Jabatan Kesihatan Masynrakat 2004: Jilid 10

THE ROLE OF PHYSIOTHERAPY AND ITS SERVICES AMONG IN-PATIENT REFERRAL IN

HOSPITAL KUALA LLMPUR
'
Ayiesah, R & Zuleha MI

ABSTRACT
The data of this retrospective study was taken from patients' files of 6,503 referrals that were referred to the
in-patient Physiotherapy Unit for the year 2003. The purpose of the study was to examine the current
referral pattern to the Physiotherapy Unit and to identify the current activity of physiotherapy services in
response to doctors' referral. Statistically, SPSS version 11.0 was used to analyze the different variables
using frequency count. Findings indicated that the in-patient Physiotherapy Unit received referrals from
different units of the hospitals with multiple conditions. Most cases referred were from the Orthopaedic
Clinic (34.6%) with musculoskeletal problems, followed by Neurology Unit (17.4%) besides the other units
comprising of the Medical Unit (1 1.7%), Surgical Unit (12.5%) and lastly Obstetric and Gynaecology Unit
(5.2%). Findings demonstrated that the patients received physiotherapy intervention in the ward for an
average of two weeks duration (33.5%) and most of them were seen within three days to three months
duration for physiotherapy intervention. The study demonstrated that from the referral received, ten
thousand eight hundred and fifty three (10,853) modalities were used not inclusive of the number of
treatment sessions patient had. The common modalities used were exercise therapy and physiotherapy
education (60.4%), chest physiotherapy (38.6%), electrotherapy (0.4%) and neurological mobilization
(0.6%).
Key words: referral, in-patient, treatment modalities.

INTRODUCTION
The World Health Organization estimated that
more than 450 million people globally were
disabled due to mental, physical and sensory
impairments (WHO 1984). In a survey
conducted in developing countries, (Mitchell et
al. 1989) estimated that 43% to 49% of people
has limbs impairment. (Helendar et al. 1983)
reported that only 10% of people with
disabilities in developing nation receive
proper-trained help due to limited funds and
poor awareness of the rehabilitation services.
This has led to severe shortage of trained
rehabilitation worker virtually in all
developing nations (Kay at al. 1994). In
Malaysia, the area of rehabilitation is still at
teething stage. However, it is now beginning to
develop in line with the Ministry of Health
mission and vision in achieving good health
for all by the year 2020 which originates from
consensus of the Alma Alta Declaration on
"Health for All by the year 3000" (WHO
1976). This allows for opportunity for role
expansion of physiotherapists to provide
increased accessibility and rehabilitation of
services (Kay et al. 1994) to all.
Physiotherapy Programme, Faculty of
Allied Health Sciences, UKM
Department of Community Health,
Medical Faculty, LIKM
In rehabilitation, it is the physiotherapists
aim to help disabled people to maximize their
potential capabilities of achieving function and
independence for activities of daily living. In
Malaysia. to receive physiotherapy services, a
patient needs to be referred by doctors or
specialists through a referral letter to the
Physiotherapy Unit. In the referral letter, a
diagnosis is stated and it may or may not include a
prescription for the kind of physical therapy to be
applied. In view of this requirement, doctors should
have a thorough understanding of both
physiotherapy modalities and evaluative
procedures.
(Levine and Kliebhan 1981) suggested
that, "a physician must understand the principles
and methods that physiotherapists use. With this
understanding, a physician can appropriately
include therapy services and comprehensive
diagnostic and treatment planning. However, it is
not enough in having this information as there must
be a clear and frequent communication between
therapists and physicians". If physicians do not
have an accurate impression of what
physiotherapists actually d o then the available
skills and services of physiotherapy will be
underutilized and the patients will not receive the
appropriate treatment that is required.
Traditionally, physiotherapy is based on a scientific
philosophy shared with the medical profession. The
more accessibility a physiotherapist is to a patient,
the better is the survival of the profession as client
choices are a form of social control (Goode 1957).
 Jabatan Kesihatan Masyarakat 2004: Jilid 10

In order to meet the demands for Hospital Kuala Lumpur is the largest referral center
physiotherapy services, a study needs to be camed in the country. The Physiotherapy Unit has the
out to examine the referral pattern to the in-patient largest number of physiotherapy staff with a
Physiotherapy Unit, the sources of referral unit, the number of physiotherapists having specializations
length of intervention by physiotherapists in the in various aspect of physiotherapy. All the cases
ward, and explore the different activities and referred by doctors were considered for analysis in
physiotherapy services in response to referral the study. The specified diagnosis by the referring
received. physicians was further categorized according to the
International Classification of Disease and Related
PHYSIOTHERAPY SERVICES AND Health Problem (ICD-10) (2002). The data
REFERRAL PATTERN collected were continuously monitored to eliminate
double recording of data. In analyzing the data,
There have been previous studies carried SPSS version 11.0 was used to compare the
out to check the service needs of physiotherapists different variables using frequency count. Prior to
based on referral rates, treatment intervention, the study, a letter of request was made to the
prescribing patterns of different specified areas as Director of Hospital and Head of Physiotherapy for
well as health outcome measures from patients approval of study to obtain information of patients'
feedback. A retrospective study by Newman (1987) record.
recorded over two and a half years on referral
pattern has identified a gap in the existing
phys~otherapyservices. It acts as a safety net for
many elderly patient discharged from hospital who
A total of 6,503 referrals from physicians to the
are at risk whether they will receive adequate
Physiotherapy Unit were reviewed and 53 referrals
follow up visits in their own homes or not. The
had missing data. As seen in Table 1, there were
study has identified several services or area that
various age range of patients that was identified
needs to be developed such as outpatient, children
ranging from less than 10 years to age group of 80
and younger disabled people, thus the need for
years. However, the commoner groups referred are
establishment of new posts to existing services.
those of 41 to 70 years of age. Among these
(Wai et al. 1994) in a study on referral pattern by
groups, 66.2% (4,273) of them are males and
content analysis of written medical referrals to the
33.8% (2,177) of them are females. In comparison
outpatient physiotherapy department between the
to ethnic groups, Malays make up 56.2% (3,627) of
years 1982 and 1989 has revealed a trend towards
cases referred, 23.4% (1,511) Chinese and 20.3%
greater clinical autonomy and clinical decision-
(1,312) Indian.
making responsibility for physiotherapists.
In a study carried out by (Lamb 1995), of twenty-
two general practitioners with a total of 569
referrals has demonstrated that the General
Practitioner (GP) referral pattern to the outpatient
Physiotherapy Unit is influenced by their
perception of physiotherapy services offered. The
study identified that the GPs' rationale of their
local 'physiotherapy quality' was their provision of
consultancy, treatment and advisory service, a fast
response, excellent results, and a high degree of
patient satisfaction. (Ritchey et al. 1989) and (Wai
et al. 1994) has indicated that qualitative
examination of referral information can also be
used as an indicator for professional change. The
inclusicn of diagnosis or specifics ordered by
doctors written in referral forms have been reported
to help explained the role expansion of
physiotherapy within the health care system.

MATERIALS AND METHODS

The study population consisted of all

incoming referrals by doctors to the in-patient
Physiotherapy Unit in Hospital Kuala Lumpur
during the year 2003 and reviewed retrospectively.
 Jabatan Kesihatan Masyarakat 2004: Jilid 10

Table 1: Demographic Data of Patients Indicating Age Group, Sex and Ethnicity

Age group (years) Number of cases (n) (%)

<10 75 1.2
>11-20 706 11.2
>21-30 1.04 1 16.5
>31 -40 820 13
> 41-50 1,134 18
>51-60 1,031 16.3
>61-70 1,012 16
>7 1-80 496 7.9
Sex
Male 4,273 66.2
Female 2,177 33.8
Ethnic
Malay 3,627 56.2
Chinese 1,511 23.4
Indian 1,312 20.3

The source of referral received are from
different units of the hospitals (Table 2)
comprising 34.6% (2,249) Orthopedic Unit,
11.7% (764) Medical Unit, 12.5% (815)
Surgical Unit, 5.2% (336) Obstetric and
Gynaecology Unit, 18.3% (1,189) Intensive
Care Unit (ICUICCUICRW), 17.470 (1,134)
Neurology Unit and 0.2% (16) others (to
include Oncology Unit and ENT ward). The
diagnosis of these conditions referred also
varies from the different units involving
conditions from cardiorespiratory,
musculoskeletal, neurological and special area
(women problems, geriatric and ICU). Most of
the patients were seen for various duration
ranging between less than 3 days to less than 3
months. However, the average length of
duration seen by the physiotherapists in the
ward is two weeks (34.5%). The patients that
were seen were treated with various
physiotherapy interventions. The common
modality used was exercise therapy and
physiotherapy education (60.4%), chest
physiotherapy (38.6%). electrotherapy (0.470)
and neurological mobilization (0.6%).

Table 2: Sources of Referral Unit, Length of Treatment Seen By Physiotherapists In The Ward and
Diagnosis Referred
Length of treatment in the wards Number of cases (n) Percentage ( %)
- -

<3 days
<7 days
<2 weeks
<I month
3 months
Others
Referral unit
Medical
Surgical
Orthopedic
Neurology
ICU/CCU/CRW
Obstetric and Gynecology
Others
 Jabatan Kesihatan Masyarakat 2004: Jilid 10

Diagnosis of conditions referred to

physiotherapists
Cervical condition 62 1
Back condition 185 2.9
Shoulder condition 18 0.3
Elbow condition 78 1.2
Hand condition 74 1.1
Hip condition 193 3
Knee condition 3 13 4.9
Foot condition 185 2.8
Facial Paralysis 5 0.1
Paralysis- peripheral nerve 56 0.9
injuries
Spinal paralysis 41 0.6
Head Injury 14 0.2
Neurological conditions 1,298 20.1
Arthritis 6 0.1
Fracture Upper limb 500 7.7
Fracture lower Limb 749 11.6
General surgery 344 5.3
Respiratory conditions 456 7.0
Medical conditions 1,394 21.4
Women's problem 188 2.9
Others 294 4.6

DISCUSSION with stiffness, weakness and dysfunction of

From the study, the Physiotherapy Unit received
referral from various clinics within the hospital.
The majority of patients referred to the in-patient
physiotherapy services are of the "working age"
ranging between 19 to 55 years of age and there is
increasing demand from those above 55 years of
age. This is consistent with the finding of (Lamb
1995) and (Akpala et al. 1988) due to the
increasing number of elderly deserving careful
attention from physiotherapy. According to
(Matthew 19861, the musculoskeletal, neurological,
and orthopaedic changes associated with the
normal process of ageing strongly suggest that
physiotherapists have a major role in the
maintenance of mobility and function of the well
elderly population with physiotherapy intervention
through movement rehabilitation, maintenance
exercise therapy and preventive health programs.
Most of the in-patient referral was from
orthopaedic unit with musculoskeletal problems
and similar proportion of patients was reported in
other studies carried out by (Akpala et al. 1988)
and (Goble et al. 1979). Patients with such
problems greatly benefits from access to
Physiotherapy Unit due to their obvious disability
functional ability. Subsequently, there is increased
referral from Intensive Care Unit (18.3%) and
Neurological Unit (18.3%). This is indicative that
doctors from these areas are aware of the services
provided by the Physiotherapy Unit. The conditions
seen are also very variable demonstrating
awareness of physiotherapy role and the problems
that can be seen by physiotherapists.
Neuromuscular disorders are also common
referral unit (17.4%). In adults and children who
have neuromuscular dysfunction, the
physiotherapists participate in the treatment of
impairments that interfere with mobility. These
impairments include weakness, abnormal balance
response, contractures, abnormal postures,
movement disorders, and motor-planning deficits.
The management of physiotherapy in
neuromuscular disorders includes neuromuscular
re-education techniques (Wang 1994), balance and
vestibular training (Shepard et al. 1993), assisting
devices (Burdett et al. 1988), functional electrical
stimulation (Baker & Parker 1930), biofeedback
(Inglis et al. 1984), adaptive seating (Hulrne et al.
1987) as well as wheelchair and transfer skills, gait
re-education, and therapeutic exercise programs.

Table 3: To Demonstrate the Different Types of Modalities Received by Patients During Each
Physiotherapy Interventions
Types of Physiotherapy
Modalities Used
1. Electrotherapy agents (Low frequency currents,
High frequency currents, Short wave
diathermy, Ultrasound therapy, Tens, Hat
packs, I-Iydrocollator therapy)
2. Exercise therapy (Active. Passive, Resisted
Exercise, Springs, Suspension and Pulleys)
3. Chest therapy (Breathing exercise, Chest
Percussions, Vibrations, Shaking. Huffing)
4. Neurological rehabilitation (Mobilization
techniques, Propr~oceptiveneuromuscular
facilitation, Transfers)
The extent to which physiotherapists are involved
in treating pulmonary disorders is also demanding.
Treating both acute and chronlc respiratory
disorders extensively making up 38.6% (4,187) of
the total intervention as seen in Table 3. These
cases can be referred mainly from the Medical,
Surgical, Intensive Care Unit as well as other
referral unit with respiratory problems. In chest
physiotherapy, techniques such as suctioning,
assisted coughing, manual or mechanical vibration,
postural drainage and percussion are used to help
remove pulmonary secretions (Cerny 1989) in
premature infants (Etches & Scott 1978) and in
patients who experience postoperative pulmonary
complication (Morran et al. 1983).
From this study, the Medical Unit also has
high referral rate to the physiotherapists (1 1.7%).
Many would not immediately associate
physiotherapy with the treatment of patients who
have a systemic disorder, such as cancer, AIDS, or
renal failure. But these cond~tions often cause
problems such as generalized weakness, pain,
oedema, and decreased independence. The role of
physiotherapists in treating gynaecologic, obstetric,
and urologic problems may, again, not be apparent.
About 5.270 (336) of patients were referral cases
from the Obstetric and Gynaecology Unit.
Treatment in this area may include exercise (Tchou
et al. 1988), neuromuscular electrical stimulation
(Blowman et al. 1991), electromyography (EMG)
and pressure biofeedback. Physiotherapists can also
play a significant role in preventing and treating
lower-back pain during pregnancy and in prenatal
educational and postnatal exercise regimens.
One of the most valuable tools for the
physiotherapy profession is therapeutic exercise.
Exercises are variously designed to improve
Jabatan Kesihatan Masyarakat 2004: Jilid 10
Intervention Intervention Total
1 2
Intervention
32 (0.6) 12 (0.2) 44 (0.4)
6.41 1 (98.5) 141 (3.2) 6,552 (60.4)
57 (0.8) 4,130 (94.9) 4,187 (38.6)
3 (0.1) 67(1.5) 70 (0.6)
6,503 j100) 4,350 (100) 10,853 (100)
strength, flexibility, muscular endurance,
cardiovascular endurance, range of motion, control
of movement, and function. The prescribed
exercise program may or may not include
specialized equipment and often is performed with
manual feedback and resistance by the therapist.
From the study, exercise therapy is the most sought
after modalities used by physiotherapists that is
about 60.4% (6,552) of the total treatment
intervention. Unless contraindicated, some form of
exercise will be included in the program for most
conditions referred for physiotherapy. The type and
level of exercise are determined by the particular
dysfunction and the patient's response. Exercise
programs often include activities that improve the
quality of movement and reinforce appropriate
muscle use. This may be required when a patient
uses inappropriate muscle activity, fails to use
synergistic patterns of muscle activity while
performing a movement, or fails to demonstrate
adequate muscular support during a particular task
or postural.
In neurological rehabilitation, only 0.6%
(70) of treatment intervention was carried out.
Although restrictions in range of motion may be
addressed with exercise, various soft-tissue
mobilization techniques can also be used. Many
physical therapists also perform joint mobilization
and manipulation techniques to increase
movement. Such indication for these specific
manual techniques varies with the clinical
presentation. For example, although the literature
indicates that manipulation or mobilization can
have a positive effect on certain types of spinal
pain, pain alone is not believed to be an indication
for manipulation (Paris 1979). This study indicated
that only a small proportion of this modality was

used. A candidate for manipulation should
demonstrate sign of a mechanical problem or
dysfunction that includes specific motion
limitation, directional components to the movement
problem, and postures or positions that are more
problematic than other. Thus, a patient whose pain
is content or not affected by movement, or who has
sign of caude equina syndrome or myelopathy, is
not a candidate for manipulation (Maitland 1986)
and the same is true for a patient on extended
steroid therapy.
Another modality that is commonly used
by physiotherapists is electrical stimulation making
up 0.4% (44) of the total intervention. Electrical
stimulation can be applied to modulate the
perception of pain, although some literatures have
contradictory comments regarding its effectiveness
(Roberts 1978). Treatment of pain with electrical
stimulation can include stimulation of acupuncture
points, trigger points, a specific peripheral nerve, or
the area surrounding a painful site. Parameters for
the use of electrical stimulation in pain
management vary with the type of pain and desired
effect. Electrical stimulation has been shown to
increase the level of endogenous opiates in blood
and CSF when used in a brief intense form
(O'Brien et al. 1984) and is believed to block
transmission of pain at the spinal cord level when
used at a sensory level (Synder-Mackler 1995). It
may also provide relief of patient who has a
disorder such as reflex sympathetic dystrophy
(Hassenbusch et al. 1996). Electrical stimulation
can be used to strengthen skeletal muscle. It has
been shown that chronic electrical stimulation can
produce strength gain in atrophied but healthy
(absence of muscle disease) innervated skeletal
muscle. This form of stimulation is used for muscle
weakness caused by disuse or inhibition. The
patient must also be capable of tolerating a high
level of contraction to gain the most benefit.
Physiotherapists can also use electrical stimulation
to preserve strength and prevent atrophy and
fibrosis after denervation of skeletal muscle. This
type of electrical stimulation uses a waveform that
directly depolarizes muscle membrane rather than
peripheral nerve. Electrical stimulation is also used
to promote healing of acute and chronic wounds of
various causes by promoting epithelialization for
more rapid wound closure, increasing collagen
synthesis for a stronger wound, and exerting an
antibacterial effect (Szuminsky et al. 1994). This
accelerates healing of pressures in patients who
have spinal cord injury, diabetes (Lundeberg et al.
1992) or vascular disease (Feeder et al. 1991).
CONCLUSION
The referrals from different units of the hospitals
have ensured full utilization of the different
Jabatan Kesihatan Masyarakat 2004: Jilid 10
physiotherapy modalities that a physiotherapist can
offer. It is obvious that the referral for
physiotherapy is appropriate for a wide variety of
problems. The objective of the physiotherapy
profession is to provide cost-effective, towards the
goal of enabling patients to be discharged earlier
from acute settings as a result of increased
independence, to accelerate their return to work
and other activities, to prevent falls and
complications that increase health care costs, and to
minimize the burden of care on the family and
other health professionals. The referral pattern
among doctors looks promising for the role
expansion of physiotherapists. To ensure further
utilization of the physiotherapy services, measures
need to be taken to create awareness of
physiotherapy role through public education and
direct discussion. The provision of continuous
medical education is necessary for better
communication between doctors and
physiotherapists.
ACKNOWLEDGEMENT
The authors wish to thank the Head of
Physiotherapy, GHKL for granting permission in
accessing patients record and Miss Zainura Karim
for recording of data.
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