Abstract
Introduction: The growing global burden of musculoskeletal (MSK) conditions could be relieved by Direct Access (DA) to physiotherapy at a time when other primary health care services are being challenged. Expanding physiotherapists' scope of practice and allowing direct access has potential to improve access to healthcare services, improve patient experience, and decrease overall costs of the MSK services provided.
Aim: This scoping review aimed to:
1. investigate the impact of DA to physiotherapy on patient outcomes, cost-effectiveness, and safety
2. investigate how prescribing rights, referral for clinical imaging, and medical certification are utilised in primary care.
Methods: We conducted an online search of English language literature published from January 201 3 to March 2025, including the databases PubMed, Ovid Medline, Scopus, and Pedro. Grey literature was sourced from Google, X, LinkedIn, and reference mining. Two reviewers screened abstracts that met inclusion criteria. Agreement was sought on the papers to be included and the full papers were reviewed.
Results: There were 66 papers accepted into the review. Sparse evidence investigating health outcomes shows no difference when DA to physiotherapy is compared to the medical model of care. Lower health costs per capita were identified with physiotherapists having capacity to order clinical imaging. Medical certification by physiotherapists was associated with better work-related outcomes, which was cost-saving. DA is considered a safe alternative, with no significant adverse effects identified. Global variance was noted in physiotherapists utilising prescribing rights, clinical imaging, and medical certification, and these activities were limited to a few countries. Physiotherapist prescribing takes place in Australia, Canada, and the UK, where the most commonly prescribed medications are analgesics and anti-inflammatories. Globally, X-ray and ultrasound are the most requested clinical images by physiotherapists. Medical certification by physiotherapists is very uncommon, with evidence for this limited to the UK and Australia.
Conclusion: Based on limited evidence, DA to physiotherapy is as effective as the medical model, safe, and likely to be cost- saving. However, there is wide global variance, with few countries allowing physiotherapists to prescribe medication or provide medical certification. More countries allow physiotherapists to request clinical imaging. An extended scope of practice tends to occur in countries that have DA. Implementation of DA has shown some difficulties and therefore a strategy that involves all stakeholders is required. This includes education of other health care professionals.