More physiotherapists are now working in advanced and extended practice roles in a range of settings including elective surgery and in orthopaedics. One area that is gaining momentum across Australia is physiotherapists working in hospital emergency departments.


Physiotherapists first began working in emergency departments in Australia about 10 years ago.

Since then, a growing number of health services and hospitals have embraced physiotherapists working in an advanced practice role in the ED.

In this new model of care, advanced musculoskeletal physiotherapists assess patients and treat minor injuries. Their work has proven to be effective in reducing wait times, achieving higher patient satisfaction rates, and in freeing up medical specialists to manage more serious life-threatening presentations.

Katherine Maka, Australian Physiotherapy Association (APA) Emergency Department National Group chair and a musculoskeletal senior physiotherapist, says physiotherapists working in an advanced practice role in EDs care for the patient directly from triage right through to discharge.

“We see them without the doctor referring to us, which is a new role in ED,” Ms Maka says.

“Historically a physiotherapist would provide what we call a secondary contact service, so we would be paged to see a patient as ordered by a doctor or nurse.

“But now in these advanced practice roles we work independently, so we determine which patient would be suited to the knowledge and skills that we have and hence best practice treatment can be provided.”

Paula Harding, a grade four musculoskeletal physiotherapist working at one of the nation’s busiest emergency departments, The Alfred Hospital in Melbourne, says the growth of the role in Australia follows its successful implementation in parts of the United Kingdom.

A physiotherapist with more than 20 years’ experience working in both the public and private sectors, Ms Harding was the project manager for the Health Workforce Australia Expanding Scope of Practice for Physiotherapists in Emergency Departments project, of which The Alfred was a lead site.

After the success of introducing the advanced musculoskeletal physiotherapy service to The Alfred in 2008, Ms Harding says The Alfred now has a team of 10 physiotherapists working in advanced practice roles, in a model of care that involves working in more than one area of advanced musculoskeletal service, such as in the outpatient setting.

The physiotherapy team provides a seven-day-a-week service in a primary care role in the ED between 9.30am and 6pm.

“We’ve been able to fill a gap in the ED, where there’s an increasing rate of people with musculoskeletal conditions presenting, and the doctors are dealing with more complex sick patients who need their attention more urgently,” she says.

“We work in the fast track area of the ED - which is patients who come in and need management there and then, who are unlikely to be admitted to the hospital.

“They present with isolated, non life-threatening musculoskeletal injuries and that’s where our expertise is - so your sprained ankle, your twisted knee, your acute back pain, small fractures like a broken hand or they’ve stubbed their toe, those are the sorts of things that we manage and deal with.”

Rewards and challenges

Ms Harding, a project manager for the Victorian Department of Health’s Implementing Advanced Musculoskeletal Physiotherapy project, says it’s a role that requires multi-tasking in a fast paced environment.

“You might have three or four patients on the go at once and you’re always pushed for space to work within - I think that’s pretty consistent in most EDs,” she says.

“Also, the patients are never at their best when they’ve been waiting and things are really busy, and particularly if they are in pain.”

Ms Harding says physiotherapists working in the role need to be considerate of other health professionals’ workloads.

“If we’ve got a consultant that we need to talk to and they’ve just had a multi-trauma come in, it’s not the right time to be asking them about someone else’s sprained ankle,” she says.

“You have got to be able to work very well in that team environment but also to respect the time of the consultants and make sure it’s the right time and the right place to grab their attention, considering the nature of the ED can be pretty full on at times.”

Ms Harding says the advanced practice physiotherapists receive “fantastic support” from the medical and nursing team, which includes nurse practitioners.

“The doctors are always there to help us with our queries if someone might need a medical review or we’re not sure of a diagnosis,” she says.

“You get to push your scope a bit but also in a very supportive way and in a way that makes sure you are doing the right thing by the patient.”

It’s a role that provides constant challenges and learning opportunities, while physiotherapists working in the ED also often liaise with other specialty units outside the ED, such as orthopaedics.

Ms Harding says it’s a work environment where physiotherapists can achieve immediate results.

“In the ED, you can often get things done there and then,” she says.

“You are doing a lot more than what you would ever do in the private practice setting.

“If it’s a fracture, you might get to work with the consultants to put that fracture in a better position, put it in plaster, get them sorted - your scope is so much broader and your access to all of the resources that you’d want to be able to have to deliver that care for the patient are much more accessible when you are in that environment.”

How do you become a physiotherapist working in ED?

The role of advanced musculoskeletal physiotherapists is still new and evolving in Australia.

As such, the qualifications and requirements, as well as the scope of practice, often vary between states and health service providers.

Ms Harding, who has completed a Masters of Manipulative Physiotherapy and a Doctorate of Clinical Physiotherapy, says the roles are for physiotherapists with at least five to seven years’ experience.

The Alfred requires physiotherapists to have a postgraduate qualification in either a Master of Musculoskeletal Physiotherapy or Sports Physiotherapy.

“They’d have to be willing to undertake extra learning because these roles do push at our traditional scope and so they have to be prepared to commit to the competency-based training and assessment program which is done in the workplace at The Alfred,” Ms Harding says.

“These physiotherapists just really need to be good clinicians with great communication skills who want a little bit more of a challenge.”

Future opportunities

The APA is advocating for appropriately credentialed physiotherapists to be able to prescribe medications within their scope of practice. The peak body is advocating for all physiotherapists to have rights to refer patients on to medical specialists with a Medicare rebate.

“There is also advocacy around our ability to interpret imaging at the moment,” Ms Maka says.

“If the patient needs to have an X-ray, generally the current practice is that we review the X-ray in conjunction with a staff specialist or registrar.

“Research supports our ability to be able to interpret imaging just as well as a medical provider.”

Ms Maka says there are now 139 members of the APA’s national emergency department network.

The numbers of physiotherapists working in this advanced practice role is expected to grow as the prevalence of musculoskeletal conditions rises and the demand on Australia’s health system continues to increase.

“It’s an exciting time to be in this role because the scope of practice is dynamic and it will continue to evolve with time as further recognition of our skills and the value-add we are to the emergency department is acknowledged,” Ms Maka says.