To,

Date : 11/04/2014

Dr. Anil Kumar,

CMO(AK)
Room No.506 D Wing, 5th Floor,
Nirman Bhawan, New Delhi-110018
Subject: Objections & Suggestions for draft minimum standards for various
categories of Clinical Establishments for implementation of the Clinical
establishments Act. Clinical Establishment Act Standards for Physiotherapy
Centre CEA /Physiotherapy Centre- 023
Respected Sir,
With the reference to the notification published on website, here I am forwarding
my views, objections & suggestions on different aspects of proposed act including
deletions as well additions in Clinical Establishment Act Standards for
Physiotherapy Centre CEA /Physiotherapy Centre- 023
OBJECTIONS:
OBJECTIONS NO.1: WRONG MENTION OF PHYSIOTHERAPY
PROFESSION IN BILL. Objection on the definition of physiotherapy clinic.
The decision of the Government to integrate Clinical Establishment Act
Standards for Physiotherapy Centre CEA /Physiotherapy Centre- 023 to
promote the practices of physiotherapy across the country is appreciable. First
time in the history of Indian health system the ministry has taken a forward step to
recognize the physiotherapy fraternity & fixed minimum criteria. However the
bill addressed profession of physiotherapy in wrong way. The definition, clause 1
of proposed draft creates doubt & confusion as it mentions physiotherapy clinic as
Para clinical establishment. The use of the word Para clinical is not appropriate
as it doesnt go with the national & international scenario & references about
status of physiotherapy profession.
While defining the physiotherapy clinic, I think the officials ignored national &
international trends & references. The reason for my belief lies in the vision policy
of clinical establishment act. The act is clearly divided its policy documents under
two categories. The first is the guidelines for practice & other is the minimum
criteria for establishing the clinic. The guidelines included the ideal way of
treatment. It is expected that the Clinical Establishment Act Standards for
Physiotherapy Centre CEA /Physiotherapy Centre- 023 should include the criteria
to start clinic & not the direction to practice. Its unfortunate to see that the

dictations are reflected about the treatment in the minimum criteria. I would like to
bring to your kind notice that similar kind of dictations are not seen in other health
profession so why its only for physiotherapy profession. It gives scope to raise
doubt on interest & motive behind such dictations.
A professional trained in diagnostic, clinical assessment & therapeutic techniques
for 4.5 years cant be labeled as para clinical.
Clinical Establishment Act Standards for Physiotherapy Centre CEA
/Physiotherapy Centre- 023 dentition of physiotherapy set up is not just against
the current national & international scenario but also not as per various reports of
Rajyasabha, Parliamentary Standing committee, central health ministry. I take
this opportunity to bring the current national & international scenario in your
notice.
Clause 8.2 of 31st report standing committee of health, Rajyasabha
Physiotherapy being considered a discipline distinct from paramedical
disciplines finds a specific mention in the title (Paramedical and Physiotherapy
Central Councils Act, 2007)
Clause 9.46 The fact that physiotherapy education over the years has made
significant advancements and has evolved as a distinct profession seems to be well
established. This is strengthened by the considered opinion of Ministry of Law
that physiotherapy profession should not be equated with the paramedical
professions
Hence, I strongly request you to address the generalization of word Para
clinical & remove it.
Refer:
www.prsindia.org/uploads/media/Paramedical%20and
%20Physiotherapy/1196830081_paramedical_20To_20be.pdf
SUGGESTION: INCLUSION OF PHYSIOTHERAPY PROFESSION WITH
APPROPRIATE STATUS

Physiotherapy is a branch of modern medical science which deals with the

orthopedic, neurological, cardiorespiratory, womens & community health,
pediatrics, geriatrics, sports, traumatic, paralytic conditions and physically
challenged population. In India, the physiotherapy education was started in
immediate post independence period. Today more than 40,000 physiotherapists are
providing their services to the Indian community through central, state
government; public, corporate, private & charitable trust running hospitals &
clinics. Sates like Delhi, Maharashtra, and Tamilnadu have independent
councils to regulate physiotherapy profession in their states. Gujarat State
assembly already passed the Gujarat Physiotherapy council Bill 2010 & is in

process for constitution of council. Karnataka state is in process to form draft for
Karnataka state Physiotherapy Council, committees have formed for the same.
At present the Physiotherapy education, practice & services are regularized
by state physiotherapy councils in three major states of country i.e. Delhi,
Maharashtra, Tamilnadu. Gujarat State assembly already passed the Gujarat
Physiotherapy council Bill 2010. I would like to bring to your kind notice that
The Delhi State Council for Physiotherapy & Occupational Therapy
(NO.F.-17 (75)/ 99MED/ DHS), Maharashtra State Council for
Occupational & Physiotherapy (II OF 2004), Tamilnadu State Council for
Physiotherapy (G.O. (MS) NO.338 TN) already awarded independent status to
physiotherapy profession.
As per Maharashtra State Occupational & Physiotherapy Council Act 2002,(Act no.
II of 2004)

"Physiotherapy" means a branch of modern medical science which includes

examination, assessment, interpretation, physical diagnosis, planning and
execution of treatment and advice to any person for the purpose of preventing,
correcting, alleviating and limiting dysfunction, acute and chronic bodily
malfunction including life saving measures via chest physiotherapy in the
intensive care units, curing physical disorders or disability, promoting physical
fitness, facilitating healing and pain relief and treatment of physical and
psychosomatic disorders through modulating physiological and physical response
using physical agents, activities and devices including exercise, mobilization,
manipulations, therapeutic ultrasound, electrical and thermal agents and
electrotherapy for diagnosis , treatment and prevention.
, I would like to bring to your Kind notice that the Physiotherapy Profession has
given Independent status & council in Maharashtra. The Maharashtra state
council for occupational therapy & physiotherapy act was passed by state
assembly in year 2002.(Act II of 2004). One year back, the state assembly passed
the Maharashtra Paramedical council Act 2011. Please note here that the
Maharashtra state paramedic council is different & State Occupational &
Physiotherapy Council is different. Physiotherapy is neither included nor
clubbed with paramedical professions. Physiotherapy is not Paramedical or
Para clinical profession its independent health profession.
Also WHO defined & awarded same status to physiotherapy.
W.H.O. Definition of Physiotherapy:
Physiotherapists assess, plan and implement rehabilitative programs that
improve or restore human motor functions, maximize movement ability, relieve
pain syndromes, and treat or prevent physical challenges associated with injuries,
diseases and other impairments. They apply a broad range of physical therapies

and techniques such as movement, ultrasound, heating, laser and other techniques.
They may develop and implement programmes for screening and prevention of
common physical ailments and disorders.
The World Health Organization (WHO) Classification of Physiotherapists:
World Health Organization (WHO) has classified physiotherapists as an
independent health professional i.e. (ISCO CODE: 2264) on the International
Standard Classification of Health Workers and paramedical professionals have
been classified in a separate entity ( ISCO code 2240).
(Reference -WHO: http://www.who.int/hrh/statistics/Health_workers_classification.pdf )

ISCOs main aims are to provide:

- a basis for the international reporting, comparison and exchange of statistical and
administrative data about occupations;
-a model for the development of national and regional classifications of
occupations; and
-a system that can be used directly in countries that have not developed their own
national classifications.
Physiotherapists and related associate professionals treat disorders of bones,
muscles and parts of the circulatory or the nervous system by manipulative
methods, and ultrasound, heating, laser or similar techniques, or apply
physiotherapy and related therapies as part of the treatment for the physically
disabled, mentally ill or unbalanced.
Tasks include (a) Advising communities and individuals on correct body postures, for work or
otherwise, to avoid injuries and strain and to strengthen muscles;
(b) Conducting examinations to make diagnoses of disorders of bones, muscles
and parts of the circulatory or the nervous system to determine proper
treatment or refer to Medical doctors, if necessary;
(c) Treating disorders of bones, muscles and parts of the circulatory or the nervous
system by manipulative methods, and the use of ultrasound, heating, laser or
similar techniques;
(d) Massaging client or patient to improve circulation, soothe or stimulate nerves,
facilitate elimination of waste matter, stretch contracted tendons and produce
other therapeutic effects;
(e) Examining body deformities and disorders to determine and write
specifications for artificial limbs or other appliances, helping to fit them and
explaining their use;
(f) Applying physiotherapy and related techniques as part of the treatment of the
mentally ill or unbalanced;
(g) Performing related tasks;
(h) Supervising other workers.

(Reference WHO:
http://www.ilo.org/public/english/bureau/stat/isco/isco88/3226.htm )
World Confederation of Physical Therapy (WCPT)
Physical therapists are qualified and professionally required to:
- undertake a comprehensive examination/assessment of the patient/client or needs
of a client group
- evaluate the findings from the examination/assessment to make clinical
judgments regarding patients/clients
- formulate a diagnosis, prognosis and plan
- provide consultation within their expertise and determine when patients/clients
need to be referred to another healthcare professional
- implement a physical therapist intervention/treatment programme
- determine the outcomes of any interventions/treatments
- make recommendations for self-management.
(Reference: http://www.wcpt.org/what-is-physical-therapy)
Documentation about Physiotherapy in the Sixtieth Report On The National
Commission For Human Resources For Health (NCHRH) Bill, 2011
Department-Related Parliamentary Standing Committee On Health And
Family Welfare), Rajyasabha
Recommendation no. 3 (viii), PAGE NO. 65
The Committee also takes note of the apprehensions expressed by some of the
professional associations like physiotherapy, dental hygienists, optometrists,
occupational therapists etc. They expressed the desire to have separate Council for
each of the professions. For example, Dental Hygienists Association felt that they
are always relegated to the background and they do not get sufficient prominence.
They also felt that their profession has not been appropriately represented in the
Bill. The Committee feels that many new fields have emerged in the health
profession but the new fields are yet to be granted the status of separate
Council so as to ensure their better growth, regulation and standards. The
Committee, therefore, recommends that their grievances may also be taken
care of and separate Councils may be provided for them, wherever feasible.
Recommendation no. 5, PAGE NO. 70
The Committee, accordingly, recommends that the Ministry may withdraw this
Bill and bring forward a fresh Bill after sufficiently addressing all the views,
suggestions and the concerns expressed. Before finalizing the fresh Bill, the
Ministry may hold discussions with all the stakeholders including the State
Governments.
Documentation about Physiotherapy in the Thirty-First report on
Paramedical and Physiotherapy Central Councils Bill-2007 (Presented to the

Rajya Sabha on 21st October,2008 and laid on the table of Lok Sabha on 21st
October,2008):
Clause 8.2 Physiotherapy being considered a discipline distinct from paramedical
disciplines finds a specific mention in the title (Paramedical and Physiotherapy
Central Councils Act, 2007)
Clause 9.36 Committees attention was also drawn to the parallel position of
Naturopathy and Yoga when compared with physiotherapy as both were based on
physical and psycho-somatic methods of diagnosis and treatment, with both
claiming benefit to the patients in a drugless manner. It was argued that both
Naturopathy and Yoga are granted equal status along with Ayurveda under
AYUSH. Thus, physiotherapy also deserved to be granted an independent
status.
Clause 9.46 The fact that physiotherapy education over the years has made
significant advancements and has evolved as a distinct profession seems to be well
established. This is strengthened by the considered opinion of Ministry of Law
that physiotherapy profession should not be equated with the paramedical
professions
Clause 9.47 The Committee also takes note of the fact as mentioned by the
representative of the Ministry that in USA, physiotherapy profession has
reached a stage where these professionals can practice independently. Not
only this, in some of the international Acts, it has been specifically provided that
physiotherapists having the required experience can give physiotherapy treatment
without a referral. These Acts also confer upon a physiotherapist the right to
practice with or without referral governed by the circumstances of the case.
Clause 25.5 During the course of interactions, the Committee observed that there
was a lot of dissatisfaction among the allied health professionals particularly
physiotherapists and occupational therapists with regard to their pay scales. It was
brought to the notice of the Committee that their entry into Government service
after completion of four and a half years degree course in the respective profession
was not being addressed properly. The Committee was given to understand that
their recurrent demands for bringing parity in the pay scales have yielded no
results so far. General perception was that discriminatory treatment was being
meted out to them as their pay scales did not commensurate with their status and
responsibility.
Clause 25.6 The Committee feels that all the allied health professionals including
physiotherapists and occupational therapists play a crucial role in the field of
medicine and physical rehabilitation. The Committee, therefore, strongly
recommends that their legitimate interests should be taken care of and their

existing pay structure may be revised according to their qualifications and duration
of the course they have to put in before entering into a Govt. job.
Committees recommendation page 51: The Committee feels that the
Physiotherapy Central Council as envisaged with two separate registers for
physiotherapy and occupational therapy will not serve the purpose. The
Committee would like to point out that an independent profession with entirely
different course of study, mode of treatment and approach in treatment and
rehabilitation of patients cannot be included under another profession. The
Committee also takes note of the fact that both the professions having entirely
separate curriculum are recognized as separate disciplines by UGC. Committees
contention is strengthened by confirmation of both the professions being entirely
different and practitioner of one discipline not allowed to practice the other in
reply to a Parliament Question given on the 20th August, 2004. In the light of the
above facts and also its observations/ recommendations in respect of Clauses 1 (1)
and 2 (1) (a) above, the Committee recommends that Clause 3 (1) be amended
to read as follows:(e) The Physiotherapy Central Council,
(f) The Occupational Therapy Central Council,
(g) The Medical Laboratory Technology Central Council, and
(h) The Radiology Technology Central Council.
The Committee also recommends that the consequential changes be made in the
Bill to reflect the above proposition.
The findings and documentation of this committee are in strong favor of an
independent status and council for Physiotherapists.
Refer:
www.prsindia.org/uploads/media/Paramedical%20and
%20Physiotherapy/1196830081_paramedical_20To_20be.pdf
Rehabilitation Council of Indias report on Physiotherapy profession:
During the year 1998/99 following three categories were notified vide Govt. Of
India Notification No. 674 dated 13.10.98 for inclusion under the Council &
subsequently same were withdrawn (through their Notification dated the 25th
June, 1999) from the purview of the Council as Ministry of Health was planning
to have a separate Council for them.
(i) Physiotherapists
(ii) Occupational Therapists
(iii) Ophthalmic Technicians
(Reference: Page 10, Ten years of progress RCU-Towards Nation building-Dr. J.
P. Singh-Rehabilitation Council of India)
Planning Commission on Independent Physiotherapy Council

Planning commission in its 11th five year plan (2007-2012) Volume II, Social
sector suggested separate council for Physiotherapy & occupational therapy
(clause 3.1.104, page 84-85)
Hence, considering the previous proposed national physiotherapy council act, the
reports of various parliamentary committees, law ministrys opinion, RCI
notification, Planning commissions policy etc. its clear that the central ministry
& governments views are in favor of Independent council in India with
independent status.
31st Report, Department Related Parliamentary Committee, Rajyasabha
Views, Comments & Recommendation On Use Of Words Medically
Directed In Relation To Physiotherapy
Clause 9.47: the committee also took opportunity to go through the definition of
physiotherapy as given in different state Acts of USA, Canada, New zeland etc.
The committee did not noticed use of the words medically directed in the
definition of physiotherapy given in these acts. The committee also likes to point
out that the definition should only describe profession enumerating its different
characteristics & not its administrative part.
The Committee also takes note of the fact as mentioned by the representative of
the Ministry that in USA, physiotherapy profession has reached a stage where
these professionals can practice independently. Not only this, in some of the
international Acts, it has been specifically provided that physiotherapists having
the required experience can give physiotherapy treatment without a referral.
These Acts also confer upon a physiotherapist the right to practice with or without
referral governed by the circumstances of the case.
Appeal & explanation:
From above information its crystal clear that the definition should only describe
profession enumerating its different characteristics & not its administrative
part. Hence, its expected that the members of Clinical Establishment Act
Standards for Physiotherapy Centre CEA /Physiotherapy Centre- 023 should take
above comments into consideration. However its really unfortunate for me to see
that the dictation given in proposed draft regarding prescription & referral
sounds biased & not as per national trends too.
If you give a close look on the various universities courses & curriculum, you will
find that health universities describes physiotherapy profession as independent or
Allied health course & not as paramedical / para clinical. E.g MUHS, RGUHS
etc.
SUGGESTION:

DELETE the definition of physiotherapy clinic as para clinical. Or

change the paraclinical to clinical or branch of modern medicine ( as
defined by Maharashtra state OT PT Council, Mumbai)

OBJECTION NO.2: OBJECTION ON USE OF WORDS REFERRAL /

PRESCRIPTION
In the proposed draft, in definition its mentioned that physiotherapist should give
treatment to patients with a recent prescription or referral from a licensed
medical doctor (physician/surgeon). After three weeks or earlier if indicated a
review and re-prescription from the treating medical doctor is required for
continuing physical therapy services.
Explanation on this irrational inclusion:
I am happy to bring to your kind notice that besides physiotherapy subjects
Physiotherapists are well trained in anatomy, physiology & other medical clinical
subjects. But similar thing is neither seen for MBBS student nor with
MD/DM/MS/MCH student. Just see syllabus, transcript hours of B.P.Th student
& M.B.B.S, MD/DM/MS/MCH student students of various state health
universities.
The proposed draft says that for receiving physiotherapy Rx Prescription or
referral from registered medical practitioner is needed. I am shocked to see this
kind of approach of guidelines drafting committee. Kindly enlighten me in which
year M.B.B.S student or even a resident is trained in physiotherapy subjects?
Where its mentioned in syllabus by university? Or even in minimum standards for
syllabus by medical council? If medicos are not trained in physiotherapy then
in what capacity they can plan, execute or modify physiotherapy treatment or
expecting that physiotherapist should follow their commands in relation to
physiotherapy Rx?
The medical fraternity is NEVER TRAINED IN PHYSIOTHERAPY subjects
& they are unaware of physiotherapy assessment & treatment. Even they learn
physiotherapy treatments; legally they are not allowed to do so. Yes, they are
prohibitated to so by laws of lands on two major states of country.
Kindly take a note that as per Maharashtra State Occupational & Physiotherapy
Council, (MHACT II OF 2004) & also The Delhi State Council for
Physiotherapy & Occupational Therapy only a registered Physiotherapist of
state council has right to plan, modify, execute & terminate Physiotherapy
treatment in respective states. Other than registered physiotherapist no one is
allowed to plan, modify, dictate & execute physiotherapy Rx. If any other
health care professional is planning, modifying or dictating physiotherapy
treatment to a physiotherapist then it is recorded as malpractice & it is a
punishable offence; the action will be taken on such members under penalty

section provisions of Maharashtra state OT PT council act & Delhi state PT OT

Council.
Clinical Establishment Act Standards are aimed to establish standards for health
care service providers to uplift & protect public health. I am saddened to see that
the Clinical Establishment Act Standards for Physiotherapy Centre CEA
/Physiotherapy Centre- 023 is encouraging the malpractice in country. Such
criteria are giving opportunity to incompetent health professionals to play with life
of people, the professionals of one profession to prescribe treatment of other
health care profession simply Quackery. I think surely, its not the main intention
of Clinical Establishment Act Standards.
10.2 Assessment and plan of care: as per proposed draft, the physiotherapist
card/slip of every registered patient must bear the minimum following legibly at
every visit: Working diagnosis as provided by the treating medical doctor who
has referred the patient, Relevant history and examination findings, Plan of care
listing the exercises and physical modalities, Signature and date of the physical
therapist, A review and re-prescription from the treating medical doctor after three
weeks for continuing plan of care.
(Objection: The treatment is determined by the Physiotherapist who is a qualified
Professional according to the current Clinical Establishment Acts and the existing
state Councils of India. 3 Weeks is not sufficient duration in case of patients with
Paraplegia, hemiplegia, Cerebral palsy etc.
Kindly refer the Ministry of Social Justice & Empowerments letter No. 93/CCD/2007 dated 15/05/2008 , Subject: Handling of Children with disabilities
and referral which states that Most of the doctors are not trained for
rehabilitation of Persons with disabilities, they often try to treat their disabilities
even when medical or surgical interventions are not required. In the process, most
critical period of six years of life is lost which is most important period to train &
rehabilitate the child with disability to utilize the residual capacity of the impaired
organs. Consequently, it is too late for such children to respond to the
rehabilitation therapies even by most qualified & skilled rehabilitation
professionals like Physiotherapists etc.
Chief Commissioner has taken notice of the complaints from parents,
Rehabilitation professionals, NGOs etc. and has directed that appropriate
instructions may be issued by Medical Council of India and Indian Medical
Association through print and electronic media to the effect that the doctors not
trained on rehabilitation should restrict their treatment of children with
disabilities to their medical illness/disease or else action be initiated against
such practices under relevant section of MCI. They should refer such children
to the qualified rehabilitation Professionals to ensure that they get appropriate
rehabilitation/therapeutic assistance well in time. The court of the Chief

Commissioner for persons with disabilities shall be constrained to initiate action

under Section 59 of the Persons with Disabilities Act, 1995 against the Doctors
who may persist with such practices.
http://www.mciindia.org/circulars/Circular-disabled-children.pdf)
From above report, its quite clear that the medical doctors are not trained in
rehabilitation. If they are not trained in rehabilitation then forget about
physiotherapy.
Suggestion: so by observing all the references, international & national trends
as discussed above, its proved that physiotherapy services are independent &
dont require prescription & reference. Hence the unjustified words
prescription & referral should be deleted from the draft as a registered
medical practitioner is legally not allowed to practice physiotherapy
Supporting Points for Modifications of Points 1, 2.1 , 6.1 &10.1 of proposed
draft
1. Delhi Council for Physiotherapy & Occupational Therapy Act 1997 :
Physiotherapy means physiotherapeutic system of medicine which includes
examination, treatment, advice and instructions to any persons preparatory to or
for the purpose of or in connection with movement dysfunction, bodily
malfunction, physical disorder, disability, healing and pain from trauma and
disease, physical and mental conditions using physical agents including exercise,
mobilization, manipulation, mechanical and electrotherapy, activity and devices or
diagnosis, treatment and prevention.
(Reference: http://delhiassembly.nic.in/aspfile/billspassed/141997.htm )
2. Maharashtra State Occupational therapy & Physiotherapy Council,
Mumbai (MH ACT II of 2001): "Physiotherapy" means a branch of modern
medical science which includes examination, assessment, interpretation, physical
diagnosis, planning and execution of treatment and advice to any person for the
purpose of preventing, correcting, alleviating and limiting dysfunction, acute and
chronic bodily malfunction including life saving measures via chest physiotherapy
in the intensive care units, curing physical disorders or disability, promoting
physical fitness, facilitating healing and pain relief and treatment of physical and
psychosomatic disorders through modulating physiological and physical response
using physical agents, activities and devices including exercise, mobilization,
manipulations, therapeutic ultrasound, electrical and thermal agents and
electrotherapy for diagnosis , treatment and prevention.
(Reference: http://www.msotptcouncil.com/OTPTActs.aspx)

Maharashtra State has Documented Physiotherapy as an Individual profession and

has passed " Maharashtra Council for Paramedical sciences & Technologies" for
Paramedics. Physiotherapy and Paramedical councils are two different councils
3. Government of India- Quality Council of India, Survey Report &
Recommendations Of Clinical Establishments
Physiotherapy Definition: The treatment of disease, bodily defects, or bodily
weaknesses by physical remedies, as massage, special exercises, etc., rather than
by drugs.
(Reference: http://clinicalestablishments.nic.in/WriteReadData/384.pdf Page11 )
4. Various Acts/Rules of the Central Government of India and State
Governments of India
'Clinical Establishment' means (i) a hospital, maternity home, nursing home,
dispensary, clinic, sanatorium or an institution by whatever name called that offers
services, facilities requiring diagnosis, treatment or care for illness, injury,
deformity, abnormality or pregnancy in any recognized system of medicine
established and administered or maintained by any person or body of persons,
whether incorporated or not;
(Reference:
http://www.ima-india.org/downloads/Clinical%20Establishment
%20Draft%20Rules%20for%20Central%20Govt.pdf
http://clinicalestablishmentstraining.nic.in/WriteReadData/293.pdf )
All the below Acts/Rules
(Karnataka Private Medical Establishments Act,2007 /The Karnataka Private
Medical Establishments (amendment) act, 2012 , The Andhra Pradesh Private
Medical Care Establishments (Registration andRegulation) Act, 2002 ,The
Bombay Nursing Homes Registration Act, 1949, The Delhi Nursing Homes
Registration Act, 1953,Manipur Homes and Clinics registration Act, 1992, The
Nagaland Health care Establishments Act, 1997, The Arunachal Pradesh Health
and Establishment Act, 2002, The Orissa Clinical Establishments (Control and
Regulation) Act, 1990, The Punjab State Nursing Home Registration Act, 1991,
The Tripura Clinical Establishment Act, 1976, The West Bengal Clinical
Establishments Act, 1950, The Jammu and Kashmir Nursing Homes and Clinical
Establishments (registration and licensing) act, 1963, Madhya Pradesh Clinical
Rules, 1973 / Madhya Pradesh Upcharya Griha Tatha Rajupchar Sanbabdu
Sthapama Adhiniyam, 1973 ) state that
Physio-therapy establishment means an establishment where massaging
,electrotherapy, hydrotherapy, remedial gymnastic or similar processes are usually
carried on, for the purpose of treatment of diseases or of infirmity or for
improvement of health or for the purpose of relaxation or for any other purpose
whatsoever

For Physical Therapy Establishment, It is under the direct supervision of a

properly qualified expert on the particular kind of treatment given in the
establishment.
Physiotherapy Clinic is documented in as a Separate type of Establishment as an
Out Patent Service under the direct supervision of a properly qualified expert and
hence in reference with the above definition of Clinical establishment, the
Physiotherapist should be able to offer services facilities requiring diagnosis,
treatment or care for illness, injury, deformity, abnormality etc in the field of
Physiotherapy.
5. Government of India- Quality Council of India , Survey Report &
Recommendations Of Clinical Establishments:
Link: http://clinicalestablishments.nic.in/En/1074-reports.aspx
http://clinicalestablishments.nic.in/WriteReadData/384.pdf
A survey was proposed by the Ministry of Health & Family welfare, Govt. of
India. It was conducted in collaboration with Quality Council of India (NABH) &
Indian Medical Association (HQ). The aim was to carry out survey in all the
districts of the 4 states and 7 Union Territories so as to help QCI in defining the
minimum requirements for different types of Clinical establishments for
implementation of the Clinical Establishment Act 2010.
Draft Minimum Standards: QCI was given task of developing draft minimum
standards for consideration of National Council. Preliminary standards on 15
categories were developed and shared with members and States for feedback.
After incorporating survey findings and feedback, draft of minimum standards for
35 categories have now been received from QCI.
(Reference: 4th Meeting of the National Council for Clinical Establishments,
Minutes of the Meeting 03/01/2014 and documented by Ministry of Health and
family
Welfare,
Directorate:
http://clinicalestablishments.nic.in/WriteReadData/521.pdf Page2 )
The documentation about Physiotherapy in this survey clearly defines and
documents Physiotherapy as an Individual Clinical Establishment. The findings on
Physiotherapy are documented below :
(i) Physiotherapy Definition: The treatment of disease, bodily defects, or bodily
weaknesses by physical remedies, as massage, special exercises, etc., rather than
by drugs.
(Reference: http://clinicalestablishments.nic.in/WriteReadData/384.pdf Page11 )

(ii) Physiotherapy Centres /Physiotherapy Clinics are mentioned as a Separate

facility
(Reference: http://clinicalestablishments.nic.in/WriteReadData/384.pdf Page No 7
,11 , 50 and 73)
(iii) Physiotherapy is categorized as a Independent System
(Reference: http://clinicalestablishments.nic.in/WriteReadData/384.pdf Page 15)
(iv) Physiotherapy Clinics are Categorized as Individual Practitioners Clinic
with 2 Clinics in Himachal Pradesh, 13 Clinics in Pondicherry ,28 Clinics in Delhi
(Reference: http://clinicalestablishments.nic.in/WriteReadData/384.pdf Page 15)
(v) Registration status of physiotherapist is a Criteria for Physiotherapy
Centre
(Reference: http://clinicalestablishments.nic.in/WriteReadData/384.pdf page 85)
(vi) Equipments: ElectroTherapy: Traction Unit Cervical Lumbar, Interferential
Therapy, Shortwave Diathermy, Cold Packs, Muscle Stimulator with Electro
Diagnostic, CPM, Hot Pack Unit, Laser, Wall Ladder, TENS, Parafin Wax Bath,
Muscle
Testing
(Reference:
http://clinicalestablishments.nic.in/WriteReadData/384.pdf Page 53 & 87)
Exercise Therapy: Wall Ladder, Shoulder Wheel, Dumbbells Weight Cuffs, Thera
Bands Thera Tubes, Spirometer, Tilt Board, Swiss ball, Vibrator for Chest
Physiotherapy, Treadmill
(Reference: http://clinicalestablishments.nic.in/WriteReadData/384.pdf Page 54,
87 & 88)
(vii) Core Group Recommendations:
PHYSIOTHERAPY
(Reference: http://clinicalestablishments.nic.in/WriteReadData/384.pdf Page 68)
6. Ministry of Social Justice & Empowerments letter No. 9-3/CCD/2007
dated 15/05/2008 Subject: Handling of Children with disabilities and referral
Most of the doctors are not trained for rehabilitation of Persons with disabilities,
they often try to treat their disabilities even when medical or surgical interventions
are not required. In the process, most critical period of six years of life is lost
which is most important period to train & rehabilitate the child with disability to
utilize the residual capacity of the impaired organs. Consequently, it is too late for
such children to respond to the rehabilitation therapies even by most qualified &
skilled rehabilitation professionals like Physiotherapists etc.
Chief Commissioner has taken notice of the complaints from parents,
Rehabilitation professionals , NGOs etc . and has directed that appropriate

instructions may be issued by Medical Council of India and Indian Medical

Association through print and electronic media to the effect that the doctors not
trained on rehabilitation should restrict their treatment of children with disabilities
to their medical illness/disease or else action be initiated against such practices
under relevant section of MCI. They should refer such children to the qualified
rehabilitation Professionals to ensure that they get appropriate
rehabilitation/therapeutic assistance well in time. The court of the Chief
Commissioner for persons with disabilities shall be constrained to initiate action
under Section 59 of the Persons with Disabilities Act, 1995 against the Doctors
who may persist with such practices.
(Reference: http://www.mciindia.org/circulars/Circular-disabled-children.pdf )
7. Findings of the Planning Commission of India (2007-2012):
Point number 3.1.104 states that In the field of paramedical education, priority
will be given for establishment of National Para Medical Council as an apex body
to determine standards and to ensure uniform enforcement throughout the country.
On similar lines, councils for physiotherapy and occupational therapy should also
be established
This differentiates Physiotherapists from paramedical.
(Reference: Page 84 and 85 Eleventh Five year Plan (2007-2012)_ Vol 2 Social
Sector Eleventh Five Year Plan(20072012)Social Sector Volume II-Planning
Commission of India)
8. Expert Opinion:
Committee also took note of the views expressed by Dr. M.K. Bhan, Professor
of Pediatrics, AIIMS and presently on deputation as Secretary, Department of
Biotechnology who pointed out that currently, access to high quality rehabilitation
was very limited in our country and physiotherapy deserved to be supported and
promoted in a decisive manner, in terms of education and training. While
accepting the fact that in planning physical rehabilitation, assessment by medical
and surgical disciplines was important, it was also mentioned that only a small
number of physicians had a reasonable understanding of physical rehabilitation. In
general it has been seen that the medical profession does not always enable
thriving of the support services and generally reluctant to grant them proper
professional status. This indirectly leads to much needed professions such as
physiotherapy becoming unattractive and in the process keeping good quality
students away. It was, accordingly, emphasized that adequate recognition
should be granted to physiotherapy through legislation and for ensuring
adequate access to physiotherapy services in the country, physiotherapists be

allowed to open independent service centers. The education of physiotherapists

should in itself provide ample understanding of when physical therapy is required
( Reference: Clause 9.39Thirty-First report on Paramedical and Physiotherapy
Central Councils Bill-2007 )
9. Clinical Establishment Act 2010- Court Notification:
The Patna high court directed the state government to frame rules to implement
the Clinical Establishment (Registration and Regulation) Act, 2010, in the state.
Hearing a PIL filed by Veteran's Forum for Transparency in Public Life, a division
bench of Justice Navin Sinha and Justice Shailesh Kumar Sinha directed the
government to frame the rules by January 31, 2014. "If it is not so done, principal
secretary, health department, shall be present in person and show cause," the court
ordered. The Act was enacted for registration and regulation of the clinical
establishments with a view to ensuring minimum standards of facilities and
services. Bihar adopted the Act in July, 2011, but the rules to implement it have
not been framed yet, petitioner's counsel Dinu Kumar submitted. According to the
Act provisions, a clinical establishment is supposed to maintain records of
outpatient, inpatient, operation theatre, labour room, MTP, case-sheets, laboratory
register, discharge summary, complaint register, number of beds, system-wise and
speciality-wise in the establishment, rates of different services, et cetera.
Additional advocate general 14 P N Shahi informed the court through a counter
affidavit that the rules are being drafted and the State Council and District
Regulation Authority will be constituted soon. However, the court termed it
"evasive" for not having proper dates and ordered the state to frame the rules, to
constitute a state council for clinical establishments and district registration
authority by January 31 and submit a report before it by February 3, 2014.
Reference: http://clinicalestablishments.nic.in/NEWS/1030.aspx
10. Ministry of Law:
Ministry of Law was of the opinion that the profession of physiotherapy should
not be covered within the meaning of the term paramedical
(Reference: Thirty-First report on Paramedical and Physiotherapy Central
Councils Bill-2007)
11. California Senate Passes Bill Allowing Direct Access to Physical Therapist
Services
SACRAMENTO, Calif., Sept. 10, 2013 /PRNewswire/ -- California's Senate
passed AB 1000 (Wieckowski/Maienschein) to allow Californians to directly
access physical therapist services. The bill passed off the Senate Floor and now
goes back to the
Assembly to approve amendments before heading to the Governor's desk.
Sponsored by the California Physical Therapy Association (CPTA), AB 1000

provides consumers with the option to directly access quality, cost-effective and
safe physical therapist services without a physician diagnosis.
http://www.physio-pedia.com/New_Zealand
http://www.healthforceontario.ca/en/Home/Other_Regulated_Health_Professional
s/Training_|_Practising_Outside_Ontario/Practice_Requirements/Physiotherapist
12. Medicine Prescription by Physiotherapist in UK, Physiotherapists in UK
can now independently prescribe medication to their patients in world first
Reference: http://www.bbc.co.uk/news/health-23752418
http://www.csp.org.uk/press-releases/2012/07/24/physiotherapists-gain-newpower-prescribe-medicines-independently-after-ca
http://www.wcpt.org/node/101751

13. PHYSICAL THERAPY PRACTICE ACT Louisiana Revised Statutes

37:2401-37:2424 Revised January 1, 2010, Chapter 29. Louisiana Physical
Therapy Practice Act
"Practice of physical therapy" is the health care profession practiced by a
physical therapist licensed under this Chapter and means the holding out of
one's self to the public as a physical therapist and as being engaged in the
business of, or the actual engagement in, the evaluation and treatment of any
physical or medical condition to restore normal function of the neuromuscular
and skeletal system, to relieve pain, or to prevent disability by use of physical
or mechanical means, including therapeutic exercise, mobilization, passive
manipulation, therapeutic modalities, and activities or devices for preventative,
therapeutic, or medical purposes, and further shall include physical therapy
evaluation, treatment planning, instruction, consultative services, and the
supervision of physical therapy supportive personnel, including physical
therapist assistants.
Reference:
www.prd.doa.louisiana.gov/boardsandcommissions/RulesAndRegulations/27_P
ractice%20Act%20and%20Rules%2010%2020%2011.pdf
http://www.laptboard.org/rules/practiceact/
14. Illinois Physical Therapy Act. (225 ILCS 90/)

"Physical therapy" means all of the following:

(A) Examining, evaluating, and testing individuals who may have
mechanical, physiological, or developmental impairments, functional limitations,
disabilities, or other health and movement related conditions, classifying these

disorders, determining a rehabilitation prognosis and plan of therapeutic

intervention, and assessing the on going effects of the interventions.
(B) Alleviating impairments, functional limitations, or disabilities by
designing, implementing, and modifying therapeutic interventions that may
include, but are not limited to, the evaluation or treatment of a person through the
use of the effective properties of physical measures and heat, cold, light, water,
radiant energy, electricity, sound, and air and use of therapeutic massage,
therapeutic exercise, mobilization, and rehabilitative procedures, with or without
assistive devices, for the purposes of preventing, correcting, or alleviating a
physical or mental impairment, functional limitation, or disability.
(C) Reducing the risk of injury, impairment, functional limitation, or
disability, including the promotion and maintenance of fitness, health, and
wellness.
(D) Engaging in administration, consultation, education, and research.
Reference www.ilga.gov/legislation/ilcs/ilcs3.asp?ActID=1319&ChapterID=24
http://law.onecle.com/illinois/225ilcs90/1.html
15. Ontario Physiotherapy Act, 1991, S.O. 1991, CHAPTER 37
Scope of practice
3. The practice of physiotherapy is the assessment of neuromuscular,
musculoskeletal and cardio respiratory systems, the diagnosis of diseases or
disorders associated with physical dysfunction, injury or pain and the treatment,
rehabilitation and prevention or relief of physical dysfunction, injury or pain to
develop, maintain, rehabilitate or augment function and promote mobility. 2009,
c. 26, s. 22 (1).
Authorized acts
4. (1) In the course of engaging in the practice of physiotherapy, a member
is authorized, subject to the terms, conditions and limitations imposed on his or
her certificate of registration, to perform the following:
1. Communicating a diagnosis identifying a disease, a physical disorder or
dysfunction as the cause of a persons symptoms.
2. Moving the joints of the spine beyond a persons usual physiological
range of motion using a fast, low amplitude thrust.
3. Tracheal suctioning.
4. Treating a wound below the dermis using any of the following
procedures:
i. cleansing, ii. soaking, iii. irrigating, iv. probing, v. debriding, vi.
packing, vii. dressing.
5. For the purpose of assessing or rehabilitating pelvic musculature relating
to incontinence or pain disorders, putting an instrument, hand or finger,

i. beyond the labia majora, or

ii. beyond the anal verge.
6. Ordering the application of a prescribed form of energy.
7. Administering a substance by inhalation. 2009, c. 26, s. 22 (2).
Reference:
http://www.e-laws.gov.on.ca/html/statutes/english/elaws_statutes_91p37_e.htm
16. THE PENNSYLVANIA CODE: Chapter 40. State board of physical
therapy.
Practice without physician referral.
The Pennsylvania code allows physiotherapists to practice without physicians
reference under clause 40.61 Certificate of authorization to practice physical
therapy without a referral.
Reference: www.pacode.com/secure/data/049/chapter40/chap40toc.html
17. Manitoba new legislation act:
A physiotherapist may plan, administer and evaluate a physiotherapy program that
includes, but is not limited to, education, ergonomics and interventions such as
exercise, massage, articular and soft tissue mobilizations and manipulations,
acupuncture, hydrotherapy, tracheal suctioning, and the use of radiant, mechanical
and electrical energy.
Reference : https://web2.gov.mb.ca/laws/statutes/ccsm/p065e.php
18. Queensland PHYSIOTHERAPISTS ACT 1964
physiotherapy means the use of those methods of treatment for curing,
alleviating or preventing abnormal conditions of the human body duly recognized
by the board as approved m ethods of treatment, and includes the assessment, ased
on specialised knowledge, of abnormalities of movement or posture and other
signs associated with physical disability, for the purpose of determining the
appropriate method of treatment.
Reference:
https://www.legislation.qld.gov.au/LEGISLTN/REPEALED/P/PhysiotherapistA64
_01C_.pdf
19. Hawaii Statutes - Chapter 461J: PHYSICAL THERAPY PRACTICE
ACT "Physical therapy" or "physical therapy services" means the examination,
treatment, and instruction of human beings to detect, assess, prevent, correct,
alleviate, and limit physical disability, bodily malfunction, pain from injury,
disease, and any other physical or mental condition as performed by a physical
therapist appropriately licensed under this chapter. It includes but is not limited to:

(1) Administration, evaluation, modification of treatment, and instruction

involving the use of physical measures, activities, and devices, for preventive and
therapeutic purposes; provided that should the care or treatment given by the
physical therapist contravene treatment diagnosed or prescribed by a medical
doctor, osteopath, or as determined by the board, the physical therapist shall confer
with the professional regarding the manner or course of treatment in conflict and
take appropriate action in the best interest of the patient; and
(2) The provision of consultative, educational, and other advisory services for the
purpose of reducing the incidence and severity of physical disability, bodily
malfunction, or pain.
"Practice of physical therapy" includes, but is not limited to, the use of the
following:
(1) Physical agents, such as heat, cold, water, air, sound, compression, light,
electricity, and electromagnetic radiation;
(2) Exercise with or without devices, joint mobilization, mechanical stimulation;
biofeedback; postural drainage; traction; positioning, massage, splinting, training
in locomotion, and other functional activities with or without assisting devices;
and correction of posture, body mechanics, and gait;
(3) Tests and measurements of: muscle strength, force, endurance, and tone; joint
motion, mobility, and stability; reflexes and automatic reaction; movement skill
and accuracy; sensation and perception; peripheral nerve integrity; locomotor skill,
stability, and endurance; activities of daily living; cardiac, pulmonary, and vascular
functions; and fit, function, and comfort of prosthetic, orthotic, and other assisting
devices; posture and body mechanics; limb strength, circumference, and volume;
thoracic excursion and breathing patterns; vital signs; nature and locus of pain and
conditions under which pain varies; photosensitivity; and the home and work
physical environments.
Reference: http://hawaii.gov/dcca/pvl/hrs/hrs_pvl_461j.pdf
http://codes.lp.findlaw.com/histatutes/2/25/461J#sthash.530KG1WI.dpuf

OBJECTION NO.3: OBJECTION ON 10.5 a. MANAGEMENT OF

BIOMEDICAL WASTE

This proposed draft recommends all type of physiotherapy establishments to

follow & manage the biomedical waste in accordance with the BMW
management and handling Rules, 1998. The bio medical waste is a serious issue.
1998 rules classified the biomedical waste in following 10 categories.
CATEGORIES OF BIO-MEDICAL WASTE
Category no 1: Human Anatomical Waste (human tissues, organs, body parts
Category no 2: Animal Waste: animal tissues, organs, body parts carcasses,
bleeding parts, fluid, blood and experimental animals used in research, waste
generated by veterinary hospitals colleges,
Category no 3: Microbiology & Biotechnology Waste i.e. wastes from
laboratory cultures, stocks or specimens of microbiology , culture used in research
and infectious agents from research and industrial laboratories, wastes from
production of biologicals, toxins, dishes and devices used for transfer of cultures)
Category no.. 4
Waste sharps: needles, syringes, scalpels, blades, glass, etc.
that may cause disinfection (chemical treat- puncture and cuts. This includes both
used and unused sharps)
Category no 5 Discarded Medicines and Cytotoxic drugs
Category No 6: Solid Waste (Items contaminated with blood, and body fluids
including cotton, dressings, soiled plaster casts, lines, beddings, other material
Category No. 7 Solid Waste
(wastes generated from disposable items other
than the waste sharps disinfection by chemical such as tubings, catheters,
intravenous sets etc).
Category No. 8: Liquid Waste (waste generated from laboratory and washing,
cleaning, house disinfection by chemical keeping and disinfecting activities)
Category No. 9 Incineration Ash (ash from incineration of any bio-medical waste)
Category No. 10

Chemical Waste (chemicals used in production of biologicals,

I am happy to bring to your kind notice that physiotherapy is non

pharmacological, non surgical & non invasive treatment method. The BMW
management also recommend that the clinics should be authorized & also should
be affiliated to district / sub district / municipal / local / private bio medical waste
plant. For which physiotherapy clinics should take affiliation & certification from
divisional / state pollution control board. Few states have already implemented it
for medical / dental / Ayush clinics. The clinics have to apply, conduct inspection

& registered with state pollution control board. Also certification has to be
renewed every year. This will put administrative & financial burden on the
physiotherapy establishment, which will be ultimately reflected on patients
pocket. The cost & financial burden of the treatment will increase. The central
govt. itself is making policies to reduce financial burden of treatment cost.
However the proposed drafts recommendations will increase it. So for better,
quality & affordable treatment the bio medical waste related clause has to be
reframed.
Suggestion: By observing nature of the physiotherapy treatment its crystal
clear that physiotherapy clinics are not BIO HAZARDOUS & doesnt
contribute in environmental pollution, hence the said clause should be deleted
or reframed after detail & realistic assessment of physiotherapy clinics.
OBJECTION NO.4 : OBJECTION ON 6 & annexure 4 HUMAN
RESOURCE
We appreciate this gesture of government as it is the most important issue & every
patient legally & morally has a right to receive treatment from authentic
professional. In the clause 6 & also annexure 4 its mentioned that the minimum
qualification for Physiotherapist should be B.P.T from recognized university.
This needs to be reframed as there are many universities which are recognized by
UGC but they were not having the permission to start physiotherapy courses. So
instead of just Recognized University it should be changed to Recognized
university & with recognized qualification. The recognized qualification
should be as per prescribed by state councils or the state / central government /
UGC.
The degree which is mentioned in annexure 4 is B.P.T degree. However I like to
throw light on the actual status of physiotherapy qualifications. In the absence of
central council, there is vast difference in nomenclature of physiotherapy
qualification. The bachelor of physiotherapy degree is mentioned as B.P.T /
B.Ph.T / B.P.Th. The Maharashtra state council for occupational &
physiotherapy council mentions the qualification as B.P.Th where as Delhi state
Physiotherapy & occupational therapy council mentions the undergraduate
qualification as B.P.T.
Before the commencement of B.P.T / B.P.Th programme physiotherapy
qualifications were mentioned as BSC (PT). The senior members of our
profession are providing services to Indian community since many years holds this
qualification.
SUGGESTION: Hence, the recommendation mentioned in annexure 4
should be reframed as Bachelor of physiotherapy / Bachelor of Science in
Physiotherapy or as B.PT / B.Ph.T / B.P.Th / BSC (PT)

OBJECTION NO.5: OBJECTION ON VARIOUS INFRASTRUCTURE

RECOMMENDATIONS
The recommendations for space, furniture, storage & basic infrastructure are
mentioned well in this draft. However, at some places it sounds slightly irrational
& impractical to implement. The reason for my opinion lies in the items listed in
annexure & its non correlation with the type of set ups & location of set ups.
The draft recommends same space, furniture; support staff requirement for all
type of clinical establishments i.e. the criteria is same for hospital & private
clinics. Also, no specifications are given related to physiotherapy set ups like
neuro rehab center / pediatric neuro rehab / ortho physiotherapy clinic /
cardiac pulmonary rehab center / ergonomics clinics etc. The generalization
of format is not sufficient to describe the requirement. On other hand, the criteria
should be specified for various type of set ups & also for hospitals depending upon
no. of beds.
No clear cut mention of furniture & instrument / equipments clause 4 & 5
respectively. In annexure 2 & 3 the equipment / instrument & furniture is
mentioned however the quantity is no where reflected. In clause 4 & 5
repeatedly its mentioned that other equipments are as per scope of service & as
per work load. The use of words like As per work load sounds subjective
one & interpretation of this silent word in future will vary from person to
person.
Suggestion: Hence, in order to prevent future misinterpretation, this word has to
be reframed taking the physiotherapy stakeholders opinion in consideration.
Regarding area
establishments:

&

criteria

for

different

types

of

physiotherapy

The metro cities have the basic problem of space for residential purpose &
commercial use too. Hence the same criteria for area of common area & treatment
area cant be recommended to all types of physiotherapy establishments. There is
need to reframe the criteria as per the types of cities & types of clinical
establishments. By observing availability of space & cost of space, the type A
& B cities deserves slight concession in this regard. Also for departments of
hospitals specific recommendations can be given on the basis of no. of beds of
hospital. Its not appropriate to put a single physiotherapists clinic, polyclinic ,
100 / 500 / 800/ above 800 bedded hospital departments in same platform, under
same criteria & on same scale. Kindly reframe the criteria. The current criteria are
too less for departments of 500 & above 500 bedded hospitals where as it will be
injustice with physiotherapist running clinics single handed.

In clause 2.2.1Electrotherapy (Adult / Paediatrics) SWD is not mentioned in

requirement but same is reflected in annexure 3 III, which creates confusion.
Hence to avoid this , add the SWD in clause 2.21
I humbly request you to take this appeal kindheartedly and convey this to
the appropriate officials related to this proposed draft & I also request you to
kindly allow us to represent all these views with documentary support to the
appropriate committee before introducing this bill for final approval. Once
again, I appreciate governments this gesture of formation of standards for
establishing criteria for physiotherapy profession. Kindly take note of the Points
mentioned in the suggestion draft and modify the Definition, Referral System
and Scope of Scope of Physiotherapy in the Clinical Establishment Act to have a
international Standard rehabilitation and habilitation services in our Country.
Looking forward for your kind contemplation.
Thanking you in anticipation.
Best Regards
Yours faithfully,