Effects of involving physiotherapists in the management of low back pain at emergency departments: a systematic review

Background
Worldwide, emergency departments are burdened with patients seeking care for low back pain (LBP), despite guidelines recommend that these patients are managed in the primary care sector. This is problematic as patients often receive low value care such as unnecessary imaging, prescription of opioids, and hospitalization. This is also the case in Denmark, where more than 10,000 patients are referred to emergency departments every year due to LBP, even though the emergency departments are not part of clinical guidelines or patient pathway programs for patients with LBP. Physiotherapists have expert knowledge about musculoskeletal conditions like LBP, but are rarely primary caregivers in the emergency departments. In several countries, research and quality assurance studies have been conducted to investigate the benefits of physiotherapists in managing patients with LBP in emergency departments, but no review of the literature has been conducted to get an overview of interventions, effects and clinical implications of existing knowledge.

Purpose
The aim of the study was to conduct a systematic review investigating the effects of physiotherapy in emergency departments on health care use and patient-reported outcomes for patients referred to emergency departements due to LBP, compared with usual care.

Methods
A search was conducted in PubMed, Cinahl and Embase in April 2023, and rerun in January 2024. Randomised and quasi-randomised trials and observational studies including adult patients referred to an emergency department due to LBP were eligible. Study quality was assessed using ROBINS-I and PEDro, and the strength of the evidence was assessed using GRADE.

Results
Included studies were three retrospective cohorts, two prospective cohorts and two randomised controlled trials, totalling 4017 patients. Four of six studies were rated as serious risk of bias, primarily due to limitations in the study design, two studies were rated as moderate risk, and one as low risk. Overall, the studies indicated a positive effect of physiotherapy in comparison with usual care in relation to length of stay, imaging and patient satisfaction. For the remaining outcomes on health-care use and patient-reported outcomes, findings were inconclusive. For all outcomes, the certainty of the evidence was considered very low or low.

Conclusion(s)
The present review indicates that there may be beneficial effects of involving physiotherapists in the management of patients with LBP in emergency departments. However, given the very given the very low certainty of evidence the findings should be interpreted with great caution. Future high level evidence studies in the field should therefore be a priority.

Implications
This review supports the use of physiotherapists in the management of patients with LBP referred to emergency departments, primarily in relation to health service outcomes and patient satisfaction. However, the certainty of the evidence is low at best, and high quality research is needed. Furthermore, the content and amount of training for physiotherapists undertaking the task of LBP management in emergency departments is poorly described in the literature, hampering our knowledge about what skills are required. Therefore, future research and/or quality studies need to clearly report this, for our profession to move forward in this field.