Declaratory Statements - Wellness

1. 09.04.01 Wellness Services - In this age of limited P.T. visits and "caps" on therapy services, more and more individuals are being discharged from therapy who are not "fully" recovered and have residual disabilities. Health clubs are catering to the geriatric population -- especially the homebound geriatric population -- for "wellness fitness" training. With the move of the health club "fitness" market to geriatrics, many ýtrainersý with minimal training and education themselves are legally "exercising" and giving advice to individuals with extensive past medical histories and chronic medical problems who exhibit gait deviations, abnormal tone, mobility problems, and to individuals who were discharged from physical therapy due to insurance limitations. Please advise whether a P.T. or a P.T.A. may work for or in a health club environment or in their own facilities, providing "wellness" education and training to patrons or clients seeking guidance. If this situation is acceptable, what limiting conditions might exist? For example, may the P.T. or P.T.A. indicate to the patient his education, training and experience in physical therapy? During an exercise session, may the P.T. or P.T.A. use his knowledge of tone inhibition, positioning, normal gait, etc? .

   The Physical Therapy Practice Act explicitly authorizes PT licensees to provide physical therapy services without a prescription or referral for conditioning, education or activities designed for injury prevention, reduction of stress or promotion of fitness. (La. R.S. 37:2410D(4)) Other provisions of the Practice Act authorize a PT to provide initial evaluations and consultations of a screening nature without referral or prescription. (La. R.S. 37:2410A.)

   In the current health environment many people are seeking to improve their quality of life and to promote optimal health and well-being by seeking direction for guided physical exercise programs in gyms, health clubs, pilates and yoga classes, martial arts programs and other venues. Often these physical activities are led by well-qualified and credentialed instructors who have training and experience that will benefit clients and sometimes this is not the case. Physical therapists and physical therapist assistants are uniquely qualified by education, training and experience to provide guidance and structure for such physical exercise programs. Their education has focused on exercise physiology, bio-mechanics, kinesiology and therapeutic exercise, for individuals with normal and patho-mechanical conditions, all of which can help them to assess client needs and to plan, direct and enrich physical exercise programs.

   While a physical therapy ýpatientý is one who is referred for physical therapy treatment by a physician, surgeon, dentist, chiropractor or podiatrist, a ýclientý coming to a physical therapist for wellness or preventative services need not have a referral from a medical professional. Such clients often initiate their own fitness programs out of a felt need to improve the quality of their lives.

   Some clients will seek out such services after discharge from medical treatment, which may have included physical therapy treatment. Some patients receiving physical therapy treatment for diagnosed conditions may seek wellness services during the same time period to enhance their overall fitness and conditioning.

   Wellness services may be provided to clients in the same facilities where physical therapy treatment is provided, or in facilities remote from a patient treatment facility.

2. 07.10.01 Documentation for Wellness or Preventative Services - What documentation is required for a physical therapist to provide wellness or preventative services?

   A physical therapist shall perform an initial screening and assessment to determine if an individual qualifies for wellness or preventative services. If the individual has not acute or chronic medical or rehabilitative condition requiring medical or physical therapy treatment, the individual may be accepted for wellness or preventative services.

   This initial screening outcome shall be documented in writing signed by the physical therapist and must indicate the basis for the finding that the individual qualifies for preventative ser ices. Preventative or wellness services shall not be billed as physical therapy treatment.

3. Assessments in a wellness setting - What role does a PTA have in the screening process? We understand that the PTA can not make the decision as to whether a screen is positive or negative, however, is the PTA able to obtain supporting information regarding a resident's needs, current/prior level of care, etc. and then present that information to the PT, who makes the decision as to whether a patient is appropiate for PT?

   The Louisiana State Board of Physical Therapy Examiners has by Declaratory Statement opinioned that a PTA may not perform screens or assessments in any clinical setting or wellness setting. The Physical Therapist is responsible for the performance of services/assessments. A physical therapist assistant can collect data and present such information to the physical therapist, However, it is the physical therapists obligation to perform the evaluation and make the appropiate plan of care.

4. ATC at athletic events - 1) Due to our new access to the well population and the fact that physical therapists can evaluate patients without a referral, can physical therapists work on the field (like at football games) without a doctor or an ATC present? 2) If the answer to the previous question is yes, what is the physical therapist's capacity with regard to evaluating and treating athletes on the field without a doctor present? For instance, can physical therapists only evaluate an injured athlete or can they perform treatment as well? 3) If physical therapists can treat on the field, how far can a physical therapist go with regards to the extent of treatment? For instance, can a therapist perform first aid, taping, modalities, stretching on the field? 4) If a therapist cannot work on the field in the absence of a doctor or ATC, who does need to be present (MD, ATC, or both) in order for the therapist to work on the field? 5) In general, what is the difference between the capacity of a therapist alone on the field compared with the capacity of the therapist in the presence of a doctor or ATC?

   1) Please understand that since the inception of the Board's jurisdiction, being January 1, 1988, a physical therapist has been able to lawfully perform an initial evaluation or consultation of a screening nature to determine the need for physical therapy without referral, but implementation of physical therapy without referral, but implementation of physical therapy treatment for a specific condition must be based on the prescription or referral of a person licensed to practice medicine, surgery, dentistry or podiatry. Therefore, the recent promulgation of Rules 305 and 307 regarding preventative services does not impact a physical therapist's right to evaluate a patient without a referral. With regards to athletic events, the Board issued a Declaratory Statement published in the 1999 Newsletter addressing this issue. For your convenience, I will quote from the earlier Declaratory Statement as follows:

   The Board has determined that the pre-event procedures of massage, ice, superficial heat, stretching and warm-up exercises, and the post-event procedures of massage, ice, superficial heat, stretching and cool down exercises fall within the concept of consultative services and are in accordance with the Physical Therapy Practice Act and the Rules and Regulations promulgated by the Board and does not require a physician referral. However, post injury modalities such as electrical stimulation, prescriptive exercises, etc. shall not be performed without the referral or prescription from a physician.

   Furthermore, consultative services as referenced in the earlier Declaratory Statement could now be categorized as preventative services for the subject matter of this inquiry. Again, please be advised that once an injury has occurred any modalities would be considered physical therapy treatment and do require a referral or prescription from the appropriate health care provider in order to be rendered by a physical therapist.

   2) Please refer to Board's Response to Question 1 above. The physical therapist may perform CPR or first aid recognized by the American Red Cross with regards to an injured athlete, however, to implement physical therapy treatment, a physical therapist must first obtain a referral or prescription from the appropriate health care provider.

   3) Please refer to Board's Responses to Questions #1 and #2 above. A physical therapist may perform first aid, taping, and stretching on the field, however, modalities may not be performed without first obtaining a referral or prescription from a person licensed to practice medicine, surgery, dentistry or podiatry.

   4) Please refer to Board's Responses to Question #1, #2, and #3 above. With regards to your specific question, in order for a physical therapist to "work on the field," which for the purposes of this response we will assume to mean the provision of physical therapy treatment, a person licensed to practice medicine, surgery, dentistry, or podiatry must be on the field in order to diagnose the specific condition and provide a prescription or referral to the physical therapist.

   5) It is hoped that the Board?s Responses to Question 1 through #4 above will adequately respond to your inquiry.

5. Community Classes - Factual Scenario: We have community classes and services in place that provide exercise to clients for maintenance of fitness and prevention of loss of function. Two of the three classes have been in operation for greater than five years. The classes are taught in the PM&R clinic and are taught by a technician. Question 1: Parkinson's Community Exercise Class: This class is taught BIW at 1:30 for one hour. The class instructor is a physical therapy technician. This class is not advertised as physical therapy, but rather clearly identified that it is not physical therapy. The participants pay a monthly fee out-of-pocket and a physician's clearance is required. The majority of the participants were never enrolled in a formal physical therapy program. The class has been in operation for approximately 7 years. Question 2: Stroke Community Exercise Class: This class is taught BIW at 10:00 and 11:00 a.m. for one hour. The class instructor is a physical therapy technician. The same guidelines are in place as above. This class has been in operation for approximately five years. The majority of participants was enrolled in physical therapy treatment and participates in this class post discharge. Question 3: Aquatic Aerobic Exercise Class: This class is taught TIW in the physical therapy pool. The instructor is a certified aquatic and fitness instructor by the Cooper Clinic. This class has been in operation approximately 6-8 months. The majority, if not all, of the participants were never enrolled in physical therapy. Medical clearance is only required if the participants have certain medical conditions. Question 4: Post Discharge Wellness Member: Former physical therapy patients are able to join the CHRISTUS Schumpert Wellness Centers at a special rate. They are allowed to access the physical therapy gym and/or pool for a limited time through their wellness membership. They do not receive one-on-one physical therapy, but have access to the physical therapy equipment. The therapy staff is present in case the participant has questions. This program has been in place for approximately a year.

   Answer 1: Pursuant to Rule 305 promulgated by the Board, the scenario you have presented would be considered preventative services and the physical therapist must screen each person to determine whether he is a physical therapy patient or a wellness client. Therefore, the wellness program or class must be established or set up by the physical therapist as further required in rule 307D. Thereafter, the physical therapist can delegate the provision of the preventative services promoted by the class in accordance with Rule 305. In particular, Rule 305 provides that the level of responsibility assigned to supportive personnel is at the discretion of the physical therapist, who is ultimately responsible for the acts or omissions of these individuals. Supportive personnel may perform only those functions for which they have documented training and skills. Please be advised that the physical therapy tech must be supervised continuously, on the premises by the physical therapist pursuant to 321 C (1). It is also advised that the class instructor not be referred to as a physical therapist technician.

   Answer 2 Please see Response to Question 1 above. Again, please be advised that the physical therapist who is required to establish or set up the program will be ultimately responsible for the acts or omissions of the class instructor.

   Answer 3 In carefully reviewing this issue, as well as the Physical Therapy Practice Act, and the Board's Rules, the Board is of the opinion that the aquatic aerobic class described by you is not a physical therapy issue.

   Answer 4 Please see responses to questions 1 and 2 above.

6. Community Wellness Aquatics Program - Our hospital wants to start up a community wellness aquatics program. My question is can a PTA conduct the community aquatics program. The pool is located off site from the main hospital and no PT would be present at the pool during the wellness sessions. If the PTA is unable to complete the program would a PT be able to complete such a community program and if so what limitations if any would there be?

   The Louisiana Physical Therapy Practice Act LA R.S. 37:2410.D states:

   2410 Practice D. A physical therapist licensed under this Chapter shall not perform physical therapy services without a prescription or referral from a person licensed to practice medicine, surgery, dentistry, podiatry, or chiropractic. However, a physical therapist licensed under this Chapter may perform physical therapy services without a prescription or referral under the following circumstances: (1) To children with a diagnosed developmental disability pursuant to the patient's plan of care. (2) As part of a home health care agency pursuant to the patient's plan of care. (3) To a patient in a nursing home pursuant to the patient's plan of care. (4) Related to conditioning or to providing education or activities in a wellness setting for the purpose of injury prevention, reduction of stress, or promotion of fitness. (5)(a) To an individual for a previously diagnosed condition or conditions for which physical therapy services are appropriate after informing the health care provider rendering the diagnosis. The diagnosis shall have been made within the previous ninety days. The physical therapist shall provide the health care provider who rendered such diagnosis with a plan of care for the physical therapy services within the first fifteen days of physical therapy. (b)Nothing in this Chapter shall be construed to create liability of any kind for the health care provider rendering the diagnosis pursuant to this Subsection for a condition, illness, or injury that manifested itself after such diagnosis or for any alleged damages as a result of physical therapy services without a prescription or referral from a person licensed to practice medicine, surgery, dentistry, podiatry, or chiropractic.

   The Rules and Regulations Section 306C.1 and 2 state: 306 Physical Therapy Services Without Prescription or Referral C. As used in connection with providing the services referred to in LSA-R.S. 37:2410 D.(4): (1) The word "client" shall mean an individual seeking or receiving information, education and/or recommended activities concerning wellness and preventative services, including conditioning, injury prevention, and reduction of stress or promotion of fitness. (2) Prior to providing services, the physical therapist shall: (a) perform an initial screening to determine whether treatment or wellness/preventative services are indicated. The therapist shall inform the individual of the screening results and make recommendations for follow-up with the appropriate health care provider if need be. (b) asses the client's wellness/preventative services needs, and, should wellness/preventative services be indicated and desired, develop a written plan, which describes the wellness/preventative services to the rendered to the client.

   Supervision requirements for the PTA as outlined in Rules and Regulations, Section 321.A.3 state: 321. Supervision Requirements A. Licensed Physical Therapist Assistant (3). With regards to the requirement of periodic supervision of client preventative services rendered by a licensed physical therapist assistant. the supervising physical therapist: (a). shall perform an initial screening to determine if an individual qualified for preventative services and document; (b). shall provide education or activities in a wellness setting through the establishment of a program for the purpose of injury prevention, reduction of stress and/or the promotion of fitness; (c).shall be readily accessible by beeper or mobile phone; (d). shall conduct face to face conference with the physical therapist assistant regarding each client at least every thirty days commencing with the initiation of the preventative services for that client; and (e). may delegate only those functions to a physical therapist assistant for which he has documented training and skills.

7. Craniosacral Therapy - Could you please define "Craniosacral Therapy?"

   Rules 305 and 307 with regards to preventative services address conditions whereby there is no acute exacerbation of a specific condition. The Practice Act, more particularly LSA R.S. 37:2410A requires a referral or prescription from the appropriate licensed healthcare provider for a physical therapist to implement physical therapy treatment on individuals with a specific condition. In contrast, Rules 305 and 307 allow a physical therapist to apply preventative services when there is no acute exacerbation of a specific condition and the provision of such service falls within the parameters of the definition of preventative services.

8. Educational Seminars - Our concern involves a request to initiate physical therapy treatment secondary to possible pre-existing injury. Is it permissible under the Physical Therapy Practice Act and the Board's Rules to conduct an initial physical therapy evaluation on an individual to determine the need for physical therapy at an educational seminar, and can a PT establish physical therapy treatment in a fitness setting if an order for physical therapy is received from the physician?

   The Board is of the opinion that this may be done during an educational seminar. However, please understand that pursuant to current law, it is necessary to obtain a physician's order prior to the initiation of physical therapy treatment.

9. PT providing massages in a Wellness Capacity - A physical therapist would like to offer massages to clients who do not present with specific underlying ailments as a means of prevention, relaxation and overall stress reduction. Do I need a doctor's prescription before administering massage to a client?

   Pursuant to Rule 305, effective July 20, 2000, preventative services is defined as follows: Preventative Services- means the use of physical therapy knowledge and skills to provide education or activities in a wellness setting for the purpose of injury prevention, reduction of stress and/or the promotion of fitness, but does not include the administration of physical therapy treatment and, therefore, can be performed without referral or prescription. Therefore, after doing the appropriate screening to determine that a client does qualify for preventative services, you may perform such "feel good" massages without the necessity of a referral of prescription. The physical therapist may bill for preventative services to the recipient or to third party payors, if the third party payors provide for coverage of preventative services.

10. Physical Therapy Patients and Massage Therapy Clients - If I am currently seeing a patient for an unrelated diagnosis (i.e. lower extremity amputation), can I also see that individual as a client and offer him/her massages? Also, are there any other concerns I should be aware of in regards to offering "feel good" massages to well individuals?

    The Board is of the opinion that if you are seeing someone for both physical therapy treatment and preventative services at the same time, then you are obligated to assess the individual's status, and document, so as to distinguish and separate the physical therapy portion of the treatment from the provision of preventative services. In other words, a clear distinction must be demonstrated in your assessment and documentation which separates the physical therapy portion from the preventative services portion.

11. Hands on Preventative Services - Can I offer hands on preventative service?

    The Board's opinion is that "hands on preventative service" is permitted as part of the wellness practice. However, once a physical therapy diagnosis or problem is identified such as chronic pain or other condition, then the client must be treated as a physical therapy client to treat and address the problem(s). The physical therapy related problem(s) can be addressed in conjunction with preventative service practices but must adhere to β305 Preventive Services of the Rules and Regulations.

12. Physical Therapists working as Pilates Trainers - Are there any rules that would prevent a physical therapist, who is also a certified pilates instructor, from working in a pilates studio as an instructor? Do the same rules apply for a physical therapist who is not licensed in Louisiana?

    Given the Practice Act (2410 A. and D.(4)) and Rules and Regulations (Section 305 and 306.C.(1) and (2)), a physical therapist must exercise caution while functioning as a pilates instructor. Specific precaution should be taken in regards to individuals "seeking and receiving information, education and/or recommended activities concerning wellness and preventative services, including conditioning, injury prevention, reduction of stress or promotion of fitness." When a participant of such an exercise class seeks or receives individualized information as outlined in the Rules and Regulations, then the physical therapist must fulfill the requirements of Section 306, C. (2) (a) and (b). Otherwise, the physical therapist is functioning only in the role of teaching a Pilates group exercise class.

13. Post Discharge Fitness Program and Wellness - 1) I work in a rural health care center providing acute care and outpatient physical therapy services. Recently, our hospital completed a 65,000 square foot outpatient facility which will house physical, occupational, and speech therapy services. Please advise regarding the following. Several of our patients have requested to continue using our exercise equipment at a fixed monthly rate following discharge from physical therapy. Can this be done if the physician writes and order for a post-discharge fitness program? 2) If our hospital considers expanding services to include wellness, can this be accomplished using physical therapy personnel or must personal trainers, exercise physiologists, etc. be employed to provide fitness expertise? Also, can therapy services and wellness services be provided simultaneously in the same area?

    1) Effective July 20, 2000, the Board promulgated Rule 307D which states that a licensed physical therapist is authorized to engage in the practice of physical therapy as set forth in the Practice Act which includes, but is not limited to, the performance of preventative services. Preventative services are defined in Rule 305A, effective July 20, 2000, as follows:

    "the use of physical therapy knowledge and skills to provide education or activities in a wellness setting for the purpose of injury prevention, reduction of stress and/or the promotion of fitness, but does not include the administration of physical therapy treatment and , therefore, can be performed without referral per prescription."

    Therefore, the Board is of the opinion that your proposed program does comply with Rules 305 and 307. Please be mindful of the physical therapist's obligation with regards to evaluation and treatment of an individual for a specific condition and the requirement for a referral from the appropriate healthcare provider. For example, during the promotion of the exercise or fitness program, an individual could present a condition which would trigger the effects of Section 2410A of the Practice Act.

    2) Pursuant to Rule 305 set forth in the Board's Response to Question #1 above, only a physical therapist is permitted to provide preventative services pursuant to the Practice Act and the Board's Rules. Effective July 20, 2000, it is not a violation of the Practice Act or the Board's Rules for a wellness center to be located next to or within a physical therapy clinic. However, please be advised for a facility to be designated as a physical therapy clinic it must have designated space in accordance with the Rules promulgated and enforced by the Louisiana Department of Health and Hospitals. In summary, with regards to the Board's regulatory authority it is permissible for therapy services and wellness services to be provided simultaneously in the same area.

14. Cold Laser for smoking cessation - May a PT use infrared therapy such as Cold Laser in a "Wellness" Program? Cold lasers are currently being used to help ease withdrawal symptoms of smoking.

    It is the opinion of the Board that the use of infrared therapy would be considered treatment, and therefore not appropriate for use in a wellness setting.