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10 Articles in Volume 17, Issue #4
Algopathy—Acknowledging the Pathological Process of Pain Chronification
Are Abuse-Deterrent Opioid Products A Double-Edged Sword?
CMS Tackles Opioid Prescribing
How do you handle end-of-life care in a patient who does not know they are dying?
Letters to the Editor: Functional Medicine, Naloxone, Hormone Testing, CRPS
Look at the Patient’s Life Story, Then Implement a Management Plan
Myofascial Pain: Overview of Treatment Options
Pain in Parkinson’s Disease: A Spotlight on Women
Patient in Pain? When to Refer for Physical Therapy
Somatic Symptom Disorder: DSM-5's Removal of Mind-Body Separation

Patient in Pain? When to Refer for Physical Therapy

Appreciating the value of, and the need for, restorative care and rehabilitation services will serve patients well, particularly when proper expectations are communicated by pain practitioners.

Physical therapy (PT) is defined by the World Confederation for Physical Therapy (WCPT) as the practice of evaluation and treatment that remediates impairments and promotes mobility, function, and quality of life through examination, diagnosis, and physical intervention (exercise, manual therapies, and modalities).1 It is carried out by physical therapists and PT assistants.

For those astute physicians who might be taken aback at the inclusion of “diagnosis” within the context of PT, it pertains to the identification of musculoskeletal (MSK) impairment, not medical pathology. Physical therapists are trained and educated in differential screening, so they are better able to identify non-MSK problems and symptoms that perhaps originate from visceral disease or adverse effects of medication.

Pain practitioners will serve patients well by referring them to physical therapy for chronic pain management.

People now have direct access to physical therapists in all 50 states, which means they can access PT without medical referral. Although the legal requirement for written referral is lifted in a direct-access environment, the regulatory (insurance) requirement for medical referral continues to be in place in many states, which has direct implications for PT reimbursement.

Growing Field

From 2009 to 2011, 24.8 million Americans (8% of the population) reported an MSK injury.2 Physical therapists are trained as experts in movement dysfunction and functional remediation and restoration. According to the Bureau of Labor Statistics, PT is one of the leading high-demand occupations in all economic categories.3 PT is a blending of pathology, pharmacology, biomechanics, exercise physiology, radiology, and rehabilitative techniques—with emphasis on biomechanics. Many physical therapists continue their training to include postgraduate courses in manipulation, mobilizations, and the myriad of available joint and soft tissue techniques available to practitioners.

An emerging role for physical therapists is that of health and wellness provider, who helps guide patients toward healthier lifestyles and positive behavior change. A physical therapist sees patients 2 to 3 times per week for several weeks to months, providing a valuable opportunity to build long-lasting relationships based on trust and confidence. These extended episodes of care provide invaluable teaching opportunities to promote a healthy lifestyle as part of the ongoing dialogue between patients and their physical therapist.

Why Refer to Physical Therapy

There are many reasons why a person might need PT. The most common patient complaint is pain, and approximately 75% of all patients referred to outpatient PT have pain as their primary symptom.4 The potential causes of pain are similar to those seen in medical and surgical practices, and include pain syndromes, diseases, injury, aging, overuse, stress, and faulty biomechanics.

Along with pain, other reasons for PT referral include weakness, inflammation, atrophy, deconditioning, spasm and tightness, tenderness, active range of motion (AROM) and mobility loss, balance and vestibular deficits, postural faults, and fear and other avoidance behaviors. This latter point is a focus of patient education sessions and a primary factor in de-conditioning, which underlies many pain states associated with centralized pain disorders. In fact, it would not be inconceivable that de-conditioning might be a pre-condition in centralizing pain disorders.5

Physicians should focus less on the methodology used by a therapist and more on the endpoint(s), including patient satisfaction levels. Physical therapists use a myriad of methods while treating patients, and these techniques generally fall into 1 of 3 categories: therapeutic exercise, manual therapy, or a modality (eg, ultrasound, electrotherapy, or traction, etc).

This inherent variation in treatments has been the subject of criticism, but the concerns are largely misplaced. Provider variation is inherent in all medical specialties, especially when making decisions about the need for surgery, drug prescriptions, ordering of tests, lab findings, outside consultations, etc. It is reflective of 3 things:

  • There is nothing more variable, complicated, and unpredictable than human behavior and physiology. What works for one patient does not for another with seemingly similar diagnoses.
  • There are at least 350 known soft tissue methods on record, along with a multitude of different modalities belonging to just as many technology categories. The number of possible combinations and permutations of these interventions, not to mention dosimetry options, makes choosing the best therapy nothing more than a value judgment, or best guess, in many cases. In the absence of comparative effectiveness research, the clinician must choose a therapy based on available evidence, clinical judgment and experience, and patient values—a similar concept to the Evidence Based Medicine paradigm suggested by David Sackett in the early 1990s.6
  • Practice environments (jurisdictions) vary from state to state and sometimes from region to region. In a perfect world, all providers would have access to their local populations. The available population is carved into groups, subsets of the total population, and defined by their insurance plan. Each plan decides, to a large degree, how therapy will be administered (which patient is approved, the stipulations, number of visits, who can treat, reimbursement parameters, reporting format, etc). For example, in our region, there has been a shift from traditional and preferred provider plans (PPOs) to the more affordable but higher deductible and co-pay health maintenance organizations (HMO) plans. These managed care organizations (MCOs) have, in many cases, closed provider panels, limiting new providers in the areas.

Clinical variation is a natural consequence of inherent variation from provider training, experiences, and beliefs; patient characteristics; and reimbursement and regulatory sources. Physical therapists’ practice patterns have been shaped not by evidence-based practice but based on what insurance companies will cover. The entire notion of doing what is best for a patient may get lost in the sea of regulatory requirements mandated by government agencies, the insurance industry, and health policy analysts.

Types of Pain Treated by Physical Therapists

Many conditions are referred for PT treatment every day. PT has shown to be an effective treatment for problems affecting human strength, endurance, power, mobility, balance, posture, motor control, neurological integrity, aerobic endurance, proprioception, and conditions involving pain and/or inflammation. Typical outpatient PT clinics see a cross section of neuro-MSK conditions with etiologies as varied as the symptoms they cause.

It is not uncommon to see a high prevalence of low back and neck pain, likely related to faulty or changing posture fueled by sedentary lifestyles and excess weight. Poor body mechanics can lead to changes in breathing patterns, spinal joint overload, ligament sprain and failure, and a myriad of downstream ill effects. Increased sedentary lifestyle can lead to excess weight, obesity, metabolic syndrome, and a host of other morbidities, including cardiovascular disease (CVD), hypertension, and diabetes.

In the working population, a physical therapist will see both work injury and workplace illness—the 2 are fundamentally different. Shoulder and knee pain are not uncommon in jobs that require handling heavy material. Strains and sprains top the list of the most commonly seen conditions, which can become progressively more complex and challenging to treat when in the form of a superior labral tear from anterior to posterior (SLAP) lesion and/or rotator cuff tear.  

Motor vehicle accidents (MVA) tend to have unique injury patterns due to the nature of the forces acting on the human body during high-speed collisions. Acceleration-deceleration trauma continues to be a vexing problem to treat reliably (conservative or otherwise). Ultrasonography has provided some useful insights into the post-MVA soft tissue changes, including fatty infiltration of muscle tissue that accompanies whiplash-type conditions, and is associated with persistent pain and disability.

We have seen an increase in referrals for an intervention known as “prehab,” or pre-surgical rehabilitation. The thinking behind this trend is to send pre-surgical patients for 4 to 6 weeks of strengthening before they undergo total knee arthroplasty, total hip procedure, or any orthopedic surgery. Patients who invest in 4 to 6 weeks of prehab will save at least 4 to 6 weeks in postoperative recovery. A recent study looking at the efficacy of the prehab model concluded that there was a better postoperative response by those who had prehab compared to patients who either opted out or were not referred to prehab.7 However, the improved treatment response appeared to come from the first 2 sessions of patient education, where patients were taught correct ambulation techniques with crutches, home exercises, posture maintenance, icing techniques, compression and elevation, and energy conservation as opposed to a strengthening component that was postulated to provide the postsurgical advantage.

Aging is inevitable, barring any unforeseen accident or disease. A natural part of the aging process is that our physical functions decline. Muscle mass, immune function, endocrine responses, our senses, memory, and cognition are just a few areas that experience failure at various rates depending on the individual circumstances.8 Age-related injury and illness are a large part of what outpatient PTs see every day, and they take the form of joint arthritis, frailness, weekend warrior injuries, balance and vestibular dysfunction, and postural strain that causes chronic pain. In cases of long-term pain, it is more a case for pain management and not a curative approach. It is unreasonable to think that pain that has evolved over many years will disappear in a few sessions.

Physical therapists see significant numbers of postsurgical cases, including total knee, hip, shoulder, and ankle reconstructions. Surgery significantly reduces muscle contractility, along with leaving the area swollen and irritable. An inflamed joint will demonstrate losses in both strength and range of motion, which translates into weakness, reduced AROM, and compromised stability and proprioception, which further compromises gait and balance in weight-bearing joints. PT has a long history of treating patients who have had orthopedic surgeries, and it may prevent the need for surgery in the first place.

Referral Considerations

In PT, the destination is the focal point for referral agents—the journey is between the patient and PT provider. Providers refer a patient to PT for specific reasons (eg, strengthening, pain reduction, improved function, etc), and a physical therapist uses many techniques and methods to achieve those goals. Judge the result, not the method used.

Here are 8 dos and don’ts:

  1. Do consider patient satisfaction and experience as important factors in evaluating PT services. After all, quality is ultimately measured through the eyes of the end user. Generally, the patient experience determines whether a patient will publicly promote a facility and return as a patient. The use of Net Promoter Scores (NPS) has become popular within our industry as a tool that measures patient satisfaction, and how that translates into a patient becoming a walking billboard for a center or service.9
  2. Do use independent (physical therapist-owned) practices as opposed to physician-owned PT practices (POP). Medicare data of approximately 4,000 patients receiving PT because of a TKA found that the POP practices used almost twice as many visits as the independent PT practices. Data analysis also showed that the POP practices provided a far greater proportion of unskilled therapy based on submitted codes, suggesting the use of non-PT providers and/or therapy extenders.10
  3. Do use certified PT providers. Regarding overall costs associated with a course of care, the data suggests that skilled PT providers perform fewer actual visits with patients than their POP counterparts, but those visits are performed at a higher service intensity level, so the comparative cost might be similar. Independent PT centers are under greater regulatory compliance mandates than POPs, which translates to higher standards of accountability from both commercial and federal agency sources. If referral integrity is important to you—then consider where your patient is directed for PT services. Referral to an independent PT center is always a safe bet.
  4. Do provide early referral to PT services. This is associated with lower costs and better outcomes. Early treatment intervention is cost effective, since the physical therapist is intervening when there is less pathology.11
  5. Do consider a one-time PT consultation for evaluation and recommendations. For example, a visit with a patient who just had a laparoscopic surgery to provide education on reconditioning his or her core is perfectly appropriate.
  6. Do recommend strength training after surgery. Sport science journals are replete with studies supporting the positive effects of an 8- to 12-week properly conducted regimen of strength training  3 times per week. This helps explain why it can take that long to effectively restore strength in a joint that has been injured or had surgery. When strengthening is a primary treatment goal, consider the strength research supporting this regimen.12
  7. Do send relevant diagnostic test results and operative findings to the physical therapist. This is important information to have when formulating a care plan. It’s not just professional courtesy—it should be a professional requirement. If a physical therapist is expected to mobilize or exercise a body part that has had surgery, they should have any relevant imaging studies.
  8. Don’t micromanage the physical therapist. Build your physical therapist relationship with trust—it’s simple courtesy and respect. Avoid identifying each element of the treatment plan for the physical therapist.  Communication is paramount to avoid disagreement, but let the therapist do his or her job.

The physical therapist of today is better equipped to screen patients for symptoms related to non-MSK causes. While physical therapists don’t diagnose medical problems, they may recognize when a problem involves other systems and co-morbidities that need to be referred back to you. Confident physicians should appreciate the extra check and balance this provides, especially in a direct-access environment where the physical therapist may well be the initial point of care into the health care system.

Mechanics of Referral

There are many ways a PT referral is generated these days, but the most common method is when a referral agent requisitions PT services via prescription. In many jurisdictions, prescriptions can be generated by MDs, DOs, DPMs, DDSs, NPs, and PAs (less frequently DCs). There is a myriad of medical specialties that use PT services, including orthopedics, internal medicine, geriatrics, pediatrics, neurology and neurosurgery, physical medicine and rehabilitation, rheumatology, anesthesia (pain), podiatry, and OB-GYN.  In the early days of PT, therapists worked directly under the supervision of physicians in hospitals. In the last 70 years, however, PT has evolved into an increasingly autonomous profession. Like most other licensed health professionals, physical therapists have independent professional governance through the American Physical Therapy Association (APTA), in conjunction with the various state licensing boards responsible for state-specific licensure and regulation of PT.

The actual prescription form, or “script,” has changed over the years from a simple in-hospital slip of paper for in-patient treatment to the more elaborate forms used today, which tend to be more descriptive and must contain certain elements deemed “valid,” at least from a Medicare standpoint. This last point is important, since the diverse US insurance marketplace has consisted of many insurance companies, third-party administrators, and self-insured entities. Many of these entities have their own unique reimbursement criteria, including PT pre-authorization. The best way for providers to feel confident that they are meeting all the various payer criteria is to simply adopt the most stringent and detailed compliance model there is—and that is the Medicare model.

A valid Medicare PT prescription must contain certain elements, including patient and physician name, patient diagnosis, date prescription written, frequency and duration of treatment, and the actual PT plan of care. PT referral is becoming increasingly complicated as payers attempt to control costs by limiting access to PT through various mechanisms, not the least of which is utilization management.

Cost shifting is another form of cost containment that uses financial barriers in the form of high deductibles and co-pays and co-insurances, which patients are ultimately responsible for during a course of care. This shifting of cost from the payer to the patient places a greater financial responsibility on a patient and usually has the insurance-intended result of limiting visits. An incomplete course of PT often leads to worse outcomes—the return of the patient with a worse prognosis and a lengthy interruption in the rehabilitation course, leading to chronicity and disability. Physicians will often get frustrated at what they might consider to be premature patient discharges by the physical therapist, but they need to understand that their expectations for patient rehab need to align with a patient’s insurance plan. In some cases, a physician’s concept of PT might be quite different to what is provided by the physical therapist due to the regulatory requirements imposed by payers. Everything from the diagnostic labeling (must be payable and a valid ICD-10 code) to the duration must coincide with insurance guidelines, and then balanced with patient affordability issues due to co-pays, co-insurance, and unmet deductibles.


The importance of PT services will increase with the shifting global demographics and the subsequent aging of America. As baby boomers age, the demand for physical restoration services is expected to rise. Many of the trends we see today are reflective of this demand to maintain a high quality of life through engagement in activities, wearable technology, and a focus on physical fitness and injury prevention.

Physical therapists today are asked to provide not only rehabilitation services, but also injury prevention and early injury detection services. Physical therapists are being hired to perform ergonomic assessments, and provide education and prevention services at business locations. The renewed focus on wellness and disease management has placed physical therapists at the forefront of public health initiatives to curb epidemics in obesity, cancer, diabetes, stroke, and cardiovascular disease. Physicians should refer for PT when medical reconditioning or functional restoration is required after an injury, surgery, or disease, or due to advancing age. We do not compete with physicians or surgeons; rather, we are an integral part of the health care team who improves the quality of life of the people around us.

Last updated on: July 12, 2017
Continue Reading:
Somatic Symptom Disorder: DSM-5's Removal of Mind-Body Separation

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