Question: What is Direct Access to Physical Therapy?

In the past, a physician prescribed physical therapy. Now several states allow patients to have direct access to physical therapy.

Answer:

Provisions for physical therapy services are governed by each individual state through a "state-practice" act. Each state lists different professionals who may refer patients to physical therapy, including podiatrists, dentists and nurse practitioners. A state that allows direct access means that it allows self-referral WITHOUT being evaluated and diagnosed by a physician or other healthcare practitioner.

By having direct access to patients, physical therapists are recognized as licensed professionals to initially manage musculoskeletal and movement disorders in patients. This also means that these therapists may also provide some form of diagnosis, and thus carry the liability for the evaluation AND management of any condition or diagnosis they treat.

The purpose of having physical therapy direct access was to 1) more quickly provide evaluation and care for patients post-injury; and 2) reduce unnecessary diagnostic imaging and testing thus reducing overall healthcare spending.

Unfortunately, metanalyses have not been able to demonstrate patients did indeed achieve better outcomes from earlier physical therapy interventions UNLESS these evaluations and interventions were initiated no later than 30 days after the acute injury or incident.

Moreover, if physical therapy was initiated more than 3 months of the acute incident, patients were often unable to achieve their self-disclosed short-term goals, and rarely were able to achieve their long-term goals. AND, no savings in healthcare spending was shown from direct access to physical therapy. As it turns out, whatever savings were deferred to the future (in images and specialist referrals), these were spent in co-pays, time off from work, fees related to transportation, or use of trained home-health aide services or home-therapy options.

From both a patient and specialty provider perspective, delay in advanced imaging, critical diagnostic testing and surgical interventions can lead to undertreated if not mistaken diagnoses. Regarding neuromusculoskeletal issues, delays in treatment for nerve compressions, circulation issues or fraying tendons and ligaments often results in the need for more complex and thus more risky surgical interventions - especially in the older patients who are often not encouraged to even consider possible palliative interventions due to their ‘age’ or ‘frailty’. Physicians are well-trained to determine appropriate surgical or procedural candidacy, and all patients should be given the option to at least have this candid discussion with an expert in their field.

Moreover, physicians are now better educated to minimize unnecessary testing and imaging, although, there is still pressure to prescribe.  Thus referral to a Physical Medicine and Rehabilitation specialist (Physiatrist) ensures that the patient will unlikely be shuttled around between Neurologist, Rheumatologist, Orthopedist and Pain Management specialists as the Physiatrist’s training in ALL of these systems allows an expedited and more complete evaluation of the patient's condition.

All in all, it is NOT that spending time with a physical therapist is wasteful of time or money, but that patients should be educated and selectively chosen to pursue this treatment option if it will more likely than not provide meaningful improvements in function, pain or independence. Otherwise, if a patient enters therapy via direct access but still cannot achieve sustainable and progressive endpoints after 4 weeks of therapy (2-3 times a week), the patient SHOULD be referred to a Physiatrist, as it is likely that there are neurological, anatomical, autoimmune, circulatory, psychological or other physiological obstacles to the patient’s success.

Is Direct Access Safe?

To date, there is no objective data indicating that self-referral to physical therapy puts patients at increased risk. However, the patient must decide if delaying a diagnosis for at least 4 weeks is an acceptable risk to their long-term health and function. For many conditions, there is not too much of a risk, but for some individuals -- and especially those who tend to neglect or ignore warning signs of more serious issues -- this can become problematic.

Of course, physical therapists are trained to recognize some of the "red flags" that may signal the need for medical intervention - and being independently licensed providers, they are obligated to pursue advanced evaluation for their patients. In those cases, referral to your physician should be made immediately.

Important Things to Consider

Many states have safety nets built into the legislation that governs the practice of physical therapy. For instance, some states allow direct access for only a certain time frame, or for only specific number of physical therapy visits during an episode of care. If the patient seems to still require skilled physical therapy after projected time frame or visit threshold is reached, referral to the patient's doctor is mandatory.

If you are suffering from a musculoskeletal condition that causes functional movement limitations, try to use your best judgment when deciding who to see first. Although a visit to your local Physical Therapist or Manual Medicine Specialist seems a safe place to start your recovery, consider all of your medical and surgical history. 

If you have noticed changes in muscle tone or size, progressively worsening cramping or muscle twitching, progressively worsening strength or sensation, changing or worsening bowel or bladder function, impaired balance or having more frequent falls -- IF YOU HAVE ANY DOUBTS AT ALL -- consider seeing a physiatrist first. The physiatrist will be glad to give you the go-ahead for physical therapy if the condition is not something more emergent.

Sources: APTA Direct Access in Practice http://www.apta.org/directaccess/; Pendergast J, Kliethermes SA, Freburger JK, Duffy PA. A comparison of health care use for physician-referred and self-referred episodes of outpatient physical therapy. Health Services Research