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Factors Associated With Surgeon Referral for Physical Therapy in Patients With Traumatic Lower-Extremity Injury: Results of a National Survey of Orthopedic Trauma Surgeons

K.R. Archer, PT, PhD, DPT, is Assistant Professor, Department of Orthopaedics and Rehabilitation, Vanderbilt University Medical Center, Medical Center East–South Tower, Ste 4200, Nashville, TN 37232 (USA).
E.J. MacKenzie, PhD, is Fred and Julie Soper Professor and Chair, Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland.
M.J. Bosse, MD, is Director of Clinical Research and Orthopaedic Traumatologist, Department of Orthopaedic Surgery, Carolinas Medical Center, Charlotte, North Carolina.
A.N. Pollak, MD, is Associate Professor of Orthopaedics and Chief, Division of Orthopaedic Traumatology, R. Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland.
L.H. Riley III, MD, is Associate Professor and Division Chief, Spine Surgery, Department of Orthopaedic Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland.

Address all correspondence to Dr Archer at: kristin.archer{at}vanderbilt.edu

Background: Variation in referral rates for physical therapy exists at both the individual physician and practice levels.

Objective: The purpose of this study was to explore the influence of physician and practice characteristics on referral for physical therapy in patients with traumatic lower-extremity injury.

Design: A cross-sectional survey was conducted.

Methods: In 2007, a Web-based survey questionnaire was distributed to 474 surgeon members of the Orthopaedic Trauma Association. The questionnaire measured physician and practice characteristics, outcome expectations, and attitude toward physical therapy. Referral for physical therapy was based on case vignettes.

Results: The response rate was 58%. Surgeons reported that 57.6% of their patients would have a positive outcome from physical therapy and 24.2% would have a negative outcome. The highest physical therapy expectations were for the appropriate use of assistive devices (80.7%) and improved strength (force-generating capacity) (76.4%). The lowest outcome expectations were for improvements in pain (35.9%), coping with the emotional aspects of disability (44.1%), and improvements in workplace limitations (51.4%). Physicians reported that 32.6% of their patients referred for physical therapy would have no improvement beyond what would occur with a surgeon-directed home exercise program. Multivariate analyses showed positive physician outcome expectations to have the largest effect on referral for physical therapy (odds ratio=2.7, P<.001).

Conclusions: The results suggest that orthopedic trauma surgeons refer patients for physical therapy based mostly on expectations for physical and motor outcomes, but may not be considering pain relief, return to work, and psychosocial aspects of recovery. Furthermore, low referral rates may be attributed to a preference for surgeon-directed home-based rehabilitation. Future research should consider the efficacy of physical therapy for pain, psychosocial and occupational outcomes, and exploring the differences between supervised physical therapy and physician-directed home exercise programs.

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This article has been cited by other articles:

				K. R. Archer, E. J MacKenzie, R. C. Castillo, and M. J. Bosse Author Response to Snyder-Mackler Physical Therapy, December 1, 2009; 89(12): e10 - e10. [Full Text] [PDF]

				K. R. Archer, E. J. MacKenzie, R. C. Castillo, M. J. Bosse, and for the LEAP Study Group Orthopedic Surgeons and Physical Therapists Differ in Assessment of Need for Physical Therapy After Traumatic Lower-Extremity Injury Physical Therapy, December 1, 2009; 89(12): 1337 - 1349. [Abstract] [Full Text] [PDF]