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Michael T. Brennan

This post was originally published in Physiotherapy Practice (Volume 6, Issue 6) on November 8, 2016 and can be accessed here

This issue of Physiotherapy Practice focuses on the current state and future evolution of the physiotherapy and rehabilitation market. For many of you, this is not a subject at the top of your list of interesting things to talk about. 

After all, providing good health care is a ‘here and now’ business: your clients’ needs are immediate and typically acute. 

Yet one of CPA’s most important responsibilities is to assess demand for physiotherapy services within a rapidly changing health care system. Demand is shaped by the irresistible forces of demographic and cultural change, and the seemingly endless cycle of health care system reform. 

Members who understand their impact are prepared to respond to change in the coming years. Physiotherapy jobs of the future won’t be the same as today, just as today’s work force looks much different than it did 30 years ago. 


As a profession we are used to change, perhaps more than any other health profession in Canada. Education, practice, regulation, gender mix, workplaces and remuneration are significantly different. 

Will this pace of change continue? There is evidence and arguments throughout this magazine that say ‘yes’. The Conference Board of Canada report confirms some important trends. 

Physiotherapy services have increased by roughly 3.8% annually. Services continue to shift to the private sector as a result of direct access and delisting. Physiotherapy employment is essentially full. 

The report also identifies a host of other health service providers that occupy a portion of the mobility and rehabilitation services spectrum. 


We can draw some basic conclusions: demand will grow at an increased rate based on increased demand from an older population with expectations of ‘healthy aging’. Unemployment will remain very low for several more years. Services will continue to shift to more open markets, typically privately paid, autonomous physiotherapists working in teams.

These are promising trends for the profession, but there are challenges that must be acknowledged and addressed. 

In the very short term, we need to manage high demand without compromising care or suffering caretaker burnout. We must guard against high-margin, low-quality services designed to reduce wait lists at the expense of good outcomes. 

We need to manage the ‘dehospitalization’1 of our health care system, where services are shifting from large hospitals to community and home-based care. We must ensure that patients have full access to necessary rehabilitation services within these new models of care.

Another, longer term responsibility is planning for increased competition. Markets constantly correct imbalances. When demand for services goes unmet, other providers and alternate services emerge. 

In addition, public and private payers constantly strive to reduce service costs. Timely, quality service at lower cost: that is our ongoing reality. We are well-equipped to compete in this environment, but we will fail if we are complacent.


The disadvantage

Today, chiropractors, massage therapists, athletic therapists, and kinesiologists claim to offer similar services to physiotherapy, and even use the word in jurisdictions where the practice term is not protected by regulation. 

Notwithstanding the frustration we rightly feel when our hard-earned reputation is borrowed by others, the more important question is how best to manage our competitive position in the mobility services market. 

In one sense we are at a disadvantage. Physiotherapists are licensed, therefore our labour force is restricted. This drives up our unit cost of labour. 

Kinesiologists and athletic therapists are, for now, mostly unlicensed, therefore their services are generally less expensive. 

It is difficult to clearly identify their specific areas of expertise since national qualification standards don’t currently exist. Yet payers and clients are attracted to these providers due to lower cost and no restriction on the claims they can make of the value of their services. 

Physiotherapy would appear to be at a disadvantage in competing on the open market for the self-directed client seeking exercise advice.


The advantage

Physiotherapy’s strength is the extensive understanding of mobility impairment due to a pathological condition. No one else in Canada is as thoroughly trained to assess mobility impairment and prescribe therapeutic exercise. 

Is there an opportunity to build consensus around this? Could we engage with athletic therapists, kinesiologists and others to define the optimal referral model? 

Today, the non-licensed fitness community is not sufficiently organized across Canada to achieve this goal. 

However, we see licensing models emerging in Ontario, and being contemplated in other provinces. This may be the optimal time to proactively lead the establishment of a referral model by consensus, rather than arbitration within the health regulation bureaucracy. 



These trends create considerable pressure on our profession, but there are several resulting opportunities for physiotherapy. 

Our ability to diagnose and our understanding of pathology mean we are well placed to lead mobility and rehabilitation teams. As noted in Fred Horne’s article, we anticipate that Canadians will demand access to a full slate of services provided by care teams that focus squarely on patient needs, use electronic health records to facilitate transitions between providers, and measure outcomes in order to demonstrate effectiveness. 

‘Bundled care’-style payment is becoming more prominent, where the dollars follow the patient. The old fee-for-service models are changing. More and more patients will pay for an outcome, rather than a service. Physiotherapists who understand these trends will be well-placed to respond with clear outcomes at reasonable cost.

Rather than compete interprofessionally, we can anticipate collaborative work consulting with family physicians, referring to other exercise specialists, and supporting treatment of complex care patients. 

This team approach, where the patient receives care from the right provider based on their needs, is becoming more entrenched across all areas of health care. 

Will it also apply to private orthopaedic physiotherapy? 

The trend may take several years to significantly change our traditional private practice model, but we would do well to pay close attention, and increase our capacity to adapt.


1 A term used by the Canadian Medical Association to define prioritization of primary health care above hospital-based services.

Shared from Physiotherapy Practice Fall 2016 


Over to you

  1. Do you agree, disagree with the above ideas? What’s your take?
  2. What are some additional concerns you‘ve noticed in the physiotherapy profession?
  3. What opportunities do you see for your profession?

By Michael T. Brennan 


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The 'dehospitalization' of health care and shortage of $ for publically funded PT for out patients is a major concern.  Many patients with out private coverage are not receiving rehabilitative services. What can  we do, what can CPA do to address this.

Access to physiotherapy is a constant concern to CPA, and we work everyday to try and improve Canadian's access to physiotherapy services.  Healthcare in Canada is a tricky subject- although much is funded by the federal government, healthcare is delivered at a provincial level- which means much of the advocacy work needs to be done by the provincial and territorial branches.  For this reason, it is very important that members become involved locally.


I use a non-traditional private practice model that doesn't make me as much money in the short term but long term it works better for me and my patients.  The biggest issue raised to me by patients that come for my experiece is that other clinics run patients through like cattle at an auction.  They don't pay attention to or listen to the patient, consider the entire body or picture nor spend the time to actually make change beyond what would be the natural history of healing.  I on the other hand do the opposite.  We spend time one on one with patients minimally 30 minutes each.  We listen and educate and charge more or less the same fee as people seeing 4 patients in an hour.  I have been practicing for 25 years and I cannot ethically permit myself to do that.  People are paying me and committing their time to get better and I in turn commit my time and talents to them.  I could not do that if I were seeing more than 2 people per hour.  How do we encourage an ethical treatment model, promote quality care by our own practitioners and compete in the marketplace?  People love my model of care but it is slow to build profit.  On one hand i have to balance my ethics of providing care and the other ensure my business is viable.  This is a challenge when marketing must be "non-competitive".  Furthermore the other thing I notice is that therapists have the advantage and opportunity to be leaders BUT they must continually update their knowledge not only of silo spefcic treatment techniques but of the progress and knowledge of treatment of conditions and illnesses affecting their patients so they can BE the leader.  This is where a huge disconnect exists.  Many practitioners take the easy route of acting more like a technician than a well rounded, knowedgeable primary care health care leader.  

Well said. I too deliver care to my patients under this model as you do. Money to earn a living but not necessarily huge profits.

Well said and I totally agree.  

The professional movement to having "physiotherapy" aids doing most of the contact with the client does not increase the creadibility of the profession.  I too only treat two clients per hour maximum.. I also treat in a private room so the client can "tell their storey" without fear of being "heard" by many,  

Many years ago, David Lamb, physiotherapist extraodinar, told us that if we listen to the client with intent, the client will tell us what is wrong and probably what is needed to progress the healing.

I believe the next progression is for us to realize that every pain has a physical, emotional and spiritual component.  With this thought process, it is amazing what clients will tell us in "their" storey about their condition.

You make reference to David Lamb. I am researching his biography for a possible film project. Please feel free to contact me at the email above and /or provide links to infrmation regarding David. Regards

Wonderful post -- a example of leadership from within.  I am a PT over 25 years making the shift from public back into private. I also hold the same non-traditional thinking with regards to practice model and have observed the same with some of my peers.  

 I also realize that a deeper bag of tools and genuine interest in people promotes a focus on quality over quantitiy.  This in turn is a reflection of the many experiences and observations obtained throug years and then  integrated with emerging research in a non-judgemental fashion.

Overtime one can become an expert on the field if one is committed to lifelong learning -- and I'm not talking about having a long line of credentials.  This is not something I appreciated earlier in my career -- or at the times I felt disenfranchised and left left the profession to work for the government.  

In the end I return to the profession as a cllincian -- as I see it is a place where I can reflect on the best parts of  my career to become a more thoughtful practitioner -- and not be the technician that the public or private sectors can easily set one up to be.

Best wishes.


I have the same philosophy and have been treating for 20+ years. I fear we are a dying breed. 

I am so pleased to hear that I am not the only one practicing this way!  I have recently left a corporate position in favour of the one on one business model and althought I make less (only slightly), I find my practice far more rewarding.  

Our patients in hospitals,clients in home health, and residents in care facilities still require physiotherapy interventions that are important to their recovery and maintenance of independent living. Let's remember and advocatae for our more vulnerable populations. Let's not always assume patients pay and/or physically get to private services to improve their health status. CPA should be highlighting the important role of physiotherapy in the Public Sector. It's easy to let the government 'dehospitalize' physiotherapy services to support other disciplines who are advocate strongly regarding their roles. CPA still needs strong advocacy for publicly funded healthcare. What makes Phyisotherapy unique and value added in hospitals and public facilities. Think about it...

Thank you for reaching out. Access to physiotherapy continues to be a priority for CPA in both public and private sectors. CPA completed a rural and remote environmental scan in 2015 to identify issues affecting the provision of physiotherapy services in those areas.


I, too, work on the above stated quality over quantity model with the same impact on financial return! The stated "exercise" model in the preceeding editorial explains a significant aspect of our physiotherapy niche. Unless physiotherapists learn to use the wider scope of our practice to include our manual assessment skills and treat patients with greater precision, range of diagnostic and treatment modalities than are available to many of our other health-care collegues, our profession will be left with a narrowing skill set (exercise prescription) that is more easily categorized by "evidence-based" double-blind "golden rules" (that carry "prestige value"), but loose the advantages that palpation-directed therapy can provide--(case in point--the diminishing number of manual therapy-based osteopathic physicians practising in the States, whose professional evolution has been flowing to a more "traditional" allopathic management model!)

Are we a rarity who intentionally provide one-on-one PT ...especially without a PT assistant? Bothers me to give guidance rarely to a PT assistant and yet have to "roster" that in Ontario, as if lumping in with the rest of the fast pace "delivery" of PT services making lots of money meeting capacity compared to the intentional investment of time and expertise provided the client. Encouraging to see your comments above.

I too have been almost thirty years in the field and have now evolved a a very comfortable practice after many years of continuing education and learning.  I feel on one hand very fortunate to enjoy such a fulfilling practice but also realize that yes I have on some level earned this level of competency.  I see patients for an unheard number of minutes and no I don't use an aide. 

The "playing field" of physical therapy has also rapidly changed with multiple players existing with a dizzying array of titles that certainly didn't exist when I started in the field. I dislike hearing from patients as I'm sure others are how many unregulated therapies they may have tried before they come to my door.  Because of this, as practitioners, we will really have to carve out our own niche in order to maintain our status in yes this myriad of therapists.  Many years I went to a course where the therapist imparted some advice that I have followed ever since.  "whatever you do make sure you doing something of value where people are ready to pay you for that our of pocket".  I know this may be shocking to those who work in public service, but the advice holds the same whether you work in the public or the private sector.  I had never ever thought of my service in those terms up until I heard those words.  Someone else had always paid the bills whereever i had it the insurance company or the public sector itself.  In order to keep up or maintain our current status, we are all going to have to step up to that plate or be left behind regardless of whether we end up being publically or privately funded.


"No one is better trained to assess mobility impairment and prescribe therapeutic exercise. "

That's a joke, right? Let's take a second and get off our high horses here shall we.  PT's are so poorly trained in exercise prescription it's laughable. I graduated in 2010 and didn't learn one exercise from my training. I had to do all the con-ed myself to become an expert in exercise prescription and tailoring it to the individual. The real issue is in the fact that we are jack of all trades and master of non. A chiropractor works with MSK issues, an RMT does a massage, a kinesiologist does exercise and ergonomic assessments. A physio? No one quite knows what we do. In no other profession can the same personal treat back pain and help a person breath better after a COPD dx. The public has no clue what we do. That's where the problem lies. 

Thank you!!! refreshing to hear someone with a realistic mindset on any of these forums!

Are comments on this read reviewed prior to posting? My comment didn't seem to get posted and I wanted to know why. 


Yes, all comments are vetted for spam, so they won't be immediately visible after you post them. Please email if your post is still not up (we've published everything for this page that we received) and we'll be happy to help.



I agree with "our patients in hospitals" comments above.  CPA needs to promote and strengthen public practice and be an advocate for publicly funded healthcare.  It is where we started.  

It is wonderful to hear from so many other physiotherapists who practice the way that I do; taking time to listen to our patients, offering them the individual treatment that will meet their needs. It is very fulfilling work and our patients truly benefit. However, it is difficult to make ends meet when only seeing 10 or 11 patients per day. I think insurance companies and other provate payers need to look at the model of service that is provided when determining how much coverage is provided for physiotherapy. Also, I would like to find a way to connect with these other therapists who practice this way. Is it possible for CPA to host a webinar on this topic? And thanks for posting this "rep"; it is much more inspiring that many of the other "reps" that have been posted this month; articles that focus on fraud and the negative side of professional practice rather than high-lighting and celebrating the excellent work of so many! 



Thank you for taking the time to comment. Please reach out to us to further describe what you are looking for in a webinar.


Has anyone here taken a business class or marketing class? These 'advantages' are only 'opportunities' if the 'customers and consumers' see the value. It really doesn't matter if 'the profession' feels it assesses mobility and health better than anyone. 

We live in a world where instagramed personal trainers hold as much klout as your university degree because we do not educated the health care consumer. Everyone knows what a massage therapist does. Everyone can tell you what a chiropractor does. How many of your friends can describe what you do as a therapist??

If we want to stop being complacent, we need accept that health care is a marketplace and reach out to the consumers.

This is bang on. No one cares what we think we are great at. It's up to the inidididual PT to provide VALUE at each visit to prove we are worth what we say we are

10-11 patients per day?!  I make a good living seeing private practise.  I spend 40 minutes, 1:1, with most, and 60 minutes with those who need more time, and they are willing to pay for the extra time.  The time includes assessment at each visit, manual therapy, teaching/coaching on exercises, new and progressions thereof, and ongoing education.  I listen, I teach, I give them tools.  At times, I refer them on to a kinesiologist, or an RMT, if appropriate, and will communicate with said professional..I bill for my time, as a PT.  The other professionals bill for the work they do.  What is so confusing about this model?  I dont' see them often, choosing to give them time to work on what they  have learned, and to work with others if that is appropriate.  If they see the kin in my clinic, I pay the kin, and it is billed as kinesiology, if kin is supervising, not me.

If they go to a Pilates studio, they pay for Pilates...if the class is held here, it is still Pilates, if I am not teaching the class. Thus, not billed as PT.  Presumably, I have OK'd for them to participate, and have also screened, and educated my Pilates instructor, so that I do not have to be present.


I think CPA's Reps have provoked us to really look at what can happen when making money becomes the prime motivation.  Yes, we mostly do a good job but let's not hide our heads in the sand, that everyone in the profession is doing what is much as some of this was dark reading, and felt negative, it did open up some good discussion.  If clarity and better practise comes out of this, then I say: Thank you, CPA!

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