What is the optimal timing and approach for ordering physical therapy for a patient presenting to an accident clinic with an acute injury, considering their potential pre-existing medical conditions and need for pain management?

Ordering Physical Therapy in an Accident Clinic Setting

For acute musculoskeletal injuries presenting to an accident clinic, initiate physical therapy immediately during the emergency department visit rather than waiting for outpatient referral, as early intervention significantly reduces pain and improves functional outcomes. 1

Immediate Physical Therapy Initiation

Begin physical therapy assessment and treatment before the patient leaves the accident clinic. Early physiotherapy intervention in the emergency department reduces pain by 1.6 points (on a 0-10 scale) at discharge and maintains pain reduction of 0.9 points at outpatient follow-up, while also increasing patient satisfaction by 2.1 points (on a 0-20 scale) 1. This approach is safe, with adverse events occurring in only 0.6% of sessions, and most requiring no additional treatment 2.

Initial Physical Therapy Components Should Include:

• Education and reassurance about expected recovery trajectory 1
• Pain management strategies including appropriate modalities 1
• Mobility and walking training with assistive devices as needed 1
• Functional assessment to identify unmet needs before discharge 3

Injury-Specific Timing and Approach

For Ankle Sprains:

• Apply Ottawa Ankle Rules first to determine if imaging is needed (inability to bear weight, bone tenderness at specific locations) 4
• Initiate functional treatment within 48-72 hours rather than immobilization 5
• Use ankle braces over tape or elastic bandages for 4-6 weeks, as braces show superior outcomes for return to work (7.1 days sooner) and sports (4.6 days sooner) compared to immobilization 5
• For severe sprains (Grade II-III): Consider below-knee cast or Aircast ankle brace, with cast being most cost-effective 4
• Begin exercise therapy early to reduce recurrent injury risk and functional instability 5

Critical caveat: If immobilization is used for severe pain/swelling, limit to maximum 10 days, then transition immediately to functional treatment 5. Prolonged immobilization (>4 weeks) produces inferior outcomes 5.

For Low Back Pain:

• Provide immediate physiotherapy intervention including interferential therapy, mobility training, and walking aids as indicated 1
• Avoid heat application in the acute phase 5

For Complex Orthopedic Injuries:

• Immediate transport to trauma center for: 4
  • Proximal amputations (above ankle)
  • Degloving or crushing injuries
  • Open fractures
  • Multiple long bone fractures

These injuries require surgical stabilization within 24 hours to prevent complications including adult respiratory distress syndrome, fat emboli, and deep venous thrombosis 6. Physical therapy is deferred until after surgical stabilization in these cases.

Pain Management Integration

Prescribe NSAIDs (piroxicam, celecoxib, naproxen) over opioids for acute injury pain, as they provide equivalent pain control with improved function, decreased swelling, and faster return to activity without the side effect profile of opioids 5. Paracetamol is equally effective as NSAIDs for pain, swelling, and range of motion if NSAIDs are contraindicated 5.

Important consideration: NSAIDs may delay natural healing by suppressing necessary inflammatory responses 5. Balance pain control against healing requirements.

Special Population Modifications

Older Adults (≥75 years):

• Mandate occupational therapy assessment before discharge to address activities of daily living 3
• Provide or arrange for adaptive equipment before release, as 51% have problems with basic activities at baseline 3
• Risk of injury/death increases after age 55 - lower threshold for trauma center transfer 5

Patients with Diabetes and Neuropathy:

• Use removable cast boots/walkers for offloading if diabetic foot ulcers present 4
• Consider specialized therapeutic footwear for high-risk patients 4

Patients on Anticoagulation:

• Individualize risk-benefit of continuing anticoagulation versus bleeding risk 5
• Restore anticoagulation as soon as safely possible to prevent thrombotic complications 5

Discharge Planning and Follow-up

Do not routinely order follow-up imaging unless clinical symptoms indicate complications 5. Most injuries heal within 3-4 months 5.

Provide specific discharge instructions:

• Avoid remaining alone for long periods 5
• Return immediately for: increasing pain, lightheadedness, nausea, vomiting 5
• Resume normal physical activities after 3-4 months for moderate-severe injuries 5
• Initiate VTE prophylaxis within 48-72 hours if no contraindications exist 5

Expected outcomes patients should understand:

• Pain decreases rapidly in first 2 weeks regardless of severity 4
• 5-33% still experience pain/instability at 1 year 4
• Recurrent sprains occur in 3-34% within first year 4
• High-level sports participation is an unfavorable prognostic factor for residual complaints 4

Common Pitfalls to Avoid

• Do not delay physical therapy until outpatient follow-up - immediate intervention is superior 1
• Do not immobilize ankle sprains beyond 10 days - functional treatment produces better outcomes 5
• Do not use compression stockings beyond acute phase - no benefit demonstrated 5
• Do not apply therapeutic ultrasound - no value demonstrated for acute ankle sprains 5
• Do not discharge older patients without functional assessment - 51% have unmet ADL needs 3