Low-severity musculoskeletal complaints evaluated in the emergency department

Physical therapy in the Emergency Department: A prospective cohort study from an Alternatives to Opioids program

Objective

Musculoskeletal pain complaints are common in the emergency department (ED). The objective of this study was to determine the impact of physical therapy (PT) in the ED on pain and ED return.

Methods

A prospective cohort study was performed with those presenting to the ED or Urgent Care at a single academic center for musculoskeletal pain between November 2020 and December 2022. All patients were referred to outpatient PT. During business hours, PT was available to begin treatment in the ED. Long-term follow-up was performed using the electronic health records. Statistical analyses included descriptive and non-parametric pairwise comparisons, Fisher's exact test, and multiple logistic regression.

Results

A total of 974 patients were included in the study with 553 completing optional surveys. Back pain was most common. Pain was reduced at ED discharge for all patients, but pain was significantly improved if patients saw PT in the ED. Patients in the ED were less likely to keep their outpatient PT appointments than others, but importantly, patients who saw PT in the ED were less likely to return to the ED for the same complaint up to 1 year later. Those who kept PT appointments were likely to establish or maintain healthcare outside emergency services later.

Conclusions

Initiating PT in this ED reduces pain at ED discharge. However, patients who utilized PT were more likely to later utilize health care resources outside of emergency services. Those who saw PT in this ED were less likely to return to the ED for the same complaint up to 1 year later.

Operative treatment in non-emergency sports injuries: a sports medicine clinic experience

PURPOSE

To elucidate referrals from sports medicine clinic (SMC) to orthopedics, consensus rates among physicians and surgeons on surgical need in these patients, and reasoning of the patients who refused to have surgery despite the recommendations by both groups in non-emergency sports injury patients.

METHODS

We conducted a retrospective cohort analysis by using the administrative and referral records of a sports medicine clinic for the 15 months between October 2017 and January 2019. Gender, age, diagnosis, and type of sport were compared between two groups (patients referred to orthopedics vs patients treated in SMC). Agreement between orthopedics and SMC on surgical need in those patients who were referred to orthopedics was evaluated. We additionally screened the hospital archive for surgery reports of patients recommended surgery, and, if a patient did not have a surgery record, we investigated the reasons by telephone interview and categorized these reasons.

RESULTS

Surgical evaluation needed for 4.7% (n = 155) of the patients. Patients referred to orthopedics were younger (median: 22.0 years), mostly male (n = 119, 76.8%), and involved in contact sports (n = 108, 69.7%) (p < 0.001 for all) compared to patients treated conservatively. Majority of the consultations were made owing to certain diagnoses such as cruciate/collateral ligament sprain (n = 70, 45.2%), meniscal tear (n = 21, 13.5%), and cartilage injuries (n = 15, 9.7%). Most of the patients diagnosed with Achilles tendon rupture (n = 2, 100%) and patellar instability (n = 13, 81.3%) were referred to surgery. Orthopedics agreed with the sports medicine physicians' opinions in most cases (n = 110, 71.0%). Thirty-four patients (30.9%) recommended surgery by the surgeon postponed/refused the treatment for various reasons or had surgery in another hospital.

CONCLUSION

Most non-emergency sports injuries can be treated conservatively. Young and male patients participating in contact sports are more likely to need surgical treatment. Non-surgeon musculoskeletal health-care providers may consider referring patients to orthopedics considering the data demonstrated in this study. Nevertheless, patient's motivation to undergo an operation should be considered before referring to orthopedics.

Assessing Referrals to a Trauma and Orthopaedic Department: Evaluation of a Traffic Light System for Virtual Fracture Clinic in the Emergency Department and Urgent Care

Background The Trauma and Orthopaedic (T&O) on-call service receives referrals from the emergency department (ED), general practice (GP) and urgent treatment centres (UTCs) and requests for inpatient reviews. The virtual fracture clinic (VFC) pathway allows ED and UTC clinicians to assess, discharge and refer when necessary. For VFC, the on-call orthopaedic consultant reviews the cases the next working day and makes an appropriate plan. This pathway consists of a traffic light system, in which practitioners can either safely discharge with written advice (green), refer to the VFC (yellow) or refer to the on-call team (red). Method The aim of this study was to assess how the VFC pathway was being utilised. All referrals to the T&O on-call team over three weeks were evaluated retrospectively. The following referrals were excluded: fractured femur, head injury, trauma calls and back pain pathway. The following data were collected: patient details, diagnosis, referral source, reason for referral, plan, double booking with VFC and appropriateness. Results A total of 191 referrals were analysed. Most referrals are from the ED (51%) and UTC (23%). Of the referrals, 39% were deemed to be inappropriate. Of the inappropriate referrals, 35% should have been referred directly to the VFC rather than the on-call team. A significant minority (7%) of inappropriate referrals were referred to the on-call team and VFC. Conclusion Education and collaboration are required with the ED and UTC to ensure the proper use of the VFC pathway. Immediate radiograph reporting may also be beneficial.

Patients with Musculoskeletal Disorders Presenting to the Emergency Department: The COVID-19 Lesson

Background: Musculoskeletal disorders (MSKDs) are the most common class of complaints among patients presenting for care in the Emergency Department (ED). There is a non-urgent patient population with musculoskeletal complaints attending ED services that creates a burgeoning waiting list and contributes to overcrowding in Emergency Departments (EDs), which is a major concern worldwide. The recent (Coronavirus disease-19) COVID-19 pandemic is an unprecedented challenge that is revealing the structural and situational strengths and weaknesses of healthcare systems. Methods: This study retrospectively and prospectively assessed patients presenting to the Emergency Department before and after the COVID-19 outbreak (from 21 February 2019 to 3 May 2019 and from 21 February 2020 to 3 May 2020) with non-traumatic or low-severity musculoskeletal conditions to test the hypothesis that these patients should have access to care outside the ED and that the COVID-19 outbreak has changed patients’ care and health perception. Results: A total of 613 patients were identified, and 542 of them (87.56%) participated in a personalized survey. From this number, 81.73% of the total accesses took place in 2019, and only 18.27% of the accesses took place during the first outbreak and lockdown. More than 90% of patients admitted to the ED accessed care during the day shift in both periods. A total of 87.30% of patients presenting to the ED with a MSKD followed their general practitioner’s (GP) advice/referral in 2019, and 73.87% did so in 2020. The differences in the means of transport to the ED was statistically significant (p-value 0.002). Conclusions: The outbreak and lockdown period confirmed that there is an inappropriate use of the ED related to patients with MSKD. However, the ED appears to be the only available solution for these patients. New services and pathways are therefore needed to enhance MSKD management and reduce ED crowding. Additional observational studies shall be developed to confirm and compare our findings with those of various EDs. The main limit of the inferential part of the study is probably due to the small sample of patients in 2020.

The aging athlete

Aging athletes, those 60 years and older, are a growing population of mature, active individuals who value sports and exercise participation throughout their lifespan. Although recommendations for younger and masters athletes have been extrapolated to this population, there remains a paucity of specific guidelines, treatment algorithms, and considerations for aging athletes. The benefits of living an active lifestyle must be weighed against the risks for unique cardiovascular, metabolic, and musculoskeletal injuries requiring diagnostic and therapeutic interventions. In this article, we review the unique cardiovascular and muscular physiology of aging athletes and how it influences the risk of specific medical conditions. We also discuss general prevention and treatment strategies. Finally, we identify areas of future research priorities and emerging treatments.

Health-Related Quality of Life of Patients Presenting to the Emergency Department with a Musculoskeletal Disorder

Background

Musculoskeletal disorders (MSKDs) are among the most disabling and costly non-fatal health conditions. They may lead to long-term consequences such as chronic pain, physical limitations, and poorer quality of life. They also account for a significant proportion of emergency department visits, representing between 18% and 25% of all visits, depending on country.

Purpose

To assess the health-related quality of life of patients presenting to the emergency department with a MSKD, to convert their answers to utility scores and to explore the association between diverse socio-demographic and clinical variables and patients’ health-related quality of life.

Patients and Methods

This is an analysis of cross-sectional data obtained during the baseline assessment performed as part of a 6-month pragmatic randomized controlled trial conducted in an academic emergency department. We included patients aged 18–80 years with a minor MSKD. The main outcome measures were health-related quality of life (five dimensions: mobility, self-care, usual activities, pain/discomfort, and anxiety/depression) and utility scores (−0.148 – worse than death, 0 – dead, 0.949 – perfect health) measured with the EQ-5D-5L. Possible associations were explored by comparing scores across subgroups based on certain socio-demographic (eg, age, gender, triage score) and clinical factors (eg, pain interference on function, pain intensity) and with reference values using descriptive statistics (mean, median), rankFD ANOVAs, and χ² tests.

Results

Sixty-nine participants completed the EQ-5D-5L. Mean and median utility scores were, respectively, 0.536 (95% CI: 0.479–0.594) and 0.531 (IQR: 0.356–0.760). Participants with higher levels of pain (<4/10: 0.741, 95% CI: 0.501–0.980; 4–7/10: 0.572, 0.500–0.644; >7/10: 0.433, 0.347–0.518) or pain interference on function (<4/10: 0.685, 95% CI: 0.605–0.764; 4–7/10: 0.463, 0.394–0.533; >7/10: 0.294, 0.126–0.463) presented significantly lower utility scores. No significant differences were found for other socio-demographic characteristics.

Conclusion

In patients with MSKDs who present to the emergency department, higher levels of pain or pain interference are associated with decreased health-related quality of life. These findings need to be confirmed on a larger scale.

Direct-access physiotherapy to help manage patients with musculoskeletal disorders in an emergency department: Results of a randomized controlled trial

OBJECTIVES

The objective was to evaluate the effects of direct-access physiotherapy on patients presenting with a musculoskeletal disorder (MSKD) to the emergency department (ED) on clinical outcomes and use of health care resources.

METHODS

We conducted a randomized controlled trial in an academic ED in Québec City, Canada. We included patients aged 18 to 80 years with minor MSKD. The intervention group had direct access to a physiotherapist (PT) in the ED immediately after triage and prior to physician assessment, and the control group received usual care by the emergency physician without PT intervention. The key variables included clinical outcomes (pain, interference of pain on function) and resources use (ED return visit, medications, diagnostic tests, additional consultations). They were analyzed using descriptive statistics and compared between groups using two-way analyses of variance, log-linear analysis, and chi-square tests.

RESULTS

Seventy-eight patients suffering from MSKDs were included (40.2 ± 17.6 years old; 44% women). For the primary clinical outcome, participants in the PT group (n = 40) had statistically lower levels of pain and pain interference at 1 and 3 months. In terms of resource use, participants in the PT group returned significantly less often to the ED. At baseline and 1 month, less prescription medication was used, including opioids, but there were no differences at 3 months. Although over-the-counter medication was recommended more at baseline in the PT group, there were no differences in use at 1 month, and the PT group had used them less at 3 months. There were no differences between groups at follow-up for imaging tests, other professionals consulted, and hospitalization rates.

CONCLUSION

Patients presenting with a MSKD to the ED with direct access to a PT had better clinical outcomes and used less services and resources than those in the usual care group after ED discharge and up to 3 months after discharge.

Musculoskeletal Conditions in the Emergency Room: A Teaching Opportunity for Medical Students and Residents

OBJECTIVE

Assess the potential value of an emergency room (ER) for the teaching of musculoskeletal (MSK) medicine to medical students and residents in training.

METHODS

Data from all encounters to the ER of a teaching hospital for calendar years 2016-2019 were extracted from an electronic database. Encounters with ICD-10-CM M codes (MSK system) and S codes (injury) were selected (MSK encounters). Frequency distributions were calculated by year, sex, and age group for all encounters and MSK encounters. Annual distributions of encounters involving the shoulder, hip, knee, and ankle joints were assessed.

RESULTS

The number of unique patients seen during the four-year period was 84,094, and the number of encounters was 187,829 (Median: 1 encounter; interquartile range: 1-2). The mean number of encounters per year was 46,957 (range: 45,311- 48,382). There was no seasonal variation. Most patients were women (45,868; 54.6%) and young (20 29 yr.) adults (15,012; 17.8%), and these groups generated the largest numbers of encounters (women: 108,799; 57.9%; young adults: 35,969; 19.1%). A total of 41,353 encounters (22.0% of all encounters) involved the MSK system. The shoulder, hip, knee, and ankle were involved in 2,768 (1.5%), 1,592 (0.8%), 3,082 (1.6%), and 1,718 (0.9%) encounters, respectively. The most common conditions for each joint were shoulder pain, femoral fracture, knee contusion, and ankle sprain.

CONCLUSION

Our findings suggest that ER physicians should have broad knowledge of MSK conditions and injuries. An ER is an excellent location for the teaching of MSK medicine to medical students and residents of other training programs.

Point-of-care Ultrasound Diagnosis of Bilateral Patellar Tendon Rupture

Musculoskeletal complaints are one cornerstone of urgent issues for which orthopedic and emergency physicians provide care. Ultrasound can be a useful diagnostic tool to help identify musculoskeletal injuries. We describe a case of bilateral patellar tendon rupture that presented after minor trauma, and had the diagnosis confirmed at the bedside by point-of-care ultrasound. Physicians caring for patients with orthopedic injuries should be familiar with the use of ultrasound to diagnose tendon ruptures.

Are Nonpharmacologic Pain Interventions Effective at Reducing Pain in Adult Patients Visiting the Emergency Department? A Systematic Review and Meta-analysis

OBJECTIVES

Pain is a common complaint in the emergency department (ED). Its management currently depends heavily on pharmacologic treatment, but evidence suggests that nonpharmacologic interventions may be beneficial. The purpose of this systematic review and meta-analysis was to assess whether nonpharmacologic interventions in the ED are effective in reducing pain.

METHODS

We conducted a systematic review of the literature on all types of nonpharmacologic interventions in the ED with pain reduction as an outcome. We performed a qualitative summary of all studies meeting inclusion criteria and meta-analysis of randomized controlled studies measuring postintervention changes in pain. Interventions were divided by type into five categories for more focused subanalyses.

RESULTS

Fifty-six studies met inclusion criteria for summary analysis. The most studied interventions were acupuncture (10 studies) and physical therapy (six studies). The type of pain most studied was musculoskeletal pain (34 studies). Most (42 studies) reported at least one improved outcome after intervention. Of these, 23 studies reported significantly reduced pain compared to control, 24 studies showed no difference, and nine studies had no control group. Meta-analysis included 22 qualifying randomized controlled trials and had a global standardized mean difference of -0.46 (95% confidence interval = -0.66 to -0.27) in favor of nonpharmacologic interventions for reducing pain.

CONCLUSION

Nonpharmacologic interventions are often effective in reducing pain in the ED. However, most existing studies are small, warranting further investigation into their use for optimizing ED pain management.

Developing quality indicators for the care of patients with musculoskeletal injuries in the Emergency Department: study protocol

BACKGROUND

Musculoskeletal injuries are a common presentation to the Emergency Department (ED). The quality of care provided is important to the patients, clinicians, organisations and purchasers of care. In the context of the increasing burden of musculoskeletal disease, quality of care needs to occur despite financial impacts, variations in care, and pressure to reach time-based performance measures. This study aims to develop a suite of evidence-based quality indicators (QI) which will provide a measure of the quality of care for patients with musculoskeletal injuries in the ED.

METHODS

This study will utilise a multi-phase mixed methods protocol, commencing with a systematic review of the literature to identify and critically appraise existing QIs for musculoskeletal injuries in the ED. The study will then build on the gaps identified in the review to develop a suite of preliminary QIs, in accordance with established research methodology under the governance of an expert panel. The developed QI set will then be field-tested for feasibility and validity in selected EDs. After field-testing, the suite will be refined in consultation with the expert panel and finalised using a formal voting process.

DISCUSSION

The assessment of performance against QIs provides a quantitative measure for the quality of care provided to patients, to identify and target quality improvement activities. The QIs developed through this study will be evidence-based and balanced across the areas of structures, processes and outcomes. The rigorous methodology used to develop and test the QIs will result in QIs that are meaningful, valid, feasible to collect and efficiently measurable, amenable to improvement, and selected by experts in the emergency medicine field. The final QI suite will have applications across EDs that affords comparison, benchmarking and optimisation of emergency care for patients.

Physician Impressions of Physical Therapist Practice in the Emergency Department: Descriptive, Comparative Analysis Over Time

BACKGROUND

Emergency department (ED) use in the United States is expected to rapidly increase. Nearly half of all ED visits are classified as semiurgent or nonurgent, and many fall into the musculoskeletal category. Despite growing international evidence that patients are appropriately and safely managed by ED physical therapists in a time-efficient manner, physical therapist practice in EDs is not widely understood or utilized in the United States. To date, no studies have reported the impressions of ED physicians about this practice.

OBJECTIVES

The purposes of this study were: (1) to assess ED physicians' impressions of ED physical therapist practice 2 years after practice was initiated and (2) to determine whether physicians' impressions changed 7 years later.

METHODS

All ED staff physicians and medical residents at a level I trauma hospital were invited to complete a survey in 2004 and 2011.

RESULTS

In both years, a majority of physicians reported favorable impressions of ED physical therapist practice. Physical therapists were valued for educating patients about safety and injury prevention, providing appropriate gait training, assisting with disposition planning, and providing interventions as alternatives to pain medication. Many physicians supported standing physical therapist orders for certain musculoskeletal conditions. The most common concern was the additional time that patients spend in the ED for a physical therapist consult.

LIMITATIONS

The results of this study may not reflect the impressions of physicians in all EDs that employ physical therapists.

CONCLUSIONS

Emergency department physicians reported favorable impressions of ED physical therapist practice 2 years and 9 years following its implementation in this hospital. This study showed that ED physicians support standing physical therapist orders for certain musculoskeletal conditions, which suggests that direct triage to ED physical therapists for these conditions could be considered.

Efficacy of knee joint aspiration in patients with acute ACL injury in the emergency department

PURPOSE

To evaluate the influence of joint aspiration on the sensitivity of physical examination for diagnosing acute anterior cruciate ligament (ACL) lesion in the second outpatient-department (OPD) follow-up referred from emergency department (ED).

METHODS

This retrospective study included sixty patients underwent ACL reconstruction with initial visit at ED. They were divided into two groups based on the presence or absence of joint aspiration at ED. All participants were referred to second OPD follow-up within 7-14days after the injury. Clinical manifestation (including visual analogue scale (VAS) for pain, range of motion (ROM), and severity of knee effusion) and physical examination (Lachman test and pivot shift test) were checked in ED and the second OPD follow-up.

RESULTS

The group of patients with joint aspiration (G1) showed substantial decreases in mean values of VAS for pain (p=0.005), ROM (p=0.001), and effusion level (p<0.001), even higher VAS and effusion level and lower ROM at the initial visit of ED than the other group (G2). The sensitivity of positive Lachman and pivot shift test was significantly (p<0.05) increased following knee joint aspiration. Positive Lachman test was recorded at 76.5% in the second follow-up in G1, which was significantly (p=0.047) higher than that (47.6%) in G2. The percentage of positive pivot shift test was recorded at 76.5% in the second follow-up in G1, which as significantly (p<0.001) higher than that (31.0%) in G2.

CONCLUSIONS

Knee joint aspiration in acute ACL injury with suspected hemarthrosis could be considered as a diagnostic procedure. Joint aspiration in early medical attendance might be able to lower pain scores or raise the sensitivity of physical examination for diagnosing acute ACL injury at follow up visit in orthopedic outpatient department.

LEVEL OF EVIDENCE

Retrospective cohort study III.

Physical Therapists as Primary Practitioners in the Emergency Department: Six-Month Prospective Practice Analysis

BACKGROUND

Increasing pressure on the emergency department (ED) throughout the world has meant the introduction of innovative ways of working. One such innovation is the advanced practice physical therapist (APP) acting as a primary contact practitioner. There has been little research into the role beyond identifying patient satisfaction with management, cost-effectiveness, and time efficiency. In order to give further support and assist in development of an APP service in the ED, an increased exploration of patient caseload demographics, resource utilization, and management outcomes is needed.

OBJECTIVES

The purpose of this study was to provide quantitative data regarding patient demographics, time efficiency, resource utilization, and management outcomes to examine the APP role in the ED.

DESIGN

This was a prospective observational study of practice.

SETTING

The study was conducted in a single ED in Melbourne, Australia.

METHOD

Data collection was conducted over a 6-month period. Patient demographics and diagnoses, assessment times, hospital resource utilization, and discharge destinations were recorded.

RESULTS

One thousand seventeen patients (45% female; median age=34 years, interquartile range=25-52) were managed by the APPs; 89% had conditions triaged as not serious or life threatening, and 97% had musculoskeletal pathologies, with the most common diagnosis being fracture or dislocation. Four-hour length-of-stay targets were met in 95% of the patients. Forty-six percent of the patients seen were managed independently, without any support from medical colleagues. The most frequent discharge destination was a referral back to the primary care physician or to hospital outpatient clinics. When comparing similar diagnostic groups, the APPs were significantly more time-efficient than ED physicians in their patient management.

CONCLUSIONS

This study described in detail the caseload managed by the APP in the ED and identified the role as a valuable asset to an ED, managing a great deal of their caseload independently, safely, and time efficiently.

[Prevalence of non-traumatic musculoskeletal pathology as main complaint and its impact in a emergency department]

BACKGROUND

Non-traumatic musculoskeletal pathology (NTMP) generates a high healthcare demand in primary care, however, European studies designed to assess its real impact in Emergency Departments are scarce. The present study aims to determine the prevalence of NTMP and its impact in Emergency Department of a university hospital in Madrid.

MATERIAL AND METHOD

Two thousand randomized medical registries were reviewed from 2008 to 2011. The epidemiological data collected were, main complaints, time consumed, image test requests, and need of further assessment within a month.

RESULTS

Prevalence of NTMP was 13.8% (95% CI; 12.1%-15.4%) of all patients. The most frequent musculoskeletal complaint was lumbar pain. An imaging test was requested in 79.1% of all the NTMP cases assessed. Patients with NTMP consumed an average of 79 minutes, with 17% of them requesting a new urgent assessment within the first month.

CONCLUSIONS

The results of this study show that NTMP is the leading cause for emergency department visits in our area, producing the highest consumption of time and the highest frequency of new queries for the same reason within a month. The overuse of the emergency services and the lack of medical training in the management of this type of pathology can cause this phenomenon. During the design of strategies to optimize patients care in emergency departments, the importance of this type of pathology should be taken into account.

Quality indicators for musculoskeletal injury management in the emergency department: a systematic review

OBJECTIVES

There is increasing importance placed on quality of health care for musculoskeletal injuries in emergency departments (EDs). This systematic review aimed to identify existing musculoskeletal quality indicators (QIs) developed for ED use and to critically evaluate their methodological quality.

METHODS

MEDLINE, EMBASE, CINAHL, and the gray literature, including relevant organizational websites, were searched in 2013. English-language articles were included that described the development of at least one QI related to the ED care of musculoskeletal injuries. Data extraction of each included article was conducted. A quality assessment was then performed by rating each relevant QI against the Appraisal of Indicators through Research and Evaluation (AIRE) Instrument. QIs with similar definitions were grouped together and categorized according to the health care quality frameworks of Donabedian and the Institute of Medicine.

RESULTS

The search revealed 1,805 potentially relevant articles, of which 15 were finally included in the review. The number of relevant QIs per article ranged from one to 11, resulting in a total of 71 QIs overall. Pain (n = 17) and fracture management (n = 13) QIs were predominant. Ten QIs scored at least 50% across all AIRE Instrument domains, and these related to pain management and appropriate imaging of the spine.

CONCLUSIONS

Methodological quality of the development of most QIs is poor. Recommendations for a core set of QIs that address the complete spectrum of musculoskeletal injury management in emergency medicine is not possible, and more work is needed. Currently, QIs with highest methodological quality are in the areas of pain management and medical imaging.

The physical therapist as a musculoskeletal specialist in the emergency department

Because patients with musculoskeletal 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 with physical therapy practice. Furthermore, early access to physical therapy, as can be provided in the ED setting, has the potential to positively influence 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.