[Purpose] To present legislation comparing direct and referred access—or other measures—to physical therapy. The focus is on the management of the most burdensome musculoskeletal disorders in terms of regulations, costs, effectiveness, safety and cost-effectiveness. [Methods] Main biomedical databases and gray literature were searched ranging from a global scenario to the analysis of targeted geographical areas and specifically Italy and the Region Piedmont. [Results] legislation on Direct Access highlights inconsistencies among the countries belonging to World Confederation for Physical Therapy. Direct Access could be an effective, safe and efficient organization model for the management of patients with musculoskeletal diseases and seems to be more effective safer and cost effective. [Conclusion] Direct Access is a virtuous model which can help improve the global quality of physical therapy services. Further studies are required to confirm this approach and determine whether the findings of the present overview can be replicated in different countries and healthcare systems.

Direct access to physical therapy (DAPT) is the patient’s ability to self-refer to a physical therapist, without previous consultation from any other professional. This model of care has been implemented in many healthcare systems since it has demonstrated better outcomes than traditional models of care. The model of DAPT mainly focuses on the management of musculoskeletal disorders, with a huge epidemiological burden and worldwide healthcare systems workload. Among the healthcare professionals, physical therapists are one of the most accessed for managing pain and disability related to musculoskeletal disorders. Additionally, the most updated guidelines recommend DAPT as a first-line treatment because of its cost-effectiveness, safety, and patients’ satisfaction compared to other interventions. DAPT was also adopted to efficiently face the diffuse crisis of the declining number of general practitioners, reducing their caseload by directly managing patients’ musculoskeletal disorders traditionally seen by general practitioners. World Physiotherapy organization also advocates DAPT as a new approach, with physical therapy in a primary care pathway to better control healthcare expenses. Thus, it is unclear why the Italian institutions have decided to recognize new professions instead of focusing on the growth of physical therapy, a long-established and autonomous health profession. Furthermore, it is unclear why DAPT is still not fully recognized, considering the historical context and its evidence. The future is now: although still preliminary, the evidence supporting DAPT is promising. Hard skills, academic paths, scientific evidence, and the legislature argue that this paradigm shift should occur in Italy.

Background:The sit-to-stand (STS) test is usually included in the clinical assessment of balance and its instrumented analysis may support clinicians in objectively assessing the risk of falling. The aim of the present study was to assess if kinetic parameters of STS collected using a force platform, with particular focus on the raising and stabilization phase, could discriminate between young and older adults. Methods: Twenty-four adults (age ranging from 18 to 65 years old) and 28 elderly adults (older than 65 years old) performed STS on a force platform. Data on ground reaction forces, sway, displacement and velocity of the center of pressure were gathered during the raising and the stabilization phases. Results: elderly subjects showed significant greater global sway (146.97 vs 119.85; p < 0.05) and a higher velocity (vs 40.03 vs 34.35 mm/s; p < 0.05) of execution of STS. Between-group comparisons highlighted a greater postural sway in the raising phase (21.63 vs 13.58; p < 0.001) and a doubled sway during the stabilization phase (12.38 vs 4.98; p < 0.001).Conclusions: The analysis of STS performed on a force platform provides further information about the age-specific pattern of STS execution. The stabilization phase of STS seems to be the more challenging for functional independent older adults and should be considered during balance assessment. Further studies are needed to confirm findings and improve generalizability of this study.

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Randomizedcontrolled trials (RCTs) evaluating individual education for patients with acute and/or subacute LBP.U DATA SYNTHESIS: Random-effects meta-analysis for clinically homogeneous RCTs. Certainty of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation approach.U RESULTS: We included 13 RCTs. There was moderate certainty evidence that individual patient education was more effective than placebo education for pain at medium term (mean difference [MD], −0.79; 95% confidence interval [CI]: -1.52, -0.07) and physical function at short term (standardized mean difference [SMD], −0.25; 95% CI: −0.47, −0.02) and medium term (SMD, −0.26; 95% CI: −0.48, −0.04), but with no clinically relevant effects. There was low-to-moderate certainty evidence that individual patient education was superior to noneducational interventions on short-term quality of life (MD, −12.00; 95% CI: −20.05, −3.95) and medium-term sick leave (odds ratio = 0.32; 95% CI: 0.11, 0.88). We found no clinically relevant betweengroup effects for any other comparison (low-to-high certainty of evidence) at any follow-up.U CONCLUSION: One or 2 hours of individual patient education probably makes little to no difference in pain and functional outcomes compared with placebo for patients with acute and/or subacute LBP. Considering its effects on other outcomes (eg, reassurance) and patients' desire for information about their condition, it is reasonable to retain patient education as part of a first-line approach when managing acute and subacute LBP.

We want to thank you for the opportunity to respond to the issues raised in the letter to the Editor of Dr. Moretti et al. [...]

Background and ObjectivesRisk of bias is a critical issue to consider when appraising studies. Generally, the higher the risk of bias of a study, the less confidence there will be that the results are valid. Considering that low back pain is recognized to have an extremely high disease burden; exercise therapy is one of the most frequently prescribed interventions for chronic low back pain (CLBP) and that most low back pain trials have methodological limitations that could bias treatment effect estimates; the objective of this study is to explore causal pathways between the sources of risk of bias and estimates of the treatment effect of exercise therapy interventions in CLBP trials.MethodsThe 249 RCTs included in the 2021 Cochrane review publication “Exercise therapy for chronic low back pain” will be included. The risk of bias will be evaluated with the Cochrane Risk of Bias 2 tool (ROB 2). Causal pathways between the exposure (risk of bias domains) and our outcomes of interest (effect sizes for pain and functional limitations) will be explored through univariable and multivariable meta-regression models. These models will be adjusted for potential confounders (sample size, trial registration, incomplete flow chart information and treatment comparisons), exploring relevant interactions within each model. Additional and sensitivity analyses will be performed to explore and test the robustness of the primary analyses.Ethics and disseminationA manuscript will be prepared and submitted for publication in an appropriate peer-reviewed journal upon study completion. We believe that the results of this investigation will be relevant to researchers paying more attention to the synthesis of the evidence to translate clinical implications to key stakeholders (healthcare providers and patients).