As a physiotherapist on the general register, you have a broad scope of practice. You also have the ability to become authorized to perform several restricted activities as written in the Health Professions Restricted Activity Regulation. It is important to remember that competency must be established prior to performing any activity and that certain restricted activities require you to apply for authorization and provide proof of competency prior to authorization being granted. From the contacts the College has received over the past couple of years, there seem to be some misconceptions as to what you can and cannot do as part of your physiotherapy practice related to restricted activities. This article will focus on clearing up some questions and misconceptions regarding what physiotherapists on the General Register can and cannot do as part of their practice.
Referring for injection or interventional radiology
Sheldon is a physiotherapist in Calgary who has been treating a client for the past few months for an acute back injury that hasn’t been resolved. He referred this client to a radiologist for a lumbar facet joint injection. Sheldon has a PracID and has received authorization from the College to order diagnostic imaging, so he assumes this referral is fine. Several weeks pass and Sheldon gets a call from the radiology clinic who are frustrated with him because they didn’t get paid for the facet joint injection through Alberta Health funding (AHCIP).
So why didn’t the radiologist get paid and what did Sheldon do that was the issue?
Physiotherapists can be authorized by the College through the HPRAR to order x-rays, diagnostic US, and MRIs. You can read more about this here. Physiotherapists through the HPRAR can also refer for a consultation with a physician/physiatrist/sports medicine doctor etc. but at no time can you refer for interventional radiology or any other injection therapies.
As stated in the Practice Guideline: Referring for Physician Consultation:
"The Medical Schedule of Benefits indicates that physiotherapy referrals are for consultations (comprehensive or limited), not for diagnostic procedures."
It is not within the scope of practice of the physiotherapy profession to determine the appropriateness of any injection intervention. An appropriate consultation must occur with a physician who has the scope of practice and individual competence to order interventional radiology or the ability to assess and determine the need for an injection. If a physiotherapist is referring to a radiologist or any other professional, it must be for consultation not to direct care outside of physiotherapy scope of practice.
Secondly, your PracID gives you the ability to refer for the consultation and for the physician to get paid under AHCIP. Referring for an injection does not meet the criteria established by the Medical Schedule of Benefits and would not be allowable under AHCIP; that is why the radiologist did not receive payment for the services provided to the client.
Injections Performed by Physiotherapists
Lucy is a physiotherapist working at a multidisciplinary clinic with several orthopedic surgeons. They have asked her to begin performing Hyaluronic Acid and PRP injections for their clients with knee osteoarthritis. Lucy thinks this would be great to add to what she can do with the clients she sees but is unsure if she can do this as a physiotherapist.
Can Lucy do this as a physiotherapist?
To answer this, you must examine the legislation which defines a physiotherapist's scope of practice.
“In their practice, physiotherapists do one or more of the following:
(a) assess physical function,
(b) diagnose and treat dysfunction caused by a pain, injury, disease or condition in order to develop, maintain and maximize independence and prevent dysfunction,
(b.1) engage in research, education and administration with respect to health services delivery and the science, techniques and practice of physiotherapy, and
(c) provide restricted activities authorized by the regulations.”
Section (c) grants health professions the authority to perform restricted activities. The legislation that provides details to this is Section 52 of The Health Professions Restricted Activity Regulation which enables physiotherapists to
- cut a body tissue, to administer anything by an invasive procedure on body tissue or to perform other invasive procedures on body tissue below the dermis or the mucous membrane for the purpose of wound debridement and care (Section 52(a))
- to cut a body tissue or to perform other invasive procedures on body tissue below the dermis or the mucous membrane for the purpose of needle acupuncture; or for the purpose of intramuscular stimulation and biofeedback, if authorization has been received from the Registrar (Sections 14 (d, e).
When we compare that wording to the wording found in Section 54 (a) relating to physicians.
to cut a body tissue, to administer anything by an invasive procedure on body tissue or to perform surgical or other invasive procedures on body tissue below the dermis or the mucous membrane or in or below the surface of the cornea;
The HPRAR legislation specifically states the intended purpose for which physiotherapists can cut a body tissue or perform an invasive procedure. When looking at professions that administer injections such as medicine which we listed above, the purpose of the authorized activity may not be explicitly stated and may be encompassed in the statement “to cut a body tissue, to administer anything by an invasive procedure on body tissue or to perform surgical or other invasive procedures on body tissue below the dermis or the mucous membrane”.
If you look further into the HPRAR at other professions that administer injections such as dentistry, nursing, or pharmacy they will again have the purpose explicitly stated. These statements can include “to administer blood or blood products, to administer vaccines”.
Taken together, these statements, make it clear that the physiotherapist’s ability to cut a body tissue or administer anything by invasive procedures is for specific purposes set out in legislation, such as acupuncture/dry needling and wound care, not injections.
However, the College is aware of instances where a physiotherapist performs these activities under the supervision of a member of another profession regulated under the Health Professions Act in Alberta. These individuals perform the activities outside of their registration with The College of Physiotherapists of Alberta and in accordance with the Performance of Restricted Activities Standard of Practice. This requires that “if a physiotherapist engages in restricted activities which they are not authorized as a physiotherapist, the expectation is that they clearly identify that the activity is not part of their physiotherapy service provision and that they are acting under the supervision and at the direction of the other regulated health professional.” The supervisor, who is a registrant of another regulatory body, must meet the supervision and other regulatory requirements of the College to which they belong.
For example, if a physician is supervising the physiotherapist who is working outside of physiotherapy scope of practice and under the direction of the physician, the relevant legislation must enable the physician to supervise the physiotherapist, and the physician must meet all the expectations of the College of Physicians and Surgeons. This would be at the sole discretion of the physician and the legislation and regulatory requirements that exist outside of the College of Physiotherapists of Alberta’s purview. Finally, in such an instance the physiotherapist must still be competent to safely perform the activity.
To summarize, yes there are instances where physiotherapists are performing these activities, but when they, do it is under the supervision and at the direction of another regulated health professional. The service is not physiotherapy and cannot be billed or represented as physiotherapy.
Point of Care Ultrasound
Jessie has opened up a new clinic in Calgary and has been approached by a vendor to purchase a point-of-care ultrasound (POCUS) imaging machine. The vendor has told her she can use the machine to visualize tendon tears, monitor muscles, and look for abnormalities to help her diagnose and treat her clients. They advise her that she will use it a significant amount in her practice to help her clients, but Jessie is not sure she is able to use it as a physiotherapist.
Can Jessie use POCUS in her practice?
The HPRAR outlines in Section 53(e) that physiotherapists are able to “order non-ionizing radiation in (i) magnetic resonance imaging, or (ii) ultrasound imaging.”
Both the actions of ordering and applying diagnostic ultrasound imaging are restricted activities in Alberta. The legislation enables physiotherapists to order diagnostic ultrasound imaging but physiotherapists are unable to apply diagnostic ultrasound such as POCUS due to the specific wording of our governing legislation. This means that physiotherapists are unable to use POCUS in clinical practice at this time and cannot be the ones applying POCUS to the client.
As with injections, the College of Physiotherapists of Alberta is aware of practice settings in which physiotherapists are assigned the activity under the supervision of a duly authorized health professional. For example, some physiotherapists working in hospital-based incontinence clinics perform assessments and treatments using POCUS under the supervision of radiologists located within the same building. For this to happen, the other health professional’s supervision of the physiotherapist’s performance of the activity must be enabled by relevant legislation and be done in a manner consistent with the other health provider’s regulatory requirements.
It is important to understand the authorizations you are eligible to apply for and the parameters in place around the activities you can gain authorization to perform as a physiotherapist. The legislation that outlines restricted activities has been in existence for many years under different titles but can now be found under the Health Professions Restricted Activity Regulation. As a regulated health professional, you are expected to know what legislation applies to your practice and you must practice within the expectations of the legislation, Standards of Practice, and Code of Ethical Conduct. Working outside your scope of practice or participating in unauthorized restricted activities can have consequences for the client and for you. If you are unsure of anything regarding restricted activities you can access the Standards of Practice – Performance of Restricted Activities, search for information on the College’s website, or contact the College’s practice advisor.
