Background. Lower-extremity injuries constitute the leading cause of traumatic hospitalizations among adolescents and adults under the age of 65. Long-term impairments are often significant and may eventually impact employment and functional independence for the 40 to 50 years of remaining life. Rehabilitation has the potential to favorably affect the recovery process; however, limited research suggests low physician referral to physical therapy and poor patient utilization of services among patients with traumatic lower-extremity injury.

Methods. Longitudinal data from the Lower Extremity Assessment Project (LEAP) was used to explore the factors associated with orthopaedic surgeon and physical therapist assessment of patient need for physical therapy and disagreement between these two providers. A survey was then designed to explore physician and practice factors associated with physician referral to physical therapy and to determine whether physician outcome expectations influenced the referral decision. Multilevel logistic regression modeling was performed to assess all associations.

Results. Variation in assessment of patient need for physical therapy was found at both the individual provider and trauma center level. Surgeons and therapists were both more likely to assess a need for physical therapy if patients had low work self-efficacy, balance limitations, impaired knee flexion range-of-motion (ROM), and previous therapy. Time of assessment, pre-injury work status, pain level, and ankle dorsiflexion ROM were predictive of disagreement between providers. For the survey analysis, positive physician outcome expectations, years in practice, solo practice, monthly trauma case workload, and general or open prescription were associated with referral to physical therapy. Negative physician outcome expectations and ownership of a therapy practice exhibited a moderate effect on the referral decision.

Conclusions. Wide variation exists in physician assessment and referral to physical therapy and much of this variability remains unexplained. Further research is recommended to understand and improve the physical therapy referral process and to identify the physician and site characteristics that contribute to inconsistent referral practice. In addition, interventions to influence physician referral behavior should focus on changing physician outcome expectations. This can be accomplished by conducting clinical trials on the efficacy of physical therapy and by disseminating results to the medical community.