The CPTA's College Conversations

Physiotherapy Alberta has been promoting telerehabilitation since 2017; however, in the context of the COVID-19 pandemic, its use in physiotherapy practice has increased dramatically. While many people envision videoconferencing when they consider this format of service delivery, telerehabilitation or digital practice includes the remote delivery of physiotherapy using all forms of electronic communication technology. This can include text or email, video- or teleconferencing, and even robotics and virtual reality.

This is not a new form of physiotherapy, but rather physiotherapy delivered in a new way. Telerehabilitation services are still subject to the same standards of practice as in-person services, but how physiotherapists meet those standards may differ from "traditional" practice. This episode dives into issues of privacy, patient selection, and clinician competence. We also touch on billing for services and platform selection and provide tips on establishing a new telerehabilitation business.

Telerehabilitation has lots of promise for providing physiotherapy services both during an unprecedented pandemic and after. However, it is not a cure-all. Physiotherapists need to take the time to consider and establish their telerehabilitation practices to ensure success in the long term.

Resources:

• Telerehabilitation Resource Guide for Alberta Physiotherapists
  • https://www.physiotherapyalberta.ca/physiotherapists/resources_to_help_you_meet_practice_standards/telerehabilitation_guide
• PABC Digital Practice Toolkit
  • https://bcphysio.org/covid-19/telerehabilitation/pabc-physiotherapy-virtual-care-toolkit
• CPTBC Webinar
  • https://register.gotowebinar.com/register/4133221844926337805

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Most Alberta physiotherapists are familiar with restricted activities, but they may not be aware of the differences between advanced restricted activities and basic restricted activities, the requirements they must meet in order to be able to perform them, and the nuances of legislation that govern these activities. In this episode, Jody and Leanne discuss all things related to restricted activities.

Ever wonder why restricted activities exist at all? Or why some are 'basic' and others 'advanced'? Do the expectations for competent practice differ depending on whether the restricted activity is 'basic' or 'advanced'? We answer these questions and more, highlighting Physiotherapy Alberta's governing legislation and the expectations established in the Standards of Practice along the way.

Towards the end of the episode we talk about why Physiotherapy Alberta recently started collecting more information about the basic restricted activities that physiotherapists perform.

As a College, we have always understood that the restricted activities identified under the Government Organization Act are there for a reason. These activities pose a risk to the public if they are performed by someone who is unskilled or unqualified to perform them.

In gathering more information, we are trying to get a better understanding of what physiotherapy practice looks like, what basic restricted activities are being done, by whom and in what clinical context. We are also trying to better understand how people are developing and maintaining their skills.

Want to learn more about restricted activities? Check out these resources:

• Standard of Practice – Performance of Restricted Activities

https://www.physiotherapyalberta.ca/physiotherapists/what_you_need_to_know_to_practice_in_alberta/standards_of_practice/performance_of_restricted_activities

• Physiotherapy Alberta – Restricted Activities https://www.physiotherapyalberta.ca/physiotherapists/what_you_need_to_know_to_practice_in_alberta/restricted_activities
• Good Practice: Restricted Activities https://www.physiotherapyalberta.ca/physiotherapists/news/good_practice_restricted_activities

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Note: The information in this episode is now considered out of date. Please visit Episode 88: Reviewing Regulatory Rules for Use of Title instead.

In this episode, Jody and Leanne discuss the dizzying array of credentials physiotherapists place behind their names and what the standards require when it comes to use of title in practice.

Use of title isn't an issue that tends to lead to complaints, but it does lead to public confusion. Physiotherapy Alberta hears from members of the public who want to know what those credentials mean and whether a particular physiotherapist is qualified to treat them.

"Some signature lines look like a veritable alphabet soup of letter combinations… The bottom line with credentials and additional training is that they need to be presented in a way that has meaning to the public. When it comes to listing credentials and additional training on a business card or website, it needs to be done in a way that your grandmother or mine can understand."

• What titles are physiotherapists and physiotherapist interns expected to use?
• What about academic credentials? Can physiotherapists use them? What order should they be listed in?
• What about other credentials, like Clinical Specialist, Doctor, or Advanced Practice Physiotherapist? What are the rules around these terms?

We answer these questions and more in this episode.

Most importantly, be proud of your protected title! You worked hard to earn it.

For more information about use of title, check out these other resources from Physiotherapy Alberta:

• Standards of Practice – Use of Titlehttps://www.physiotherapyalberta.ca/physiotherapists/what_you_need_to_know_to_practice_in_alberta/standards_of_practice/use_of_title
• Good Practice: Using Your Professional Title Appropriately https://www.physiotherapyalberta.ca/physiotherapists/news/good_practice_using_your_professional_title_appropriately

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This episode was inspired by Don Cherry's infamous comments on Hockey Night in Canada and the public and media reactions to those comments. Moyra McAllister, Physiotherapy Alberta's Complaints Director, joins the podcast to talk about communication concerns and on-duty or off-duty conduct that can lead to patient complaints.

Like George Bernard Shaw said, "the single biggest problem in communication is the illusion that it has taken place." Communication is at the core of nearly every complaint that Physiotherapy Alberta receives.

Patients expect that communication with their physiotherapist will be respectful and professional. Physiotherapy Alberta and employers alike have expectations about what is or is not acceptable on-duty conduct. The expectations outlined in the Standards of Practice represent the minimum requirements, but employers can set the bar higher. That's not to suggest that the Standards set the bar low, they are just the minimum expectations that all physiotherapists must meet. We start the episode by discussing those expectations.

But do those expectations apply when the physiotherapist is off-duty? Are physiotherapists ever really off-duty? In the latter half of the episode we address that topic and highlight interesting conduct cases where off-duty conduct led to complaints and sanctions against regulated professionals.

Want to read the Standard of Practice – Communication or the Code of Ethical Conduct for yourself? Check them out here:

• Standards of Practice – Communication https://www.physiotherapyalberta.ca/physiotherapists/what_you_need_to_know_to_practice_in_alberta/standards_of_practice/communication
• Code of Ethical Conduct https://www.physiotherapyalberta.ca/physiotherapists/what_you_need_to_know_to_practice_in_alberta/code_of_ethical_conduct

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Note: Due to changes to legislation this content is no longer up to date. Please refer to "Episode 86: Four Actions you Can Take Now to Improve Client Privacy in Your Practice Setting" for updated privacy information.

Jody Prohar, Registrar and Executive Director of Physiotherapy Alberta and Leanne Loranger, Manager of Policy and Practice discuss the dizzying landscape of privacy legislation for physiotherapists in Alberta.

"Alberta physiotherapists are currently subject to 4 different pieces of privacy legislation... In some practice settings, more than one piece of privacy legislation can apply to patient records. So, when we talk about privacy for Alberta physiotherapists, we have to be thoughtful about the fact that different rules can apply to the same physiotherapist even when they are working at just one practice site."

Luckily, privacy legislation is founded on several shared principles, so a physiotherapist can take a principles-based approach to privacy and be well on their way to compliance with the rules that are relevant to their practice.

Later in the episode we discuss some of the common privacy challenges that physiotherapists encounter, such as

• Only using private information for purposes identified at the time of collection.
• Being attentive to the privacy challenges related to use of personal devices in practice.

We close with a discussion of what would happen if physiotherapists were declared custodians under the Health Information Act, what this would mean in terms of becoming eligible to be an authorized custodian under the Act (hello Netcare access), and the process of becoming an authorized custodian. (Hint: it's not as simple as you may think.)

Resources:

• https://www.physiotherapyalberta.ca/files/practice_standard_privacy_confidentiality.pdf

https://www.physiotherapyalberta.ca/files/guide_privacy_for_ab_physiotherapists.pdf

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Individuals on the Provisional Register are a diverse group of people working to fulfill the requirements of registration on Physiotherapy Alberta's General Register. Until those requirements are fulfilled, supervision is required to help protect the interests of patients and facilitate the delivery of quality care. In this episode, Simon Cooke, Physiotherapy Alberta Council Vice-President and Leanne Loranger, Manager of Policy and Practice discuss the considerations, challenges, and rewards of supervising Physiotherapy Interns.

"Think of it as a contract between Physiotherapy Alberta and the public."Physiotherapy Alberta registers physiotherapy interns to practice but requires they be supervised. Without the Provisional Register, individuals would not be able to practice until they fulfilled all the registration requirements and were added to the General Register, and that delay could contribute to the erosion of clinical skills. Permitting practice helps physiotherapy interns to maintain and further develop their skills and provides patients with access to valuable health-care providers.

The Provisional Register, and supervision of physiotherapy interns is an attempt to balance all the interests at play.

The requirements of supervision, challenges if things don't proceed as hoped, and importance of having a supervision contingency plan are highlighted. Intricacies of use of title, providing receipts for treatment from physiotherapy interns and co-signing charts are also reviewed.

Do you understand what's expected when you supervise a physiotherapy intern? This episode will help to clear up any questions you have.

Resources:

• https://www.physiotherapyalberta.ca/physiotherapists/what_you_need_to_know_to_practice_in_alberta/standards_of_practice/supervision
• https://www.physiotherapyalberta.ca/files/supervision_agreement.pdf
• https://www.physiotherapyalberta.ca/physiotherapists/resources_to_help_you_meet_practice_standards/supervision_guide
• https://www.physiotherapyalberta.ca/xchange/continuing_professional_development/elearning_center/supervising_physiotherapy_interns_expectations_and_challenges/
• https://www.physiotherapyalberta.ca/physiotherapists/news/good_practice_physiotherapist_interns_students_and_advanced_restricted_activities

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In this episode, Physiotherapy Alberta's Council President Karin Eldred and Leanne Loranger, Manager of Policy and Practice answer common questions that arise when physiotherapists seek consent for treatment, including:

• Is it OK to accept verbal consent?
• Why isn't it OK to get consent on an intake form?
• When can a physiotherapist accept consent from a minor?
• Who should a physiotherapist get consent from if they think their patient has a cognitive impairment?

Physiotherapists need to know that consent is only valid if it is informed. While physiotherapists can choose to accept either verbal or written consent from their patients, they need to inform their patients of the proposed intervention and its rationale, the benefits and risks of the intervention and the risks of not undergoing the treatment before seeking the patient's consent.

Physiotherapists also need to recognize that consent is an ongoing process. "It's not one and done… You don't obtain consent once and are 'good to go' indefinitely."

Later in the podcast we delve into the concept of capacity to provide consent, as it relates to minors and to older adults, realizing that capacity isn't a switch that gets thrown on a person's 18th (or 65th) birthday. Finally, we discuss what to do when a person with capacity is not consenting to treatment or is making a decision that the physiotherapist thinks is unsafe.

Resources:

• https://www.physiotherapyalberta.ca/files/practice_standard_consent.pdf
• https://www.physiotherapyalberta.ca/files/practice_guideline_consent.pdf

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Jody Prohar, Registrar and Executive Director of Physiotherapy Alberta and Leanne Loranger, Manager of Policy and Practice discuss emerging physiotherapy practices.

"When asked whether an activity is within the scope of practice for physiotherapists, we need to provide an answer with public interest/public protection top of mind. But it's not always easy to settle on an answer."

When asked about activities as diverse as cupping, shock wave and blood flow restriction, Physiotherapy Alberta reviews governing legislation and regulations, the evolution of the profession, physiotherapist education and competence, and the evidence regarding the proposed treatment.

When it comes to emerging practices, their spread and adoption will vary depending on the rules and context of different jurisdictions. Are we "falling behind" or are there factors that make a practice safe and effective in one jurisdiction, that are absent and make the same activity unsafe in Alberta?

Physiotherapy Alberta has a role to play in asking questions and staying informed about emerging practices as part of fulfilling our mandate of public protection. Similarly, physiotherapists need to ask tough questions and pause before jumping on trendy treatment approaches.

In this episode we discuss our approach to reviewing emerging practices using the Canadian Alliance of Physiotherapy Regulators "Is it Physiotherapy?" tool and encourage members to do the same.

Resources:

• https://www.physiotherapyalberta.ca/physiotherapists/news/good_practice_emerging_practices_and_treatment

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"With prevalence numbers at 30-40%… physiotherapists should act under the assumption that every patient they encounter has experienced sexual abuse or sexual assault of some type."

In this episode, Jody Prohar, Registrar and Executive Director of Physiotherapy Alberta and Leanne Loranger, Manager of Policy and Practice talk about how a history of sexual assault has the potential to affect the patient-physiotherapist relationship.

When physiotherapy assessments or interventions are clinically appropriate they do not constitute sexual abuse or sexual misconduct but, is that going to be a comfort to the physiotherapist if a patient makes a complaint because they thought the physiotherapist did something inappropriate?

Could a history of sexual assault effect how the patient perceives the physiotherapist's actions?

Clear communication and strong consent practices are the key to avoiding misunderstandings or patient distress.

With the high prevalence of sexual assault in Canada, physiotherapists should view sensitive practice as a universal precaution. They need to know about the effects of trauma and how triggers can powerfully remind a person of a past assault causing them to re-live it.

Towards the end of the episode we highlight some things physiotherapists can do to try to avoid triggering a traumatic memory, discuss patient reactions that may indicate that a memory has been triggered and provide suggestions for where physiotherapists can go to learn more about these topics.

Resources:

• https://www.physiotherapyalberta.ca/
• https://www.physiotherapyalberta.ca/physiotherapists/news/power_and_the_therapeutic_relationship_considerations_for_physiotherapists?
• https://www.physiotherapyalberta.ca/public_and_patients/protecting_patients_from_sexual_abuse_or_misconduct
• https://www.physiotherapyalberta.ca/physiotherapists/what_you_need_to_know_to_practice_in_alberta/protecting_patients_from_sexual_abuse_or_misconduct

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"If I tell a friend a dirty joke, it's just me telling my friend a dirty joke. But if I do the same thing with a patient, I'm at risk of a complaint of sexual misconduct and could face a license suspension."

In episode 1, Jody Prohar, Registrar and Executive Director of Physiotherapy Alberta and Leanne Loranger, Manager of Policy and Practice touched on behaviours that are normal in a personal relationship, but unacceptable in a physiotherapist-patient relationship.

In this episode we go into greater detail about how dirty jokes and other seemingly innocent comments could lead to big trouble for physiotherapists because of how sexual misconduct is defined by theHealth Professions Act.We discuss the concepts of professionalism, power, and power imbalance in therapeutic relationships.

Towards the end of the episode, we highlight strategies physiotherapists can use to try to share power with their patients.

Can the power imbalance between patient and physiotherapist ever be fully equalized?

Resources:

• https://www.physiotherapyalberta.ca/files/practice_standard_sexual_abuse_misconduct.pdf
• https://www.physiotherapyalberta.ca/public_and_patients/protecting_patients_from_sexual_abuse_or_misconduct
• https://www.physiotherapyalberta.ca/physiotherapists/what_you_need_to_know_to_practice_in_alberta/protecting_patients_from_sexual_abuse_or_misconduct
• https://www.physiotherapyalberta.ca/physiotherapists/news/power_and_the_therapeutic_relationship_considerations_for_physiotherapists?

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