Referral patterns for surgical consult in the management of patients with foot drop due to acute lumbar disc herniation: a survey study of physical therapists in the United States

ABSTRACT

Background

There is a lack of consensus for optimal management of patients with foot drop due to acute lumbar disc herniation (LDH) with lumbar radiculopathy (LR), which is a clinical scenario that may be encountered by physical therapists. Consequently, it is important to explore physical therapists’ referral practice patterns for surgical consult. Currently, physical therapist referral patterns for surgical consult in this patient population are unknown.

Objectives

To describe physical therapist referral patterns for immediate neurosurgical consult in patients with foot drop due to suspected acute LDH with LR.

Design

Cross-sectional descriptive research design using an electronic, internet-based survey that utilized two clinical vignettes.

Method

An electronic survey was developed by an expert peer review panel. Survey participants were licensed physical therapists in the United States and members of the Orthopedic Section of the American Physical Therapy Association.

Results

Of the individuals receiving the survey invitation, 2172 completed the survey. Depending on the severity of foot drop, 34–61% were likely to refer for immediate neurosurgical consult. Presence of imaging to confirm suspected clinical diagnosis slightly affected the likelihood of referral (4–12% increase) for immediate neurosurgical consult.

Conclusion

In patients with foot drop due to suspected acute LDH with LR, this study found that physical therapist referral patterns for immediate neurosurgical consult varied and are likely influenced by the severity of weakness and availability of MRI findings. Further research regarding the optimal management of this patient population and potential reasons for variation in practice is warranted.

1. Introduction

Physical therapy practice has evolved significantly over the past two decades to include greater autonomy within the healthcare environment. This has been demonstrated via the implementation of ‘direct access’ within the United States in all 50 states plus the District of Columbia [1], which allows healthcare consumers to seek physical therapy services without a referral from a physician or other medical provider, and may also include diagnostic imaging referral privileges for physical therapists [2]. Accordingly, a higher level of clinical decision-making is required of physical therapists in order to determine the appropriate management of patients who present in a direct-access setting. The importance of higher-level clinical decision-making is also supported in the ‘Guide to Physical Therapist Practice’ [3], which discusses physical therapists’ responsibility to determine appropriateness for potential referral to another healthcare provider based on examination findings. The referral patterns of physical therapists to other healthcare providers for various medical conditions, including low back pain (LBP)-related disorders, have been examined in several studies [4–8]. Additionally, physical therapists are increasingly referring patients directly for diagnostic imaging studies [2].

LBP is the number one cause of disability worldwide [9] and along with neck pain represents the third-largest source of healthcare spending in the United States [10]. Resultantly, physical therapists may commonly encounter patients with several types of LBP-related disorders, including those with lumbar disc herniation (LDH) with associated lumbar radiculopathy (LR). LR is characterized by the presence of objective neurological signs during clinical examination and may include sensory, reflex, or motor deficits [11]. When motor deficits result in limited ankle and/or toe dorsiflexion in LDH with LR, this is commonly referred to as ‘foot drop’ [12–14]. In individuals with LBP-related disorders, the prevalence of foot drop due to LDH with LR is unknown, while an estimated 3.2–12.9% of surgical candidates with LDH and associated LR demonstrate foot drop [15–17].

Current evidence suggests several management options for patients with acute LDH and LR, including both operative and non-operative management [18–20]. For those who demonstrate associated motor deficits such as foot drop, insufficient evidence exists to make a recommendation for or against urgent surgery [20]. Notably, in a systematic review, authors were unable to conclude that early surgery significantly improved motor recovery in cases of foot drop in LR due to LDH, though the quality of most studies was poor [21].

Due to a lack of evidence for preferred management of foot drop secondary to acute LDH with LR, plan of care decisions by physical therapists may vary. To date, referral patterns of physical therapists in managing this type of patient population have not been examined. Due to the growing role of physical therapists as direct access providers, examining referral patterns can highlight potential variability in clinical decision-making and inform clinical practice. Therefore, the purpose of this study was to describe physical therapist referral patterns for immediate neurosurgical consult in patients with foot drop due to acute LDH with LR.

2. Methods

A cross-sectional descriptive research design was used to collect quantitative data using an electronic survey for currently practicing physical therapists.

2.1. Participants

Participants were recruited from a convenience sample of physical therapists. Participants were included if they were physical therapists who were members in the Orthopedic Section of the American Physical Therapy Association (APTA). The study was approved by the Institutional Review Board of the University of Illinois at Chicago (USA) and all participants electronically signed an informed consent prior to completing the survey.

2.2. Procedures

An invitation to participate in the study was sent via e-mail to 16,626 physical therapists in the fall of 2014. Reminder e-mails about survey completion were sent 1 week later. The survey remained open for an additional 1.5 weeks before being closed giving participants a total of 17 days to complete the survey. Survey completion time was estimated to be 10 minutes.

2.3. Survey development

Because a preexisting survey did not meet the purpose of this study, a novel survey was created. The survey formulation process was similar to several other published survey studies regarding physical therapists’ practice patterns [22,23]. The survey was developed in three phases: (1). Question generation, (2). Expert peer review, (3). Survey completion. Following a comprehensive literature review, a panel of three experts were consulted to assist with question generation. Each expert was a physical therapist and faculty member within an orthopedic physical therapy residency and Doctor of Physical Therapy (DPT) program. The primary author (AW) drafted the questions, including the expert’s suggestions. The same three faculty experts along with two additional physical therapists (specializing in orthopedic physical therapy) reviewed the survey, providing additional quality improvement suggestions regarding survey structure, flow, and content based on their knowledge of the literature and clinical experience. The primary author incorporated the expert panel’s suggestions and created a web-based version of the survey (Qualtrics, Provo, UT). In the final phase of survey development, the same panel of five experts mentioned above performed a mechanical review by completing the web-based survey to ensure it was functioning correctly.

The created survey included nine questions on demographic and professional characteristics and nine clinical questions examining referral patterns regarding two different clinical vignettes (Appendix A). Myotomal strength in these vignettes was defined via manual muscle testing (MMT) score, based on a commonly utilized scale [24]. A clinical vignette is a brief, case history of a fictional yet realistic clinical situation with accompanying questions exploring a clinician’s decision-making [25] and is a strong methodological choice for assessing practice variation amongst clinicians using an efficient and effective survey tool [25,26]. The two respective clinical vignettes differed regarding the severity of myotomal weakness with which the patient presented.

2.4. Statistical analysis

Descriptive statistics, with frequency distribution and percentages, were used to measure physical therapists’ characteristics and referral patterns relative to referral for a neurosurgical consult (Appendix A, Questions 12, 15, 17, 18). For the clinical questions examining referral patterns, each selection criterion was rated on a 6-point Likert response scale (1 = very unlikely, 6 = very likely).

3. Results

3.1. Participant characteristics

Survey invitations were sent to 16,626 physical therapists with 192 message delivery errors. Therefore, it was assumed the remaining 16,434 physical therapists received the survey invitation with 2172 completing a portion of the survey (response rate: 13.22%). Survey participants were represented by various levels of physical therapy degrees (BSPT/MPT = 37.13%, DPT = 62.87%). All age group categories were represented in the survey, with the greatest percentage (29.76%) of respondents aged 30–40 and the lowest percentage (7.32%) aged 60 +. Additionally, a variety of practice settings were represented with most respondents reporting their primary setting as either a physical therapist-owned private practice (44.04%) or hospital system (32.58%). A minority of participants (38.33%) reported having earned clinical specialist certification through the American Board of Physical Therapy Specialties (ABPTS), while 7.49% were fellows of the American Academy of Orthopedic Manual Physical Therapists (FAAOMPT). Additional demographic and professional backgrounds of participants are presented in Table 1. Response rates per question are presented in Tables 2 and 3.

Table 1.

Survey Respondent Demographics

Respondents (n = 2172)	Frequency, n (%)
Sex
Male	1094 (50.37)
Female	1078 (49.63)
Age
20–30	429 (19.76)
30–40	646 (29.76)
40–50	496 (22.85)
50–60	441 (20.31)
60+	159 (7.32)
Years of PT experience
0–2	258 (11.88)
2–5	313 (14.42)
5–8	213 (9.81)
8–12	203 (9.35)
12–15	183 (8.43)
15+	1001 (46.11)
Primary Practice Setting
Hospital System	705 (32.58)
Academics/Research	148 (6.84)
PT-owned private practice	953 (44.04)
Physician-owned PT practice	145 (6.70)
Home Health	25 (1.16)
Other	188 (8.69)
Highest level of physical therapy degree
BSPT/MPT	801 (37.13)
DPT	1356 (62.87)
FAAOMPT Certification
Yes	162 (7.49)
No	2001 (92.51)
ABPTS Certification (any)
Yes	828 (38.33)
No	1332 (61.67)
Academic Degree
MA or MS	441 (20.44)
PhD, DHS, DSc, EdD	148 (6.86)
No academic degree	1568 (72.69)
Currently in clinical practice
Yes	2068 (95.21)
No	89 (4.79)

ABPTS, American Board of Physical Therapy Specialties; BSPT, Bachelor of science degree in physical therapy; DPT, Doctor of physical therapy degree; FAAOMPT, Fellow of the American Academy of Orthopedic Manual Physical Therapists; MPT, Master’s degree in physical therapy; PT, Physical therapist.

Table 2.

Clinical Vignette #1 and Neurosurgical Consult Referral Patterns

Likelihood of Referral	A. Frequency, n (%)	B. Frequency, n (%)
Very Unlikely	314 (15.10)	221 (11.21)
Unlikely	477 (22.93)	313 (15.88)
Somewhat Unlikely	262 (12.60)	232 (11.77)
Somewhat Likely	330 (15.87)	290 (14.71)
Likely	326 (15.67)	374 (18.98)
Very Likely	371 (17.84)	541 (27.45)

EHL, extensor hallicus longus; MMT, manual muscle testing; RLE, right lower extremity; TA, tibialis anterior.

The patient presents with acute onset (1-week history) of lower back and unilateral RLE pain after lifting injury (mechanism of injury: attempting to lift a heavy object in a position of increased lumbar flexion and rotation). During examination, you discover myotomal weakness of TA and EHL. Your subjective and objective examination suggests foot drop secondary to lumbar disc herniation. The patient has undergone lumbar spine radiographs which are unremarkable. Your clinical reasoning determines that there are no red flags present that would preclude a physical therapy examination and evaluation.

Assuming myotomal weakness with MMT between 0/5 and 1/5 (assume TA and EHL test at the same grade), please describe your most likely course of action in regard to the following:

A. How likely are you to refer for immediate neurosurgical consult?

Very Unlikely

Unlikely

Somewhat unlikely

Somewhat likely

Likely

Very Likely

B. Assume that the patient presents to initial evaluation with MRI report/impression stating a large broad-based disc protrusion between L4 and L5 with lumbar nerve root compression and myotomal weakness (MMT between 0 and 1) during your clinical exam. What is the likelihood that you refer this patient for immediate neurosurgical consult?

Very Unlikely

Unlikely

Somewhat unlikely

Somewhat likely

Likely

Very Likely.

Table 3.

Clinical Vignette #2 and Neurosurgical Consult Referral Patterns

Likelihood of Referral	A. Frequency, n (%)	B. Frequency, n (%)
Very Unlikely	513 (25.84)	405 (20.64)
Unlikely	495 (24.94)	468 (23.85)
Somewhat Unlikely	300 (15.11)	340 (17.33)
Somewhat Likely	300 (15.11)	331 (16.87)
Likely	203 (10.23)	275 (14.02)
Very Likely	174 (8.77)	143 (7.29)

EHL, extensor hallicus longus; MMT, manual muscle testing; RLE, right lower extremity; TA, tibialis anterior.

The patient presents with acute onset (1-week history) of lower back and unilateral RLE pain after lifting injury mechanism of injury: attempting to lift a heavy object in a position of increased lumbar flexion and rotation. During examination, you discover myotomal weakness of TA and EHL. Your subjective and objective examination suggests foot drop secondary to lumbar disc herniation. The patient has undergone lumbar spine radiographs which are unremarkable. Your clinical reasoning determines that there are no red flags present that would preclude a physical therapy evaluation.

Assuming myotomal weakness with MMT between 2-/5 and 3-/5 (assume TA and EHL test at the same grade), please describe your most likely course of action in regard to the following questions:

A. How likely are you to refer for immediate neurosurgical consult?

Very Unlikely

Unlikely

Somewhat unlikely

Somewhat likely

Likely

Very Likely

B. Assume that the patient presents to initial evaluation with MRI report/impression stating a large broad-based disc protrusion between L4 and L5 with lumbar nerve root compression and myotomal weakness (MMT between 2-/5 to 3-/5) during your clinical exam. What is the likelihood that you refer this patient for immediate neurosurgical consult?

Very Unlikely

Unlikely

Somewhat unlikely

Somewhat likely

Likely

Very Likely.

3.2. Referral patterns

Clinical decisions regarding referral for neurosurgical consult are presented in Tables 2 and 3. To more concisely summarize clinical decisions, ‘somewhat likely’, ‘likely’ and ‘very likely’ were combined to reflect a ‘likely to refer’ decision, while ‘very unlikely’, ‘unlikely’, and ‘somewhat unlikely’ were combined to reflect an ‘unlikely to refer’ decision. When results were combined in this manner, 49.38% of physical therapists reported they would refer for neurosurgical consult in the case vignette with ‘severe’ weakness (MMT of 0/5 to 1/5) when MRI results were not available. With the addition of MRI findings confirming acute LDH, respondents were approximately 12% more likely to refer (from 49.38% to 61.14%).

In the clinical vignette describing ‘moderate’ weakness (MMT of 2-/5 to 3-/5), respondents were approximately 15% less likely to refer for neurosurgical consult compared to severe weakness (34.11% vs. 49.38%). The addition of MRI findings confirming acute LDH in the ‘moderate’ weakness vignette increased how likely respondents were to refer by just 4% (from 34.11% to 38.18%). Overall, in the presence of confirmatory MRI findings, respondents were approximately 23% more likely to refer for neurosurgical consult when comparing ‘severe’ vs. ‘moderate’ weakness vignettes (61.14% vs. 38.18%).

4. Discussion

The primary purpose of this study was to describe physical therapist referral patterns for immediate neurosurgical consult in patients with foot drop due to acute LDH with LR. This study found variability in patterns of referral for neurosurgical consult for LDH with LR by physical therapists, which may be influenced when considering additional MRI results and/or severity of muscle weakness during the clinical examination. As more physical therapists begin to function in direct access roles, understanding when patients are referred and/or should be referred to other healthcare providers continues to be a topic worthy of consideration. The variability in clinical decision-making based on the results of this study warrants further discussion regarding potential contributing factors.

Currently, there is not a preferred management option (i.e. conservative vs. surgical) in the early phases of recovery in patients with acute LDH and LR, including cases where motor deficits (i.e. foot drop) are present [18–20]. This lack of a clear advantage for either management strategy may be reflected in the results of this study, given that survey respondents did not demonstrate a clear preference regarding immediate referral for surgical consult, particularly when severe weakness was present. Therefore, a trial of conservative management may be considered in this clinical scenario in cases when other ‘red flag’ findings are absent, without a need for immediate neurosurgical consult. The potential for spontaneous regression of LDH and improved clinical outcomes has also been demonstrated in a systematic review by Chiu et al[27], though interestingly the correlation between improvements of LDH on imaging and improved clinical outcomes was inconsistent. This also suggests that imaging-confirmed LDH in the acute phase of LDH with LR and foot drop (in the absence of other ‘red flags’ as described in our clinical vignettes) may not provide additional insight regarding clinical outcomes vs. a brief trial of conservative management (i.e. ‘wait-and-see’) without imaging.

However, current guidelines recommend MRI for LBP-related conditions if motor deficits are present [20,27–29] or if MRI results will guide changes in clinical management [28,30,31]. These recommendations may provide ambiguity in the clinical reasoning process regarding the necessity of early MRI in patients with foot drop due to LDH and LR, as motor deficits may not necessarily warrant an immediate change in clinical management (e.g. surgical intervention). Therefore, given that the initial management of patients with foot drop in acute LDH with LR may be similar to other LBP-conditions (i.e. conservative), the necessity of immediate MRI in patients with motor deficits due to LDH and LR may be questioned in cases where other ‘red flag’ findings are absent. This consideration is due to the potential for immediate imaging to increase the utilization of more invasive and costly medical procedures [32,33] in those with LBP, in the absence of improved clinical outcomes [34]. Results from our study also demonstrated that the presence of MRI results (despite no other differences in the presented clinical scenario) resulted in a 4–12% increase in referral for immediate neurosurgical consult (i.e. increased healthcare utilization). It is possible that the presence of MRI findings biased survey participants, resulting in increased rates of referral. Another possibility is that the MRI results, when combined with other examination findings, influenced clinical reasoning and management decisions [35]. Despite these possibilities, the exact reasons for the increased rates of referral with MRI findings in our study cannot be fully elucidated without further investigation. Further, the value of early MRI for determining prognosis or clinical outcomes in the acute stage of LDH with LR with foot drop remains unclear and is a topic that warrants further research. Though MRI-confirmed LDH with nerve root impingement has been cited as meaningful for diagnosis of LR [36], others have questioned the diagnostic utility and accuracy of MRI for detecting lumbosacral nerve compromise [35]. Collectively, this provides further ambiguity regarding the relevance of early MRI results in clinical decision-making in patients with LDH with LR.

Though no recommendations currently advocate a preferred management option for patients with acute LDH and LR, a consideration regarding patients who present with myotomal weakness is maximizing the potential for recovery of motor deficits. Balaji et al. [21] examined studies that assessed recovery of myotomal deficits with operative and non-operative management of LDH and demonstrated a 6.4% greater rate of recovery of motor deficits in patients who underwent surgical intervention vs. non-operative management (38.4% vs. 32%). An additional finding was that greater severity of motor deficit may generally be a negative prognostic factor for recovery; however, multivariate analysis examining the severity of motor deficit, time to surgery, and recovery of strength was not performed. Our study findings demonstrated that respondents were more likely to refer for immediate neurosurgical consult when motor deficits were more severe vs. moderate weakness, which may reflect concerns that increased severity of weakness with LR potentially warrants earlier and more invasive management. However, Balaji et al. [21] also reported that earlier time to surgery was also generally not shown to be associated with recovery of motor deficits, though the surgical timelines examined were <25 days in most studies. Overall, given the limited number and quality of studies, the authors could not demonstrate the advantage of early surgery to improve the chances of motor recovery due to LDH and highlighted the need for further high-quality research. The ambiguity regarding an ‘optimal’ management strategy for improved motor recovery (as demonstrated by Balaji et al.) was also reflected in the results of our survey, as respondents did not demonstrate a clear preference regarding referral for immediate neurosurgical consult. However, given that 34.11% of survey respondents were inclined to refer for immediate neurosurgical consult (i.e. 65.89% would not refer) with moderate weakness, a lower severity of weakness may have been less concerning to respondents regarding the potential for lack of motor recovery or limitation in function. This variability in clinical management amongst physical therapists regarding the degree of motor weakness in suspected LDH with LR warrants further investigation.

4.1. Strengths and limitations

There were several strengths of this study. First, the demographic characteristics of participants represented a variety of physical therapist backgrounds from which to explore practice patterns and seemed representative of the most recent demographic profile of APTA members [37]. Additionally, most respondents (>95%) reported currently being in clinical practice, demonstrating that the observed results are representative of current clinical decision-making and practice patterns in our study population.

There were several limitations to this study. The inclusion of a limited number of examination findings in the clinical vignettes may limit the applicability of these scenarios to clinical practice. Although motor weakness (specifically, ankle dorsiflexion and great toe extension) has demonstrated good specificity, the sensitivity of motor tests in diagnosing LR is generally poor and motor weakness may lack the ability to differentiate between segmental nerve roots [38]. However, information in the vignettes was intentionally limited to highlight the main features of interest (clear mechanism of injury, associated clinical hypothesis, and objective myotomal loss) when making a clinical decision. Other factors such as patient preferences, pain interference with function, and disability may also influence clinical decisions for/against additional referral. Also, only members APTA and Orthopedic Section were sampled, which represents a small portion (30% and 10%, respectively) of all physical therapists in the United States [23]. Last, though the development process of the survey followed that of other previous survey studies [22,23] the reliability and validity of our survey were not examined.

5. Conclusion

The results of this survey indicated varying practice patterns regarding referral for immediate neurosurgical consult for patients with foot drop due to suspected LDH with LR, based on the clinical vignettes utilized. As physical therapists in the United States may increasingly be the primary point of contact for patients into the healthcare system, it is even more important to explore the profession’s practice patterns to improve consistency of care and to explore potential reasons for variation in practice. There is currently a paucity of high-quality research on optimal management of patients with acute lumbar disc herniation with lumbar radiculopathy, which seemed to be reflected in our results given a lack of clear preference for additional referral for neurosurgical consult. As a result, future research should investigate methods to aid clinical-decision making for all healthcare practitioners who encounter this patient population to optimize patient outcomes and health-related quality of life.

Biographies

Dr. Adam Wielechowski currently serves as visiting clinical assistant professor at the University of Illinois at Chicago (UIC). He is a board certified orthopedic clinical specialist and a fellow of the American Academy of Orthopaedic Manual Physical Therapists. He currently provides both clinical care and education in the Doctor of Physical Therapy and orthopedic physical therapy residency programs at UIC, and has also presented at national conferences regarding various topics related to clinical management of musculoskeletal conditions.

Dr. Aaron Keil currently serves as clinical associate professor at UIC. He is a frequent speaker at national conferences on the topics of direct access and diagnostic imaging and has provided continuing education courses and guidance for several institutions across the country who are implementing these initiatives. Dr. Keil has published on the topics of direct access and diagnostic imaging and served on the authorship committee for the APTA-sponsored white paper, Diagnostic and Procedural Imaging in Physical Therapist Practice. He has functioned as a first-contact provider at Georgetown University Hospital in Washington D.C., the Johns Hopkins Hospital in Baltimore Maryland and currently, at the University of Illinois at Chicago.

Dr. Karrie Hamstra-Wright is a Visiting Clinical Associate Professor and Director of the undergraduate Kinesiology program in the Department of Kinesiology and Nutrition at the University of Illinois at Chicago. As a certified athletic trainer with doctoral and post-doctoral training in lower extremity biomechanics, her research focuses on prevention and treatment of lower extremity overuse injury in active populations. Dr. Hamstra-Wright also has experience outside of academia working as an athletic trainer, director of operations, and wellness coach, all of which inform and shape her scientific and teaching approaches

Appendix A. Survey

The following questions are to provide demographic information.

1. What is your gender?

Male

Female

2. What is your age?

20–30

30–40

40–50

50–60

60–70

70+

*3. How many years of experience do you have as a licensed physical therapist?

0–2

2 – 5

5–8

8 – 12

12–15

15+

4. In which setting are you currently practicing (if more than one, list primary setting)?

Hospital system

Academics/research

PT-owned private practice

Physician-owned private practice

Home Health

Other:

^{* †} 5. Which of the following is your highest level of physical therapy degree?

BSPT

MPT

DPT

* 6. Are you a Fellow of the American Academy of Orthopedic Manual Physical Therapists (FAAOMPT)?

Yes

No

* 7. Do you have a clinical specialist certification by the American Board of Physical Therapy Specialties (e.g. OCS, NCS, etc.)

Yes

No

8. Do you have an academic degree? Please select below from available options.

MA, MS

PhD, DHS, DSc, EdD

I do not have an academic degree

9. Are you currently in clinical practice?

Yes

No

^‡ Clinical questions:

Case 1: Assuming myotomal weakness with manual muscle testing (MMT) between 0/5 and 1/5 (assume TA and EHL test at the same grade), please describe your most likely course of action in regards to the following 3 questions.

11. How likely are you to refer this patient to the appropriate healthcare provider for possible magnetic resonance imaging (MRI) at the initial evaluation?

Very Unlikely

Unlikely

Somewhat unlikely

Somewhat likely

Likely

Very Likely

12. How likely are you to refer for neurosurgical consult?

Very Unlikely

Unlikely

Somewhat unlikely

Somewhat likely

Likely

Very Likely

13. How likely are you to initiate physical therapy treatment within the clinic?

Very Unlikely

Unlikely

Somewhat unlikely

Somewhat likely

Likely

Very Likely

Case 2: Assuming myotomal weakness with manual muscle testing (MMT) between 2-/5 and 3-/5 (assume TA and EHL test at the same grade), please describe your most likely course of action in regards to the following 3 questions.

14. How likely are you to refer this patient to the appropriate healthcare provider for possible magnetic resonance imaging (MRI) at the initial evaluation?

Very Unlikely

Unlikely

Somewhat unlikely

Somewhat likely

Likely

Very Likely

15. How likely are you to refer for neurosurgical consult?

Very Unlikely

Unlikely

Somewhat unlikely

Somewhat likely

Likely

Very Likely

16. How likely are you to initiate physical therapy treatment within the clinic?

Very Unlikely

Unlikely

Somewhat unlikely

Somewhat likely

Likely

Very Likely

17. Assume that the patient presents to initial evaluation with MRI report/impression stating a large broad-based disc protrusion between L4 and L5 with lumbar nerve root compression and myotomal weakness (MMT between 0 and 1) during your clinical exam. What is the likelihood that you refer this patient for immediate neurosurgical consult?

Very Unlikely

Unlikely

Somewhat unlikely

Somewhat likely

Likely

Very Likely

18. Assume that the patient presents to initial evaluation with MRI report/impression stating a large broad-based disc protrusion between L4 and L5 with lumbar nerve root compression and myotomal weakness (MMT between 2-/5 to 3-/5) during your clinical exam. What is the likelihood that you refer this patient for immediate neurosurgical consult?

Very Unlikely

Unlikely

Somewhat unlikely

Somewhat likely

Likely

Very Likely

19. Assume that you decided to initiate formal physical therapy without immediate referral for neurosurgical consult (assume MMT scores of 2-/5 to 3-/5). During the course of treatment, the patient presents with progressive decreases in myotomal strength over the period of 1–2 weeks and reports increased incidence of stumbling/tripping. How likely are you to refer for neurosurgical consult?

Very Unlikely

Unlikely

Somewhat unlikely

Somewhat likely

Likely

Very Likely

None of these (I would not have initiated formal physical therapy)

* These demographic questions were included in discussion for the primary purpose of the study

^† BSPT and MPT combined into one category for data analysis

‡ Indicates that the following question responses of Very Unlikely, Unlikely, and Somewhat unlikely pooled into ‘unlikely’ category for data analysis. Very Likely, Likely, Somewhat likely pooled into ‘likely’ category for data analysis.

Funding Statement

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Consent/ethical approval

The study was approved by the Institutional Review Board of the University of Illinois at Chicago. All participants electronically signed an informed consent prior to completing the survey.

Disclosure statement

The authors report no conflict of interest.