Temple University Employees With Musculoskeletal Conditions Receive Physical Therapy to Treat Limitations Early

Traditionally, when individuals sustain a musculoskeletal injury and require physical therapy
intervention, a referral is obtained from a physician to prescribe therapy. Currently, for
non-work related injuries, 48 out of the 50 United States are "direct access physical therapy
states" meaning a consumer can be evaluated and treated by a physical therapist directly
without physician referral. The number of direct access states is much less for work-related
injuries, with only 17 of the 50 United States practice acts permitting direct access, and of
these, most insurance companies still require a physician referral for reimbursement. A
previous systematic review of the literature on this topic suggests that requiring a referral
is associated with more drug prescriptions, more imaging ordered, and higher costs to the
patient and health care system with no advantage in health outcomes. However, the cited
studies were of low quality (i.e. below Level 1 evidence), so a high quality study with
strict experimental controls is still necessary.

This project proposes to conduct a blinded randomized controlled trial to determine if a
"direct access physical therapy portal of entry" is more effective than a "physician portal
of entry" in decreasing total episode cost and improving outcomes for individuals with a
recent onset of musculoskeletal conditions. The project's definition of musculoskeletal pain
is any "mechanical" spine or extremity pain from either a work condition (workers
compensation) or a non-work related condition. The project investigators plan to recruit
potential subjects directly from Temple University employees and supervisors. Subjects who
consent to and pass a baseline screening will be randomized to one of two groups: direct
access physical therapy management or Employee Health physician management. All PT and
physician providers will be "study providers". Subjects randomized to direct access physical
therapy will be evaluated and treated by a physical therapist. If the presentation requires
further work up, the therapist will refer the patient for imaging or specialty consult.
Subjects randomized to the Employee Health physician will receive a similar evaluation
ordering relevant work up, and if appropriate, the physician will refer the patient to a
physical therapist. Health outcomes for the two groups will be compared with a mixed-model
repeated measures analysis at 1 month after enrollment. Total episode cost and medical
utilization will be compared at one year after enrollment.

If this direct access "Temple University model" is feasible and effective for managing
compensated and non-compensated musculoskeletal conditions, it could serve as a paradigm for
other universities to implement across the United States. Furthermore, this study would be
the first data set in the literature that studied a physical therapy direct access model for
evaluation and treatment of employees with "workers-compensation" conditions in the United
States.

Inclusion Criteria:

- Temple University Employees who speak English sufficiently to understand informed
consent.

- Has a primary complaint that is potentially of neuro-musculoskeletal origin. This is
defined by a primary complaint of pain, numbness, or decreased function due to
symptoms within regions of spine, shoulder, elbow, wrist/hand pain, pelvic/SI, hip,
knee, or ankle pain, temporomandibular joint pain, or headaches. The complaint could
be work related (workers compensation) or non-work related. This definition does not
include abrasions, contusions, etc. that result in pain but do not affect the
employee's function.

- Age greater than or equal to 18 years old.

- Employee's primary complaint began ≤3 months upon initial study screening. This could
include a recent exacerbation (within ≤3 months onset) of a condition with a history
of previous episodes. If the patient reports more than one complaint, all complaints
will be addressed in the study with intervention that began within the ≤3 month
timeframe.

Exclusion Criteria:

- Met with another medical provider for advice for the condition prior to study
enrollment (including physical therapist, chiropractor, physician, surgeon,
physician-assistant, or nurse, etc.).

- Medical history of surgery for a prior episode of complaint.

- Any major psychiatric disease in their past medical history.

- Red flags cannot be ruled out during the medical screening examination (e.g., cauda
equina compression, inflammatory arthritis, malignancy, fracture, serious illness or
comorbidity). Any musculoskeletal injuries that can be managed by a physical therapist
will not be excluded (radiculopathy, potential ACL tear, peripheral nerve entrapments,
etc.)