Physical Therapy in the Emergency Department

Emily Ho, MD
University of Pennsylvania Hospital System, Department of Emergency Medicine
C. Michael Lee, DO CAQSM
Kaiser Permanente Central Valley, Department of Emergency Medicine

Introduction

Physical therapy (PT) is an appropriate treatment modality for multiple conditions evaluated in the emergency department (ED) including musculoskeletal (MSK) ailments, peripheral vertigo, gait disturbances, deconditioning, and frequent falls. In the ED, access is often limited, and patients may be instructed to follow-up outpatient for PT for referrals or even be admitted to the hospital for PT evaluation. However, patients may struggle to get timely appointments or follow-up for PT which may result in repeat ED visits, and admission solely for PT evaluation can strain an increasingly burdened healthcare system. Over the last decade, a new practice model where PT is initiated from the ED has been emerging, and this approach not only seems to be both well-received by patients and physicians but may also confer benefits to patients and the healthcare system.^1,2

Effects of Physical Therapy on Opioid Administration and Prescriptions

It is estimated that up to 20% of ED visits are MSK in nature, and this number is only expected to rise as the patient population ages.³ Common MSK complaints, such as low back pain or neck pain, are often managed with a combination of pharmacologic and non-pharmagologic treatments, such as non-steroidal anti-inflammatory drugs (NSAIDS), acetaminophen, lidocaine patches, heat/ice packs, and occasionally steroids. Other medications like cyclobenzaprine, methocarbamol, benzodiazepines, and opioids may also be utilized despite the potential drawbacks including drowsiness, which may lead to falls and subsequent injuries, the inconvenience of being unable to drive, and addiction potential.

Because of these potential negative side effects and concerns about the ongoing opioid epidemic in the United States, physicians should consider different methods to mitigate these risks. Incorporating PT early may be one such approach. One study found that early PT, defined as at least one PT session within 90 days of when a patient received a MSK diagnosis of shoulder, neck, knee, or low back pain, was associated with decreased opioid use and reduction in the amount of opioids used.⁴ Another study found that patients receiving PT for low back pain within 30 days of the ED visit had a lower risk of long-term opioid use when compared to those patients that received PT 31-90 days after the ED visit.⁵  

Another study evaluating patients who presented to the ED for neck and back pain found that a more conservative approach from the ED (referral to PCP or PT) led to decreased opioid prescriptions when compared to escalated care (hospital admission, repeat ED visit, referral to specialist).⁶  There also appears to be a potential decrease in opioid use when PT is initiated or performed in the ED. One prospective observational study found that patients who presented to the ED with MSK pain had lower opioid administration in the ED if they underwent PT while in the ED although this finding did not hold true for the low back pain subgroup, and there was no decrease in outpatient opioid prescription.⁷ A different prospective observational study, however, did find that patients with acute low back pain receiving PT in the ED had a lower use of high-risk medications (opioids, benzodiazepines, and muscle relaxers).⁸

Physical Therapy for Falls in Geriatric Patients

Geriatric patients are at higher risk for falls due to a combination of factors including age-related muscle atrophy, decreased proprioception, and decreased psychomotor speed or reaction times, which consequently puts them at increased risk for fractures, intracranial injuries, hospitalization, and death.⁹ Many of these patients suffer from recurrent falls, with one study finding that approximately 26% of geriatric patients who presented to the ED for a fall fell at least one more time within a year, and about half of the recurrent falls occurred within the first 3 months after discharge from the initial fall.¹⁰

National guidelines recommend performing fall-risk assessments in the ED and providing resources to decrease chances of a future fall; however, despite these recommendations, there is no clear consensus or guidance on how to implement these assessments or interventions.^10,11 Only 40% of accredited geriatric EDs in the United States have a program for post-ED visit fall prevention, and many of them do not incorporate PT evaluations.¹¹

Although PT evaluation and other fall-risk prevention measures in the ED are not yet a widespread practice, there has been some data suggesting benefit. One analysis found that patients 65 years of age or older who received PT services while in the ED for a ground-level fall had a significantly lower probability of a fall-related ED visit at 1 and 2 months.¹² Another study found that providing a structured pharmacy and PT consultation in the ED to older patients with a recent fall led to these patients being about one-third less likely to have a fall-related ED visit in the next 6 months.¹³. Not only do these interventions have potential benefit in terms of reducing repeat visits, but they do not necessarily increase the duration of the ED visit, and over 95% of patients and clinicians would recommend the PT consult.¹⁴

Even if PT is not initiated in the ED, starting an early exercise program after discharge from the ED does lead to significantly less functional decline at 3 months when compared to patients who did not complete the exercise program.¹⁵ Elderly patients that received a training session and walking aid prior to discharge from the ED also had improved mobility and decreased fear of falling at 90 days when compared to a control group.¹⁶

Effects of Physical Therapy on the Healthcare System

With increasing patient volumes and aging population, hospital and ED administrators are searching for strategies to address overcrowding and reduce costs and resource utilization. Initiating PT in the ED may be beneficial in expediting treatment for certain patients and decreasing length of stay (LOS) times. A prospective observational study found that providing PT assessment in the ED for MSK pain decreased LOS by about 2 hours and also led to lower x-ray rates.⁷ A different prospective study found that initiating PT in the ED had both short-term and long-term benefits as patients that underwent PT in the ED had significantly improved pain at the time of ED discharge than those that did not see PT; furthermore, these patients were less likely to return to the ED or urgent care for the same complaint in the next year and were also more likely to establish and maintain care outside of emergency services.¹⁷ Admission to the hospital for the sole purpose of PT evaluation may put strain on the hospital as it utilizes additional resources, increases LOS, and is costly to patients and health care systems, but initiation of PT in the ED appears to be a reasonable intervention to decrease hospital admissions with a very low bounceback rate within 72 hours when applied to patients that had issues with ambulation but were otherwise medically cleared.² Even if patients did not receive PT in the ED, early PT after an ED visit for low back pain led to lower risk of lumbar surgery, decreased advanced imaging, and fewer healthcare costs in the 12 months after the ED visit.⁵

Conclusion

Emergency departments continue to serve as the frontline for the healthcare system, and PT is a cornerstone of management for many of the issues that ED physicians encounter such as MSK complaints, falls, deconditioning, and functional decline. Implementing PT into emergency care has promising upsides including reducing opioid administration and use, lowering imaging utilization, decreasing length of stay and hospital admissions, and curtailing repeat visits.  

Admittedly, implementing PT in the ED does pose logistical challenges. Emergency departments, by definition, provide continuous care at all hours, while PT typically operates during business hours. Holding patients in the ED to see PT may help with overall hospital flow but may worsen already extreme boarding times for the ED itself. Additionally, hospital policy may not permit PT to see patients until they are admitted to inpatient floors. Some hospitals may not even have any PT services available, and although there may be long-term cost savings, hiring PT and establishing a PT program will require upfront costs that the hospital may not be able to afford.

Despite these obstacles, initiating PT in the ED can potentially serve as a tool in augmenting value-based care by improving outcomes and limiting healthcare costs in the long-term. Broader adoption of this healthcare model would allow PT to be a routine and integral component of emergency care rather than an underutilized adjunct.  

REFERENCES

• Kim HS, Strickland KJ, Mullen KA, Lebec MT. Physical therapy in the emergency department: A new opportunity for collaborative care. The American Journal of Emergency Medicine. 2018;36(8):1492-1496. doi:https://doi.org/10.1016/j.ajem.2018.05.053
• 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. Journal of the American College of Emergency Physicians Open. 2020;1(5):880-886. doi:https://doi.org/10.1002/emp2.12075
• Miller A. Evaluation of Common Musculoskeletal Injuries in the Urgent Setting. MedEdPORTAL Publications. 2016;12. doi:https://doi.org/10.15766/mep_2374-8265.10514
• Sun E, Moshfegh J, Rishel CA, Cook CE, Goode AP, George SZ. Association of Early Physical Therapy With Long-term Opioid Use Among Opioid-Naive Patients With Musculoskeletal Pain. JAMA Network Open. 2018;1(8):e185909. doi:https://doi.org/10.1001/jamanetworkopen.2018.5909
• Magel J, Kim J, Fritz JM, Freburger JK. Time Between an Emergency Department Visit and Initiation of Physical Therapist Intervention: Health Care Utilization and Costs. Physical Therapy. 2020;100(10):1782-1792. doi:https://doi.org/10.1093/ptj/pzaa100
• Horn ME, Simon CB, Lee HJ, Eucker SA. Associations Between Management Pathway and Opioid Prescriptions for Patients Entering the Emergency Department With Neck and Back Pain. Mayo Clinic Proceedings Innovations Quality & Outcomes. 2023;7(5):490-498. doi:https://doi.org/10.1016/j.mayocpiqo.2023.08.001
• Pugh A, Roper K, Magel J, et al. Dedicated emergency department physical therapy is associated with reduced imaging, opioid administration, and length of stay: A prospective observational study. Miller AC, ed. PLOS ONE. 2020;15(4):e0231476. doi:https://doi.org/10.1371/journal.pone.0231476
• 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):pzaa219. doi:10.1093/ptj/pzaa219
• Kilaitė J, Dadelienė R, Ginevičienė V, et al. Psychomotor Speed and Fall Risk in Older Adults with Sarcopenia and Frailty: A Cross-Sectional Study. Medicina. 2025;61(4):706. doi:https://doi.org/10.3390/medicina61040706
• Curran-Groome W, Klein G, Miller SB, et al. Risk Factors of Recurrent Falls Among Older Adults Admitted to the Trauma Surgery Department. Geriatric Orthopaedic Surgery & Rehabilitation. 2020;11:215145932094316. doi:https://doi.org/10.1177/2151459320943165
• Southerland LT, Chesko D, Arendts G, et al. Outcomes of Physical and Occupational Therapy Evaluation in the Emergency Department for Older Adults With Falls: A Retrospective Multicenter Cohort. JACEP Open. 2025;6(4):100141. doi:https://doi.org/10.1016/j.acepjo.2025.100141
• 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. Journal of the American Geriatrics Society. 2018;66(11):2205-2212. doi:https://doi.org/10.1111/jgs.15469
• Goldberg EM, Marks SJ, Resnik LJ, Long S, Mellott H, Merchant RC. Can an emergency department–initiated intervention prevent subsequent falls and health care use in older adults? A randomized controlled trial. Annals of Emergency Medicine. 2020;76(6). doi:https://doi.org/10.1016/j.annemergmed.2020.07.025
• Goldberg EM, Marks SJ, Ilegbusi A, Resnik L, Strauss DH, Merchant RC. GAPcare: The Geriatric Acute and Post‐Acute Fall Prevention Intervention in the Emergency Department: Preliminary Data. Journal of the American Geriatrics Society. 2019;68(1):198-206. doi:https://doi.org/10.1111/jgs.16210
• Sirois M, Blais J, Mylène Aubertin‐Leheudre, et al. Effectiveness of Exercise in Older Adults Discharged From the ER After Minor Injuries: The CEDeComS Stepped‐Wedge Trial. Journal of the American Geriatrics Society. Published online October 20, 2025. doi:https://doi.org/10.1111/jgs.70166
• Polesel FS, Denadai S, Morinaga CV, et al. Walking Aids and Locomotion Training in the Emergency Department: A Randomized Clinical Trial. JAMA network open. 2025;8(11):e2544535. doi:https://doi.org/10.1001/jamanetworkopen.2025.44535
• Stilley J, Bogler M, Sampson C, et al. Physical therapy in the Emergency Department: A prospective cohort study from an Alternatives to Opioids program. Journal of the American College of Emergency Physicians Open. 2024;5(3). doi:https://doi.org/10.1002/emp2.13185