Weekly Physical Therapy Literature Review

Physical therapy care continues to evolve, with new research shedding light on patient behaviors, treatment outcomes, and healthcare utilization patterns. This week's literature review examines five recent studies that collectively paint a picture of both challenges and opportunities in musculoskeletal care delivery.

The No-Show Crisis: A Hidden Healthcare Inefficiency

A concerning finding emerges from recent research examining physical therapy attendance rates across the United States. According to a comprehensive study analyzing data from 828 clinics across 26 states, 73% of patients with musculoskeletal conditions missed at least one physical therapy appointment during their treatment episode (Bhavsar et al., 2021). This statistic represents more than just scheduling inconvenience, it signals a fundamental inefficiency that may be undermining the delivery of evidence-based care.

The disparities in no-show rates reveal troubling patterns. Patients with Medicaid insurance had an 85% no-show rate, while those with Workers' Compensation showed a 79% rate, both significantly higher than Medicare or commercial insurance holders. Young adults aged 18-44 demonstrated the highest no-show rate at 78%, suggesting that traditional healthcare delivery models may not be meeting the needs of working-age Americans.

Perhaps most telling was the finding that previous cancellation history served as the strongest predictor of future no-shows, a pattern that suggests some patients may be struggling with systemic barriers to care rather than simple scheduling conflicts.

What Actually Works: Evidence from Israeli Clinics

While attendance challenges persist, research from Israel's outpatient physical therapy system offers hope about what drives successful outcomes. A large observational study following 22,019 patients across 54 clinics identified several key factors associated with better functional outcomes (Deutscher et al., 2009).

Patient compliance with self-exercise programs and therapy attendance emerged as crucial predictors of success, as did the use of therapeutic exercise and manual therapy. Interestingly, patients who completed three or more functional assessments during their care episode also achieved better results, suggesting that ongoing measurement and adjustment of treatment plans may be critical.

The research also revealed concerning disparities: women generally had worse outcomes than men, and certain interventions like electrotherapy for pain management and therapeutic ultrasound for shoulder problems were associated with poorer results. These findings challenge some commonly used treatment approaches and highlight the need for more personalized, evidence-based care protocols.

The Revolving Door Phenomenon

Perhaps one of the most significant challenges facing the physical therapy system is the pattern of recurrent care. New research reveals that 14% of patients return for additional episodes of physical therapy, often for the same or related conditions (George et al., 2021). This "revolving door" pattern raises important questions about the durability of initial treatment outcomes.

The study identified several risk factors for recurrent care, including workers' compensation or Medicare insurance, arthritis, post-operative status, and being in the 44-64 age range. Patients reporting night sweats or night pain were also at higher risk for returning to therapy.

While some recurrence may be expected for chronic conditions, these patterns suggest opportunities for improving initial care quality and developing better strategies for long-term condition management.

The Self-Referral Revolution

One promising development in healthcare access is the growing availability of direct-access physical therapy, which allows patients to seek care without a physician referral. Qualitative research with 32 healthcare workers in South Carolina reveals distinct characteristics between patients who self-refer versus those who seek provider referrals (Alshareef et al., 2023).

Self-referred patients typically possessed three key attributes: knowledge of direct-access programs, skepticism about pharmaceutical interventions, and positive prior experiences with physical therapy. These patients viewed physical therapy as a first-line treatment rather than a last resort, often assuming that physicians would eventually recommend it anyway.

In contrast, patients who sought provider referrals often lacked awareness of direct-access options, preferred quick pharmaceutical fixes, or needed physician reassurance to rule out serious conditions. These findings suggest that patient education about direct-access options could significantly improve care efficiency and reduce costs.

The Pain Priority Problem

Perhaps the most troubling finding comes from research examining how patients' treatment priorities affect their long-term healthcare utilization. A study of 246 patients identified three distinct groups based on their stated treatment priorities, with concerning outcomes for those focused solely on pain reduction (Zeppieri Jr. et al., 2021).

Patients in the "Pain Important" subgroup—those who prioritized pain relief above functional improvement, showed dramatically higher rates of additional healthcare utilization after completing physical therapy. Specifically, they were 2.47 times more likely to seek additional care, 9.45 times more likely to use opioids, 4.09 times more likely to receive injections, and 5.10 times more likely to undergo surgery.

This finding suggests that patients who view pain reduction as the primary goal may be setting themselves up for ongoing healthcare needs and potentially more invasive interventions. It underscores the importance of education about the multifaceted nature of musculoskeletal recovery, which includes functional improvement alongside pain management.

Implications for Healthcare Policy and Practice

These studies collectively highlight several critical areas for healthcare system improvement. The high no-show rates, particularly among vulnerable populations, suggest that traditional appointment-based care models may need fundamental restructuring. Telemedicine and flexible scheduling options could address some of these barriers.

The evidence supporting certain treatment approaches over others calls for more rigorous implementation of evidence-based protocols, potentially moving away from commonly used but less effective interventions like electrotherapy and therapeutic ultrasound.

The recurrent care patterns indicate a need for better initial treatment protocols and long-term management strategies, particularly for high-risk populations. This might include extended follow-up programs or integration with primary care for ongoing monitoring.

Finally, the findings about patient priorities and outcomes suggest that healthcare providers need to carefully manage patient expectations, emphasizing functional improvement alongside pain relief to potentially reduce long-term healthcare utilization and improve overall outcomes.

As healthcare costs continue to rise and musculoskeletal conditions become increasingly prevalent, these insights offer valuable guidance for creating more effective, efficient, and patient-centered care delivery systems.

References

Alshareef, N., Cozad, M., Macauda, M., Ostermann, J., & Thigpen, C. (2023). Patient attitudes and beliefs associated with self-referral to physical therapy for musculoskeletal complaints: A qualitative study. BMC Health Services Research, 23, Article 80. https://doi.org/10.1186/s12913-022-08989-x

Bhavsar, N. A., Doerfler, S. M., Giczewska, A., Alhanti, B., Lutz, A., Thigpen, C. A., & George, S. Z. (2021). Prevalence and predictors of no-shows to physical therapy for musculoskeletal conditions. PLOS ONE, 16(5), e0251336. https://doi.org/10.1371/journal.pone.0251336

Deutscher, D., Horn, S. D., Dickstein, R., Hart, D. L., Smout, R. J., Gutvirtz, M., & Ariel, I. (2009). Associations between treatment processes, patient characteristics, and outcomes in outpatient physical therapy practice. Archives of Physical Medicine and Rehabilitation, 90(8), 1349–1363. https://doi.org/10.1016/j.apmr.2009.02.005

George, S. Z., Giczewska, A., Alhanti, B., Lutz, A. D., Shanley, E., Thigpen, C. A., & Bhavsar, N. A. (2021). Predicting recurrent care seeking of physical therapy for musculoskeletal pain conditions. Pain Medicine, 22(8), 1837–1849. https://doi.org/10.1093/pm/pnab154

Zeppieri Jr, G., George, S. Z., Bialosky, J., & Lentz, T. A. (2021). Patient‐centered outcomes: Domain importance predicts health care use following physical therapy. PM&R, 14(9), 1044–1055. https://doi.org/10.1002/pmrj.12680