Note to readers: This document is current as of the date of publication and reflects the rules and requirements for Alberta physiotherapists. In the event of a discrepancy between this information and the directives of provincial public health authorities, the directions of provincial public health authorities prevail.
Additional information will be provided to registrants as directives or CMOH Orders change or as new information becomes available.

June 30, 2021

Click here to view Guidance for Physiotherapy Practice: What Does Alberta's 'Open for Summer' Plan Mean for Physiotherapists? as a PDF.

The COVID-19 pandemic has been and remains an unprecedented challenge to health-care providers and society at large. Over the last 16 months, physiotherapists have played a critical role in addressing the health and well-being needs of Albertans. Whether working in a private practice clinic, a hospital, or any other setting where direct patient care is provided, we applaud the efforts that physiotherapists continue to make to serve patients and adhere to the instructions of public health experts.

Over the course of the pandemic, the only certainty has been uncertainty. We recognize the toll that this takes on physiotherapists, the anxiety that it provokes, and the challenge that a fluid and rapidly changing situation poses to clinicians, leaders, business owners and others involved in the delivery of physiotherapy services.  

Physiotherapy Alberta remains committed to providing guidance to help physiotherapists address this challenge. When directives are received from the Chief Medical Officer of Health (CMOH) and Alberta Health, Physiotherapy Alberta will continue to share that information with our regulated members. However, as July 1, 2021, approaches, and province-wide restrictions are lifted, physiotherapists enter a new phase of the pandemic, one in which employers and front-line clinicians will have increased autonomy and responsibility to monitor their unique risks and emerging trends in the practice environment, and to implement the measures that they deem necessary to control those risks.

The information provided in this document is informed by the directives and orders of the CMOH, existing best practices, the Code of Ethical Conduct, and the Standards of Practice. The following guiding principles and assumptions underly the directions provided.

Guiding principles and assumptions

  • All physiotherapists will follow the directions provided by the CMOH.
  • Physiotherapists employed by hospitals, health authorities, and continuing care facilities will comply with the directions of their employers and the CMOH.
  • The direction in this document pertains to the delivery of care outside of these settings (e.g., private practice clinics, private mobile or home-based practices).
  • Physiotherapists will complete a Point of Care Risk Assessment prior to providing any in-person services, in any practice setting.
  • The physiotherapist providing services must determine the need for additional measures such as personal protective equipment, on the basis of the Point of Care Risk Assessment.
  • Telerehabilitation services should be considered an option to meet the patient’s care needs, when indicated by the risks associated with providing in-person services and the services required.
  • The easing of restrictions as part of the Open for Summer Plan does not mean a return to business as it was in 2019. Practice has fundamentally changed due to the pandemic and many changes are expected to continue for the long-term.
  • Point of Care Risk Assessments are and will remain a mainstay of safe clinical practice as mandatory measures to prevent the spread of COVID-19 are rescinded. Physiotherapists will need to complete these assessments prior to every patient interaction, considering the task, the patient, and the environment, as well as the physiotherapist’s own risk tolerance, when determining what personal protective equipment to employ.
  • Some measures mandated to enable clinical practice during the pandemic are clinical best practices for infection prevention and control and were always expected of physiotherapists. These include cleaning and disinfecting high touch surfaces and equipment between patients and routine, effective hand hygiene.
  • As with other infectious diseases, physiotherapists should employ the concept of universal precautions when determining the actions or measures appropriate to protect themselves and others in the practice environment. Physiotherapists should have a high index of suspicion that the patients they encounter in the clinical environment pose a risk of COVID-19 exposure and should act accordingly.
  • Telerehabilitation services are a safe and viable option for the provision of physiotherapy services. While some interventions and patient populations cannot be well managed using telerehabilitation, for other patient groups the outcomes of telerehabilitation services are similar to those of in-person services and may provide other benefits such as increased access to care or convenience for the patient.
  • Physiotherapists have a duty of care towards their patients which encompasses both the provision of safe, effective services and the mitigation of risks. This includes the risks related to COVID-19. While COVID-19 related risks are reduced in the context of decreasing active case numbers and increasing vaccination rates, they are not fully eliminated and will fluctuate over time as the situation continues to evolve.
  • Employers have a legislated responsibility under provincial Occupational Health and Safety (OH&S) law to provide a safe environment for patrons and staff. This includes the use of administrative, technical, and physical controls to address hazards in the work environment. Within the OH&S framework, COVID-19 is a foreseeable biological hazard that may be present in the work environment.  
  • Alberta’s CMOH may reinstate restrictions on in-person services if key indicators demonstrate increased spread of COVID-19 and threats to the health system. Similarly, municipalities may enact and enforce local bylaws. This means that businesses may go through further cycles of increasing and decreasing restrictions in the months ahead. Businesses should anticipate and prepare for this eventuality. Business owners and physiotherapists alike are advised to pay close attention to the COVID-19 situation and bylaws in effect in their local region or municipality.

The expectations outlined in the Infection Control Standard are relevant to the current COVID-19 situation. In accordance with the Standard, the physiotherapist:

  • Adheres to best practices of infection prevention and control in physiotherapy practice according to applicable legislation, regulatory requirements, standards, and guidelines.
  • Maintains the cleanliness of all spaces, equipment, and devices according to appropriate legislation, infection prevention and control standards/policies, and manufacturer’s recommendations.
  • Uses routine practices (e.g., hand washing, point-of-care risk assessment, use of personal protective equipment) to minimize or prevent the spread of acquired infections in the health-care setting.

Hand Hygiene

Hand hygiene is recognized as the single most important IPC practice to break the chain of transmission of infectious diseases.1 While hand hygiene practices gained much attention at the start of the pandemic, routine, vigorous hand hygiene is a best practice that should be employed to control the spread of all infectious diseases, at all times, and in all patient care settings.

Hand hygiene can be completed using alcohol-based hand rub (minimum 60% alcohol content), or through hand washing using soap and water. However, when hands are visibly soiled, they must be cleaned with soap and water as opposed to using alcohol-based hand rub.

Physiotherapists are expected to practice routine hand hygiene consistent with the World Health Organization’s “5 Moments for Hand Hygiene”:2

  • Before touching a patient
  • Before clean/aseptic procedures
  • After body fluid exposure or risk
  • After touching a patient
  • After touching patient surroundings

Physiotherapists are also advised to continue to avoid touching their face and to practice respiratory etiquette by coughing or sneezing into their elbow or covering coughs and sneezes with a facial tissue and then disposing of the tissue immediately.

Hand hygiene facilities (soap and water or alcohol-based hand rub) should be readily available within the practice environment and patients should be encouraged to complete hand hygiene at the following times:

  • Upon arrival at the practice setting
  • Before and after use of weights, exercise equipment or similar shared equipment
  • Prior to processing payment
  • Prior to departure from the practice

Cleaning and Disinfecting

Like hand hygiene, cleaning and disinfecting practices gained much attention at the start of the COVID-19 pandemic; however, these practices are recognized and accepted best practices and are expected to be employed at all times. Practice settings must continue their use of cleaning and disinfection practices in accordance with manufacturer’s instructions for cleaning and disinfecting of equipment. These practices control biological hazards in the practice setting. Effective environmental cleaning for infectious diseases, including COVID-19, requires both cleaning and disinfection of surfaces within the practice environment.3 Cleaning refers to the removal of visible dirt and debris. Disinfection inactivates disease producing agents.

  • Virucidal disinfectants or diluted bleach solution must be used to complete the disinfection step of cleaning and disinfecting surfaces.3
  • Cleaning and disinfecting products must be used according to manufacturer’s directions for application and contact time.
    • Physiotherapists are directed to check the Health Canada database to confirm that the virucide in use is effective against COVID-19.
  • If using bleach, follow label directions for proper dilution ratios.  
  • Cleaning products that do not have a DIN or are not bleach (e.g., vinegar, tea tree oil) must not be used in clinical practice as they are not proven effective and approved for use.

Frequency of Cleaning and Disinfection

The frequency of cleaning and disinfection is dependent on the nature of use/contact of the surface/item in question:

  • Patient care/patient contact items must be cleaned and disinfected between each patient/use.4 Examples include but are not limited to:
    • Treatment beds
    • Exercise equipment
    • Goniometers and reflex hammers
    • Pin pads used to process payment
  • High touch, non-patient care items should be cleaned and disinfected twice a day, and more frequently as use and circumstances warrant. Examples include but are not limited to:
    • Doorknobs and light switches
    • Hydrocollator handles
    • Washrooms, sinks/faucets and hand sanitizer dispensers
    • Treatment area counter tops, staff room desktops, clipboards, pens, and shared computers
    • Telephones, keyboards, and mobile devices
  • Other surfaces in the practice environment can be a potential reservoir for infectious agents. Cleaning and disinfection of these surfaces should occur regularly and at any time when visibly soiled. Examples include but are not limited to:
  • Legs and undersides of treatment beds
  • Cubicle curtains
  • Items that cannot be effectively cleaned and disinfected between use should not be present in the clinic environment (e.g., magazines or toys in waiting areas). This includes but is not limited to exercise equipment if it cannot be properly disinfected, items with porous fabric upholstery, and treatment beds with torn surfaces or patched with tape.
  • Physiotherapists and business owners are encouraged to establish clear responsibilities and accountabilities for staff involved in cleaning and disinfection activities and allocate PPE (gloves and masks) for use during cleaning and disinfecting activities, according to product specifications, to protect workers engaged in these activities.
  • Where feasible, physiotherapists should continue to avoid sharing equipment (e.g., goniometers, reflex hammers, pens) or treatment rooms. Any shared equipment should be cleaned and disinfected between users according to manufacturer’s directions.

As mandatory universal measures come to an end, completing Point of Care Risk Assessments (PoCRA) prior to every patient interaction, regardless of the practice setting in which you work, becomes increasingly important.
Physiotherapists are advised to assess the task, the patient, and the environment to determine the risk of exposure to blood or body fluids and the PPE required to perform the patient care task safely.

Risks can relate to patient factors, provider factors, and the interventions performed, including but not limited to considerations such as:

  • Patient factors:
    • Patient comorbidities, health status, and vulnerability
    • Cognition and ability to practice respiratory hygiene/manage secretions
  • Provider factors:
    • Health status and vulnerability
    • Vaccine status
    • Personal considerations (e.g., caregiver to a young child or frail elder at risk of severe health outcomes)
  • Interventions:
    • Proximity to the patient and duration of close contact
    • Direct contact with mucous membranes (e.g., TMJ treatment)

Physiotherapists are advised not to ask patients about their vaccine status as this may constitute an unreasonable collection of private health information unrelated to the patient’s physiotherapy treatment needs and may create a false sense of security.

Each physiotherapist will need to consider their individual risk tolerance when determining the personal protective equipment to employ when engaging in direct patient care activities.

The measures indicated by the PoCRA must be consistent with or in addition to any mandatory measures in place at the direction of the CMOH or municipal governments.

Screening

Over the past 16 months physiotherapists and others within the practice environment have grown accustomed to screening individuals seeking physiotherapy services. Active screening involves directly questioning patients regarding signs and symptoms, travel history, and close contacts at the time of booking and upon the patient’s arrival at the practice site. Passive screening involves posting signage asking patients to defer their appointment if they are experiencing signs and symptoms or have other risk factors for COVID-19.

Physiotherapists working in community health settings (e.g., private practice clinics, mobile practice settings), are advised to continue to engage in active screening of both patients and staff prior to their admittance to the practice environment.

Physiotherapists are reminded that individuals with even mild symptoms of COVID-19 are legally required to self-isolate and must not be in the practice setting, regardless of their vaccination status.

Physiotherapists are advised to make themselves aware of the current isolation and quarantine rules for individuals who are fully, partially or unvaccinated and who are identified as a close contact to an individual diagnosed with COVID-19. Similarly, physiotherapists are advised to monitor the rules related to quarantine following international travel for individuals who are fully, partially or unvaccinated.

However, physiotherapists are advised not to ask patients about their vaccine status. Asking about vaccination may constitute an unreasonable collection of private health information, could create a false sense of security, and may result in incorrect assumptions about a patient’s quarantine requirements.

Due to the multiple considerations that may affect the direction an individual may receive regarding the requirement to quarantine, physiotherapists are advised to add the following question to their current screening processes:

Have you been directed by Alberta Health Services or the Canadian Border Services Agency to quarantine?

Individuals who have been directed to quarantine must not be in the practice setting.

Physiotherapist Use of Masks

Chief Medical Officer of Health, Dr Hinshaw announced on June 22, 2021 that continuous masking will continue to be required in continuing care centers and acute care facilities. On June 29, Dr. Hinshaw announced that the continuous masking requirement will be extended to all AHS and Covenant Health community facilities (e.g. COVID-19 testing centres, vaccination clinics, and labs).

At this time, Physiotherapy Alberta strongly recommends physiotherapists in all practice settings continue to wear medical grade surgical or procedure masks at all times and in all areas of the workplace if they are either providing direct patient care or cannot maintain two-meter distance from patients and co-workers. This recommendation is consistent with the guidance on use of masks contained in the Alberta Public Health Disease Management Guidelines: Coronavirus – COVID-19.

The further rationale for ongoing mask use is as follows:

  • Data suggests that although the B1.1.7 variant is currently the dominant strain of COVID-19 in Alberta, the B1.617 variant (also known as the delta variant) is increasing in prevalence.
    • The delta variant is more transmissible than the original virus or prior variants.5
    • Some data suggests that a single dose of vaccine is not sufficient to prevent illness from the delta variant.6  
  • There is a lack of data regarding whether an asymptomatic, fully vaccinated person, can transmit COVID-19 to others whom they come in close contact with.7
  • Many patients accessing community health settings will not have had the opportunity to receive both vaccine doses at the time of Stage 3 re-opening.

Use of masks in community health settings helps to prevent clinicians from exposure to COVID-19 from asymptomatic carriers of the virus, including those who have been fully vaccinated. This in turn, may help to prevent onward spread by the physiotherapist to other patients, colleagues in the practice setting, and personal contacts.

Use of masks in community health settings also helps to prevent the spread of the virus from clinicians who may be fully vaccinated, but who also could conceivably be asymptomatic carriers of the virus, to patients who are not fully vaccinated.

Physiotherapists are reminded that employers can establish higher expectations and requirements than those of Physiotherapy Alberta. As such, an employer may establish a requirement for continuous masking in a community health setting in order to fulfill their legislative responsibilities under OHS law and to mitigate the risks within the work environment.

Physiotherapists working with patients known or suspected of having COVID-19 (e.g., in ICU or acute care environments) are to follow their employer’s directions regarding PPE use with this patient population and for the tasks performed.

Patient Use of Masks

Comments made on June 22, 2021, by the CMOH appear to indicate that ongoing mask use in continuing care and acute care environments will apply to all individuals in those environments including patients and visitors.
At this time, patient use of masks in community health settings has not been mandated by the CMOH. As such, physiotherapists may question whether they can require masking as a condition of service.

As Physiotherapy Alberta has stated previously, according to the Legislative Responsibilities Standard of Practice, physiotherapists are required to be knowledgeable of and compliant with the legislation relevant to their practice. This includes having knowledge of any CMOH Orders which require indoor mask use, and municipal bylaws regarding mask use that may remain in effect when the provincial order is rescinded.

At the same time, the Code of Ethical Conduct states that members of the physiotherapy profession have an ethical responsibility to “Act in a respectful manner and do not refuse care or treatment to any client on the prohibited grounds of discrimination as specified in the Canadian Human Rights Act as well as on the grounds of social or health status.”

Declining to provide care is a serious matter. There are conflicting needs, values and rights involved in such a decision, including:

  • The patient’s right to access to care and the requirement that access not be denied on the basis of a protected ground or health status, including health conditions that may preclude the use of a mask.
  • The physiotherapist’s duty to comply with legislation relevant to their practice.
  • Patients’ expectations that they will receive safe care, as stated in the Safety Standard of Practice.
  • The health and safety of everyone that enters the practice environment.

Physiotherapists and physiotherapy business owners should understand the many implications of refusing to provide care to a patient who declines to wear a mask in the practice setting. They should also consider the other measures in place and options available to provide care to patients who decline to wear masks, including the use of other public health measures to limit risk, the use of telerehabilitation to deliver physiotherapy services, and limiting access to the practice setting for unmasked patients to designated times.

Eye Protection

Alberta Health recommends the use of eye protection as an additional layer of protection for all patient interactions within two metres, in areas where there are ongoing high levels of community transmission.

Eye protection is intended to protect the health-care provider from potential COVID exposures arising from interactions with patients who had symptoms that were not recognized to be COVID-19 at the time of their appointment (e.g., due to patient confusion).

However, Alberta Health continues to indicate that “continuous masking (medical/surgical masks) and proper hand hygiene is considered to offer sufficient protection for HCWs who have cared for patients with presymptomatic/asymptomatic COVID-19 infection.”

Further, the current situation in Alberta is one in which community transmission levels are no longer considered to be high. As such, use of eye protection, during routine clinical care may not be necessary, depending on the Point of Care Risk Assessment performed by the treating physiotherapist.

Examples of appropriate eye protection include safety glasses, reusable goggles, face shields or face masks with built-in eye shields. Vision correcting eyeglasses are not classified as eye protection and do not address PPE recommendations.

Some eye protection is single use, while other products are reusable following cleaning and disinfection. Follow manufacturer instructions regarding whether eye protection is reusable and the approved cleaning and disinfecting products for the eye protection in use.

For physiotherapists working with patients who are not symptomatic, eye protection may be worn continuously and changed when a mask is changed, or when the eye protection becomes wet or soiled.

Physiotherapists working with patients with known or presumed COVID-19 must follow the directions of Infection Prevention and Control officials regarding PPE use and when PPE must be changed or discarded.

While other PPE may not be required to prevent the spread of COVID-19 when working with asymptomatic patients, physiotherapists should assess the tasks they are planning and continue to employ PPE typically used when performing the interventions planned (e.g., gloves when needling).

Additional measures, such as maintaining physical distance in waiting areas and in gym or treatment spaces, use of physical barriers such as plexiglass between patients and reception staff, and tracking of individuals onsite for contact tracing purposes, remain recommended practices.

Employers are also advised to consider the measures needed to maintain worker safety as part of their duties under Occupational Health and Safety legislation, in addition to requirements and recommendations of Physiotherapy Alberta, as restrictions ease. 

  1. Physiotherapy Alberta. Infection Prevention and Control Resource Guide for Alberta Physiotherapists. Available at: https://www.physiotherapyalberta.ca/files/practice_guideline_infection_prevention_control.pdf.  Accessed June 24, 2021.
  2. World Health Organization. WHO Guidelines on Hand Hygiene in Health Care: A Summary. Geneva: WHO Press, 2009. Available at https://www.who.int/publications/i/item/9789241597906-summary. Accessed June 24, 2021.
  3. Government of Canada. COVID-19: Cleaning and Disinfecting. Available at: https://www.canada.ca/en/public-health/services/diseases/2019-novel-coronavirus-infection/prevention-risks/cleaning-disinfecting.html Accessed June 24, 2021.
  4. Public Health Agency of Canada. Routine Practices and Additional Precautions for Preventing the Transmission of Infection in Healthcare Settings. 2016. Available at: https://www.canada.ca/content/dam/phac-aspc/documents/services/publications/diseases-conditions/routine-practices-precautions-healthcare-associated-infections/routine-practices-precautions-healthcare-associated-infections-2016-FINAL-eng.pdf. Accessed June 24, 2021.
  5. Government of Canada. Coronavirus Disease (COVID-19): Outbreak Update. Available at:  https://www.canada.ca/en/public-health/services/diseases/2019-novel-coronavirus-infection.html#a8. Accessed June 24, 2021.
  6. Government of Canada, National Advisory Committee on Immunization. Recommendations on the Use of COVID-19 Vaccines. Available at: https://www.canada.ca/en/public-health/services/immunization/national-advisory-committee-on-immunization-naci/recommendations-use-covid-19-vaccines.html. Accessed June 24, 2021.
  7. Centers for Disease Control and Prevention. Key Things to Know About COVID-19 Vaccines. Available at: https://www.cdc.gov/coronavirus/2019-ncov/vaccines/keythingstoknow.html. Accessed June 24, 2021.