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Treating Pain In The ED

Pain is a constant in most any hospital emergency department, or E.D.,  and its treatment and management is a continual challenge. Health care teams working in these high-pressure environments see a high volume of patients with everything from life-threatening trauma to relatively minor health care needs. And they are on the front line of pain control for tens of thousands of people each year. Our nation’s concern about opioid use and the related search for non-addictive pain interventions is one force behind a new program at Barnes-Jewish Hospital: P.T. (physical therapy) in the E.D.

Low back pain alone accounts for more than 3 million emergency-department visits annually. Treating this condition with medication alone can mask symptoms without addressing the cause, notes Robert Poirier, MD,  a Washington University emergency physician at Barnes-Jewish Hospital who was instrumental in introducing PT to the ED. “Physicians may not be trained in the biomechanics of movement,” he notes. But physical therapists are trained to teach people how to walk and sit, and how to lift objects properly. And they can use supportive treatments, such as splints or kinesiology taping, to address pain, and reduce hospital admissions and recurrent ED visits.

Physical therapist Debbie McDonnell, DPT, works in the ED at Barnes-Jewish Hospital, where she provides consultation and treatment to patients with a range of problems, including acute musculoskeletal pain caused by trauma or other health issues.

“I treat people in the ED for pain and mobility problems after underlying causes, such as stroke, have been ruled out,” McDonnell says. Before receiving therapy for pain, patients are assessed to determine whether they need ongoing rehabilitation or hospital admission.

In many cases, McDonnell notes, she works with patients to help them learn how to move and function without exacerbating existing conditions. “And I work to teach patients how to manage their pain levels themselves,” McDonnell adds. “For some people, this is a new concept. Often they assume drugs are the only answer to pain.”

“My experience with patients in the ED suggests that we are able to prescribe less opioid and anti-inflammatory medications to those who receive physical-therapy intervention,” Poirier says. “And  there are times when a physical therapist can confirm that a patient’s pain is not musculoskeletal, so we can begin to search for other causes.” In short, physical therapy can also be used to help make a quick and accurate diagnosis, he adds.

During McDonnell’s tenure in the ED, she has seen both heightened awareness of and increased demand for PT as a treatment for pain, though she notes that the presence of PT providers in EDs across the U.S.  can still be unusual.

Brent Ruoff, MD, Barnes-Jewish Hospital’s chief of emergency medicine, agrees with her. “When we decided to work with other EDs to determine best practices, we weren’t able to find many departments with similar programs,” he says. “We don’t yet have hard data on outcomes, but our preliminary comparative data show improvement in patient-reported pain and a decreased use of narcotics.”

Few studies of the efficacy of PT in the ED have been published to date. However, a September 2016 article in the journal Physical Therapy notes that physicians are coming to appreciate the value of physical therapists in emergency-medicine settings.

Ruoff describes PT in the ED as a novel approach, noting that a common public perception of physical therapy is that it is “something a doctor orders for rehabilitation.” Instead, Ruoff says, it can be part of a patient’s primary evaluation and an effective intervention for pain.  

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