Case of the Month

Read real cases and their outcomes

  • When Acupuncture Goes Very, Very Wrong

    Nov 13, 2018

    The Case

    The College received a complaint from a patient who sustained bilateral pneumothoraces (collapsed lungs) as the result of acupuncture treatment she received from her physiotherapist.

    The patient had attended physiotherapy treatment regularly for almost 10 years before returning for neck, shoulder and upper back pain. The physiotherapist who treated her previously recommended both acupuncture and ultrasound to treat the pain during the patient’s final visit.

    During acupuncture treatment, the patient indicated that the insertion of one of the needles was so painful that she cried out and the PT then moved it.

    The patient laid with the needles inserted for approximately 20 minutes before they were removed by a physiotherapist assistant (PTA). The patient was then given ultrasound treatment followed by a heat pack applied for 10–15 minutes in an effort to alleviate her pain.

    The patient said that she had undergone acupuncture treatments numerous times but had never felt the level of pain that she did on this occasion. The day after her appointment she met with her family physician who recommended x-rays. The x-rays revealed bilateral pneumothoraces—a diagnosis that was subsequently confirmed by a surgeon in a hospital emergency room two days later. The patient said she was not made aware of the potential risks of acupuncture treatment at any time during her appointment.

    In a written submission to the College the physiotherapist indicated that she assessed the patient and concluded that her symptoms and objective findings were consistent with a diagnosis of myositis affecting the neck and upper back, plus possible underlying degenerative changes at the cervical spine. She noted that the patient’s history included: sarcoidosis, anemia, kidney dysfunction and a splenectomy, and observed that she had kyphosis of the thoracic spine.

    According to the physio, the patient suffered a similar condition previously which was successfully treated with acupuncture, ultrasound and cervical traction, so she proceeded with the same course of treatment. She noted that the patient had responded favourably to acupuncture in the past and it accounted for the majority of her treatment at the clinic.

    There was no record of the physiotherapist discussing the possible risks associated with acupuncture with the patient in the chart, and the PT did admit that she asked a physiotherapist assistant to remove the acupuncture needles as she was busy with another patient.

    The Standards

    The Working with Physiotherapist Assistants Standard restricts physiotherapists from assigning any part of acupuncture treatment to a PTA—this includes removing needles.

    A crucial element of the consent process is a conversation between the physiotherapist and the patient and the physiotherapist needs to ensure that the patient has a clear understanding of their treatment. In this case, the patient was unaware of the potential risks associated with acupuncture and there was no note in the chart to indicate that informed consent had been obtained.

    Additionally, it’s a physiotherapists responsibility to consider the overall health of the patient, as well as any contraindications or risks associated with the treatment before proceeding.

    When a PT selects a particular treatment, they must provide clinical justification for their decision.

    In this case, the physio chose to mirror the patient’s previous treatments but neglected to consider whether conditions including sarcoidosis and kyphosis were contraindications to the use of acupuncture.

    The Outcome

    The physiotherapist was not permitted to provide acupuncture treatments until successfully completing an educational course focused on safe and effective acupuncture practice as part of a Specified Continuing Education and Remediation Plan (SCERP). This information now appears permanently on the Public Register.

    More about Consent

    Working with Physiotherapist Assistants Standard

    Record Keeping Standard

    Physiotherapist Essential Competencies

    A Case of the Month about acupuncture treatment going horribly wrong, leading to a complaint against a physiotherapist.
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    • physiotherapist
    • physiotherapy
    • acupuncture
    • Case of the Month
  • 1,200 Hours Short of a Certificate

    Oct 19, 2018
    A College of Physiotherapists of Ontario Case of the Month about a physiotherapist who did not have sufficient practice hours when applying for a certificate of registration.
    Full story
    • Ontario
    • College of Physiotherapists
    • physiotherapist
    • Case of the Month
    • practice hours
    • registration
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  • Can’t We All Just Get Along?

    Sep 17, 2018
    A College of Physiotherapists of Ontario Case of the Month about physiotherapists managing challenging collaborative care relationships.
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    • specialty designations
    • restricted titles
    • PTA
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    • physiotherapist
    • physiotherapy
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  • Don’t You Forget About Me

    Aug 21, 2018
    College of Physiotherapists of Ontario Case of the Month about a physiotherapist who forgot about a patient during an acupuncture session.
    Full story
    • ICRC Committee
    • essential competencies
    • physiotherapy
    • acupuncture
    • Case of the Month
  • Caught Up in the Cryo Hype

    Jul 18, 2018
    A Case of the Month detailing how a physiotherapist wrongly incorporated cryotherapy in treatment plans and billed the services as physiotherapy, violating the standards of the College of Physiotherapists of Ontario.
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    • physiotherapist assistant
    • advertising
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    • physiotherapy
    • cryotherapy
  • You Can’t Laser Over History

    Jun 14, 2018
    June 2018 Case of the Month from the College of Physiotherapists of Ontario. The case outlines the use of laser therapy on a patient with a history of melanoma.
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    • physiotherapist
    • College of Physiotherapists
    • essential competencies
    • record keeping
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    Feb 20, 2018
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    Dec 11, 2017
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    May 10, 2017
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  • Using Restraints on a Patient: Helpful or Harmful?

    May 09, 2017
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  • Physiotherapists MUST register with the College to Practice in Ontario

    Apr 04, 2017
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  • Does Past Behaviour Indicate Future Actions?

    Apr 04, 2017
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  • No Second Chances When It Comes to Patient Care and Record Keeping

    Feb 15, 2017
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  • How to Be Insensitive with Your Patients?

    Dec 09, 2016
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  • Three Strikes, You’re SCERPed

    Aug 15, 2016
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  • When "I Didn't Know" Isn't Enough

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  • Financial Irregularities

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