Thursday, November 30, 2006

physical agent modalities and competency in occupational therapy

It will be interesting to see how far and wide this issue travels - I expect that my answer will make some people angry and other people very happy - but either way I view this as a question that comes along that is just too good for me to ignore -

Today I was asked for my opinion on the following question:

"I am a COTA and I have attended a couple of workshops on Anadyne Therapy. It is an infrared treatment modality used to treat patients with peripheral neuropathy. Treatment will initially consist of a pre-sensory test (Semmes-Weinstein monofilaments), treatment with the Anadyne and fine motor exercises. The question is: Does an OTR have to do the initial evaluation which would be the pre-sensory test prior to the treament? I am able to conduct the test and the treatment but I don't know if legally I can."

Here is my response:

According to the NY State Board of Regents, occupational therapy assistants as a rule have not demonstrated competence to perform evaluations, so they generally do not perform them. All licensed individuals must practice within their personal scope of competence. However, the occupational therapy supervisor may delegate performing an evaluation to the occupational therapy assistant if the occupational therapy assistant has demonstrated competence to perform evaluations. That leaves professional responsibility for errors of commission or omission between the OTR and COTA who decide to have the COTA complete an evaluation. So whether or not you are capable of completing evaluations is entirely between you and your supervising OTR.

In any event, the individual practitioner is subject to Part 29 Rules of the Board of Regents which requires that licensees practice within their personal scope of competence. If you are not competent to provide a service that you are legally allowed to provide, then you may not provide that service. As a licensed professional, it is your responsibility to practice within the scope of your abilities and expertise. If you practice outside your personal scope of competence, you can be charged with professional misconduct.

Under the Regulations of the Commissioner, Part 76, it states that OT interventions include, where appropriate for such purposes, and under appropriate conditions, modalities and techniques based on approaches taught in an occupational therapy curriculum and included in a program of professional education in occupational therapy registered by the department, and consistent with areas of individual competence. These approaches are based on:

The neurological and physiological sciences as taught in a registered occupational therapy professional education program. Modalities and techniques may be based on, but not limited to, any one or more of the following:

sensory integrative approaches;
developmental approaches;
sensorimotor approaches;
neurophysiological treatment approaches;
muscle reeducation;
superficial heat and cold; or
cognitive and perceptual remediation.

Infrared or phototherapy is not mentioned at all in the regulations. I am not aware that this is a standard part of any occupational therapy curriculum and I do not know that it really falls within the occupational therapy scope of practice. I would highly doubt that infrared biophysiology is taught in the typical OTA curriculum, as it involves high level educational background in both chemistry and physics.

As the use of infrared can cause severe harm if inadvertently applied over a malignancy or a pregnancy, and as there is reason to debate if it is even an appropriate OT modality, and particularly given the fact that attending a couple inservices certainly doesn't qualify someone to use a potentially dangerous modality - I would strongly suggest that a COTAs use of this modality in these circumstances could potentially constitute professional misconduct.

Unless you have background in chemistry and physics, and unless you can understand and articulate and explain the biophysical changes that are occurring at the tissue level as a result of the IR (e.g. nitric oxide microcirculation effects), and unless you have had formal training that involves evaluation and competency assessment - I would recommend that you steer clear of this intervention modality.

As an OTR with a clinical doctorate and 20 years of experience and who has taken chemistry and physics courses and who has a basic understanding of how IR works - I still don't believe it is an appropriate OT modality and I would never use it. That is my professional opinion.

This has nothing to do with the potential efficacy of IR interventions - this is just a statement on competency and appropriateness of this modality for OT in general and by COTAs in particular.

As an aside, I am continually shocked and amazed at what some OTs think they are qualified to do. I hope that PTs far and wide smack down any OTs who use modalities that they are not appropriately educated and trained to use. Training also has to include competency assessment.

A final thought for OTs: if you look at a problem and all you can see is a peripheral neuropathy and that perhaps the best intervention is to mediate the problem with a physical agent modality and exercise - are you really still an occupational therapist?


Check your state's licensure laws - here is the link to the NY info:


Anonymous said...

I am not so amazed by what OT's believe they are compentant to do, however, I am astounded at what many OT's believe that they are too good to do....ADL's

Chris said...

Even more amazing - it took over a year to get a comment on this entry. Maybe people don't get as outraged at things as I do.

Anonymous said...

Thank you Chris for your insights.
I'm currently fighting for proper utilization
Of COTA's in my current work environment.
It surprisese to find that people frequently
disregard these important ethical issues at the
risk of hurting their patients or the possibility
Of loosing their hard earned licence to practice.

Anonymous said...

I just came across this post whilst research modalities. This is something I am very unfamiliar with, but have recently learned I am required to take a course in. I am training as an OT in the UK and we don't routinely learn about this, it's a physio role. But to sit sit the NBCOT I have to learn. Reading your post has made me think about how much I need to research this, I haven't started the course yet, but i am a little concerned about learning this via distance learning.

Christopher Alterio said...

Use of physical agent modalities continues to be an important topic for OTs in the US because many states have specific and different regulations about their use. If you ever plan on coming to the US you might want to look at the regulations for the state you are interested in practicing in so you can see their requirements. New ACOTE standards B.5.15 and B.5.16 are quite specific about what needs to be included now in educational programs that follow ACOTE criteria. Those standards go into effect in July 2013.

Anonymous said...

Thanks Chris, I have been directed to an AOTA approved course. There are a couple of courses I need to take to meet the standards, so that I can take the exam later this year. I will research modalities more!