Maintaining Professional Boundaries in Physical Therapy

Laura M. Cascella, MA, CPHRM

Maintaining professional boundaries is essential in healthcare. When boundaries are crossed — or the patient perceives they are crossed — the provider–patient relationship can quickly deteriorate. As a result, the provider may face allegations of misconduct and/or malpractice.

Sexual misconduct is a growing concern in various healthcare settings, and physical therapy is no exception. In fact, physical therapists (PTs) and physical therapist assistants (PTAs) should have heightened vigilance due to the nature of the care and treatment they provide, which often involves a very hands-on approach. Additionally, PTs and PTAs often see patients with a degree of frequency that lends itself to more personal and familiar relationships, which can blur the lines of professionalism.

Unfortunately, no universal rules or standards exist when it comes to maintaining professional boundaries. Obvious strategies include not engaging in romantic or personal relationships with patients, not touching patients in ways that are not therapeutically necessary, not photographing patients without their permission, not making innuendoes or sexual jokes, and so on.

Yet, malpractice claims indicate that issues related to sexual misconduct often arise from less conspicuous circumstances. Actions or behaviors that might seem innocuous could potentially feel like a violation to a patient based on their background, perspective, culture, or other factors. Sometimes these situations may occur due to a simple lack of understanding about treatment, inadequate communication, cultural differences, or environmental factors.

Thus, careful attention to verbal and nonverbal indicators as well as sensitivity to patients’ privacy, dignity, and modesty are imperative. The following strategies can help PTs and PTAs address shifting boundaries and maintain professional and ethical relationships with patients:

• Follow professional standards and guidance regarding the provision of care and provider–patient relationships (e.g., the American Physical Therapy Association’s Code of Ethics for the Physical Therapist and Standards of Ethical Conduct for the Physical Therapist Assistant).
• Adhere to professional policies and standards for electronic communication, such as email, texting, and social media. Policies should address behaviors that might violate professional boundaries (e.g., sending patients requests to connect, accepting requests from patients to connect, and using the internet to find personal details about patients).
• Develop a clinical chaperone policy that specifies the availability and use of chaperones for assessments or therapies that are sensitive in nature. Chaperones can give patients a sense of security and verify that the provider’s behavior was appropriate. Make sure chaperones are trained professionals.
• Notify patients of their right to request a chaperone. Specify in your new patient welcome brochure or information packet that chaperones are available and how patients can make the request.
• Encourage parents or guardians to be present during the care and treatment of minor patients. Parental presence can help all parties feel more comfortable.
• Prior to initiating care, explain to patients the nature of the therapy as well as benefits, risks, and possible alternatives. The Federation of State Boards of Physical Therapy explains that “Prior to beginning physical therapy services and throughout the episode of care, the patient/client must be given reasonable opportunity to ask questions, have them answered, and resolve concerns.”¹
• Ask for patients’ consent before physically touching them. Explain what you’re doing as you’re doing it, and encourage them to speak up if they are uncomfortable. Doing so can help alleviate feelings of vulnerability.
• Use only the necessary amount of physical contact to examine patients and provide therapy. Wear gloves when touching patients in sensitive areas or when potential contact with bodily fluids or nonintact skin might occur.
• Avoid comments about patients’ bodies that are not clinically relevant to their care. Even comments intended as compliments might make patients uncomfortable.
• Be mindful of varying degrees of patient modesty and respond appropriately to each patient’s needs. Consider the cultural implications of privacy and modesty when interacting with diverse patient populations.  
• Engage in respectful behaviors that honor patient’s confidentiality and privacy. For example:
  • Conduct discussions that involve personal or sensitive information in private areas and lower your voice to avoid inadvertent disclosure.
  • If patients need to fully or partially remove any clothing for treatment, specifically tell them which items to remove and which items they can still wear. If they need to change clothing for treatment, leave the room while they do so.
  • During treatments such as massage therapy and dry needling, properly drape patients to minimize exposure but allow adequate access to sensitive treatment areas.
• Include questions about respectful, professional care in patient satisfaction surveys. Review feedback to determine strategies for further improving patients’ experience.
• Make sure a mechanism is in place for patients to report concerns and complaints, and develop a protocol to consistently investigate these reports.
• Be aware that patients might initiate boundary violations, either intentionally or unintentionally. Develop protocols for responding to inappropriate behavior, including redirecting the patient (e.g., “we need to keep this professional”) or naming the behavior and giving specific directions (e.g., “what you’re doing is harassment; you need to stop”). Make sure all staff members feel empowered to raise concerns about patients and report inappropriate patient interactions.
• Participate in and provide training to staff members on professionalism, ethics, professional boundaries, sexual misconduct, and sexual harassment. Make sure training covers a range of scenarios, including both clear-cut and gray areas of misconduct.

Professional and ethical behavior is vital to establishing trust, building rapport, and creating safe patient encounters. When boundaries are crossed, even inadvertently, significant fallout can occur. The patient might experience physical and emotional harm, and the provider might face reputational damage, liability exposure, and financial implications.

Developing policies and approaches that support ethical behavior and reinforce respectful patient interactions can help physical therapy practices avoid potential misconduct pitfalls and ensure patients receive high-quality and sensitive care.

To learn more, take MedPro’s on-demand continuing education programs titled Sexual Misconduct: Crossing Professional Boundaries and Sexual Misconduct: Risk Strategies and Insights.

¹ Federation of State Boards of Physical Therapy. (2025). Informed consent guide for physical therapy. Retrieved from www.fsbpt.org/Portals/0/documents/free-resources/FSBPT%20Informed%20Consent%20Guide%2005.02.25%20final.pdf

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