Scope of practice review: providers for triage and assessment of spine-related disorders

Figures & data

Table 1 Providers best suited to complete assessment and triage of patients with nonspecific low back pain

	Chiropractors	Occupational therapists	Physiotherapists	Athletic therapists
College or regulatory body	Alberta College and Association of Chiropractors	Alberta College of Occupational Therapists	Physiotherapy Alberta – College and Association	Alberta Athletic Therapists Association
Regulated vs unregulated	Regulated	Regulated	Regulated	Unregulated
Initial training (entry level of practice)	• Doctor of chiropractor (4-year) • Prerequisite for the program is at least 3 years of university training with specific coursework; however, most are not admitted without an undergraduate degree • Includes internship	• Master’s degree in occupational therapy • Prerequisite to the program is an undergraduate degree (ie, education, kinesiology, psychology) • Includes fieldwork placements	• Master’s degree in physiotherapy • Prerequisite to the program is an undergraduate degree with specific coursework • Includes clinical placements	• Advanced certificate in athletic therapy; often completed as part of a bachelor’s degree • Complete Sports First Responder or Emergency Medical Responder course • 1,200 practical hours; 600 in athletic field setting, 600 in clinical setting
Approach to assessment	• Holistic approach (ie, functionality, psychosocial issues, patient history, comorbidities) • Initial focus is on intervention with the acute episode, then rehabilitation • Experts in musculoskeletal (MSK) assessment	• Holistic approach (ie, physical, cognitive, environment, life roles, history, comorbidities) • Complete MSK assessments • Evaluate interaction between the person, environment, and occupation	• Foundation is based on movement science • Holistic approach to both physiological and psychological assessments • Experts in biomechanical assessments	• Involved in complete care continuum (see initial injury, complete assessment, and rehabilitation) and regularly complete MSK assessments • Experts in patient rehabilitation and return to activity
Referrals	• Able to make referrals to all medical specialists • Able to receive referrals, often from family physicians for initial assessment and care of spine issues	• Able to make referrals, depending on identified need (ie, to a physiotherapist or general practitioner) • Able to receive referrals from a variety of providers such as general practitioners, specialists, allied health providers and Workers’ Compensation Board	• Physiotherapists with a PracID (practitioner identification number) can refer directly to specialists • Patients seek services without a referral although a referral may be required in some circumstances • Able to receive referrals from any provider	• Able to make referrals to primary care providers only • Able to receive referrals from primary care physicians
Restricted activities	• Spinal manipulative therapy • Authorized to administer diagnostic imaging, ionizing radiation in medical radiography, and nonionizing radiation in magnetic resonance imaging (MRI) and ultrasounds	• Authorized to administer diagnostic imaging contrast agents and perform psychosocial interventions	• Physiotherapists who are authorized can order X-rays, diagnostic ultrasounds, and MRIs • Not authorized to prescribe or dispense any medication; can refer patients to pharmacists with prescribing authority	• Not authorized to perform restricted activities

Table 2 Scope of practice review: providers for assessment and triage of nonspecific low back pain

Responsibilities	Family physicians	Nurse practitioners	Registered nurses	Licensed practical nurses	Registered psychiatric nurses	Chiropractors	Physiotherapists	Occupational therapists	Athletic therapists	Psychologists	Paramedics
Perform musculoskeletal assessment	X	X	X	X	X	X	X	X	X		X
Assess medical history	X	X	X	X	Xe	X	X	X	Xe	Xe	X
Screen for comorbidities	X	X	X	X	Xe	X	X	Xe		Xe	X
Refer to other providers	X	X	Xc	X	X	Xe	Xe	Xe	Xc	X	X
Receive referrals from other providers	X	X	Xe	Xe	Xe	Xe	X	Xe	Xe	Xe
Order or apply X-rays and magnetic resonance imaging	X	X				X	X				Xd
Administer diagnostic imaging contrast agents	Xa	X	X	X	X			X
Prescribe medication (Schedule 1 drug)	X	X
Dispense, compound, provide for selling, or sell a Schedule 1 drug or Schedule 2 drug within the meaning of the Pharmacy and Drug Act	Xb	X	Xe	Xe	X

Notes:

a Clarification received in interview, although legislation does not restrict family physicians from administering diagnostic imaging contrast agents, this activity will normally be referred to a radiologist.

b Clarification received in interview, family physicians as part of their routine activities do not generally complete this activity; this activity is normally passed on to a pharmacist. However, as an exception, some physicians may perform this activity as a service only to their patients.

c Clarification received in interview, registered nurses, and athletic therapists cannot refer directly to specialists, but only to primary care providers (ie, family physicians).

d Paramedics cannot administer diagnostic imaging, but require knowledge of and can interpret laboratory and diagnostic imaging results;

e information came from interview.