Great question! Physiotherapists use many different technical and non-technical skills to deliver physiotherapy services. Physiotherapists assess, diagnose and treat a wide range of conditions, but they always operate within the governing legislation of the profession, scope of practice, and within the context of physiotherapy. For example:
Physiotherapy is provided by physiotherapists, to human patients.
If you are treating anything other than a human being…you are not working as a physiotherapist.
Physiotherapy is provided in a manner consistent with the profession’s governing legislation, Standards of Practice and Code of Ethical Conduct.
If you are performing an injection of any kind…you are not working as a physiotherapist.
If you are offering a community exercise class… you are not working as a physiotherapist.
Physiotherapy is delivered by competent health professionals working within the scope of practice of the profession and is evidence-informed.
If you are providing lactation consulting…you are not working as a physiotherapist.
This article will elaborate further on those examples and discuss the components that compel us to conclude that the service provided was physiotherapy.
Services as defined in legislation
The first step is to determine whether the service fits within the legislated definition of physiotherapy. Physiotherapy is defined in The Health Professions Act as follows:
“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.”
The Health Professions Act, which regulates physiotherapy practice and grants protection to the title physiotherapist, pertains to health services provided to people. There are no provisions within the Act for the delivery of care to animals. The provision of care to animals is addressed in the Veterinary Profession Act. The College does not have jurisdiction to regulate treatment of animals, which is why you are not working as a physiotherapist and must not use your protected title if you are treating anything other than a human being.
Similarly, performing injections is not a restricted activity authorized to the physiotherapy profession through the Physical Therapists Profession Regulation. If you are performing a restricted activity not authorized to the profession through the Regulation, you are not doing so as a physiotherapist, and need to clearly state this to patients and payers. The only way for a physiotherapist to perform an injection legally is to do so under the supervision of and at the direction of a regulated health professional who is authorized to perform the activity. If you are performing an injection of any kind, you are not working as a physiotherapist, but rather as an assistant of the other regulated professional.
Consistent with the Standards of Practice
The Client Assessment, Diagnosis, Intervention Standard of Practice sets expectations for these core point-of-care elements of physiotherapy practice:
- Assessment: Applies appropriate assessment procedures to evaluate clients’ health status using standardized measures as available.
- Diagnosis: Uses critical thinking and professional judgment to interpret the assessment findings and determine a physiotherapy diagnosis.
- Treatment Plan: Collaborates with clients, and develops realistic intervention plans to address clients’ needs and goals.
These three components must be done in the scope and purview of physiotherapy as mentioned above, and they must be present in your patient interactions – they are the building blocks of physiotherapy.
If you do not include these three components of care, then you are straying away from providing physiotherapy services. For example, if you are offering a yoga class at your community hall, one where any member of the public can sign up or drop in at any time, without a physiotherapy assessment first to determine their appropriateness to participate in the class, and to decide on the specific yoga poses the person should do to address their identified health concerns and goals, you have not met the requirements for the class to be considered physiotherapy.
Scope of practice and evidence-informed practice
Scope of practice can be tricky to pin down. Physiotherapy is an evolving profession with emerging therapies constantly being considered. Beyond legislation and regulatory rules that guide practice, the College uses the “Is it Physiotherapy Tool” developed by the Canadian Alliance of Physiotherapy Regulators to consider if an emerging practice is within the scope of practice of physiotherapy.
As a regulator, the College’s focus is to protect the public and that means looking specifically at emerging areas of practice and making decisions on whether that practice should be considered physiotherapy. The tool provides a consistent framework to evaluate the emerging practice, the legislative considerations, the profession’s related knowledge and competence, and the current evidence regarding the practice. In a nutshell, it takes you through decision making steps to help guide the user to a decision.
If you are considering incorporating a new treatment method or approach, you can use the tool to reflect on whether it is in scope for the profession. If you are ever unsure, please contact the College and we would be happy to help walk you through this.
Scenarios: dual practice
In my brief time as practice advisor, I have come across many different scenarios in which physiotherapists work not only as physiotherapist but in other health professional roles. Some physiotherapists are registered as other regulated health professions such as chiropractors and acupuncturists. Many more physiotherapists fill roles outside of a regulated profession such as yoga instructors, personal trainers, strength coaches, personal care givers, etc. Often, conversations about whether a service fits the description and qualifies as a physiotherapy service comes up because a physiotherapist fulfills more than one role in the health system. It is important for the public to not be confused by the services they are receiving so in this section we will talk about how to wear those different hats appropriately.
Physiotherapy + another regulated health profession
It is possible to be both a regulated physiotherapist and a member of another regulated health profession such as an acupuncturist or a chiropractor. Since there is no protected scope of practice in Alberta, multiple professions can perform treatments ranging from exercise prescription to restricted activities such as dry needling.
The overlap in treatments offered can be confusing to the public, the funder and sometimes even the physiotherapist as to which service is being provided – physiotherapy or something else. The physiotherapist must know which hat they are wearing and clearly communicate that consistently and transparently to avoid confusion and to maintain a positive therapeutic relationship with the patient.
For those practicing two regulated health professions you would be expected to:
- Be compliant with the registration and practice permit requirements of the other profession, in addition to the registration requirements of the College of Physiotherapists of Alberta.
- Communicate clearly to your patient when you are providing physiotherapy services and when the services are not physiotherapy.
- Establish each health and business practice as a distinct entity, maintaining:
- Separate billing and financial records for each practice.
- Different entries in a shared client record that clearly identify which professional role/service was provided or establishing separate client records for each health service.
- Separate appointment books and/or distinct days and times for providing each service.
- Clearly chart which services were being provided at each appointment.
Physiotherapy + unregulated health profession
This is where the College gets the most questions from physiotherapists, and commonly the questions are along the lines of “does my work as a strength and performance coach qualify as physiotherapy?” or “is my group yoga class a physiotherapy service?” Sometimes when physiotherapists also want to work as strength coaches or yoga instructors, they are clear that they want these to be two separate roles. When that happens, the College encourages the individual to follow the same direction as they would if they were both a physiotherapist and a chiropractor. Keep the two business entities separate and distinct and make sure you clearly communicate when the service you are providing is physiotherapy and when it is not.
For those who are less clear about where the dividing line is drawn, here are some things to think about:
We already spoke about the definition of physiotherapy in the Health Professions Act, so, lets dive a little deeper and ask some questions about your proposed services to help you figure out if it would be considered a physiotherapy service.
Am I using the knowledge and skills I developed during my physiotherapy education and training?
Clearly, physiotherapists continue to learn and develop their skills after they finish their entry to practice education; however, most physiotherapy continuing professional development will build on the knowledge and skills developed during entry to practice, and should be based on reliable, quality scientific evidence. If the practice or activity you are considering is not related in any way to that education or is not grounded in scientific evidence, you are entering shaky territory.
An example is lactation consulting. It’s fair to say that positioning a new mom to be able to comfortably nurse their baby and teaching them biomechanics or giving instruction about positioning when feeding a baby with torticollis builds off a physiotherapist’s knowledge of posture and biomechanics. If a physiotherapist is engaged in these activities, it is reasonable to say that they are providing physiotherapy services. However, teaching about latch or assessing a baby’s suck and swallow are far removed from a physiotherapist’s education and knowledge base and the service is not physiotherapy.
Conversely, it is hard to un-know something. So, if you are working as a strength and conditioning coach it can be hard to step back from looking at a person the way you would as a physiotherapist, to not assess their movement and challenges the way a physiotherapist would. It is not to say that a physiotherapist could not work as a strength coach; however, it is a slippery slope. The physiotherapist should consider that a patient may have higher expectations of the services they receive if they know that their coach is also a physiotherapist. This is clearly a situation that requires caution and intentional management.
Am I assessing, diagnosing, and building a treatment plan with my skill set as a physiotherapist?
As your practice or even your patient population evolves you can find yourself sliding into areas of practice that no longer look like your typical hospital or private practice setting. That being said, it is important to recognize when you have moved outside of physiotherapy entirely. Using yoga poses in your home exercise prescription or teaching a patient sun salutations can be considered physiotherapy if you have conducted a thorough assessment, provided a diagnosis and consulted with the patient to reach the conclusion that learning sun salutations and performing them daily is an appropriate way for the patient to get through this stage of their shoulder injury. However, as already said, teaching yoga whether in a private lesson or to a group without appropriately assessing, diagnosing, and developing a treatment plan does not meet the College’s expectations. You can apply this thought process to similar scenarios such as bike fitting, personal training, or other practices.
Am I the best person to deliver this service?
Does the service already exist within another profession’s scope of practice and are they better equipped to provide the service than you? This consideration is particularly important if there are no legislative restrictions to you performing the service. The fact that the Health Professions Act does not prohibit a physiotherapist from taking on an activity does not mean they are the best person to do so. Recent examples include dysphagia screening, and high-flow oxygen titration.
Speech-language pathologists and occupational therapists are better equipped to perform a feeding and swallowing screen or assessment than physiotherapists and most communities have enough of those professionals to meet the need. Similarly, most acute care facilities will have respiratory therapists who are better trained in oxygen titration. Sometimes physiotherapists will engage in practices outside of traditional scope of physiotherapy practice when other better qualified providers are not available, but under normal circumstances this is rare. If it does occur the physiotherapist must adhere to the legislation and regulatory guidelines, ensure that they are competent to perform the activity, and hold patient interest and safety as the paramount considerations.
Will my patients easily understand what I am proposing? Is there a chance for miscommunication?
You should have a clear plan of how your services will be implemented. If you are working a side-gig as personal care aide, it should be clear that you are a personal care aide in this role and not a physiotherapist. There should be no confusion to your patient when you are assisting them in their home as to the role you are providing.
Most often when we get these questions, they come from individuals that have previous education or experience in other realms of the health industry. Sometimes they have worked as a personal trainer or have done their yoga teacher training and want to bring those skill sets to their physiotherapy practice. Or they might work in a rural or under-served area and recognize a need in the community and wish to fill it. There is nothing wrong with using all your skills to enhance patient outcomes, but the issue comes with the logistics of how this occurs and how it is explained to the patient.
To keep them separate you must recognize when you are no longer working as a physiotherapist, and you must communicate that to your patient. If you had an insurance company call to ask about the treatment you provided in a gym setting, could you justify that that session was physiotherapy? If you had a complaint come to you regarding a patient who felt they didn’t receive the treatment they expected would you be able to defend that what you provided was physiotherapy? Regardless the situation, communicate with your patients so they are clear on the services you are providing, and provide the services which the patient sought. Keep in mind that for physiotherapy to be called physiotherapy it must involve a physiotherapy-based assessment, diagnosis, and treatment plan and adhere to the Standards of Practice and other professional expectations.
