Physiotherapy Can Help Recover Functional Status in Community-dwelling Seniors Assessed in Emergency Departments for Minor Injuries

Background: Around 75% of seniors seeking treatment for injuries in Emergency Departments (ED) are discharged home with minor injuries that put them at risk of functional decline in the following months. Objectives: To 1) describe seniors’ characteristics using or not physiotherapy services following ED visits for minor injuries and 2) examine their functional status according to physiotherapy use. Methods: Secondary data analyses of the Canadian Emergency Team Initiative cohort study. Participants were 65 years and older, discharged home after consulting EDs for minor injuries and assessed three times: ED, 3-and 6-months. Physiotherapy use was recorded as yes/no. Functional status


Introduction
Community-dwelling seniors aged 65 and older sustaining minor injuries are susceptible to mobility loss and limitations in their everyday activities [1].In Canada, a large proportion (62%) of seniors seek treatment at emergency departments (ED) following such trauma [1].Falls are the principal cause of various minor injuries, such as contusions (14%), lacerations (9%), sprains (37%), and minor fractures (26%) [1].As such, most of these injuries are not life-threatening, and around 75% of community-dwelling seniors are discharged back home after being assessed at EDs [2].
It has been reported that around 17% of previously independent community-dwelling seniors showed persisting functional decline six months following an ED consultation for a minor trauma [3].The presence of gait impairments, slower walking, lower limb muscle weakness, and fear of falling, as measured during ED consult, may predict these functional losses (Sirois et al., 2015).Such physical impairments can hinder post-injury physical and social activities in injured older adults, triggering a downward spiral of decline and threatening the independence of the elderly [4,5].Moreover, among community-dwelling seniors treated in the ED for a minor injury, frail individuals were shown to be ten times more at risk of functional decline following discharge (Sirois et al., 2015).
Global physical and functional evaluations are recommended for geriatric patients presenting to the ED after a fall [6,7].Functional evaluations are also strongly recommended to improve physical function and health for seniors identi ied as frail [8].At ED discharge, referral to targeted home-based interventions, including physical activity programs, effectively improve seniors' functional status [7].Unfortunately, independent older seniors with minor injuries currently receive insuf icient care management services in the ED [9,10] and are released without recommended care [11,12].
Physiotherapists are experts in assessing the impact of injuries on movement and function and optimizing recovery [13,14].Physiotherapy interventions, such as individualized exercise programs, can prevent disability and functional decline [15], decrease fear of falling, and improve gait speed in community-dwelling pre-frail seniors [16].Newly introduced as ef icient front-line providers for musculoskeletal injuries in EDs [17,18], physiotherapists are not systematically part of ED teams in Canada and rarely assess independent seniors with minor trauma.
While they may be key in preventing functional decline following minor injuries in older adults discharged from the ED, the potential impact of physiotherapy services in this population has not yet been studied.
The objectives of the present study were to 1) describe the characteristics of older adults receiving or not physiotherapy services after an ED consultation for a minor injury and 2) examine their changes in functional status in the following six months.We also explored the change in functional status between older adults receiving or not physiotherapy services among subgroups of participants.).The main goals and results of the CETI cohort are detailed elsewhere [19].Brie ly, the CETI estimated the cumulative incidence of functional decline over six months following ED assessments of nonhospitalized injuries and identi ied its main determinants.

Participants
Participants were 1) aged 65 years and older, 2) seen in the ED within two weeks of a minor traumatic injury (signi icant soft tissue or osseous lesion that did not require hospitalization), 3) independent in 7 basic activities of daily living (BADL, described below) in the four-weeks preceding the injury, and 4) discharged home.Were excluded those who were 1) hospitalized, 2) living long-term-care facilities, or 3) were unable to give consent or communicate in French or English.

Data collection procedure
ED physicians and/or research assistants (RA) screened patients for study inclusion 24 hours a day, seven days a week.Trained RA collected data at three time points: during the ED visit (or within one week of it) and at 3-and 6-month post-ED visit.The research ethics boards of each center approved the study.

Measures
The Use of physiotherapy services was assessed through self-report at the three-time points by asking patients if they had used (yes/no) physiotherapy in the three months preceding the interview.Participants answering "yes" were assigned to the group having received physiotherapy services, while those responding "no" were assigned to the "no" group.Functional status was measured at the three times points using the Older American Resources and Services functional scale (OARS) [20], which is validated for ED use and has good test-retest reliability [21].The OARS assesses independence in seven basic activities of daily living (BADL: eating, grooming, https://doi.org/10.29328/journal.jnpr.1001052dressing, transferring, walking, bathing, and continence) and seven instrumental ADLs (meal preparation, homemaking, shopping, using transportation, using the phone, managing medication and money).Each of the 14 items is scored either 0 (unable to perform without human assistance), 1 (performed with an assistive device), or 2 (completely independent).Total scores range from 0 (completely dependent) to 28 (completely independent).OARS changes of 1 or 2 points [22] are clinically signi icant.Sociodemographic variables were collected at the baseline, including age, gender, and years of schooling.Social support was measured using the social support index (SSI) from the Quebec Health Surveys [23].The SSI assesses the quantity and satisfaction of the available social support.An SSI ≥ 60.3/100 is considered good.
Injury-related variables included mechanism of injury and pain level assessed with a Visual Analog Scale (0[no pain]-10[maximum pain]) [24] as recorded by treating physicians as well as type, locations, and severity of each injury that were coded according to the 2005 revision of the Abbreviated Injury Scale (AIS) [25], in order to compute the aggregated Injury Severity Scores (ISS) which ranges from 1 (minor) to 75 (unsurvivable) [26].

Health-related variables
The number of self-reported comorbidities and general practitioner visits in the three months preceding the ED visit was recorded.The EP estimated the probability of functional decline using a 10-cm visual analog scale (0 cm = no risk; 10 cm = high risk).A 3/10 cut-off value was found to optimize the sensitivity and speci icity of this variable [3].Cognitive impairments were measured with the Montreal Cognitive Assessment (MoCA) [27] or the modi ied Telephone Interview for Cognitive Status (TICS-M) [28], using cut-off for impairments of 23/50 [29] and 31/50 [30], respectively.Mobility measures included the number of falls in the previous three months, number of outings outside the home/ week, frequency of use of a walking aid, walking speed (Timed Up-and-Go) [31], and fear of falling (Short Falls Ef icacy scale international) [32].
Frailty status was assessed by the Canadian Study of Health and Aging-clinical frailty scale (CFS) at the ED visit [33].It classi ies older adults as very it (level 1), well (level 2), well with treated comorbidities (level 3), apparently vulnerable (level 4) and mildly (level 5), moderately (level 6), or severely frail (level 7).

Analyses
Participants were classi ied into two groups based on their use of physiotherapy services within the six months following their ED visit.The baseline characteristics of participants were compared across groups using chi-square tests.The latter was also used to compare characteristics of patients lost to followup with those of participants.
The change in functional status between baseline and six months post-ED visit was computed for each participant.The mean changes in OARS score were irst compared across groups using t-tests and univariate linear regression analyses.Multivariate linear regressions using the Least Absolute Shrinkage and Selection Operator (LASSO) method to select the models' more appropriate co-variables among potential confounders known to have a clinical impact on functional status (age, use of a walking aid, number of outings outside the home per week, falls, baseline independence level, frailty status) [3].Finally, using linear regressions, we explored raw changes in functional status among subgroups of participants according to frailty status, injury severity, self-reported mobility dif iculty (BADL) at baseline, age, number of outings per week, and injury type.All analyses were conducted with SAS version 9.4 (SAS Institute, Inc, Cary, NC).

Participants
As shown in Figure 1, of the 23,183 patients screened in the EDs, 4109 were eligible, and 2929 were enrolled in the main study.There were 2169 participants with available data for the current study.Among those, 565 (26%) received physiotherapy services during follow-up, while 1604 did not.At baseline, older adults lost to follow-up had fewer comorbidities (e.g., 5 to 11: comorbidities: 32.7% vs. 38.9%,p = 0.0003) than participants.They also had more cognitive impairments (35.2% vs. 24.6%,p < 0.0001), and a higher proportion of them had under 12 years of schooling (61.8 vs. 51.5, p < 0.0001).Finally, more seniors lost to follow-up were frail (CFS=5-7/7) compared to the participants at baseline (8.1% vs. 12.4%, p = 0.006).
Table 1 describes the participants' characteristics according to their use of physiotherapy services during the six months follow-up.Signi icant differences between groups were found: patients who received physiotherapy services were more likely to be female, more educated, and less cognitively impaired.A higher proportion of them were previous users of physiotherapy, were occasional users of a walking aid, and consulted the ED because of a fracture or a more severe injury.To note, patients identi ied as at higher risk of functional decline by ED physicians received physiotherapy services in a lower proportion following the injury (Table 1).It is also noteworthy that overall, participants were referred to physiotherapy by the treating ED physicians.

Functional status
The overall mean change in OARS scores at six months was a loss of 0.31 points (I.C. 95%: -0.55; -0.28).Table 2 describes the mean change in OARS scores across groups between initial assessments and the 6-month follow-up.The participants who received physiotherapy had a slightly lower mean OARS score throughout the study.Overall, once measures were adjusted for confounders, there were no signi icant differences in functional status changes across groups at the 6-month follow-up (Table 2).
Figure 2 shows the mean OARS score change (0-6 months) according to the use of physiotherapy in subgroups of participants at higher risk of functional decline.Signi icant group differences were found among frail elders and participants with more severe injuries (ISS ≥5).Frail participants who did not receive physiotherapy services (n = 96) lost clinically signi icant OARS points, while those who received physiotherapy (n = 47) lost close to 0 points, thus maintaining a higher independence level 6 months postinjury (Figure 2).The subgroup of more severely injured participants who received physiotherapy services (n = 38) gained function (OARS points) at six months, while those who did not lost function (n = 74, Figure 2).There was no difference in OARS score change according to the use of physiotherapy among robust or less severely injured participants (ISS 1-4, data not shown).Finally, there was no difference between groups in subgroup analyses based on older age, number of outings outside the home per week, and types of injury.

Discussion
This study's primary objectives-were to describe the pro ile of community-dwelling older adults who received physiotherapy services vs. those who did not in the six months following an ED visit for a minor injury and to examine their changes in functional status accordingly.
This study highlighted the differences between physiotherapy receivers and non-receivers in communitydwelling seniors discharged home following a minor injury.
Seniors who were fallers before the ED visit and those who had sustained fractures or needed a walking aid were more likely to receive physiotherapy services.This concurs with the general physiotherapists' expertise in fall prevention, assistive device prescription, and progressive exercise program prescriptions following injuries [13,14,34].The 25% of participants who received physiotherapy also had a higher education and cognitive level.Moreover, they were more frequent users of physiotherapy before the injury and had more social resources.As only 3% of participants were referred to physiotherapy by the ED physicians, this suggests that elders who felt the need for physiotherapy consultation most likely had the necessary help or resources to initiate the process themselves.Indeed, although publicly-funded physiotherapy is available under medical prescription, waiting lists are remarkably long in many Canadian provinces and can reach up to one year, even for increasingly vulnerable patients [35].
Additionally, since ED physicians scarcely prescribe physiotherapy at ED discharge for older adults with minor injuries [11,36], seniors in this study likely had to consult in private clinics at their own cost.Future studies with available   data on funding sources for physiotherapy services in this older population could help better understand use patterns post-ED visits.
Whether or not participants had received physiotherapy, they tended to experience slight functional loss at six months post-ED visit.This observation is not surprising, as an important proportion of seniors from the cohort were independent and at low risk of functional decline following a minor injury [3].Most likely for the same reason, we did not observe any difference between changes in overall functional status according to physiotherapy exposure.However, the exploratory subgroup analyses revealed that frail and more severely injured seniors seemed to have bene ited most from physiotherapy services.Frail seniors who received physiotherapy services lost less functional capacity, and the more severely injured improved their function.Those subgroups were those at higher risk of functional decline in the six months post-injury.While our subgroup analyses must be interpreted cautiously due to the smaller number of participants within subgroups, these results are consistent with existing evidence about the effectiveness of physiotherapy services for patients at risk of functional decline.Indeed, a study about hospitalized older adults reported that patients who received early physiotherapy interventions had shorter lengths of stay and returned to the community in higher proportions (Hartley et al., 2017).Comprehensive assessments in the ED by a multidisciplinary team, including physiotherapy, reduced hospital admissions, and repeated ED visits in a frail population at risk of readmission [37].Results from a pilot study suggest the ef iciency of a preventive physiotherapy program for community-dwelling older adults at high risk of becoming homebound due to functional limitations [38].
This study presents some limitations.First, we did not have information about the types of physiotherapy services received by the participants, as the CETI study was not initially designed for this speci ic purpose.In addition, funding sources for physiotherapy services (public or private), the content of interventions, nd treatment compliance were not documented.There was also a possible selection bias induced by the differences observed between the participants and those lost to follow-up, the latter having more frailty factors than the participants.This may limit the generalizability of our results.One main strength of this study is that it is the irst to assess the relationship between exposition to physiotherapy services and functional status in previously independent, communityliving seniors consulting EDs for minor injuries.Moreover, it was based on data from a large multi-center Canadian cohort representing a population that is only sparsely studied.

Conclusion
The results of this study suggest that among communityliving seniors consulting EDs for minor injuries, frail and more severely injured individuals may bene it from being systematically referred to physiotherapy services at discharge.
The current study is based on secondary analyses of a multicenter prospective cohort study conducted by the Canadian Emergency Team Initiative (CETI) team between March 2009 and June 2016 in Canadian teaching EDs (CHU de Quebec [Quebec City], Sacre-Coeur Hospital [Montreal], The Ottawa Hospital-Civic Campus [Ottawa], Hamilton General Hospital [Hamilton], Sunnybrook Health Sciences Center [Toronto] and Alberta Health Services [Calgary]

22 Figure 2 :
Figure 2: Mean change in 0-6 months OARS score post ED visit of subgroups of participants according to exposition to physiotherapy services.ISS: Injury Severity Score, BADL: Basic activities of daily living.
American Resources and Services Scale; CI: Confi dence Interval.*T -tests ªResults are obtained by a linear model b Results are obtained by a linear model adjusted for confounding variables, i.e. age, fall 3 months prior to the injury, getting out of home less than 5 times /week, use of a walking aid, baseline IADL independence, and frailty status.https://doi.org/10.29328/journal.jnpr.1001052

Table 1 :
Baseline characteristics of community-dwelling seniors with or without physiotherapy services in the 6 months following an emergency department visit for a minor injury.
SSI: Social Support Index; ED: Emergency Department; BADL: Basic Activities of Daily Living; FES-1: Modifi ed Falls Effi cacy Scale; MOCA: Montreal Cognitive Assessment; TICS-M: Modifi ed Telephone Cognitive Assessment; CFS: Canadian Study in Health and Aging -Clinical Frailty Scale; EP: Emergency Physician.a:Total do not fi t with the total N due to missing data.https://doi.org/10.29328/journal.jnpr.1001052

Table 2 :
Mean post-injury OARS scores in community-dwelling seniors with or without physiotherapy services in the 6 months following an emergency department visit for a minor injury.