Physical Therapists Can Be Value-Added Providers in Wilderness Medicine

As the research base and scope of practice for physical therapists continues to grow, nontraditional roles are emerging that place physical therapists outside of customary clinical environments. One exciting emerging role is “wilderness physical therapy” in which physical therapists provide onsite care for the rapidly increasing and currently underserved population of people who become injured or ill in difficult-to-reach backcountry/wilderness environments.¹ In 2021, the US National Park Service recorded over 297 million visitors—many of whom participated in backcountry recreational activities such as hiking, trail running, mountain biking, and skiing.² In addition to this recreational use, tens of thousands of people fight wildfires each year, and a similar number participate in search and rescue (SAR), backcountry research, and law enforcement.^3,4 As more enthusiasts go to the backcountry, the number of injuries, especially to the musculoskeletal system, has skyrocketed, creating a great opportunity for interested physical therapists to become involved.

Backcountry medical problems often occur in austere and potentially dangerous environments that require professional and volunteer wilderness medical and rescue personnel to face substantial challenges as they locate, treat, and evacuate people under often difficult conditions.⁵ The physical therapist’s ability to provide onsite patient-centered, nonpharmacologic, noninvasive care in an environment with limited resources adds great value (Fig. 1). This Point of View describes how physical therapist skills can be beneficial in addressing the unique challenges of patient care in austere, backcountry environments, and identifies specific opportunities for physical therapists to become involved in the emerging field of wilderness physical therapy.

Overview of Wilderness Medicine

Wilderness medicine is a growing field in which patient care takes place in resource-constrained, remote environments.⁵ Individuals from numerous medical professions participate as care providers in wilderness medicine, including physicians, paramedics, emergency medical technicians, nurses, physician assistants, and, more recently, physical therapists. Wilderness care providers function in many roles and may be members of SAR teams, medical staff in remote facilities, or Good Samaritans who happen to be on the scene. The key defining feature of wilderness medicine is that environmental factors such as terrain, weather, and high elevation often make it difficult to access patients and can create serious concerns for the health and safety of all people who are on the scene. A global definition of wilderness medicine was put forth by Hawkins⁶: “Medical care and problem-solving in circumstances where the surrounding environment has more power over our well-being than does the infrastructure of our civilization.”

The Challenges of Wilderness Patient Care

Scene Safety

As with all emergency medical activities, the fundamental concern of wilderness medical care is to establish and maintain scene safety. Numerous potential threats exist in the backcountry that can lead to injuries and increase the risk of crew safety. For example, extreme weather often hinders the locating and evacuating of patients and increases the potential for environmental problems such as hypothermia, frost bite, heat stress, dehydration, and/or heat stroke to affect everyone who is on the scene.

Emergencies often occur in high mountainous terrain where patients and care givers are at increased risk for conditions such as high-altitude cerebral edema or high-altitude pulmonary edema that often manifest as initially subtle changes in mental status or respiratory function and rapidly progress to life threats.⁵ Another common concern during wilderness care is that the backcountry often lacks roads or trails that will allow vehicles to access the scene. This requires care providers to have skills in patient handling to improvise ways to transport injured people through difficult terrain. Other environmental factors such as lightning, wildfires, floods, and threats from wildlife can compromise scene safety and create rapidly increasing risks for all persons, requiring everyone on scene to maintain situational awareness. Wilderness medicine care givers must have appropriate clothing, equipment, and skills to function safely and effectively under these conditions, and as stewards of the environment all wilderness medicine personnel adhere to leave no trace principles (Fig. 2).

Need for Extended Emergency Patient Management

One of the key features of wilderness medicine is that there often is a need to spend considerable time at the scene of the injury or illness. “Front country” (urban or suburban) emergency medical providers typically try to minimize time on scene and move the patient to the ambulance where most secondary examination and first aid is done during transport.⁷ In contrast to this, in backcountry emergencies, evacuating a patient too quickly can make things worse; therefore, providers typically stay on the scene to attempt to stabilize and support the patient while developing a plan to evacuate, seek help, or both. In many cases, patients and care providers will need to shelter in place and “sit-on” a patient while waiting for weather or darkness to abate or for help to arrive. Members of wilderness medicine teams therefore need training in survival skills such as shelter building, fire starting, and obtaining food and water (Fig. 2). It is critically important to be aware that injured people and exhausted care givers have increased susceptibility to hypothermia⁸ and dehydration that can heighten fear-related emotional responses during prolonged time on scene. Leadership and teamwork that maintain a positive group dynamic in these situations is a critical component of wilderness medicine.

Limited Resources and the Need to Innovate

In many but not all cases, wilderness medicine care providers have limited medical equipment, ranging from light-weight backcountry first aid kits, to only a bandana and water bottle. Innovation is a key skill for wilderness care providers as they are often tasked with constructing urgently needed medical equipment to treat conditions such as bleeding, fractures, and hypothermia. Examples include creating slings from rain jackets, cervical collars from backpack waist bands, splints from sleeping pads, wound irrigation devices from plastic bags, and hypothermia “burrito” wraps comprised of ponchos, heated water bottles, and sleeping bags.

Conceptualizing the Wilderness Physical Therapist

Physical therapists who have outdoor skills and advanced first aid training (Figs. 2 and 3) can add great benefit to wilderness medicine care. In one example, the physical therapist may be a Good Samaritan bystander or member of a SAR team who is tasked with providing onsite first aid care. Importantly, physical therapists in this instance would represent themselves as first aid providers and perform within the scope of practice of their highest level of first aid certification. They would not provide or bill for specific physical therapist services. During the first aid evaluation, the physical therapist’s skills in the recognition of subtle but important clinical symptoms and signs when obtaining a patient history and during systems examination, palpation, and taking and monitoring vital signs can make a critical difference. The physical therapist skill set will also add enormous value during first aid treatments such as applying splints, reducing dislocations, performing spine stabilization,⁹ providing wound care, and patient packaging and transport (Fig. 3). A central component of the physical therapist’s involvement is the establishment of a therapeutic alliance with patients and the provision of effective and respectful communication with all people on the scene. This calm, professional behavior and leadership by physical therapists can be of inestimable value to diffuse potentially frightening and chaotic wilderness emergencies.

In another example, the physical therapist may function as a remote primary care provider for people with musculoskeletal problems in a direct access or near–direct access environment within the scope of physical therapist practice for a given agency or state. Physical therapists have long functioned in this role in the US military, US Public Health Service, sports medicine, and, more recently, performing arts and emergency departments. A substantial body of literature has reported that physical therapists serving as direct access providers is associated with increased patient satisfaction, decreased wait times, improved clinical and operational outcomes, reduced resource use and cost of care, and decreased hospital admission rates and length of stay without increased adverse effects.^10–19 Additionally, US military physical therapists have demonstrated clinical competence for performing point of contact evaluations and administering effective onsite treatment for a wide range of patients in challenging wilderness and combat environments as “mobile physical therapists” working out of a rucksack. Direct access physical therapists in this role have led to substantial decreases in evacuations and a nearly 50% greater return to duty rate compared with patients who were initially seen by a physician.¹⁶ These compelling findings suggest that physical therapists can be of great value as primary care providers for musculoskeletal injuries in wilderness environments.

Call to Action

Backcountry medical problems can range from minor inconveniences to terrifying emergencies for patients, family members, and co-workers.²⁰ Physical therapists with advanced first aid and outdoor skills can add great value in virtually every aspect of patient evaluation, treatment, and transport.^1,7–21 The time is right for the profession to embrace a creative vision in which interested physical therapists can become involved in wilderness medicine.

There are many ways for physical therapists to attain skills for wilderness medicine. Opportunities for Wilderness First Aid and Wilderness First Responder certification are available from many agencies nationwide. The first Wilderness First Aid certification course designed specifically for physical therapists will be offered at the American Physical Therapy Association (APTA) Colorado Chapter meeting in the fall of 2022. Participation as a volunteer in community organizations such as SAR, Community Emergency Response Teams, and Ski Patrol is also a great way to develop wilderness medicine skills. These diverse organizations facilitate training for members and provide key services for communities with an emphasis on teamwork and coordination with other agencies.

APTA should continue to support the development of competencies for wilderness physical therapists where current efforts are underway to create educational and research opportunities through the formation of an Educational Special Interest Group housed in the Orthopedic Academy. APTA can also help with advocacy as exciting possibilities are emerging to create professional full- and part-time positions for physical therapists to work closely with National Park Service Rangers and wildland fire fighters.²¹ These positions would involve the provision of onsite physical therapist care following the model developed by the US military and would emphasize patient-centered care for individuals working in challenging environments.^{11,16,19–22} Physical therapists would perform consultation and, when appropriate, provide personalized rehabilitation. Other emerging professional roles for physical therapists include onsite care in wilderness expeditions or treks, backcountry/wilderness adaptive and ultra-sports events, and a variety of wilderness therapy activities that are geared toward improvement in participants’ physical capacity, mental health, and wellness.

As more and more people access the backcountry to experience what Thoreau called “the tonic of the wilderness,” there is growing need for uniquely skilled professionals to help the increasing number of individuals who become injured. Physical therapists have the ideal skills to address this need.

Author Contributions

Concept/idea/research design: P. Beattie, D. Jernigan, S. McDavitt, D. Hearn

Writing: P. Beattie, D. Jernigan, S. McDavitt, D. Hearn

Consultation (including review of manuscript before submitting): P. Beattie, D. Jernigan, S. McDavitt, D. Hearn

Funding

There was no funding for this work.

Disclosures

The authors completed the ICMJE Form of Disclosure of Potential Conflicts of Interest and reported no conflicts of interest.

References