Get PT 1st is a movement within the physical therapy profession to promote Direct Access and utilization of conservative measures for musculoskeletal pain and disability without needing unnecessary surgery, expensive imaging and addictive medications.

I am a big believer of Direct Access and have found it to be highly effective in reducing costs and overall time in pain and discomfort from injuries.  Below are abstracts and then my own impression of the article on the evidence behind seeing a physical therapist FIRST for a musculoskeletal injury.


J Allied Health. 2015 Fall;44(3):164-8.

Direct Access to Physical Therapy Services Is Safe in a University Student Health Center Setting.


The purpose of this retrospective descriptive study was to determine if direct access to physical therapy (PT) in a university health center placed patients at risk for adverse events.


Direct access to PT is underutilized, even though it has been reported to reduce medical costs; however, there is a paucity of evidence on the clinical risks related to this practice.


The University of Colorado at Boulder instituted a direct access musculoskeletal injury clinic in 2000. A retrospective analysis was performed on patient visits to Wardenburg Student Health Center from January 1, 2001 to December 31, 2011. Descriptive statistics were analyzed for the number of new patients examined with and without a referral, documented patient adverse events, and any disciplinary or legal action against aphysical therapist.


During the 10-year data collection period, 12,976 patients accessed PT without a referral. There were no reported unidentified cases of serious medical pathology or adverse events and none of the PTs had their credentials or licenses modified or revoked for disciplinary action.


Patients managed through direct access are at minimal to no risk for negligent care when evaluated and treated by PTs in a university student health center setting.

How can you deter the benefit of Direct Access to a Physical Therapist when this type of study, led by Dr. Paul Mintken, is showing NO adverse events following a ten, yes, TEN year period.  This is by far one of the most powerful studies in regards to length of time that patients are followed following seeing a physical therapist under Direct Access.  Not many studies have a 10 year follow up at all in any setting of medicine.  Props to Dr. Mintken and colleagues for collecting data on over 12 thousand patients and stick with the data collection for ten years to show what we see everyday in clinical practice—simply a positive benefit from seeking our services.

J Orthop Sports Phys Ther. 2015 Aug;45(8):642. doi: 10.2519/jospt.2015.0408.

Fracture of the Scaphoid During a Bench-Press Exercise.

The patient was a 21-year-old male cadet at a military academy who was evaluated by a physical therapist in a directaccess capacity for a chief complaint of left wrist pain that began 1 day after injuring his wrist while performing a bench-press exercise. Due to concern for a scaphoid fracture and because radiographic imaging was not immediately available, a physical therapist credentialed to utilize fluoroscopy evaluated the left wrist. Radiographs were subsequently ordered, which confirmed a mid-waist, nondisplaced scaphoid fracture.


Clinical reasoning and objective testing led Dr. Mason to perform further testing and then referral to appropriate medical profession; in this case, an orthopedic surgeon.  Correct call was made and a positive outcome led to unrestricted duty for the serviceman following healing.


J Health Care Poor Underserved. 2014 Nov;25(4):1966-81. doi: 10.1353/hpu.2014.0192.

Student perceived competence in direct access to physical therapy in a doctor of physical therapy program at a historically black university.

Physical therapists provide care via direct access in many states. Greater perceived competence with direct access among graduating physical therapists is critical. The purpose of this study was to assess student physical therapists’ perceived competence with direct access.A survey instrument was created to determine levels of perceived competence at three phases of the physical therapy curriculum. The Friedman two-way ANOVA by ranks was used to assess differences between year one, year two, and year three responses for each individual survey question and the overall survey score.Total survey score demonstrated significant increased student perceived competence with direct access to physical therapy care direct access from year one total to year two (p = .018), year one to year three (p = .005), and year two to year three (p = .016).More favorable attitudes among graduating physical therapists may have an influence on primary care for musculoskeletal conditions.

This doesn’t surprise me that increased experience led to more favorable attitudes towards treating under Direct Access.  If a potential patient is reading this article, I suggest seeking out a physical therapist with experience, especially in the specialty (i.e. orthopedics, spine, etc) that you are seeking out care for.

Phys Ther. 2014 Mar;94(3):363-70. doi: 10.2522/ptj.20120330. Epub 2013 Oct 3.

Direct access to physical therapy for patients with low back pain in the Netherlands: prevalence and predictors.


In the Netherlands, direct access to physical therapy was introduced in 2006. Although many patients with back pain visit physicaltherapists through direct access, the frequency and characteristics of episodes of care are unknown.


The purposes of this study were: (1) to investigate the prevalence of direct access to physical therapy for patients with low back pain in the Netherlands from 2006 to 2009, (2) to examine associations between mode of access (direct versus referral) and patient characteristics, and (3) to describe the severity of the back complaints at the beginning and end of treatment for direct access and referral-based physical therapy.


A cross-sectional study was conducted using registration data of physical therapists obtained from a longitudinal study.


Data were used from the National Information Service for Allied Health Care, a registration network of Dutch physical therapists. Mode ofaccess (direct or referral) was registered for each episode of physical therapy care due to back pain from 2006 to 2009. Logistic regression analysis was used to explore associations between mode of access and patient/clinical characteristics.


The percentage of episodes of care for which patients with back pain directly accessed a physical therapist increased from 28.9% in 2006 to 52.1% in 2009. Characteristics associated with direct access were: middle or higher education level (odds ratio [OR]=1.3 and 2.0, respectively), previous physical therapy care (OR=1.7), recurrent back pain (OR=1.7), duration of back pain <7 days (OR=4.2), and age >55 years (OR=0.6).


The study could not compare outcomes of physical therapy care by mode of access because this information was not registered from the beginning of data collection and, therefore, was missing for too many cases.


Direct access was used for an increasing percentage of episodes of physical therapy care in the years 2006 to 2009. Patient/clinical characteristics associated with the mode of access were education level, recurrent back pain, previous physical therapy sessions, and age.

Even though outcomes were not conducted in this study to compare results from seeing a physical therapist for low back pain vs another healthcare provider, this article does show us that there are certain patient characteristics associated with seeking out Direct Access care.  I see this on a personal basis with my patients—not necessarily education level but connections and speaking with other people who have received very positive results from my office have led to increase percentage of patients seeking care from physical therapy for Direct Access.

Phys Ther. 2014 Jan;94(1):14-30. doi: 10.2522/ptj.20130096. Epub 2013 Sep 12.

Direct access compared with referred physical therapy episodes of care: a systematic review.


Evidence suggests that physical therapy through direct access may help decrease costs and improve patient outcomes compared with physical therapy by physician referral.


The purpose of this study was to conduct a systematic review of the literature on patients with musculoskeletal injuries and compare health care costs and patient outcomes in episodes of physical therapy by direct access compared with referred physical therapy.


Ovid MEDLINE, CINAHL (EBSCO), Web of Science, and PEDro were searched using terms related to physical therapy and directaccess. Included articles were hand searched for additional references.


Included studies compared data from physical therapy by direct access with physical therapy by physician referral, studying cost, outcomes, or harm. The studies were appraised using the Centre for Evidence-Based Medicine (CEBM) levels of evidence criteria and assigned a methodological score.


Of the 1,501 articles that were screened, 8 articles at levels 3 to 4 on the CEBM scale were included. There were statistically significant and clinically meaningful findings across studies that satisfaction and outcomes were superior, and numbers of physical therapy visits, imaging ordered, medications prescribed, and additional non-physical therapy appointments were less in cohorts receiving physical therapy by directaccess compared with referred episodes of care. There was no evidence for harm.


There is evidence across level 3 and 4 studies (grade B to C CEBM level of recommendation) that physical therapy by directaccess compared with referred episodes of care is associated with improved patient outcomes and decreased costs.


Primary limitations were lack of group randomization, potential for selection bias, and limited generalizability.


Physical therapy by way of direct access may contain health care costs and promote high-quality health care. Third-party payers should consider paying for physical therapy by direct access to decrease health care costs and incentivize optimal patient outcomes.

The conclusions of this systematic review (by the way…the highest level of healthcare evidence) says it all: Third-party payers should consider paying for physical therapy by direct access to decrease health care costs and incentivize optimal patient outcomes.  Nothing else is needed to state here…

Phys Ther. 2013 Apr;93(4):449-59. doi: 10.2522/ptj.20120060. Epub 2012 Nov 29.

A global view of direct access and patient self-referral to physical therapy: implications for the profession.


International policy advocates for direct access, but the extent to which it exists worldwide was unknown.


The purpose of this study was to map the presence of direct access to physical therapy services in the member organizations of the World Confederation for Physical Therapy (WCPT) in the context of physical therapist practice and health systems.


A 2-stage, mixed-method, descriptive study was conducted.


A purposive sample of member organizations of WCPT in Europe was used to refine the survey instrument, followed by an online survey sent to all WCPT member organizations. Data were analyzed using descriptive statistics, and content analysis was used to analyze open-ended responses to identify themes.


A response rate of 68% (72/106) was achieved. Direct access to physical therapy was reported by 58% of the respondents, with greater prevalence in private settings. Organizations reported that professional (entry-level) education equipped physical therapists for direct access in 69% of the countries. National physical therapy associations (89%) and the public (84%) were thought to be in support of direct access, with less support perceived from policy makers (35%) and physicians (16%). Physical therapists’ ability to assess, diagnose, and refer patients on to specialists was more prevalent in the presence of direct access.


The findings may not be representative of the Asia Western Pacific (AWP) region, where there was a lower response rate.


Professional legislation, the medical profession, politicians, and policy makers are perceived to act as both barriers to and facilitators of direct access. Evidence for clinical effectiveness and cost-effectiveness and examples of good practice are seen as vital resources that could be shared internationally, and professional leadership has an important role to play in facilitating change and advocacy.

There are definitely barriers to Direct Access in physical therapy profession.  If you are a patient seeking out services, remember, the barriers are not necessary driven by the knowledge/expertise by the professionals in physical therapy; but simply by politics.  The differences in Direct Access throughout the states is bizarre.  Nevertheless, if you are having musculoskeletal issues (i.e back pain, neck pain, shoulder pain, etc); seek out the services of a physical therapist.

J Orthop Sports Phys Ther. 2012 May;42(5):446-54. doi: 10.2519/jospt.2012.3890. Epub 2012 Jan 25.

Physical therapists referring patients to physicians: a review of case reports and series.




An important role for physical therapists in the healthcare delivery system is to recognize when patient referral to a physician or other healthcare provider is indicated. Few studies exist describing physical therapists’ evaluative and diagnostic processes leading to patient referral to a physician.


To summarize published patient case reports that described physical therapist/patient episodes of care that resulted in the referral of the patient to a physician and a subsequent diagnosis of medical disease.


A literature search identified 78 case reports describing physical therapist referral of patients to physicians with subsequent diagnosis of a medical condition. Two evaluators reviewed the cases and summarized (1) how and when patients accessed physical therapy services, (2) timing of patient referral to a physician, (3) resultant medical diagnoses, (4) physical therapists’ role in referral of patients for diagnostic testing, and (5) relevant patient symptom description, health history, review of systems, and physical examination findings.


Fifty-eight (74.4%) of 78 patients had been referred to a physical therapist by their physician, while the remaining 20 patients accessedphysical therapy services via direct access. The patients’ primary presenting symptoms included pain (n = 60), weakness (n = 4), tingling/numbness (n = 2), or a combination (n = 12). Patient referrals to a physician occurred at the initial physical therapy session in 58 (74.4%) of 78 cases. A majority of patient referrals to a physician (n = 65) were related to primary presenting symptoms, including manifestations inconsistent with physician diagnosis, recent worsening without cause, unusual accompanying symptoms such as fatigue and/or weakness, and inadequate response to treatment. Resultant diagnoses included neuromusculoskeletal disorders (n = 53; fractures and tumors most common), visceral disorders (n = 14; cardiovascular involvement most common), and medication-related disorders (n = 3).


This review of published patient case reports provides numerous examples of physical therapists using effective multifactorial screening strategies for referred and directaccess patients, leading to timely patient referrals to physicians. The therapist-initiated patient referral to a physician led to subsequent diagnosis of a wide range of conditions and pathological processes.

This is a fantastic piece of literature to show that the clinical reasoning behind a physical therapist’s mind leads to appropriate screening and referring out, if necessary.  This is by far the biggest barrier from other professionals—in that PTs are unable to recognize non-musculoskeletal conditions.  Now this is just a sample of case reports, but how else would you recommend examining if we have the power to refer out?

Phys Ther. 2012 Feb;92(2):236-50. doi: 10.2522/ptj.20100421. Epub 2011 Oct 27.

Direct consumer access to physical therapy in Michigan: challenges to policy adoption.

Background. Michigan is 1 of only 4 states that require a physician referral or prescription before a consumer can receive treatment from a physicaltherapist.Objective. The purpose of the present analysis was to examine why the most recent attempts to pass direct access legislation in Michigan failed.Methods. The Policy Analysis Triangle approach, which considers the relevant actors, processes, and context in which a policy must be considered, was used to analyze legislative efforts to attain direct access in Michigan during the 2001–2002, 2003–2004, and 2005–2006 legislative sessions. Data sources included Michigan House and Senate legislative analyses, literature review, stakeholder position statements, political action committee contributions, and expert opinion.Results. Three successive direct access legislative attempts failed despite an increasing body of evidence supporting direct access and an increasing number of states allowing direct access. Proponents represented a relatively small number of individuals with limited political influence. Opponents represented a larger number of individuals who were able to exert greater political influence through large political action committee contributions and through physician legislators in positions of power who had influence over the bills’ dispositions.Conclusions. Several prominent contextual and process-related barriers to policy adoption must be overcome in future attempts at directaccess based on the findings from this analysis: (1) a limited constituency supporting direct access with regard to number of individuals and their political influence, (2) a perception that only the physician can independently diagnose and treat patient problems, and (3) legislators in positions of power who oppose a bill [corrected].

Any disregard to Direct Access can be summed up by a sentence in this piece of work: Opponents represented a larger number of individuals who were able to exert greater political influence through large political action committee contributions and through physician legislators in positions of power who had influence over the bills’ dispositions.

Mil Med. 2007 Apr;172(4):440-5.

Knowledge in managing musculoskeletal conditions and educational preparation of physical therapists in the uniformed services.

The purpose of this study was to describe knowledge in managing musculoskeletal conditions among physical therapists in the uniformed services based on their educational background and preparation. A cross-sectional design was used. A total of 182 physical therapists in the uniformed services completed a standardized examination that assesses knowledge in managing musculoskeletal conditions. Physical therapists in the uniformed services who graduated from the U.S. Army-Baylor Doctoral Program in Physical Therapy or had attended a specific continuing medical education course that emphasizes the management of musculoskeletal conditions achieved higher scores and passing rates than their colleagues who had not. Compared with previously published data, physical therapists in the uniformed services demonstrated higher scores than medical students, physician interns and residents, active duty military physicians, and all physician specialists except for orthopedists. Physical therapists in the uniformed services have the requisite knowledge to provide direct access for patients with musculoskeletal conditions. These data may have implications for health and public policy decisions within the military health care system related to the utilization and educational preparation of physical therapists in the uniformed services.

Granted the knowledge exposed in this work is of PTs in a uniformed services from Baylor; but I expect this to be of any PTs who graduated form an accredited university setting.  Either way, powerful knowledge was shown from this study by PTs—-showing higher test scores compared to all other professions besides orthopedists.  This study continues to be quoted by Direct Access proponents even if almost 10 years old now.

Phys Ther. 2006 Dec;86(12):1619-29.

Decision-making ability of physical therapists: physical therapy intervention or medical referral.


Opponents of direct access to physical therapy argue that physical therapists may overlook serious medical conditions. More information is needed to determine the ability of physical therapists to practice safely in directaccess environments. The purpose of this study was to describe the ability of physical therapists to make decisions about the management of patients in a directaccess environment.


Of a random sample of 1,000 members of the Private Practice Section of the American Physical Therapy Association, 394 participated.


A survey included 12 hypothetical case scenarios. For each case, participants determined whether they would provide intervention without referral, provide intervention and refer, or refer before intervention. The percentage of correct decisions for each group of scenarios was calculated for each participant, and participants were classified as having made correct decisions for 100% of cases or less for each group. Three sets of logistic regressions were completed to determine the characteristics of the participants in relation to the decision category.


The average percentages of correct decisions were 87%, 88%, and 79% for musculoskeletal, noncritical medical, and critical medical conditions, respectively. Of all participants, approximately 50% made correct decisions for all cases within each group. The odds of making 100% correct decisions if a physical therapist had an orthopedic specialization were 2.23 (95% confidence interval=1.35-3.71) for musculoskeletal conditions and 1.89 (95% confidence interval=1.14-3.15) for critical medical conditions.


Physical therapists with an orthopedic specialization were almost twice as likely to make correct decisions for critical medical and musculoskeletal conditions.

If you’re a patient seeking out services—choose a PT with advanced training—bottom line.

J Orthop Sports Phys Ther. 2005 Oct;35(10):651-8.

Cancer as a cause of low back pain in a patient seen in a direct access physical therapy setting.


Resident’s case problem.


This paper describes the clinical course of a patient with low back pain (LBP) and left lower extremity pain and tingling, and how thephysical therapist used clinical examination findings and a lack of improvement with conservative measures to initiate further medical evaluation, which resulted in a diagnosis of cancer as the primary cause of the patient’s low back and hip pain.


A 45-year-old man with chief complaints of left-sided LBP, left posterior thigh pain, and tingling along the anterolateral aspect of his left lower extremity was initially seen by a physical therapist in a direct access setting. Several components of the patient’s history and physicalexamination were consistent with a mechanical neuromusculoskeletal dysfunction. However, there were signs and symptoms present that may have been suggestive of more serious underlying disease. Specifically, the patient’s most intense pain was in the evening and into the night and an atypical pattern of restricted motion at the left hip was noted. Therefore, the physical therapist recommended that the patient schedule an appointment with his physician for medical evaluation. A short-term course of physical therapy treatment was also undertaken to address neuromusculoskeletal impairments. Despite 5 physical therapy visits over the course of a month, while the patient waited for his scheduled physician appointment, the patient’s condition gradually worsened. After medical evaluation, the patient was eventually diagnosed with small cell carcinoma of the lung, with metastases to the spine and pelvis. Despite 2 cycles of chemotherapy, the patient succumbed to the cancer 5 months after he was first seen inphysical therapy.


It is important that physical therapists have an understanding of the clinical findings associated with the presence of serious underlying diseases causing LBP, as this information provides guidance as to when communication with the patient’s physician is warranted.

A fantastic case report expressing the clinical reasoning and differential diagnosis of a physical therapist to refer out for a non-musculoskeletal condition and symptoms of low back pain.

BMC Musculoskelet Disord. 2005 Jun 17;6:32.

A description of physical therapists’ knowledge in managing musculoskeletal conditions.


Physical therapists increasingly provide direct access services to patients with musculoskeletal conditions, and growing evidence supports the cost-effectiveness of this mode of healthcare delivery. However, further evidence is needed to determine if physical therapists have the requisite knowledge necessary to manage musculoskeletal conditions. Therefore, the purpose of this study was to describe physical therapists’ knowledge in managing musculoskeletal conditions.


This study utilized a cross-sectional design in which 174 physical therapist students from randomly selected educational programs and 182 experienced physical therapists completed a standardized examination assessing knowledge in managing musculoskeletal conditions. This same examination has been previously been used to assess knowledge in musculoskeletal medicine among medical students, physician interns and residents, and across a variety of physician specialties.


Experienced physical therapists had higher levels of knowledge in managing musculoskeletal conditions than medical students, physician interns and residents, and all physician specialists except for orthopaedists. Physical therapist students enrolled in doctoral degree educational programs achieved significantly higher scores than their peers enrolled in master’s degree programs. Furthermore, experienced physical therapists who were board-certified in orthopaedic or sports physical therapy achieved significantly higher scores and passing rates than their non board-certified colleagues.


The results of this study may have implications for health and public policy decisions regarding the suitability of utilizing physical therapists to provide direct access care for patients with musculoskeletal conditions.

Another highly quoted article to show the knowledge of physical therapists in the realm of musculoskeletal care.  Again, just like in future studies—-choose a PT who is experienced and has board certifications.

J Allied Health. 2001 Spring;30(1):35-8.

Physical therapy as primary health care: public perceptions.

This study investigated the public’s knowledge of direct access and the role of physical therapists, and whether the public would consider using aphysical therapist for primary care. Persons living in South Florida were selected at random by dialing telephone numbers. Using three-digit telephone number prefixes, four-digit suffixes were generated by rolling dice. When consent was obtained, the respondents’ answers were recorded on a self-generated questionnaire. No knowledge of direct access was reported by 67.3% of the sample. Additionally, 57.4% of the sample had never been to aphysical therapist. A substantial number of respondents (73.4%) stated that they would go directly to a physical therapist. Thus, the public poorly understands direct access and the role of the physical therapist. The members of the public might use physical therapists as primary care practitioners if they were aware of this option.

15 years old by the time this review was written—so I’m assuming by 2016 more than 57.4% of the population has at least been to a physical therapist but nevertheless, 3/4 of the respondents DID state that they would go directly to a physical therapist.  This is huge…especially back in 2001.

Br J Gen Pract. 1997 May;47(418):314-8.

Should general practitioners refer patients directly to physical therapists?

Several advantages have been claimed for general practitioners having direct access to physical therapy (defined as having a practice-based physicaltherapist or open access to a hospital-based physical therapist), and general practice fundholders are increasingly committing resources to ensure such services are available to their patients. This may lead to potential increases in costs as a larger total number of patients are treated owing to improved access and awareness of such services. A review of the available published literature found eight studies that compared two or more models of providing physical therapy services. Analysis of the studies revealed that there are several advantages for patients who are referred directly for physical therapy. The main advantages are significant reductions in waiting times, convenience, reduced costs for the patient and a lower cost per treated patient. There is also some evidence that the recovery time may be slightly better for patients who have direct access to a physical therapist.

Almost 20 years old (when this was written in 2016)—and we can suggest that recovery time IS better for patients who have direct access to a physical therapist.

Phys Ther. 1997 Jan;77(1):10-8.

A comparison of resource use and cost in direct access versus physician referral episodes of physical therapy.


Access to physical therapy in many states is contingent on prescription or referral by a physician. Other states have enacted direct access legislation enabling consumers to obtain physical therapy without a physician referral. Critics of direct access cite potential overutilization of services, increased costs, and inappropriate care.


Using paid claims data for the period 1989 to 1993 from Blue Cross-Blue Shield of Maryland, a direct access state, we compiled episodes of physical therapy for acute musculoskeletal disorders and categorized them as direct access (n = 252) or physician referral (n = 353) using algorithms devised by a clinician advisory panel. Relative to physician referral episodes, direct access episodes encompassed fewer numbers of services (7.6 versus 12.2 physical therapy office visits) and substantially less cost ($1,004 versus $2,236).


Direct access episodes were shorter, encompassed fewer numbers of services, and were less costly than those classified as physician referral episodes. There are several potential reasons why this may be the case, such as lower severity of the patient’s condition, overutilization of services by physicians, and underutilization of services by physical therapists. Concern that direct access will result in overutilization of services or will increase costs appears to be unwarranted.

Read the conclusions—-shorter visits, less cost====no brainer to seek out physical therapy FIRST.



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