Comparison of Physical Therapy and Physician Pathways for Employees with Recent Onset Musculoskeletal Pain: A Randomized Controlled Trial

Abstract

Background Life expectancy of the U.S. population will continue to rise, increasing the workforce demands in the treatment of musculoskeletal pathologies. With a declining primary care physician workforce, physical therapists (PT) may be in a unique situation to help absorb this demand. Objective Our primary objective was to compare physical function between two primary care groups, a “physical therapy‐led pathway” versus “physician‐led pathway” in the management of recent‐onset musculoskeletal pain at 1‐month follow‐up. Our secondary objectives were to compare other patient‐important outcomes between the groups at 1 month and health utilization at 1 month and 1 year. Methods A pragmatic randomized controlled trial with a 1‐year follow‐up was conducted, enrolling 150 university employees with recent onset musculoskeletal pain. Participants were randomized at first contact to either a PT‐led pathway or physician‐led pathway. The primary outcome was change in Patient‐Reported Outcomes Measurement Information System (PROMIS) ShortForm v1‐Physical Function 10a at 1 month; groups were compared with repeated measurement of analysis of variance and chi‐square for both primary and secondary outcomes, except for satisfaction score at 1 month, which was cross‐sectionally compared by independent two‐sample t‐test. At 1 year, healthcare utilization was assessed through medical record extraction, and healthcare utilization was converted to total episodic standard cost. Utilization was compared between groups using chi‐square and Wilcoxon rank‐sum tests. Results Both groups demonstrated improvement at 1‐month follow‐up but showed no significant between‐group difference in mean PROMIS scores at 1 month (PT‐led pathway vs physician‐led pathway, 2.04, [95% CI ‐0.28 to 4.36]; P = .082). At 1 year, there was no difference in healthcare utilization or cost between groups. No harm or misdiagnosis was found, filed, or reported by participants at 1 year. Conclusion This study shows equivalence in outcomes for two low‐cost musculoskeletal care pathways with no risk of harm. These results reinforce other findings in the literature that support PTs as safe and effective initial providers for individuals with musculoskeletal disorders.

Effectiveness and Consequences of Direct Access in Physiotherapy: A Systematic Review

“…Of the 63 articles screened for full text, a total of 28 articles were included in the review. The 28 included studies were published from 1999 to 2022 [ 9 , 16 , 17 , 18 , 19 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 ]. The following study designs were identified: 10 RCTs, 9 prospective longitudinal cohort studies, 4 case control studies, 3 retrospective observational studies, and 2 prospective observational studies [ 9 , 16 , 17 , 18 , 19 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 ].…”

“…Seven studies [ 16 , 19 , 26 , 29 , 39 , 40 , 41 ] did not include a control. Interventions for the control group were delivered by a physician in eight studies [ 27 , 28 , 31 , 34 , 43 , 45 , 46 , 48 ]; by a general practitioner in eight studies [ 9 , 32 , 35 , 36 , 37 , 38 , 44 , 47 ], and by an orthopedic physician in five studies [ 17 , 18 , 30 , 33 , 42 ].…”

“…The different setting of care is reported in Figure 2 : eight studies were performed in an outpatient setting [ 16 , 19 , 26 , 34 , 41 , 42 , 43 , 46 ], one study in a military service setting [ 48 ], and twenty in a primary care hospital setting [ 8 , 9 , 17 , 18 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 35 , 36 , 37 , 38 , 39 , 40 , 44 , 45 , 47 ].…”

“…Fourteen studies evaluated the triage proficiency of physiotherapists [ 16 , 18 , 19 , 26 , 29 , 31 , 33 , 36 , 40 , 41 , 42 , 46 , 47 , 49 ]. Most commonly, physiotherapists triage patients without additional medical consultation [ 16 , 18 , 19 , 26 , 31 , 36 , 40 , 41 , 42 , 46 , 47 ].…”

“…Fourteen studies evaluated the triage proficiency of physiotherapists [ 16 , 18 , 19 , 26 , 29 , 31 , 33 , 36 , 40 , 41 , 42 , 46 , 47 , 49 ]. Most commonly, physiotherapists triage patients without additional medical consultation [ 16 , 18 , 19 , 26 , 31 , 36 , 40 , 41 , 42 , 46 , 47 ]. Three studies compared the surgical conversion rate expressed as a percentage (i.e., surgical conversion rate is considered a useful measure of appropriateness of referrals, as it is a measure of the percentage of patients that were referred to a physician and underwent surgery) [ 19 , 40 , 41 ].…”