Pattern of Direct Access and Patient Self-Referral to Physical Therapy in Pakistan: Implications for the Profession

Abstract

Background: Direct access and self-referral in physical therapy have demonstrated significant benefits in high-income countries, yet remain underexplored in lower-middle-income settings like Pakistan. The lack of national legislation and limited stakeholder engagement present a major barrier to system-wide implementation, creating a critical gap in evidence around readiness, feasibility, and professional perspectives. Objective: This study aimed to evaluate the current status of self-referral and direct access practices among physical therapists in Pakistan, examining the regulatory environment, professional competency, stakeholder support, and perceived barriers and facilitators to identify opportunities for policy reform and service improvement. Methods: A cross-sectional observational study was conducted involving licensed physical therapists across Pakistan (n = 95). Participants were recruited through national professional networks and selected via non-probability purposive sampling. Inclusion criteria were active clinical practice and valid licensure, with exclusion of non-practicing or non-consenting individuals. Data were collected using a structured electronic questionnaire assessing practice permissions, service models, perceived barriers, and facilitators. Ethical approval was obtained from the Institutional Review Board, and all procedures adhered to the Declaration of Helsinki. Descriptive and inferential statistics, including Chi-square tests and odds ratios, were calculated using SPSS version 25.0 to explore associations between stakeholder support and reported barriers. Results: A total of 95 physical therapists participated, with 100% confirming autonomy in assessment, diagnosis, treatment, and referral, despite the absence of formal legislation. Self-referral was available to 86.3% of patients in private settings, while no such access existed in the public sector. Stakeholder support varied, with strong endorsement from PT organizations (95.8%) and the public (73.7%), but minimal support from physicians (3.2%). Political support was significantly associated with fewer reported barriers (p = 0.020; OR = 0.30, 95% CI: 0.10–0.89). Educational preparedness was high, with 90.5% agreeing that entry-level training sufficiently prepared graduates for independent practice. Conclusion: Although direct access is functionally practiced in the private sector, systemic implementation in Pakistan is hindered by legislative gaps and limited interprofessional support. Strengthening stakeholder alliances and establishing policy frameworks based on existing competency and service readiness can enhance the accessibility and efficiency of physical therapy services in Pakistan’s evolving healthcare landscape.