WEEKLY LITERATURE REVIEW

This week traces a single argument across five studies: physical therapy’s clinical evidence is strong and improving, but the delivery infrastructure carrying it to patients has not kept pace. Monday quantifies the referral-to-attendance gap. Tuesday and Wednesday test whether removing the physician-first gatekeeping step closes that gap cost-effectively. Tuesday uses retrospective data; Wednesday uses a randomized trial. Thursday examines what happens clinically once patients are in the room. Friday synthesizes all four into a systems-level path forward.

MONDAY - THE ACCESS GAP

The Referral Isn’t the Finish Line: Physical Therapy’s Silent 76% Drop-Off.

Health systems tend to measure physical therapy access by counting referrals generated rather than patients treated. A retrospective cohort study from the University of Utah Health suggests that’s the wrong metric entirely. Among more than 86,000 adults who presented with a new musculoskeletal complaint, a referral to PT turned out to be the beginning of a long, leaky pathway -one where roughly three out of every four referred patients never made it into a treatment room.

By the Numbers

Patients screened: 86,186 adults, ages 18–64, new MSK visit

Referred to PT: 15,870 (18% of eligible patients)

Attended within 30 days: 3,812 of referred patients (24%)

Model predictive accuracy: C-statistic ≈ 0.63 (weak)

Referral Volume Isn’t the Metric That Matters

It’s tempting for a health system to treat a completed referral as a completed job. The patient was pointed toward evidence-based care, and what happens next is up to them. The Utah data argue against that framing. Referral is an intention, not an outcome. The gap between the two is where most of the value of PT is lost. A system that reports referral volume as an access metric is grading itself on effort rather than delivery.

Who Gets Left Behind

The predictors of non-attendance cluster into two familiar categories: enabling factors patients can’t control and predisposing factors tied to who they are. Distance to the clinic was the strongest quantifiable driver. Patients living 10 to 20 kilometers away were about half as likely to attend as those nearby. That likelihood fell further, to about a third, beyond 20 kilometers. Public insurance tracked with meaningfully lower uptake, more so for Medicare than Medicaid. Hispanic/Latino patients and patients with obesity were also significantly less likely to attend, pointing to structural and socioeconomic barriers-cost, transportation, language, documentation, and clinic hours-that sit upstream of any individual clinical encounter.

Referral source mattered just as much as patient characteristics. Orthopedic referrals converted to attendance at meaningfully higher rates than those from primary care or urgent care. That’s a workflow signal as much as a patient one. How a referral is framed, whether scheduling support is built in, and how legitimate the recommendation feels to the patient all vary by department. Those variations show up directly in attendance rates. Workers’ compensation cases, by contrast, were attended at higher rates than any diagnostic category, likely reflecting financial incentive and closer case management.

The Limits of Administrative Prediction

The multivariable model built from all of this-insurance, distance, diagnosis, referral source, demographics-still only reached a C-statistic of about 0.63, weak by any standard. That’s the most important finding in the study, arguably more important than any single predictor. It means the variables that actually determine whether a referred patient shows up-perceived need, co-pay amount, wait time, prior PT experience, work and family constraints, language, mental health-mostly aren’t in the EHR. Administrative data can describe who is more or less likely to attend; it can’t yet explain why.

Strategic Implication for Health System Leaders

This gap is addressable but only if tracked as a distinct metric from referral volume. Three moves follow directly from the data. First, build navigation and warm hand-off support into referral workflows, especially from primary and urgent care where conversion lags behind orthopedics. Second, target outreach-interpreter services, flexible scheduling, telehealth PT-at the specific groups shown to under-access care. Third, treat the referral source itself as a modifiable variable, since the gap between departments suggests a training and process fix, not just a patient-behavior problem.

“A referral logged in the EHR is not the same thing as a patient in a treatment room. Until health systems measure the distance between the two, they are managing a number that doesn’t reflect the care actually delivered.”

Strategic Takeaways

Referral-to-attendance, not referral volume, is the access metric that reflects real care delivery.

Distance and insurance type are the strongest quantifiable predictors of drop-off after referral.

Orthopedic-sourced referrals convert at meaningfully higher rates than primary or urgent care referrals -a workflow signal worth investigating.

Administrative data models will continue to underperform until systems capture the psychosocial and logistical variables that actually drive adherence.

Source: Sharpe, J. A., Martin, B., Fritz, J. M., Newman, M. G., Magel, J., Vanneman, M. E., & Thackeray, A. (2021). Identifying patients who access musculoskeletal physical therapy: a retrospective cohort analysis. Family Practice, 38(3), 203–209. https://doi.org/10.1093/fampra/cmaa104

Audience: Health System Executives | Referral Coordinators | Population Health Leaders | Payers

Quick Summary

📉 Only 24% of referred patients started PT within 30 days.

🧭 Distance to clinic was the single strongest predictor of non-attendance.

💳 Public insurance (Medicaid, Medicare) tracked with significantly lower uptake.

⚖️ Hispanic/Latino patients and patients with obesity were less likely to attend.

🏥 Orthopedic referrals converted at higher rates than primary or urgent care referrals.

🧩 Predictive accuracy was weak (C-statistic 0.63) -the real drivers aren’t in the chart.

TUESDAY -THE ECONOMIC CASE

What Happens When You Remove the Gatekeeper: The Direct Access Cost Evidence

If Monday’s data shows referral pathways leaking patients, Tuesday’s question is more fundamental: what if the physician-first authorization step itself is part of the problem? A 2021 systematic review and meta-analysis pooling five U.S. studies put a dollar figure on the answer. It compared direct access to physical therapy with traditional physician-first pathways for musculoskeletal disorders, primarily spine-related conditions.

By the Numbers

Evidence base: 5 retrospective U.S. studies, 1997–2019

PT cost per patient: ≈ $243 lower with direct access

Total health care cost: ≈ $1,828 lower per patient with direct access

PT visits per episode: ≈ 1 fewer visit with direct access

Functional outcome, between-group: Small effect, not statistically significant

The Pooled Numbers

Across the five studies, direct access produced consistently lower costs on every dimension measured: PT-specific cost, total health care cost, and number of visits per episode. Converted to clinical units, the total-cost effect is roughly $1,828 less per patient. This figure is large enough to matter at the population level for any payer or system managing musculoskeletal spend, even considering the modest effect sizes.

Where the Savings Actually Come From

The mechanism is not that direct-access patients get less treatment. Visit counts dropped by only about one visit per episode. The larger driver is what direct access removes upstream: fewer physician visits, less imaging, and fewer interim procedures before active care begins. Removing the authorization step shortens the path to evidence-based exercise and education. It cuts out utilization that adds cost without adding proportional value.

Function Was a Wash -And That’s the Point

Both pathways produced clinically meaningful within-group improvement in function. The between-group difference was small and its confidence interval crossed zero. This means the review can’t claim direct access produces better outcomes, only that it doesn’t produce worse ones at lower cost. For a system evaluating this model, that is the more defensible claim: the savings didn’t come at the expense of the patient’s functional recovery, at least in the spine-focused populations studied here.

Reading the Fine Print

The evidence base is real but thin. Five retrospective studies spanning more than two decades, with heterogeneous designs and settings, provide a modest foundation for a policy shift. Observational data carry an unavoidable risk of selection bias because patients who choose or are steered toward direct access may differ systematically from those who don’t. The scope is also narrow: nearly all included studies focused on spine-related musculoskeletal disorders, so generalizing to extremity or postoperative populations is speculative. Safety data is sparse. Only one included study explicitly searched for missed diagnoses or adverse events, finding none, which is reassuring but far from definitive.

Strategic Implication

Retrospective, associational data of this quality is a reasonable basis for designing a pilot but not sufficient grounds for a full policy overhaul. The honest reading is that direct access appears economically attractive and clinically non-inferior in the populations studied. The causal claim requires a study design that removes the selection-bias objection entirely. That’s exactly the gap Wednesday’s evidence closes.

“The savings in this evidence base come from what direct access removes upstream -not from what physical therapy adds downstream. That distinction is the one payers will want explained before they act on it.”

Strategic Takeaways

Direct access is associated with lower cost and fewer visits without a statistically significant loss of function, in spine-related MSD populations.

Savings are driven primarily by reduced downstream utilization -fewer physician visits and less imaging -rather than by compressed treatment.

The evidence base is real but thin: five retrospective studies, limited harm surveillance, and a spine-only scope.

Prospective, non-spine, harm-inclusive trial data is the next evidentiary bar for broader policy adoption.

Source: Hon, S., Ritter, R., & Allen, D. D. (2021). Cost-effectiveness and outcomes of direct access to physical therapy for musculoskeletal disorders compared to physician-first access in the United States: Systematic review and meta-analysis. Physical Therapy, 101, 1–11. https://doi.org/10.1093/ptj/pzaa201

Audience: Health System Executives | Payers & Policymakers | PT Clinical Directors

Quick Summary

💸 Direct access tracked with ~$243 lower PT cost and ~$1,828 lower total cost per patient.

🔽 About one fewer PT visit per episode.

🩺 Functional outcomes were comparable between direct access and physician-first pathways.

⚖️ Evidence quality is moderate: five retrospective studies, real but limited causal certainty.

🛡️ Safety surveillance was sparse -an open question, not a resolved one.

🔬 Prospective, non-spine trials are the logical next evidentiary step.

WEDNESDAY -THE PROSPECTIVE TEST

A Randomized Trial Puts Physiotherapist-First Triage to the Test

Retrospective associations, however consistent, invite an obvious objection: patients who use direct access may simply be different from those who don’t. A Swedish pragmatic randomized controlled trial sidesteps that problem by randomizing patients with suspected knee osteoarthritis to a physiotherapist-first or physician-first assessment pathway. It tracks cost and quality-adjusted outcomes for a full year.

By the Numbers

Design: Assessor-blinded pragmatic RCT, 12-month follow-up

Randomized: 69 patients (35 physiotherapist-first, 34 physician-first)

Total cost, societal perspective: €633 vs. €996 per patient (PT-first lower)

Total cost, health-care perspective: €515 vs. €748 per patient (PT-first lower)

QALYs at 12 months: ~0.75 vs. ~0.74 -no significant difference

Probability PT-first is less costly, ≤±0.1 QALY: 72–80%

Why Randomization Changes the Argument

Unlike Tuesday’s pooled retrospective data, this trial randomized patients to their assessment pathway using a computer-generated allocation list. That design choice removes the selection-bias objection that limits how far observational evidence can be trusted. It’s a small trial -69 patients against a planned enrollment of 100 -but what it lacks in power it makes up for in the strength of its causal inference.

Where the Money Goes

The cost gap wasn’t driven by treatment intensity; it was driven by what happened before treatment. The physician-first group generated significantly higher costs for physician visits and radiography (p < 0.001 and p = 0.01, respectively). The physiotherapist-first group substituted more telephone contacts, a cheaper, lower-friction touchpoint. In other words, the savings mirror Tuesday’s mechanism almost exactly: less upstream utilization, not less care.

Equivalent, Not Inferior

Both groups improved their health-related quality of life over the 12-month follow-up period compared with baseline, and the QALY difference between groups was not statistically significant. That’s the finding that makes the cost data usable: physiotherapist-first care didn’t trade quality of life for savings. It delivered comparable outcomes through a cheaper front door.

The Caveat Leadership Needs to Hear

The trial was underpowered -69 patients against a planned 100 -leaving wide confidence intervals around the cost differences, which did not reach statistical significance despite favoring physiotherapist-first care on every measure. The one-year horizon also can’t capture longer-term outcomes such as eventual surgery rates. The single-region Swedish primary care setting limits how directly the findings translate to other health systems. The probability estimates (72–80% likely less costly with negligible QALY loss) are informative, but they are probabilities, not proof.

Strategic Implication

This is exactly the kind of evidence that justifies a funded pilot or a larger, adequately powered, multi-region trial -not yet a system-wide reimbursement mandate. The consistency between this randomized result and Tuesday’s retrospective meta-analysis, obtained through entirely different designs and in a different country, is the more persuasive signal than either study alone. Two independent lines of evidence pointing in the same direction reduce the risk that either result is a fluke of study design.

“Two small trial arms and a wide confidence interval are not proof. But a point estimate this consistent, replicated across a different study design and a different country, is not noise either.”

Strategic Takeaways

Randomization strengthens, but does not, by itself, resolve the case for physiotherapist-first triage.

Cost savings were driven by fewer physician visits and less radiography -not by different or reduced treatment.

Quality-of-life outcomes were statistically equivalent between pathways at 12 months.

An underpowered sample and a one-year horizon mean this evidence supports funded pilots and larger trials, not policy mandates, for now.

Source: Ho-Henriksson, C.-M., Svensson, M., Thorstensson, C. A., & Nordeman, L. (2022). Physiotherapist or physician as primary assessor for patients with suspected knee osteoarthritis in primary care – a cost-effectiveness analysis of a pragmatic trial. BMC Musculoskeletal Disorders, 23, 260. https://doi.org/10.1186/s12891-022-05201-3

Audience: Health System Executives | PT Clinical Leaders | Payers & Policymakers

Quick Summary

🎲 Randomization removes the selection-bias objection that limits observational evidence.

💶 Total cost was lower in the physiotherapist-first group from both societal and health-care perspectives.

🖥️ Physician-first care generated significantly more physician visits and radiography.

⚖️ Quality-adjusted outcomes were statistically equivalent between pathways at 12 months.

📏 The trial was underpowered (69 of a planned 100 patients) -wide confidence intervals remain.

🔁 Findings echo Tuesday’s retrospective meta-analysis via an entirely different study design.

THURSDAY -THE CLINICAL MODEL

Access Solves Half the Equation: Why the Care Delivered Inside PT Still Matters

The first three days of this week made the case for access: patients aren’t reaching PT, and when the pathway to PT is shortened, systems save money without sacrificing outcomes. But access is a delivery mechanism, not the therapy itself. A 2025 narrative review argues that once a patient is in the room, physical activity-not passive modalities or procedures-is the intervention doing most of the clinical work. It works across a wider footprint than pain alone.

By the Numbers

Review scope: Narrative synthesis, MEDLINE/Embase/Cochrane through Nov 2024

Domains linked to exercise: Pain, sleep, stress/HPA regulation, diet/metabolism, smoking

Pain mechanism: Endorphin, endocannabinoid, and BDNF-mediated analgesia

Anti-inflammatory effect: Reduced pro-inflammatory cytokines (e.g., IL-6, IL-8)

Sleep effect size: Small but significant across exercise modalities

The Mechanistic Case for Exercise-Centered Care

The review synthesizes a substantial mechanistic literature showing exercise drives pain reduction through multiple, overlapping neurobiological pathways. Increased endorphins, enkephalins, and endocannabinoids activate descending inhibitory control. Elevated BDNF and serotonin support neuroplastic, adaptive reorganization. Regular activity modulates immune signaling, reducing pro-inflammatory cytokines and improving mitochondrial function. This isn’t a single mechanism producing a single effect. It’s a convergence of systems, which is part of why exercise-based care tends to outperform any one narrowly targeted intervention.

Beyond Pain: The Multiplier Effect

The more strategically relevant finding is that exercise’s benefit isn’t confined to the musculoskeletal complaint that brought the patient into care. Sleep improves modestly across aerobic, resistance, and mind-body exercise modalities. The effect often falls short of clinical thresholds on its own, so cognitive behavioral therapy for insomnia remains necessary as an adjunct when sleep disruption is significant. Stress resilience improves with reduced resting sympathetic tone and basal cortisol levels. Diet and metabolic profiles improve through enhanced insulin sensitivity and regulation of appetite hormones. This pathway is directly relevant to chronic pain populations, in which metabolic inflammation contributes to pain chronification. Even smoking behavior shows a plausible, if less clinically tested, benefit through reward-system modulation.

For a chronic pain population managed under value-based or bundled payment models, this matters operationally: a single, well-delivered active-care intervention is doing simultaneous work across four comorbid risk domains that would otherwise require four separate referrals.

Where the Evidence Is Still Thin

This is a narrative review, not a systematic one -the authors selected the literature thematically rather than through a formal risk-of-bias assessment, and the underlying studies are heterogeneous in their populations, interventions, and outcomes. Several of the mechanistic claims, particularly around smoking cessation and dietary behavior change, rest on preclinical or indirect evidence rather than clinical trials conducted specifically in chronic pain populations. The dose, timing, intensity, and modality of exercise needed to reliably produce sleep and circadian benefits also remain undefined.

Strategic Implication

If exercise is producing this much downstream value, the operational risk is that efficiency pressures-shorter visit times, higher productivity targets, reimbursement structures that don’t distinguish between active and passive care-quietly erode the very mechanism doing the clinical work. Health systems building bundled or value-based musculoskeletal programs have a direct incentive to protect dosing and time for active, exercise-centered care rather than let it be the first thing compressed under margin pressure.

“Exercise is not one lever among several in chronic pain care -it’s the lever pulling on pain, sleep, stress, metabolic health, and smoking behavior simultaneously. Compressing the time it takes compresses all five outcomes at once.”

Strategic Takeaways

Exercise-driven analgesia operates through multiple convergent neurobiological pathways, not a single mechanism.

The same intervention delivers measurable, if variable, benefit across sleep, stress, metabolic health, and smoking behavior -a multiplier effect relevant to bundled and value-based payment models.

The evidence is narrative and mechanistically heavy; clinical RCTs testing exercise specifically for sleep, diet, and smoking outcomes in chronic pain populations remain sparse.

Protecting time and dosing for active care against efficiency pressure is itself a value-based-care decision, not just a clinical one.

Source: Núñez-Cortés, R., Salazar-Méndez, J., & Nijs, J. (2025). Physical activity as a central pillar of lifestyle modification in the management of chronic musculoskeletal pain: A narrative review. Journal of Functional Morphology and Kinesiology, 10, 183. https://doi.org/10.3390/jfmk10020183

Audience: PT Clinical Leaders | Value-Based Care Executives | Clinicians

Quick Summary

🧠 Exercise drives analgesia via endorphins, endocannabinoids, and BDNF-supported neuroplasticity.

🌿 Anti-inflammatory effects include lower pro-inflammatory cytokines and improved mitochondrial function.

🛌 Sleep improves modestly with exercise; combine with CBT-I when insomnia is clinically significant.

🧘 Lower resting cortisol and sympathetic tone track with better stress tolerance.

🥗 Improved insulin sensitivity and appetite regulation support weight control and lower metabolic inflammation.

🚭 Reward-system modulation makes exercise a plausible adjunct for smoking cessation.

FRIDAY -THE SYSTEMS PRESCRIPTION

Democratizing Access to Physical Therapy: Closing the Week’s Gaps

Five studies, one throughline. Monday showed that a referral is not access -three-quarters of referred patients never enter treatment. Tuesday and Wednesday showed that removing the physician-first gatekeeping step reduces costs without sacrificing outcomes, first in retrospective data and then in a randomized trial. Thursday showed that once patients do get in, exercise-centered care delivers value across pain, sleep, stress, metabolic health, and smoking behavior simultaneously. A 2024 editorial in the Brazilian Journal of Physical Therapy offers the frame that ties these findings together: physical therapy’s clinical evidence is not the limiting factor in chronic pain care. The infrastructure to deliver it equitably is.

The Week in Review: Five Signals, One Diagnosis

Chronic pain is framed in the editorial as a biopsychosocial condition shaped substantially by the social and economic conditions in which people live and work -a framing that gives Monday’s findings on distance, insurance status, and ethnicity their explanatory logic rather than treating them as isolated statistical quirks. The direct-access evidence from Tuesday and Wednesday demonstrates that removing a structural barrier -physician-first authorization -measurably improves the economics of care without harming outcomes. Thursday’s review demonstrates that what happens after access is achieved further compounds the value. Read together, the week’s evidence base doesn’t describe five unrelated problems. It describes a system in which clinical effectiveness has outpaced the delivery structure built around it.

Four Pillars for Closing the Gap

Policy and Culture: Expanding coverage and resource allocation for PT, paired with culturally sensitive, patient-centered program design, directly addresses the enabling and predisposing barriers identified in Monday’s data -insurance type, distance, and demographic disparities in uptake.

Workforce and Education: Training clinicians in communication, pain science, and lifestyle counseling -and reinforcing the therapeutic alliance and shared decision-making -protects the exercise-centered, multi-domain value described in Thursday’s review from being compressed by productivity pressures.

Technology: Scaled telerehabilitation, mobile-enabled programs, and responsibly deployed AI for education and triage extend reach to the very populations Monday’s data flagged as underserved: patients living farther from clinics and those facing scheduling or transportation constraints.

Social Networks and Open Science: Public-facing, credible communication counters harmful pain beliefs and accelerates the spread of evidence-based practice -a lever that operates upstream of all the clinical and economic findings in this week’s review, shaping whether patients seek care and what they expect from it.

What This Means for the Stakeholders in This Room

For health system executives, the week’s evidence supports a specific, sequenced investment case: fix referral-to-attendance tracking and navigation first (Monday), pilot physiotherapist-first triage in a defined population with adequate power (Wednesday), and protect visit time and dosing for active care in any value-based contract (Thursday). For payers and policymakers, the direct-access evidence -retrospective and now randomized -is strong enough to justify funding pilots and larger trials, though not yet strong enough, on its own, to justify blanket reimbursement mandates. For PT clinical leaders, the throughline is a mandate to defend exercise-centered, relationship-based care against efficiency pressures that would otherwise erode the very mechanism producing multi-domain clinical value.

Community Impact and Conclusion

The editorial’s own conclusion is worth taking seriously as a caution: isolated clinical interventions are not sufficient. A better exercise program, a shorter referral form, or a single telehealth pilot will each move the needle a little. None of them, alone, closes a 76% referral-to-attendance gap or reaches the patients furthest from care. What this week’s evidence collectively argues for is coordinated investment across policy, workforce, technology, and public communication -implemented and measured together, with attention to the specific populations shown to be falling through the cracks. The clinical case for physical therapy in musculoskeletal and chronic pain care is not in question. The infrastructure to deliver it equitably to everyone who could benefit from it is the work still ahead.

“This week’s evidence doesn’t describe five separate problems in physical therapy delivery. It describes one system where the clinical case has outpaced the infrastructure built to deliver it -and that gap is the work ahead.”

Strategic Takeaways

The referral-to-attendance gap, the direct-access economic case, and the exercise-centered clinical model are not separate initiatives -they are sequential points in the same delivery pipeline.

Direct-access evidence is strong enough to fund pilots and larger trials now; it is not yet strong enough to justify blanket reimbursement mandates.

Protecting active-care time against efficiency pressure is a value-based-care decision with measurable downstream consequences.

Durable progress requires coordinated investment across policy, workforce training, technology, and public communication -not any one lever in isolation.

Source: Núñez-Cortés, R., Lluch, E., & Cruz-Montecinos, C. (2024). Democratizing access to physical therapy to address the challenge of chronic pain. Brazilian Journal of Physical Therapy, 28, 101084. https://doi.org/10.1016/j.bjpt.2024.101084

Audience: Health System Executives | Clinical Leaders | Payers & Policymakers | PT Clinicians

Quick Summary

🌍 Chronic pain is a biopsychosocial problem shaped by social and economic conditions.

⚖️ Democratizing PT access aims to close gaps that disproportionately harm vulnerable populations.

🧭 Four pillars: Policy/Culture, Workforce/Education, Technology, Social Networks/Open Science.

💻 Telerehab, mobile tools, and responsible AI can extend reach to underserved patients.

🗣️ Clinician communication and public pain education shape whether patients seek and trust care.

🔬 Next step: implement these pillars together and evaluate outcomes, costs, and equity impact as one program.

Sources Cited This Week

Sharpe, J. A., Martin, B., Fritz, J. M., Newman, M. G., Magel, J., Vanneman, M. E., & Thackeray, A. (2021). Identifying patients who access musculoskeletal physical therapy: a retrospective cohort analysis. Family Practice, 38(3), 203–209. https://doi.org/10.1093/fampra/cmaa104

Hon, S., Ritter, R., & Allen, D. D. (2021). Cost-effectiveness and outcomes of direct access to physical therapy for musculoskeletal disorders compared to physician-first access in the United States: Systematic review and meta-analysis. Physical Therapy, 101, 1–11. https://doi.org/10.1093/ptj/pzaa201

Ho-Henriksson, C.-M., Svensson, M., Thorstensson, C. A., & Nordeman, L. (2022). Physiotherapist or physician as primary assessor for patients with suspected knee osteoarthritis in primary care – a cost-effectiveness analysis of a pragmatic trial. BMC Musculoskeletal Disorders, 23, 260. https://doi.org/10.1186/s12891-022-05201-3

Núñez-Cortés, R., Salazar-Méndez, J., & Nijs, J. (2025). Physical activity as a central pillar of lifestyle modification in the management of chronic musculoskeletal pain: A narrative review. Journal of Functional Morphology and Kinesiology, 10, 183. https://doi.org/10.3390/jfmk10020183

Núñez-Cortés, R., Lluch, E., & Cruz-Montecinos, C. (2024). Democratizing access to physical therapy to address the challenge of chronic pain. Brazilian Journal of Physical Therapy, 28, 101084. https://doi.org/10.1016/j.bjpt.2024.101084