Direct Access to Physiotherapy for musculoskeletal disorders: a Scoping Review on clinical effectiveness, costs and safety

Autori

Di Dio Antonio [Università di Messina, Messina, Italia]

Cavallaro Filippo [Università di Messina, Messina, Italia]

Sposito Francesca [Università di Messina, Messina, Italia]

Di Marco Giada [Università di Messina, Messina, Italia]

Saraceno Silvia [Università di Messina, Messina, Italia]

Bonanno Francesco [Università di Messina, Messina, Italia]

Background and aims

Direct access to physiotherapy allows patients to consult physiotherapists without prior medical referral, recognising their autonomy in assessment, treatment, and referral when needed. This model, adopted in several countries, shows clinical outcomes comparable or superior to traditional pathways[1], with reduced costs and faster recovery [2]. Early intervention can prevent chronicity, particularly in conditions like low back pain. Importantly, this approach supports multidisciplinary care, with physiotherapists trained to identify red flags and refer to physicians appropriately. This scoping review aims to analyse the literature on direct access in physiotherapy, focusing on clinical outcomes, economic impact, and safety.

Methods

The electronic databases PubMed, Scopus, Cochrane Library were investigated, using the following keywords, which were combined to achieve maximum search strategy sensitivity: “direct access” AND “physiotherapy”. First, articles were screened by title and abstract, using the following inclusion criteria for selection: (1) randomized controlled trials (RCTs); (2) written in English language; (3) published on indexed journals from 2015 to 2025. The exclusion criteria were: (1) non-randomized trials; (2) reviews; (3) papers written in other languages than English. Second, the full texts of the selected articles were screened with further exclusions according to the previously described criteria. A PRISMA flowchart of the selection and screening method is provided in Figure 1.

Results

Table 1 summaries the principal key point of each article analyzed. All of the authors pointed out that direct access to physiotherapy for musculoskeletal conditions leads to a reduction in overall healthcare costs, fewer unnecessary medical visits and diagnostic investigations, and less use of prescribed drugs, while maintaining comparable clinical outcomes but with shorter treatment times, without compromising safety and quality of care.

Conclusion

The literature reviewed confirms that direct access to physiotherapy is an effective, safe, and sustainable model for managing musculoskeletal conditions, with benefits in terms of clinical outcomes, costs, and accessibility. Promoting health policies that facilitate their implementation, with a view to multidisciplinary collaboration, is a strategic step towards a more efficient and patient-centred care system.

REFERENCES

1. Ojha HA, Snyder RS, Davenport TE. Direct access compared with referred physical therapy episodes of care: a systematic review. Phys Ther. 2014 Jan;94(1):14-30. doi: 10.2522/ptj.20130096. Epub 2013 Sep 12. PMID: 24029295.
2. Moore, J. H., & McMillian, D. J. (2020). The effectiveness of direct access to physical therapy in the treatment of musculoskeletal disorders: a meta-analysis. Journal of Orthopaedic & Sports Physical Therapy, 50(5), 252-259.

Effectiveness of Strength Training in Reducing Kinesiophobia in Individuals with Chronic Low Back Pain: A Systematic Review

Autori

Galeotti Alessio [Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Campus of Savona, Savona, Italy]

Testa Marco [Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Campus of Savona, Savona, Italy]

Gambugini Riccardo [Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Campus of Savona, Savona, Italy]

Buzzatti Luca [School of Allied Health, Anglia Ruskin University, CB1 1PT Cambridge, UK]

Background and aims

Background: Kinesiophobia is a key psychological factor in the chronification of low back pain (LBP) and represents a significant barrier to functional recovery. Strength exercises are commonly recommended for chronic low back pain, yet their specific impact on kinesiophobia remains unclear.
Aim: To evaluate, through a systematic literature review, the effectiveness of lumbar strengthening exercises in reducing kinesiophobia in individuals with chronic non-specific low back pain (CLBP).

Methods

Methods: A systematic review was conducted in accordance with PRISMA 2020 and PERSiST guidelines. Only randomized controlled trials (RCTs) published since 2000 were included, involving adults with CLBP undergoing lumbar strengthening interventions. Primary outcomes were assessed using the Tampa Scale of Kinesiophobia (TSK) and/or the Fear Avoidance Beliefs Questionnaire (FABQ).

Results

Results: Out of 673 initially identified records, only 3 RCTs (n = 110 participants) met the eligibility criteria. Results indicate a reduction in kinesiophobia in the experimental groups, although high heterogeneity (I² = 94%) and non-significant overall effect (p = 0.12) limit the robustness of the findings.

Conclusion

Conclusion: Lumbar strengthening exercises may offer potential benefits in reducing kinesiophobia among individuals with CLBP, but current evidence is scarce and methodologically limited. Further high-quality RCTs are needed to clarify the specific role of strength training in this context.

REFERENCES

1. Harts, C. C., Helmhout, P. H., de Bie, R. A., & Staal, J. B. (2008). A high-intensity lumbar extensor strengthening program is little better than a low-intensity program or a waiting list control group for chronic low back pain: a randomised clinical trial. The Australian journal of physiotherapy, 54(1), 23–31.
2.  Vincent, H. K., George, S. Z., Seay, A. N., Vincent, K. R., & Hurley, R. W. (2014). Resistance exercise, disability, and pain catastrophizing in obese adults with back pain. Medicine and science in sports and exercise, 46(9), 1693–1701.
3. Nambi, G., Basuodan, R. M., Alwhaibi, R. M., Ebrahim, E. E., Verma, A., Syed, S., Pakkir Mohamed, S. H., Aldhafian, O. R., Nwihadh, N. A., & Saleh, A. K. (2023). Clinical and Endocrinological Responses to Different Exercise Training Methods in Chronic Low Back Pain: A Randomized Controlled Trial. Endocrine, metabolic & immune disorders drug targets, 23(6), 801–810.

Virtual Reality as a Therapeutic Approach for Entrapment Neuropathies: A Scoping Review

Autori

Giacomello Matteo [University of Padova, Padova, Italy]

Lando Alex [Department of Biomedical and Neuromotor Sciences (DIBINEM), Alma Mater Studiorum University of Bologna, Bologna, Italy]

Lazzaretti Eleonora [Department of Rehabilitation, Ulss 7 Pedemontana, Bassano del Grappa, Italy]

Background and aims

Over the past decade, advanced digital technologies have reshaped rehabilitation by enabling highly customisable, immersive interventions that engage both motor and sensory pathways. Virtual reality (VR) systems, ranging from fully immersive headsets to motion-tracking gamified platforms, have shown efficacy in enhancing motor control and reducing pain in both neurological and musculoskeletal conditions. VR also supports brain plasticity and activates the mirror neuron system. Entrapment neuropathies (EN), such as carpal tunnel syndrome (CTS), continue to impose chronic pain, sensory disturbances, and functional impairments, which are not always resolved by conservative or surgical treatments. Despite the success of VR in related domains, its specific application in EN rehabilitation remains unclear. This scoping review therefore aims to comprehensively map the current landscape of VR-based interventions for EN, detailing intervention types, dosing protocols, and clinical as well as engagement outcomes, to guide future research and clinical integration.

Methods

Following the Joanna Briggs Institute methodology and PRISMA-ScR guidelines, we registered our protocol a priori on Figshare (DOI: 10.6084/m9.figshare.28009196.v1). MEDLINE, Cochrane Central, CINAHLComplete, Scopus, and PEDro were searched from inception to January 2025, without restrictions on study design or publication status. Only English-language records were included. Grey literature sources (i.e., Google Scholar) and reference lists were also screened. Two reviewers independently screened title/abstract and full-text using Ryann QRCI software, with conflicts resolved by a third reviewer. Data were extracted into a standardised form, including study design, VR modality, intervention dose, and outcome measures. Results were synthesised in tabular and narrative formats.

Results

Of 372 records retrieved, 7 studies met inclusion criteria, all targeting VR-based rehabilitation for CTS. Publication years spanned 2006-2025. Study designs included two randomized controlled trials, one pilot study, one qualitative study, one narrative review, one book chapter, and one conference proceeding. VR interventions ranged from immersive headsets to semi-immersive gamified tasks and motion-capture exercises. Intervention doses varied from single sessions to multi-week protocols. Primary outcomes assessed included symptom severity (pain intensity, paresthesia), functional status (grip strength, dexterity, range of motion), and patient engagement (usability, motivation scales). Across studies, VR interventions were associated with clinically meaningful reductions in pain, improvements in sensory and motor function, and high levels of adherence and user satisfaction.

Conclusion

Preliminary evidence suggests that VR is a feasible, engaging, and beneficial adjunct to standard care for individuals with EN. Future large-scale, methodologically rigorous trials should refine dosing, assess long-term outcomes, and expand to other EN types.

REFERENCES

• Girach A, Julian TH, Varrassi G, Paladini A, Vadalouka A, Zis P. Quality of Life in Painful Peripheral Neuropathies: A Systematic Review. Pain Res Manag. 2019 May 23;2019:2091960. doi: 10.1155/2019/2091960. PMID: 31249636; PMCID: PMC6556282.
• Padua L, Cuccagna C, Giovannini S, Coraci D, Pelosi L, Loreti C, Bernabei R, Hobson-Webb LD. Carpal tunnel syndrome: updated evidence and new questions. Lancet Neurol. 2023 Mar;22(3):255-267. doi: 10.1016/S1474-4422(22)00432-X. Epub 2022 Dec 13. PMID: 36525982.
• Rutkowski S, Kiper P, Cacciante L, Cieślik B, Mazurek J, Turolla A, Szczepańska-Gieracha J. Use of virtual reality-based training in different fields of rehabilitation: A systematic review and meta-analysis. J Rehabil Med. 2020 Nov 19;52(11):jrm00121. doi: 10.2340/16501977-2755. PMID: 33073855.
• Ahmadpour N, Randall H, Choksi H, Gao A, Vaughan C, Poronnik P. Virtual Reality interventions for acute and chronic pain management. The International Journal of Biochemistry & Cell Biology. 2019 Sep;114:105568.
• Tricco AC, Lillie E, Zarin W et al. (2018) PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation. Ann Intern Med, 169(7): 467-473. doi: 10.7326/M18-0850.

From assessment to participation: appropriateness of the rehabilitation pathway in Pallister-Killian Syndrome.

Autori

Moscato Francesca [Life s.r.l. Centro di riabilitazione Estensiva, Isola di Capo Rizzuto KR, Italia]

Castiglione Chiara [SCDO Medicina Fisica – Neuroriabilitazione, Azienda Ospedaliero-Universitaria San Luigi Gonzaga, Torino, Italia]

Inzitari Maria Teresa [Medicina Fisica e Riabilitativa, Azienda Ospedaliero-Universitaria “Renato Dulbecco”, Catanzaro, Italia][Medicina Fisica e Riabilitativa, Dipartimento di Scienze Mediche e Chirurgiche, Università degli Studi “Magna Graecia”, Catanzaro, Italia]

Background and aims

Pallister-Killian syndrome (PKS) is a rare genetic disorder caused by tetrasomy of chromosome 12p, characterised by intellectual disability, hypotonia, and various craniofacial and multisystem anomalies [1]. It requires an individualised, multidisciplinary rehabilitation approach. This study aimed to assess adaptive functioning in PKS patients using the Vineland Adaptive Behaviour Scales, Second Edition (Vineland-II).

Methods

The project was approved by the Ethics Committee of the Calabria Region. It was included paediatric subjects aged 3 to 16 years diagnosed with Pallister-Killian Syndrome. Adaptive functioning was evaluated using the Vineland Adaptive Behaviour Scales, Second Edition (Vineland-II), which assesses four domains: Communication, Daily Living Skills, Socialisation, and Motor Skills, each with specific subscales [2]. Items are scored from 0 to 2 based on independence and activity frequency [3]. Raw scores for each subscale were calculated, and the total score allowed comparison of functional abilities across domains at a single time point.

Results

A total of 23 patients were recruited. Analysis of the raw scores indicated that the most developed skills were communication (C–Receptive: 28.26%) and socialisation (S–Interpersonal Relationships: 17.5%). The most critical areas included writing (C–Written: 6.95%), and domestic and community living skills (DLS–Domestic: 5.07%; DLS–Community: 5.08%). Motor skill (MS), both fine (FineMS: 15.57%) and gross (GrossMS: 15.27%), showed balanced development, but with considerable potential for improvement.

Conclusion

The results indicate a heterogeneous functional profile in subjects with Pallister-Killian Syndrome. The Vineland-II is valid tool for tailoring therapy and determining the level of support needed in home, school, and social settings. Further research is needed to guide and design tailored rehabilitation interventions for this population and to ensure continuity of care, and enhance support systems for families.

REFERENCES

[1] Izumi, Kosuke, and Ian D Krantz. “Pallister-Killian syndrome.” American journal of medical genetics. Part C, Seminars in medical genetics vol. 166C,4 (2014).

[2] Sparrow, S.S., Balla, D.A., Cicchetti, D.V. Vineland Adaptive Behavior Scales, Second Edition. Pearson Assessments.

[3] Balboni, G., Belacchi, C., Bonichini, S., Coscarelli, A. Vineland-II. Vineland Adaptive Behavior Scale Second Edition. Survey forms. Firenze: Giunti O.S., (2016).

Muscle co-contraction activity in altered visual perception of the hand: a case report on a stroke patient in virtual rehabilitation-guided reaching and grasping tasks

Autori

Pagano Alessandro [Department of Experimental and Clinical Medicine – University Politecnica delle Marche, Ancona, Italy]

Tigrini Andrea [Department of Information Engineering – Università Politecnica delle Marche, Ancona, Italy]

Bonci Viviana [Department of Experimental and Clinical Medicine – Università Politecnica delle Marche, Ancona, Italy]

Capriotti Alessandro [Department of Mental and Physical Health – Unicampania, Naples, Italy]

Ceravolo Maria Gabriella [Department of Experimental and Clinical Medicine – Università Politecnica delle Marche, Ancona, Italy]

Burattini Laura [Department of Information Engineering – Università Politecnica delle Marche, Ancona, Italy]

Capecci Marianna [Department of Experimental and Clinical Medicine – Università Politecnica delle Marche, Ancona, Italy]

Introduction to clinical case

Visuomotor adaptation (VMA) is a form of motor learning that enables individuals to adjust their movements in response to visual distortions [1]. This adaptive process is often compromised in post-stroke patients due to motor and sensory deficits, including abnormal co-contraction of agonist and antagonist muscles and altered body representation. Immersive virtual reality (VR) offers new possibilities to study and promote neuroplasticity, with promising effects on motor control and VMA [2]. However, no studies have yet examined how VR-induced modifications of internal body representation affect VMA. This study investigates whether visually altering hand size in a virtual environment can influence VMA, potentially informing new strategies for motor rehabilitation in stroke survivors.

Methods

Surface electromyographic (sEMG) activity was recorded using the FREEEMG system (BTS Bioengineering) from eight upper limb muscles: adductor pollicis (AP), flexor and extensor carpi radialis (FC, EC), finger extensor (ED), biceps brachii (BB), triceps brachii (TB), anterior deltoid (DA), and upper trapezius (TS). Participants performed reaching and grasping tasks in a virtual environment while viewing a visual representation of their hand with either enlarged or reduced dimensions. The same tasks were repeated in two control conditions: a real-world setting and a virtual environment with no hand-size alteration. EMG signals were band-pass filtered (20–450 Hz), rectified, and envelope-extracted. An on–off detection algorithm was used to segment EMG activity across repetitions [3]. The co-contraction index (CCI) [4] was calculated for each agonist-antagonist muscle pair. Statistical comparisons between conditions (modified hand-size vs normal size) were made using the Wilcoxon rank-sum test (p < 0.05).

Results

A significant difference was observed for the EC–FC muscle pair, with a lower CCI found during tasks involving altered hand size (median 0.18) compared to tasks with normal hand size (0.42, p < 10⁻⁴). Although not statistically significant, consistent decreases in CCI were also observed for the DA–TS (0.55 vs. 0.63) and TB–BB (0.40 vs. 0.46) pairs under altered visual conditions. Interestingly, the ED–AP pair was the only case showing a higher median CCI in the altered hand size condition (0.44) compared to the normal one (0.36), though this difference also did not reach statistical significance (p > 0.05).

Discussion and clinical relevance

These preliminary findings suggest that altered visual feedback in VR may reduce pathological muscle co-contraction, promoting more efficient and synergistic movements. Further research on larger post-stroke populations is needed to confirm these effects and explore their clinical potential.

REFERENCES

[1] E. Tzvi, S. Loens, et al. Cerebellum. (2022): 306–313

[2] F. Amin, A. Waris et al. IEEE Trans Neural Syst Rehabil Eng. (2024): 32:2060-2069

[3] Rashid, Usman, et al. Journal of Electromyography and Kinesiology 48 (2019): 103-111.

[4] Unnithan, V. B., et al. Electromyography and clinical neurophysiology 36.8 (1996): 487-494.