The problem the RESHAP-ED team set out to address is a familiar one to anyone working in a busy public hospital – patients with musculoskeletal conditions accumulating in the emergency department (ED), often waiting many hours for assessment because their presentation is considered low acuity. 

Although musculoskeletal presentations make up a high proportion (approximately 15 per cent) of all ED visits, much of the care is focused on immediately life-threating or high-acuity conditions.

Patients presenting with back pain, joint injuries, simple fractures, dislocations and other uncomplicated musculoskeletal problems
can be left waiting. 

Physiotherapist researcher Dr Tarcisio de Campos APAM, a member of the RESHAP-ED trial investigator team, says most of those patients are in severe pain and can wait for many hours while higher priority cases are managed.

The scale of the issue is considerable, Tarcisio says. More than 1.3 million ED presentations in Australia each year are attributed to musculoskeletal conditions. 

While these patients may be clinically stable, their needs are not necessarily simple. 

They require accurate assessment, differential diagnosis, identification of red flags, appropriate investigation and imaging decisions as well as symptom management, education, rehabilitation advice and, where appropriate, discharge planning.

RESHAP-ED – a trial of physiotherapist-led care for musculoskeletal conditions in the ED, published in The Lancet – was designed to provide something that previous observational research could not: robust evidence about whether a physiotherapist-led care model actually improves outcomes compared with usual care. 

The pragmatic, multi-centre, open-label, two-arm randomised controlled trial was conducted across five public hospital EDs in New South Wales to investigate the effectiveness, safety and cost-effectiveness of a physiotherapist-led care pathway compared with the usual physician/nurse practitioner-led care pathway for adults presenting with an uncomplicated musculoskeletal condition.

The RESHAP-ED trial was led by principal investigators Specialist Research Physiotherapist (as awarded by the Australian College of Physiotherapists in 2012) Professor Chris Maher AM FACP and Associate Professor Gustavo Machado APAM, alongside Tarcisio, Dr Danielle Coombs and Dr Chathurani Sigera, whose clinical and research expertise contributed to the trial’s design implementation and evaluation.

Plan in action

Between November 2023 and March 2025, 1491 patients were recruited for the trial. Tarcisio says participants were randomly allocated to either usual care, led by emergency physicians or nurse practitioners, or care led by a physiotherapist. 

The randomised controlled trial design was important, he adds, because it removed much of the selection bias and confounding inherent in observational study designs.

The difference was striking, says Tarcisio. 

Patients assigned to the physiotherapist-led care group spent an average of 2.4 hours in the ED compared with 3.4 hours for those receiving usual care – an estimated reduction of an hour in total ED length of stay. Patients were assessed 40 minutes sooner and were three times more likely to be seen within the recommended triage timeframe. 

Ninety per cent were discharged within four hours. He notes that the improvements in efficiency were achieved without compromising pain, quality of life, adverse events or other clinical outcomes.

For physiotherapists, however, the significance of the findings goes beyond a reduction in waiting times. 

Dr Tarcisio de Campos APAM.

The model tested a fundamental shift in the traditional position of the physiotherapist within the multidisciplinary ED team: from a clinician who receives a referral after a medical assessment to one who acts as the leading clinician initiating the patient’s assessment, investigations and treatment.

‘That means quite a lot because they actually take on the role of leading the care of those patients,’ Tarcisio says. 

Under the model, the physiotherapist undertakes the initial assessment, establishes the diagnosis, develops and implements the management plan and, where clinically appropriate, can discharge the patient without the need for a physician assessment.

This, Tarcisio says, requires a different level of clinical responsibility and autonomy. 

A physiotherapist working in this setting needs to be able to undertake comprehensive clinical reasoning, distinguish mechanical and non-mechanical presentations, identify red flags and recognise when a patient’s presentation sits outside their scope of practice or requires medical investigation or escalation. 

The model is not, therefore, simply about moving an existing physiotherapy consultation further upstream; it is about positioning appropriately skilled physiotherapists as frontline clinicians within the ED. That does not mean that physiotherapists work in isolation, Tarcisio adds. He is clear that escalation remains an important part of the model. 

If a physiotherapist identifies red flags or other concerns during assessment and management, the patient is brought back to the wider ED team so that an appropriate clinical decision can be made.

A waiting game

For patients, the model potentially changes the experience of attending the ED for a musculoskeletal problem. 

Rather than waiting for an initial physician assessment before being referred to physiotherapy, the patient can be assessed by a clinician whose core expertise lies in the presentation in front of them.

That assessment can incorporate movement, function, neurological screening, clinical examination and consideration of the patient’s psychosocial context, followed by education, exercise or activity advice, manual therapy where appropriate, self-management strategies and referral or escalation when indicated.

Tarcisio says this is particularly relevant for presentations such as acute low back pain, where the challenge moves beyond identifying a painful structure and into determining whether there is an indication for urgent investigation or specialist medical input. 

It also creates an opportunity to address issues such as fear avoidance, expectations about imaging, appropriate activity and analgesia early in the patient journey rather than allowing an ED attendance to reinforce a passive or biomedical approach to persistent musculoskeletal pain.

Tarcisio points to the potential for physiotherapy to change some of the patterns traditionally associated with musculoskeletal presentations in emergency care, including unnecessary imaging and medication use. 

‘Physios are well prepared and well trained to look after those conditions,’ he says, highlighting the profession’s role in assessment and treatment as well as in educating patients and helping them to understand their condition and what they can do to manage it.

The patient experience also matters, Tarcisio says. 

Those receiving physiotherapist-led care reported higher satisfaction than those receiving usual care in the RESHAP-ED trial, suggesting that the benefits of the model are not simply matters of hospital efficiency. 

For a patient who has presented to an ED with acute pain, being assessed sooner, receiving an explanation of what is happening and having clear management and a discharge plan can make a meaningful difference to their experience of the health system.

The numbers add up

There is a wider health implication too, he says. ED crowding is not just an inconvenience for patients; it affects the capacity of hospitals to respond to acute injury and illness. 

Every hour that can be safely removed from the patient journey has the potential to release capacity for other patients, he says.

The economic evaluation undertaken alongside RESHAP-ED estimated that implementing physiotherapist-led care across New South Wales could save hospitals around $19 million a year and release more than 540,000 hours of ED capacity.

For health services and governments, this provides a compelling argument for considering physiotherapists as part of the frontline ED workforce. 

However, Tarcisio says that demonstrating effectiveness is only one part of the challenge. 

Embedding physiotherapists into routine frontline ED practice requires considerable planning in terms of governance, electronic medical record access, finance, data collection, service agreements, workforce and funding.

The practical realities of establishing the model were a significant focus of Tarcisio’s presentation at the APA’s national scientific conference in Adelaide last year. 

In his presentation he noted that some hospitals already had primary contact physiotherapy services, while others needed the model to be implemented as part of the trial. 

That meant developing the necessary agreements and processes, training clinicians and working out how the physiotherapy service could be integrated into existing ED systems without creating additional administrative or clinical burden.

Workforce availability was another consideration, Tarcisio added, noting that at one participating hospital, physiotherapy coverage had traditionally been limited to one physiotherapist working from 9 am to 5 pm, Monday to Friday. 

That was despite many of the musculoskeletal presentations occurring outside those hours, including on weekends. 

He says that if the profession is to take on a genuine primary contact role in EDs, services will need to consider coverage across evenings and weekends, alongside appropriate credentialing, education and access to senior clinical support.

Scope for more to come

Scope of practice, Tarcisio says, will continue to be part of the conversation. 

He points to the differences between jurisdictions, including medication prescribing, as an example of how the tools available to physiotherapists can influence their capacity to work 
autonomously. 

The research provides evidence that appropriately trained physiotherapists can safely assume greater responsibility for the management of suitable musculoskeletal patients but implementation will require health services and regulators to consider what competencies, governance and scope are necessary to support that role.

There may be opportunities to extend the principle beyond musculoskeletal physiotherapy. 

Tarcisio suggests that the multidisciplinary model could incorporate other clinicians with specific expertise, particularly for patients with more complex presentations such as chronic back pain and associated psychological distress. 

‘If you have a multidisciplinary team working together within that setting, I think the care they will deliver to patients would improve.’

Perhaps one of the most important messages from the RESHAP-ED trial is that the value of physiotherapy is not confined to the treatment delivered during a consultation, Tarcisio says. 

It is also about where physiotherapists are positioned within the health system, the decisions they are empowered to make and the problems they can help health services solve. 

He says the research demonstrates that having a physiotherapist-led care model can improve patient flow, reduce demand on other clinicians and offer a more efficient use of limited hospital resources.

He hopes the evidence will ultimately lead to this physiotherapist-led model of care becoming available in every Australian ED.

‘Our wish is for every single ED in Australia to have this model of care implemented.’ 

For a profession increasingly being asked to demonstrate its value within stretched health systems, RESHAP-ED offers something particularly powerful: evidence that putting physiotherapists in frontline care where their skills are most relevant can be good for patients, clinicians and the broader health system, Tarcisio says.

‘We all want to deliver better care and to reduce people’s suffering and not make them waste too much time sitting in emergency departments.’

Find out more about the RESHAP-ED trial here.