This article will explore the use of imaging by California physical therapists. With the passing of AB 1000 allowing “direct access” to California physical therapists in 2014, and technological advances in all types of imaging, physical therapy and imaging seem to be a match made in heaven. In fact, the Commission on Accreditation in Physical Therapy Education (“CAPTE”) requires imaging to be included in the curriculum of all doctorate of physical therapy programs.
As the American Physical Therapy Association notes:
Physical therapists have been using imaging in practice, research and education for decades. Recent advances in imaging technology such as functional magnetic resonance imaging and ultrasound imaging has opened new opportunities to further incorporate imaging to physical therapist practice, research and education. Ultrasound has moved from the radiology suite to the point-of-care and into the hands of physical therapists. Physical therapists are finding new and innovative way to use imaging. The goal of this site is to highlight all expanding possibilities of imaging with physical therapy to evaluate and manage injury and disease and study human movement. Expanding the knowledge and availability of imaging in physical therapist practice will better inform patient management. This website is a resource for clinicians, students, clients, caregivers, and researchers to stay current on the emerging trends and uses of imaging in physical therapy.
Based upon the above, it seems that physical therapists in California should, therefore, embrace diagnostic imaging. So why should they avoid the temptation to order and review imaging in California? The answer is the California Physical Therapy Practice Act.
California Physical Therapy Practice Act
The Physical Therapy Practice Act (“Act”) remains the main impediment to integrating imaging into a physical therapist’s practice in California. The scope of physical therapy practice still contains an express prohibition against diagnosis and limit on x-rays:
Physical therapy means the art and science of physical or corrective rehabilitation or physical or corrective treatment of any bodily or mental condition of any person by the use of physical, chemical, and other properties of heat, light, water, electricity, sound, massage, and active, passive, and resistive exercise, and shall include physical therapy evaluation, treatment planning, instruction and consultative services. The practice of physical therapy includes the promotion and maintenance of physical fitness to enhance the bodily movement related health and wellness of individuals through the use of physical therapy interventions. The use of roentgen rays and radioactive materials, for diagnostic and therapeutic purposes, and the use of electricity for surgical purposes, including cauterization, are not authorized under the term “physical therapy” as used in this chapter, and a license issued pursuant to this chapter does not authorize the diagnosis of disease.
Not only does the Act prohibit x-rays for diagnostic purposes, which is understandable, it similarly prohibits their use for therapeutic purposes.
The only enlightenment the PT Board has offered over the years on this issue is from its February 2, 2004 meeting in San Diego. In response to a practice issues inquiry, the Board’s meeting minutes state:
The Committee directed staff to respond that the Physical Therapy Practice Act precludes a physical therapist from actually taking x-rays or utilizing x-rays to make a diagnosis. A physical therapist can only take x-rays if they are also certified as a radiologist technician through the Department of Health Services. The physical therapist is required to obtain a diagnosis from another professional that is licensed to diagnose in order to treat physical therapy. The Committee directed staff to send the Direct Access letter which explains a physical therapist needing a diagnosis to treat. However, the Physical Therapy Practice Act does not preclude a physical therapist from ordering an x-ray.
Despite the advancing imaging technology, the Act has stayed the same and without legislative change, a practicing physical therapist must be cautious.
Use Caution Regarding Imaging
While a physical therapist cannot take x-rays (unless certified as an x-ray technician) and cannot use them to diagnose or even treat, he or she can order them. But what then does the physical therapist do with them? The Board has not retreated from the 1965 Attorney General’s opinion which clearly states that Business and Professions Code section 2660 prohibits a physical therapist from diagnosing.
Similarly it is concluded that the Legislature, in adopting the language of section 2660, could have competently determined, and undoubtedly did determine, that although the educational requirements for licensure as a physical therapist are sufficient to permit the therapist to conduct certain specified treatments for human ailments, that educational standard is insufficient, with due regard to the public health and safety, to permit him to diagnose human ailments and disease..
The language of the Act specifically prohibits “roentgen rays and radioactive materials for diagnostic and therapeutic purposes.” The natural question then becomes “Can a physical therapist use ultrasound or magnetic resonance imaging that do not involve radiation?” These are not expressly banned in the Act, but neither are they expressly authorized.
When a physical therapist orders or even reviews any imaging, he or she should take great care to document in the patient record the purpose of obtaining the imaging, and that it is not for diagnosis, or in the case of x-rays, not even for therapy. In addition, without an already existing diagnosis for the patient, simply ordering imaging without sufficient documentation could place the physical therapist at risk. Why else would a physical therapist have ordered or have copies of “diagnostic” imaging? The answer should be clearly documented to show how the physical therapist obtained the images and who interpreted them (not the physical therapist). Also, if x-rays, the physical therapist needs to note that they are not used for diagnosing or therapy. If ultrasound or MRI, the notes should state the non-diagnostic purpose for which the physical therapist has the imaging.
Despite the enormous benefits to patients and the practice of physical therapy from diagnostic imaging, California law, namely the Act, has not evolved sufficiently to allow physical therapists to order and freely use imaging in their practice without significant risk. To assist in navigating these waters, we recommend that physical therapy practitioners consult qualified legal counsel.
Steven L. Simas is the founder of the Government and Administrative Law firm of Simas & Associates, Ltd., in Sacramento, San Luis Obispo, San Jose, and San Diego, California. Mr. Simas practices in the areas of Healthcare Regulation, Professional Licensing and Regulation and Workplace and Employment Regulation.
The firm has proudly served as legal counsel to the California Physical Therapy Association since 2004 and can be reached at email@example.com.