Richter

Photo courtesy of Holistic Veterinary Care and Rehabilitation Center

Animal physical rehabilitation is a growing field, especially for dogs. As it evolves, regulators are faced with questions about who is most qualified to provide treatment.

A bill that would allow physical therapists to treat non-human animals without a veterinarian on the premises cleared the California Assembly last week by a 66-to-2 vote, bucking more than a decade of opposition by the state veterinary establishment.

AB 814, now in a Senate committee, changes the state's physical therapy practice act to include the treatment of animals. In addition, it allows physical therapists to operate independent animal rehabilitation facilities and treat animals with a veterinarian's referral. It also instructs the California Veterinary Medical Board, which regulates veterinarians in the state, to create a registration program for physical therapists (and their premises) who want to provide animal physical rehabilitation.

"We are highly concerned about this bill," Dr. Grant Miller, director of regulatory affairs for the California Veterinary Medical Association, an advocacy group for veterinarians, said on Wednesday. "We are strongly opposed and see no room for compromise on the bill."

In a letter to lawmakers, a coalition of veterinary associations argues that animal physical rehabilitation (APR) as "the treatment of an injury or an illness to address pain and improve function by means of physical corrective treatment" sits squarely within the practice of veterinary medicine and therefore, should be performed only by or under a veterinarian's direct supervision.

The association says allowing physical therapists — who have no formal training or aptitude testing to address emergency conditions in animals — "to work without veterinary supervision poses a threat to both animal welfare and consumer protection."

Proponents of AB 814, who comprise the bill-sponsoring Animal Physical Therapy Coalition, say the legislation is sorely needed to expand veterinary health care options for consumers.

"It is well known that there is a profound access-to-rehabilitative-care issue in California, so the Legislature is doing what they can to solve the problems they can by passing common sense legislation like this," the coalition president, Karen Atlas said in an email to the VIN News Service. "The topic of animal rehabilitation/physical therapy has plagued California for over 15 years, so we (the coalition) are looking forward to this solution so more animals can be served."

Atlas, who is a licensed physical therapist certified in canine rehabilitation, added that the coalition acknowledges the gap in education between therapists and veterinarians, so the bill mandates additional training and certification for those wishing to work on veterinary patients.

The bill was authored by Assemblymember Josh Lowenthal. His office did not respond to requests for an interview.

Regulating an evolving field

Sports medicine and rehabilitation/physical therapy are growing fields in veterinary medicine. The past two decades have seen the expansion of animal rehabilitation-related education, training and certification at veterinary schools and independent programs; the establishment of board certification in veterinary sports medicine and rehabilitation; and a veterinary technician specialty in rehabilitation therapy.

Meanwhile, physical therapists trained to treat human patients have been pursuing education and training in animal rehabilitation therapy and seeking a more significant role in veterinary medicine.

That's raised concerns among some veterinarians, compelling state professional boards and associations to sort through the competing claims and interests of the two medical disciplines. The conflict comes down to a matter of expertise: Veterinarians know animal anatomy, physiology and behavior, but not necessarily physical therapy tools and techniques. Physical therapists know the treatment approach but lack animal health and behavior expertise.

As of 2017, the last time the American Veterinary Medical Association compiled statistics, 30 states did not specify anything about "physical therapy" in their veterinary medical practice acts; 13 specifically defined physical therapy as part of the practice of veterinary medicine and/or specified that veterinarians must directly supervise animal physical therapists; and seven had adopted some version of an "indirect-supervision" model for animal physical therapy.

(Direct supervision is defined in California as the supervising veterinarian being physically present at the location and easily accessible. Indirect supervision means the supervising veterinarian is not physically present but has given written or oral instructions for treatment.)

The debate over animal physical rehabilitation has been especially long fought in California. The state veterinary board began discussing the issue in 2011, according to a summary prepared by the board. 

In 2015, it approved language that it withdrew a month later, after policy and legal issues were raised. Among complaints were concerns that the board was "attempting to limit business competition and protect the profession's financial interests, not to further its consumer protection mandate," according to a summary prepared by the board.

The Legislature directed the board to create a task force comprised of veterinarians, registered veterinary technicians, animal rehabilitation and related animal industry professionals, consumers and legislative representatives to make recommendations to the board.

The Animal Rehabilitation Task Force, as it was called, recommended that the state allow trained physical therapists to perform animal physical therapy under the direct or indirect supervision of a veterinarian and that the veterinary and physical therapy boards work collaboratively to establish minimum standards for physical therapists to practice on animals.

The board rejected the task force proposal in 2017, saying that following the recommended actions would exceed its authority. It independently proceeded to develop regulations for animal physical rehabilitation.

That same year, the Animal Physical Therapy Coalition was founded. Its membership includes physical therapists, veterinarians, veterinary technicians and consumers.

Frustrated by the veterinary board process, the coalition backed the Animal Rehabilitation Act of 2018, which would have created an advanced certificate in animal physical rehabilitation in the state's veterinary medicine practice act and allow qualified physical therapists to operate on their own premises, with the referral of a veterinarian. The measure didn't make it out of the Assembly Appropriations Committee, presumably because of concerns about the potential financial cost to the state, according to Atlas.

In 2022, the board issued its long-awaited regulations. In effect since January, they specify that only veterinary technicians can perform APR under the indirect supervision of a veterinarian.

Miller said generations of board members have considered the issue, "and they've all come to the same conclusion that in the best interest of consumer protection and animal safety, a veterinarian needs to oversee somebody performing these procedures on animals because this is the practice of veterinary medicine."

If AB 814 passes, it will override the regulations.

Parsing degrees of supervision

AB 814 gives latitude to veterinarians on the degree of supervision (direct or indirect) they require when working with "registered animal physical therapists." Each side of the debate positions indirect supervision a little differently. Bill proponents emphasize the involvement of veterinarians in directing the course of treatment, regardless of where it takes place.

To opponents, the "where" is key. CVMA's Miller said that in the context of the veterinary team, indirect supervision describes a scenario where the supervising veterinarian is not present on the premises, while staff, such as a veterinary technician or an assistant, carries out a task directed by the veterinarian.

By contrast, Miller said, physical therapists "want to work by referral, which means that the veterinarians are not involved during the time that the physical therapists are working on the animals. That's not indirect supervision — that's referral, and we only refer to other veterinarians."

A CVMA Legislative Update last month highlighted other concerns. One is that the bill would allow physical therapists, after a certification course that focuses on dogs, to work on all species of animals. (There is a certification track for physical therapists that focuses on horses, but this subset of practitioners has not been vocal about the legislation.) 

Another concern is that the provisions for registering APR facilities could create disparities between the minimum standards required in practices operated by veterinarians compared with those operated by physical therapists.

"If you look at a veterinary practice … they have to have emergency drugs on hand, they have to have oxygen, which implies that they have to have the knowledge to use it," Miller said. "The physical therapist would never be able to provide those things because they don't have that same knowledge, which means that if you put a physical therapy practice right next to a veterinary [rehabilitation] practice, the veterinary practice is at a disadvantage because it has requirements of it that will not be required of the physical therapy practice."

Atlas agrees that existing veterinary premise permits encompass standards for a range of disciplines, such as radiology, oncology, pharmacology and surgery. "You won't see those same standards for an animal physical rehab premise permit because those disciplines are clearly outside the animal PT's scope of practice," she said. However, she rejects the idea that this gives a physical therapist a leg up.

"If you want to characterize in terms of advantage and disadvantage, the vet clearly has the advantage since they first must examine the animal, refer the animal and remain in complete control of the rehab relationship with the animal physical therapist," she said

Access-to-care argument

The central argument for AB 814 begins and ends with pet owners' desire for animal physical therapy services.

"Consumers have been asking for well over a decade to have more access to qualified animal PTs, and they want more options for their pets," Atlas said. "There are not enough qualified veterinarians that have adequate training in rehab; otherwise there would not be such a profound need."

Over the years, bill proponents have provided testimony from pet owners who said they were forced to drive for hours to obtain care.

The veterinary board's new, more restrictive regulatory language, along with veterinary shortages driven by the Covid-19 pandemic, have exacerbated the issues around access, Atlas said.

In an April meeting of the state veterinary board, its president, Dr. Christina Bradbury, called Atlas' claim that the new regulations imposed new restrictions to be a "persistent misunderstanding." Bradbury said, the requirement for direct veterinary supervision of physical therapists was already in place under the state; the new rule just clarified it. "Consequently, if an APR practice was not employing a licensed veterinarian to directly supervise the performance of APR by a physical therapist, that APR practice was operating in violation of existing law" all along, she said.

The board voted unanimously to oppose AB 814 at that same meeting.

CVMA says that all of the more than 13,000 licensed veterinarians in California have knowledge, ability and experience in rehabilitating animals. In addition, it says there are at least 40 practices that focus solely on animal rehabilitation and around 15 veterinary sports medicine and rehabilitation specialists in the state, which has more than 39 million residents. 

Atlas rebuts: "While it's true that a veterinarian is trained to treat animals and has clear-cut expertise in the care and treatment of animals, it is also true that only a small part of the training for the majority of vets includes physical therapy or APR."

Atlas didn't have a figure for the number of physical therapists in the state who are certified in canine rehabilitation. Two U.S. education programs — the University of Tennessee and the Canine Rehabilitation Institute — offer a certificate in canine rehabilitation. Their websites list a combined total of 23 physical therapists certified in canine rehabilitation working in California. They also list around 100 veterinarians in California who also are certified in canine rehabilition by these programs.

Who will pay for the program?

Miller said he was surprised by how quickly AB 814 flew through the Assembly. He thinks that's due, in part, to how the bill's proponents calibrated their messaging around access.

"The sponsors of this bill have advertised the bill under the rubric of 'access to veterinary care,' and the Legislature is particularly sensitive to any access-to-care issue, especially post-Covid," Miller said. "They're looking for opportunities to allow consumers more options for medical care. However, this particular issue is not part of access to veterinary care."

The CVMA has argued that hindrances to access are rooted primarily in the financial inability of one out of four pet-owning households to afford basic veterinary services, such as care for sick animals, emergency care, vaccines and parasite control.

"You can put a physical therapist on every street corner; it's not going to change the access-to-veterinary-care issue," he said, "because, again, one out of every four households will not be able to walk in and pay for those services."

Beyond the questions of animal welfare and consumer protection, Miller said the cost of regulating animal physical therapists is another significant issue.

According to an Assembly Appropriations Committee summary, the veterinary board estimates that starting and running the program for the first two years could cost more than $1.2 million. (The physical therapy board estimated the total fiscal impact of creating the program on its side would be $27,000.)

The veterinary board, which is funded solely by licensing fees paid by veterinary professionals, would not receive money from the state for the program.

"The CVMA will not stand for our licensing fees bankrolling physical therapists working on animals," Miller said.

The parties don't agree on this point, either. Atlas countered: "CVMA's concern that veterinarian dues will be used to pay for another program is not realistic, since by way of policy, regulatory fees in all of the boards in the Department of Consumer Affairs do not cross-fund other programs."

She said that fees paid by veterinarians are used to pay for programs affecting veterinarians, and registered veterinary technician fees are earmarked for RVTs. She posits the same would be true for animal physical therapists.

VIN News asked the veterinary board about what fees would fund the program. It was not able to provide a response before publication.

Atlas called the veterinary board's estimate "concerning," especially in what she calls "fiscally difficult times." At the same time, she implied the estimate is too high. She said bill proponents will work with the Senate Appropriations Committee, the next step in the bill's journey, and stakeholders to reduce the price and "to get accurate cost projections."

The linked letter in support of AB 814 has been changed because proponents initially supplied the wrong copy of the letter.

Update: AB 814 progress is stalled. A Senate Business, Professions and Economic Development Committee hearing for the bill was canceled at the request of the author on July 6. The committee doesn't meet again until 2024. Atlas said bill sponsors will revise the bill in the meantime.