Take 5 – Direct Access Physiotherapy to Help Manage Patients With Musculoskeletal Disorders in an Emergency Department: Results of a randomized controlled trial

Gagnon R, Perreault K, Berthelot S, Matifat E, Desmeules F, Achou B, Laroche MC, Van Neste C, Tremblay S, Leblond J, Hébert LJ. Direct-access physiotherapy to help manage patients with musculoskeletal disorders in an emergency department: Results of a randomized controlled trial. Acad Emerg Med. 2021 Aug;28(8):848-858. doi: 10.1111/acem.14237. Epub 2021 Apr 16. PMID: 33617696.

Video version here.

By Dr. Nica Jacobson

Take 5 – 5 Critical Takeaways to Improve your Practice

1. Patients with musculoskeletal conditions that see a PT direct access in the ED have better clinical outcomes and use less resources than those who received physician only care at ED discharge and up to 3 months after.
2. The PT group had low pain intensity and interference than those in the control group at 1 and 3 months.
3. PTs used fewer resources and services: physicians prescribed 40% more imaging compared to the PT group.
4. PTs recommended 60% more over the counter medication and 25% less prescription medication compared to the control group.
5. Return visit rates to the ED were very different between intervention groups.

A patient comes into the ED with back pain from an injury at home when they went to pick up a heavy box. Their pain hasn’t improved since the incident yesterday and they want to get evaluated for an injury and pain control. Which provider(s) can help them? And how can they be helped? How can we ensure the patient gets better today, one month, and three months from now?

The study “Direct Access Physiotherapy to Help Manage Patients With Musculoskeletal Disorders in an Emergency Department: Results of a randomized controlled trial studied the difference in clinical outcomes and use of resources with two groups: the experimental group saw a direct access PT and an ED physician prior to discharge and the control group saw an ED physician only.

Since the US is playing catch up to direct access PT, especially in the ED setting, I wanted to highlight an article that uses valid and reliable outcome measures (the NPRS and BPI) to assess the differences between PT+physician versus physician only interventions and makes an excellent case for expanding PT scope of practice as a direct access provider. Here are the five biggest takeaways from this article. 

1. Patients with musculoskeletal conditions that see a PT direct access in the ED have better clinical outcomes and use less resources than those who received physician only care at ED discharge and up to 3 months after.

PTs are valuable! While this is the main conclusion of the study, make sure to see the points below to understand the depth and breath of why PTs make this type of difference for patients and other providers in the ED. While we do love to see these research outcomes, it is important to recognize the limitations of this study including a limited sample size, differences in groups (age and sex), no follow up beyond 3 months, losing 20% subjects to follow up, research performed in the Canadian health care system, and the study lacking a group that received no treatment. 

2. The PT group had low pain intensity and interference than those in the control group at 1 and 3 months.

The PT interventions used included education and reassurance, which the authors attribute to the significant difference between the PT and control group pain outcomes. Part of the value of direct access PT in the ED is addressing pain day of, as well as making a lasting impact on pain and disability over the short and long term. From a patient outcome and health care use perspective, this takeaway speaks for itself. Additional follow up past 3 months would have been valuable in measuring the impact of PT intervention.

3. PTs used fewer resources and services: physicians prescribed 40% more imaging compared to the PT group.

When people come to the ED with MSK and pain complaints, they typically expect imaging to confirm their symptoms and a medical intervention to make them better. But when their visit could have been in the outpatient setting, their imaging is negative, and/or their complaint is labeled “non-emergent” they are left wondering, “Why do I have to wait for imaging?” or “Why are they saying I don’t need it at all?” or “How am I supposed to get through my next day of work in this type of pain?” 

In the discussion, the authors attribute this finding to PTs following clinical practice guidelines more closely, as well as supporting evidence from other articles about inter-rater reliability of PT MSK exam and physician MSK exam plus imaging, as well as overuse of imaging for non-traumatic MSK injuries. Not only did PTs use less imaging, but no adverse effects were found in both groups, indicating appropriate management of patient complaints from PTs.

As far as addressing the patient questions and concerns about not getting imaging, PTs may be able to spend more time with the patient explaining their diagnosis and symptoms and being provided PT interventions like exercise, reassurance, and pain education. 

4. PTs recommended 60% more over the counter medication and 25% less prescription medication compared to the control group.

With the opioid crisis in full effect, seeing reduced use of prescription medications at ED, 1 month, and 3 month time points is promising. Although the use of over the counter medication is  associated with worse outcomes (compared to no medication) and uncertain efficacy for treatment of minor MSK complaints(1), the PT group still had 25% less over the counter medication use at 3 months compared to the control group. This can be attributed to patient education, reassurance, and exercise that PT intervention provides. 

5. Return visit rates to the ED were very different between intervention groups.

The PT group had no return ED visits in the first 3 months, while the control group had 21% return within the first month. With EDs always trying to overcome high patient volume and improve cost effective care, PTs may help keep the EDs more open for patients with true emergencies and reduce hospital costs for outpatient type visits. The authors of the article attribute this finding to the type of PT intervention (pain neuroscience education, reassurance, etc.). I also wonder how much time a PT gets to spend with a patient compared to an ED physician, and if this affects this finding at all?

I hope this article can support a department’s decision to provide direct access PT in the ED to supplement and support the care physicians and APPs provide to patients, especially those presenting with non-traumatic musculoskeletal conditions. It would be interesting to see this type of research in a US healthcare setting, as well as for patients with other complaints like vertigo. PTs are an invaluable asset in any ED and this type of research helps support this claim.

1. Gagnon R, Perreault K, Berthelot S, Matifat E, Desmeules F, Achou B, Laroche MC, Van Neste C, Tremblay S, Leblond J, Hébert LJ. Direct-access physiotherapy to help manage patients with musculoskeletal disorders in an emergency department: Results of a randomized controlled trial. Acad Emerg Med. 2021 Aug;28(8):848-858. doi: 10.1111/acem.14237. Epub 2021 Apr 16. PMID: 33617696.