Weekly Literature Review: The Future of Physical Therapy in Health System Reform

Welcome to our weekly literature review, where we synthesize the latest research to provide a clear, strategic overview of the forces shaping physical therapy and the broader healthcare landscape. This week, we've explored a collection of articles that, when taken together, paint a compelling picture of a profession poised to lead in musculoskeletal (MSK) care. We'll look into the persistent challenges of Evidence-Based Practice (EBP), the irrefutable case for direct access, and the emerging professional identity of the Primary Spine Practitioner.

Monday: The EBP Paradox - A Global Reality Check

Summary: Our week began with a deep dive into the systemic barriers to Evidence-Based Practice (EBP) in physical therapy. A systematic review by da Silva et al. (2015) analyzed data from over 6,000 clinicians across nine countries, revealing a universal paradox: while an overwhelming majority of physical therapists value EBP as essential for quality care, their ability to implement it is significantly hampered.

Analysis & Review: This research is crucial because it moves the conversation beyond "why EBP is important" to "why it's so hard to do." The study's findings are a roadmap for strategic leaders in allied health. The most frequently cited barriers—lack of time, limited statistical literacy, and a shortage of workplace support—are not individual failings but systemic flaws. To bridge this gap, we must invest in structured, ongoing mentorship and training that is practical and integrated into the workflow. We also need to lobby for policy changes and reimbursement models that recognize and reward the time spent on critical appraisal and evidence implementation, not just patient volume. This is a call to action for health system innovation, reminding us that EBP is a team sport that requires a supportive ecosystem to thrive.

Tuesday: Direct Access to PT - A Military Success Story

Summary: We continued our exploration by reviewing a compelling editorial from Clark et al. (2022), which argues for the expansion of direct access (DA) to physical therapy in the US civilian healthcare system by using the US military as a blueprint. The authors present robust evidence that military physical therapists (PTs) serving as primary contact providers for MSK conditions deliver superior outcomes, reduce costs, and maintain an impeccable safety record.

Analysis & Review: This editorial is a powerful piece of advocacy. The data points are not merely academic; they are a direct challenge to the status quo. The fact that military PTs outperform most medical specialties in MSK assessments and have a perfect safety record over tens of thousands of patient visits is a potent message for policymakers and payers. It dismantles the argument that a physician referral is a necessary safeguard. The military's success, which includes faster return-to-duty rates and millions in cost savings, is a compelling, real-world case study for broader civilian adoption. This research provides the kind of hard evidence that is essential for driving meaningful health policy reform, especially in an era of looming physician shortages and rising healthcare costs.

Wednesday: The Cost-Effectiveness of Unrestricted Direct Access

Summary: Building on Tuesday's post, we analyzed a nationwide retrospective cohort study by Garrity et al. (2020) that evaluated the cost and utilization of care for new-onset low back pain. The study compared outcomes in states with unrestricted direct access to PT versus those with provisional access. The findings reveal that regulatory restrictions may actually increase, not decrease, healthcare costs and utilization.

Analysis & Review: This study provides the civilian data to back up the military's anecdotal evidence. By demonstrating that unrestricted access leads to fewer physician visits, less unnecessary imaging, and reduced short-term costs, it directly addresses one of the most significant concerns of payers and health system administrators. The finding that provisional-access states, with their gatekeeping requirements, saw higher costs and utilization is a critical insight. It suggests that a small administrative hurdle can lead to a cascade of expensive and often unnecessary medical interventions. For leaders in value-based care, this study is a must-read, as it reinforces the strategic importance of empowering physical therapists to manage MSK conditions from the first point of contact.

Thursday: The Primary Spine Practitioner - A New Professional Identity

Summary: We concluded our review of direct access by looking at a forward-thinking article by Dr. Nabiha Arain (2025) that proposes a new professional identity: the Primary Spine Practitioner (PSP). This concept envisions physical therapists with advanced training in clinical reasoning, differential diagnosis, and other extended skills, who would serve as the first point of contact for patients with spine-related disorders.

Analysis & Review: The PSP concept is a natural evolution of the direct access movement. It moves beyond a discussion of what PTs can do and focuses on who they are. By formalizing this role, the profession can better articulate its value proposition to health systems, policymakers, and the public. The article highlights how this specialization would reduce the burden on primary care, streamline patient pathways, and align with modern, evidence-based care models. For our profession, this is an opportunity to solidify our identity and position ourselves as strategic partners in musculoskeletal healthcare reform.

Friday: Synthesis and Strategic Outlook

Summary: This week’s literature paints a clear picture: physical therapy is at a pivotal moment. The research demonstrates that while the profession's commitment to EBP is strong, systemic barriers hinder its full implementation. Simultaneously, robust evidence from military and civilian settings proves that physical therapists, when granted direct and unrestricted access, are safe, cost-effective, and provide superior care for MSK conditions. The concept of the Primary Spine Practitioner further refines this vision, offering a clear and actionable path for professional specialization and integration into the broader healthcare system.

Strategic Conclusion: To fully realize our potential, we must bridge the gap between our ideals and our realities. This means:

• For Clinicians and Educators: We must champion EBP by seeking out mentorship, investing in skills like statistical literacy and critical appraisal, and demanding that these competencies are prioritized in educational and professional development programs.

• For Leaders and Policymakers: We must use the powerful data on direct access to advocate for legislative and regulatory reform. This means pushing for unrestricted practice in all 50 states and working with payers to create reimbursement models that support this shift.

• For the Profession: We need to continue to define and promote advanced roles like the Primary Spine Practitioner. By doing so, we can attract and retain talent, create new professional pathways, and solidify our position as the leaders in musculoskeletal health.

Physical Therapy as Healthcare's Strategic Solution

For Healthcare Systems and Payers: Physical therapy represents the most cost-effective, evidence-based solution to the musculoskeletal care crisis. Our profession delivers measurably lower healthcare costs, reduces unnecessary procedures and imaging, and improves patient outcomes when positioned as the primary entry point for MSK conditions.

For Patients: Direct access to physical therapy means faster pain relief, fewer invasive procedures, reduced medication dependence, and better long-term functional outcomes. Patients receive expert, specialized care without the delays and complications of traditional referral pathways.

For the Healthcare Workforce: Physical therapists are uniquely positioned to lead musculoskeletal care through our combination of movement expertise, diagnostic skills, and patient-centered approach. Our profession offers the specialized knowledge and cost-effective care delivery that healthcare reform demands.

The Competitive Advantage: Unlike other healthcare disciplines adapting to value-based care models, physical therapy was designed for this environment. We are the natural leaders in preventive, non-invasive, cost-effective treatment of the conditions that drive healthcare utilization and costs.

The Bottom Line: Investing in physical therapy as primary musculoskeletal care providers isn't just good for patients—it's essential for sustainable healthcare economics. The military has proven this model works. The research confirms the cost savings. The only question is whether healthcare leaders will embrace this evidence-based solution or continue supporting more expensive, less effective traditional pathways.

Call to Action: Healthcare transformation requires leaders who combine clinical excellence with business acumen. Physical therapy professionals who commit to evidence-based practice, advanced training, and advocacy are positioning themselves—and their organizations—at the forefront of healthcare's inevitable evolution toward value-based, cost-effective care delivery.