Authors’ reply to: “Comments on: Impact of direct  access on the quality of primary care musculoskeletal  physiotherapy: a scoping review from a patient,  provider, and societal perspective”

Erik Cattrysse; Jona Van Den Broeck; Robin Petroons; Amber Teugels; Aldo Scafoglieri; Emiel van Trijffel

doi:10.33393/aop.2025.3666

Authors

Erik Cattrysse Experimental Anatomy Research Group (EXAN), Department of Physiotherapy, Human Physiology and Anatomy (KIMA), Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel, Brussels - Belgium https://orcid.org/0000-0003-4325-9576
Jona Van Den Broeck Experimental Anatomy Research Group (EXAN), Department of Physiotherapy, Human Physiology and Anatomy (KIMA), Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel, Brussels - Belgium
Robin Petroons Experimental Anatomy Research Group (EXAN), Department of Physiotherapy, Human Physiology and Anatomy (KIMA), Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel, Brussels - Belgium
Amber Teugels Experimental Anatomy Research Group (EXAN), Department of Physiotherapy, Human Physiology and Anatomy (KIMA), Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel, Brussels - Belgium
Aldo Scafoglieri Experimental Anatomy Research Group (EXAN), Department of Physiotherapy, Human Physiology and Anatomy (KIMA), Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel, Brussels - Belgium https://orcid.org/0000-0002-9692-9513
Emiel van Trijffel Experimental Anatomy Research Group (EXAN), Department of Physiotherapy, Human Physiology and Anatomy (KIMA), Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel, Brussels - Belgium and Ziekenhuisgroep Twente, ZGT Academy, Almelo - Netherlands https://orcid.org/0009-0008-9816-480X

DOI:

https://doi.org/10.33393/aop.2025.3666

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Thank you for your detailed reading of our scoping review titled “Impact of direct access on the quality of primary care musculoskeletal physiotherapy: a scoping review from a patient, provider, and societal perspective.” We appreciate the critical engagement and the opportunity to respond to the points raised in both your letter and the accompanying commentary.

It is acknowledged that careful assessment of study selection and quality is fundamental in any review process. While scoping reviews differ from systematic reviews in their objectives and methodology, we recognize the importance of ensuring methodological rigor and transparency. The concern regarding the perceived low impact or potentially predatory nature of the included studies warrants clarification. Of the five systematic reviews incorporated in our study, four were published in Q1-ranked journals and one in a Q2 journal. The single studies were primarily drawn from Q2 and Q3 journals, with one published in a Q1 journal. While there was variation in study quality—as assessed using the ROBIS tool—this was transparently reported and critically appraised in the review. As a scoping review, our objective was to map the available evidence on direct access (DA) in musculoskeletal physiotherapy rather than to assess intervention effectiveness through meta-analysis. The application of PRISMA-ScR guidelines facilitated comprehensive and transparent reporting, including limitations inherent in the included literature.

Regarding the diagnostic role of physiotherapists and the issue of patient safety, we share your view that diagnosing musculoskeletal disorders (MSKDs) is a complex and critical task requiring appropriate training. Our intention was not to suggest that physiotherapists replace physicians in this role. Instead, our review sought to describe how DA is currently implemented in different contexts, where physiotherapists typically operate within well-defined scopes of practice and often in collaboration with medical professionals. While red and yellow flags are indeed not diagnostic tools in themselves, we referenced them as part of structured screening approaches used in clinical reasoning. This aspect of practice was explored in several studies we included, and we appreciate the opportunity to clarify this point.

The issue of heterogeneity in training and healthcare systems was also addressed in our discussion. We acknowledge that such variability limits the generalizability of findings and emphasized this point by cautioning against broad extrapolation. The review aimed to synthesize and present the current body of evidence on DA while highlighting the importance of contextual adaptation in clinical and policy applications.

On the subject of regulatory frameworks, we agree that effective governance is crucial to ensuring patient safety and professional accountability. While an in-depth evaluation of regulatory mechanisms fell outside the scope of our review, the importance of professional oversight and interprofessional collaboration was noted, and World Physiotherapy was cited as a global body exemplifying these principles. This remains a key area for further investigation.

Concerns regarding the paucity of comprehensive economic evaluations and limited safety data are well-founded. Our findings similarly indicated a lack of robust data in these domains. Consequently, the review called for more rigorous studies, particularly those involving health economic analyses and systematic monitoring of adverse outcomes, in order to inform policy and practice more effectively.

In summary, we acknowledge the value of continued scholarly dialogue in this evolving field. While our scoping review aimed to map the current state of knowledge regarding DA in MSK physiotherapy, it also identified critical gaps and areas for further inquiry. Your feedback contributes meaningfully to that process, and we thank you for your engagement.

On behalf of the authors.