Inpatient Physical Therapy After Orthopedic Lower Extremity Surgery in Children With Cerebral Palsy : Pediatric Physical Therapy

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Inpatient Physical Therapy After Orthopedic Lower Extremity Surgery in Children With Cerebral Palsy

Bailes, Amy F. PT, PhD; Mangeot, Colleen MS; Murphy, Natalie J. MPH; Richardson, Zachary PhD; McCarthy, James MD, MHCM; McManus, Beth M. PT, ScD, MPH

Author Information
Pediatric Physical Therapy 35(1):p 57-64, January 2023. | DOI: 10.1097/PEP.0000000000000970



Cerebral palsy (CP) describes a group of permanent disorders of movement and posture attributed to nonprogressive disturbances in the developing brain1 that affects 3.1 to 3.6 per 1000 children in the United States.2 Inpatient (IP) hospital utilization is increasing for children with CP in the United States.3 A common reason children with CP are admitted to the hospital is for orthopedic surgical intervention to address deformities that occur with growth4,5; bony and soft-tissue musculoskeletal procedures are 2 frequent procedures performed.6 It is common for multiple bony or soft-tissue procedures to be performed during one surgery requiring only one IP stay.5

Identifying optimal patterns of physical therapy care for children with CP is a national priority.7 In particular, evidence to guide the provision of optimal IP care is limited for children with chronic conditions such as CP.8 Pediatric IP physical therapy is recommended not only to improve function and prevent secondary complications but also to educate children and families and to provide assistance with transition to home and community.9,10 Physical therapy treatments vary across institutions and practitioners. There are no clear guidelines available to inform decision making.

Despite the importance of rehabilitation after lower extremity (LE) orthopedic surgery,5 past studies examining outcomes fail to account for details of the physical therapy provided5,11–13 and focus on outpatient therapy after the acute phase following surgery.11 Understanding existing patterns of IP physical therapy during the acute phase for children with CP after LE orthopedic surgery as it relates to sociodemographic factors and child characteristics is a first step to design and plan the most effective ways to organize, manage, and deliver high-quality care.14 A previous study6 using a sample of national data summarized all surgical procedures (not limited to LE) for children with CP and did not provide details on physical therapy. Analysis of large data sets can provide information about patterns of pediatric physical therapy services, inform policy, and promote improved service delivery for children with conditions such as CP.

The Pediatric Health Information Systems (PHIS) database is an administrative database of more than 40 not-for-profit freestanding tertiary care children's hospitals in the United States, affiliated with the Children's Hospital Association (Washington, District of Columbia). Data quality and reliability are maintained by the Children's Hospital Association and includes audits and reviews of data from each contributing hospital. Despite including billing codes of IP physical therapy delivered, we are unaware of any studies that have investigated IP physical therapy services. The PHIS database offers an opportunity to study IP physical therapy services provided to large populations of children with CP undergoing orthopedic surgery at hospitals in the United States.

The purposes of this study were to characterize LE orthopedic surgery for individuals with CP and to examine the variability in receipt of IP physical therapy across hospital-level and individual characteristics.


Study Design and Setting

This was a multicenter retrospective cohort analysis of the PHIS data from October 1, 2015, through September 30, 2017. The start date was chosen because International Classification of Diseases, Tenth Revision (ICD-10) codes were implemented October 1, 2015. The end date was selected to coincide with the release of the American Academy of Cerebral Palsy and Developmental Medicine (AACPDM) hip surveillance care pathway15 September 2017 before centers could implement pathway. The study was reviewed by Cincinnati Children's Hospital Institutional Review Board and determined to be exempt from oversight as it was not considered human subject research. A PHIS direct access agreement was signed by the institution PHIS sponsor to obtain use of the data.


Participants were individuals (all ages) with a diagnosis of CP (ICD-10 codes G80.0-G80.4, G80.8-G80.9, 333.71) and LE orthopedic surgery that resulted in discharges from October 1, 2015, to September 30, 2017, in the participating PHIS hospitals. Participants 18 years or older were included as it is not unusual for adults with CP to continue to receive care at pediatric hospitals.16 Participants were included if they received 1 or more LE procedures on the same day during one surgery. If the participant had more than 1 admission during the time period, the first admission with LE orthopedic procedures was used as the index admission. Surgical procedures were identified with Common Procedural Terminology (CPT) coding beginning with OS joints, OQ bone, OL tendon, and OK muscle. Orthopedic procedures to the pelvis or LE were included and further characterized according to region of body (pelvis/hip, upper leg/knee, lower leg, foot/ankle) and type (bone or soft tissue). We excluded hardware removal procedures as these procedures typically do not have a long recovery or require IP physical therapy. If there was uncertainty in including and categorizing joint procedures, we consulted with an expert panel that included a biomechanist with 21 years of experience and 3 pediatric physical therapists with 19, 19, and 26 years of experience treating a variety of pediatric conditions, respectively. A table of the 396 included procedures is provided in Supplemental Digital Content 1 (available at:

Main Outcome Measure

The main outcome measure was receipt of IP physical therapy services (yes or no) and was determined by the presence of any physical therapy clinical services billing codes associated with the index admission in the PHIS database (including evaluation codes 535011, 535019 and treatment codes 535110, 535213, 535215, 535217, 535227, 535299, 535301, 535303, 535307, 535311, 535313, 535353, 535357). Secondary outcomes of interest were number of days from surgery to initiation of IP physical therapy and number of days on IP physical therapy services.

Independent Variables

Hospital and individual characteristics were the main independent variables. Hospital characteristics included hospital size (small, <250; medium, 250-500; large, >500 beds) and region of the United States (Northeast, Midwest, South, and West). Individual characteristics were also recorded from PHIS data and included gender, age (0-5, 6-10, 11-14, 15-17, and 18+ years), ethnicity (White non-Hispanic, Black non-Hispanic, Other non-Hispanic, and Hispanic), payer category (commercial, pubic, or self-pay/other), and technology dependency.17 The technology dependency indicator distinguishes those individuals requiring medical devices (eg, shunts, tracheostomy, gastrostomy tube, and ventilator) and was dichotomized as “yes” or “no.” Surgical burden was determined on the basis of type of procedure (bone or soft tissue) and the number of procedures performed.18 A participant was determined to have a high surgical burden if he or she had 2 or more osteotomies on one or both legs with any number of soft-tissue operations on either or both legs. A participant was determined to have a low surgical burden if he or she had a single osteotomy (1 leg only) or less (soft tissue only) and could include any number of soft-tissue operations on one or both legs.

Statistical Analysis

Descriptive statistics for hospital-level variables and individual characteristics were calculated to describe the population and stratified by receipt of IP physical therapy. For categorical variables, we computed counts and percentages; for continuous variables, we computed medians and interquartile ranges (IQRs). Unadjusted logistic regression was conducted for each independent variable to describe its relationship with the main outcome measure (ie, receipt of IP physical therapy) for each study covariate. Subsequently, multivariable logistic regression was used to estimate the associations between independent variables and receiving IP physical therapy. To achieve the most parsimonious model, some variables that did not describe the data well were not included in the final model. The analysis automatically drops individuals with missing information for variables included in the model; counts are presented for all models. All analyses were performed using SAS 9.4 (SAS Institute Inc, Cary, North Carolina) and presented as odds ratios (ORs) and 95% confidence intervals (CIs).


Characterization of Lower Extremity Orthopedic Surgery and Receipt of Inpatient Physical Therapy

Participants. From October 1, 2015, October 1, 2017, there were a total of 39 535 individuals with CP, with a hospital stay resulting in discharge from a PHIS hospital. There were 2678 individuals with CP who met criteria for an index hospitalization with an orthopedic LE surgery of interest, representing 46 pediatric hospitals in the United States (Midwest: n = 12; Northeast: n = 7; South: n = 16; and West: n = 11). The median age of individuals was 10 years (IQR = 7, 14), with median length of stay (LOS) of 3 days (IQR = 1, 4).

A total of 9873 procedures were identified. The mean number of procedures per individual was 3.3 (SD = 2.5). The Figure graphs the procedures by region of body and type (bone or soft tissue). The majority of surgical procedures performed were in the region of upper leg/knee (4735; 48%), with the fewest in the ankle/foot (1151; 11.7%). Soft-tissue procedures accounted for 5479 (55%) of all procedures, and 4394 (45%) were bony. For the upper leg/knee region, bony procedures were performed more frequently than soft-tissue procedures, while soft-tissue procedures were performed more often in the other regions of the LE.

Summary of procedures by region of body and type orthopedic lower extremity surgery in US freestanding hospitals.

Table 1 summarizes hospital-level and individual characteristics for the 2678 participants with CP and orthopedic LE surgery. Consistent with other studies2,19 demonstrating that CP affects a greater number of males than females, the sample in this study also reports a larger percentage of males (59%). The majority of individuals were at medium-sized hospitals (59%), White non-Hispanic (49%), and publicly insured (64%). Roughly half were technology dependent (46%) and had a low surgical burden (54%). Seventy-five percent received IP physical therapy during the hospital stay.

TABLE 1 - Hospital and Individual Characteristics of Children With Cerebral Palsy Having Orthopedic Lower Extremity Surgery in US Freestanding Children's Hospitalsa
Characteristics Total, N (%) Received IP Physical Therapy, n (%) Did Not Receive IP Physical Therapy, n (%)
2678 (100) 2020 (75) 658 (25)
Hospital region
Northeast 404 (100) 349 (86) 55 (14)
Midwest 608 (100) 462 (76) 146 (24)
South 827 (100) 604 (73) 223 (27)
West 839 (100) 605 (72) 234 (28)
Hospital size (beds)
Small (<250) 346 (100) 261 (75) 85 (25)
Medium (250-500) 1582 (100) 1141 (72) 441 (28)
Large (>500) 750 (100) 618 (82) 132 (18)
Age grouping
0-5 y 422 (100) 289 (68) 133 (32)
6-10 y 1033 (100) 777 (75) 256 (25)
11-14 y 699 (100) 552 (79) 147 (21)
15-17 y 319 (100) 251 (79) 68 (21)
18+ y 205 (100) 151 (74) 54 (26)
Female 1103 (100) 820 (74) 283 (26)
Male 1575 (100) 1200 (76) 375 (24)
White NH 1242 (100) 946 (76) 296 (24)
Black NH 440 (100) 340 (77) 100 (23)
Other NH 231 (100) 180 (78) 51 (22)
Hispanic or Latino 614 (100) 443 (72) 171 (28)
Payer categoryb
Commercial 915 (100) 717 (78) 198 (22)
Public 1688 (100) 1258 (75) 430 (25)
Self-pay/other 54 (100) 42 (78) 12 (22)
Technology dependent
No 1454 (100) 1164 (80) 290 (20)
Yes 1224 (100) 856 (70) 386 (30)
Surgical burden
High 1230 (100) 1032 (84) 198 (16)
Low 1448 (100) 988 (68) 460 (32)
Length of stay in days, median (IQR) 3.0 (1.0, 4.0) 3.0 (2.0, 5.0) 2.0 (1.0, 4.0)
Number of days from surgery to initial IP physical therapy visit, median (IQR) NA 1.0 (1, 2) NA
Days with IP physical therapy service, median (IQR) NA 1.0 (1, 2) NA
Abbreviations: IP, inpatient; IQR, interquartile range; NA, not applicable; NH, non-Hispanic.
aCounts and percentages are presented for categorical variables and medians and (IQR) for continuous variables.
bMissing data included Race/Ethnicity (n = 151; 5.6%), Payer category (n = 21; 0.7%).

There was a significant difference in the LOS (P < .001) between those who did not receive IP physical therapy (median = 2; IQR = 1, 4) and those who did receive IP physical therapy (median = 3 days; IQR = 2, 5). Of those index admissions that received IP physical therapy, the median number of days from surgery to initial IP physical therapy visit was 1 day (IQR = 1, 2) and length of IP physical therapy services was also 1 day (IQR = 1, 2).

Variability in Receipt of Inpatient Physical Therapy After Surgery

Unadjusted analyses demonstrated region of hospital, hospital size, age, technology dependency, payer (commercial vs public), and surgical burden to be significantly associated with receiving IP physical therapy (Table 2). Although payer category was significant in unadjusted testing, it was excluded from the final multivariable model for a few reasons. First, when it was included, it lost statistical significance. This may be an indication of collinearity with other variables. Second, although one may expect this variable to reflect income level, it may not in this particular population. Based on disability, many of these children qualify for public insurance regardless of income level. Relatedly, states have differing public insurance regulations, and due to the diversity of states in this sample, including this characteristic in the model may convolute the findings.

TABLE 2 - Unadjusted OR and 95% CI for Receipt of Inpatient Physical Therapy Among a Sample of Individuals With Cerebral Palsy by Hospital-Level and Individual Characteristics
Variable OR (95% CI)
Census region (n = 2624)
Northeast Ref
Midwest 0.47 (0.33-0.67)
South 0.41 (0.29-0.57)
West 0.39 (0.28-0.54)
Hospital size (n = 2624)
Medium Ref
Small 1.15 (0.88-1.51)
Large 1.80 (1.44-2.24)
Age (n = 2624)
0-5 y Ref
6-10 y 1.37 (1.06-1.76)
11-14 y 1.72 (1.31-2.27)
15-17 y 1.69 (1.21-2.38)
18+ y 1.24 (0.85-1.81)
Gender (n = 2624): Female vs Male 0.91 (0.76-1.09)
Race/Ethnicity (n = 2484)
White NH Ref
Black NH 1.06 (0.82-1.37)
Other NH 1.04 (0.74-1.47)
Hispanic or Latino 0.81 (0.65-1.01)
Payer categorya (n = 2603): Public vs Commercial 0.81 (0.67-0.98)
Technology dependent (n = 2624): Yes vs No 0.57 (0.48-0.69)
Surgical burden (n =2 624): High vs Low 2.44 (2.02-2.95)
Abbreviations: CI, confidence interval; NH, non-Hispanic; OR, odds ratio.
aSelf-pay other category not included in analysis because of low numbers in this category.

Adjusted (multivariate) logistic regression supported that individuals from hospitals in the South (OR = 0.45; 95% CI, 0.32-0.65), West (OR = O.41; 95% CI, 0.28-0.59), and Midwest (OR = 0.50; 95%, CI 0.34-0.71) were less likely to receive IP physical therapy than those in the Northeast, while large hospitals (OR = 1.75; 95%, CI 1.38-2.23) and those aged 11 to 14 years (OR = 1.67; 95% CI, 1.23-2.25) were more likely to receive IP physical therapy (compared with medium-sized hospitals and children aged 0-5 years, respectively). Individuals who were technology dependent were less likely (OR = 0.52; 95% CI, 0.43-0.63), while those with a high surgical burden were more likely (OR = 2.71; 95% CI, 2.21-3.33) to receive IP physical therapy (Table 3).

TABLE 3 - Adjusted OR and 95% CI for Receipt of Inpatient Physical Therapy Among Sample of Individuals With Cerebral Palsy by Hospital-Level and Individual Characteristics (N = 2484)
Variable OR (95% CI)
Region of the United States
Northeast Ref
Midwest 0.49 (0.34-0.71)
South 0.45 (0.32-0.65)
West 0.41 (0.29-0.59)
Hospital size (beds)
Medium: 250-500 Ref
Small: <250 1.01 (0.75-1.37)
Large: >500 1.75 (1.38-2.23)
Age category
0-5 y Ref
6-10 y 1.29 (0.99-1.70)
11-14 y 1.67 (1.23-2.25)
15-17 y 1.73 (1.20-2.51)
18+ y 1.28 (0.85-1.92)
Gender: Male vs Female 1.08 (0.89-1.31)
White NH Ref
Black NH 1.02 (0.77-1.35)
Other NH 1.2 (0.83-1.73)
Hispanic or Latino 0.91 (0.71-1.16)
Technology dependent: Yes vs No 0.52 (0.43-0.63)
Surgical burden: High vs Low 2.71 (2.21-3.33)
Abbreviations: CI, confidence interval; NH, non-Hispanic; OR, odds ratio.


This is the first study to examine the variability of receipt of IP physical therapy after orthopedic LE surgery in individuals with CP using national data. This study provides information about orthopedic LE surgical procedures in individuals with CP and highlights the receipt of IP physical therapy in pediatric hospitals in the United States. The current sample represents 6.7% of all CP encounters in the PHIS database during the study period, which is less than reported in a Canadian study,4 where 20% of all IP admissions of children in Canada with CP were related to musculoskeletal system and connective tissue imbalances. The current study focused on LE procedures and, unlike the Canadian study, excluded spine surgical procedures, as these procedures likely require a different postoperative course of physical therapy than LE procedures. Results from the current study align with a US report6 indicating soft-tissue and hip procedures are the most common orthopedic procedures. In the current study, the majority of procedures were soft tissue (55%) and in the upper leg/knee region (48%). Murphy et al6 combined hip and femur procedures, while the current study chose to separate pelvic/hip procedures from femur (upper leg/knee) procedures to obtain a more detailed understanding of surgical procedures performed. Results from this study may provide a benchmark to compare the number of procedures being performed and region of body moving forward. We intentionally chose dates prior to release of the AACPDM care pathway for hip surveillance.15 Researchers in Scotland20 recently reported a decreased incidence of displacement and dislocation after 5 years of hip surveillance. Therefore, to establish a baseline prior to its release and potential implementation across the United States, we believed it was important to collect data prior to the release of the AACPDM pathway. The study in Scotland did not examine the procedures performed, but authors speculate increased surveillance may result in a trend toward femoral procedures without need for combined pelvic reconstruction. In addition, Dobson et al21 suggest improved surveillance could lead to increase in soft-tissue procedures and decrease in boney procedures. Although there is no population-based surveillance program in the United States,22 with the release of the AACPDM hip pathway and as individual centers adopt surveillance, the PHIS database could provide an opportunity to monitor trends in the type and number of procedures over time.

Of specific interest was the variation in receipt of IP physical therapy based on surgical burden, geographical region in the United States, and technology dependency. Although 75% of patients did receive IP physical therapy, these findings warrant further investigation and highlight opportunities to improve care, as virtually all patients would ideally receive IP physical therapy after the included procedures. The current study examined receipt of IP physical therapy by surgical burden categories of high and low as recommended by McGinley et al5 and reported by others.18,23 In children classified as Gross Motor Function Classification System (GMFCS) I-III, surgical burden has previously been found to influence postsurgical variability in StepWatch activity23 and to be associated with slower recovery after surgery.18 It is encouraging then that our findings indicate those with a higher surgical burden were more likely to receive IP physical therapy. Examining the influence of surgical burden on other outcomes is warranted and should be considered in efforts to standardize or develop algorithms to guide care.

To our knowledge, this is the first study to examine geographic variability with receipt of pediatric IP physical therapy using national data. Studies of postoperative care in adults have also found geographical variation, with those in the Northeast having higher odds of discharge to home health agency, skilled nursing, or IP rehabilitation than home with self-care.24 Health care expenditure growth also varies by geographical region.25 There is limited extant pediatric literature to compare our findings. There is a growing body of literature to suggest similar geographic differences in pediatric physical therapy services use. For example, studies examining use of early intervention services for infants and toddlers with developmental delays and disabilities suggest children living in the South access services less than similar children living in the Northeast and West.26,27 However, these previous studies included younger children with a variety of diagnoses and examined home-based care. Studies of school-based services suggest regional differences in how services are delivered,28 how much is delivered,29,30 and what type of activities are delivered.29,30 However, none of these were associated with outcomes. School-based services are likely influenced by regional differences in state and local policies.28–30 Future research investigating geographic variation in pediatric IP physical therapy, the mechanisms driving possible differences, and the relationship to outcomes is warranted.

The current study examined receipt of IP physical therapy services for individuals dependent on technology as done by Dumas et al31 and similarly found those indicated as technology dependent were less likely to have IP physical therapy. The Dumas et al study was specific to IP rehabilitation, while the current study was specific to acute services after surgery. A possible explanation for both our results and those of Dumas et al might be that the caregiver was familiar with care needed because of experience and level of care needed prior to admission or surgery. However, this finding could represent an unmet need. Interestingly, technology dependency recorded in the PHIS database may be related but not a direct indicator of functional or ambulatory status. Literature suggests children who do not walk and with CP are more likely to use technology such as assistive devices,32 wheelchairs,33 and feeding tubes.34 Future work should include validating the technology dependency field as an indication of ambulatory status since PHIS data do not include specific information on a child's mobility using the GMFCS.35 In a small sample from our institution, 41% of children undergoing single-event multilevel surgery were not walking (GMFCS level IV-V).36 If technology dependency is a good indicator of walking status, it may suggest that more than 40% of children in the United States having LE orthopedic surgery are not walking. Understanding caregiver needs and preferences for postoperative therapy for children with CP and technology dependency is warranted.

Our results demonstrate minimal variation in the days to first IP physical therapy encounter and number of days on IP physical therapy services. Unfortunately, there is limited evidence on the most effective ways to manage acute IP therapy needs in individuals with CP. Past studies examine IP use for other conditions or on specific units of the hospital.37–39 However, the current study's finding that individuals received therapy for 1 day aligns with the APTA fact sheet on pediatric services in the acute care setting.40 The fact sheet suggests that 1 to 2 visits are appropriate for children with chronic impairments or known developmental delays, with possible need for assistance to referral for outpatient services, family caregiver education, equipment recommendations, or need for communication with local resources. The PHIS database is limited to billing code information, which does not provide sufficient detail to understand what interventions were delivered in the therapy sessions. Standardized documentation of session details as described in recent reports used across sites would provide an opportunity to study details of therapy across centers.41,42 The short LOS and variation in receipt of IP physical therapy reported in the current study highlight the need to examine care occurring after the acute phase as recommended to maximize outcomes and recovery after orthopedic LE surgery.

Although not a focus of this study, our work suggests that the PHIS database may be a valuable resource to the physical therapy profession to study IP service provision for conditions served by pediatric physical therapists. While there have been numerous articles using the PHIS database to study medical care in children's hospitals,43 none have examined physical therapy care. While available literature recommends IP physical therapy for children with cancer,44 in the neonatal intensive care units,45 and children with burns,46 studies of IP pediatric physical therapy patterns across multiple acute care setting are lacking. This information could be useful in describing clinical caseloads for pediatric acute care administrators, helpful to educators preparing future generations of physical therapists, payers determining coverage of services, and to our professional organization in defining the scope of pediatric physical therapy practice.


The findings presented here have limitations. Because this was a secondary analysis of historical data, we have presented associations, which cannot be confused with causation. These associations may still have important implications for practice. As identification of the study population is dependent on the accuracy of diagnostic coding in administrative data, there is potential for misclassification if the administrative data contain inaccuracies. However, PHIS data quality and reliability are assured through the Children's Hospital Association and participating hospitals. In addition, results from this study may not be generalizable to all individuals with CP undergoing orthopedic LE surgery as PHIS data do not include all hospitals where these surgical procedures occur, such as Shriners Hospitals for Children. However, this data set includes a large number of hospitals representing diverse regions of the United States. PHIS data do not provide information on outpatient physical therapy services provided; therefore, the current study was not able to examine postoperative physical therapy after the acute phase, which studies suggest is important to recovery and may continue for up to 1 to 2 years after surgery.47

Despite limitations, these findings represent a starting point for future research on the discrepancies of acute physical therapy services across the nation in children diagnosed with CP. Also, the findings underscore the number of individuals with CP having orthopedic LE surgery across the United States and describe variability in receipt of IP physical therapy. Future research should monitor trends of orthopedic LE surgery in individuals with CP, examine variation in physical therapy services delivered across the full recovery period and trajectory of care (acute, post-acute, and outpatient) to identify best practice, and assess whether current systems of care are meeting the needs of children and families.

What This Adds to the Evidence

There is variation in receipt of IP physical therapy after orthopedic surgery in children with CP. Reasons for these differences are not clear. More studies are warranted to understand reasons for variation in practice and to understand caregiver needs and preferences. The PHIS database provides an opportunity to study IP pediatric physical therapy across different conditions.


The authors acknowledge the expert panel consisting of Mark Paterno, Jason Long, Kelly Greve, and Caroline Colvin, who assisted in determination of procedure codes to include.


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cerebral palsy; inpatient; physical therapy

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