Regulatory and Practice Issues for the Veterinary and Physical Therapy Professions

Regulatory and Practice Issues for the Veterinary and Physical Therapy Professions

David Levine and Darryl Millis

Definition of Physical Therapy

The authors would like to acknowledge Nancy Murphy for her work on this chapter in the previous edition.

The American Physical Therapy Association (APTA) has developed a model definition of physical therapy. In this model definition, physical therapy includes examining and evaluating patients with impairments, functional limitations, disability, and other health-related conditions to determine a diagnosis, prognosis, and intervention. Some examples of areas that may be examined include aerobic capacity, arousal, cognition, assistive and supportive devices, barriers, ergonomics, gait, balance, pain, posture, prosthetic requirements, and range of motion.¹

Physical therapists also alleviate impairments and functional limitations by designing, implementing, and modifying therapeutic interventions. Some examples of these activities include therapeutic exercise, functional training, manual therapy techniques, electrotherapeutic modalities, and patient-related instruction. Physical therapists are also involved with helping to prevent injury, impairments, functional limitations, and disability, and with the promotion and maintenance of fitness, health, and quality of life in all age populations. Physical therapists accomplish these tasks in a variety of situations, including patient consultation, education, and research.

Definition of Veterinary Medicine

The practice of veterinary medicine is described in the directory of the American Veterinary Medical Association (AVMA) in a section titled The Model Practice Act (Act).² The Act has been periodically updated and revised, and in the current version (2012, Section 2.16), the practice of veterinary medicine means:

a. To diagnose, prognose, treat, correct, change, alleviate, or prevent animal disease, illness, pain, deformity, defect, injury, or other physical, dental, or mental conditions by any method or mode; including the:

i. performance of any medical or surgical procedure, or

ii. prescription, dispensing, administration, or application of any drug, medicine, biologic, apparatus, anesthetic, or other therapeutic or diagnostic substance, or

iii. use of complementary, alternative, and integrative therapies, or

iv. use of any procedure for reproductive management, including but not limited to the diagnosis or treatment of pregnancy, fertility, sterility, or infertility, or

v. determination of the health, fitness, or soundness of an animal, or

vi. rendering of advice or recommendation by any means including telephonic and other electronic communications with regard to any of the above.

b. To represent, directly or indirectly, publicly or privately, an ability and willingness to do an act described in subsection 16(a).

c. To use any title, words, abbreviation, or letters in a manner or under circumstances that induce the belief that the person using them is qualified to do any act described in subsection 16(a).

This updated Model Veterinary Practice Act includes the use of complementary, alternative, and integrative therapies. Until 2001 these had been listed under Guidelines for Alternative and Complementary Veterinary Medicine, which is now referred to as “Complementary, Alternative, and Integrative Therapies.” These guidelines describe the potential use and application of these therapies for veterinary patients.³ The Model Veterinary Practice Act has included these forms of treatment to help protect the public, by placing the definitions under the Practice of Veterinary Medicine. Approximately 20 states have followed the AVMA Model Practice Act and included complementary and alternative medicine in their state practice act definition of veterinary medicine, while another 20 have enacted exemptions for certain therapies, generally requiring veterinary supervision or referral.

Complementary, Alternative, and Integrative Therapies

The AVMA Guidelines for Complementary and Alternative Veterinary Medicine address topics such as veterinary acupuncture and acutherapy, and acupressure; low-energy photon therapy; magnetic field therapy; veterinary chiropractic; veterinary physical medicine and rehabilitation; veterinary homeopathy; and nutraceutical medicine.³ The guidelines state:

The AVMA believes that all veterinary medicine, including CAVM, should be held to the same standards. Claims for safety and effectiveness ultimately should be proven by the scientific method. Circumstances commonly require that veterinarians extrapolate information when formulating a course of therapy. Veterinarians should exercise caution in such circumstances. Practices and philosophies that are ineffective or unsafe should be discarded.

“The AVMA believes veterinarians should ensure that they have the requisite skills and knowledge for any treatment modality they may consider using.”

Recommendations for patient care state that:

“The foremost objective in veterinary medicine is patient welfare. Ideally, sound veterinary medicine is effective, safe, proven, and holistic in that it considers all aspects of the animal patient in the context of its environment.

Diagnosis should be based on sound, accepted principles of veterinary medicine. Proven treatment methods should be discussed with the owner or authorized agent when presenting the treatment options available. Owner consent should be obtained prior to initiating any treatment, including CAVM. Clients usually choose a medical course of action on the advice of their veterinarian. Recommendations for effective and safe care should be based on available scientific knowledge and the medical judgment of the veterinarian.”

The veterinarian also undertakes responsibilities, including:

“These guidelines support the requisite interaction described in the definition of the veterinarian-client-patient relationship.¹ Accordingly, a veterinarian should examine an animal and establish a preliminary diagnosis before any treatment is initiated.

The quality of studies and reports pertaining to CAVM varies; therefore, it is incumbent on a veterinarian to critically evaluate the literature and other sources of information. Veterinarians and organizations providing or promoting CAVM are encouraged to join with the AVMA in advocating sound research necessary to establish proof of safety and efficacy.

Medical records should meet statutory requirements. Information should be clear and complete. Records should contain documentation of client communications and owner consent.

In general, veterinarians should not use treatments that conflict with state or federal regulations. Veterinarians should be aware that animal nutritional supplements and botanicals typically are not subject to premarketing evaluation by the FDA for purity, safety, or efficacy and may contain active pharmacologic agents or unknown substances. Manufacturers of veterinary devices may not be required to obtain premarketing approval by the FDA for assurance of safety or efficacy. Data establishing the efficacy and safety of such products and devices should ultimately be demonstrated. To assure the safety of the food supply, veterinarians should be judicious in the use of products or devices for the treatment of food-producing animals.

If a human health hazard is anticipated in the course of a disease or as a result of therapy, it should be made known to the client.”

Veterinary Physical Rehabilitation

Veterinary physical rehabilitation is the use of noninvasive techniques, excluding veterinary chiropractic, for the rehabilitation of injuries in nonhuman animals. Veterinary physical rehabilitation performed by nonveterinarians should be limited to the use of stretching; massage therapy; stimulation by use of low-level lasers, electrical sources, magnetic fields, and ultrasound; rehabilitative exercises; hydrotherapy; and applications of heat and cold. Veterinary physical rehabilitation should be performed by a licensed veterinarian or, where in accordance with state practice acts, by a licensed, certified, or registered veterinary or animal health technician educated in veterinary physical rehabilitation or a licensed physical therapist educated in nonhuman animal anatomy and physiology. Veterinary physical rehabilitation performed by a nonveterinarian should be performed under the supervision of, or referral by, a licensed veterinarian who is providing concurrent care.

Massage Therapy

Massage therapy is a technique in which the therapist uses only his or her hands and body to massage soft tissues. Massage therapy on nonhuman animals should be performed by a licensed veterinarian with education in massage therapy or, where in accordance with state veterinary practice acts, by a graduate of an accredited massage school who has been educated in nonhuman animal massage therapy. When performed by a nonveterinarian, massage therapy should be performed under the supervision of, or referral by, a licensed veterinarian who is providing concurrent care.³

The development of the AVMA Guidelines for Complementary and Alternative Veterinary Medicine is a recognition by the veterinary profession that other health care professionals have information and knowledge that may benefit veterinary patients. Veterinarians should not hesitate to seek the help, advice, and expertise of others to improve the care and management of their patients. When this expertise, assistance, and advice is sought, however, the responsibility for the care, diagnosis, treatment, and management of the patient remains with the attending veterinarian, and a veterinarian–client–patient relationship (VCPR) will be established.

The Veterinarian–Client–Patient Relationship

The concept of the VCPR was introduced by the AVMA to clearly describe the relationship of the veterinarian to clients (the owners) and patients served by the profession. This VCPR is the basis for professional interactions and has become part of a variety of official AVMA documents, including the Principles of Veterinary Medical Ethics, the Model Practice Act, and the Guidelines for Veterinary Prescription Drugs. The Guidelines for Complementary and Alternative Veterinary Medicine also refer to the VCPR, and, because these modalities are considered to be part of the practice of veterinary medicine, they should be offered only in the context of a valid VCPR.

As stated in the Principles of Veterinary Medical Ethics,⁴ the VCPR is the basis for interaction among veterinarians, owners, and patients. A VCPR exists when all of the following conditions have been met:

1. The veterinarian has assumed responsibility for making clinical judgments regarding the health of the animal or animals and the need for medical treatment, and the client has agreed to follow the veterinarian’s instructions.

2. The veterinarian has sufficient knowledge of the animals to initiate at least a general or preliminary diagnosis of the medical condition of the animals. This means that the veterinarian has recently seen and is personally acquainted with the keeping and care of the animals by virtue of an examination, or by medically appropriate and timely visits to the premises where the animals are kept.

3. The veterinarian is readily available, or has arranged for emergency coverage, for follow-up evaluation in the event of adverse reactions or the failure of the treatment regimen.

The Principles additionally state that when a VCPR exists, veterinarians must maintain medical records, which should contain information on the diagnosis, care, and treatment of patients.⁴

The Principles also discuss the termination of the VCPR, which applies when professional services are no longer assumed by the veterinarian or no longer needed by the client. Veterinarians may terminate a VCPR under certain conditions, and they have an ethical obligation to use courtesy and tact in discharging this responsibility. Guidelines for terminating the VCPR are as follows:

1. If there is no ongoing medical condition, veterinarians may terminate a VCPR by notifying the client that they no longer wish to serve that patient and client.

2. If there is an ongoing medical or surgical condition, the patient should be referred to another veterinarian for diagnosis, care, and treatment. The former attending veterinarian should continue to provide care, as needed, during the transition.

The Principles state that clients may terminate the VCPR at any time.⁴

Guidelines for Referrals

The expansion and growth of knowledge, the emergence of specialization, and the use of the services and expertise of other health care professionals have necessitated the increased use of referrals in veterinary medicine. Referrals are to be encouraged among veterinarians, and the Guidelines for Referrals ⁵ approved by the AVMA in 1990 and revised in 2009 should be followed when referrals are used. These referral guidelines are summarized and paraphrased as follows:

Definitions

The referring veterinarian is the veterinarian who was in charge of the patient at the time of the referral. The receiving veterinarian or the referral veterinarian is the veterinarian to whom a patient is sent either by referral or for consultation. A consultation is a deliberation between two or more veterinarians concerning the diagnosis of a disease and the proper management of the case. A referral is the transfer of responsibility of diagnosis, care, and treatment from the referring veterinarian to the receiving veterinarian, and a new VCPR is established with the receiving veterinarian.

In these descriptions and definitions, the assumption is made that referrals and consultations may occur only between veterinarians. The Guidelines for Referrals do not address a situation in which the individual who is referring or receiving the patient is not a veterinarian. If these Guidelines for Referrals apply only to veterinarians, then other health care professionals may not actually accept or recommend referrals without the involvement of a veterinarian and the establishment of a valid VCPR. However, when a treatment modality such as physical therapy is required, a referral directly to a therapist may be appropriate. In that instance, specific written instructions and orders must accompany the referral. Because of the necessity of a valid VCPR, other health care professionals who might be involved in the diagnosis, care, and treatment of veterinary patients must work closely with veterinarians so a valid VCPR will be established and maintained.

Method of Referral

When a referral is being considered, communication among veterinarians and other health care professionals is essential. Communications may occur by letter, telephone, direct contact, or other means, and the most appropriate method of communication should be determined by the individuals involved. The referring veterinarian should provide the receiving veterinarian with all the appropriate information pertinent to the case before or at the time of the first contact with the patient or the owner. When the referred patient has been examined and a diagnosis has been established, the referring veterinarian should be promptly informed of those findings. Information provided should include diagnosis, proposed care, treatment plans, and other recommendations. If the patient undergoes a prolonged treatment or hospitalization, then immediately on discharge of the patient, the referring veterinarian should receive a detailed and complete report, preferably written, and should be advised as to continuing care of the patient or termination of the case. Each veterinarian involved in the case is entitled to collect fees for service, care, and treatments for professional services; fee splitting is not allowed.⁴

All licensed veterinarians may receive referrals, and referring veterinarians may refer to whomever they believe appropriate for the situation. Referrals should occur in a timely manner, and veterinarians who solicit or encourage referrals should abide by the AVMA Principles of Veterinary Medical Ethics. The receiving veterinarian should provide only services or treatments relative to the referred condition and should consult the referring veterinarian if other services or treatments are needed.

When referrals are made to other health care providers who may not be licensed veterinarians, the same standards and guidelines must apply. Other health care professionals (nonveterinarians) who are involved with the care and treatment of veterinary patients cannot assume a valid VCPR, and therefore the ultimate responsibility for diagnosis, care, and treatment of the patient remains with the referring veterinarian, as a VCPR must be in effect at all times.

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Tags: Canine Rehabilitation and Physical Therapy

Jul 8, 2016 | Posted by admin in SUGERY, ORTHOPEDICS & ANESTHESIA | Comments Off

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