Should PTs Be the First Provider for Musculoskeletal Pain?

In this episode, host Dr. Nick Rainey is joined by Dr. Bremen Abuhl and Dr. Dallas Ehrmantraut to discuss their 2025 Physical Therapy Journal article, “First Contact Physical Therapy Compared to Usual Primary Care for Musculoskeletal Disorders: A Systematic Review and Meta-Analysis of RCTs.” The conversation explores whether physical therapists should serve as the first point of contact for patients with musculoskeletal disorders and how first contact PT compares with usual primary care. Dr. Abuhl and Dr. Ehrmantraut discuss their findings, including reduced imaging utilization, reduced prescription medication utilization, and similar clinical outcomes for pain, disability, and health-related quality of life. They also unpack the terminology around direct access, first contact PT, and primary care PT, and explain why direct triage models may offer a more efficient pathway for patients. The episode also addresses real-world implementation barriers, including reimbursement models, state scope-of-practice variation, imaging privileges, medication prescribing, stakeholder buy-in, and the need for PTs to step confidently into first contact roles. Key Takeaways 01. First contact PT is not the same as direct access. 02. Direct access means patients can choose PT without referral. First contact PT means the PT is the first provider evaluating the patient for that episode of care. 03. The study found lower healthcare utilization. 04. First contact PT was associated with 45% less imaging and 71% less prescription medication utilization compared with usual primary care. 05. Clinical outcomes were similar. 06. Pain, disability, and health-related quality of life outcomes were statistically similar between first contact PT and usual primary care. 07. Less imaging is not automatically the goal. 08. The more important question is appropriate utilization: avoiding both overuse and underuse. 09. Implementation is a system problem. 10. Scope of practice, reimbursement, stakeholder buy-in, state law, and health system workflows all influence whether first contact PT can work. 11. Direct triage may be the stronger model. 12. Compared with warm handoffs, direct triage allows patients with appropriate MSK presentations to start with PT as the first provider. 13. PTs need to be ready for real-world first contact care. 14. That includes identifying red flags, determining urgency, ordering or recommending imaging when appropriate, and referring to the right provider when needed. Chapters: 00:00 — Welcome and guest introductions 01:17 — Dr. Bremen Abuhl’s path into first contact PT research 03:13 — Dr. Dallas Ehrmantraut’s clinical spark for the topic 06:16 — Overview of the PTJ systematic review and meta-analysis 09:52 — Direct access vs first contact PT vs primary care PT 13:15 — Global evidence and limited U.S.-based RCTs 16:24 — Imaging findings and appropriate utilization 20:37 — Medication utilization findings 23:27 — Clinical outcomes: pain, disability, and quality of life 25:20 — Study limitations and downstream utilization 27:13 — Why longer-term outcomes matter 31:15 — Risk of bias and crossover between groups 33:36 — U.S. system barriers to first contact PT 36:37 — Reimbursement, payer models, and stakeholder concerns 40:45 — Direct triage vs warm handoff models 44:15 — Scope of practice and state-level barriers 46:08 — Real-world safety, red flags, and PT decision-making 48:01 — Call to action for physical therapists 50:06 — Closing thoughts