Scope Of Practice

Recent meetings of both the Public Protection Task Force (February 28, 2024) and the Board (March 6, 2024) considered this question. Research into the topic included:

• Review of Commission on Accreditation in Physical Therapy Education (CAPTE) curriculum requirements for PTA Education Programs (Standard 7 and more specifically 7A2, 7D1-8);
• Discussion with CAPTE accredited PTA programs in NC, along with Board-Certified Cardiovascular and Pulmonary Clinical Specialists in NC who are subject matter experts;
• Examination of the 2022 Academy of Cardiovascular & Pulmonary Physical Therapy publication: Entry-Level Physical Therapist Competencies in Cardiovascular & Pulmonary Physical Therapy; and
• Consultation with rehab managers in long-term acute care settings regarding current practice.

Since this question incorporates the appropriate delegation and supervision of the PTA by the PT, a scope of practice analysis is necessary. As with all scope of practice considerations, the Board reviewed and applied NC Physical Therapy Board Rule 21 NCAC 48C .0101 PERMITTED PRACTICE (a) Physical therapy is presumed to include any acts, tests, procedures, modalities, treatments, or interventions that are routinely taught in educational programs or in continuing education programs for physical therapists and are routinely performed in practice settings.

The APTA Academy of Cardiovascular & Pulmonary Physical Therapy publication, Entry-Level Physical Therapist Competencies in Cardiovascular & Pulmonary Physical Therapy , differentiates oropharyngeal suctioning (airway suctioning) and tracheal suctioning (deep, inline suctioning) when defining entry-level physical therapist competencies. Since the opinions of the NC Board- Certified Cardiovascular and Pulmonary Clinical Specialists and the experiences of the rehab managers surveyed in long-term acute care settings aligned with these categories of suctioning, oropharyngeal and tracheal suctioning were the operational definitions utilized by the Board.

After review, the Board determined both oropharyngeal and tracheal suctioning fall within the scope of practice for PTs who have the requisite training, education, and competency. The skill and knowledge required of PTs performing tracheal suctioning are considered advanced and would not be appropriate for an entry-level licensee to perform. Additionally, levels of complexity (both patient and the setting), as highlighted in the Academy of Cardiovascular & Pulmonary Physical Therapy 2022 publication noted above, should be considered as PTs assess their own personal level of proficiency and competence when practicing suctioning. Advanced training may be required for more complex patients and settings. The Board defines “advanced training” as “beyond entry-level” for the skill level or training required.

Since the clinical skills required to perform oropharyngeal and tracheal suctioning range from entry-level to advanced, a PT student should only perform these skills under the supervision of a trained, educated, and competent PT.

Similarly, PTAs always work under the supervision of a PT. The supervising PT is responsible for determining the competence of a PTA to perform any delegated activity. Delegated activities must be deemed safe and effective for the patient and within the PT patient care plan. It is the responsibility of the PTA to perform only those delegated activities within their scope of practice, and for which the individual PTA has the education and training to perform, ensuring compliance with Board Rule 21 NCAC 48C .0101.

The Board previously determined that physical therapists who possess the advanced training, education, and competence to perform evaluations and interventions for pelvic health related conditions may utilize or recommend use of vaginal dilators. Pelvic health physical therapy is considered within the scope of practice in North Carolina (see NCBPTE Position Statement on Pelvic Health in the NC PT Scope of Practice on the website). Physical therapists routinely recommend, refer, or “prescribe” use of a variety of assistive devices in clinical practice.

At its meeting March 6, 2024, the NC Board of PT Examiners reviewed this question in response to several inquiries and to FDA approval of a specific vaginal dilator requiring a prescription. The Board determined it would not be a violation of NC PT Practice Act and Board rules for PTs to write a prescription for assistive devices that are within the PT scope of practice. While the PT may write a prescription for a device, the Board does not have the authority to review or enforce payment issues related to the policies of the FDA, the State or Federal government, or other third parties. Any payment issues for a prescribed device would be between the beneficiary (patient) and the payer.

The Board received a request from Christine Hydock, Chief, Medical Programs Division of FMCSA, for the Board to review the criteria and physical qualification standards to help determine eligibility of a NC licensed Physical Therapist/Doctor of Physical Therapy to become a FMCSA Certified Medical Examiner.

After review, the Board determined it is within the scope of practice in NC for a PT/DPT to assess the qualification standards of drivers to determine if they are qualified to drive a commercial motor vehicle in interstate commerce. The physical therapist would be required to (1) conduct the testing and physical examination of body systems required on the Medical Examination Report, (2) determine whether the driver is physically qualified to drive a commercial motor vehicle in interstate commerce, and (3) complete the Medical Examiner’s certificate upon completion of the requisite medical examiner training and certification as provided by FMCSA approved providers.

Based on the Board response, the FMCSA made the determination that NC licensed physical therapists are eligible to pursue certification. PTs/DPTs in NC are now able to register, complete the required training, take/pass the exam, and become certified. Certification equates to authorization to conduct physical qualification examinations of interstate commercial motor vehicle drivers, and for the name of the PT to be placed on the National Registry. Interested licensees should visit the FMCSA website.

The Board continues to regularly respond to questions concerning the physical therapy practice of dry needling in NC. At the time of the development of this position statement, four different dry needling scope of practice questions are addressed on the Board website. These include the questions of whether perineural and connective tissue dry needling are within the scope of practice, hours of training required to perform dry needling, and the use of musculoskeletal ultrasound to guide needle placement when performing dry needling. In response to public questions concerning dry needling, the Board also defined “advanced training.”

In previous responses to scope of practice questions surrounding dry needling, the Board referenced dry needling as defined in the 2016 NCBPTE Declaratory Ruling (20-21) and subsequently in the NC Supreme Court Case brought by the Acupuncture Board (8). In both references, dry needling is defined as “a treatment that uses physical or rehabilitative procedures, with assistive devices, for the purpose of correcting or alleviating myofascial pain, a physical disability.” Therefore, any utilization of dry needling techniques that satisfy the foregoing language is within the scope of physical therapy practice in NC. At its Board meeting on March 9, 2022, the Board determined that perineural dry needling extends beyond the current definition of dry needling thereby is not within the scope of physical therapy practice in NC.

Moreover, the Board previously determined that dry needling, while within the scope of practice of physical therapists in NC, is an advanced skill which requires “ advanced training ” as defined on the Board website. After careful review of the literature, discussion with subject matter experts which includes but is not limited to regulators in other jurisdictions and physical therapists who practice dry needling, review of FSBPT and APTA dry needling resources, consultation with educational institutions, and research of dry needling certification requirements from course providers referenced in the FSBPT Resource Paper Regarding Dry Needling 11th Edition, December 2021, the NCBPTE strongly encourages the following principles be satisfied for the practice of dry needling by physical therapists in NC.

• Prior to introducing dry needling into a personal scope of practice, the physical therapist should attest to having attained the knowledge, skill, ability, and competence to perform dry needling.
• Prior to administering dry needling, the physical therapist should communicate the plan of care and obtain informed consent from the patient/client or their legally authorized representative.
• All physical therapists engaging in the practice of dry needling should acquire the appropriate “advanced training” as defined below.
• All physical therapists engaging in the practice of dry needling should retain documentation as proof of successful completion of “advanced training.”
• A physical therapist should not delegate any portion of the dry needling treatment/intervention to a physical therapist assistant or physical therapy aide.
• Student physical therapists do not meet the Board’s definition of “advanced training” therefore should not engage in the practice of dry needling, regardless of the level of supervision from the supervising physical therapist.

***NCBPTE Recommended Advanced Training***

• Completion of at least 1 year of licensed practice as a physical therapist.

-AND-

• Completion of a formalized course of study on the topic of dry needling from an approved provider in accordance with 21 NCAC 48G .0105-.0112. The course of study should include:
  • A minimum of 50 hours of in-person (not online) instruction which includes at least 50% of the course study spent on practical, clinical application.
  • Certification of completion of all program requirements.
  -OR-
  • Formal education, training, and mentorship that is equivalent to the above.

  Resources:

  • 2016 NCBPTE Declaratory Ruling for Dry Needling.

  • 2018 NC Acupuncture Licensing Board vs NC Board of Physical Therapy Examiners Supreme Court Case/ Decision
  • FSBPT HumRRO Dry Needling Competencies Review: Report Memo 2020
  • FSBPT Resource Paper Regarding Dry Needling 11th Edition

The Board received recent scope of practice inquiries concerning the use of cupping in physical therapy practice by NC PT/PTA licensees. Given the most recent Board response was September 2016, the Board reviewed scope of practice evidence surrounding cupping at its meeting in September 2023.

When evaluating scope of practice questions, the Board first considers the NC PT Practice Act and Board rules, with special emphasis on Board rule 21 NCAC 48C .0101 PERMITTED PRACTICE.

• (a) Physical therapy is presumed to include any acts, tests, procedures, modalities, treatments, or interventions that are routinely taught in educational programs or in continuing education programs for physical therapists and are routinely performed in practice settings.

In consideration of cupping, the Board also consulted with NC DPT and PTA educational programs across the state, FSBPT staff and resources, and scholarly sources. After review and discussion, the Board determined that cupping satisfies criteria to be included within the scope of physical therapy practice in NC because it is being taught or introduced in entry level physical therapy education, taught routinely in continuing education programs, and performed routinely in physical therapy practice.

As with any physical therapy treatment technique, it is each NC PT/PTA licensee's responsibility to ascertain they have the appropriate education and training to be competent to perform cupping. Additionally, PTAs always work under the supervision of a PT. Should the supervising PT delegate cupping to a PTA, the supervising PT is responsible for determining the PTA's competence to perform cupping, must deem cupping is safe and effective for the patient, and must include cupping within the PT patient care plan.

Finally, licensed NC PTs and PTAs are reminded that cupping is also within the scope of practice of many other healthcare professionals. As such, the public receiving cupping as part of a physical therapy plan of care should understand they are receiving physical therapy treatment provided or supervised by a licensed physical therapist.

The Board considered this question at its meeting June 7, 2023. While this question specifically concerns the PTA's scope of practice, it is important to consider the scope of physical therapy practice on a broader scale. When responding to physical therapy scope of practice questions, the Board considers Rule 21 NCAC 48C .0101, Permited Practice, and other factors. Medication review and management are taught in educational programs, and pharmacology is a CAPTE requirement in PT program curriculum (within required element 7A). Additionally, there are a plethora of pharmacology continuing education programs that are specifically intended for physical therapy providers.

According to 21 NCAC 48C .0102, Responsibilities (of physical therapists), (a)(b) and (c) as well as 21 NCAC 48C .0202, Prohibited Practice (of physical therapist assistants), PTAs always work under the supervision of a PT. The supervising PT is responsible for determining the PTA’s competence to perform any delegated activity. Delegated activities must be deemed safe and effective for the patient and within the PT patient care plan. It is the PTA’s responsibility to perform only those delegated activities within their scope of practice for which they have the education and training to perform.

If the application of “appropriately prescribed topical medications” meets each requirement outlined in the referenced Board Rules, it is within the scope of the PTA’s practice.

The Board considered these questions at its meeting on March 8, 2023. In responding to physical therapy scope of practice questions, the Board considers Rule 21 NCAC 48C .0101, Permitted Practice, and other factors (see rule below). After reviewing information from subject matter experts in various pediatric settings (from premature infants to school-aged children), and considering whether pediatric feeding is routinely performed in practice and a part of entry-level and continuing education, the Board determined that aspects of pediatric feeding therapy and treatment of tongue tie related issues do meet the requirements of the NC PT Practice Act and Board Rules.

While aspects of pediatric feeding therapy such as positioning, postural related assessment and interventions, equipment assessment, and muscular strength/endurance may be within the PT scope of practice, the skill and knowledge required of physical therapists involved are considered advanced and would not be appropriate for an entry-level licensee to perform. The Board definition of “advanced training” can be found on the home page of the Board website under Scope of Practice.

Further, there are aspects of feeding therapy, such as swallowing, that are outside the scope of PT practice. When considering aspects of feeding therapy which are outside the scope of PT practice, additional training, continuing education, or experience would not qualify a physical therapist to perform these services. Feeding therapy teams often are multidisciplinary. According to Board Rule 21 NCAC 48C .0103 (a), Prohibited Practice, it is the responsibility of the physical therapist to refer out any aspect of pediatric feeding therapy beyond the scope of physical therapy.

Treatment of tongue tie related issues is similarly determined to be within the scope of PT practice. As with feeding therapy, the skill and knowledge required of physical therapists involved are considered advanced and would not be appropriate for an entry-level licensee to perform. Advanced training, as previously defined by the Board, is required for physical therapists involved in the evaluation and treatment of pediatric patients with tongue tie related issues.

Since both pediatric feeding therapy and treatment of tongue tie related issues are considered advanced skills for the physical therapist, a PT student should only perform these skills under the supervision of a trained, educated, and competent physical therapist.

Similarly, physical therapist assistants (PTAs) always work under the supervision of a PT. The supervising PT is responsible for determining the PTA’s competence to perform any delegated activity. Delegated activities must be deemed safe and effective for the patient and within the PT patient care plan. It is the PTA’s responsibility to perform only those delegated activities within their scope of practice for which they have the education and training to perform.

In response to the billing questions, billing and payment policy are not under the jurisdiction of the North Carolina Board of PT Examiners. The Board’s recommendation would be to contact payers directly or seek information from the APTA-NC or the APTA.

• (a) Physical therapy is presumed to include any acts, tests, procedures, modalities, treatments, or interventions that are routinely taught in educational programs or in continuing education programs for physical therapists and are routinely performed in practice settings.

The Board considered this question at its meeting on March 8, 2023. The Board response below includes feedback from the North Carolina Medical Board and our own Board attorney. The response also reflects in depth research by Board staff and other NC PT subject matter experts.

21 NCAC 48C .0101 PERMITTED PRACTICE

• (a) Physical therapy is presumed to include any acts, tests, procedures, modalities, treatments, or interventions that are routinely taught in educational programs or in continuing education programs for physical therapists and are routinely performed in practice settings.
• (d) The practice of physical therapy includes tests of joint motion, muscle length and strength, posture and gait, limb length and circumference, activities of daily living, pulmonary function, cardio-vascular function, nerve and muscle electrical properties, . . .

After consulting CAPTE accredited DPT programs in NC, Board-Certified Cardiovascular and Pulmonary Clinical Specialists in NC who are considered subject matter experts, and the 2022 Academy of Cardiovascular & Pulmonary Physical Therapy’s Entry-Level Physical Therapist Competencies in Cardiovascular & Pulmonary Physical Therapy , the Board determined basic ECG interpretation solely for the purposes of determining whether physical therapy may continue or whether a referral to a medical doctor is necessary does meet the requirements of the NC PT Practice Act and Board Rule 21 NCAC 48C .0101 Permitted Practice (as referenced above). Basic ECG interpretation, which includes monitoring heart rates, rhythms or abnormalities that show a patient is at risk, would take place within the context of a PT evaluation or plan of care and does not include any diagnosis or final assessment. Any information or outcome obtained as a result of an ECG interpretation that is beyond the PT scope of practice, is required by the NC PT Practice Act 90-270.12 to be referred to a licensed medical doctor. If the patient does not have a medical doctor, it is the responsibility of the PT licensee to refer the patient to the appropriate healthcare provider for services beyond the scope of the physical therapist.

Basic ECG interpretation at entry level would fall within the scope of practice for physical therapists who have the training, education, and are competent to perform this as noted above. Since the clinical skills required to interpret basic ECG range from entry-level to advanced, a PT student should only perform this skill under the supervision of a trained, educated, and competent PT.

Similarly, physical therapist assistants (PTAs) always work under the supervision of a PT. The supervising PT is responsible for determining the PTA’s competence to perform any delegated activity. Delegated activities must be deemed safe and effective for the patient and within the PT patient care plan. It is the PTA’s responsibility to perform only those delegated activities within their scope of practice for which they have the education and training to perform.

The, above referenced, Academy of Cardiovascular & Pulmonary Physical Therapy’s 2022 publication defines levels of competency as “proficient, emerging, familiarity, or none-not entry-level.” The same publication also defines “complex patients” and “complex settings.” In doing so, physical therapists must recognize their own personal level of proficiency and competence when practicing basic ECG monitoring and interpretation. Advanced training is required for more complex patients and settings (see Board definition of “advanced training” on the home page of the Board website under Scope of Practice).

At its March 8, 2023 meeting, the NCBPTE considered questions posed regarding the PTA scope of practice. Below you will find the Board’s response concerning the role of the PTA in patient assessment.

The Board acknowledges that the word “assessment” has different meanings depending on the context. “Assessment” utilized during patient treatment is different than “assessment” based upon a physical therapist’s evaluation or re-evaluation that results in establishing or altering a plan of care.

PTAs are always under the supervision of a physical therapist who has established each patient’s plan of care and determined the safe and appropriate delegation of treatment interventions. Furthermore, PTs should consider a PTA’s education and training when delegating treatment interventions per Article 90- 270.90. In doing so and when deemed appropriate by the PT, PTAs may collect objective, measurable data that PTs may then utilize in plan of care decisions.

Regardless of whether a PT or PTA licensee is delivering a patient treatment intervention, patient “assessment” is required to promote safe and effective patient care. Board rules support the PTA’s use of “assessment” in this manner to make “modifications of treatment programs that are consistent with the established patient plan of care” (21 NCAC 48C .0201(b)), document “patient status,” “changes in clinical status,” and “response to treatment based on subjective and objective findings, including any adverse reactions to an intervention.” (21 NCAC 48C .0201(f) (4)(5)(8)).

Complexity, both of the patient and of patient settings, is one of many factors the PT should consider when delegating treatment intervention.

Additionally, there is one other resource the Board considered concerning the role of PTAs in clinical practice. While researching scope of practice questions presented by licensees, the Board considers CAPTE program requirements. One recent response from Sharon Zirges, CAPTE Manager of PTA programs, the Board found helpful in creating a framework when considering a PTA’s scope of practice. Zirges responded specifically to a question concerning ECG interpretation, but the answer can be extrapolated into other areas of practice.

According to Zirges, “The CAPTE standards and required elements relate to the education of the physical therapist assistant and states the following:

• 7C The technical education component of the curriculum includes content and learning experiences that prepares the student to work as an entry-level physical therapist assistant under the direction and supervision of the physical therapist.
• Evidence of Compliance: - Narrative:
  
  • List the objectives that demonstrate how the curriculum prepares graduates to work under the direction and supervision of a physical therapist who directs and supervises the physical therapist assistant in the provision of physical therapy.
• This terminology is key to the interpretation of the work of the PTA in a clinical environment which requires exercise and the minute to minute physiological response seen in the ECG of the patient during this exercise. The PTA cannot lead or define the exercise parameters as that must be under the direction and supervision of the PT but the PTA should understand what a change in ECG related to exercise/treatment looks like to be able to modify/stop the intervention. This is further defined in CAPTE required elements 7D19-21.
  
  • 7D19 Monitor and adjust interventions in the plan of care in response to patient/client status and clinical indications.
  • 7D20 Report any changes in patient/client status or progress to the supervising physical therapist.
  • 7D21 Determine when an intervention should not be performed due to clinical indications or when the direction to perform the intervention is beyond that which is appropriate for the physical therapist assistant.”

There are several Board rules and position statements provided below that address topics relevant to the PTA’s scope of practice, and more specifically, to the PTA role in patient assessment. These serve as references for review and consideration.

NC PT Practice Act § 90-270.90.
Definitions. In this Article, unless the context otherwise requires, the following definitions shall apply:

• (3) "Physical therapist assistant" means any person who assists in the practice of physical therapy in accordance with the provisions of this Article, and who works under the supervision of a physical therapist by performing such patient-related activities assigned by a physical therapist which are commensurate with the physical therapist assistant's education and training, but an assistant's work shall not include the interpretation and implementation of referrals from licensed medical doctors or dentists, the performance of evaluations, or the determination or major modification of treatment programs.

NC Board of PT Examiners - Rules
SECTION .0200 – PHYSICAL THERAPIST ASSISTANTS 21 NCAC 48C .0201 SUPERVISION BY PHYSICAL THERAPIST

• (a) A physical therapist assistant may assist in the practice of physical therapy only to the extent allowed by the supervising physical therapist.
• (b) A physical therapist assistant may make modifications of treatment programs that are consistent with the established patient care plan.
• (c) A physical therapist assistant may engage in off-site patient related activities that are appropriate for the physical therapist assistant's qualifications and the status of the patient.
• (d) A physical therapist assistant may document care provided without the co-signature of the supervising physical therapist.
• (e) A physical therapist assistant who is supervising a physical therapy aide or student must be present in the same facility when patient care is provided.
• (f) The physical therapist assistant must document every intervention/treatment, which must include the following elements:
  • (1) Authentication (signature and designation) by the physical therapist assistant who performed the service;
  • (2) Date of the intervention/treatment;
  • (3) Length of time of total treatment session;
  • (4) Patient status report;
  • (5) Changes in clinical status;
  • (6) Identification of specific elements of each intervention/modality provided. Frequency, intensity, or other details may be included in the plan of care and if so, do not need to be repeated in the daily note;
  • (7) Equipment provided to the patient or client; and
  • (8) Response to treatment based on subjective and objective findings, including any adverse reactions to an intervention.

History Note: Authority G.S. 90-270.90; 90-270.92; 90-270.102; Eff. December 30, 1985; Amended Eff. December 1, 2006; August 1, 2002; Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. May 1, 2018.

21 NCAC 48C .0202 PROHIBITED PRACTICE

(a) A physical therapist assistant shall not engage in practices requiring the knowledge and skill of a physical therapist.

(b) A physical therapist assistant shall not engage in acts beyond the scope of practice delegated by the supervising physical therapist.

History Note: Authority G.S. 90-270.90; 90-270.92; 90-270.102; Eff. December 30, 1985; Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. May 1, 2018.

Position Statements

Position Statement 13. NCBPTE Position Statement on Pelvic Health in the NC Physical Therapy Scope of Practice

To further clarify, “APTA Pelvic Health advises that physical therapy examination of and interventions to the internal pelvic muscles be taught to physical therapists, supervised physical therapist students and PTAs. PTAs may be instructed in examination and interventions of the internal pelvic muscles under the provision that this education is intended for foundational knowledge and that examination of the pelvic dysfunction should remain within the scope of the licensed physical therapist.” “Furthermore, interventions for pelvic dysfunction including, but not limited to, therapeutic exercise, neuromuscular re-education, manual therapy and behavioral 2 retraining may require immediate and continuous examination and evaluation throughout the intervention while at other times may be relatively routine. In routine circumstances, those interventions may be delegated to PTAs and student physical therapists under direct supervision. When immediate and continuous examination and evaluation is necessary, those interventions should be performed only by a licensed physical therapist.” (APTA Pelvic Health)

Position Statement 14. Performance of Sharp Debridement by a Physical Therapist Assistant

The NCBPTE has determined that in those limited situations in which engaging in interventions involving sharp debridement does not require continuing evaluation during the intervention, it is not a violation of the North Carolina Physical Therapy Practice Act or Board rules for a physical therapist assistant who is properly trained and appropriately supervised to perform sharp debridement provided that the debridement is strictly treatment. If a continuing evaluation is required during the treatment, then performance by the physical therapist is required, and the determination of whether sharp debridement should be performed is made by the physical therapist.

Position Statement 15. Performance of Mobilization by a Physical Therapist Assistant

Can a PTA perform peripheral and spinal mobilization in North Carolina?

This question was addressed by the NCBPTE at its March 29, 2001 meeting. GS 90-270.90(3) authorizes the PTA to perform patient-related activities “which are commensurate with the PTA’s education and training.” The same section prohibits a PTA from interpreting and implementing referrals from licensed medical doctors or dentists, performing evaluations, or determining treatment programs, and making major modifications thereof.

The NCBPTE was clear in its determination that it would be inappropriate for a PTA to engage in spinal mobilization under any circumstances. The question of whether a PTA can engage in peripheral mobilization is less clear. Some members felt that it is difficult to perform peripheral mobilization without continuing evaluations. However, it was also recognized that PTAs have been engaged in peripheral mobilization in this State. Under any circumstances, a PTA must have the requisite knowledge and skill to engage in peripheral mobilization.

The NCBPTE was advised that since the typical PTA education program does not provide the sufficient education and training for a graduate to be able to perform peripheral mobilization, those skills must be developed by additional training before a PTA can perform peripheral mobilization in a practice setting.

Position Statement 16. Scope of Authority of the Physical Therapist Assistant to Assist the Physical Therapist with Functional Capacity Evaluations

It is the position of the North Carolina Board of Physical Therapy Examiners that a physical therapist assistant (PTA) is qualified and permitted by the North Carolina Physical Therapy Practice Act to assist a physical therapist (PT) with the performance of a Functional Capacity Evaluation (FCE) on a limited and restricted basis. A PTA may not perform FCEs independently. The following principles support this position:

• The purpose of an FCE is to provide an objective measure of safe functional abilities compared to the physical demands of work.
• The performance of an FCE generally takes from four to eight hours over a period of one to two days.
• An FCE is an evaluative procedure, the performance of which is limited to PTs.
• A PTA may assist in the practice of physical therapy, but may not perform evaluations. NCGS §90- 270.24(3).
• A PT should only delegate those limited aspects of an FCE that are appropriate to the PTA’s education, experience, knowledge, and skill.
• A PTA may participate in the collection of objective data. It is the responsibility of the PT to interpret data.
• A PTA may participate in the performance of objective tests and measures that do not require evaluation or the judgment of a PT.
• Data collection, tests and measures performed to assess patient response during an FCE require a different set of skills than data collection, tests and measures performed in connection with patient intervention.
• Training and education beyond entry-level skills are required before a PTA can assist a PT with an FCE.

Conclusions

• An FCE must be performed by the PT.
• Before proceeding with an FCE, the PT must assess the patient’s medical condition and whether the tests can be performed without further injury to the patient.
• A PTA can utilize a form to ask a patient questions regarding medical history, incidents of pain or dysfunction and work history.
• If a standard form is used to obtain responses from each patient to basic questions, a PT must ask any questions generated by the patient’s responses to the basic questions.
• When assisting with the performance of an FCE, a PTA cannot perform tests of cardiovascular or pulmonary capacity, observations of integumentary changes, or assessments of musculoskeletal or neuromuscular function.
• An appropriately trained PTA may perform objective tests and measures related to strength and lifting and range of motion.
• A PTA can determine whether a patient is performing a test in a safe and correct manner.
• A PT must make all observations that require an evaluation or determination, including whether a task can be performed in the workplace, at what level a task can be performed, or how long the task can be performed.
• Any observations made by a PTA should be reported to the supervising PT.
• A PTA must document in the patient record all procedures performed by the PTA.

Position Statement 17. Utilization of the Physical Therapist Assistant to Assist the Physical Therapist With Patient Screens

It is the position of the North Carolina Board of Physical Therapy Examiners that the physical therapist assistant (PTA) is qualified and permitted by the North Carolina Physical Therapy Practice Act to assist the physical therapist (PT) with the performance of patient screens. A physical therapist assistant may not perform screens independently. The following assumptions support this position:

• The physical therapist retains the ultimate responsibility for the provision of physical therapy services.
• The purpose of a screen is to determine if an examination of a patient by a physical therapist is indicated.
• Screens may be either “hands-on” or “hands-off” procedures.
• The physical therapist should only delegate aspects of a patient screen that are appropriate to the assistant’s education, experience, knowledge, and skill according to the guidelines identified herein under: Delegation and Supervision.
• The physical therapist assistant may participate in the collection of data. It is the responsibility of the physical therapist to interpret the data.
• The physical therapist assistant may review the patient medical record to gather information to assist the physical therapist with the screen.
• The physical therapist assistant should never make a determination whether the patient needs to be seen by a physical therapist or another healthcare professional.

The Board reviewed your question at its meeting December 7, 2022 and has the following response:

Medical discharge from a hospital would require a physician or appropriate medical provider, as physical therapists do not make medical diagnoses. The NC PT Practice Act and Board rules allow for unrestricted direct access to PTs in NC (see Board Position on the Board website). The Board does not have authority over employers or payers and their policies. An employer may have requirements in addition to the legal requirements of the Practice Act as long as the legal requirements are being met.

In terms of physical therapy and physical function post-surgery, the NC PT Practice Act requires that a physical therapist evaluate a patient and have first-hand knowledge of the patient. In order to determine if a patient can perform the functional requirements and training mentioned (ambulate, transfer, perform stair climbing, do a toilet transfer (if needed), teach precautions/review an education booklet, teach family to assist (if needed) and complete a car transfer) an appropriate evaluation prior to performing activities is required. It would not be considered a “progress note” because the patient has not been evaluated and progress would not be able to be determined.

The Board addressed this question at its meeting December 7, 2022 on general terms. The North Carolina PT Practice Act, 90-270.90 (4), states that “physical therapy does not include . . . medical diagnosis of disease.” Medical examinations where a diagnosis is provided falls within the scope of the North Carolina Board of Medicine. Physical therapists do provide examinations in order to determine a diagnosis, prognosis and interventions within the physical therapist’s scope of practice, as outlined in Board rule 21 NCAC 48C .0101 Permitted Practice. If the IME is performed according to the state law and Board rules, the Board determined it would not be a violation of the NC PT Scope of Practice.

NCBPTE Position Statement on Pelvic Health in the NC PT Scope of Practice (also includes Performance of soft tissue mobilization using biofeedback, electrical stimulation, and internal pelvic floor muscle techniques vaginally or rectally by a PTA - reviewed 06-05-24

See the Board Position Statment on Dry Needling for additional Information.

At its meeting March 9, 2022, the Board discussed the question, is "binding" and "gaffing" part of the NC PT Scope of Practice? The standard for making this determination is contained in Board Rule 48C .0101 (a) Permitted Practice, which states, “Physical therapy is presumed to include any acts, test, procedures, modalities, treatments, or interventions that are routinely taught in educational programs, or in continuing education programs for physical therapists and are routinely performed in practice settings.”

The Board determined that the standards of Board Rule 48C .0101 (a) are not met at this time at this time. Therefore, "binding" and "gaffing" would not be part of the NC PT scope of practice; physical therapist licensees may be trained to perform these techniques if required by their facility or employer but clients receiving this technique should not be advised or led to believe they are receiving physical therapy and should not be billed for physical therapy.

If new or additional information is provided regarding this topic where this is taught in entry-level or continuing education and is routinely practiced by physical therapists, the Board will review the new information and make a determination.

At its December 1, 2021 meeting the Board defined advanced training. Further revisions by the Board occurred on March 9, 2022 and May 31, 2022. The revised definition below was adopted by the Board at it June 8, 2022 meeting.

The Board has recently been asked to respond to several inquiries regarding student performance of physical therapy interventions learned in entry level and whether they may be performed in clinicals prior to graduation. In addition, responses to scope of practice questions from the Board may utilize the term “advanced training.” For example, the Board has previously determined dry needling and internal pelvic examinations to be “advanced” skills that require advanced training.

The Board reviews and makes determinations on scope of practice questions for licensees based on several criteria including what is taught in entry level PT academic education and meets the criteria outlined in Board rule 21 NCAC 48C .0101 Permitted Practice. The rule states: Physical therapy is presumed to include any acts, tests, procedures, modalities, treatments, or interventions that are routinely taught in educational programs or in continuing education programs for physical therapists and are routinely performed in practice settings. The Merriam-Webster definition of “advanced” is:

1. far on in time or course - a man advanced in years
2. 
   a: being beyond others in progress or ideas - tastes a bit too advanced for the times
   b: being beyond the elementary or introductory - advanced chemistry
   c: greatly developed beyond an initial stage - the most advanced scientific methods, advanced weapons systems
   

Using the Board rule noted and the Merriam-Webster definition of the word “advanced”, students who are in the process of didactic and clinical training have not had advanced training. While some NC PT/PTA programs may choose to offer additional training not required as part of a required CAPTE entry level curriculum, the Board must consider training throughout the state for consistency and allowing the Board to meet its legislative mandate of protecting the safety and welfare of the citizens of North Carolina and establishing minimum standards for the practice of physical therapy.

To achieve advanced level skill, additional training is necessary to become competent. It is useful for licensees to participate in additional training via mentored practice for specific higher risk techniques prior to performing these in clinical practice. Therefore, for the reasons stated above, when the Board uses the term “advanced” it means “beyond entry-level” for the skill level or training required. This term is currently used in, but not limited to position statements and responses to scope of practice questions.

See the Board Position Statment on Dry Needling for additional Information.

At its meeting September 22, 2021, the Board reviewed the following statement by the Federation of State Boards of Physical Therapy Board of Directors and supports this response to questions regarding providing misinformation to patients.

FSBPT promotes scientific data, research, and analyses in understanding health related matters. FSBPT also strongly discourages the spread of misinformation. In consultation with other health care regulatory groups, the FSBPT Board of Directors has issued the following statement:

“Healthcare professionals who generate and spread misinformation or disinformation about the COVID-19 vaccine are putting the public at risk. Because of their specialized knowledge and training, licensed Physical Therapists and Physical Therapist Assistants possess a high degree of public trust and therefore have a powerful platform in society, whether they recognize it or not. They also have an ethical and professional responsibility to provide health care in the best interests of their patients and must share information that is factual, scientifically grounded, and evidence-based for the betterment of public health. Spreading inaccurate information contradicts that responsibility, threatens to further erode public trust in health care, and puts all patients at risk.”

After discussing the materials and content of the presentation provided, and whether this technique is routinely taught in entry level and continuing education and routinely performed in practice, the Board determined the following at its December 11, 2019 meeting:

“…Blood Flow Restriction training satisfies the criteria to be included within the scope of physical therapy practice in North Carolina because it is an advanced skill being taught in entry level PT education, taught routinely in continuing educational programs and routinely performed nationally in PT practice. It is incumbent upon the licensee to obtain the appropriate training and education to be competent to perform this technique in a manner that is considered safe and effective for the patient.”

Regarding Blood Flow Restriction Training and whether a PTA may perform the technique, I have consulted with the Board Attorney. First, if the technique does not require evaluation, it may be delegated to a PTA who has the education/training and competence to perform the technique. It is incumbent upon the PT license to assure that the PTA always works under the supervision of a PT, the PT delegates only portions of the plan of care that are safe and effective for the patient and the PTA is trained to perform.

Both the Public Protection Task Force (PPTF) and the Board, at their respective June 2023 meetings, reconsidered the Board response in 2019 to the musculoskeletal ultrasound scope of practice questions. The Board attorney, NC PT subject matter experts, and CAPTE accredited DPT programs in NC were consulted. Musculoskeletal ultrasound (MSK US) scholarly sources were also reviewed.

The Board review highlighted the broad nature of the term MSK US. The term, “Ultrasound imaging,” synonymous with MSK US, was found to be the most descriptive when considering practical application in physical therapy practice. Scholarly sources suggested MSK US be further divided into either two general categories: procedural and diagnostic; or four descriptive categories: diagnostic, rehabilitative, interventional, and research.

Board review also emphasized distinct differences in MSK US and “therapeutic ultrasound;” the latter term referring to the more traditional, decades‐old physical therapy treatment technique involving the heating of soft tissue. MSK US, on the other hand, is emerging as a physical therapy evaluation and treatment imaging tool. Consequently, there is extensive variability in the understanding, education, and implementation of MSK US in physical therapy practice.

As stated in the 2019 response, the Board reviews and makes determinations regarding scope of practice questions for licensees based, first and foremost, on Board Rule 21 NCAC 48C .0101 PERMITTED PRACTICE. According to this rule (a) “Physical therapy is presumed to include any acts, tests, procedures, modalities, treatments, or interventions that are routinely taught in educational programs or in continuing education programs for physical therapists and are routinely performed in practice settings.” The Board must consider training and practice throughout the state for consistency which allows the Board to meet its legislative mandate of protecting the safety and welfare of the citizens of NC and establishing minimum standards for physical therapy practice.

In summary, research by the Board determined only one of the six CAPTE accredited DPT programs in NC that responded to the Board inquiry offer instruction beyond “introducing” or “mentioning” MSK US in their curriculum. None of the six offers MSK hands‐on lab training. Additionally, the FSBPT 2022 Practice Analysis Report from HumRRO determined ultrasound imaging of the musculoskeletal system (and other systems as well) be “selected for omission from the NPTE Content Outline.” Results from the 2022 Practice Analysis Report were “very similar” to the 2016 report. Lastly, while musculoskeletal ultrasound can be found in continuing education offerings, it is often not the primary subject matter taught.

While the Board acknowledges MSK US has promising research to support its use in physical therapy practice, none of the information gleaned from extensive review provides evidence to support a change in the 2019 Board response. While MSK US categorization was considered in the Board scope of practice review, the categorization creates additional complexity and variance.

Therefore, the use of Musculoskeletal Ultrasound for diagnostic purposes or guiding needle placement during dry needling and physical therapy documentation requirements is not currently within the scope of physical therapy practice in North Carolina. Further, clients receiving this technique should not be advised or led to believe they are receiving physical therapy.

The Board appreciates your inquiry and invites you to reach out again in the future.

After reviewing available information and discussing the matter the Board, at its December 11, 2019 meeting, determined a response to the licensee would be the following: The standard against which the question must be analyzed is contained in Board Rule 48C .0101 (a) Permitted Practice - “Physical therapy is presumed to include any acts, test, procedures, modalities, treatments, or interventions that are routinely taught in educational programs, or in continuing education programs for physical therapists and are routinely performed in practice settings.”

At this time, the Board was unable to determine that Radial Pressure Wave treatment satisfies the standards of Board Rule 48C .0101 (a) based on the information reviewed. If new or additional information is provided to the Board regarding where this is taught in entry-level or continuing education and is routinely practiced by physical therapists, it will review the new information and make a determination.

After reviewing available information and discussing the matter, at its December 11, 2019 meeting, the Board determined a response to the licensee would be the following: “The standard against which the question must be analyzed is contained in Board Rule 48C .0101 (a) Permitted Practice - “Physical therapy is presumed to include any acts, test, procedures, modalities, treatments, or interventions that are routinely taught in educational programs, or in continuing education programs for physical therapists and are routinely performed in practice settings.” At this time, the Board was unable to determine that PTs casting patients with the use of rigid cast material satisfies the standards of Board Rule 48C .0101 (a). If new or additional information is provided to the Board regarding where this is taught in entry-level or continuing education and is routinely practiced by physical therapists, it will review the new information and make a determination. It would be helpful if we could speak on the phone to provide additional information or clarification.

The NC PT Practice Act and Board’s Rules apply to the delivery of physical therapy services via telehealth. In response to this question, at its September 12, 2018 Board meeting, the NC Board of Physical Therapy Examiners considered some questions regarding the parameters of using telehealth in the provision of physical therapy services in North Carolina; the Board determined the following general principles will apply:

• Telehealth is a delivery model for physical therapy services and as such it is not a question of scope of physical therapy practice.
• PT licensees must comply with the NC PT Practice Act and Board rules when performing physical therapy services using telecommunications.
• In order to provide physical therapy services to a patient geographically located in NC, the provider of telehealth services must possess an active NC PT license.
• To address questions of whether a PT licensee or other healthcare provider or nonhealthcare individual must be with the patient in the remote location and the level of expertise that person needs, the answer depends on various factors, including the status and safety of the patient, whether it is an initial evaluation or ongoing treatment, and the complexity of the services being provided.
• For questions related to the use of telehealth in physical therapy practice in North Carolina that are not answered by these general principles, the Board will continue to respond to questions on a case-by-case basis.

As the use of telehealth in healthcare practice continues to evolve the Board must keep the protection of North Carolina citizens in mind. The Board will utilize current information based on education, training and routine clinical practices of PT licensees to inform responses to questions. I am not able to address reimbursement questions as the Board does not have jurisdiction over payers or payer policy.

At its September 2, 2020 meeting, The Board determined that assessment of heart sounds is not routinely taught in PTA academic education which does not meet the Board standard for a procedure to be considered within the scope of practice. In addition, the NC PT Practice Act considers assessment outside the scope of practice for a PTA

At its meeting on December 9, 2020, the Board considered your question regarding PTA performance of manual lumbar traction of the spine using a mobilization belt. The standard for making this determination is contained in Board Rule 48C .0101 (a) Permitted Practice, which states, “Physical therapy is presumed to include any acts, test, procedures, modalities, treatments, or interventions that are routinely taught in educational programs, or in continuing education programs for physical therapists and are routinely performed in practice settings.” After review of the information available on this topic and discussion by the Board, the Board determined that that the standards of Board Rule 48C .0101 (a) are not met at this time at this time. Therefore, the use of manual lumbar traction is not currently within the scope of practice for the PTA in North Carolina.

In response to your question to the NC Board of PT Examiners, at its meeting September 22, 2021, the Board addressed the question, “…is it within the scope of practice for PTs to perform IV removal?” After the Board discussion, and review of information available, the Board provided this response, the standard for making this determination is contained in Board Rule 21 NCAC 48C .0101 (a) Permitted Practice, which states, “Physical therapy is presumed to include any acts, test, procedures, modalities, treatments, or interventions that are routinely taught in educational programs, or in continuing education programs for physical therapists and are routinely performed in practice settings.” The Board determined that removal of IVs is not routinely taught in entry level education or continuing education and is not routinely performed in PT practice which does not meet the Board standard for a procedure to be considered within the scope of practice.

See the Board Position Statment on Dry Needling for additional Information.

The NC Board of PT Examiners responded to this question at its September 22, 2021 meeting and noted that a patient’s ambulatory status is usually included as part of a physical therapy evaluation if the patient is physically and mentally able to participate.

The Practice Act states the following:

If the physical therapist has performed an evaluation and created the plan of care and goals, delegation of a portion of that plan to the PTA is allowed. In some cases, a PTA progressing a patient to ambulation may be considered a major modification. However, there may be other cases that it would not. For example: There may be times that a physical therapist could evaluate a patient who is not quite ready to ambulate (such as a patient with ankle surgery who is still a little groggy from anesthesia), so the PT cannot perform a “gait evaluation”; however, due to the patient’s prior functional status, diagnosis, physical condition, setting, experience of PTA, and the working relationship between the PT and the PTA, the PT feels comfortable having the PTA progress the patient to gait training without performing an “official gait evaluation” (based on the patient’s age, strength, sitting balance, etc.). Ultimately, the decision and responsibility to make this determination would be up to the judgment of the physical therapist who performed the evaluation, which should always include patient safety at the forefront of the treatment goals and plan-of-care. If the PT feels that a gait evaluation needs to be performed before the PTA initiates gait training, then the PTA should follow the direction of the PT. For a PTA, failure to follow the direction of the PT may be considered practicing beyond the scope of practice and could be a violation of the Practice Act and Board Rules. If the PTA has received direction to begin ambulation with a patient yet believes that upon seeing the patient it would not be safe or effective for that patient, the PTA should not begin the intervention. The PTA is responsible for communicating the status of the patient to the PT if they believe there may be an adverse event and may make minor modifications to the treatment plan consistent with the plan of care. Whether the PT sees the patient for reassessment is up to the PT. Although the PTA is trained to assist the PT and generally does what the PT delegates, the PTA must still rely on his/her own judgment and training regarding safety and standards of care. If the patient were injured, the PTA’s license would be in jeopardy just like the PT’s. PTAs should document communications with the PT regarding recommended actions and notate “per the PT.”

At its September 21, 2020 meeting, the Board affirmed the position that the use of CBD oil in clinical practice is not part of the PT scope of practice. If CBD oil is going to be sold by a PT, it should be made abundantly clear that it is not physical therapy and is unrelated to any PT plan of care. The patient perception must be clear on this issue. Position statement #20 posted on the Board website provides this information. Also see the November 2021 newsletter with an article by Board attorney, David Gadd, on this issue.

In response to your emailed question to the NC Board of PT Examiners, at its meeting September 22, 2021, the Board addressed the question, “…this question, “does first-hand knowledge of the patient means if the patient is being seen by a PTA, to supervise does the PT needs to see them in-person?” While this rule may have been written prior to the advent of electronic medical records when remote access to a patient’s entire record was not available, the intent of the rule is that a patient being treated by a PTA who requires PT supervision and is not onsite or in the same physical area with the PTA has sufficient information to be able to supervise the PTA and assure that the patient receives safe and effective physical therapy care. The medical records alone may not be sufficient to become familiar with that patient. An in-person visit or virtual visit may be required. While there are circumstances where an in-person visit may not be required by the PT to assure they have first-hand knowledge of the patient for safe and effective care to be taking place it is the responsibility of the PT to do whatever is required to assure appropriate patient care management and oversight of any delegated portions of the plan of care. If a PT supervising a PTA needs to be out for the day or is leaving a practice, it is incumbent upon the PT to assure the care is transitioned to another supervising PT and that transition is documented. If a licensee does not have first-hand knowledge it should be sought before treating or supervising a PTA, Aide or student.

The Board, at its March 11, 2021 meeting, affirmed that performing vaccinations is not in the PT Scope of Practice, thus a licensee is not performing physical therapy and should not imply to a client that they are receiving physical therapy services if they are performing vaccinations. Because vaccinations are not considered in the scope of PT practice, there are no regulations for the Board to modify or waive related to individuals who may perform vaccinations. Specifically, to address the questions regarding students, students are not licensees, thus they would need to obtain the appropriate training, become competent to perform vaccinations and follow all applicable state laws in the same way that PT licensees would do so.

The Board guidance, which will be posted on the Board website, www.ncptboard.org, will state: “In response to emailed questions to the NC Board of PT Examiners, giving vaccinations would not be considered within the scope of PT practice; however, it will not be considered a violation of the NC PT Practice Act or Board rules for a PT licensee to perform vaccinations if they have the proper education, training, are competent to do so and it is safe for the recipient. In addition the licensee should follow all other applicable state laws regarding providing vaccinations. If a PT licensee is performing vaccinations they would not be called PT, nor is a PT license being used when providing the vaccination. A licensee should therefore avoid creating the perception that what they are doing is physical therapy.”

The Board has been made aware of these potential training resources as follows:

• NC AHEC - NC AHEC Program vaccine module for volunteers is live and free: https://www.charlotteahec.org/continuing-professional-development/event.cfm?eventid=65572 There is a certificate at the end that learners can print as proof that they have taken the course.
• NCDHHS - https://files.nc.gov/covid/documents/COVIDImmunization/12.10.20_cvms_orientation_training.pdf Obtain training under a supervising MD who will be onsite during vaccination performance and provide supervision.

The Board also encourages licensee to seek other volunteer options to help support the vaccination effort and slowing the spread of COVID-19: Resource recommended by NCBON - a person can register through “TERMS” – Training Exercise Response Management System - then receive the additional training needed. Link: http://terms.ncem.org/TRS/ Individuals may seek training and opportunities to volunteer through their employers and local health departments.

The Board does not license business entities and is unable to advise legally about the type of business entity to form. A memo written by our current Board attorney addresses the types of business entities physical therapists can utilize in providing physical therapy services in North Carolina. (Click here for the full memo.) See also the April 2024 Newsletter.

The Board does not approve business names or provide “letters of approval.”

An attorney or accountant may be consulted to provide additional information regarding the formation of business entities in North Carolina.

To learn more about starting and registering a business in North Carolina, consult the NC Secretary of State website. NOTE: the information listed in “Professional Entities” under the heading “Choose a Business Structure” does not pertain to physical therapists as the physical therapy profession is not currently listed in NC GS 55B-5.