Direct access to physiotherapy in Hong Kong

Musculoskeletal disorders such as low back pain are ranked within the top three diseases or injuries contributing to disability-adjusted life years (DALYs) in developed Western countries [1-3]. Individuals presenting with musculoskeletal conditions commonly seek care directly from or are referred to a health professional such as a physiotherapist. The ability of individuals to consult a regulated health professional other than a physician without requiring a referral is commonly known as direct access [4]. In 1975, Australia became the pioneer in direct access physiotherapy. It has been adopted in numerous countries around the world such as New Zealand, Canada, and throughout Europe [5]. In the US, 47 out of the 50 states having some form of direct access to physiotherapy [4].

There are many benefits of direct access care for patients [4, 6]. Direct access to health professionals allows individuals to be in control of their healthcare. This is congruent with the biopsychosocial model, where healthcare is centred around the patient, rather than the physician being the gatekeeper [7-10]. According to the WCPT, patients who self-refer to physiotherapy are:

  • More proactive
  • Take less time off work
  • Return to work sooner
  • Satisfied with their care
  • More interested in self-management

Other benefits of a system where patients do not need to consult their medical practitioner for primary care relate to improving the efficiency of the medical system. A recent systematic review identified that direct access had the potential to decrease medical costs with musculoskeletal conditions without the need for medication prescription or ordering imaging [4]. As such, the systematic review supported the safety, efficacy, and cost-effectiveness of physiotherapy services by way of direct access compared with physician-referred episodes of care

Unlike many individuals living in the developed world, people living in Hong Kong do not have the ability to access physiotherapy directly; a physician is required to medically assesses whether it is appropriate for a patient to access physiotherapy. One of the common arguments against direct access to physiotherapy services is the potential for adverse effects on patient safety. However there is no scientific literature currently available to support this claim; Ojha (2014) showed that there was no evidence of harm when patients self-referred directly to a physiotherapist. A second argument against direct access to physiotherapy in Hong Kong is there is a lack of knowledge of physiotherapy in the general public and the medical system [11]. This in itself does not preclude the implementation of direct access to physiotherapy services.

In Feb 2014, Eleanor Chan discussed the issue of direct access at the Hong Kong Physiotherapist Union’s AGM. The presentation can be found here. Issues that need to be resolved before direct access can be implemented include: evidence of clinical effectiveness of direct access, improvements in the education of physiotherapists, and a review to changes to legislation [5]. Although heading in the right direction towards direct access, there is a long way to go before people in Hong Kong can access physiotherapy without a doctor’s referral. It is an exciting time for physiotherapy in Asia, but it also has a long way of catching up with other countries where physiotherapists are beginning to have the ability to prescribe certain medications. Hopefully it will happen during my time here.

Treat well,

Alex Chan


1.         US Burden of Disease Collaborators, The state of US health, 1990-2010: burden of diseases, injuries, and risk factors. JAMA, 2013. 310(6): p. 591-608.

2.         Duthey, B. Priority Medicines for Europe and the World: A Public Health Approach to Innovation – Update on 2004 background paper. 2013 4/11/14; Available from:

3.         Murray, C.J., et al., Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. The Lancet, 2013. 380(9859): p. 2197-2223.

4.         Ojha, H.A., R.S. Snyder, and T.E. Davenport, Direct access compared with referred physical therapy episodes of care: a systematic review. Phys Ther, 2014. 94(1): p. 14-30.

5.         Bury, T.J. and E.K. Stokes, Direct access and patient/client self-referral to physiotherapy: a review of contemporary practice within the European Union. Physiotherapy, 2013. 99(4): p. 285-91.

6.         Leemrijse, C.J., I.C. Swinkels, and C. Veenhof, Direct access to physical therapy in the Netherlands: results from the first year in community-based physical therapy. Phys Ther, 2008. 88(8): p. 936-46.

7.         Moore, A. and G. Jull, Patient-centredness. Man Ther, 2012. 17(5): p. 377.

8.         Cooper, K., B.H. Smith, and E. Hancock, Patient-centredness in physiotherapy from the perspective of the chronic low back pain patient. Physiotherapy, 2008. 94(3): p. 244-252.

9.         Weiner, B.K., Spine update: the biopsychosocial model and spine care. Spine (Phila Pa 1976), 2008. 33(2): p. 219-23.

10.       Waddell, G., 1987 Volvo award in clinical sciences. A new clinical model for the treatment of low-back pain. Spine (Phila Pa 1976), 1987. 12(7): p. 632-44.