The Role of Physical Therapists in the Emergency Department

Over the past two decades, physical therapists have become key players within U.S. Emergency Departments (ED) in response to an overburdened healthcare system.1 According to the Emergency Medicine Treatment and Labor Act (EMTALA) enacted by the U.S. Congress in 1986, EDs are obligated to provide medical examination, medical stabilization, and if needed, hospital admission or transfer to any individual who requests such services, irrespective of diagnosis, gravity of symptoms, or ability to pay.2 In recent years, ED overcrowding has steadily increased in the U.S. and abroad,3 leading to a decrease in emergency department efficiency, longer wait times, patient and provider dissatisfaction, and higher work-related stress.4

The scope of practice of the ED PT is not consistent across the world.5 In some countries, the Emergency Department physical therapist (ED PT) acts as a primary ED provider and is tasked with triage, ordering of imaging, and medication prescription along with routine treatment and disposition planning.5,6 Within the U.S., EMTALA requires hospitals to designate qualified medical providers to initially evaluate patients in the emergency room, and this list of approved providers does not include physical therapists.2 Therefore, consultation of the ED PT occurs only after being cleared by the referring ED provider.1,6  

In the U.S., triage of a patient within the ED is based on the Emergency Severity Index, an algorithm that classifies a patient based on urgency and need.  Group 1 and group 5 are defined as the most and least urgent, respectively.7 Most cases seen by ED PTs fall within categories 3 through 5.1 Musculoskeletal diagnoses make up 20% of all ED visits, and they are the most common condition managed by ED PT’s followed by orthopaedic traumas, falls, and vertigo.1,5,8 Given that most patients that present to the ED with musculoskeletal issues and/or pain do not access traditional outpatient PT services due to a lack of referral, personal resolve, or medical coverage, ED PT may be their only opportunity to receive care.8

Preliminary evidence suggests that ED PTs in the U.S. positively impact patients and the overall healthcare systems.1,9 ED PT has been associated with decreased wait times, treatment times, and length of emergency room stays.  In addition, ED PT is associated with less inappropriate admissions and diagnostic imaging, resulting in significant cost savings.1,9,10 Older adults that are evaluated by an ED PT following a fall are more likely to be discharged with appropriate placement, thereby avoiding a hospital admission and subsequent ED visits within 30-60 days.10,11 Moreover, patients who receive care from an ED PT report higher rates of satisfaction, significantly less pain upon discharge, reduced use of analgesics, and greater functional improvements compared to standard care.5,12,13


In addition to improving the overall flow of the emergency department, ED PTs in the U.S. provide non-pharmacological pain management, assist with disposition planning, provide injury prevention training, and facilitate return to function.9,14 As a secondary contact, ED PTs perform bedside evaluations and treatments for any number of musculoskeletal, cardiopulmonary, neurological, vestibular, and integumentary dysfunctions.13 They also perform safety evaluations, prescribe assistive devices, administer wound care, and make recommendations regarding follow-up specialty services and admission disposition.14


Given the aforementioned duties of an ED PT, they must be proficient in non-pharmacological pain management and advanced clinical reasoning and possess strong communication skills.5,8


One of the primary reasons why patients visit the ED is pain management.1 A key variable in the management of acute pain in the ED is selecting approaches that improve pain and function while minimizing prescription opioids.15 The American Academy of Emergency Medicine White Paper on Acute Pain Management encourages the use of non-pharmacological approaches to pain within the Emergency Department, including modalities, dry needling/acupuncture, muscle energy techniques, osteopathic manipulation techniques, softtissue mobilization and exercise, among others.16,17 While patients in the ED often describe exercise as “painful,” “difficult to perform,” and/or simply unnecessary,18,19 evidence overwhelmingly supports the use of movement to optimize function, particularly in the early stages of traumatic and non-traumatic injury.20-22Moreover, according to the literature, patients referred to ED PT expect the use of manual therapy to manage pain.19 Low to moderate evidence supports the use of manual therapy techniques such as mobilization and manipulation for patients with musculoskeletal conditions to improve pain and function.23-26 For example, in patients with sacroiliac dysfunction, joint manipulation has been shown to be more effective than exercise for short-term reduction in pain.27 Interventions including osteopathic manipulations, early mobilization and education help decrease pain in patients presenting to the ED with acute low back pain when compared to control treatment (SMD: -0.39; 95% CI: -0.64, -0.13).17 Cervical manipulation, soft-tissue mobilization, and muscle energy techniques have also led to statistically meaningful changes in pain within one hour for patients with mechanical neck pain compared to intramuscular ketorolac.28 Furthermore, emerging evidence highlights the efficacy of direct interventions such as dry needling/acupuncture and softtissue mobilization for the management of acute pain in the ED (SMD: –0.40; 95% CI: –0.67, –0.13).17


Physical therapists employed in the ED are expected to provide insight into the diagnosis and treatment of neuromusculoskeletal conditions for patients of any age, health condition, or stage of injury.8 ED PTs are increasingly becoming valuable members of the ED team, as they have the knowledge and expertise to evaluate and manage complex patients and treat a broad array of neuromusculoskeletal conditions.14,29However, since most ED patients have multisystem involvement, ED PTs must possess the clinical reasoning, medical screening, and differential diagnosis skills to identify red and yellow flags and provide appropriate treatment beyond the musculoskeletal system.8,14,29 For example, an ED PT must be able to distinguish mechanical shoulder pain from an infected shoulder joint in the absence of red flags in a homeless man with a history of addiction,30 mechanical low back pain versus a pelvic ring fracture in an elderly woman with a history of falls,31 concussion versus a head bleed in an individual recently involved in an MVA,32 and benign hypoglycemia versus cardiac autonomic neuropathy in an individual with uncontrolled type II diabetes experiencing recurrent episodes of syncope and falls.33


Communication is as an essential skill for the ED PT to possess as it is closely linked with teamwork.19,34 Communication and teamwork are well-documented as integral components of the ED that lead to reduced clinical errors and sentinel events, improved diagnosis and treatment efficiency, and reduced wait times.35 Not all medical teams are the same: ED teams are unique within the healthcare system, as both the team members and the work demands are constantly changing.34 ED PTs must therefore be able to adapt to a continuously evolving work environment.33 Moreover, they must be able to relate to a variety of personality types and integrate various healthcare strategies with patient values.34 Finally, ED PTs must be able to communicate to team members and patients, while staying calm and portraying empathy and encouragement.14,19


In short, the skill level required for ED PTs exceeds that of an entry-level physical therapist, and the advanced training required by ED PTs remains a topic of debate in the literature.8 Moreover, ED PTs must be able to demonstrate meaningful change in considerably less time due to the lack of patient follow-up with outpatient services.8 Notably, physical therapists considered “experts” value the use of manual skills and touch over technology and equipment for the management of pain.36 Rodeghero et al found that fellowship-trained PTs may have better treatment results in fewer sessions compared to residency-trained physical therapists or those without post-professional residency or fellowship training.37 Resnik and Hart found that clinicians with any form of advanced orthopaedic training such as a board certification in Orthopaedics (OCS), a certification in manual therapy (MTC) or credentials from the American Academy of Orthopaedic Manual Physical Therapy (FAAOMPT) had better outcomes than those without in patients experiencing low back pain.38 Moreover, preliminary evidence suggests that post-professional training or certification may be important in developing improved clinical reasoning39 and communication skills40 required in an ED setting.


Practicing ED PTs require advanced training. Some have even suggested that ED PTs should have a unique residency and fellowship curriculum.8 Then again, maybe its time to rethink “entry-level” physical therapy.  Instead of investing time and money into the advanced-level training necessary to be an effective ED PT, perhaps its time to re-evaluate the Commission on Accreditation in Physical Therapy Education (CAPTE) requirements.  Given the projected shortage of physicians over the next 10-15 years,41 a stronger entry-level foundation may be required.  Perhaps formal residency training within a specialty of choice should part of the DPT curriculum, thereby elevating clinical reasoning, manual therapy, medical screening and communication proficiency across a broader array of settings. Elevating the standard of entry-level DPT education may give physical therapists a unique opportunity to step-up as physician extenders with a neuromusculoskeletal specialty to truly become the preferred providers and standard of conservative care in the ED setting.    


Germaine Hermann, DPT
Fellow-in-Training, AAMT Fellowship in Orthopaedic Manual Physical Therapy
Physical Therapist, Eskenazi Health, Indianapolis, IN

Raymond Butts, PhD, DPT, MSc, Dip. Osteopractic
Senior Instructor, American Academy of Manipulative Therapy
Coordinator, AAMT Fellowship in Orthopaedic Manual Physical Therapy
Louisville, KY

James Dunning, PhD, DPT, MSc, FAAOMPT, Dip. Osteopractic
Director, AAMT Fellowship in Orthopaedic Manual Physical Therapy
Owner, Montgomery Osteopractic Physical Therapy & Acupuncture Clinic
Montgomery, AL


1.         Matifat E, Mequignon M, Cunningham C, Blake C, Fennelly O, Desmeules F. Benefits of Musculoskeletal Physical Therapy in Emergency Departments: A Systematic Review. Phys Ther. 2019;99(9):1150-1166.

2. State Operations Manual: Appendix V Interpretive Guidelines Responsibilities of Medicare Participating Hospitals in Emergency Cases. Accessed April 9, 2021.

3.         Berchet C. Emergency care services: trends, drivers and interventions to manage the demand, OECD health working papers, no. 83. Paris: OECD Publishing; 2015.

4.         Vainieri M, Panero C, Coletta L. Waiting times in emergency departments: a resource allocation or an efficiency issue? BMC Health Serv Res. 2020;20(1):549.

5.         Ferreira GE, Traeger AC, Maher CG. Review article: A scoping review of physiotherapists in the adult emergency department. Emerg Med Australas. 2019;31(1):43-57.

6.         Kim HS, Strickland KJ, Mullen KA, Lebec MT. Physical therapy in the emergency department: A new opportunity for collaborative care. Am J Emerg Med. 2018;36(8):1492-1496.

7.         Emergency Severity Index (ESI): A Triage Tool for Emergency Departments. Content last reviewed May 2020. Agency for Healthcare Research and Quality, Rockville, MD. Accessed April 9, 2021.

8.         Lebec MT, Jogodka CE. The physical therapist as a musculoskeletal specialist in the emergency department. J Orthop Sports Phys Ther. 2009;39(3):221-229.

9.         Fruth SJ, Wiley S. Physician Impressions of Physical Therapist Practice in the Emergency Department: Descriptive, Comparative Analysis Over Time. Phys Ther. 2016;96(9):1333-1341.

10.      Gurley KL, Blodgett MS, Burke R, Shapiro NI, Edlow JA, Grossman SA. The utility of emergency department physical therapy and case management consultation in reducing hospital admissions. J Am Coll Emerg Physicians Open. 2020;1(5):880-886.

11.      Lesser A, Israni J, Kent T, Ko KJ. Association Between Physical Therapy in the Emergency Department and Emergency Department Revisits for Older Adult Fallers: A Nationally Representative Analysis. J Am Geriatr Soc. 2018;66(11):2205-2212.

12.      Lau PM, Chow DH, Pope MH. Early physiotherapy intervention in an Accident and Emergency Department reduces pain and improves satisfaction for patients with acute low back pain: a randomised trial. Aust J Physiother. 2008;54(4):243-249.

13.      Kim HS, Ciolino JD, Lancki N, et al. A Prospective Observational Study of Emergency Department-Initiated Physical Therapy for Acute Low Back Pain. Phys Ther. 2021;101(3).

14.      Ferreira GE, Traeger AC, O’Keeffe M, Maher CG. Staff and patients have mostly positive perceptions of physiotherapists working in emergency departments: a systematic review. J Physiother. 2018;64(4):229-236.

15.      The Interagency Pain Research Coordinating Committee. National pain strategy: a comprehensive population health level strategy for pain. Bethesda, MD: National Institutes of Health; 2016.

16.      Motov S, Strayer R, Hayes BD, et al. The Treatment of Acute Pain in the Emergency Department: A White Paper Position Statement Prepared for the American Academy of Emergency Medicine. J Emerg Med. 2018;54(5):731-736.

17.      Sakamoto JT, Ward HB, Vissoci JRN, Eucker SA. Are Nonpharmacologic Pain Interventions Effective at Reducing Pain in Adult Patients Visiting the Emergency Department? A Systematic Review and Meta-analysis. Acad Emerg Med. 2018.

18.      Sheppard LA, Anaf S, Gordon J. Patient satisfaction with physiotherapy in the emergency department. Int Emerg Nurs. 2010;18(4):196-202.

19.      Anaf S, Sheppard LA. Lost in translation? How patients perceive the extended scope of physiotherapy in the emergency department. Physiotherapy. 2010;96(2):160-168.

20.      Beckmann M, Bruun-Olsen V, Pripp AH, Bergland A, Smith T, Heiberg KE. Effect of exercise interventions in the early phase to improve physical function after hip fracture – A systematic review and meta-analysis. Physiotherapy. 2020;108:90-97.

21.      Wong JJ, Cote P, Shearer HM, et al. Clinical practice guidelines for the management of conditions related to traffic collisions: a systematic review by the OPTIMa Collaboration. Disabil Rehabil. 2015;37(6):471-489.

22.      Williams RM, Westmorland MG, Lin CA, Schmuck G, Creen M. Effectiveness of workplace rehabilitation interventions in the treatment of work-related low back pain: a systematic review. Disabil Rehabil. 2007;29(8):607-624.

23.      Weerasekara I, Osmotherly P, Snodgrass S, Marquez J, de Zoete R, Rivett DA. Clinical Benefits of Joint Mobilization on Ankle Sprains: A Systematic Review and Meta-Analysis. Arch Phys Med Rehabil. 2018;99(7):1395-1412 e1395.

24.      Ayub A, Osama M, Ahmad S. Effects of active versus passive upper extremity neural mobilization combined with mechanical traction and joint mobilization in females with cervical radiculopathy: A randomized controlled trial. J Back Musculoskelet Rehabil. 2019;32(5):725-730.

25.      Slaven EJ, Goode AP, Coronado RA, Poole C, Hegedus EJ. The relative effectiveness of segment specific level and non-specific level spinal joint mobilization on pain and range of motion: results of a systematic review and meta-analysis. J Man Manip Ther. 2013;21(1):7-17.

26.      Vincent K, Maigne JY, Fischhoff C, Lanlo O, Dagenais S. Systematic review of manual therapies for nonspecific neck pain. Joint Bone Spine. 2013;80(5):508-515.

27.      Al-Subahi M, Alayat M, Alshehri MA, et al. The effectiveness of physiotherapy interventions for sacroiliac joint dysfunction: a systematic review. J Phys Ther Sci. 2017;29(9):1689-1694.

28.      McReynolds TM, Sheridan BJ. Intramuscular ketorolac versus osteopathic manipulative treatment in the management of acute neck pain in the emergency department: a randomized clinical trial. J Am Osteopath Assoc. 2005;105(2):57-68.

29.      Lefmann SA, Sheppard LA. Perceptions of emergency department staff of the role of physiotherapists in the system: a qualitative investigation. Physiotherapy. 2014;100(1):86-91.

30.      Herman PM, Hurwitz EL, Shekelle PG, Whitley MD, Coulter ID. Clinical Scenarios for Which Spinal Mobilization and Manipulation Are Considered by an Expert Panel to be Inappropriate (and Appropriate) for Patients With Chronic Low Back Pain. Med Care. 2019;57(5):391-398.

31.      Stapleton ZM, Bohra M, Florence N. Pelvic Ring Fractures: Role of Physical Therapy in the Emergency Department. J Orthop Sports Phys Ther. 2019;49(12):942.

32.      Kim G, Miller J. Assessing Patients in the Wake of Motor Vehicle Accidents. The Journal of Urgent Care Medicine. 2009:11-19.

33.      Hermann, GM. Cardiac Autonomic Neuropathy: A Case Report. Unpublished work. 

34.      Manser T. Teamwork and patient safety in dynamic domains of healthcare: a review of the literature. Acta Anaesthesiol Scand. 2009;53(2):143-151.

35.      Kilner E, Sheppard LA. The role of teamwork and communication in the emergency department: a systematic review. Int Emerg Nurs. 2010;18(3):127-137.

36.      Jensen GM, Gwyer J, Shepard KF. Expert practice in physical therapy. Phys Ther. 2000;80(1):28-43; discussion 44-52.

37.      Rodeghero J, Wang YC, Flynn T, Cleland JA, Wainner RS, Whitman JM. The impact of physical therapy residency or fellowship education on clinical outcomes for patients with musculoskeletal conditions. J Orthop Sports Phys Ther. 2015;45(2):86-96.

38.      Resnik L, Hart DL. Influence of advanced orthopaedic certification on clinical outcomes of patients with low back pain. J Man Manip Ther. 2004; 12: 32– 43.

39.      Souter C, Musy E, Hartstein A, et al. Education and Experiential Factors Associated with Physical Therapits’ Diagnostic Reasoning. J Phy Ther Educ. 2019;33:198-208.

40.      Briggs MS, Whitman J, Olson-Kellogg B, et al. Employer Perceptions of Physical Therapists’ Residency and Fellowship Training: Insights for Career Development Planning. J Phy Ther Educ. 2019;33:40-48.

41.      Burns J. Does the U.S. Have a Shortage of Physicians? Managed Healthcare Executive. 2021;31(2).