Controlled Acts & Other Restricted Activities FAQs

FAQs: Controlled Acts

• What are controlled acts?

  A controlled act is a healthcare activity that can cause harm if a person who is not qualified or skilled performs it. 
  
  There are 14 controlled acts listed in the Regulated Health Professions Act (RHPA). The RHPA also outlines which activities can be performed by each of the regulated health care professions. 
  
  Be sure to look at the College’s Controlled Acts and Restricted Activities Standard. 

• Which controlled acts can physiotherapists in Ontario perform?

  There are seven controlled acts (sometimes referred to as authorized activities) that Ontario PTs can perform. A physiotherapist must roster (complete an online declaration) with the College if they perform any of the following controlled acts. 

  - Spinal manipulation

  - Tracheal suctioning

  - Acupuncture (this includes dry needling)

  - Treating wounds below the dermis by cleansing, soaking, irrigating, soaking, probing, debriding, packing or dressing

  - Inserting a hand, finger, or instrument beyond the labia majora or anal verge for the purposes of assessing or rehabilitating pelvic musculature relating to incontinence or pain

  - Administering a substance by inhalation (when the substance has been ordered by an authorized person)

  Physiotherapists do not have to roster for communicating a diagnosis identifying a disease, physical disorder, or dysfunction as the cause of a person's symptoms because this is a fundamental part of PT practice. Learn more about rostering. 

• Do I need to roster for each individual controlled act?

  Rostering is the process where physiotherapists add their names to a public list indicating they have the required training, education and experience to safely perform the higher risk activity. Physiotherapists who perform authorized activities must roster for each individual authorized activity they perform. 
  
  The only exception is communicating a diagnosis. This is an authorized activity that does not require rostering as it is considered an essential competency.
  
  PTs must roster for the following activities:

  - tracheal suctioning

  - spinal manipulation

  - acupuncture (including dry needling)

  - treating a wound below the dermis

  - pelvic internal exams (this includes putting an instrument, hand or finger, beyond the labia majora, or beyond the anal verge)

  - administering a substance by inhalation

  Read the Controlled Acts and Other Restricted Activities Standard to learn more. 
  
  

• Can a physiotherapist delegate a controlled act to another person?

  Physiotherapists may delegate 3 of the controlled acts they are authorized to perform: tracheal suctioning, wound care and administering a substance by inhalation.
  
  Physiotherapist may NOT delegate: acupuncture, communicating a diagnosis, spinal manipulation, or internal assessment treatment of pelvic musculature
  
  Before delegating to another person, physiotherapists must document that they have:

  - Ensured the person they are delegating to has the knowledge, skills, and judgment to carry out the activity safely, competently, and ethically.

  - Explained when the person can and cannot perform the controlled act. If the patient’s condition changes or they are high risk for example, it may not be appropriate to delegate a controlled act in this case. 

  - Ensured that the person who is carrying out the activity knows how to manage any adverse outcome that can reasonably be foreseen. They must be familiar with the written plan that has been created by the person delegating the activity.  

  - Confirmed that the person knows they must not delegate the act to anyone else.

   

• How does delegation take place? What is the difference between a direct order and a medical directive?

  Delegation is a formal transfer of authority and can take place either through a direct order or a medical directive. 
  
  Direct orders are when you get the authority to perform a controlled act from another healthcare provider (usually a physician) for a specific client. 
  
  A direct order can be written or verbal (although if received verbally, you should document that it was received). A typical direct order would include for example “Patient X to ambulate with 3L O2 maintain SaO2 94+%.”
  
  A medical directive is an order that can be used for several patients when certain conditions exist. For example, a PT may be asked to order x-rays or routine blood work for total hip arthroplasty patients. Medical directives are always written.
  
  Useful Resource for Multi-Disciplinary Teams
  An Interprofessional Guide on the Use of Orders, Directives and Delegation for Regulated Health Professionals  
  

• Can I delegate O2 titration to a physiotherapist assistant (PTA)?

  Yes, you can delegate 02 titration to a PTA. Physiotherapists can delegate to anyone who has the knowledge, skills and judgement to safely and competently perform the activity – this includes assistants and anyone other health care professional the PT believes is competent. 
  
  The acts that can be delegated are:

  - administering O2

  - suctioning

  - wound care

  The acts that cannot be delegated are:

  - acupuncture (dry needling) and this includes all parts, even removing needles

  - spinal manipulation

  - communicating a diagnosis

  - internal assessment and treatment of pelvic musculature

  Remember, when delegating a controlled act to another person, the physiotherapist must document that they have:

  - Made sure the person performing the act has the knowledge, skills, and judgement to do so safely, competently and ethically.

  - Explained the circumstances in which the person can perform the controlled act, as well as the types of patient with the certain conditions and any other limitations.

  - Ensured the assistant knows how to deal with possible adverse outcomes and has a written plan.

  - Confirmed that the person they are delegating understands that they cannot delegate this act to anyone else.

  Please consider using the Physiotherapist Assistant Competency Checklist when assessing competency and considering delegating any activity.
  
  

• The PTA will need to switch the patient from the wall supply to a portable O2 tank, and stay at 2 L/min. Does this require delegation?

  Yes, delegation is required in this scenario. The controlled act given to physiotherapists is "administering a substance by inhalation" and requires that there be an order for the substance. Even though the PTA is not adjusting the amount of oxygen delivered, if the PTA is changing the delivery of oxygen from the wall to a portable tank, they will need to set up the portable O2 system, which is the same as administering O2 and delegation is required. 

• I have a patient who is on 2 LPM (L/min) of oxygen by nasal prongs. I want to assign gait training to a physiotherapist assistant (PTA). The PTA will need to switch the patient from the wall supply to a portable O2 tank, and stay at 2 L/min.

  Yes, delegation is required in this scenario. The controlled act given to physiotherapists is "administering a substance by inhalation" and is not limited to adjusting O2 levels. Oxygen is a prescription.  

  
  If the PTA is changing the delivery of oxygen from the wall to a portable tank, they will need to set up the portable O2 system which is administering O2 and delegation is required. 
  
  This activity involves risk. The PTA needs special knowledge to do the activity. 
  
  For example, the PTA will need to make sure the tank is turned on and has enough oxygen in it. They will need to be certain that they reconnect the hose to the oxygen and not to the air valve. The PTA should know whether to monitor SpO2  during the activity, meaning they may need to increase the flow rate if the patient desaturates. This activity could be a risk to patients and therefore requires delegation. If the patient requires a face mask for their O2 needs, the PTA will need for example to understand the impact on FiO2 and any humidification requirements.

• Do physiotherapists need to be rostered to increase a patient’s supplemental O2 level?

  Yes, any time you want to adjust a patient's 02 level you need to either be rostered or have the authority (to administer, titrate or adjust) delegated to you by an MD (Dentist, Nurse Practitioner, midwife). An order for 02 and the parameters for administration is also always needed.
   
  Same thing with switching between the wall and portable 02 - you may not be adjusting the levels, but you are changing the system where O2 is delivered. The competencies are needed to set up and adjust 02 levels are the same.
   
  If you are not administering or adjusting or titrating or doing anything with a patient's 02, then you do not need to be rostered.
  
  

• I treat patients with urinary and bowel incontinence. Can I ask a patient to document their fibre and fluid intake, add some types of fibre where appropriate and reduce certain foods to evaluate the food types' influence on bowels?

  The function of the pelvic floor is what you, as a physiotherapist, are addressing during the session. Bowel and bladder functions can be closely related to the integrity of the musculoskeletal condition of the pelvic floor.
  
  If you are doing your due diligence during an assessment and asking questions about the frequency of bowel and bladder elimination to assess the pelvic floor, then it does seem reasonable. 
  
  If you have highlighted a problem and suggest fibre intake to improve the patient's bowel motility, you should assess the risk of the recommendation. The risk is there could be another medical condition that you do not have the competency as a PT to evaluate thoroughly.
  
  A physiotherapist cannot diagnose a patient nutritional issue. Of the scenarios in question, the most problematic one is the prescription of the specific elimination diet. It is essential that results from a prescriptive diet are not interpreted by a PT as a nutritional diagnosis. 
  
  A physiotherapist should work with an MD or an RD to help guide a patient's care who is living with chronic diarrhea, as this is not a physiotherapy diagnosis. 
  
  Collaborative Care Standard
  

• Do physiotherapists need to take a formal course to roster for a controlled act?

  Physiotherapists must be able to prove that they have successfully completed training for the controlled acts they perform. This can be formal education or training delivered on the job. During the training, the physiotherapist must: 

  • Learn the indications, contraindications, adverse outcomes, and risks associated with performing the controlled act. 
  • Practice the controlled act under the supervision of a person who is authorized to perform it. 
  • Be evaluated on the knowledge, judgement, and practical skills needed to perform the controlled act.
  • Show that they are able to safely and competently perform the controlled act. 

  You can find the full list of requirements that need to be in place before performing a controlled act in the Controlled Acts and Restricted Activities Standard. 

• I have been redeployed to provide PT care in a critical care unit. Can PTs perform tracheal suctioning?

  In Ontario, physiotherapists are legally authorized to perform a number of activities referred to in the Regulated Health Professions Act, 1991 (“RHPA”) as controlled acts (or authorized activities). These are activities that are seen to involve a higher level of risk than other activities, so only certain regulated healthcare professionals can perform them. 
  
  Physiotherapists are entitled to perform the controlled act / authorized activity of tracheal suctioning if they are on the College’s roster allowing them to perform this activity (which means they have received specific training with respect to this procedure), or they can perform tracheal suctioning if it has been delegated to them by another regulated professional (such as a physician) who has the legal authority to perform tracheal suctioning. Physiotherapists should not accept delegation of any controlled act that they do not believe they are competent to perform. Physiotherapists are encouraged to review the Controlled Acts and Other Restricted Activities Standard before undertaking this work.  
  
  The actual controlled act involved in performing tracheal suctioning involves putting an instrument, hand or finger 

  • beyond the point in the nasal passages where they normally narrow,
  • beyond the larynx, or
  • into an artificial opening into the body 

  With the current health human resource shortages, physiotherapists may be asked to assist with patient care in ways they have not experienced before. 
  
  Physiotherapists may require additional training to enhance their skills so that they can provide safe, competent care.  

FAQs: Physiotherapy Scope of Practice

• Can I be asked to do activities that are not typically in the scope of physiotherapy practice?

  In a health emergency such as a pandemic, physiotherapists are valuable health team members who may be asked to participate in activities that are outside their normal duties.
  
  For example, PTs may be asked to assist with mask fit testing or screening procedures. Some of the activities that physiotherapists may be asked to perform are considered controlled acts and require delegation by a practitioner who is authorized to perform them.
  
  Recognizing these activities may not be common practice for PTs, they could only be done with adequate training on the procedures and if given the required personal protective equipment.
  
  With appropriate safeguards in place we would expect physiotherapists to be flexible during situations of health emergencies to assist the health care system manage increased demands. There may be exceptions to this and we encourage those PTs to have discussions with their organizations to address any concerns.

• What changes came into effect on September 1, 2011 as a result of amendments to the Physiotherapy Act?

  On September 1, 2011, several changes to the Physiotherapy Act came into effect. These amendments:

  - Updated the scope of practice of physiotherapy. The new statement adds the component of diagnosis of physical dysfunction and it is restructured to emphasize a systems approach, and

  - Added a number of new authorized acts to the ones that physiotherapists/physical therapists were already allowed to perform. 

  Physiotherapists should also note that the Controlled Acts and Restricted Activities Standard replaced the previous Standard of Professional Practice: Controlled Acts.

• What authorized activities were granted in the amendments to the Physiotherapy Act?

  As of February 2012, physiotherapists can perform the following activities:
  
   •  Spinal manipulation
   •  Tracheal suctioning
   •  Acupuncture
   •  Treating wounds below the dermis
   •  Assessing or rehabilitating pelvic musculature
   •  Administering a substance by inhalation (when the substance has been ordered by an authorized person)
  
  All of these activities require rostering. 
  
  The following three activities have not received government approval and cannot be independently performed by physiotherapists. PTs can only perform these activities when the authority to do so has been delegated to them by another healthcare provider.
  
  

   •  Ordering a prescribed form of energy (e.g. diagnostic ultrasound or MRI)
   •  Ordering diagnostics (e.g. x-rays or CAT scans)
   •  Ordering specified laboratory tests

   

• What is the difference between a controlled act and an authorized activity?

  Authorized activities include all legally restricted health care activities that may only be performed by people who have the appropriate legal authority.
  
  Controlled acts are a subset of authorized activities specific to the Regulated Health Professions Act (RHPA). Other authorized activities are restricted under different laws such as the Healing Arts Radiation Protection Act (HARP) and Laboratory and Specimen Collection Centre Licensing Act (LSCCLA) and their regulations.

• What is a roster and how and when do I get on the roster?

  A roster is a list of physiotherapists who are allowed to perform a specific authorized activity under their own independent authority. These lists are managed by the College of Physiotherapists of Ontario.
  
  Registrants are required to add their names to the roster (list) for each of the authorized activities they plan to perform. Some physiotherapists will choose not to perform authorized activities and will not need to add their names to any roster with the College.

  Part of the application process requires a signed legal declaration stating the individual is competent to perform the authorized activity. Information on the rosters is accessible on the Public Register. There are no fees for getting on a roster. Online rostering has been available since February 1, 2012.

• Can physiotherapists use ultrasound to treat a blocked duct in the breast of a lactating patient?

  While breast health does not fall within the scope of physiotherapy, and a blocked duct would not be a physiotherapy diagnosis, this may be an activity a physiotherapist could perform under the right circumstances. The physiotherapist would need to work with a regulated health care professional who has breast health within their scope (e.g. physician, midwife, nurse practitioner) who had assessed the patient, diagnosed the blocked duct, and determined whether therapeutic ultrasound would be an appropriate treatment. 

  Physiotherapists should only provide the care if they have the knowledge, skills, and judgement to do so safely and competently, and have information to support it as a safe and effective treatment. The PT should work collaboratively with the referring health care provider and consider how they will monitor for efficacy of treatment and progress. The PT should also have a conversation with the patient regarding the nature of the treatment, its benefits and risks, alternatives to treatment, and provide information that the PT is working collaboratively with another health care professional. See the Collaborative Care standard for more information. 

  Want to introduce something new to your practice? Not sure if something falls within physiotherapy scope? Have a look at the "Is It Physiotherapy" decision-making tool.

• What is the role of a physiotherapist in the assessment and management of concussions?

  Remember that a physiotherapist’s scope of practice is outlined in the Physiotherapy Act. According to the Canadian Alliance of Physiotherapy Regulators’ Position Statement on The Role of Physiotherapists in the Assessment and Management of Concussions:
  
  "A comprehensive, medical assessment is required to diagnose a concussion. Only medical doctors and nurse practitioners are qualified to provide a concussion diagnosis. 
  
  In conjunction with a concussion management team, physiotherapy diagnosis is appropriate in cases of symptoms and physical injuries or impairments that are associated with cervical spine, the sensorimotor and neuromotor control systems or the physical injuries, impairments or symptoms related to common concussion co-morbidities resulting from falls, whiplash, spinal cord injury or assault etc."
  
  View the complete position statement from CAPR.
  
  Physiotherapy Scope FAQs

• Can a physiotherapist recommend a patient take supplements, like vitamin C, as part of their treatment plan?

  No, physiotherapists are not allowed to prescribe or recommend medications, including over-the-counter drugs or supplements like vitamins, as part of a treatment plan. They also can’t suggest specific diets. However, physiotherapists can share general information if there’s evidence that supplements might help the patient reach their goals in physiotherapy. They should advise patients to talk to a healthcare provider (like a doctor, nurse practitioner, or pharmacist) who can answer questions about how supplements or medications might interact with any current medications and affect their health.
  
  Physiotherapists must be careful to stay within their training and scope of practice and think about any risks, like possible drug interactions, when talking about supplements with patients.