Understanding the Regulation of Orthotics and Biomechanical Assessments in Canada

In Canada, the healthcare system categorizes certain medical procedures as "controlled acts." These acts are considered high-risk and are strictly regulated to ensure they are performed only by qualified professionals. However, orthotics and biomechanical assessments do not fall under this category. This distinction is based on their non-invasive nature and lower associated risks compared to controlled acts such as surgery or prescribing medication. Consequently, orthotics and biomechanical assessments are not tightly regulated as controlled acts and are considered part of the public domain.

What "Public Domain" Means in This Context

In healthcare, when a service or practice is described as being in the "public domain," it signifies that the service is not restricted exclusively to certain regulated professionals. While providing orthotics and conducting biomechanical assessments still require proper training and expertise, a broader range of professionals can offer these services provided they meet the necessary qualifications. This public domain status allows for greater accessibility and flexibility in who can provide these services without being bound by the stringent regulatory constraints that govern controlled acts.

Unique Scope of Chiropody

A key profession uniquely authorized to prescribe and dispense orthotics is chiropody, as defined by the Chiropody Act.

Section 4 of the Chiropody Act explicitly defines the scope of practice for chiropody as the assessment of the foot and the treatment and prevention of diseases, disorders, or dysfunctions of the foot by therapeutic, orthotic, or palliative means. This legislative framework ensures that chiropodists are distinctly recognized for their expertise in foot health, including the use of orthotic interventions. It legally endorses their specialized qualifications, allowing them to address complex foot issues comprehensively through orthotics. Unlike other professionals, chiropodists can both prescribe and dispense orthotic devices, streamlining the process for patients seeking foot-related care.

Professions Commonly Involved in Providing Orthotics

1. Chiropodists and Podiatrists

   • Regulation: Governed by provincial bodies such as the College of Chiropodists of Ontario.
   • Scope of Practice: Authorized to perform biomechanical assessments and prescribe orthotics as part of their comprehensive foot care services.
   • Unique Role: Can both prescribe and dispense orthotic devices directly to patients.

2. Physiotherapists

   • Regulation: Also regulated provincially by bodies such as the College of Physiotherapists.
   • Scope of Practice: Capable of performing biomechanical assessments and recommending orthotics as part of rehabilitation therapy.
   • Prescription Authority: While physiotherapists can assess and recommend orthotics, actual prescription and dispensation may require collaboration with podiatrists, chiropodists, or pedorthists depending on regional regulations and insurance policies.

3. Pedorthists

   • Regulation: Certified through the Pedorthic Association of Canada and regulated by the College of Pedorthics of Canada.
   • Scope of Practice: Specialize in the design, fabrication, modification, and fitting of orthotics and therapeutic footwear.
   • Role: Often require a prescription from a healthcare provider to dispense orthotics, ensuring that devices are tailored to the patient’s specific needs.

4. Nurses and Other Healthcare Professionals

   • Regulation and Scope: Nurses and other healthcare providers can provide orthotics if they receive appropriate training and certification in biomechanics and orthotic therapy.
   • Insurance Considerations: The ability of nurses to prescribe and dispense orthotics is influenced by their regulatory scope of practice and the policies of insurance companies. Often, additional training and collaboration with specialists are required.
   • Prescriptive Authority: Typically, nurses cannot independently prescribe orthotics without meeting specific regulatory and training requirements, and insurance may require a prescription from a recognized healthcare provider.

Insurance Industry’s Role in Prescribing and Dispensing Orthotics

The insurance industry plays a pivotal role in determining which healthcare professionals can prescribe and dispense orthotics based on their coverage policies. This influence affects patient access to orthotic services and the workflow among healthcare providers.

1. Chiropodists

   • Insurance Coverage: Insurance plans often recognize chiropodists as authorized prescribers and dispensers of orthotics due to their specialized training and defined scope of practice under the Chiropody Act.
   • Streamlined Process: Patients can receive both the prescription and the orthotic device directly from chiropodists, simplifying the process and reducing the need for multiple referrals.

2. Family Doctors and General Practitioners

   • Referral Requirement: Some insurance policies require a prescription from a family doctor or general practitioner before covering the cost of orthotics. A pedorthist or another qualified professional then carries out the actual dispensing.
   • Collaborative Care: This approach ensures that orthotic prescriptions are medically necessary and coordinated through primary care providers.

3. Physiotherapists and Pedorthists

   • Insurance Limitations: While physiotherapists can recommend orthotics, insurance coverage for these recommendations may necessitate a referral or prescription from a podiatrist, chiropodist, or physician.
   • Conditional Coverage: Insurance companies may have specific criteria that need to be met for physiotherapist-prescribed orthotics to be covered, such as demonstrating the medical necessity through detailed assessments.

4. Nurses and Other Healthcare Providers

   • Conditional Authorization: Insurance may cover orthotics provided by nurses only if they have advanced training and operate within a collaborative care framework with other specialists.
   • Policy Variations: Coverage policies can vary significantly, with some insurers allowing limited orthotic provision by nurses under certain conditions while others may not.

Impact on Patient Access and Care

The interplay between professional scopes of practice and insurance policies significantly impacts patient access to orthotic services. When insurance companies require prescriptions from specific healthcare providers, it can streamline patient care through recognized specialists and may introduce additional steps for patients needing referrals. Conversely, professions like chiropody, which are both prescribers and dispensers of orthotics, can offer more immediate and integrated care, enhancing patient convenience and reducing administrative hurdles.

Conclusion

Orthotics and biomechanical assessments are integral components of musculoskeletal healthcare in Canada, classified within the public domain due to their non-invasive nature and lower risk profile. This classification allows a diverse range of healthcare professionals—including chiropodists, physiotherapists, pedorthists, and, conditionally, nurses—to provide these services, each contributing their specialized expertise. The insurance industry's policies further shape the landscape by influencing which professionals can prescribe and dispense orthotics, affecting patient access and care pathways. Understanding these regulatory and insurance dynamics is essential for healthcare providers and patients to navigate the provision and coverage of orthotic services effectively.

What are Orthotics?

The term "orthotic" comes from the Greek word "ortho", which means to straighten or correct. Sometimes called arch supports, orthotics allow people to stand, walk, and run more efficiently and comfortably. Custom-made orthotics are made to fit an individual's unique foot structure.

Correcting biomechanical dysfunctions in the lower limb can stabilize the structure and reduce or eliminate repetitive stresses. Custom orthotics, worn in proper footwear, can improve proper lower limb function. They are inserted in a shoe to replace the original manufacturer's insert.  

We want our patients to know that custom orthotic devices come in many shapes, sizes, and materials and fall into functional and accommodative categories. Functional are those that change foot function, primarily protect the foot, and combine functional control and protection. Accommodative orthotics are designed to cushion and deflect without changing the foot function. 

How are they made?

Functional orthotics are made from an impression of the foot in a subtalar neutral joint position. The impressions can be taken using a 3D computerized pin system, a plaster cast, or laser technology. 

Orthotics control motion in the foot joints directly below the ankle joint and, as part of a management plan, may improve or eliminate strains, aches, and pains in the legs, thighs, and lower back. 

How Impressions Are Taken

3D Computerized System