The Emergency Department: Why the Physical Therapist is the Most Appropriate Musculoskeletal Specialist

Studies have shown that the emergency department (ED) is becoming an increasingly popular entry-point into the health care system for non-critical conditions.¹  Many of these visits are related to musculoskeletal complaints, which can range from traumatic injuries such as sprains and strains to more chronic conditions including low back and neck pain.  Research has reported that physicians, excluding orthopedic surgeons, may not be adequately prepared to properly manage musculoskeletal complaints.²  In fact, a study in 2003 reported that nearly 50% of the 122 medical schools in the US required no instruction in musculoskeletal medicine.³ Due to these facts, several hospitals in the US have begun adding physical therapists to their ED team in order to better manage patients presenting with musculoskeletal complaints.

The physical therapist (PT) is a musculoskeletal specialist who is trained to distinguish musculoskeletal complaints from non-musculoskeletal conditions.  Institutions that have included the PT in the ED team have shown decreased overall costs of care and increased patient satisfaction as compared to visits where nurse practitioners and physicians were involved in the management of musculoskeletal dysfunction.^4,5  Critics of this system argue that PTs are unable to truly separate medical pathologies from musculoskeletal impairments and that patients will be at a greater risk for adverse events when not screened by a physician.  However, the exact opposite has been shown to be true.  Stowell et al demonstrated that physical therapists were able to independently differentiate medical issues from musculoskeletal complaints and were effective in managing pain-related conditions in first-contact situations.⁶  A study by Moore et al examined the cases of 50,799 patients who were seen directly by physical therapists and showed no increase in adverse events or injury.  Furthermore, patients with musculoskeletal complaints who are seen by a PT in the ED are more likely to be referred for further outpatient care and return to work sooner.⁷ 

In conclusion, emergency department visits for noncritical musculoskeletal complaints are increasing dramatically.  These conditions are often not managed appropriately as the current ED model does not include a musculoskeletal specialist.  One solution, that has been successful internationally and more recently in several US hospitals, is the addition of the physical therapist to the ED team.  The physical therapist has been shown to be superior to physicians in terms of musculoskeletal knowledge and effective in managing patients in first-contact situations.  Patients with musculoskeletal conditions who see a physical therapist in the ED are more likely to receive continued outpatient care and return to work earlier, thereby reducing further financial burden on the healthcare system.

1. Nawar EW, Niska RW, Xu J. National Hospital Ambulatory Medical Care Survey: 2005 Emergency Department Summary (NHAMCS). Advance Data from Vital and Health Statistics—Centers for Disease Control and Prevention, Department of Health and Human Services. No. 386, June 2007.
2. Childs JD, Whitman JM, Sizer PS, et al. A description of physical therapists’ knowledge in managing musculoskeletal conditions. BMC Musculoskelet Disord. 2005;6:32.
3. DiCaprio MR, Covey A, Bernstein J. Curricular requirements for musculoskeletal medicine in American medical schools. J Bone Joint Surg Am. 2003;85:565–567.
4. Richardson B, Shepstone L, Poland F, et al. Randomised controlled trial and cost consequences study comparing initial physiotherapy assessment and management with routine practice for selected patients in an accident and emergency department of an acute hospital. Emerg Med J. 2005;22:87–92.
5. McClellan CM, Greenwood R, Benger JR. Effect of an extended scope physiotherapy service on patient satisfaction and the outcome of soft tissue injuries in an adult emergency department. Emerg Med J. 2006;23:384–387.
6. Stowell T, Cioffredi W, Greiner A, Cleland J. Abdominal differential diagnosis in a patient referred to a physical therapy clinic for low back pain. J Orthop Sports Phys Ther. 2005;35:755–764.
7. Hackett GI, Bundred P, Hutton JL, et al. Management of joint and soft tissue issues in three general practices: value of on-site physiotherapy. Br J Gen Pract. 1993;43:61–64.

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