Clinical Decision Making, Red-Flag Recognition, and Scope-of-Practice Perspectives for Direct Access Physical Therapy in Saudi Arabia

Background/Objectives: This survey examined referral decisions, the recognition and screening of warning features (red flags) of serious disease, regulatory interpretations, and barriers to direct-access physical therapy in Saudi Arabia. Methods: An English-language cross-sectional convenience survey (May–July 2026) used an investigator-developed questionnaire with 12 clinical vignettes (written patient cases) and 20 warning-feature items paired with screening questions. The primary outcome was choosing medical referral before physical therapy in all four urgent/critical vignettes: suspected gastrointestinal bleeding, cauda equina syndrome, abdominal aortic aneurysm, and spinal infection. This definition was finalised after data collection. Results: Of 131 Saudi physical therapists, 77 (58.8%; 95% confidence interval [CI] 50.2–66.8) chose referral before treatment in all four vignettes. Another 36 included referral in every vignette but would also start treatment while arranging referral in at least one; 18 chose treatment without referral at least once. In an exploratory six-predictor analysis, postgraduate academic qualifications were associated with higher odds of meeting the primary outcome (adjusted odds ratio 4.14, 95% CI 1.63–10.51; Holm-adjusted p = 0.017) and older age with lower odds (0.92/year, 95% CI 0.86–0.98; Holm-adjusted p = 0.047). Across 17 core warning features, 74.0% of responses identified a red flag; 49.1% of screening responses indicated checking often or always. Regulatory views differed: 45.8% believed direct access was permitted in limited settings. The highest-rated barriers concerned policy, law, reimbursement, and physician support. Conclusions: These findings identify priorities for evaluating training, clarifying regulations, and coordinating referral pathways. Vignettes and self-reported practices cannot establish safety in clinical practice, show that qualifications improve decisions, or determine workforce readiness.