KINE 427 exam 2

What is scope of practice?

the legal boundaries that define the manner in which clinicians practice. established on state-by-state basis, institutional policies and procedures manual should refelct state practice acts and professinal standards of practice

best scope of practice statement example: NATA?

National Athletic Trainer's’ Association

Administrative concerns- what are legal considerations? prescription and confidentiality

Legal and administrative: your minimum legal duty to prevnt further harm by working in a professionaly accepted manner, and to know every device’s (modality) effects, contraindications and mainteneance before use.

prescription: varies by state (physician referral vs direct access). Modalities deliver prescription dugs (phonophoresis, iontophoresis) require a prescription for each patient.

confidentiality: HIPAA (health insurance portability and accountability act) controls protected health information (PHI)- past present and future records; records need written permission to release. FERPA (family education rights privacy act) protects education records, including school medical files.

What is negligence? What is commission vs omission? what is the clinician and patient link?

Negligence: care below the minimally accepted standard

Commission: occurs when an individual acts on a situation but doe NOT perform at the level that a reasonable and prudent person would (someone is bleeding out, and you put pressure on incorrect place or not enough pressure is applied- incorrect or inappropriate action)

Omission: occurs when an individual fails to respond to a given situation when a response is necessary to limit or reduce harm (someone is bleeding out and you do nothing, omits to acts)

Clinical link: both are measured against your duty to the patient; also negligent: unsafe facilities or equipment

Insurance- medicare has A, B, C, D

what is an insurance claim?

what is EOB?

A: hospital insurance

B: non-hospital (annual wellness)

C: medicare advantage

D: medication coverage

An insurance claim: the formal request to a payer for payment of sevices you rendered

EOB: explanation of benefits

Informed consent, what is it, what must be for negligence to be determined for a lack of IC?

• except in emergency situations, every patient must grant their consent to be treated (seeking treatment implies consent)

• for negligence to be determined for a lack of IC, the patient must suffer hard from the care rendered

• educate patient on each treatment before - what he or she should expect

• signed IC should be on FILE- <18, consent signed by parent or legal guardian

what is the FDA, what do they oversee/responsible for? what in the FDA role in for therpautic modality use (CDRH)?

FDA: food and drug administration, it is the major regulator for over-the-counter and prescription medications. FDA’s Center for Devices and Radiologic Health regulate a wide range of therapeutic devices to ensure patient safety, checks efficacy claims (is it producing desired intentional result), and eliminates unnecessary exposure to radiation emitted from the device.

what is OSHA? enforecemnt branch? each institution must develop a…?

OSHA: occupational safety and health administration: develops codes, safety standards and regulations to prevent work-related injuries and illnesses. the enforcement branch will fine and prosecute employers who do not comply with the standards

• universal standards help prevent against accidental contact with biohazards

• each institution must develop an exposure control plan to protect its employees

Safety of electrical devices (cords, etc.) inspection, voltage outlets #? GFI? what to do if defect is found in plug or cord, GFI continues to trip?

• all therapuetic modalities must be inspected and calibrated by qualified technician yearly

• the inspection or service date, the technician, and the services performed should be documented and kept on file

• defect in plug or cord, GFI continues to trip- unplug, label as “inoperative” remove it from treatment area, call for qualified tech

some modalities operate on 110v outlets while others require 220v

GFI: Ground fault interrupters- the reset/on button, required for all outlets that will serve patients

Billing codes: ICD? CPT? how does this impact billing?

ICD: international classification of diseases codes- describes the patients pathology

CPT: current procedural terminology codes- describes the care provided to the patient

impact to billing: improper coding can result in a claim being rejected, facility audits (inconsistencies found), loss of provider status, fines

reimbursement documentation? what is key for riembursment? how can payment for services be declined

insurance companies require the use of goal-based treatments plans for reimbursement.

therapeutic services billed for this purpose will only be reimbursed if they meet the patients treatment goals… if patient does not show improvement or if treatment protocols does not appear to match goals, payment for services can be declined

medical documentation- “if you don’t document it, it didn’t happen”; clinically relevant treatment, continuity of care, discharge planning

1.) clinically relevant treatment: document the day’s treatments should describe the date, time, individual providing care, the pathology being treated, the therapuetic modalities and exercises that were used, and parameters used… pre and post interview documented on medical record

2.) it is necessary so that continuity of care can be maintained when more than one clinician is involved in the patients’s care, should include all communication to and from other health-care providers, any clinicain can pick up care where it was left off

3.) discharge planning: document patient’s status at discharge, goals, met, and at home program or follow-up

• failure to maintain accurate and legible medical records may result in professional negligence; the length of time records are required to be kept post patient’s care changes state by state

SOAP documentation

S- subjective

O- objective

A- assessment

P- plan

what is the purpose of patient goals? what to do about changes if there is no improvement?

patient goals: Drives treatment plan, justify payment and let you measure progress. care provided must be in the best interest of the patient, be safe and effective and progress toward their goals.

no improvement or change in status? reassess, modify the protocol or goals, and refer back to the physician if needed. continuing plan that does not match goals gets payment declined

evidence-based practice:

payer want proof that treatment is actually working and produces the effect you claim. evidence that the treatment being rendered are beneficial to meeting patient’s treatment goals

what are the 3 categories of pain?

Nociceptive: somatic, visceral, cutaneous (related to tendons and ligaments, internal organs, and skin)

neuropathic: pain directly to the nervous system system itself, central (can’t sense pain) and peripheral (i.e. neuropathy)

nocioplastic: pain caused by layered processing in the central nervous system, occurring without clear evidence oof tissue damage or nerve injury (pain from altered nociocpetors)

hydrotherapy area regulations, treatment area?

hydrotherpay area:

• well ventilated and air conditioned to maintain 40-50% humidity and air recycled 8-10 minutes per hour

• remain interruptable and observable

treatment area:

• tables should be ~30 in high (adjustable for diff types of treatment and to meet ADA), should be spacious and well lighted,

where does pain come from, the 4 types?

• cutaneous pain: sharp, bright burning, can have fast or slow onset

• deep somatic pain: stems from tendons, muscles, joints, periosteum and blood vessels

• visceral pain: originates from internal organs; diffused @ 1st and later may be localized (appendicitis)

• psychogenic pain: individual feels pain but cause is emotional rather than physical

Pain vs nociception:

nociception is encoding and processing of noxious stimuli, it only becomes pain when higher brain centers interpret it… the actual sensation → interpreted→ the actual experience

The stimulus for nociceptive pain?

nociceptors fire to extreme mechanical, thermal or chemical energy

Pain perception depends on… what is ABC; how is this related to pain intensity

depends on past experiences, expectations, anxiety, suggestions

A: Affective- one’s emotional factors that can affect pain experience

B: Behavioral- how one expresses or controls pain

C: Cognitive- one’s beliefs (attitudes) about pain

intensity of pain changes with how people perceive their pain^^

A-delta fibers vs C fibers (fast vs slow pain)

• A-delta/Fast: localized; carried through A-delta axons in skin, are myelinated, larger, carry impulses @ rate of 5-20 m/second

  • fight or flight. withdrawal reflex (hot stove)

• C-Fibers/Slow: aching, throbbing, burning; unmyelianated, carry impulses @ 0.5—2.0 m/sec

  • tissue damage, memory of injury (the aching after pulling away from hot stove)

*both carry nociceptive input to the spinal cord

acute vs chronic has nothing to do with fiber types

what is PQRST- formula for what questions to ask about pain

Provocation: how the injury occurred & what activities increase/decrease pain (what provokes the pain? what happened to initially provoke pain)

Quality: characteristics of pain- aching, burning, sharp, radiating within dermatome

Referral/Radiation:

• referred: site distant to damaged tissue that does not follow the course of peripheral nerves

• radiating: follows peripheral nerves; diffuse

Severity: How bad is it? PAIN SCALE

Timing: When does it occur? pm or am, before during after activiity, all the time, during sleep?

what is pain tolerance? pain threshold? and how does it differ patient to patient.

Pain tolerance= amount of pain a person is willing or able to tolerate

Pain threshold= the stimulus level needed to alert you to a threat to tissue- a loud warning

pain tolerance varies patient to patient with expectations, past experience, anxiety, emotions and beliefs- two people with the same injury can report very different intensity.

Pain intensity application:

Use a pain scale and treat patient’s own report, and pair it with objective findings rather than comparing patients

terminology: accommodation phenomenon, hyperesthesia, parathesia

accommodation phenomenon: adaptation by the sensory receptors to various stimuli over an extended period of time- less sensitive to stimuli (when you hit your head you first go to touch it to try and override the apin stimulus sent to CNS)

hyperesthesia: abnormal acuteness of sensitivity to touch, pain, or other sensory stimuli

parathesia: abnormal sensation such as burning, prickling, tingling- fall asleep on arm, foot falls asleep

What is referred pain? examples and types (2)

pain that occurs away from the pain site

examples: McBurney’s point (a spot in lower right quadrant of abdomen to help diagnose appendicitis) and kehr’s sign (pain in left tip of shoulder indicates irritation of spleen/diaphragm)

TYPES:

• Myofascial pain: trigger points (active- hyperirritable, obvious complaint & latent- dormant, produces no pain except loss of ROM)

• Sclerotomic and dermatomic pain: deep pain (sclerotome- area of bone/fascia supplied by single nerve root; myotome- muscle supplied by single nerve root)

What is the 5-step application process of modalities ?

1.) foundation- describe modality and basis of how it operates, the effects, advantages (benefits), disadvantages (negative effects), indications, contraindications, precautions (situation that could cause harm if not used carefully)

2.) pre-application (SPPE)

3.) application- procedure (turn on unit, adjust outputs, check for patients response), dosagem length of application time, frequency (2xwk, duuration of therap (days, weeks)

4.) post-application- (RRCIR)

5.) maintenance- regular equipment cleaning, routine maintenance, simple repair (troubleshooting)

what are the pre-application tasks? a,b,c,d steps (SPPE)

A. Select proper modality: determine pathological and physiological changes associated with injury

• evaluate/reevaluate patient, review patient response to previous treatment. establish goals, match therapuetic goals with modality to achieve those goals, make sure the modality is not contraindicated by injury and patient

B. Preparing the patient psychologically: explain the purpose and expected outcome of the procedure, desrcibe body’s basic physio. response to treatment, explain what the patient might feel (tingling, gentle warmth, etc.), demonstrate on yourself if needed, warn patient of precautions

C. Prepare patient Physically: remove clothing to expose skin if necessary, remove bandages, position patient in comfortable manner yet accessible for modality.

D. Prepare the equipment: set up equipment, check equipment operation, perform safety check

What are the post-application tasks? a,b,c,d steps (RRCIR)

remove, replace and clean, instruct, record

A. equipment removal and patient clean up (remove ecg)

B. equipment replacement; area and equip cleanup (throw disposable, disinfect, replace new caps)

C. Instruction to patient: written if they are extensive/complicated;

1.) schedule next treatment

2.) instruct patient about level of activity/self treatment that should be adminstrated

3.) instruct patient about what they should feel after treatment

D. record treatment, including unique patient reponse

Proper positioning for patient and pressure points

proper positioning: comfort, prevent soft-tissue joint contractures, support and stbaility of patients trunk and upper extremeties, access and exposure to areas to be treated, promote efficient function of patients organ systems, provide position changes (prevent prolonged pressure to soft tissue), proper draping coverings

types:

• supine- heels, sacrum, elbows, scapula, head

• lateral recumbent- malleoulus, condyles, trochanter, ribs, acromion, ear

• prone- toes, knees, gentials, breasts, acromion, cheek

• seated (short or long)

“hot spots” - on bony places

What is purpose of intermittent compression?

used to control and reduce swelling after an acute injury or for pitting edema

facilitates movement of lymphatic fluid

elevate during treatment

what is massage- what does it do?

systematic manipulation of soft tissues

encourages venous/lymphatic drainage

mildly stretches scar tissue (mobilizes scar)

increases circulation and metabolism

promotes relaxation

What are the 5 different massage strokes?

1.) Effleurage- stroking

2.) Petrissage: kneading

3.) friction: moving in circular/opposite motion

4.) tapotement: percussion (cupping, hacking, pinching)

5.) Vibration: quivering, trembling effect

thermotherapy: what is the best way to apply heat? how to protect patients when applying heat, what are the contraindications? what are the precautions? what is thrombophlebitis?

best way: moist heat pack (hydrocollator), layered towels, 20-30 minutes, with compression (weight or wrap) for the most benefit

lay the pack on the patient, never the patient on the pack. Tell patient to report if it gets too hot, also make sure they can feel the heat!

Pair with stretching or exercise afterward

CONTRAINDICATIONS: never apply heat when… there is a loss of sensation, directly after injury, a decrease in arterial circulation, never directly to eyes or genitals, on abdomen of a pregnant woman, don’t apply to body part that exhibits signs of acute inflammation

PRECAUTIONS: pregnancy, edema, cardiac arrythmias/MI, metal, combining with counterirritants (using topical heating agent- biofreeze icyhot and heat pad), RA/OA

thrombophlebitis: vasodilation can move blood clot elsewhere, causing a MI, pulmonary embolism or stroke

Abnormalities with heat use and adverse responses

ABNORMAL

rebound vasoconstriction: the blood vessel’s initial response to hear is vasodilation but after about 20 minutes of treatment, it will have the opposite response (like the cold hunting response)- maximum vasodilation has been reached, the body’s attempt to save the underlying tissues via sacrificing the superficial tissue

ADVERSE

mottling- ghost-white areas and beet red spoltches.. STOP TREATMENT

burns from too much intensity or duration, increase edema

What is a contrast bath?

Alternating between hot and cold, known as contrast whirlpool (or ice bucket)

20 minutes hot, 5 minutes cold

may be effective for increasing blood flow without increasing edema, start with cold for 5-10 minutes then alternate… creates a “pumping” effect

acute: end with cold

chronic: end with heat

what is vapocoolant spray, and the depth it is effective for?

brief surface cooling, it is superficial, skin level only, so it is not a deep-cooling tool.

What is cryotherapy and cryokinetics, what is the difference?

cryotherapy: cold applied alone

cryokinetics: cold plus exercise. ice about 5 minutes until numb, exercise, ice another 5 min, exercise, repeat 3 rounds total- the goal is anesthesia (numb) first, then work on ROM and exercise

what is cold hypersensitivity? what are the symptoms? what is raynaud’s phenomenon? what is paroxysmal cold hemoglobinuria? what is it called to be allergic to cold?

when people react abnormally to cold… some people experience raynauds phenomenon or allergic reaction

Raynaud's phenomenon: cold triggers vasospasm of the digital arteries (finger or toes blanch, then turn blue or red, with pain or numbness)

paroxysmal cold hemoglobinuria: rare, can lead to renal dysfunction, secondary hypertension and coma (produces biphasic IgG that destroys RBC)

cold can cause nerve palsy, allergic- cold urticaria syndrome (hives, itching, swelling after cold contact)

how does heat affect extensibility- collagen fibers?

heating collagen rich tissue- tendon, muscle, capsule or fascia to 104-112 deg F for about 5 minutes lets it elongate (plastic deformation), but only if you apply tension

heat alone does nothing to lengthen anything, heat THEN stretch and stretch while tissues is still warm

What are the 4 systemic effects of heat exposure?

1.) increase body temp

2.) increase HR (pulse rate)

3.) increase respiratory rate

4.) decrease in blood pressure

local effects of heat application; for each increase in 18 deg F in skin temp, cell’s metabolic rate increases by a factor of

increase vasodilation, increase rate of cell metabolism, increase capillary permeability, increase delivery of leukocytes, edema formation, removal of metabolic waste, increase elasticity of ligaments, capsules, and muscles, analgesia and sedation of nerves (complete partial relief of pain), increase nerve conduction (velocity), decrease muscle tone, decrease muscle spasm, perspiration, decreases fluid viscosity

metabolic rate increases by factor or 2-3

temperature benchmarks for heat application

102 F: enzyme activity starts rising

106 F: O2 release is about double

104-114 FP: collagen-rich tissue can deform plastically

above 113 F: protein damage and cell destruction

too little heat does nothing, too much heat is harmful

Rewarming: skin cools fast after removal, but superficial muscle stays warm about 30 minutes post removal

heat and cold, use cold for … use heat…

common practice (no clear cut answer of when to use hot and when to use cold):

use cold for first 24 hours

use heat for the next 48 hours

always use cold after exercise

cold- for acute stages of inflammation reaction, before ROM exercies, post exercise

heat- control inflammation reaction in its subacute chronic stages, encourage tissue healing, to reduce edema and ecchymosis, improve ROM before PA or rehab, promote drainage of an infected site

questions to ask athlete/patient when using hot or cold

is the area warm? tender to light touch, swelling increasing, worse with activity, pain limiting ROM, still responding to cold

ultrasound: the different MHz (megahertz) and the uses for them

1 MHz (1.75 W/cm²): deeper targets, tissue (5-7cm) most common; rotator cuff, vastus intermedius, and gastrocnemius- 10-12 min

3 MHz (1.4 W/cm²): superficial tissue (up to 3 cm); ex: patellar tendon, MCL, and brachialis- 3-4 min

the difference between diagnostic and therapeutic ultrasound

diagnostic: imaging, pictures of tissues (babies, cancers, appendix)

therapeutic: delivers acoustic energy with a treatment goal

how does ultrasound work? how to perform ultrasound therapy?

the head of the probe contains a piezoelectric crystal in the transducer. electrical current makes the crystal vibrate, which converts electricity into sound waves (Compression and rarefaction)→ acoustic vibrations and pressures through conducting gel to the tissues→ thermal energy is transferred through supersonic waves that is then absorbed in the tissues

how to guide:

• check for contraindications, pick mode and coupling, clean area, mark a field 2-3 times the ERA, spread gel

• explain sensation (mild to moderate warmth)

• intensity to 0 before power on, set mode, watt meter and timer

• start moving head, then slowly raise intensity, add gel if gel wears thin and head sticks

• circular motions

• end: lower intensoty before lifting off, wipe off gel, record frequency, intesneity, duration, duty cycle and running treatment count, stretch right away

what is attenuation?

the gradual loss of ultrasound energy as the sound waves travel through the tissue; 1 MHz attenuates les than 3 MHz

non-thermal effects- what is cavitation

cavitation is the behavior of tiny gas bubbles int he sound field and fluid movement (streaming) that support tissue healing. excess intensity can cause discomfort or injury

what is ERA?

effective radiating area- “how great of an area the treatment will radiate into”

what is a duty cycle, high vs low? what is intensity?

duty cycle determines the proportion of thermal and non-thermal effects; % of time sound is on, 100% is continuous, pulse flow= intermittent, output cycles on and off

high duty cycle- majority thermal effects (subacute and chronic conditions)

low duty cycle- majority non-thermal effects (may suit acute stages)

intensity= the acoustic power delivered (W/cm²)

why do you need to see the skin where ultrasound is being used? contraindication and precautions

you need clean, hair free skin and good gel coverage to couple the sound

you can only rule out contraindications and watch skin’s reaction if you see it, patient also must be able to feel heat sensations

avoid!! acute injuries at 100% duty cycle, ischemic or impaired circulation, DVT, anesthetic areas (no sensatinon), cancer active infection, spinal cord or large nerve plexus or lumbar area at high doses, eyes, heart, skill, genitals, pacemaker over the thorax (even on upper back), pelvic area in pregnancy or mensturation, unhealed fractures, and osteoporosis

precaution!! symptoms may flare after the first treatments. metal implants are not contraindications just keep moving head, use caution at epiphyseal plates and after laminectomy

What is coupling? direct, immersion, pad/bladder

sound cannot cross air, so use a water-based medium on a clean, relatively hair free area; couple tranducer with other medium (gel, water, oil)

direct (gel): use liberally; pass the head over the area to clear bubbles before raising power

immersion: degassed water, transducer about 1 inch from the skin; with tap water add 0.5 W/cm²- good for irregular areas

pad/bladder: conforms to the area; commercial pads limit field size

what is phonophoresis?

method for driving chemical through the skin using the mechanical vibrations of ultrasound, preheating area to increase absorption of a medication, only improved ultrasound transmission media (direct coupling method recommended)

What is iontophoresis?

method of transporting chemical ions through the skin using an electrical current

paraffin baths- what is it and its uses- immersion and dip and wrap

part wax, part mineral oil (great moisturizer), ideal for superficial heating for small irregular area, particularly in the hand (commonly used in OT, difficult to treat other areas), after treatment wax can be used for gripping exercises or returned to bath

immersion: dips repeatedly to apply layers of wax, then immerse for 5-10 minutes

dip and wrap: dips 4-5 times to apply adequate layer of wax, wrap in ice bag, then towel/oven mit for up to 20 min

stretching and flexibility - limiting factors, types (prom, arom, ballistic, PNF)

limiting factors of flexibility: bone (fracture-calcium deposits), excess fat, inelastic scar skin, muscle and tendon, connective tissues (adhesive capsulitis), age (less with age), gender (less in males)

active ROM: dynamic- patient moves joints through full range with their own muscle contraction

passive ROM: static- someone else moves the joint to the end of its range or it moves with no muscle contraction

ballistic: bouncing; repeated agonist contractions give quick stretches of the antagonist, can cause soreness, is best after static stretching or a full warm-up

PNF: proprioceptive neuromuscular facilitation

what is the most frequently treated causes of pain?

hypomobility - significant decrease in ROM

improving felxibility for a patient (plan), what is optimal temp. of muscle before stretching

1.) warm the tissue first 9exercise or a heat modality)- optimal temperature of muscle prior to stretvhing is 103 deg F

2.) stretch while warm; static hold for 30 seconds or PNF contract-relax

3.) add dynamic work before activity and balsitic only after static or a full warm-up

4.) reinforce agonist and antagonist strength balance; progress from passive to active ROM as the patient allows

agonist vs antagonist

agonist: muscle that contracts to produce movement

antagonist: muscle being stretched in response to agonist contraction

a balance between the agonist and antagonist muscles is necessary for smooth movement and to decrease injury

effects of heat application on the injury response

primary effects of heat modalities are increased cell metabolism and rate of inflammation, both require increase O2

if heat is applied too soon in the injury response process, the increased cell metabolism increases the number of cells injured or destroyed because of hypoxia

increasing the inflammatory response rate could extend the acute and subacute inflammatory stages