Do OTs Need Extra Training to Use Physical Agent Modalities? The Rules in Every State

In most states, an OT can use ultrasound, e-stim, heat and cold under the license they already hold, as long as they are competent to do it. Twenty-one jurisdictions name physical agent modalities (PAMs) in the OT scope and add nothing else, and nine don't mention them. The rest add a step: six want board approval or a certificate first, seven set training hours in a law or rule, and eight require training or documented competence without setting hours. The main differences are whether heat and cold are treated more lightly than ultrasound and electrical stimulation, and whether OTAs need the same training as OTs.

I'm an occupational therapist, so this one is close to home. This article goes through every state for OTs and OTAs: the rule that applies, quoted, with a direct link to the official source.

This isn't legal advice. I checked every rule on November 9, 2026, on the state's own legislature, code or board site. Your board's current rule is the one that counts.

The Short Answer

• Board approval or a certificate first (6): California, Georgia, Kentucky (deep modalities only), Montana (superficial modalities), Nebraska and Tennessee.
• Training hours set in a law or rule, no board filing (7): Florida (prescription e-stim and ultrasound devices), Illinois, Maryland (electrical modalities), New Hampshire (ultrasound and electrical), New Jersey (advanced modalities), South Dakota and Wyoming. Hours range from 4 in Florida to 30 in New Jersey, usually plus supervised treatments.
• Training or competence required, no hours (8): Arizona (board statement), Delaware, Idaho (deep thermal and electrotherapeutic), Nevada, New York, Utah, West Virginia and Wisconsin.
• Named in the OT scope, nothing more (21): Alabama, Colorado, DC, Hawaii, Indiana, Iowa, Kansas, Louisiana, Maine, Massachusetts (heat and cold only), Michigan, Minnesota, Mississippi, New Mexico, North Carolina, North Dakota, Ohio, Oregon, Texas, Vermont and Washington (only within wound care).
• Not mentioned at all (9): Alaska, Arkansas, Connecticut, Missouri, Oklahoma, Pennsylvania, Rhode Island (it names only "modalities" in general), South Carolina and Virginia.
• Heat and cold are often treated differently. At least ten states set different rules for different kinds of modalities, usually leaving hot packs and ice alone and putting the training rule on ultrasound and electrical stimulation.
• OTAs: in 11 states the OTA meets the same training or certificate rule as the OT, sometimes with more hours or closer supervision. Kentucky asks OTAs for 72 hours, twice the OT's 36.
• Purpose: at least 17 states say in their law or rules that PAMs are used as an adjunct to, or in preparation for, purposeful activity or occupation.

What AOTA Says

The national layer is the American Occupational Therapy Association. It doesn't license anyone, so its position is guidance, not law. Its Policy E.18: Interventions to Support Occupations (opens in a new tab) (2023) covers PAMs, dry needling and similar techniques:

Interventions to support occupations should not be used in isolation or in the absence of occupation-based assessment and intervention.

On training, the same policy says these interventions "may not be entry-level skills and may require advanced training and/or certification," that "There is no consensus from state to state on the minimum standards for evaluating competency or certification," and, for assistants, that "Occupational therapy assistants may utilize PAMs and other interventions to support occupations with appropriate supervision in accordance with local and state policies, rules, and regulations." (AOTA Policy E.18 (opens in a new tab))

AOTA's longer position statement, Physical Agent, Mechanical, and Instrument-Assisted Modalities in Occupational Therapy Practice (opens in a new tab) (2024), says the same things at more length. Several states point to AOTA's documents in their own rules, and Wisconsin names AOTA's PAM position paper as an example of how to judge competence.

Every State at a Glance

None stated means the act and rules set no training, approval or competency step for PAMs beyond the general duty to practice within your competence. Not named means the OT scope doesn't mention physical agent modalities. No specific rule means nothing in the act, rules or board statements speaks to the point, and the citation is the section that would govern. Each citation links to the official source I read.

The States That Want Board Approval First

Six states won't let you start until the board has signed off. In each one, check whether your entry-level degree or a hand therapy certification counts, because several give credit for them.

• California. PAMs are an advanced practice. "Physical agent modalities may be used only when an occupational therapist has demonstrated to the Board in an application filed pursuant to section 4155 that they have met the post professional education and training requirements established by this section as follows: (1) Education: Completion of 30 contact hours in the subjects listed in Code section 2570.3(f). (2) Training: Completion of 240 hours of supervised on-the-job training, clinical internship or affiliation, which may be paid or voluntary, pertaining to physical agent modalities." A certified hand therapist meets the requirement. (16 CCR § 4152 (opens in a new tab)) While you build those hours, the statute lets you practice "under the supervision of an occupational therapist who has already met the requirements established by the board, a physical therapist, or a physician and surgeon." (B&P Code § 2570.3(g) (opens in a new tab)) The board's FAQ (opens in a new tab) answers two common questions: icing used for sensory stimulation "is not considered a modality requiring advanced practice approval," and using electrical stimulation such as VitalStim or ultrasound for swallowing needs PAM approval on top of swallowing approval.
• Georgia. "Any occupational therapist and occupational therapy assistant who wishes to utilize O.T. techniques involving physical agent modalities, must document, successful completion of a minimum of 90 contact hours of instruction or training approved by the Board". At least 36 of those hours must be "directly related to the specific theories and practical application of physical agent modalities." Using PAMs without the board's certification "is in violation of O.C.G.A. Sec. 43-28-8.1," and a certified OTA "may only use those modalities when supervised by a licensed occupational therapist certified to use physical agent modalities under this rule." (Ga. Comp. R. & Regs. 671-6-.02, .03 (opens in a new tab))
• Kentucky. Only deep modalities need the certificate. The law defines them as "any device that uses sound waves or agents which supply or induce an electric current through the body," including iontophoresis, ultrasound, TENS and FES, and lists hot packs, cold packs, ice, fluidotherapy and paraffin as superficial. (KRS 319A.010 (opens in a new tab)) For deep modalities an OT needs "a minimum of thirty-six (36) hours of training or instruction that meets the requirements specified in administrative regulations promulgated by the board, as well as five (5) treatments under supervision," and an OTA needs "a minimum of seventy-two (72) hours of training or instruction." (KRS 319A.080(4) (opens in a new tab)) "A DPAM Specialty Certification shall be issued by the board before the individual can begin using deep physical agent modalities," and the training can't be all online: "Training shall not consist of all on-line courses that do not provide hands on lab instruction." (201 KAR 28:170 (opens in a new tab))
• Montana. It runs the other way from most states. For superficial modalities a person must have "successfully completed 16 hours of instruction or training in superficial physical agent modalities and documents competency, as approved by the board" and must limit them "to the shoulder, arm, elbow, forearm, wrist, and hand." (MCA 37-24-105 (opens in a new tab)) The board's rule approves instruction for "licensees seeking endorsement to provide superficial physical agent modalities." (ARM 24.119.809 (opens in a new tab)) For sound and electrical modalities the statute now asks only that the person "is licensed under this chapter" and "limits application of sound and electrical physical agent modalities to the shoulder, arm, elbow, forearm, wrist, or hand to restore and enhance upper extremity function." (MCA 37-24-106 (opens in a new tab)) Using them to deliver medication is different: iontophoresis and phonophoresis with topical medications take "5 hours of instruction or training in pharmacology relevant to topical medications" plus proctored treatments. (MCA 37-24-107 (opens in a new tab))
• Nebraska. The statute was rewritten in 2025. An OT whose "occupational therapy educational program does not include education in superficial thermal, deep thermal, electrotherapeutic, and mechanical devices" and who isn't a certified hand therapist "shall request approval from the board to practice physical agent and instrument-assisted modalities." The department issues a certificate to an OT who passed a board-approved course and exam, holds hand therapy certification, has five years of experience and passes an exam, or "Has completed education during a basic educational program which included demonstration of competencies for application of physical agent and instrument-assisted modalities." Nebraska also says outright: "An occupational therapist may not use diathermy." (Neb. Rev. Stat. § 38-2530 (opens in a new tab)) The board's rules, written before the 2025 change, still set course hours: "a minimum of 6 hours of Board approved training" for superficial thermal agents, "a minimum of 12 hours of Board approved training" for deep thermal agents and "a minimum of 22 hours of Board approved training" for electrotherapeutic agents. (172 NAC 114-003.03 (opens in a new tab))
• Tennessee. "The use of physical agent modalities by any licensee requires additional certification pursuant to Rule 1150-02-.04." There are two certifications. Electrical stimulation takes "a total of twenty-five (25) contact hours of didactic and laboratory experiences which include five (5) treatments on clinical patients." Thermal agents take "a total of twenty (20) contact hours of didactic and laboratory experiences which include ten (10) treatments on clinical patients," and "Five (5) of the ten (10) treatments shall utilize ultrasound." Current hand therapy certification is the alternative. (Tenn. Comp. R. & Regs. 1150-02-.04(4), 1150-02-.12(2) (opens in a new tab))

The States That Set Training Hours

These seven write the hours into a law or rule but don't ask you to file with the board first. You keep the proof and hand it over if asked.

• Florida covers only prescription devices. "Use of an electrical stimulation device for which a prescription is required by Federal law, 21 C.F.R. §801.109, is expressly prohibited by Section 468.203(4), F.S., except by an occupational therapist or an occupational therapy assistant who has received training as prescribed in this rule." The training for electrical stimulation, and the same for ultrasound, "shall include didactic training of at least four (4) hours and performance of at least five (5) treatments under supervision in a clinical setting." (Fla. Admin. Code R. 64B11-4.001 (opens in a new tab))
• Illinois covers electrical, thermal (superficial and deep heat and cryotherapy) and mechanical modalities. The training "shall include: A) a minimum of 14 hours of didactic training in a program defined in subsection (b)(2) that includes demonstration and return demonstration as part of a lab component and an examination," and "B) five clinical treatments in each modality supervised by a licensed health care professional trained in the use of the modality." "Training shall be completed prior to the use of these modalities." (68 Ill. Adm. Code 1315.162 (opens in a new tab))
• Maryland covers electrical modalities only. A licensee must "Complete 15 contact hours of continuing education relative to electrical physical agent modalities which includes a minimum of: (a) 5 contact hours specific to ultrasound; and (b) 5 contact hours specific to electromuscular stimulation," then "apply a minimum of five client treatments within the context of a therapeutic treatment program for each specific modality under the direct clinical education of an educator." (COMAR 10.46.06.04 (opens in a new tab)) For heat and cold: "A licensee may apply superficial physical agent modalities including, but not limited to, hot packs, cold packs, paraffin, fluidotherapy, and icing." (COMAR 10.46.06.08 (opens in a new tab))
• New Hampshire stopped issuing PAM certificates in 2021 but kept the hours. Ultrasound education must "Be at least 6 hours in duration for occupational therapists and occupational therapy assistants," and electrical stimulation education must "Be at least 15 hours in duration for occupational therapists and occupational therapy assistants." Online courses count. (N.H. Admin. R. Occ 304.03, 304.04 (opens in a new tab))
• New Jersey covers advanced modalities: "diathermy; high-voltage galvanic stimulation; micro current stimulation; transcutaneous electrical nerve stimulation; neuromuscular electrical stimulation; iontophoresis; therapeutic ultrasound; phonophoresis; and cold lasers." The Council-approved course must include "at least 30 hours of didactic instruction," split into heat, "Sixteen hours of training in the use of electric wave physical agent modalities," sound and light, with hands-on practice in person. (N.J.A.C. 13:44K-5.4 (opens in a new tab))
• South Dakota puts the qualification in its licensure-application section under the heading certification, and its rules set no separate PAM application. An OT or OTA qualifies by having "successfully completed twenty-five hours of American Occupational Therapy Association or American Physical Therapy Association approved education covering physical agent modalities and completed a supervised mentorship to include five case studies on each class of modality to be incorporated into patient care," by holding hand therapy certification, or by having "completed education during a basic occupational therapy educational program that included demonstration of competencies on each class of the physical agent modalities." (SDCL 36-31-6(6) (opens in a new tab)) PAMs are also limited to the upper extremities. (SDCL 36-31-1(3) (opens in a new tab))
• Wyoming applies to every modality. "The OT or OTA must complete six (6) hours of post professional education in the appropriate use of physical agent modalities," and "shall complete five (5) supervised direct administrations of each modality demonstrating the appropriate use of each physical agent modality." Skipping it "shall constitute unprofessional conduct and grounds for disciplinary action." (Wyo. OT Board Rules ch. 3, §§ 6, 9 (opens in a new tab))

Training Required, No Hours Set

Eight states require training or documented competence but don't say how much. You decide what's enough, and you'd better be able to show it.

• Arizona, in a board web page, not a rule: "It is the responsibility of each individual Occupational Therapist or Occupational Therapy Assistant to secure the necessary training and supervision, certification, and professional competency pertaining to the use of all selected Physical Agent Modalities". (Arizona OT board (opens in a new tab))
• Delaware: "Competence may be shown by documented professional education, such as continuing education, in-service training or accredited higher education programs with documented coursework related to the modality in question. Determination of competence is at the discretion of the Board." (24 Del. Admin. Code 2000-5.0 (opens in a new tab))
• Idaho puts superficial modalities in the basic scope and separates deep thermal and electrotherapeutic modalities, which take "specialized knowledge and skills as attained through continuing education and experience." The statute says this is "as defined by rules adopted by the board," but the current rules don't define it. (Idaho Code § 54-3702 (opens in a new tab))
• Nevada lets the board "Require a person licensed pursuant to this chapter to submit to the Board such documentation as the Board deems necessary to determine whether the licensee has acquired the skills necessary to perform physical agent modalities". (NRS 640A.110 (opens in a new tab))
• New York's guideline says "Professional educational programs in New York State provide an instructional foundation for the use of physical agent modalities, including deep heat modalities." It also says "Physical agent modalities may not be used as a stand-alone treatment". It isn't binding on its own: "Not adhering to this Guideline may be interpreted as professional misconduct only if the conduct also violates pertinent law, rules and regulations." (NYSED guideline (opens in a new tab))
• Utah requires "the necessary training as the division determines by rule made in collaboration with the board". (Utah Code § 58-42a-102 (opens in a new tab)) I couldn't read the division's rule on the official rules site, so check with the Division of Professional Licensing for what it counts as training.
• West Virginia: "Training shall be completed prior to the use of the specific treatment technique and/or modality. Documentation of training shall be made available to the Board upon request." For OTAs using deep thermal or electrical modalities, the rule adds that the board audits. (13 CSR 5 (opens in a new tab))
• Wisconsin points to AOTA: "An example of standards for evaluating theoretical background, technical skill and competence is the position paper on physical agent modalities issued by the American occupational therapy association (AOTA)." (Wis. Admin. Code OT 4.02 (opens in a new tab))

Heat and Cold Versus Ultrasound and E-Stim

The biggest practical split is between superficial modalities, like hot packs, cold packs, ice and paraffin, and deep or electrical ones, like ultrasound, phonophoresis, TENS, NMES and iontophoresis. At least ten states draw that line somewhere:

• The extra rule covers only deep or electrical modalities: Kentucky, Maryland, New Hampshire, New Jersey and Idaho. Florida's rule reaches only prescription e-stim and ultrasound devices.
• The scope names only heat and cold: Delaware names "thermal agent modalities, including paraffin, hot and cold packs, and fluido therapy" (24 Del. C. § 2002 (opens in a new tab)), and Massachusetts names "designated modalities, superficial heat and cold" (M.G.L. c. 112, § 23A (opens in a new tab)). Neither says anything about ultrasound or electrical stimulation, so the answer there is silence, not permission.
• Separate hours for each kind: Nebraska's rules (6, 12 and 22 hours) and Tennessee's two certifications.
• Montana is the odd one out: 16 hours for superficial modalities, none for sound and electrical.
• West Virginia draws the line for OTAs only.

Everywhere else the rule, if there is one, covers PAMs as a group. In California, Georgia, Illinois, South Dakota and Wyoming, that means the training rule reaches hot packs too. California's board has carved out one case: icing used for sensory stimulation isn't a modality that needs approval.

What OTAs Can Do

Most states let OTAs use PAMs that the supervising OT has planned. The differences are in the training and the supervision:

• The same training or certificate as the OT (11): Florida, Georgia, Illinois, Kentucky (72 hours instead of 36), Maryland, Nebraska, New Hampshire, New Jersey, South Dakota, Tennessee and Wyoming.
• Tighter supervision: Georgia requires a supervising OT who is PAM-certified. Nebraska's OTA must be supervised by an OT "who is approved to administer physical agent modalities." (Neb. Rev. Stat. § 38-2530 (opens in a new tab)) New Jersey requires close supervision, with the OT observing each type of modality at least five times. Montana requires direct supervision.
• Off limits for OTAs: Nebraska bars dry needling and diathermy, and Louisiana bars dry needling.
• The OT keeps the evaluation and plan. Nebraska and West Virginia say so outright: an OTA "shall not complete evaluation, reevaluation, treatment planning, or treatment goal setting related to physical agent modality use." (Neb. Rev. Stat. § 38-2530 (opens in a new tab))

In home health, where the OTA is often alone in the home, this matters more. If your OTA uses a TENS or NMES unit on visits, make sure their training is documented to your state's standard and that your supervision meets your state's rule. Our guide to supervisory visit requirements in home health covers the visit side.

The Adjunct Rule

At least 17 states write the purpose into the law or rules: PAMs are used with occupation, not instead of it. Kansas's wording is typical: "applying physical agent modalities as an adjunct to or in preparation for engagement in occupations" (K.S.A. 65-5402 (opens in a new tab)). Language like it appears in California, Delaware, Illinois, Indiana, Kansas, Kentucky, Louisiana, Maryland, Minnesota, Montana, Nebraska, New Hampshire, New Jersey, Rhode Island, Vermont, West Virginia and Wyoming. California's version: "These techniques are used as adjunctive methods in conjunction with, or in immediate preparation for, occupational therapy services." (B&P Code § 2570.2(n) (opens in a new tab))

Georgia makes it a discipline ground: a certified licensee who uses PAMs "for purposes other than within the philosophical framework of occupational therapy" is in violation. (Ga. Comp. R. & Regs. 671-6-.03 (opens in a new tab)) In practice, the note should show the modality leading into a functional activity in the same session, and the goal should be an occupational one.

Rules That Changed

If you learned the rules a while ago, a few have moved:

• Minnesota dropped its PAM approval in 2014. The old section is marked repealed by 2014 c 291 art 4 s 59. (Minn. Stat. § 148.6440 (opens in a new tab))
• New Hampshire repealed its PAM certificates in 2021 and kept the training hours. (N.H. Admin. R. Occ 304 (opens in a new tab))
• Nebraska rewrote its statute in 2025 (LB257) so that entry-level education with demonstrated competencies qualifies. (Neb. Rev. Stat. § 38-2530 (opens in a new tab))
• West Virginia adopted a new version of its competency rule effective July 1, 2025. (13 CSR 5 (opens in a new tab))

If you work in more than one state, by telehealth or on an OT Compact privilege, the rule of the state where the patient is applies. Our OT Compact guide covers how the privilege works.

Key Takeaways

• In most states your OT license covers PAMs if you're competent. Twenty-one jurisdictions name them in scope with nothing more, and nine don't mention them.
• Six states want board approval or a certificate first: California, Georgia, Kentucky (deep modalities), Montana (superficial modalities), Nebraska and Tennessee.
• Seven set training hours without a board filing: Florida, Illinois, Maryland, New Hampshire, New Jersey, South Dakota and Wyoming.
• Ultrasound and electrical stimulation get more rules than heat and cold in most of the states that regulate PAMs.
• OTAs usually meet the same training rule as the OT, and some states add supervision limits or bar certain modalities.
• PAMs are an adjunct to occupation, not a treatment on their own, in every state that says anything about it.
• This isn't legal advice. I checked these rules on November 9, 2026, and your board's current rule is the one that counts.

Frequently asked questions

Do occupational therapists need certification to use physical agent modalities?

In most states, no. Twenty-one jurisdictions name physical agent modalities in the OT scope and add nothing more, and nine don't mention them at all. But six states want board approval or a certificate first: California, Georgia, Kentucky (for ultrasound and electrical modalities), Montana (for heat and cold), Nebraska and Tennessee. Seven more set training hours in a law or rule without a board filing, and eight require training or documented competence with no hours set.

Can an OTA use ultrasound or electrical stimulation?

In most states the rules allow it under an OT's supervision, and many add conditions. In Florida, Georgia, Illinois, Maryland, New Hampshire, New Jersey, South Dakota, Tennessee and Wyoming, the OTA meets the same training rule as the OT. Kentucky asks OTAs for 72 hours of training for deep modalities, twice the OT's 36. Nebraska bars OTAs from diathermy and dry needling. Montana limits OTAs to the shoulder through the hand, under direct supervision, and West Virginia wants documented training before an OTA uses deep thermal or electrical modalities.

Which states require board approval to use physical agent modalities?

Six. California requires advanced practice approval: 30 contact hours and 240 hours of supervised training. Georgia requires board certification after 90 contact hours. Kentucky requires a board certificate for deep modalities after 36 hours for OTs or 72 for OTAs, plus five supervised treatments. Montana requires 16 hours and board-approved competency for superficial modalities. Nebraska issues a department certificate, and Tennessee certifies electrical stimulation and thermal agents separately.

Do I need extra training to use hot packs, cold packs or paraffin?

Usually not, but it depends on the state. Kentucky, Maryland, New Hampshire, New Jersey and Idaho put their extra rules on electrical and deep modalities and leave heat and cold alone, and West Virginia does the same for OTAs. California, Georgia, Illinois, Nebraska, South Dakota, Tennessee and Wyoming write their rules for physical agent modalities generally or name thermal agents, so heat and cold are covered too. Montana sets 16 hours for superficial modalities in particular.

What does AOTA say about physical agent modalities?

AOTA's policy says modalities may be used to prepare a client for occupation or alongside it, not in isolation, and that they may not be entry-level skills and may require advanced training or certification. It also says states vary and that OTAs may use them with appropriate supervision under state rules. AOTA can't license anyone, so your state's rule is the one that decides.

Sources

Every state's rule is linked in the table, to the state's legislature, its official administrative code publisher or its OT board. All were read on November 9, 2026.

• AOTA, Policy E.18: Interventions to Support Occupations (opens in a new tab) (2023).
• AOTA, Physical Agent, Mechanical, and Instrument-Assisted Modalities in Occupational Therapy Practice (opens in a new tab), position statement, American Journal of Occupational Therapy, 78(Suppl. 1) (2024).
• California Board of Occupational Therapy, Advanced Practice (opens in a new tab) and Advanced Practices FAQ (opens in a new tab).
• Montana Board of Physical, Rehabilitative, and Developmental Health Care Professionals, ARM 24.119.809 (opens in a new tab) (approved modality instruction).
• New York State Education Department, Physical Agent Modalities (PAMs) (opens in a new tab) practice guideline for OTs, and the same guideline for OTAs (opens in a new tab).