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Physical Therapy: Rehabilitation Principles, Coordination, and Collaboration

Kent H. Do, MD, DPT, CAQSM
Alexander C. Knobloch, MD, CAQSM
Carlton J. Covey, MD, MEd, CAQSM

American Family Physician. 2026;114(3):248-259.

Author Disclosure: No relevant financial relationships.

This clinical content conforms to AAFP criteria for CME.

Musculoskeletal concerns account for nearly 40% of visits to primary care, and up to 20% of cases result in a referral for physical therapy. Physical therapists are independent, doctoral-level clinicians with expertise in the evaluation and treatment of musculoskeletal and neuromuscular conditions. Family physicians can effectively coordinate and collaborate with physical therapists by identifying patients for referral, using core rehabilitation principles to bridge care to physical therapy, and understanding the effectiveness of adjunctive modalities used by physical therapists to augment neuromuscular reeducation and therapeutic exercise. Slow resistance exercises are an integral part of many musculoskeletal rehabilitation programs. They are as effective as eccentric-only exercises for some conditions, are easier to describe, and require less frequency. Pain-monitoring rules are helpful in guiding treatment. Rehabilitation programs that allow for some pain have shown improvements in pain and return-to-play clearance times equivalent to those of pain-free programs. When patients do not progress with appropriate rehabilitation, physicians should assess factors that impede recovery, including suboptimal adherence, persistent mechanical overload, insufficient improvement, and inappropriate exercise prescription.

Musculoskeletal concerns account for nearly 40% of visits to primary care.1 Up to 20% of these visits result in a referral for physical therapy (PT), which underscores the importance of coordination with physical therapists.2 Physical therapists specialize in assessment and management of musculoskeletal and neuromuscular conditions, including use of a multifaceted approach to patient rehabilitation.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments
Use pain-monitoring rules for treatment of acute and chronic musculoskeletal conditions. Rehabilitation programs that allow for some pain have shown improvements in pain and return-to-play clearance times equivalent to those of pain-free programs.24,40ARandomized controlled trial, systematic review, and meta-analysis
Slow-resistance exercises are an integral part of treatment for patellar and Achilles tendinopathies; they are as effective as eccentric-only training and are a more patient-friendly alternative to eccentric exercises.30,31ATwo randomized controlled trials with consistent results
Limit home physical therapy programs to three to five exercises for better adherence.65–67CConsensus, disease-oriented evidence, small observational studies

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

PT has evolved into an independent profession in which licensed clinicians can practice autonomously. Since 2016, all physical therapists entering the profession earn a Doctor of Physical Therapy degree and can pursue board certification in 10 specialty areas.3,4

Family physicians should have a framework to diagnose, treat, and refer patients with musculoskeletal conditions to physical therapists. Physicians should be familiar with PT treatment approaches because many insurance companies require primary care referral for coverage. They should be knowledgeable about the supporting evidence for PT treatments as well as state regulations that may limit the care physical therapists can provide. It is also beneficial to know how to approach a patient if rehabilitation is ineffective.

ACCESS

Patient access to PT varies. In health maintenance organizations, referrals are often restricted to a known provider network, which can facilitate communication but may limit referral options and cause delays. Although direct access to PT without physician referral is permitted in the United States, insurance policies may impose limitations or require authorization.5

KENT H. DO, MD, DPT, CAQSM, is a family and sports medicine physician in the 18th Medical Group at Kadena Air Base, Japan.

ALEXANDER C. KNOBLOCH, MD, CAQSM, FAAFP, is an assistant professor of family medicine at the F. Edward Hébert School of Medicine at the Uniformed Services University of the Health Sciences, Bethesda, Maryland. He practices family and sports medicine at the David Grant Medical Center at Travis Air Force Base, California.

CARLTON J. COVEY, MD, MEd, CAQSM, FAAFP, is a professor of family medicine at the F. Edward Hébert School of Medicine at the Uniformed Services University of the Health Sciences, Bethesda. He practices family and sports medicine at the David Grant Medical Center at Travis Air Force Base.

Address correspondence to Carlton J. Covey, MD, MEd, CAQSM, at carlcovey24@gmail.com.

Author Disclosure: No relevant financial relationships.

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