Orthopedic Surgeons and Physical Therapists Differ in Assessment of Need for Physical Therapy After Traumatic Lower-Extremity Injury

Introduction

Lower-extremity injuries constitute the leading cause of traumahospitalizations among adolescents and adults under the ageof 65 years.^1–3 Long-term impairments often are significant,with research showing moderate to severe levels of disability,low rates of return to employment, and chronic pain for up to7 years after injury.^4–7 Rehabilitation has the potentialto favorably affect these long-term outcomes, but limited researchhas suggested low levels of use of physical therapy in patientswith traumatic lower-extremity injuries.^2,3,8–13 Physicianreferral practices may contribute to the low levels of use ofrehabilitation services. The literature on referral to physicaltherapists has indicated wide variability in referral rates.^14–17 Research also has demonstrated variations in physicianattitudes toward physical therapy and knowledge of availableservices.^18–20 Overall, these studies on referral patternshave suggested that variations may result in underreferral orinappropriate referral practices.^14–20

Concerns about the implications of referral variability foraccess to services and patient outcomes have prompted researchersto examine the physical therapy referral process. In severalstudies, the content of physician referral with regard to theprovision of specific diagnoses and therapeutic procedures hasbeen examined to provide a better understanding of the professionalrole of physical therapists.^19,21–23 Findings consistentlyhave shown that limited referral information is provided tophysical therapists and that physicians perceive therapistsas technicians rather than as professional colleagues.²¹ Researchalso has explored patient-related factors associated with referralto physical therapists, with evidence supporting associationswith the age and sex of patients, injury severity, and insurancestatus.^14–21 However, patient-related factors explainonly a small proportion of the observed variations in physicaltherapy referral rates.^14,15,24 To our knowledge, in only onestudy have the clinical factors associated with referral tophysical therapists been examined. Freburger et al¹⁵ found thatscores on the Oswestry Disability Index and on the bodily pain,physical function, and role–physical subscales of theMedical Outcomes Study 36-Item Health Survey Questionnaire wereassociated with referral for the treatment of spine disorders.These authors also reported significant variations in physicaltherapy referral rates from center to center.

On the basis of the poor long-term outcomes of patients withtraumatic lower-extremity injuries and the potential for significantprovider and site variations in referral practices, the goalsof our study were to use the Lower-Extremity Assessment Project(LEAP) database to explore variability in assessments of theneed for physical therapy and to compare the factors associatedwith orthopedic surgeon and physical therapist assessments ofneed in patients with traumatic lower-extremity injuries. TheLEAP database is unique because it allows for comparisons acrossvarious centers and of surgeon and therapist clinical decisionmaking. Specifically, we aimed to examine variability in assessmentsof the need for physical therapy in patients across 8 levelI trauma centers and to examine the patient-related, medical,and clinical factors associated with surgeon and physical therapistassessments of the need for physical therapy.

After a review of the literature on both physical therapy referraland outcomes after traumatic lower-extremity injuries, we testedthe hypotheses that variability in assessments of the need forphysical therapy would exist at the trauma center level andthat patients who had traumatic lower-extremity injuries, patientswho were not working, and patients who experienced more painwould be more likely to be assessed as needing physical therapy.

Method

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Method

For the present study, we used a retrospective cohort design.Data on 395 patients (16–69 years of age) treated by lower-extremityreconstruction were obtained from the LEAP database.

The LEAP was a multicenter, prospective cohort study designedto examine differences in functional outcomes after reconstructionor amputation because of traumatic lower-extremity injuries.A total of 601 patients were enrolled between March 1994 andJune 1997 at 8 level I trauma centers (Carolinas Medical Center,Cleveland MetroHealth Medical Center, Harborview Medical Center,North Carolina Baptist Hospital, R. Adams Cowley Shock TraumaCenter, Tampa General Hospital, University of Texas SouthwesternMedical Center, and Vanderbilt University Medical Center).²⁵Lower-extremity trauma was defined, as described by Gustiloet al,²⁶ as type IIIB and IIIC fractures, selected type IIIAfractures, dysvascular limbs, major soft tissue injuries, andsevere foot or ankle injuries. The most notable exclusion criteriawere scores of less than 15 on the Glasgow Coma Scale at admission,spinal cord deficits, prior amputation, third-degree burns,inability to speak English or Spanish, documented psychiatricdisorders, and active military duty.⁴

Participants were evaluated at hospital discharge and at 3,6, and 12 months after hospitalization. Follow-up assessmentsincluded a nurse interview and separate orthopedic surgeon andphysical therapist evaluations.

Measurement of Variables

Outcomes.
Outcomes included surgeon and physical therapist assessmentsof a patient's need for physical therapy and disagreements aboutassessments of need. At follow-up visits at 3, 6, and 12 months,surgeons and physical therapists conducted separate evaluationsof participants. Each provider independently documented either"yes" or "no" as to whether a participant would need physicaltherapy between that assessment and the next follow-up assessment.A positive, or "yes," response was considered to be an assessmentof the need for physical therapy, and a negative, or "no," responsewas considered to be an assessment of no need for physical therapy.

Characteristics of participants.
Data on the age, sex, race, education, health insurance coverage,poverty level, health before injury, and smoking status of theparticipants during the initial hospitalization were collected.Poverty was calculated by relating total household income tohousehold size and was categorized as follows: not poor—incomeshigher than 200% of the federal poverty level defined by theUS Census Bureau, nearly poor—incomes within 125% of thefederal poverty level, or poor—incomes lower than 125%of the federal poverty level.^25,27 Participants rated theirhealth before injury as excellent, good, fair, or poor and wereclassified as active if they reported involvement in regularexercise at least once per week. Participants were asked ifthey had any of the following health conditions before injury:asthma, chronic bronchitis, emphysema, arthritis, hypertension,stroke, diabetes, cancer, tuberculosis, or kidney disease. Apositive response for at least one of the conditions led tothe classification of an individual as having a prior healthcondition. Participants also were asked if they had ever requiredmedical attention for joint disease, fracture, dislocation,sprain or strain, burn, or ligament injury that involved eitherleg. A positive response for any of the injury categories indicateda prior leg condition.

At each follow-up assessment, participants reported their useof physical therapy services. Participants were asked at 3 monthsif they had received physical therapy since hospital dischargeand were asked at 6 and 12 months if they had received physicaltherapy since last speaking with the interviewers.

Characteristics of injuries.
Lower-extremity injuries were classified at the time of admissionas tibia shaft or articular fractures, severe ankle or footinjuries, and major soft tissue or dysvascular injuries. TheHannover Fracture Scale²⁸ was used to indicate the extent ofbone loss (<2 or >2 cm) and contamination (none, single,multiple, or massive). The Predictive Salvage Index²⁹ was usedto categorize bone and muscle injuries as mild, moderate, orsevere.

Complications at each follow-up visit were noted, and surgeonsrecorded whether these complications resulted in a subsequenthospitalization. Fracture healing, as determined from radiographs,was rated as completed healing, progressive healing, or no healing.Edema was described as no edema, mild edema (1+), or moderateto severe edema (2+ to 4+).

Occupational factors.
Preinjury work status was recorded during the initial hospitalizationas either working or not working, and current work status wasassessed at each follow-up visit. Participants who reportedreturning to work either full time or part time were categorizedas working.

Work self-efficacy was measured in the hospital by asking participantsto rate from 1 to 10 how confident they were in their abilityto return to work within 1, 3, 6, and 12 months.⁵ A score of1 indicated that they were not at all confident, and a scoreof 10 indicated that they were completely confident. A workself-efficacy score was calculated by multiplying the mean forthe 4 levels of confidence by 10. These 4 levels and the scoringmethod were adapted from self-efficacy scales that were usedby Bandura et al³⁰ and Ewart et al³¹ and that were found tohave moderate test-retest reliability and validity, with Pearsoncorrelation coefficients of greater than .80.^30,31

Pain.
Participants rated their average daily leg pain from "no pain"to "unbearable pain" by using a visual analog scale (VAS), ahorizontal line from 0 to 100 mm. The VAS scores were recordedby measuring the distance from 0 (no pain) to the participant'smark on the line. The scores were categorized as no pain (0–4mm), mild pain (5–44 mm), moderate pain (45–74 mm),or severe pain (75–100 mm).³²

Disability.
The Sickness Impact Profile (SIP) was administered to measureself-reported health status, with a score of greater than 20indicating severe disability.³³ The SIP consists of 136 itemsgrouped into 12 categories and 2 dimensions of health (physicaland psychosocial). The physical dimension comprises the ambulation,mobility, and body care and movement categories, and the psychosocialdimension includes the communication, alertness, and emotionalbehavior categories. Scores can range from 0 to 100 for theoverall instrument, each category, and the 2 dimensions of health.The SIP has been shown to have high test-retest reliability(r=.92) and internal consistency (r=.94), a multidimensionalperspective on function, and sensitivity to small differencesin function.^34,35

Weight bearing and balance.
The weight-bearing status of the injured leg was documentedat each follow-up visit as full weight bearing, partial weightbearing, toe touch weight bearing, or non–weight bearing.Two categories were used: full weight bearing and not full weightbearing (including partial weight bearing and toe touch weightbearing).

Balancing on the involved limb was assessed with an unsupportedsingle-leg stance task. Participants were asked to stand on1 leg with their eyes open and their arms across their chestfor 30 seconds. The number of seconds a participant was ableto stand before dropping the other leg was recorded. A scoreof 0 seconds was attributed to participants who were unableto perform the task. Participants were classified as eitherbeing able to perform the balance task (standing for $≥$ 30 seconds)or being unable to perform the task (standing for <30 seconds).A score of less than 30 seconds in an unsupported single-legstance task has been defined as functionally poor.^36,37

Range of motion (ROM).
Participants were placed in the supine position and asked toactively move the hip and knee joints through flexion and theankle joint through dorsiflexion (DF) and plantar flexion (PF).In the prone position, participants were asked to lift the hipinto extension. The ROM of the hip and knee joints was measuredwith a universal goniometer, and the ROM of the ankle was measuredwith a small, full-circle goniometer.³⁸ High intrarater reliabilityof the goniometers for knee ROM and ankle ROM has been reported,with intraclass correlation coefficients ranging from .97 to.99 for the knee and from .82 to .86 for the ankle.^39,40 Thestarting and ending positions of each joint, as recommendedby the American Academy of Orthopaedic Surgeons, were used toappropriately record measurements; norms were determined onthe basis of the averages published by the American Academyof Orthopaedic Surgeons.⁴¹

Strength (force-generating capacity).
Hip flexion and extension, knee flexion and extension, and ankleDF and PF strength were measured with a Force Evaluation andTesting System (model FET5000) force gauge^* anchored to a table;this instrument previously was found to have acceptable levelsof interrater and intrarater reliability.^42,43 Participantswere placed into antigravity positions and asked to apply maximumforce against the forceplates. A force transducer produced anoutput that represented each participant's force, and the outputwas displayed on a digital panel meter. Three measurements ofeach motion of the involved and uninvolved limbs were recorded.An average strength score for the involved and uninvolved limbsand the ratio of the maximum effort of the injured limb to thatof the uninjured limb were calculated.

Data Analysis

Descriptive statistics explored the percentages of participantsneeding physical therapy, as assessed by surgeons and physicaltherapists at each follow-up visit. Chi-square tests were usedto compare surgeon and physical therapist assessments of theneed for physical therapy in participants across the 8 levelI trauma centers.

Two outcomes were of interest: surgeon assessment of a participant'sneed for physical therapy and physical therapist assessmentof a participant's need for therapy. Separate multilevel logisticregression analyses (1 for surgeon assessment of need and 1for physical therapist assessment of need) were performed forthe 3-, 6-, and 12-month follow-up visits. Random effects wereincluded in all analyses to account for the clustering of visitsat the provider and center levels. Subsequently, 2-level random-interceptmodels were analyzed with the generalized linear latent andmixed model (GLLAMM) macro in the Stata statistical package,version 9.0.^,^44,45 The GLLAMM macro produced estimates of thevariance of the random effects for providers ( ${tau}$ ²) and centers( ${omega}$ ²) but not for participants ( ${sigma}$ ²). The fractions of the varianceattributable to differences between providers and differencesbetween centers were calculated by dividing the variance ofthe specific random effect by the total variance ( ${sigma}$ ² + ${tau}$ ² + ${omega}$ ²)in the model. The variance for ${sigma}$ ² was considered to be ${pi}$ ²/3 forcalculation purposes.^44,45

Separate multilevel bivariate regression analyses at each ofthe 3 follow-up visits included the following variables forthe participants: age, sex, race, education, insurance status,poverty status, smoking status, prior health status, activitylevel, and prior health conditions and leg injuries; injurytype, bone loss, contamination, complications, subsequent hospitalizations,and bone and muscle damage; work self-efficacy and prior andcurrent work status; and fracture healing, edema level, VASpain score, SIP score, weight-bearing status, single-leg balancingon the involved leg, hip and knee flexion and extension ROM,ankle DF and PF ROM, dynamometric strength measurements of hipand knee flexion and extension and ankle DF and PF, and useof physical therapy services. Independent variables that hadP values of less than or equal to .25 (Wald test) or that wereconsidered to be relevant to the assessment decision were identifiedand entered into multiple-variable mixed-model forward and backwardlogistic regression models.⁴⁴ The .25 level was used as a screeningcriterion to allow for the possibility that several variables,each of which may be weakly associated with the outcome, maybecome important predictors when placed in a model together.⁴⁶ Patient-related factors (sex, race, insurance status, andprior physical therapy), occupational factors (work status andself-efficacy), injury-related factors (injury severity, fracturehealing, and edema level), and clinical factors (VAS pain score,weight-bearing status, balance, knee flexion and extension ROMand strength, and ankle DF and PF strength) were entered asseparate groups.

Likelihood ratio tests were conducted to remove the least significantcovariates, and models also were compared with goodness-of-fittests. Multicollinearity was explored after regression withthe variance inflation factor. Variables that had P values ofless than .05 or that were relevant from a theoretical (participant'ssex, race, insurance status, and prior physical therapy) orclinical (injury severity and work status) perspective wereretained. The stability of the final model was tested by addingback in each excluded variable one at a time.

Overall, missing data represented less than 5% of the followingvariables: self-efficacy, edema level, VAS pain score, balance,hip flexion and extension ROM and strength, knee flexion andextension ROM and strength, and ankle DF and PF ROM and strength.Missing data were processed by multiple imputation with regressionmodels that imputed the missing values as a function of theother covariates. More specifically, each regression model wasanalyzed 5 times, and the results were combined to produce afinal estimate for the missing values.^47,48

Role of the Funding Source

This research was supported with funds from the National Instituteof Arthritis and Musculoskeletal and Skin Diseases, NationalInstitutes of Health (ROI-AR42659); the Johns Hopkins Educationand Research Center for Occupational Safety and Health at theJohns Hopkins Bloomberg School of Public Health, which is sponsoredby the National Institute for Occupational Safety and Health(T42OH00842428); and the Johns Hopkins Center for Injury Researchand Policy at the Johns Hopkins Bloomberg School of Public Health,which is funded by the National Center for Injury Preventionand Control, Centers for Disease Control and Prevention (CE000198-03).

Results

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Results

Selected demographic characteristics of the study populationare shown in Table 1. A complete description of this populationcan be found elsewhere.^4,25 Most participants were white (71%),were men (75%), and were between 25 and 54 years of age (70%).Approximately 50% of injuries occurred through motor vehicleand motorcycle collisions. The distribution of injuries includedtibia fractures (52.4%), severe foot or ankle injuries (29.4%),and major soft tissue or dysvascular injuries (18.2%).

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Table 1. Baseline Demographic Characteristics of Study Population (N=395)

Seventy-nine percent of the participants and 75% of the participantswere assessed as needing physical therapy by surgeons and byphysical therapists, respectively, at the 3-month follow-upvisit. The need for physical therapy, as assessed by surgeons,steadily declined, with 52% of the participants needing therapyat 6 months and 28% of the participants needing therapy at 12months. In comparison, physical therapists found that 70% and47% of the participants needed therapy at 6 months and at 12months, respectively.

Chi-square analyses were used to test variability in assessmentsof the need for physical therapy in participants across the8 level I trauma centers; these analyses revealed that surgeonassessments of need differed statistically across sites at the3-, 6-, and 12-month follow-up visits (P<.01) (Tab. 2). Surgeonassessments of the need for physical therapy ranged from 94%to 47%, 74% to 36%, and 47% to 6% at the 3-, 6-, and 12-monthfollow-up visits, respectively. Physical therapist assessmentsof need differed statistically across sites at the 3- and 6-monthfollow-up visits (P<.01). The ranges of physical therapistassessments were 97% to 44%, 86% to 44%, and 59% to 13% at the3-, 6-, and 12-month follow-up visits, respectively. The centershad different numbers of surgeons and physical therapists participatingin the study; some centers had fewer than 15 surgeons and 3or 4 therapists, whereas others had more than 20 surgeons and5 therapists.

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Table 2. Chi-Square Results for Surgeon and Physical Therapist Assessments of Need for Physical Therapy in Participants Across Level I Trauma Centers

Factors Associated With Assessments of Need for Physical Therapy at 3 Months

Table 3 shows multiple-variable multilevel logistic regressionresults for both surgeon and physical therapist assessmentsof the need for physical therapy at the 3-month follow-up visit.

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Table 3. Factors Associated With Orthopedic Surgeon and Physical Therapist Assessments of Need for Physical Therapy in Participants at 3-Month Follow-up Visit^{^a}

Characteristics of participants.
The sex of the participants was statistically associated withtherapist assessments of the need for therapy, with men beingassessed as needing therapy less often than women (odds ratio[OR]=0.38, P<.05).

Characteristics of injuries.
Surgeons assessed participants with articular injuries (OR=3.1,P<.01) as needing therapy more often than participants withnonarticular injuries, whereas therapists assessed participantswith articular injuries (OR=0.39, P<.05) as needing therapyless often than participants with nonarticular injuries.

Occupational factors.
Higher work self-efficacy beliefs were negatively associatedwith surgeon assessments of the need for physical therapy (OR=0.97,P<.01).

Clinical factors.
No association was found between surgeon assessments of needand participants’ VAS pain scores, but physical therapistswere more likely to assess participants as needing therapy whenthey had moderate to severe pain (OR=4.3, P<.05) rather thanno pain. However, participants with weight-bearing limitationswere more likely to be assessed as needing therapy by surgeons(OR=6.5, P<.01), whereas no association was found with therapistassessments. Impaired knee flexion ROM was statistically associatedwith surgeon assessments of the need for physical therapy (OR=3.0,P<.01).

Random effects.
The fractions of the variance attributable to nonmeasured providercharacteristics were 0% in the surgeon assessment model and38% in the therapist assessment model. Trauma center characteristicsexplained 33% and 19% of the variance in the surgeon and therapistmodels, respectively.

Factors Associated With Assessments of Need for Physical Therapy at 6 Months

Table 4 shows multiple-variable multilevel logistic regressionresults for both surgeon and physical therapist assessmentsof the need for physical therapy at the 6-month follow-up visit.

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Table 4. Factors Associated With Orthopedic Surgeon and Physical Therapist Assessments of Need for Physical Therapy in Participants at 6-Month Follow-up Visit^{^a}

Characteristics of injuries.
Progressive healing or no fracture healing (OR=1.7) was statisticallyassociated with surgeon assessments of the need for physicaltherapy (P<.05).

Occupational factors.
Higher work self-efficacy beliefs were negatively associatedwith therapist assessments of the need for physical therapy(OR=0.98, P<.01).

Clinical factors.
No association was found between surgeon assessments of needand participants’ VAS pain scores, but physical therapistswere more likely to assess participants as needing therapy whenthey had mild pain (OR=2.4, P<.05) or moderate to severepain (OR=2.8, P<.05) rather than no pain. However, participantswith weight-bearing limitations were more likely to be assessedas needing therapy by surgeons (OR=3.1, P<.01), whereas noassociation was found with therapist assessments. Limitationsof the involved leg in the single-leg balance task and impairedknee flexion ROM were statistically associated with both surgeonand therapist assessments of the need for physical therapy (P<.05).

Random effects.
The fractions of the variance attributable to nonmeasured providercharacteristics were 10% in the surgeon assessment model and27% in the therapist assessment model. Trauma center characteristicsexplained 0% and 1% of the variance in the surgeon and therapistmodels, respectively.

Factors Associated With Assessment of Need for Physical Therapy at 12 Months

Table 5 shows multiple-variable multilevel logistic regressionresults for both surgeon and physical therapist assessmentsof the need for physical therapy at the 12-month follow-up visit.

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Table 5. Factors Associated With Orthopedic Surgeon and Physical Therapist Assessments of Need for Physical Therapy in Participants at 12-Month Follow-up Visit^{^a}

Characteristics of injuries.
Progressive or no fracture healing (OR=2.8) was statisticallyassociated with surgeon assessments of the need for physicaltherapy (P<.01).

Occupational factors.
Higher work self-efficacy beliefs were negatively associatedwith therapist assessments of the need for physical therapy(OR=0.98, P<.05).

Clinical factors.
No association was found between surgeon assessments of needand participants’ VAS pain scores, but physical therapistswere more likely to assess participants as needing therapy whenthey had moderate to severe pain (OR=2.6, P<.05) rather thanno pain. However, participants with weight-bearing limitationswere more likely to be assessed as needing therapy by surgeons(OR=8.0, P<.01), whereas no association was found with therapistassessments. Limitations of the involved leg in the single-legbalance task and impaired knee flexion ROM were statisticallyassociated with both surgeon and therapist assessments of theneed for physical therapy (P<.05).

Random effects.
The fractions of the variance attributable to nonmeasured providercharacteristics were 36% in the surgeon assessment model and10% in the therapist assessment model. Trauma center characteristicsexplained 5% and 0% of the variance in the surgeon and therapistmodels, respectively.

Discussion

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Discussion

A weight-bearing limitation and impaired knee flexion ROM wereconsistently associated with surgeon assessments of the needfor physical therapy across a 12-month recovery period in participantswith traumatic lower-extremity injuries; for physical therapists,the associated factor was moderate to severe pain. Injury severitywas important to both surgeons and physical therapists at the3-month follow-up assessment, and balance limitations and impairedknee flexion ROM were important at the 6- and 12-month assessments.Characteristics of injuries associated only with surgeon assessmentsof need at 6 and 12 months included delayed fracture healing.

Although these findings provide insight into similarities anddifferences in surgeon and therapist assessments of the needfor physical therapy, they explain only a small proportion ofthe observed assessment variability. The variability in assessmentsacross the 8 participating level I trauma centers and betweenproviders and the variance of the random effects indicate thatsome of the variability can be attributed to trauma center andprovider characteristics. As indicated in the literature, providercharacteristics may include practice style, clinical uncertainty,outcome expectations, and knowledge of and experience with physicaltherapy, and trauma center characteristics such as medical culture,colleagues’ expectations, and training protocols may influencethe assessment process.^49–56

Characteristics of the participants were not found to significantlyinfluence surgeon assessments of the need for physical therapy.This finding was surprising because studies of physician referralto both physical therapists and medical specialists have reportedan association between referral and the age, sex, education,and insurance coverage of the participants.^15,50–57 However,these studies did not control for the extensive clinical andinjury factors included in our analyses. In addition, this differencemight be attributable to the severity of the injuries in ourstudy population.

As expected, participants with more severe injuries, such asarticular fractures and delayed fracture healing, were morelikely to be assessed by surgeons as needing physical therapy.However, fracture healing did not significantly influence therapistassessments of need, and an articular injury was negativelyassociated with a therapist assessment at 3 months. This differencemight have been a result of minimal communication between thesurgeon and the therapist about the nature of the injury, thesurgical procedure, and postoperative radiographic findings.Further support for a lack of communication between providerswas demonstrated by the findings for weight-bearing limitations.Surgeons considered weight bearing to be one of the most importantfactors during assessments of the need for physical therapyat all follow-up time points, but weight bearing was not statisticallyassociated with therapist assessments. This difference mighthave reflected a desire by therapists to postpone gait rehabilitationuntil later in the recovery period and to focus instead on painand on ROM and balance impairments. An important finding wasthat, although ROM was explored for the hip, knee, and ankle,only the knee appeared to be particularly relevant to assessmentsof the need for physical therapy. The insignificant hip jointfindings might have been related to the distribution of injuriesin the present study because relatively few participants hadhip impairments (as opposed to knee and ankle impairments).

Our hypothesis that pain would be associated with surgeon assessmentsof the need for physical therapy was not supported by the studyresults. This finding was unexpected because pain has been foundto contribute to long-term disability and poor vocational outcomes^10,58,59 and because clinical trials have found physical therapyto favorably affect pain in patients with various musculoskeletalconditions.^60–63 On the basis of the poor long-term outcomesof this patient population, it is important to determine thespecific effects of physical therapy on patients’ paincomplaints and disseminate this information to both surgeonsand physical therapists treating traumatic lower-extremity injuries.In addition, it would be beneficial to examine orthopedic surgeons’attitudes and beliefs about the management of postoperativepain.

The nonsignificant finding for work status was also unexpectedbecause rehabilitation has been shown to improve occupationaloutcomes^3,64,65 and often has been considered an appropriatetreatment for patients experiencing workplace limitations.^66,67 Instead, patients’ work self-efficacy was significantlyrelated to surgeon assessments of the need for physical therapyat 3 months and therapist assessments at 6 and 12 months, suggestingthat patients’ belief in their ability to return to workand not their actual work status influenced assessments. Thisfinding might be explained by the severity of injuries in thispatient population. Lower-extremity injuries treated by reconstructionhave high rates of complications and often require additionalsurgery during the first year of recovery, leading to a delayedreturn to work.^68,69 Thus, physical deficits and patients’work self-efficacy, important predictors of a return to work,¹⁰ may be more important during the first 12 months of recoverythan employment status per se.

Of interest was the finding of differences in assessments betweensurgeons and physical therapists across the 12-month recoveryperiod. The results suggested that surgeons and therapists tendedto assess participants as needing physical therapy at 3 monthsbut that, although there was a steady decline in surgeon assessmentsof participants as needing therapy at 6 and 12 months, the ratesof therapist assessments of the need for therapy remained relativelyhigh. Seventy percent of the participants at 6 months and almosthalf of the participants at 12 months were assessed by therapistsas needing therapy. The results suggested that participantswith traumatic lower-extremity injuries might not be referredby surgeons for physical therapy further into their recovery.The findings support the need for more communication betweensurgeons and physical therapists about the plan of care forparticipants at 6- and 12-month follow-up evaluations.

The limitations of the present study must be taken into accountin interpretations of the results. First, the LEAP study wasconducted more than 10 years ago. Studies have documented littlechange in the physical therapy referral process,^19,21,22 withvariability in referral rates, the content of referral prescriptions,the limited professional role of physical therapists, and theinfluence of patient-related factors on referral to physicaltherapists remaining consistent.^14–24,70 However, bothformal and informal roles of physical therapists in the healthcare system have expanded during the last decade; thus, studyresults need to be interpreted with caution because of the ageof the data set. We attempted to mitigate this limitation ofthe present study by conducting a prospective, cross-sectionalsurvey of 274 surgeon members of the Orthopaedic Trauma Association(OTA) to verify the findings in the surgeon assessment model.⁷¹ Surgeons were asked to make physical therapy referral decisionson the basis of traumatic lower-extremity cases abstracted fromthe LEAP database. The results supported the association betweensurgeon referral to physical therapists and weight-bearing status,knee flexion ROM, and injury severity. Furthermore, pain reliefand return to work did not appear to be expected outcomes ofreferral to physical therapists for the treatment of traumaticlower-extremity injury.

A second limitation is that the outcome measures of assessmentsof need for physical therapy were not confirmed with documentedreferral prescriptions, a fact that limited the generalizabilityof our findings to the broader referral process. Also, the resultsmight not be generalizable beyond providers at level I traumacenters because of their training and expertise. Third, theoccupational factors of preinjury work status and current workstatus were based on patient self-report, a fact that mighthave resulted in an underestimation of the association betweenwork status and the assessment of need. Fourth, orthopedic surgeonsand physical therapists followed different evaluation protocols,a fact that might have contributed to the differences in theassessment models. However, surgeon and physical therapist evaluationprocedures are inherently different because of training andexperience, and the LEAP study procedures represented currentclinical practice at level I trauma centers.

Despite these study limitations, we found evidence that variabilityin assessments of the need for physical therapy existed notonly at the provider and trauma center levels but also throughoutthe 12-month recovery period. The findings emphasized the needfor communication about the nature of the patient's injury,the surgical procedure, postoperative healing status, the patient'spain level, and weight-bearing status. Focusing on these factorshas the potential to improve access to and appropriate use ofphysical therapy for patients with traumatic lower-extremityinjuries.

On the basis of the findings of the present study, specificrecommendations for future research on traumatic lower-extremityinjuries include identifying the surgeon and level I traumacenter characteristics that contribute to variations in referralpractices to facilitate the development of an effective strategyfor decreasing variability; determining surgeon perceptionsand management of postoperative pain and work status in patientsto facilitate an understanding of current clinical practice;and exploring the optimal time for referral to physical therapistsof patients with traumatic lower-extremity injuries. Furthermore,examining the effects of physical therapy on pain and work outcomesin this patient population and disseminating this informationto orthopedic surgeons have the potential to improve the long-termoutcomes associated with traumatic lower-extremity injuries.

Footnotes

All authors provided concept/idea/research design and data analysis.Dr Archer, Dr MacKenzie, and Dr Castillo provided writing. DrCastillo and Dr Bosse provided data collection and fund procurement.Dr Castillo provided project management. Dr Bosse provided participants.Dr MacKenzie provided institutional liaisons. Dr Archer andDr Castillo provided consultation (including review of manuscriptbefore submission).

This study was approved by the institutional review boards atthe coordinating center (Johns Hopkins School of Public Health,Baltimore, Maryland) and at each study site.

This research was supported with funds from the National Instituteof Arthritis and Musculoskeletal and Skin Diseases, NationalInstitutes of Health (ROI-AR42659); the Johns Hopkins Educationand Research Center for Occupational Safety and Health at theJohns Hopkins Bloomberg School of Public Health, which is sponsoredby the National Institute for Occupational Safety and Health(T42OH00842428); and the Johns Hopkins Center for Injury Researchand Policy at the Johns Hopkins Bloomberg School of Public Health,which is funded by the National Center for Injury Preventionand Control, Centers for Disease Control and Prevention (CE000198-03).

A platform presentation of this research was given at the AnnualConference and Exposition of the American Physical Therapy Association;June 11–14, 2008; San Antonio, Texas.

^* Hoggan Health Industries, PO Box 488, West Jordan, Utah 84084.

Stata Corp, 4905 Lakeway Dr, College Station, TX 77845.

References

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