Physical therapy is truly a union of science, art and emotion where the intention to do good is fueled by a knowledgeable mind, a caring heart, and skillful hands. As clinicians, we are taught to observe, analyze, and execute a plan. We are often so focused on our responsibility to heal our patients that we may fail to recognize when it is necessary to refer physical therapy patients to other providers. How can we learn to identify appropriate opportunities for other professionals to render their treatments without compromising our role in our patients’ care? How do we know when it’s time to gracefully step aside and fully allow another provider to work their magic?
As physical therapists, we are qualified to offer many interventions that can alleviate pain and restore function. For some patients, we may be the sole practitioner aside from their primary physician, which puts us in the unique position of acting as a liaison in connecting the patient with other resources. This is especially important for patients who present with chronic pain or complex medical issues as it is critical to recognize the need for a team approach to their care. Embracing the team approach also means that you may be the person who initiates a referral.
As we gain clinical experience, we are exposed to many different situations that necessitate this referral process. This may involve advising a patient to return to his or her referring physician for further examination, recommending a consult with a specialist to allow access to an alternative or adjunctive treatment, or referring the patient for a completely different type of treatment altogether.
Here are five signs that it’s time to refer your patient:
1) The patient is not responding as expected to treatment:
Imagine that you are treating a patient who has just had a knee replacement. You are focused on improving the patient’s knee flexion and you have educated your patient about the expected prognosis during the rehabilitation program. There were no immediate signs of complications after surgery, however knee flexion remains very limited despite all of your efforts to relieve the pain and improve soft tissue and joint mobility. The patient has not demonstrated adequate improvement although you have provided a variety of interventions including manual techniques, pain relief measures, therapeutic exercise and functional training.
You have used all of the techniques that you know, reviewed continuing education coursework and consulted your more experienced colleagues for treatment ideas, to no avail. Not only is this patient not progressing – this has amounted to a major setback.
This is a situation in which it is crucial to identify the problem in a timely manner for prompt referral back to the surgeon. I have encountered situations in which the patient is resistant to returning to the surgeon for various reasons- the next follow up appointment isn’t for a few more weeks, the person doesn’t have the time, energy or money to visit the surgeon sooner than anticipated, or maybe the patient is nervous about what has to be done to address the possible complications.
Regardless of the patient’s response, it is important to communicate that you are obligated to notify the surgeon promptly in order to assure that the most appropriate treatment can be offered as soon as possible. As therapists, we have high expectations of our ability to heal our patients.
While we do everything we can to help our patients avoid additional medical or surgical interventions, this is not always in our control. I have found that the best way to handle these situations is to make it clear to your patients from the outset that you will always act as an advocate for them, maintaining their safety and health as your highest priority. While we cannot always promise that the results will align with their expectations, we can promise that we will do anything possible to help them achieve success.
2) The patient is presenting with additional medical issues that require further evaluation:
You have just completed an evaluation of a 48 year old man with complaints of back pain, who arrived to the clinic without a prescription. The patient is being seen by you under Direct Access as he did not consult a physician prior to the appointment. The patient reported a history of back pain which occurred after spraining his ankle last year. It resolved on its own, but it ‘acts up’ periodically. He stated that the back pain returned last month and seemed to come out of nowhere as he does not recall any recent trauma. He described the pain as burning, noting that it is sometimes worse after sitting for prolonged periods of time. He was vague about the exact location of his pain, stating that it is not always in the same region- sometimes more in his mid to lower back, sometimes extending around the side of his ribcage. The patient’s medical history includes angina with an MI two years ago for which he is taking medication, lung cancer which was successfully treated into remission, HTN, and chronic UTIs.
Through your continued questioning, you have assessed that his pain is most prominent in the mid to lower back, is most noticeable or worse after eating and is accompanied by nausea and bloating. The patient stated that the pain was relieved with OTC NSAIDs after his initial injury, so he tried a few doses in the past few weeks however did not experience relief. He recalled feeling worse after taking two pills the other day. He indicated that changing positions does not necessarily alleviate the pain and that he has a hard time finding a comfortable position in which to sleep. When you asked if he has consulted with his primary physician about these various complaints, he replied that he had intended to notify his doctor however he missed his annual physical which was scheduled for last month and has not rescheduled it to his busy work schedule. He also mentioned that his job as an attorney is extremely stressful and more recently, he has noticed extreme fatigue, which he attributes to working longer hours on a difficult case. He stated that his friend advised him to try PT and he figured that you could “fix” his back and save him a trip to his doctor.
On physical examination, you palpated a significant amount of tension in his paraspinals with restrictions in the psoas bilaterally however you were not able to reproduce the pain by quality or location. You observed a restricted breathing pattern with decreased excursion of his diaphragm and ribs. You also noticed his tendency to sit in slumped posture, however he was able to correct this with verbal cues. His standing trunk range of motion was grossly WNL without onset or increased pain in any direction, however he reported stiffness when he bent forwards and backwards. His neurological screen was clear however he exhibited some mild weakness in his right ankle. You communicated your findings to the patient and advised him to re-schedule his visit with his physician before he makes a follow up PT appointment as you feel that he needs further medical screening to rule out other causes of back pain. The patient insisted that he is fine and that he wants to have PT for his back.
This is an example of a ‘typical’ patient who may present to an outpatient clinic with a complaint of back pain. As back pain is one of the most common reasons for which patients are referred to or even seek PT on their own, it is critical that we sharpen our differential diagnosis skills. In this case, it would be advisable to refer the patient back to his primary doctor and notify the physician of your findings. Given the patient’s history of cancer, MI and chronic UTIs, the source of his back pain is not clear and does not appear to be orthopedic in origin based on your exam.
It is also important to note that these symptoms could be associated with an undiagnosed ulcer or another medical issue. In this case, the patient is insisting on being treated. It is important to distinguish when appeasing such a request is appropriate vs. when it is not. There are situations in which patients do present with an issue that can be appropriately treated with PT however there may also be a concurrent undiagnosed medical issue which is complicating the problem that you are addressing. Ruling out serious medical issues is always the prudent thing to do. Building upon your differential diagnosis skills will allow you to gain confidence in navigating these situations and responding appropriately.
3) The patient requires treatment by another type of provider instead of or in addition to PT:
You greet a patient who you are scheduled to treat this week in your co-worker’s absence. Your co-worker briefly discussed her case with you before he left for vacation, mentioning that he hasn’t been able to identify a successful treatment plan yet as he has only seen this patient a few times due to inconsistent attendance. You had previously reviewed her intake forms as she was evaluated by your colleague a few weeks ago; however, you asked additional questions as you conducted your physical examination to get more information.
Since her last session, her pain was slightly better immediately following but she stated ‘the neck pain just keeps coming back and my jaw hurts, too. I’m also having a lot of headaches.’ She mentioned that she feels depressed and has not been sleeping well. She also stated that she was referred to PT by her doctor as her neck pain has worsened in the past three months. She is not sure if she is improving with PT since she has only been able to attend a few times. She mentioned that she is a college student, having almost completed the first semester of her senior year. Her neck pain and headaches developed over the summer suddenly. According to the evaluation, she denied physical trauma, including car accidents, prior to the onset of pain. She mentioned that she has recently been under more stress while studying for exams last week, which is why she had to cancel her last appointment. As you examined her, you identified some abnormal postural patterns and noted some muscle shortening and tension in her upper traps, levator, suboccipitals and pec minor.
As you began to implement some manual treatment and stretching, you instruct her in diaphragmatic breathing to facilitate muscle relaxation. She appeared to be tolerating the treatment well, however she began to cry, and this soon progressed into sobbing. You closed the door to the treatment room for more privacy and asked her if she was ok. She began to tell you about a trauma that she experienced before the end of the previous semester. She stated that she was physically assaulted by someone from her dorm and that she just experienced a flashback of this during the manual therapy session. She discussed the incident with you further and admitted that she was too afraid and ashamed to report it.
As she explained the full extent of what occured, you realized that her physical symptoms may be associated with the trauma since the assault occurred shortly before the onset of her pain, for which there was no other explanation. You also acknowledge that you are not equipped to provide the degree of psychological care that she may require. You offer to help her notify her referring physician and encourage her to consult the appropriate authorities at her university. You also suggest that she consider speaking to a counselor, such as a licensed social worker or clinical psychologist, as these professionals have the knowledge to offer her the specific type of support she needs.
While you are unsure if PT is the correct treatment to address her physical symptoms, you decide that it would not be wise to suggest that she stop PT immediately since you cannot rule out the potential to alleviate her current symptoms. After the incident, you notify your supervisor confidentially of the discussion and you explain the steps that you took to support the patient. Your supervisor praises you for how you handled the situation and also agreed that it is too early to tell whether or not this patient should be discharged from PT. Your supervisor also offered you the opportunity to debrief further about this experience if any other concerns come up later, so as to provide support to you as a caregiver (kudos to this supervisor for recognizing the potential impact of this situation on the clinician).
Dealing with unexpected scenarios can be unnerving, whether you are a new or a seasoned clinician. We are often not prepared for the emotions that patients express, and this can be overwhelming for the therapist just as it is for the patient. It is important to learn the tools to ground ourselves in these moments so that we are able to respond with clarity and compassion. In a situation such as this, the patient may need to discontinue PT and focus on counseling to address the underlying causes that perpetuate the physical pain, or she may benefit from both treatments to address the physical and emotional aspects of her symptoms. Gaining clinical experience also offers the opportunity to learn how to respond to these situations with proper sensitivity and timing.
4) The patient is experiencing other issues which affect your ability to provide treatment within your scope of practice:
You have recently taken on a role within your outpatient department’s home therapy division and you will be rendering some treatment sessions at your patients’ homes. You have evaluated a patient with MS who lives alone. Her niece recently took her to the neurologist and she was given a prescription for PT. After you complete your evaluation, you discuss some safety issues that are concerning you. The home is a multilevel home with the patient’s bedroom on the main floor. There is a sunken living room, throw rugs throughout the home that are not properly secured, areas of clutter and cracked tiles leading into the kitchen and bathroom, which present various environmental hazards, which increase the patient’s risk of falls.
The patient cannot exit the home independently as she cannot transport the rollator walker that she uses outdoors down the steps on her own. She stated that she has not attempted leaving her house without a family member since last year after she sustained a right hip fracture, however she is concerned about how she would get out in an emergency. The patient fractured her hip last year when she was negotiating the steps inside her house. She had been able to go up the stairs to access the second level of her home without too much difficulty, however she lost her balance when coming back down the stairs, which caused her to fall and fracture her hip. She was alone for several hours after the accident until her niece arrived, as she was not able to access her phone to call for help. Her niece contacted 911 and she was taken by ambulance to the hospital where she underwent ORIF surgery. After a long hospitalization with an inpatient rehabilitation stay, she returned home with home care. She said that it was determined she could continue to reside in her home as she was able to stay on the main level once inside to access her bedroom, bathroom and kitchen.
At that time, her niece stayed with her for a few weeks and assisted her as needed. Once she recovered adequately, her niece moved out however still comes to check on her several times a week. The patient stated that she was doing well until she recently experienced an exacerbation of MS which has rendered her left leg weaker. She denied falls in the past 6 months, however stated that she has been having more difficulty with walking due to her left leg being weaker and due to recurrent right hip pain. She had progressed to walking with a cane prior to her hip fracture, however she has been relying more on her rolling walker after the injury. Her gait is antalgic during stance on the right leg and she also exhibits decreased stance time on the left with genu recurvatum and foot drop.
She showed you a brace that she received in the hospital last year (a solid AFO) however stated that she has not been able to wear it in the past month since her left ankle has become swollen. She expressed that it is taking her more time and energy to do basic tasks and she becomes fatigued and loses balance when getting dressed and showering. She stated that she almost slipped yesterday while getting out of the bathtub. When you observed her bathroom, you see that she has a tub bench however it does not appear to be adequate for the level of assistance that she currently needs for transfers.
The patient’s risk for falls is high due to her current functional status and environmental hazards. She wishes to continue to live on her own and does not want any strangers coming into her house to help her with personal care. Her insurance does not cover the cost of a home health aide and you inquire if she has the resources to pay for one privately – she stated that she does not. In this type of scenario, the patient would benefit from several referrals.
It would be advisable to inform the patient that you will be contacting her neurologist to collaborate with the doctor to develop a comprehensive plan. A prescription for OT would also be useful in this case to reassess the need for adaptive devices for bathing and dressing and other applicable treatments pertaining to ADLs and self-care. Since there are various safety issues related to self-care and home accessibility, it would also be useful to request an assessment by a social worker and/or a nurse case manager. If the patient remains unwilling or it is not financially viable to arrange home health services, it would also be wise to educate the patient on obtaining a device such as a Life Alert so that she can access help in an emergency situation.
You may also investigate the possibility of obtaining a stair lift to improve her safety within the home and create the potential to independently exit and enter her home. As physical therapists, we are often called upon to temporarily fill the roles that would normally be addressed by other disciplines. It is important to recognize how these situations impact our ability to deliver the care that we are qualified to render. Once we identify the other professionals who should be involved in the patient’s care, we can discuss this with the patient and physician(s) to expand the team of caregivers. Recognizing the value of a team approach is critical in this scenario for the safety and well-being of the patient and to maximize the potential benefits of PT.
It is important to keep in mind that there are other issues that may present barriers to participation and progress, such as socioeconomic, environmental or issues related to family dynamics. As therapists, we may find ourselves in situations which call for us to address these or other factors. Whenever possible, it is imperative that we request assistance from our colleagues, supervisors, managers or other disciplines (e.g. a social worker, an outside organization that offers specific support to patients).
5) The patient has reached a plateau in therapy or may require alternative or adjunctive treatments to reach their goals:
As therapists, it is important to recognize that there will be times that the goals we established for our patients are not achieved due to issues that may be better addressed by other professionals. Identifying a plateau can be tricky as we may not be able to determine with certainty that the individual will not continue to make progress. It is helpful to consider treatment in a broader context in these scenarios. There may be a situation in which a patient might benefit more from treatment by another provider altogether, such as a chiropractor, acupuncturist, cranio-sacral therapist or even a reiki practitioner.
While our knowledge and belief systems about “alternative” treatments is variable, it is important to maintain an open mind. Some clinicians may even venture to learn non-traditional techniques and find ways to offer these treatments, even if they cannot be administered in the typical context or setting. There are many individuals who suffer from chronic pain conditions or progressive medical issues who make great strides with PT however they may also benefit from other interventions to help them reach their highest levels of function or maintain a better quality of life.
We may serve to bridge the various gaps in care by maintaining an open dialogue with each other as professionals and with our patients, their families and caregivers. We often meet our patients at points of desperation, during times in which they are seeking any avenue that may provide solutions and relief. Becoming well informed about the full spectrum of care outside of our scope is imperative to upholding our responsibility as educators. It also takes wisdom on our part to identify the most appropriate ways to communicate this information.
What might be an appropriate suggestion for one patient may not be for another as there are the constraints of accessibility, financial limitations and even resistance on the part of other medical providers in recommending treatments that are non-traditional. Acknowledging that we may be just one integral part of a larger wellness team allows us to become confidently rooted in our expertise and also make space for other professionals to contribute to the patient’s healing process.
As we support our patients in the pursuit of comprehensive care, it is important that we recognize the value of a holistic approach. Knowing when to call upon the expertise of other professionals is equally as important as the treatment that we deliver. It is through this awareness that we realize that our impact on our patients’ lives may extend far beyond our hands. Approaching patient care both from a place of confidence and humility allows us to build solid relationships through which true healing can take place.