A call to action: direct access to physical therapy is highly successful in the US military. When will professional bodies, legislatures, and payors provide the same advantages to all US civilian physical therapists?

ABSTRACT

Objectives

In 2000, the American PT Association (APTA) published its Vision statement advocating for DA (DA) to PT. This narrative review of the literature aims to identify the current state of DA in the United States (US) and compare that status to the US Military.

Methods

Initial PubMed search in the English language with keywords physical therapy (PT), physiotherapy, DA, self-referral, and primary contact from the year 2000 onwards with subsequent focused searches using keywords DA/self-referral/primary contact of physical therapists/physiotherapists on outcomes/autonomous practice/economic impact/patient satisfaction yielded 103 applicable studies on the topic. This paper excluded 40 international articles to focus on US military and civilian research.

Results

Current literature supports Physical Therapists (PTs) in an initial contact role based on patient safety, satisfaction, access to care, efficiency, healthcare utilization, and potential cost savings.

Conclusions

Despite its success in the US Military, DA to PT in the US civilians remains limited and incomplete. PTs still await unrestricted DA and privileges associated with autonomous practice including the ability to order imaging and prescribe some medications.

KEYWORDS:

• Physiotherapy, Primary Contact Providers, Advanced practice physiotherapists

Introduction

In 2000, the APTA adopted ‘Vision 2020’ outlining that ‘PT, by 2020, will be provided by PTs who are doctors of PT and who may be board-certified specialists. Consumers will have DA to PTs in all environments for patient/client management, prevention, and wellness services. PTs will be practitioners of choice in patients’/clients’ health networks and will hold all privileges of autonomous practice’ [1]. Over the past 20 years, some of Vision 2020 has been achieved, but much is still a work in progress. Since 2015, all accredited PT (PT) programs are Doctor of PT (DPT) programs in the US and, as of 2016, 34.7% of the PT workforce had entry-level DPT degrees [2,3]. Furthermore, in 2016, over 55% of the PT workforce were doctors of PT with 38.7% graduating with DPT degrees and 17.1% completing transitional-DPT programs [3]. In addition to DPT degrees becoming the standard for PTs, DA is now available in all 50 states; however, only 20 states allow for unrestricted DA [4]. With limitations or provisions on DA in 60% of states, the goal of PTs becoming the practitioner of choice for patients and an autonomous member of the health-care team has yet to be accomplished. In 2001, a survey by Snow et al. found that 67% of South Florida Residents did not know about DA to PT, but 73.4% of the 162 respondents indicated they would go to a PT for an evaluation first if covered by insurance [5]. Nearly 10 years later in another part of the US, Kearns and colleagues described the public perception of PTs as practitioners of choice [6]. In a survey of Western New York residents, the authors found that medical doctors were the first choice of treatment for 16 of 17 common conditions within the PT scope of practice [6]. For only one condition, poor posture, the first choice of treatment was not a medical doctor; instead, PTs and chiropractors were tied as the primary choice [6]. Lack of understanding of the scope of PT practice is one of many barriers PTs face as they strive for unrestricted DA. PTs must advocate for further responsibility within the health-care team, especially with ongoing changes and challenges to the medical landscape.

According to a report for the American Academy of Medical Colleges, there will be a shortage of primary care physicians between 21,400 and 55,200 by 2033 [7]. Physician office caseloads indicate musculoskeletal conditions account for 8–18% of visits [8,9]. Specifically, back/spine pain and arthritis account for 2 of the top 10 reasons for a primary care visit [10]. Since PTs ‘are movement experts who improve quality of life through prescribed exercise, hands-on care, and patient education’ [11] and management guidelines recommend exercise for back and arthritis conditions [12,13], PTs can and should treat these patients due to primary care physician shortages for patients with musculoskeletal complaints. The World Confederation for PT states that ‘PT entry-level education prepares PTs to be primary contact autonomous practitioners, able to examine/assess, evaluate, diagnose, intervene/treat, determine outcomes and discharge patients/clients without referral from other health professions or third party’ [14]. In the US military, PTs participate in a primary care role for patients with musculoskeletal conditions; however, civilian PTs as primary musculoskeletal health-care providers lack a defined role in the US health-care system. This paper focuses on the current literature discussing DA comparisons between the US military and civilian PTs (Table 1). Additional international articles will be discussed in a subsequent paper.

Table 1. United States Military and United States Civilian physical therapy health-care outcomes.

United States Military Physical Therapists
Studies	Health-care Outcomes
Childs et al. [17,18]	PTs outperform all medical specialties with the exception of Orthopedic surgeons on a standardized musculoskeletal assessment
Ross et al. [19]	PTs demonstrate better understanding of guidelines for management of LBP vs GP
Moore et al. [20]	No adverse events or licenses revoked or suspended in 40-month period
McGill [21]	PT care vs family practice group, patients were prescribed less medications (24% vs 90.5% of patients), referred for fewer radiological studies (11% vs 82% of patients), and had 50% higher return-to-work rate [56].
Moore et al. [22]	96.1% of patients seen by PTs for a first-time evaluation were returned to full or only partially limited duty
Mabry et al. [23]	PT vs FP: diagnostic imaging for 1/37 encounters vs 1/5 referred to other providers 1/52 encounters vs <1/3 visits for FP
Moore et al. [25]	Equal clinical diagnostic accuracy between PT and orthopedic specialists
Rhon et al. [26]	Case studies of PTs identifying misdiagnosed MSK diagnoses
Keil and Brown [29]	15% Referral rate from PTs for diagnostic imaging
Crowell et al. [27]	83.2% of referrals for additional imaging met the ACR guidelines for appropriate referral for MRIs or MRAs
Keil et al. [28]	91% of 108 imaging studies met ACR guidelines
United States Civilian Physical Therapists
Mintken et al. [35]	No adverse events, no serious pathologies unidentified, and no licenses or credentials revoked in 10-year period
Boissonnault and Ross [36]	74% Cases underlying pathology was missed by other health-care provider
Leerar et al. [37]	PTs documented 8/11 red flags associated with LBP over 98%
Boissonnault et al. [38]	Physicians agreed with 100% of patient-care decisions made by physical therapists
Denninger et al. [39]	DA led to fewer physical therapy treatment sessions, lower radiology costs, and lower other costs associated with care while maintaining similar patient outcomes in pain and disability
Pendergast et al. [40]	14% Fewer PT visits for DA
Badke et al. [41]	1.5 Fewer visits for DA Physician referred care: more X-ray (92%) and advanced imaging (193%) utilization than direct access via PT.
Riley et al. [42]	Pts completed an average of 6 visits for an average cost of $765.01 compared to 9.1 visits for $1169.99 for patients referred to PT with specific treatment guidelines
Fritz et al. [44]	Pts accessing care via PT first received statistically fewer imaging studies, injections, surgery consults, as well as significantly fewer surgeries when compared to physiatrists
Frogner [49]	Decreased imaging and opioid prescriptions
Kazis et al. [50]	Lower short- and long-term opioid use for patients seeing PT first
Hon et al. [43]	DA resulted in fewer PT visits, PT cost, Total health cost with no difference in functional outcomes
Fritz et al. [47]	ODI and pain better at 4-weeks, 6-month and 1-year for Early PT

PTs, physical therapists; LBP, low back pain; GP, general practitioner; MSK, musculoskeletal; FP, family practice; ACR, American College of Radiology; DA, direct access; ODI, Oswestry Disability Index; MRI, magnetic resonance imaging; MRA, magnetic resonance angiography.

Methods

A PubMed search was completed with a combination of the following terms: PT, physiotherapy, DA, self-referral, and primary contact. Time-frame was restricted from 2000 when the APTA first established Vision 2020 and searches began in July 2020 and ended in February 2021. Articles were filtered for English-language only. The primary goal of the search was to establish the current state of practice in countries with DA. Research articles pertaining to DA/self-referral/primary contact of PTs/physiotherapists on outcomes/autonomous practice/economic impact/patient satisfaction for musculoskeletal conditions OR comparisons between PTs and physicians for patient care and musculoskeletal knowledge were considered to meet the search criteria.

The initial search yielded 3452 articles with further title analysis narrowing the number of articles pertaining to the topic to 204 with 140 unique articles. Once duplicates were removed, two researchers completed a further analysis of abstracts to determine relevance to the topic. Consensus from both researchers was achieved before removing an article from the list. Once completed, 74 articles remained. Using the reference lists from these 74 papers in addition to the ‘cited by’ and ‘similar articles’ recommendations from PubMed, an additional 29 articles met the initial criteria for a total of 103 research articles. To further focus on the US military and civilian populations 40 international articles were excluded.

Physical therapists in the United States military

In the US, PTs in the military have primary care roles in the management of patients with neuromusculoskeletal (NMS) conditions. To meet demands for primary care and lack of orthopedic surgeons, the US army implemented regulations in 1972 allowing PTs to act as non-physician providers for patients with NMS conditions [15]. These regulations required a supervising physician, similar to regulations for physician assistants, for PTs performing primary NMS evaluations [15]. Additionally, PTs typically participate in a 6-month training program that can include additional coursework in diagnostic imaging, medical screening and pharmacological management prior to receiving full credentialing status within the health-care facility where the clinician works [16]. Recertification of credentials typically occurs on a 2-year cycle and once granted, PTs are qualified to refer patients for appropriate imaging, refer patients to other medical specialties, restrict work and training, and in some instances prescribe NSAIDs and other analgesic medications [16]. Since its inception in 1972, the role of PTs as primary care providers in the military has been extensively studied and data support in a primary care role.

Physical therapists in the military: knowledge and safety

In order to support the role of PTs as first providers, data must show that PTs have equivalent, if not better than physicians, knowledge on the appropriate management of patients with NMS conditions. Additionally, PTs must provide safe, high-quality care while managing health-care resources responsibly. In two studies [17,18], Childs et al. compared PT knowledge of musculoskeletal conditions to that of other providers in the health-care team. The researchers found that PTs performed better than all other specialty providers with the exception of orthopedic surgeons on a standardized musculoskeletal examination. Additionally, PTs with specialty certifications in orthopedics and sports performed better than their peers [17]. Childs et al. [18] also assessed whether participants in the US Army-Baylor DPT program as well as participants in the annual 2-week COL Doug Kersey Neuromusculoskeletal Evaluation Course performed better than their peers and found that in both scenarios, PTs performed better than their peers. In all instances, PTs outperformed all other medical specialists and PCPs with the exception of orthopedic surgeons supporting PTs role as primary care providers for NMS conditions requiring conservative care. Furthermore, in an analysis of management of simple low back pain knowledge, Ross et al. [19] determined that PTs had significantly better knowledge regarding management compared to PCPs. PTs recommended the correct drug treatments in accordance with accepted Clinical Practice Guidelines and more frequently believed in the importance of patient encouragement and education in the long-term management of this condition. In addition to demonstrating expertise to manage patients with NMS conditions, PTs provide safe care. In a retrospective analysis over the course of 40 months in 25 military health-care sites [20], PTs treated 50,799 patients via DA and completed 472,013 visits. In that time frame, there were no documented adverse effects or revocation of credentials or licenses for disciplinary actions or litigation cases filed against PTs indicating a high level of safety and appropriate differential diagnosis skills [20]. PTs display expert understanding of neuromusculoskeletal pathologies and provide safe care. With continually rising health-care costs, safe care from providers with the requisite knowledge base is a foundational component to establishing efficient health-care delivery pathways. Providers must also effectively manage health-care resources. Based on US military research [21–33], PTs in a primary NMS role provide effective and efficient use of health-care resources.

Physical therapists in the military: effectiveness and cost

In a retrospective medical chart review [21], McGill compared the effectiveness of PTs serving as primary care musculoskeletal providers to family practice providers in a deployed combat location in Afghanistan. McGill found that patients who received direct PT care compared to care from the family practice group were prescribed less medications (24% vs 90.5% of patients), referred for fewer radiological studies (11% vs 82% of patients), and had 50% higher return to work rate [21]. Similarly Moore et al. [22], in a descriptive analysis of the PT role within the military at Combat Support Hospitals from 2004 to 2010, determined that 96.1% of patients seen by PTs for a first-time evaluation were returned to full or only partially limited duty. Further assessment revealed that, had these patients not been evaluated by PTs first, 17.7% would have been medically evacuated at an estimated cost of over 28 million dollars. Additionally, PTs assigned to Brigade Combat teams returned 97.9% of patients to duty instead of an estimated 30.9% of those patients being evacuated had they not seen a PT first [22]. In a more recent comparison of PT vs family practice (FP) care, Mabry et al. [23] analyzed referral rates, finding that PTs ordered diagnostic imaging for 1/37 encounters compared to 1/5 for FP and referred to other providers only 1/52 encounters versus 1/3 visits for FP. Although not specifically identified, fewer referrals to both imaging and additional health-care providers likely result in lower health-care costs. Unfortunately, in the US, few civilian PTs have the ability to refer for medical imaging and to other health-care providers, leading to one of the greatest potential barriers to PT DA to care.

Although most civilian PTs in the US do not have the ability to refer for imaging, studies within the US Military support the ability and knowledge of PTs to have this capability. As of 2014, in a survey of 155 PT (152 DPT) programs across the US, 98.1% of PT programs included imaging in their curricula with 96.7 programs testing students on imaging content [24]. PTs have at minimum a foundational understanding of imaging. Moore et al. [25] evaluated PTs, orthopedic surgeons, and non-orthopedic providers’ clinical diagnostic accuracy for MRIs of patients with musculoskeletal injuries and determined equal accuracy between PTs and orthopedic surgeons and significantly better accuracy with PTs (74.5%) versus non-orthopedic providers (35.4%). Rhon et al. [26] provide three specific case examples of PTs referring for additional imaging identifying fractures that had gone undetected by other health-care providers further emphasizing the importance of PTs referring capabilities. In further support for PTs providing appropriate referral for imaging, Crowell et al. [27], in a retrospective observational study, found that 83.2% of PT referrals for additional imaging met the American College of Radiology (ACR) guidelines for appropriate referral for MRIs or MRAs. Similarly, Keil et al. [28] identified 91% of 108 imaging studies met ACR guidelines in a 5-year retrospective practice analysis at an academic medical center and all studies were reimbursed by insurance. Keil and Brown [29] determined a 15% referral rate for imaging for patients accessing PT via DA and again 100% reimbursement for these imaging studies further supporting PTs appropriately managing health-care resources.

In 2013, Kale et al. [30] identified ordering radiographs for back pain as an overuse quality indicator contributing to the rising costs of health care Additionally, Lehnert and Bree [31] determined that 26% of medical images ordered are inappropriate with 53% inappropriate referral rate for CT scans, and 35% inappropriate referral rate for MRI. Furthermore, Flynn et al. [32] identified a number of harmful effects associated with the inappropriate use of lumbar spine imaging including radiation exposure, increased risk of surgery, and poor patient labeling leading to lower self-rated general health, lack of patient understanding, and poorer outcomes. Fortunately, the role of diagnostic imaging within PT is beginning to change within the US with some states incorporating language within the PT practice act that would indicate the ability of providers to refer for imaging. Both the District of Columbia and Wisconsin Boards of PT have provided rulings confirming the right of the Physical Therapist to refer for additional imaging [33]. The evidence illustrates PTs have the appropriate knowledge and understanding of imaging to support its role within the DA realm of PT. Currently, most civilian PTs in the US lack the requisite patient DA and health-care provider privileges to act in a primary care role similar to PTs in the US military.

Civilian physical therapists in the United States

PTs in the US military have practiced via DA since 1972¹⁵; however, DA to civilian PTs is a more recent development since the declaration of PTs being ‘practitioners of choice in patients’/clients’ health networks and will hold all privileges of autonomous practice’ in the APTA Vision 2020 statement 20 years ago [1]. As of 2015, all PT programs are doctoral programs and DA is allowed, to some extent, in all 50 states [2,4]. Through the course of its implementation, many researchers have evaluated the safety, cost, resource utilization, and effectiveness of PT provision of DA care (Table 2).

Table 2. Advantages of the US Military and US Civilian Physical Therapy Profession.

	Physician Comparison/Physical Therapists Knowledge	Cost-Effectiveness	Patient Outcomes	Resource Utilization	Safety
US Military Physical Therapists	17–19, 25, 26	21,22		21,23,26–29	20,26
US Civilian Physical Therapists		39,42–44,48	45–47	40–42,44,48–50	35–38

Numbers represent the references in the manuscript. US, United States.

Civilian physical therapists: knowledge and safety

As an autonomous member of the health-care team, PTs can and do provide a safe alternative entry point for patients with neuromusculoskeletal conditions. An important argument for PTs acting as primary care providers is the ability to accurately identify red and yellow flags and to determine when PT care is inappropriate and when referrals to other members of the health-care team are warranted. In an analysis of 55 DPT programs, Young et al. [34] reported that students spent an average of 67.2 hours of time learning musculoskeletal differential diagnosis. Programs either presented this topic in a stand-alone course or incorporated this information throughout the DPT curricula. From the foundational education in PT school on differential diagnosis, practicing PTs demonstrate appropriate decision-making for safety in patient care. In a 10-year retrospective analysis of 12,972 DA patients in a University Health Center, Mintken et al. [35] determined that there were no adverse events, no serious pathologies unidentified, and no licenses or credentials revoked or suspended via the Colorado PT board. Furthermore, Boissonnault and Ross [36] provide numerous examples of timely and accurate PT management of patients with underlying medical conditions. In 74% of the cases identified, patients had been referred to PT by physicians who had missed the underlying pathology [36]. Specifically for low back pain (LBP), Leerer et al. [37], in an analysis of red flag identification in patients with LBP, concluded that PTs documented 8/11 red flags associated with LBP over 98% of the time. Consistently inquiring about and documenting red flags for patients with LBP and other musculoskeletal conditions allows PTs to identify patients that are appropriate for PT care or in need of referral to other health-care providers. In an administrative case report analyzing the implementation of DA in an academic medical center, researchers found that physicians agreed with 100% of patient-care decisions made by PTs [38]. In this study by Boissonnault et al, in addition to DA for patients, PTs could refer patients for imaging and to other medical providers. The success of the program led to its implementation in all PT outpatient clinics within that medical system [38]. PTs prioritize patient safety in every interaction, assessment, and treatment with patients. DA to PT does not compromise patient safety and in numerous cases, PTs identify underlying medical conditions overlooked by other health-care providers.

Civilian physical therapists: effectiveness and cost

DA to PT is safe for patients and it also offers multiple benefits to the overall quality of health care the USA. Denninger et al. [39], in a retrospective analysis of insurance claims for patients accessing PT via DA versus physician referral discovered a significant decrease in cost for patients accessing treatment via DA. Data illustrated that patients accessing care via DA had fewer PT treatment sessions, lower radiology costs, and other lower costs associated with care while maintaining similar patient outcomes in pain and disability [39]. Similarly, Pendergast et al. [40] determined that patients accessing PT via DA completed 14% fewer PT visits and patients in the study by Badke et al. [41] received 1.5 fewer PT visits on average. Patients referred to PT with nonspecific musculoskeletal diagnoses in the study by Riley et al. [42] completed an average of 6 visits for an average cost of $765.01 compared to 9.1 visits for $1169.99 for patients referred to PT with specific treatment guidelines. More recently, in a systematic review by Hon et al., data showed that DA resulted in fewer PT visits, lower PT cost, and lower total health cost with no difference in functional outcomes [43]. Published research indicates that PTs, when responsible for directing patient evaluation and treatment, manage patient care more efficiently and cost-effectively compared to traditional physician-directed care. Decreased PT visits providing potential cost savings further support DA to PT as an improvement to the current health-care system in the US.

Receiving musculoskeletal care with a physical therapist via DA reduces PT visits and costs. In addition, earlier access to PT reduces utilization of additional health-care resources, leading to decreased downstream costs. Fritz et al. [44], comparing the differences in health-care utilization between the first provider a patient consults for acute low back pain (LBP), found that patients accessing care via PT first received statistically fewer imaging studies, injections, surgery consults, as well as significantly fewer surgeries when compared to physiatrists. In fact, none of the patients in the PT-first group underwent surgery for their LBP during the follow-up time of the study. In related studies, Fritz et al. [45–47] determined that early access to PT services led to decreased likelihood of advanced imaging, fewer additional physician visits, major surgery, lumbar spine injections, and opioid medications while improving patient outcomes and quality of life. Additionally, costs for care were an average of $2736.23 lower when receiving early PT [48]. Badke et al. [41], in an analysis of a hospital-based DA program for spine and sport PT, also reported more radiograph (92%) and advanced imaging (193%) utilization for patients receiving physician referred care. Meanwhile, Frogner et al. [49], in an analysis of commercial health insurance claims data from 2009 to 2013, found that patients who received PT care first received fewer imaging studies as well as decreased rates of opioid prescriptions. Kazis et al. [50] evaluated the relationship between early and long-term opioid use with initial health-care provider and reported an 85% decrease in early use as well as a 73% decrease in long-term opioid use with patients who received PT care first for their acute LBP. Although strictly not true DA, other authors [51–56] have argued that early access to PT care resulted in fewer injections [51,52], surgeries [48,51,52], additional physician visits [48,51], opioid prescriptions [48,52,53], less advanced imaging [48,52,53], and fewer emergency department visits [52]. By promoting DA to PT in the US, patients will have earlier access to high-quality care. DA to PT is safe, efficient, and provides reduced health-care resource utilization and costs.

Conclusion

PTs are important members of the multidisciplinary health-care team, especially for patients with musculoskeletal conditions. The US military provides a successful framework utilizing PTs in DA/primary care roles for patients with musculoskeletal conditions. The current literature supports PTs in this initial contact role based on patient safety [20,35,37], satisfaction [56,57], access to care/efficiency [57], health-care utilization [21,23,40,41,49,54,58] and potential cost savings [39,43,46,48,54,55,58]. Despite a long history of DA within the US military, the US is delayed in meeting the APTA ‘Vision 2020’ for DA and an autonomous role for PTs. Currently, only 40% of states in the US allow unrestricted DA [4] and PTs do not ‘hold all privileges of autonomous practice’ in any state outside of the US military.

In comparing patients in states with unrestricted DA versus provisional DA, Garrity et al. [54] concluded that less restrictions on DA to PT were associated with reduced physician visits, radiographic imaging, and cost of care. In addition, several recent systematic reviews provide consistent support for DA to PT as an alternative to physician-led care for patients with musculoskeletal conditions [55–58]. These reviews indicate DA to PT is as safe as typical care for musculoskeletal conditions with no increase in adverse events [55–58]. In addition to being as safe as typical care, Ojha et al. concluded that DA may lead to decrease in cost and improved outcomes for patients [55]. Whereas Demont et al found weak to moderate quality evidence for DA PT providing better outcomes for disability and quality of life but not pain for patients with musculoskeletal conditions [57]. Furthermore, Demont and colleagues, using the Oxford Centre of Evidence-Based Medicine recommendation, indicated Grade B recommendations for decreased waiting times, decreased primary care physician visits after initial PT visit, pharmacological treatments/prescriptions, treatment compliance, health costs, and patient satisfaction for DA [57]. In contrast, Marks et al. found no significant change to patient health outcomes and inconsistent changes in health-care resource utilization with substituting physical therapist for physicians in managing patients with musculoskeletal conditions [56]; however, Marks et al. indicate diagnostic and management decisions are similar between PTs and orthopedic surgeons and patient satisfaction is equivalent or higher when seeing a PT for musculoskeletal condition [56]. In a recent systematic review, Babatunde et al. indicated that health-care costs, utilization and work absence may be improved with the same safety for patients with musculoskeletal conditions accessing care through PT DA, but there was no difference with usual physician-led care for pain and function outcomes [58]. The literature at this time supports DA to PT as a safe alternative for musculoskeletal care that is satisfactory to the patient with less clear benefits, but unlikely to be detrimental, for health-care outcomes, resource utilization and costs.

Future considerations

As previously stated, the US will have a shortage of primary care physicians of 21,400 to 55,200 by 2033 [7]. In contrast, the APTA reports, in a workforce analysis, a likely surplus of 25,235 PTs by the year 2030 [59]. With a surplus of PTs, who have the requisite skills to act as initial-contact health-care providers, and a shortage of primary care physicians, an opportunity exists in the US to better match care for patients with musculoskeletal condition to qualified providers. Many lessons and changes will be derived from the ongoing COVID-19 pandemic regarding the US health-care system. One of these lessons should be the need for improved care pathways for patients. Specifically, the health-care system should allow patients with medical conditions to seek care from medical providers and for patients with non-medical musculoskeletal conditions to be able to access musculoskeletal care with PTs. As indicated in several studies [24,25,28,37], initiating care for musculoskeletal conditions with a PT may lead to reduce health-care utilization. By reducing the use of health-care resources by patients with musculoskeletal conditions, the availability of these resources will increase for patients with other medical conditions. In order to have the greatest impact on improving access to the appropriate care pathways for patients with musculoskeletal and medical conditions, PTs will need to gain unrestricted DA and hold autonomous privileges as musculoskeletal providers. This should include referral privileges for imaging and some medications. How this is implemented and the necessary training will have to be determined; however, the US military provides an example to implement changes needed to allow PTs to become primary care providers for patients with musculoskeletal conditions. By working toward these changes, the PT profession could achieve the goals of becoming providers of choice through DA as an autonomous member of the health-care team, for the benefit of the public. Successful implementation of nationwide DA for PTs will require concerted advocacy efforts by the APTA and affiliated state chapters and sections. The APTA educational and advocacy efforts must continue to be directed at federal and state legislators, the Centers for Medicare & Medicaid Services (CMS) and health insurance companies.

Author statement

All authors have materially participated in the research, data analysis, and/or article preparation.

Competing interests

All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare no support from any organization for the submitted work; no financial relationships with any organizations that might have an interest in the submitted work in the previous 3 years; no other relationships or activities that could appear to have influenced the submitted work.

Additional information

Funding

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.