In one study, 45% of
patients visiting the ED cited problems
accessing primary care as the reason for
choosing this treatment setting, with 38%
of these conveying that they would forego
their ED visit if they could schedule a visit
with their physician in a reasonable pe-
riod.31 Other sources state that as many as
30% of patients seen in the ED use this
setting as their only accessible form of
healthcare.74 In light of this information, it
appears that a large percentage of patients
treated in the ED present with no greater
acuity than those being treated in other
healthcare environments and are similar
in health status to a number of patients
commonly referred to physical therapy.
For those patients who do present in
a stereotypically acute fashion, the body
224 | march 2009 | volume 39 | number 3 | journal of orthopaedic & sports physical therapy
of evidence suggests that physical thera-
py has much to offer. This is particularly
true during the early stages of the healing
process. Various studies support the use
of modalities commonly used by physi-
cal therapists, such as electrical stimula-
tion,9,45,62,72 for the purpose of managing
acute pain and inflammation. Proper
education on the use of cryotherapy for
self-management of acute injuries has
also been shown to be of benefit for in-
creasing return to function.34 Perhaps
of most benefit is the early addition of
therapeutic exercise. Properly prescribed
early movement can facilitate the removal
of edema,29 reduce pain,22 prevent disuse
atrophy,1,8 and restore normal movement
patterns.73 Clinical trials comparing early
introduction of exercise and “treatment as
usual” support the above conclusions. The
authors of the majority of these studies
report that patients receiving early exer-
cise instruction achieve greater function-
al outcomes,21,22,28,32,47,48,68-70,76,77,80,83 though
a few others conclude otherwise.20,42,71
Lastly, recent evidence indicates that
manual treatment, such as spinal ma-
nipulation13,16 and joint mobilization, has
a positive impact on certain patients after
acute or subacute injury.17,43,78
The most definitive perspective on
how physical therapists may enhance
emergency care comes from analysis of
the typical recommendations given to
patients in the ED after acute musculo-
skeletal trauma. The medical literature
provides excellent practice guidelines
for management of such patients. These
include the use of protection, rest, ice,
compression, and elevation (PRICE) for
acute soft tissue trauma,15,37 while mini-
mizing excessive immobilization and
encouraging these patients to return to
activity as early as possible.22 As is true
in many healthcare settings, the use of
such contemporary evidence-based prin-
ciples is not always reflected in ED prac-
tice. For example, one study indicated
that the majority of patients presenting
to Danish EDs with ankle sprains and
muscle contusions were not treated with
or informed about rest, ice, compression,
]
or elevation.37 A more recent study per-
formed in the United States supported
these findings, indicating that proper
instructions for managing acute ankle
sprains were given inconsistently with
respect to use of ice (given to 41% of pa-
tients), compression (43%), and elevation
(55%).15 Recommendations for early mo-
bilization after injury are also poorly un-
derstood and inconsistently provided in
the ED setting. When surveyed, only 43%
of a group of American emergency physi-
cians reported that they felt prepared to
recommend exercise for patients, while
just 37% viewed themselves as success-
ful in this practice.81 This was illustrated
by an investigation showing that cast im-
mobilization was suggested for grade II
and III ankle sprains by 28% to 61% of
physicians, while early mobilization was
advocated by less than 3% of providers. 39
Furthermore, it has been reported that
less than 10% of patients presenting to
the ED after soft tissue injury receive any
written instructions utilizing rehabilita-
tion principles for self-management.37 In
the previously reported US-based study
examining management of ankle inju-
ries, only 5% of patients sustaining ankle
sprains received instructions for range-
of-motion exercises, while less than 1%
received recommendations for strength-
ening or proprioception.15 In contrast, ED
physiotherapists gave significantly great-
er amounts of oral or written instructions
for self-care than what was provided by
other ED practitioners.7 These results
also indicated that therapists encour-
aged early mobility in patients by being
less likely to provide structural support,
such as crutches. This practice is consis-
tent with current guidelines for manage-
ment of acute musculoskeletal injuries, as
it is frequently reported that early weight
bearing and movement are more ben-
eficial than delayed weight bearing and
immobilization.6,22,38,59,61
Studies examining recommenda-
tions for movement after spinal injury
describe similar patterns. For example,
cervical collars have been recommended
over movement by as many as 50% of ED
 physicians.49 Approximately 75% of ED
physicians in another study advised mul-
tiple days of bed rest for acute low back
pain.23 Furthermore, it has been reported
that physicians’ recommendations for
exercise or mobility are often limited to
very general instructions, such as to “be
active” or “walk more.”60 Such directives
may have limited value when placed in
the context of a patient with a complex
acute injury.
While the extent to which these stud-
ies reflect standard ED practice in the
United States may be debated, they are
examples of situations in which patient
Downloaded from www.jospt.org at on August 5, 2019. For personal use only. No other uses without permission.
management can be improved. Reasons
for such disparities may range from the
typical lag time associated with the emer-
gence of proper guidelines and their ac-
tual use in practice to the possibility that
Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
ED physicians are too overburdened to
consistently provide comprehensive pa-
tient education.66 Regardless, the cou-
pling of physical therapists’ knowledge of
musculoskeletal practice and appropriate
recommendations for acute to subacute
injury management can greatly improve
the present ED system and benefit many
of the patients accessing it.
Journal of Orthopaedic & Sports Physical Therapy®
LWbk[" Kj_b_jo" WdZ 9eij0 ?i ;: F^oi_YWb
J^[hWfoWd;÷[Yj_l[Ki[e\H[iekhY[i5
Economics of an Individual Program The
initial consideration for establishing the
value of an ED physical therapy program
is fiscal sustainability. A program is fea-
sible if it, at least, can generate revenues
sufficient to cover the costs of delivery.
Obtaining effective reimbursement for
services rendered is, of course, fundamen-
tal to this process. Because ED physical
therapy services are a novel and unique
form of care, a standard system for billing
and reimbursement of services may not
exist. The financial structure of hospital
systems and insurance plans are complex
and vary greatly by region and facility.
An extensive discussion of the potential
to profit through ED physical therapy
programs is, therefore, premature and
beyond the scope of this manuscript. In-
stead, a general example illustrating how
journal of orthopaedic & sports physical therapy | volume 39 | number 3 | march 2009 | 225
existing programs have addressed these
issues is provided.
The program described at the hospital
in Tucson, Arizona was among the first to
consistently provide and charge for phys-
ical therapist interventions in the ED.82
In this facility, services are rendered as
needed, independent of the ED patient’s
insurance. Reimbursement for these
services, however, is dependent upon
the individual’s plan and varies greatly.
Therefore, some patient encounters
generate significant revenue, some are
reimbursed minimally, while others are
not funded at all. Additional revenue is
often generated by the hospital when pa-
tients not normally referred to outpatient
physical therapy receive such recommen-
dations. To maintain ethical standards, it
is made clear that patients have the free-
dom to choose where they seek follow-up
intervention.
Profit or loss is thus a reflection of the
fees, which have been reimbursed in rela-
tion to the cost of providing the service.
Fortunately, the direct expenditures asso-
ciated with such programs are minimal
and consist solely of the wages paid for
the physical therapist and supplies used
during treatment. In this program, the
physical therapist functions quite in-
dependently within the confines of the
existing ED environment, without ad-
ditional support or administrative staff.
This arrangement helps minimize the ex-
penses of providing the program. Due to
the uncertainty with which services ren-
dered are reimbursed, the success of the
program is reliant on sufficient quantities
of appropriate patients visiting the ED,
as well as having physicians consistently
seek physical therapist consultations.
Societal Cost Effectiveness: Justifying
Expense on a Grander Scale Justifying
widespread implementation of a new ser-
vice such as ED physical therapy requires
considering not only the operational
costs but also the effects it has on societal
healthcare expenses. This perspective on
a service’s value is often described as its
cost effectiveness43,75 and considers both
the direct costs of care and the savings
produced by the introduction of an inter-
vention, when indirect expenditures, such
as time off work, medication use, and sur-
gery, are avoided.53 There is substantial
evidence that illustrates the relationship
between the types of services provided by
physical therapists in the ED and the cost
effectiveness of these approaches. For ex-
ample, physical therapist interventions
have been shown to be effective and cost
effective for the management of cervical
pain,43,48,51 low back pain,28,51,75 and whip-
lash-associated disorders.69 Specific ben-
efits and indirect cost savings shown to be
associated with early physical therapy in-
tervention have included decreased nar-
cotic use,28 reduced healthcare visits,28,83
less time away from work,21,32,48,83 and a
reduction in the development of chronic
conditions.48
Though the nature of this research
limits direct conclusions about cost ef-
fectiveness to the above situations, there
are reasons to hypothesize that other as-
pects of the service may result in indirect
savings and may therefore be worthy of
further investigation. For example, pain
management provided by ED physical
therapists may help avoid costs associated
with prescribing medications and treat-
ing addictions resulting from overuse.52
A physical therapist’s functional assess-
ment could circumvent costs associated
with an unnecessary inpatient admission
or an injury resulting from an inappro-
priate discharge to the home setting.65
And because ED physical therapy consul-
tation often inaugurates the patient into
the rehabilitation track of the healthcare
system at the earliest opportunity, there
is better potential to prevent chronic
progression and its high associated costs.
For many patients with acute musculo-
skeletal conditions, there is evidence that
an earlier referral of this nature produces
such benefits.21,48
Similar considerations for improving
ED cost effectiveness through physical
therapist involvement exist with respect
to patient triage and musculoskeletal
imaging. Because triage policy in the ED
is controversial and in flux,10,54 physi-
 [ CLINICAL COMMENTARY
100%
Safety/mobility (514)
Elbow/hand/wrist (526)
90%
80%
70%
60%
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50%
Cervical/headache (3082)
40%
Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
30%
20%
Journal of Orthopaedic & Sports Physical Therapy®
10%
0%
<?=KH;($Number of patients (in parentheses) seen by an emergency department physical therapist by reason for
consultation over the period from June 1998 to May 2006.36
cal therapists have an opportunity to
improve this process by reducing the
extensive backlog of patients10,31 with
nonemergency musculoskeletal inju-
ries.27,31,55 This approach could conserve
resources if a hospital elects to designate
physical therapists as “qualified provid-
ers” for the sake of screening conditions
within the physical therapy scope of prac-
tice and avoiding the expenses of multi-
ple-practitioner involvement.12 Multiple
publications describing international ED
practice support these ideas and outline
the potential roles for physiotherapists in
patient triage.7,35,56
226 | march 2009 | volume 39 | number 3 | journal of orthopaedic & sports physical therapy
Wound care (123)
Vertigo (700)
Thoracic/rib (925)
Foot/ankle (1086)
Other (1198)
Shoulder (1288)
Hip/knee (1798)
Low back (5662)
Likewise, the unique examination
and evaluation skills of physical thera-
pists may limit expenses associated with
overutilized and expensive services, such
as diagnostic imaging.11,23 In existing pro-
grams in the United States, official orders
for imaging are submitted by physicians
or designated staff. However, as is the
case in the model program described in
Tucson, Arizona,82 physicians frequently
solicit or entertain physical therapist
recommendations whether or not imag-
ing will be beneficial for certain patients.
Thus, for many noncritical patient diag-
noses, physical therapist knowledge of
]
musculoskeletal pathology and existing
plain film radiographic utilization guide-
lines may help direct imaging decisions
to clarify a patient’s diagnosis or elimi-
nate the use of unnecessary imaging in
cases where these tests would not in any
way alter the clinical outcome.
The model utilized by the Virginia
Mason Medical Center illustrates many
of these ideas in action.26 This institu-
tion has implemented a system in which
patients often receive an initial physical
therapy consultation, as opposed to being
referred after seeing multiple physicians
and specialists or receiving other expen-
sive services. For many conditions, this
arrangement has resulted in significantly
reduced healthcare costs and decreased
utilization of expensive imaging by as
much as one third. Such a program dem-
onstrates how early physical therapy in-
tervention, as is provided in the ED, may
positively affect overall costs.
A final perspective on the value of
physical therapist consultation concerns
intangible benefits, such as its effect on
patient satisfaction in the ED. Due to
long wait times, overcrowding, and the
nature of ED conditions, satisfaction is
a commonly cited problem.19,31 To this
end, authors have reported that hav-
ing a physical therapist participate in
ED care significantly increases patient
satisfaction as compared to traditional
ED practice.56,67 Specifically, the service
has been found to reduce ED wait times
and increase patient flow. Furthermore,
emergency medicine physicians have re-
ported the perception that their patients
receive better care and are more satisfied
when managed by a physical therapist.46
Because the literature clearly states that
policymakers should invest in maximiz-
ing the perception of the ED experience
and hold patient satisfaction as a top
priority,19,54,79 the manner in which physi-
cal therapy services may affect this issue
should be considered.
GkWb_ÓYWj_ediWdZIa_bbiH[gk_h[Ze\;:
F^oi_YWbJ^[hWf_iji
Selecting physical therapists with the
 appropriate profile may maximize the
potential to provide a specialist’s per-
spective and aid in approaching the out-
comes described in this commentary.
While the majority of ED consultation
cases are orthopedic related, ED physi-
cal therapists should be expected to as-
sist in the diagnosis and management
of multiple system problems within the
physical therapy scope of practice. <?=-
KH;( reinforces this concept by illustrat-
ing the varied distribution of cases seen
in 1 ED physical therapy program over
an extensive period.36 Therefore, an ED
therapist should be a strong musculosk-
Downloaded from www.jospt.org at on August 5, 2019. For personal use only. No other uses without permission.
eletal practitioner and also an effective
physical therapy generalist prepared to
encounter a wide range of impairments
for individuals of all ages, health statuses,
or phases of injury. Because applying this
Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
knowledge can be difficult for those with
limited exposure to this unique setting,
considerable mentoring with an experi-
enced ED physical therapist is strongly
advised for those transitioning into this
environment. Ideally, future prepara-
tion would occur in a postgraduate ED
residency given its distinctive and broad
reaching demands.
Journal of Orthopaedic & Sports Physical Therapy®
Another necessity for the ED physical
therapist is knowledge of evidence-based
principles, such as clinical decision rules
(CDRs). These tools can be particularly
useful in the ED to allow expedient
bedside decisions, while decreasing the
uncertainty of clinical judgments. Fur-
thermore, they may facilitate greater
standardization of ED physical therapy
practice, which can be quite beneficial in
this unique and developing environment.
Physical therapists must also understand
the limitations of CDRs within this prac-
tice setting. These include the fact that
many of these tools have not been vali-
dated for ED use and that many lengthy
self-reporting tools are not practical for
the pace of this department.24 Developing
shortened formats of these tools and in-
vestigating their validity with patients in
the ED could aid this process and would
likely be of benefit for many areas of
physical therapy and medical practice.
journal of orthopaedic & sports physical therapy | volume 39 | number 3 | march 2009 | 227
Equally important qualifications for
consideration are personal characteris-
tics and clinical experience possessed by
ED physical therapists. Self-confidence
and a teamwork approach are vital for
building rapport with ED physicians and
staff who often have limited experience
working with rehabilitation profession-
als. Overcrowding, patient acuity, and se-
vere fluctuations in patient flow increase
the need for ED physical therapists to be
flexible and efficient while managing a
swiftly varying schedule.46 The value of
clinical experience for ED therapists is
undeniable and aids in making timely
and accurate decisions regarding diagno-
ses and patient management. Conversely,
extensive clinical experience may hinder
therapists who are very accustomed to a
certain practice setting. Because func-
tioning within the ED involves a com-
prehension of the associated culture and
often requires a paradigm shift away from
traditional treatment philosophies, some
individuals may have difficulty making
this transition.44 Thus, perhaps the ideal
candidate for ED practice is one who has
accumulated at least a few solid years of
experience but has maintained the flex-
ibility to adapt to practice within this
unique environment.
9ED9BKI?ED
T
his clinical commentary pro-
vides support for the use of physical
therapist consultation as a means
to enhance the management of patients
with musculoskeletal dysfunction in the
ED setting. Physical therapists possess a
level of expertise that is not commonly
available in the ED and present ED prac-
tice suggests that there is both a role and
a need for such services. The literature
suggests that ED physical therapy has
the potential to be a valuable and cost-
effective service. To further evolve the
role of ED physical therapists, future
steps could include further defining the
required expertise, developing a special-
interest group, communicating specific
illustrations of existing practice models,
and, perhaps most importantly, engaging
in the generation of specific evidence that
ED physical therapist intervention im-
proves patient outcomes. Through these
and other pathways, ED practice offers a
novel opportunity for physical therapists
to serve as pioneers attempting to simul-
taneously advance both quality of care
and the direction of their profession. T
H;<;H;D9;I
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