Clinical skills exam 4

Order of what to do for the practical? (7)

Wash hands

Introduce yourself

Get consent

Explain what you will do and why and for how long

Position and drape

Ask allergies and contraindications

Reassess skin

What are the selection of modalities to choose from? (3 categories)

Heat

• Ultrasound

• Paraffin

Cold

• Ice pack

• Ice massage

Electrical currents

• Ten conventional/high rate

• IFC conventional

• Pre modulated acupuncture

• NMES contraction (VMS)

What is heat used for?

Heat

• Decreasing pain (NOT IN ACUTE)

• Increase ROM and joint mobility

• Increase tissue healing (In subacute or chronic)

• Increase tissue extensibility (ability to stretch)

Contraindications for heat?

Heat contraindications

• Recent or potential hemorrhage

• Thrombophlebitis

• malignant tumor

• Impaired sensation

• Impaired mentation

• IR radiation of the eyes

What are the steps for doing paraffin? When is it used? How long for it to be left on?

Used to apply heat to distal extremities, gets in the crevices and areas that normal heat agents cant normally get to.

• Remove all jewelry and inspect skin

• Wash and dry area to be treated

• With fingers apart, dip the hand in paraffin then remove (completely submerge distal extremities, don’t touch the sides, avoid pt. moving fingers)

• Wait for the layer to harden and re-dip and repeat 5-10 times

• Wrap the patient’s hand in a plastic bag, wax paper or treatment table paper and then with a towel

• Leave on for 10-15 minutes

• Peel paraffin from hand and discard, then inspect skin again

What is ultrasound used for? (Ask about tomorrow)

US (FOR DEEP TISSUES)

• Prior to stretching of shortened tissue

• Increase blood flow

• Decrease pain

(May also be what is down below ?)

Shortened tissue

Increase blood flow

Decrease pain (not in acute)

Increase ROM and joint mobility

Increase tissue heal sub & chronic

Increase tissue extensibility

Contraindications for US?

US contraindications

• Malignant tumor

• Thrombophlebitis

• Pacemaker or implantable cardiac rhythm device

• Plastic components

• Pregnancy

• CNS tissue

• Joint cement

• Eyes

• Reproductive organs

Steps for US (heat) ? Movement speed and area? For how long?

US steps

• First determine the depth of tissue

  • For deep (5cm): 1MHZ, 1.5 - 2.0 W/cm²

  • For superficial (2cm): 3MHZ, 0.5 W/cm²

• Set duty cycle to continuous (100%)

• Before beginning, show bottle for allergies

• Drape and US gel applied to area and US head

• Place US head on area before turning on

• Now turn on and start circling

• Movement speed is 4 cm per second and area is 2x the head of US

• Preform for 5 - 10 minutes

• When done, turn off, remove gel from pt and US head. Reassess skin and ask how patient feels

When is cold used?

Cold is used for

• Control pain and swelling and spasticity (in acute)

• Facilitate a muscle contraction

What are the contraindications of cold?

Cold contraindications

• Cold hypersensitivity (cold induced urticaria)

• Raynaud disease or phenomenon

• Cryoglobulinemia

• Cold intolerance

• Paroxysmal cold hemoglobinuria

• Over regenerating peripheral nerve

• Over an area with circulatory compromise or peripheral vascular disease

Steps for cold pack? How long?

Steps for cold pack

• Create the cold pack by filling ice into the bag, removing the air in it, tying the top, and flattening it out

• Wrap ice bag in towel

• remove jewelry and inspect skin

• Place icepack and secure it with a elastic wrap

• elevate area

• Leave on for 10 - 20 minutes

• after removing, inspect skin again

Steps for ice massage? how long? when to use it over ice bag?

Ice massage steps

• Remove jewelry and inspect skin

• rub ice over treatment area in small overlapping circles

• wipe away water as it melts

• preform for 5 - 10 minutes

• Inspect skin after

Used for small irregular areas that ice pack cant effectively get to, such as tendons

When is electrical currents used? For each? (Convectional or acupuncture, superficial or deep, large or small areas)

Tens: Conventional high rate. Superficial and immediate. Large and small areas

IFC: Conventional. Deep and immediate. Large areas

Pre mod: Acupuncture. Deep and long lasting. Small areas

NMES Stim: Prevent atrophy, decrease edema and increase strength. Quad will be the only one

Contraindications for E Stim?

Contraidications for E stim

• Pacemaker or implanted defibrillator

• Unstable arrhythmia

• Over areas where venous or arterial thrombosis or thrombophlebitis is present

• Seizures history

• Pregnancy – around abdomen or low back

• Placement over carotid sinus

• For muscle contraction- when contraction may disrupt healing (IE achilies tendon rupture stim will cause gastroc to contract and cause issues)

What should you do before preforming E stim?

•Wash hands

•Confirm which E-stim configuration is appropriate

•Screen for contraindications

•Set the unit for the appropriate parameters

•Explain procedure to patient *

•Position patient

•Inspect and clean skin, clip hair if necessary (no alcohol swab- reduced conduction)

•Check electrode wires

•Place electrodes on skin and attached lead wires

•Start treatment, slowly progress amplitude

•Upon completion (TURN OFF UNIT) remove electrodes, check skin, ask how it feels

What to know about electrode placement?

Do not place directly over bony prominences

• Poor adhesion = reduced effectiveness and greater risk of burns

Distance of electrodes affects depth and path of current

• closer = superficial

• Far apart= deep

•Document:

Area treated

•Patient position

•Specific stimulation parameters

•Electrode placement

•Treatment duration

•Patient response

Parameters for TENS conventional and placement and feel and time

Black device

• Superfical and large or small areas (EX upper trap guarding). No particular direction of electrodes

• Immediate but not long lasting

• Frequency 100 - 150 pps

• Pulse Dur: 50 - 80 ns (4000 Hz)

• Time: up to 24 hours

• Feel: slight tingling

Parameters for IFC conventional and placement and feel and time

Frequency

Pulse duration/carrier frrequency

time

feel

Large machine

• Deep and large (LBP or knee). Cross two channels

• Immediate but not long lasting

• Frequency 100 - 150 pps

• Pulse duration: Carrier frequency of 4000 Hz

• Time: up to 24 hours

• Feel: Slight tingling

Parameters for pre mod acupuncture and placement and feel and time

frequency

pulse duration/carrier frequency

time

feel

Large machine

• Deep and small (Ex rtc tendon). Configuration does not matter, just place on muscle belly.

• Not immediate but long lasting relief up to 5 hours

• Frequency: 2 - 10 pps

• Pulse duration: Carrier fq 2500 HZ

• Time: 20 - 30 minutes

• Feel: Visible muscle contraction w/o pain

Parameters for High intensity NMES and placement and feel and time

intensity

pulse width/duration

frequency

ramp

cycle

time

feel

Large machine

• Muscle contractions (On quad)

  

• prevent atrophy, decrease edema, increase strength

• Intensity: 50% of Maximum Voluntary Isometric Contraction (Say this verbally)

• Pulse width/duration: 400us

• Frequency: 50 - 75 pps (use 75 as its not as harsh)

• Ramp: 2 seconds

• Cycle: 10/50

• Time: 15 - 20 minutes every 2 - 3 hours. Needs 80% of LSI (80% of other leg range, test this passively

• Feel: Strong contraction, may be uncomfortable but necessary for future health