EFFECTIVENESS OF DIRECT ACCESS PHYSIOTHERAPY IN MUSCULOSKELETAL CARE: A RANDOMIZED CONTROLLED TRIAL ASSESSING CLINICAL OUTCOMES, HEALTHCARE UTILIZATION, AND PRIMARY CARE WORKLOAD

Abstract

Background

Musculoskeletal disorders (MSDs) are among the leading causes of disability worldwide and contribute substantially to healthcare utilization and primary care workload. Conventional physician-led referral pathways may delay access to rehabilitation services and increase healthcare resource consumption. Direct access physiotherapy has emerged as an alternative model of care; however, evidence from low- and middle-income countries remains limited.

Objective

To evaluate the effectiveness of direct access physiotherapy in musculoskeletal care by assessing clinical outcomes, healthcare utilization, and primary care workload among patients attending a tertiary care teaching hospital.

Methods

A parallel-group randomized controlled trial was conducted at Mufti Mehmood Memorial Teaching Hospital MTI Dera Ismail Khan Khyber Pakhtunkhwa, Pakistan. A total of 160 participants with musculoskeletal disorders were randomly assigned to either the Direct Access Physiotherapy (DAP) group (n = 80) or the Conventional Referral Care (CRC) group (n = 80). Participants in the DAP group received supervised physiotherapy twice weekly for 12 weeks, whereas participants in the CRC group followed the routine physician-led referral pathway. Primary outcomes included the Numeric Pain Rating Scale (NPRS), Patient-Specific Functional Scale (PSFS), Pain Disability Index (PDI), EuroQol Five-Dimension Five-Level Questionnaire (EQ-5D-5L), and Patient Satisfaction Questionnaire Short Form (PSQ-18). Secondary outcomes included healthcare utilization and primary care workload indicators. Assessments were conducted at baseline, Week 6, and Week 12. Data was analyzed using mixed repeated-measures analysis, with statistical significance established at p < 0.05.

Results

Of the 160 randomized participants, 150 completed the 12-week follow-up and were included in the final analysis. Significant group × time interactions were observed for all primary outcomes (p < 0.05). Participants receiving direct access physiotherapy demonstrated greater reductions in NPRS scores (2.8 ± 1.3 vs 4.1 ± 1.8; p < 0.001) and PDI scores (21.4 ± 8.6 vs 29.7 ± 9.4; p < 0.001), alongside superior improvements in PSFS (78.6 ± 11.2 vs 68.1 ± 12.9; p < 0.001), EQ-5D-5L (0.82 ± 0.09 vs 0.73 ± 0.11; p = 0.002), and PSQ-18 scores (8.7 ± 1.2 vs 7.4 ± 1.5; p = 0.001) at Week 12. The DAP group also demonstrated lower healthcare utilization, including physician consultations (1.3 ± 0.7 vs 3.1 ± 1.1; p < 0.001), imaging requests (22.5% vs 46.2%; p = 0.003), medication prescriptions (32.5% vs 61.2%; p < 0.001), and specialist referrals (8.8% vs 20.0%; p = 0.041). Primary care workload indicators, including consultation duration (9.4 ± 2.3 minutes vs 14.8 ± 3.1 minutes; p < 0.001) and follow-up consultations (1.1 ± 0.6 vs 2.4 ± 1.0; p < 0.001), were significantly reduced in the DAP group.

Conclusion

Direct access physiotherapy was associated with improved clinical outcomes, reduced healthcare utilization, and decreased primary care workload among patients with musculoskeletal disorders. These findings suggest that direct access physiotherapy may represent an effective and sustainable model of musculoskeletal care within tertiary healthcare settings in Pakistan.