Orthopedic surgeons and physical therapists differ regarding rehabilitative needs after lower extremity fracture repair

Abstract

Background:

Little evidence is available to guide physical therapy (PT) following lower extremity fracture repair distal to the hip. As such, variability has been reported in the way PT is utilized post-operatively. Examination of current practice by orthopaedic surgeons (OS) and physical therapists is needed to inform clinical practice guidelines in this area.

Objective:

To describe current PT referral practices among OS, identify patient and clinical factors that affect PT referral, and examine differences between OS and physical therapists with regard to visit frequency, duration, and use of specific PT interventions.

Methods:

Provider surveys.

Results:

Surveys were completed by 100 OS and 347 physical therapists. Over half (54%) of OS reported referring “most patients” to PT and identified joint stiffness and strength limitations as top reasons for PT referral. Over 80% of OS and physical therapists indicated that joint stiffness, strength limitations, and patients’ functional goals affected their recommendations for PT visit frequency. More physical therapists than OS reported pain severity (55% vs 25%, p < 0.001), maladaptive pain behaviors (64% vs. 33%, p < 0.001), and patient self-efficacy (70% vs. 49%, p = 0.003) affected their visit frequency recommendations. While OS recommended more frequent PT for patients with peri-articular fractures, fracture type had minimal impact on the visit frequencies recommended by physical therapists.

Conclusion:

OS and physical therapists consider similar physical impairments when determining the need for PT and visit frequencies, however, physical therapists consider pain and psychosocial factors more often, with OS focusing more on injury type.

INTRODUCTION

Lower extremity fractures have been associated with disability and physical impairment that can last up to 7-years post-injury, depending on the mechanism and severity of the injury (MacKenzie and Bosse, 2006; Mackenzie et al, 2005). Acute management of these injuries most often includes surgical repair using hardware such as nails, screws and plates. Despite evidence that indicates physical therapy (PT) improves outcomes such as range of motion and gait speed after lower extremity fracture repair (Castillo et al, 2008), the number of patients that attend PT after lower extremity fracture varies greatly and it does not appear to be a routine component of post-operative care (Antonova, Le, Burge, and Mershon, 2013; Castillo et al, 2005; McLaughlin et al, 2021). For example, recent studies have reported that only 44 to 69% of patients surgically treated for a lower extremity fracture attend at least 1 outpatient PT visit after surgery. Among patients that do attend PT, the number of visits that patients attend varies greatly, with studies reporting patients attending an average of 18 to 30 visits (Castillo et al, 2005; McLaughlin et al, 2021). The reasons for this variability are not entirely known.

One possible reason for the observed variability in PT attendance centers around orthopaedic surgeon (OS) referral (Castillo et al, 2005). Previous studies have reported that over half (58–99%) of OSs believe PT will be beneficial for their patients after lower extremity fracture repair and that the primary reasons they refer to PT are to improve strength and range of motion and for patients to undergo gait training with assistive devices (Archer et al., 2009; Dusik, Buckley, and Robertson-More, 2013). While these studies have helped to elucidate OS expectations for PT following lower extremity fracture repair, it is still unclear how OS determine which patients will be referred to PT and if there are any specific factors (e.g. fracture type and psychosocial factors) that they consider during this process. Furthermore, it is unclear how OS prescribe visit frequency and duration of PT care, which likely has a major impact on the total number of visits that patients attend. It is also unclear what proportion of OS prescribe specific therapy interventions following fracture repair, and which interventions they prescribe. Further research is needed that examines the current practice of OS as it pertains to PT referral to better understand variability in post-operative PT following lower extremity fracture repair. The purpose of this study was to describe current PT referral practices among OS and identify patient and clinical factors that affect PT referral following lower extremity fracture repair (excluding hip fractures). In addition, we sought to examine current practice among physical therapists that treat patients following lower extremity fracture repair, as physical therapists have not been included in prior studies in this area. It is likely that not all OS include specific recommendations for PT on their referrals and that the care delivered by physical therapists may differ or expand upon recommendations that are included by OS. The results of this study will help to inform the development of clinical practice guidelines and treatment protocols for PT following lower extremity fracture repair.

METHODS

Survey Development

Two surveys (one each for OS and physical therapists) were developed by a multi-disciplinary team that included: a physical therapist (KM); an OS (BS); a health services researcher (LR); and a rehabilitation psychologist (SW) with experience in survey development and extensive research and clinical experience in orthopaedic injuries. Surveys were administered through the Research Electronic Data Capture System (REDCap) (Harris et al, 2009; Harris et al, 2019) and took under 15 minutes to complete. Both surveys captured respondent demographics, practice setting, geographic region, years of experience, training, and the proportion of patients that clinicians treat with lower extremity fractures.

The OS survey consisted of 4 sections: 1) factors affecting referral to PT; 2) factors affecting recommended PT visit frequency; 3) interventions included on PT referrals; and 4) factors affecting duration of PT care. The physical therapist survey consisted of three sections: 1) factors affecting visit frequency; 2) interventions employed during PT sessions; and 3) factors affecting duration of PT care. Respondents were asked how often each factor affected PT referral, frequency of therapy visits or duration of care on a 5-point Likert scale (i.e. [1] Never, [2] Almost never, [3] Sometimes, [4] Almost always, and [5] Always). Factors included: injury characteristics (e.g. fracture severity); psychosocial factors (e.g. maladaptive pain behaviors); and other patient-level factors (e.g. insurance status). Respondents were also asked how often they recommended or utilized specific PT interventions including standard strengthening, balance, and mobility exercises as well as specialized therapies like blood flow restriction and antigravity treadmill therapy. To reduce social desirability bias, the list of interventions was designed to be comprehensive and was not exclusive to expert-recommended interventions. Both surveys were designed to be as similar as possible with minor wording changes to ensure questions were applicable to each provider type.

The survey was pilot tested for clarity and relevance among 3 OS and 6 outpatient physical therapists. Pilot testing included the length of time it took participants to complete surveys as well as recommendations from participants on question clarity, relevance, and the addition of any interventions or factors not included on the original lists that could impact patient referral or PT care. Feedback was provided in person as a group to promote discussion amongst participants and study team. Feedback was incorporated into final versions of each survey, available in Supplemental Material. The final OS survey contained 28 questions and the physical therapist version contained 24 questions.

Survey Dissemination

This study was approved by the Johns Hopkins Medicine Institutional Review Board (IRB00199752, IRB00199845). Surveys were distributed in August 2019. Physical therapist surveys were electronically mailed to members of the Academy of Orthopaedic Physical Therapy, consisting of approximately 18,000 physical therapists. The physical therapist version of the survey was sent via email blast and could only be sent once with participants having up to 3 months to respond. OS surveys were electronically mailed to OS at hospitals participating in a large orthopaedic trauma research consortium, consisting of approximately 460 surgeons. OS were sent 3 reminders over 3 months to complete the survey. Responses from all OS and physical therapists completing the full surveys were included in analysis.

Statistical Analysis

Descriptive statistics were calculated for respondent characteristics, OS referral rates to PT, and the percentage of OS that reported “always or almost always” for each factor that affected their decision to refer patients to PT. Chi-squared tests were used to compare percentage of OS and physical therapists that reported at least “almost always” for each intervention recommended or used in PT; and for each factor that affected frequency of PT visits. Differences were considered statistically significant if p < 0.05. Analysis was conducted using Stata 15 (2017) (StataCorp, College Station, TX).

RESULTS

We received 347 responses to the physical therapist survey and 100 responses to the OS survey. Nearly all OS specialized in trauma (91%), had >10 years of experience (70%), saw large case volumes defined as > 225 cases per year (75%), and worked in academic settings (90%). Nearly all physical therapists specialized in orthopaedics (95%), over half held board certifications (54%), 14% were fellowship trained, the largest proportion worked in private or hospital-based outpatient clinics (55%) and most reported that lower extremity fractures made up <25% of their caseloads (Table 1).

Table 1.

Survey respondent characteristics and practice setting

Respondent Characteristics
Orthopaedic Surgeon (N=100)		Physical Therapist (N=347)
Years since residency, N (%)		Years as a physical therapist, N (%)
<5 years	7 (7.0)	<5 years	86 (24.8)
5–10 years	23 (23.0)	5–10 years	70 (20.2)
11–20 years	32 (32.0)	11–20 years	75 (21.6)
>20 years	38 (38.0)	>20 years	115 (33.1)
		Missing	1 (0.3)
Gender, N (%)		Gender, N (%)
Female	11 (11.0)	Female	193 (55.6)
Male	88 (88.0)	Male	147 (42.4)
Prefer not to say	1 (1.0)	Prefer not to say	6 (1.7)
		Missing	1 (0.3)
Trauma fellowship training, N (%)		Fellowship training, N (%)
Yes	88 (88.0)	Yes	50 (14.4)
No	9 (9.0)	No	296 (85.3)
Missing	3 (3.0)	Missing	1 (0.3)
		Fellowship training area, N (%)
		Orthopaedic manual therapy	47 (94.0)
		Spine	2 (4.0)
		Hand therapy	1 (2.0)
Trauma cases per year, N (%)		Lower extremity trauma caseload, N (%)
<75	3 (3.0)	<10%	138 (39.8)
75–149	7 (7.0)	10–25%	157 (45.2)
150–225	15 (15.0)	26–50%	43 (12.4)
>225	75 (75.0)	>50%	7 (2.0)
		Missing	2 (0.6)
Practice Setting
Setting, N (%)		Setting, N (%)
Academic	90 (90.0)	Private outpatient	191 (55.0)
Hospital-based	5 (5.0)	Hospital-based outpatient	131 (37.8)
Group practice	4 (4.0)	Other†	25 (7.2)
Solo practice	0
Missing	1 (1.0)
Ownership of or share revenue with a physical therapy clinic, N (%)
Yes	4 (4.0)
No	95 (95.0)
Missing	1 (1.0)
Practice area, N (%)		Specialty area, N (%)
General orthopaedics	2 (2.0)	Orthopaedics	180 (94.7)
Trauma	91 (91.0)	Sports	6 (3.2)
Foot and ankle	4 (4.0)	Pediatrics	1 (0.5)
Other**	3 (3.0)	Missing	3 (1.6)
		Board certification, N (%)
		Yes	190 (54.8)
		No	156 (45.0)
		Missing	1 (0.3)
Region, N (%)		Region, N (%)
East Coast	45 (45.0)	East Coast	138 (39.8)
West Coast‡	9 (9.0)	West Coast‡	57 (16.4)
South	20 (20.0)	South	39 (11.24)
Midwest/Southwest	25 (25.0)	Midwest/Southwest	112 (32.28)
Missing	1 (1.0)	Missing	1 (0.3)
Specific location, N (%)		Specific location, N (%)
Inner-city	71 (71.0)	Inner-city	72 (20.8)
Rural	7 (7.0)	Rural	63 (18.2)
Suburb	22 (22.0)	Suburb	211 (61.0)

^*Some categories do not add to 100% due to rounding;

^**Other surgical practice areas include pediatrics, spine, and oncology;

^†Other physical therapy settings include Acute care hospital, academic institution, health and wellness center, research center, industry;

^‡Includes Hawaii and Alaska

Surgeon Referral to Physical Therapy

All OS reported referring at least some of their patients to PT with 54% responding that they refer “most patients” to PT (Figure 1). The fractures that surgeons most frequently refer to PT included: tibial plateau fractures (81%); distal tibia/pilon fractures (76%); and distal femur fractures (76%) (Figure 2). The two fracture types referred to PT least often by OS were midfoot (36%) and forefoot fractures (18%). Over half (51%) of OS reported that fracture repair technique (e.g. intermedullary nail and open reduction with internal fixation) did not affect their decision to refer to PT.

Figure 1. Surgeon’s Referral to Physical Therapy for Patients with Lower Extremity Trauma.

Percentages indicate the proportion of surveyed surgeons that reporting sending “every,” “most,” “half,” “some,” or “no patients” to physical therapy following lower extremity fracture repair. N=100

Figure 2. Proportion of surgeon’s that “always” or “almost always” refer patients to physical therapy by fracture type.

Percentages indicate the proportion of surveyed surgeons that indicated they “always” or “almost always” refer patients with each type of fracture to physical therapy following surgical repair. Number of responses per fracture type ranged from 97–100

The factors that OS most frequently rated “almost always” or “always” affected their decision to refer patients to PT included: joint stiffness (98%); patients’ functional goals (80%); strength limitations (76%); and patient preference for PT (72%). Factors considered least often by OS included pain severity (29%) and insurance status (29%) (Table 2).

Table 2.

Patient and injury factors that affect orthopaedic surgeon decision to refer to physical therapy after lower extremity fracture repair

Factor	“Almost Always” or “Always”Ɨ, N (%)*
Joint stiffness (range of motion)	97 (98)
Strength limitations	76 (76)
Patient’s functional goals	80 (80)
Patient preference for PT	72 (72)
Maladaptive pain behaviors	62 (62)
Tolerance for weight bearing	63 (64)
Patient self-efficacy	61 (61)
Amount of soft tissue damage	40 (41)
Patient access to therapy (e.g. transportation and time constraints)	39 (39)
Fracture severity	41 (41)
Patient’s likelihood to attend	38 (38)
Pain severity	29 (29)
Insurance plan/status	29 (29)

^ƗIndicates that orthopaedic surgeons reported “always” or “almost always” considering this factor when determining the need for a physical therapy referral;

^*Response totals for each question varied between 98–100

Physical Therapy Interventions

Over 90% of OS reported that they include specific interventions on PT referrals. Most OS included: gait training (87%); joint mobilizations (85%); and strengthening exercises (84%) on their PT referrals (Table 3). In their practice, most physical therapists used: strengthening exercises (99%); gait training (95%); balance exercises (94%); passive range of motion (84%); pain education (82%); graded activity/exposure (79%); and joint mobilizations (75%) (Table 3). Fewer than 10% of OS and physical therapists prescribed or used newer technologies such as anti-gravity treadmill training, blood flow restriction therapy, or virtual reality training.

Table 3.

Physical therapy interventions for patients with lower extremity fracture repair

Intervention	“Always” or “Almost Always” Ɨ		P-Value‡
	Orthopaedic Surgeons, N (%)*	Physical Therapists, N (%)*
Strengthening Exercises	77 (84)	342 (99)	< 0.001
Gait Training (with/without assistive device)	80 (87)	328 (95)	0.005
Balance Exercises	49 (53)	327 (94)	< 0.001
Passive range of motion	57 (62)	289 (84)	< 0.001
Pain education	16 (18)	285 (82)	< 0.001
Graded activity/exposure	17 (19)	272 (79)	< 0.001
Joint Mobilization	77 (85)	259 (75)	0.059
Cryotherapy	12 (13)	196 (57)	< 0.001
Nerve Glides	3 (3)	92 (27)	< 0.001
Neuromuscular electric stimulation	5 (5)	74 (22)	< 0.001
Pain modalities (Ultrasound, TENS, laser)	23 (25)	74 (21)	0.200
Relaxation/mindfulness	2 (2)	54 (16)	0.001
Vasopneumatic compression	4 (4)	48 (14)	0.013
Aquatic therapy	10 (11)	24 (7)	0.219
Anti-gravity treadmill training	3 (3)	20 (6)	0.335
Blood flow restriction therapy	0	10 (3)	0.100
Virtual reality training	1 (1)	1 (<1)	0.307

^ƗIndicates that provider reported “always” or “almost always” including this intervention in their referral (orthopaedic surgeons) or plan of care (physical therapists);

^‡Calculated using chi-squared tests;

^*Number of responses varied by intervention. Surgeon range: 90–92 Physical therapist range: 342–347; (TENS) transcutaneous electric nerve stimulation, (PT) physical therapy

Visit Frequency and Duration of PT Care

Over half (63%) of OS reported including visit frequency on their referrals to PT with variability in the number of visits they typically prescribed per week. Approximately half of the OS surveyed prescribed ≥ 3 visits per week for distal femur fractures (48%), tibial plateau fractures (48%), and distal tibia/pilon fractures (53%); ≤1 visit per week for forefoot fractures (47%) and 2 visits per week for all other fractures. Only 13% of physical therapists reported differentiating visit frequency based on fracture type. Most saw patients twice per week regardless of fracture types, except tibial plateau fractures which they reported seeing ≥ 3 times per week (Table 4).

Table 4.

Number of physical therapy visits recommended by orthopaedic surgeons versus physical therapists by fracture type

		≤1x per wk	2x per wk	≥3x per wk	P-value***
Diaphyseal (mid-shaft) femur	PT*	9 (22.0)	20 (48.8)	12 (20.3)	0.94
	Surgeon**	15 (24.6)	28 (45.9)	18 (29.5)
Distal femur	PT	8 (19.1)	20 (47.6)	14 (33.3)	0.30
	Surgeon	7 (11.5)	25 (41.0)	29 (47.5)
Tibial plateau	PT	7 (16.3)	15 (34.9)	21 (48.4)	0.22
	Surgeon	4 (6.4)	28 (45.2)	30 (48.4)
Diaphyseal (mid-shaft) tibia	PT	11 (26.8)	26 (63.4)	4 (9.8)	0.05
	Surgeon	16 (26.2)	27 (44.3)	18 (29.5)
Distal tibia/Pilon fracture	PT	6 (14.6)	25 (61.0)	10 (24.4)	0.02
	Surgeon	6 (9.7)	23 (37.1)	33 (53.2)
Isolated Fibula/Ankle	PT	12 (27.9)	20 (46.5)	11 (25.6)	0.74
	Surgeon	17 (27.4)	25 (40.3)	20 (32.3)
Hindfoot (calcaneus, talus)	PT	11 (25.6)	24 (55.8)	8 (18.6)	0.26
	Surgeon	16 (26.7)	25 (41.7)	19 (31.7)
Midfoot (navicular, cuneiforms)	PT	13 (29.6)	24 (54.6)	7 (15.9)	0.28
	Surgeon	22 (37.3)	23 (39.0)	14 (23.7)
Forefoot	PT	16 (38.1)	24 (57.1)	2 (4.8)	0.01
	Surgeon	27 (47.4)	17 (29.8)	13 (22.8)

^*Responses from therapists for each question varied between 41–44 participants;

^**Responses from surgeons for each question varied between 57–62 participants;

^***Calculated using Chi2

Most OS reported that joint stiffness (83%), strength limitations (82%), and patients’ functional goals (64%) “almost always” or “always” affected their prescribed PT visit frequency (Table 5). Most physical therapists also reported joint stiffness (88%), strength limitations (88%), and patient’s functional goals were important factors. However, more physical therapists than OS reported that pain severity, maladaptive pain behaviors, and patient self-efficacy affected their plan of care (p < 0.01). Both OS and physical therapists typically recommended 6–8 weeks of PT and agreed (92% and 84%, respectively) that the duration of PT care should be based on patient response to therapy and achievement of functional goals rather than fixed time frames.

Table 5.

Factors that affect frequency of physical therapy visits after surgical fracture repair

Factor	“Almost Always” or “Always” Ɨ		P-Value‡
	Orthopaedic Surgeons, N (%)*	Physical Therapists, N (%)*
Joint stiffness/Range of Motion	50 (83)	306 (88)	0.159
Patient’s functional goals	40 (64)	277 (80)	0.007
Strength limitations	50 (82)	306 (88)	0.159
Length of time since surgery (PT survey)	N/A	214 (62)	---
Patient preference	22 (36)	206 (60)	0.001
Surgeon preference	N/A-	211 (61)	---
Pain severity	15 (25)	190 (55)	< 0.001
Injury severity (PT survey)	N/A	250 (72)	---
Fracture severity (surgeon survey)	18 (30)	N/A	---
Soft tissue damage (surgeon)	24 (39)	N/A	---
Patient self-efficacy	30 (49)	241 (70)	0.003
Maladaptive pain behaviors	20 (33)	219 (64)	< 0.001
Patient access to therapy (e.g. transportation and time constraints)	18 (30)	182 (53)	0.001
Tolerance for weight bearing	35 (57)	189 (54)	0.674
Insurance plan/status	14 (23)	181 (52)	< 0.001
Patient’s likelihood to attend/no show rate	17 (28)	104 (30)	0.798
Rapport with patient (PT survey)	N/A	51 (15)	---
Clinic volume	N/A	44 (14)	---
Personal caseload volume (PT survey)	N/A	37 (11)	---

^ƗIndicates that provider reported “always” or “almost always” considering this factor when determining appropriate physical therapy visit frequency for patients;

^*Number of responses varied by factor. Surgeon range: 60–61 Physical therapist range: 344–347;

^‡Calculated using chi-squared tests

DISCUSSION

This study provides current information regarding PT referral and practice following lower extremity fracture repair and builds on previous research in this area by identifying specific factors that OS consider when determining the need for PT referrals. We also build on previous work by including physical therapists’ perspectives and by more closely examining how both provider types determine visit frequencies and which types of interventions they prescribe or provide following lower extremity fracture repair. Importantly, the results of our study indicate that individual OS vary in how frequently they refer to PT and both provider types vary in the visit frequency they recommend post-operatively. Lastly, we found that both provider types consider physical impairments (i.e. range of motion and strength) when determining the need for PT services but differ on how they consider other factors, such as fracture type and pain severity.

The factors we identified as being important to OS in determining the need for PT are in alignment with the results reported by Archer et al. (2009) which found that OS primarily referred patients to PT to improve range of motion, strength, and for the use of assistive devices. Similar results were reported from a retrospective study published by the same author that found OS were more likely to assess a need for PT services following severe lower extremity trauma when patients presented with decreased range of motion or weight bearing tolerance, whereas physical therapists were more likely to assess a need for these services among patients with higher pain levels (Archer, Mackenzie, Castillo, and Bosse, 2009). Our study found that over half of physical therapists reported maladaptive pain behaviors and pain severity affected visit frequency whereas only a third of OS indicated that pain was a consideration for PT referral. These results are important considering the current opioid epidemic and the need for expanded use of non-pharmacologic pain management strategies. PT utilization has been associated with decreased opioid consumption for those with musculoskeletal pain and should be considered as a pain management strategy following lower extremity fracture repairs (Frenkel Rutenberg et al, 2020; Pritchard et al, 2021; Sun et al, 2018).

Surgeons reported that they refer patients with peri-articular fractures (i.e. tibial plateau, distal femur, and pilon) to PT more often and at higher visit frequencies than those with diaphyseal or foot fractures. These results are similar to a previous study that used claims data to examine PT utilization after tibia fractures and found patients with upper tibia fractures including tibial plateau attend PT more often than those with tibia shaft (diaphyseal) fractures (McLaughlin et al, 2021). This is likely due to the propensity for patients with peri-articular fractures to develop stiffness in the knee or ankle following surgical repair (Bishop, Agel, and Dunbar, 2012; Kugelman et al, 2018; Pujol, Boisrenoult, and Beaufils, 2015; Thordarson, 2000). Interestingly, very few physical therapists reported adjusting visit frequency based on fracture type. It is possible that this is because they consider individual physical impairment and psychosocial factors more than fracture type alone. Additional analyses did not find that the decision to alter visit frequency based on fracture type was associated with physical therapist experience, training, or the proportion of their caseload comprised of patients with lower extremity fracture repairs.

Previous studies have found that only about two thirds of patients attend PT after lower extremity fracture repair and there is a large variance in the number of PT visits attended by these patients (Antonova, Le, Burge, and Mershon, 2013; Castillo et al, 2005; McLaughlin et al, 2021). While there are a number of non-clinical reasons (e.g. transportation and insurance coverage) that impact PT attendance (Castillo et al, 2005) it is possible that some of the factors identified in this study that influence OS referral and physical therapist practice may contribute to this variance. For example, patients with peri-articular injuries and high pain severity might be prescribed or provided more visits than those with diaphyseal injuries and lower pain severity. Future studies are needed that examine whether these factors may also help identify patients most likely to benefit from PT services after lower extremity fractures. It is also possible that the variability between individual OS and physical therapists observed in this study may contribute to the reported variability in PT utilization.

There are multiple limitations to this study that should be considered alongside the reported results. Due to electronic survey delivery methods and methods used to maintain survey responder anonymity, we are unable to account for the number of survey invitations that were undelivered, unopened, or sent in duplicate. As such, we cannot report true survey response rates. However, the total number of responses we received is similar to those in other studies utilizing surveys among similar provider populations (Brown-Taylor et al, 2020; Dale, Thomas, and Hazle, 2019; Dusik, Buckley, and Robertson-More, 2013) Second, those who did respond to our surveys were primarily academic trauma surgeons and certified orthopaedic PT specialists and their responses may not reflect the views of OS and physical therapists as a whole. However, these groups were targeted as they were most likely to have experience working with this patient population. Lastly, it is important to consider that based on the nature of PT, physical therapists can include new interventions in their plan of care and adapt visit frequency based on how patients respond to PT over time. OS have less frequent interactions with patients after surgery and their decisions surrounding specific interventions and visit frequencies are generally made prior to PT beginning. These differences should be considered when making direct comparisons between provider types.

CONCLUSION

The results of our study indicate that OS refer to PT most often and recommend the highest visit frequencies for patients with peri-articular fractures and those with specific physical impairments. While physical therapists consider many of the same physical impairments when determining visit frequency, they also consider pain severity and psychosocial factors considered less frequently by OS. Further research is needed to identify factors that predict whether patients will benefit from PT after lower extremity fractures and how visit frequency and length of care affect patient outcomes in order to establish post-operative rehabilitation guidelines.