Factors associated with surgeon referral for physical therapy in patients with traumatic lower-extremity injury: results of a national survey of orthopedic trauma surgeons

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.

Evidence based guidelines and current practice for physiotherapy management of knee osteoarthritis

OBJECTIVES

To document physiotherapy provision for patients with knee osteoarthritis (OA) in relation to the United Kingdom (UK) recently published National Institute of health and Clinical Excellence (NICE) guidelines for osteoarthritis.

DESIGN

Questionnaire survey of chartered physiotherapists.

METHOD

300 postal questionnaires were distributed to Physiotherapy Departments requesting information regarding source of referrals, treatment aims, preferred methods of treatment and service delivery.

RESULTS

Responses were received from 83 physiotherapists (28 %), predominantly working in the UK National Health Service. Approximately equal numbers of referrals came from primary and secondary care. Aims of physiotherapy management were to; encourage self-management; increase strength and range of movement; reduce pain; and improve function. To achieve these, exercise was utilised by 100% of practitioners, often supplemented with electrotherapeutic modalities (66%), manual therapy (64%) and acupuncture (60%). The majority of patients received individual treatment for a total contact time of 1-2 hours, whilst most group interventions lasted 5-6 hours. Approximately half (54%) of respondents reported using outcome measures to determine treatment efficacy.

CONCLUSIONS

Although knee OA is usually managed in primary care, the similar number of referrals from primary and secondary care may suggest a deviation from evidence-based management guidelines. The guidelines' recommendations of exercise, patient education and self-management are observed by physiotherapists, but other modalities are often used despite poor or no research evidence supporting their efficacy. Whether any of these interventions are clinically beneficial is speculative as treatment outcomes were frequently under-evaluated.

GP referral for physiotherapy to musculoskeletal conditions--a qualitative study

BACKGROUND

Little is known about the dynamics of GP referral for physiotherapy. Better understanding of this process is important because of the growing number of physiotherapy referrals by GPs.

OBJECTIVES

Our aim was to achieve insight into the experiences and views of patients, GPs and physiotherapists in relation to physiotherapy referral for musculoskeletal conditions.

METHOD

The study involved qualitative methodology using 22 semi-structured in-depth interviews. The interviews were recorded and transcribed verbatim. The transcripts were coded and analysed using the methods developed in grounded theory. Interviews were undertaken with GPs in primary care, Health Authority and hospital locations. Interviews with physiotherapists and patients were undertaken within community and district hospital locations.

RESULTS

Three classifications of referral type were developed by the authors from the data, 'appropriate referral', 'load-sharing referral' and 'dumping referral'. There are descriptions of influences on GP referral behaviour, physiotherapists' response to appropriateness and expectations from the perspective of GPs and physiotherapists. Communication was shown as important in determining appropriate referral, but the quality of communication was variable. GPs' past experience of physiotherapy significantly affected referral. Patients' expectations about physiotherapy were described as variable and sometimes unrealistic.

CONCLUSIONS

The selection of appropriate referrals by GPs could be helped by improved communication and better definitions of appropriateness. Closer working between the two professions would result in the better management of problematic patients and prevent wasted resources through avoiding inappropriate referral. Written guidelines appeared to be of less use than direct contact. The concept of expectations appeared relevant to multiple aspects of physiotherapy referral.