chiropractic assistants procedures program …...capp september 2019 10 mborc regulations 19 4.02:...

TOP EDUCATION LLC (c) 2019 9/20/2019

CAPP SEPTEMBER 2019 1

www.toolsofpractice.com

Chiropractic Assistants Procedures Program(C.A.P.P.)

Presenters:

Mark A, Davini, DC, DABCN, CPCOPaul Andrews, LMT, CCCA, CPCO

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T.O.P. Education, LLC

To provide reliable education, resources and tools of practice to advance your clinical expertise, business development and professional growth.

Mark and Paul

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Paul P. Andrews, LMT, CCCA, CPCOStarted as a Chiropractic Assistant

Began consulting for chiropractic offices

Began teaching seminars

Started Andrews Billing Solutions

MCS Valuable Service to the Chiropractic Profession Award

Membership Coordinator for the Massachusetts Chiropractic Society Inc. until 2009

Appointed to Mashpee, MA Board of Assessors

MCS Valuable Service to the Chiropractic Profession Award

Public Member, Massachusetts Board of Registration of Cosmetology

(Served as Board Chair from July 2013 – May 2015)

Vice Chair ‐ Board Member Massachusetts Board of Massage Therapists

(Served as Board Chair from 2015 ‐ 2019)

Co‐founded TOP Education, LLC with Dr. Mark Davini

Certified Chiropractic Clinical Assistant

Certified Professional Compliance Officer

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Mark A. Davini, DC, DABCN, CPCO1981 graduate of Palmer College of Chiropractic

24 years in active practice

Diplomate in Chiropractic Neurology

Certified Chiropractic Industrial Consultant

Certified Professional Compliance Officer

Past Chairman of the MA Board of Registration of Chiropractors

Mass Chiropractic Society, Vice‐President of Public Information and Education

Mass Chiropractic Society, Chairman of the Ethics Committee

Lecturer for various state and national associations continuing education programs to include chiropractors, nurses, dentists, theCouncil on Licensing, Enforcement and Regulation for the Commonwealth of MA, and 2nd and 3rd year medical students at theUniversity of Massachusetts Medical School.

Dr. Davini co‐developed and teaches the Chiropractic Assistants Procedures Program (C.A.P.P.)

Co‐Developer of TOP Education, LLC

Active in the defense of chiropractors involved in malpractice litigation.

Compliance Auditor/Clinical Monitor as well as a pattern practice analyst

Awarded 2 U.S. Patents on the “M‐Brace” for Carpal Tunnel Syndrome

Chiropractor of the Year by the Massachusetts Chiropractic Society in 1996.

“Doctor of the Year” by the Worcester County Chiropractic Society in 1987

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Our REMOTE COMPLIANCE OFFICER ASSISTANT (RCOA) makes compliance beyond easy; simply it is a no brainer…

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RCOA is only offered to TOP Education’s Privilege Members.

RCOA will provide you with a PERSONAL web page with YOUR COP program that can be viewed at any time.

RCOA will remove the need for extensive training. Leave it to the experts.

RCOA will set up and customize your STATE SPECIFIC COP manual.

RCOA will keep you on track. TOP Ed will CALL YOUR OFFICE MONTHLY to ensure current compliance.

RCOA eliminates searching and clicking to find what and how to do it.

TOP Ed will review all reports, Business Associate Agreements, forms, logs, receipts, training, and more…

TOP Ed will insert all updates and archives, no more CUT AND PASTE.

TOP Ed will maintain your State and Federal Exclusion list of employees.

And of course as a Privilege Member you will have access to us through the Privilege Member’s support email for all questions compliance related or not.

While you’re here…

No audio or video recording

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C.A.P.P. Course Schedule

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Day One

• Registration 7:30 am

• Start time 8:00 am

• Break (15 min) 9:30 am

• Lunch (on your own) Noon

• Resume time 1:00 pm

• Break (15 min) 3:00 pm

• End 5:00 pm

C.A.P.P. Course Schedule

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Day Two

• Start time 8:00 am

• Break (15 min) 9:30 am

• Lunch (on your own) Noon

• Start time 1:00 pm

• Break (15 min) 3:00 pm

• End 5:00 pm

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C.A.P.P. Course Requirements

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Complete 24 hours in class instruction

Complete 12 hours office Externship

Pass Examination

C.A.P.P. Externship Requirements

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1. 48 documented therapies

2. Forms for documentation are in your handouts

3. Requires the doctor's supervision and signature

4. Must be completed before Examination results are released

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C.A.P.P. Examination

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Exam will be 50 multiple choice, matching, & true/false questions.

You must pass with a 77% or better.

Certificates will be emailed in about two weeks from exam date.

‐ Enter your Name and Email address with iPad

C.A.P.P. Course Objective

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This course is designed to educate the basic principles of safe and effective assisting with common Supportive Procedures.

This course is not meant to teach the Chiropractic Assistants clinical decision making.

Operational parameters are under direction and supervision of the doctor who orders the service and ultimately has the final say.

This course is not meant to circumvent the doctor’s individual clinical process.

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C.A.P.P. Certification

“Make a life, not just a living”Unknown

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C.A.P.P. Topics

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Course and Certification

History

MBoRC Laws, Regulations, Policies ⌫Types of Chiropractic Assistants

Responsibilities

Definitions/Terminology

Anatomy and Physiology

Types of Care

Contraindications

Documentation

Instructions

Procedures and Protocols

⌫ indicates not on national test

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C.A.P.P. Course Supportive Procedures (most common to the chiropractic practice)

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Superficial Heat focus on Hot Moist Packs

Cryotherapy focus on Cold packs

Electrical Stimulation attended & unattended

Photo Therapy Low Level Laser Therapy

Deep Heat (diathermy) focus on Ultrasound

Mechanical Traction focus on Intersegmental

Therapeutic Exercise focus on how to assist

Neuromuscular Re‐Education focus on how to assist

History

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Founded on September 18, 1895

D.D. Palmer

Davenport, IA

First Patient‐Harvey Lillard

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CHIROPRACTIC(done by hand)

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A General Laws Chapter 112, Section 89 ⌫

“Chiropractic”, the science of locating, and removing interference with the transmission or expression of nerveforce in the human body, by the correction of misalignments or subluxations of the bony articulation andadjacent structures, more especially those of the vertebra column and pelvis, for the purpose of restoring andmaintaining health. It shall exclude operative surgery, prescription or use of drugs or medicines, the practice ofobstetrics, the treatment of infectious diseases, and internal examinations whether or not diagnostic instrumentsare used except that the X‐ray and analytical instruments may be used solely for the purposes of chiropracticexaminations.

Nothing in this definition shall exclude the use of supportive procedures and therapy, including braces, traction,heat, cold, sound, electricity, and dietary and nutritional advice, as treatment supplemental to a chiropracticadjustment.

MA Board of Registration of Chiropractors(MBoRC) ⌫

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MA Division of Professional Licensure

MA Department of Consumer Affairs

Enforces:

Laws, Regulations, Policies

Scope

Limitations

Division of Professional Licensure1000 Washington Street, Suite 710

Boston MA 02118‐6100617‐727‐3093

www.mass.gov/dpl

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MBoRC Regulations ⌫

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4.02: Definition and Use of Supportive Procedures and Therapies 1) For purposes of 233CMR4.00,the term "supportive procedures and therapies” means those modes of care which

may be administered, dispensed or prescribed in addition to the primary Chiropractic procedure (i.e., Chiropractic adjustments or techniques/manipulative techniques, as defined in M.G.L. c. 112, §§ 89, 94 and 97). Such supportive procedures and therapies include but are not limited to the use of braces, casting, supports, traction, thermal modalities, ultrasound, electrical modalities, hydrotherapy, myotherapy, dietary and nutritional advice and/or supplementation, and rehabilitative exercise therapy. The purpose of supportive procedures and therapies is to aid the chiropractor in assisting a patient to achieve a timely and favorable clinical outcome. A chiropractor shall not be required to apply supportive procedures and therapies in the practice of Chiropractic.

2) All decisions made by a chiropractor regarding the use of supportive procedures and therapies shall be predicated upon a properly documented clinical rationale which is consistent with present educational and practice standards. The details of all supportive procedures or therapies provided shall be recorded when performed.

3) The decision to use supportive procedures shall be based upon the clinical judgment of the chiropractor. Supportive procedures shall be used as a supplement to the primary Chiropractic procedure. However, if a chiropractor, in the reasonable exercise of his or her professional judgment, decides that a primary Chiropractic procedure is not prudent under the circumstances, he or she may properly apply any of the above supportive procedures or therapies for a reasonable time, if their use is clinically indicated and properly documented.

4) No supportive procedure shall be administered unless a duly licensed chiropractor is on the premises.

MBoRC Regulations ⌫

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4.03: Limits on Delegation of Patient Care Functions

1) A licensed chiropractor shall be responsible for all patient care provided by him or her, or by any of his or her agents or employees, and shall be responsible for any and all acts or omissions of such agents or employees.

2) A licensed chiropractor shall not delegate any clinical function for which licensure, registration or certification is required under any other applicable provision of state law or regulations to any person who does not possess the appropriate license, registration or certification required by said law or regulation.

3) A licensed chiropractor shall not delegate any of the following clinical functions to any person who is not duly registered to practice Chiropractic in the Commonwealth of Massachusetts:

(a) Performing any primary Chiropractic procedure as defined in 233 CMR 2.01: Definitions;(b) Initiating or altering any treatment plan or regimen without prior evaluation and approval by a licensed

chiropractor; (c) Modifying a specific treatment procedure without the prior approval of the licensed chiropractor; (d) Interpreting clinical data or rendering opinions about such data; or (e) Rendering opinions about a patient’s current status or prognosis.

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MBoRC Policy ⌫

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1) The patient must be properly evaluated by the licensed chiropractor and a determination made that a supportive procedure or therapy is clinically indicated before any supportive procedure or therapy may be applied to the patient by an unlicensed assistant during the same patient visit.

2) The licensed chiropractor must make all clinical decisions regarding the type of supportive procedure or therapy to be applied, the location to which such supportive procedure or therapy will be applied, and the duration and intensity of the supportive procedure or therapy where applicable.

3) The licensed chiropractor must generally supervise the unlicensed assistant in the application of any supportive procedure or therapy by being present on the premises and readily available to provide direction and guidance to the unlicensed assistant throughout the performance of the supportive procedure or therapy.

4) The licensed chiropractor must ensure that the assistant possesses a sufficient level of education and training in the application and use of the supportive procedure or therapy. The licensed chiropractor must maintain written documentation of the education and training possessed by each office assistant regarding the proper application and use of supportive procedures and therapies.

5) The licensed chiropractor must properly report and code any supportive procedure or therapy in a manner consistent with appropriate reporting and coding requirements.

“Chiropractic Supportive Procedures & Therapies performed by Chiropractic Assistants” #09‐002

MBoRC Policy ⌫

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Advertising in public media shall not include the use of the terms Physical Therapy or Physiotherapy.

“Physical Therapy or Physiotherapy” April 18, 1984

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Types of Chiropractic Assistants

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Administrative:

•Managerial/Compliance

• Reception

• Scheduling

• File Management

• Billing

• Bookkeeping

• Patient Relations

Types of Chiropractic Assistants

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Clinical:

• Clinical notes

• Patient preparation

• Application of Supportive Therapies

• Assist in physical Examinations

• Discharge (check out) for the visit

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Delegation / Respondent Superior

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Liability falls with the Doctor

Always stay within your training

Professionalism:

• Chiropractic is a profession, not a job• Put patients first• Look for chances to improve your patients experience• Relationships are important and influence the patients outcomes• Be proud of your work, patients notice

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Teamwork:

• Teams understands Purpose

• Teams Communication is H.O.T. (Honest, Open, Two‐Way)

• Teams are proud of their work

• Teams respect each other• Teams create an atmosphere of trust, confidence and healing

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Use of Authority :

• Relationship between the CA and the doctor has an important influence on the patient and outcome of chiropractic care

• Relationship between the CA and the patient has an important influence on the patient and outcome of chiropractic care

• Creates an atmosphere of trust and confidence

• Protects the confidential nature of the caregiver‐patient relationship

• The CA should consider the patient to be their partner in the care process

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Patient Relationship:

• CAs are caregivers and therefore must be compassionate and sensitive to the patient’s needs while recognizing the importance of good communication skills

• Provide appropriate and understandable explanations and instructions

• Recognize and respond to patient feedback and questions and concerns

• Recognize significant non‐verbal signs and behaviors exhibited by the patient

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Confidentiality:

• Be aware of the confidential nature of the Caregiver‐Patient relationship (Use of Authority)

• Observe all HIPAA (not HIPPA) rules and regulations• NEVER discuss patient treatment with anyone who is not authorized

Example:o Verifying benefits within earshot of other patients or other peopleo Booking diagnostics for a patient within earshot of others

o Talking about a patient within earshot of others

o JUST THE FACT A PATIENT IS A PATIENT IS CONFIDENTIAL

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Knowledge and Experience:

• Know Chiropractic• Experience Chiropractic• Appreciate Chiropractic• Get adjusted regularly• If patients knew what you know would they ever debate regular care

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Acceptance:

Question: If a patient leaves your office, who is responsible?Answer: You (the office) are a 100% responsible if a patient stays or goes

• But that may be OK, sometimes they need or want something you are unwilling or unable to give

• Sometimes it just happens

• In all cases, assess the reason and decide if changes need to be made

• BUT, remember you do not have to be everything to everybody

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Patient Comfort:

• Be careful of hair and jewelry on both patient and CA

• Proper draping

• Room temperature

• Site Integrity ‐ Five Sense TX space

• Equipment integrity

• Emergency notification defined

Hygiene:

• Maintain a clean environment• What is the “germiest” part of a doctor’s office?

1. Clipboard pen has 46,000 times more germs than anything else.2. Doctor’s Keyboard.3. Reception room arm rests on chairs.

• New standard is BBE = Bare Below Elbow ‐ No watch, No jewelry, etc. • Proper hand sanitation• Wear gloves ‐ whenever there is a possibility of coming in contact with

blood or other potentially infectious materials• Dispose of all contaminated personal protective equipment in an

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Proper Glove Removal:

1. Pinch and hold the outside of the glove area by the wrist;

2. Pull downward away from the wrist and turn inside out;

3. Pull all the way off and place in palm of the other gloved hand;

4. With your ungloved hand slide two fingers under the wrist of the gloved hand careful not to touch the outside of the glove’

5. Peel downward over the palm with the other glove in it; and

6. Continue to pull the glove off with the other glove inside it and dispose of properly.

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Safety:

• Do you know CPR• Do you know where the First‐Aid Kit is and how to use it• Do you know where the Fire Extinguishers are and how to use them• Do you know how to operate an AED?(Automated External Defibrillator)• Do you know your Emergency Action Plan:

o Local emergency numbers areo Electrical shut off for the X‐Ray iso Emergency exitso Emergency Coordinator, etc.

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Boundaries:

• Respect for boundaries is the framework of successful patient interaction

• Attitude and demeanor, e.g. subliminal messages

• Be aware of patient apprehension• You may know what to expect but they may not

• Avoid statements and physical responses that may exacerbate concern, e.g. “oops”, “OMG that’s bad”

• Leave your problems outside the office

• Keep the conversation on the patient and their care• Stay focused and in present time consciousness

• Avoid controversial topics37

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Boundaries/Space:

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Boundaries:

Boundaries/Touching:

• A patient grants you permission to enter their personal space

• You must not abuse the privilege

• The influence of being an authority is more than you imagine

• Be aware of hand placement at all times

• Use as few fingers as necessary to perform function

• Patients feel vulnerable when face down and/or in a gown

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Boundaries/Improper Comments:

Three Strike Rule:Strike 1 Overlook/Ignore, make doctor aware

Strike 2 Make clear statement of inappropriateness, make doctor aware

Strike 3 You're out ‐ leave and get Doctor

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Boundaries/Improper Touching:

One Strike Rule:

You are out and get the doctor immediately!

Communication:

“The imparting or exchanging of information.”

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Listen –This is the ground floor of all effective communication

Care

Compromise if needed Only to a point

Stay calm

Ask Questions

Be Realistic with Promises

Use Resources

Be Positive and Appreciative

Steps to Effective Communication:

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Communication Assumptions:

• Whenever two people are together they are communicating

• The next message you send will be misunderstood

• Communication is not a simple exchange of words, there are text and subtext

• The meaning of a word is not always found in a dictionary

• Skills are learned

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Skills:Some Assembly Required…

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Communication Cautions:

• Again be aware of the unique nature of the Caregiver‐Patient relationship (Use of Authority)

• Again observe all HIPAA (Not HIPPA) rules and regulations

• Honesty is essential, but at the same time you must be skillful

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Verbal Communication

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Verbal = All forms of language transmission, not just oral.

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• 2% are actual words: Scripting Language Phrases

• 7% Tone: Loud Talkers Inflection ‐ Is the inflection inquisitive, suggestive or assaulting Same words different meaning

• 11% is Body Language:

Close Talkers ‐ Space Invaders Arms crossed ‐ Closed mindedness Finger Pointing – Comes across as bossy

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Scripting: A word about words….

• The purpose is to remove interference between you and your patients

• Ensures complete and consistent communication

• Ensures all patients receive the same info

• Efficient and effective

• Some say “Its not me”

• It is not about you, it is about the patient

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Scripting Examples:

• Common phrase on the first call, patient calls and states they want to make an appointment.

Could say: When was the last time you were in to see the doctor?

• If the patient states they never saw the doctor you know they are a New Patient

• If they say it has been a while, you know they may be a reactivation and may need an update exam

• Avoids the chance of not knowing someone you should recognize

• Avoids scheduling errors

• Allows for accurate quoting of time and fees

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Scripting Examples Continued:

• Common phrase: Dr. wants to see you…

This implies the doctor needs to see the patient, opposite of the truth

Could say: You will need to see the doctor in …

Places the concept in their minds the care is for them

• Common phrase: What time do you want?

This gives them an open book, and that rarely works in a busy practice

Could say: Would you prefer morning or afternoon, earlier or later?

This avoids a lot of back and forth

Direct them to where you want them in your schedule

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Scripting Language Cautions:

Jargon/Slang If not in a dictionary use caution

Idioms Peculiar to a group, “bubbler” instead of “water fountain”

Profanity Don’t use these “ x*#%v” words

Chiropractic Specific Phrases Terms need to be useful and understood

Red Flag Words “LISTEN”‐Telling someone what to do

Vague or Abstract Language “Kinda” ‐ is it or isn’t it

Overly Complex Words Too “MAGISTERIAL & SENTENTIOUS” for example

Too many repeated Clichés’ “At the end of the day”

Euphemisms Negative impression words “SWEAT instead of PERSPERATION”

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Scripting Phrases:

Negative Positive

Waiting room Reception roomOld patient Established or regular patientDoctor is running late Doctor had an interruption in scheduleCancellation Change in scheduleYou missed an appointment We had you in our bookDoctor is at a convention Doctor attending post‐graduate seminarGirl/Guy at the front desk Use name of assistantPay for Take care ofThat will be 35 dollars please That will be 35 please

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Non‐Verbal Communication

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Non‐Verbal:

Messages received through our sensesusually within the first 3 seconds without knowing = Subliminal

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Subliminal: Messages are below threshold of consciousness and awareness?

• What do your clothes say• Where are your eyes• Body Language• Environment:

o Musico Printed materialso Posterso Temperatureo Colorso Patterns/Symmetryo Smellso Textureso Sanitationo Web Site

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What do you mean:

• Messages are transmitted through combination of both verbal and non‐verbal

• Collectively this is your office choreography, you are the lead• Ask your self, are you saying what you intend to say? • Saying one thing and preach another?

(Example: preach wellness but all office materials are about pain relief?)

• Make sure your text and subtext are congruent

• How often do you and the staff (including the doctor) get checked. • You can’t expect a patient to do more than you

• Keep it simple

Verbal & Non‐Verbal Communication

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Communication

Technique:

• Use patient’s first name only if they prefer it, ask…

• Smile and make eye contact

• Firm handshake

• Care about their needs, remember it is not about you

• You should know more about them than they do about you

• Inform them of the time expectations

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Communication

Technique:

1. Tell them what you going to do

2. Tell them why you are doing it

3. Tell them how you are going to do it

4. Tell them what you have done

5. Ask if they have any questions or concerns

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Communication

Consent:

Implied Consent

General Consent

Informed Consent

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Definitions/TerminologyCommon Prefixes

a‐ withoutcontra‐ againsthyper‐ increasedhypo‐ decreasedinfra‐ belowinter‐ betweenIntra‐ withinpara‐ besidepre‐ beforepost‐ aftersub‐ under/less thansupra‐ aboveultra‐ beyondosteo‐ bonemyo‐ musclearthro‐ jointpatho‐ diseaseneuro‐ nerve

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Definitions/TerminologyCommon Suffixes

‐algia pain

‐itis inflammation

‐ology study of

‐opathy disease

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Definitions/TerminologyCommon Abbreviations

Hx History

Sx Symptom

Ex Examination

Dx Diagnosis

Px Prognosis

Tx Treatment

Rx Prescription

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Definitions/TerminologyCommon Terms

acute sharp, severe, recent

chronic long term/constant

antalgic posture or gait to avoid pain

cavitation popping sound with osseous adjustments

Chiropractor of Record DC responsible for facility ⌫Compliance Officer person responsible for compliance program

contraindications not clinically appropriate

extremity The end of something ‐ arm or leg

homeostasis balance of body systems

diagnosis determining disease/named disease

impression probable diagnosis

prognosis expected recovery

palpation to examine by touch

inspection to examine by observation

radiograph x‐ray

strain tendon/muscle injury

sprain ligament/joint injury

hypertonicity increased muscle tone

hypotonicity decreased muscle tone

spasm involuntary forceful contraction

somatic external structure/frame

visceral internal organs

treatment procedure/protocol to effect positive change

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Definitions/TerminologyPositions and Directions

Anterior/Ventral toward the front

Posterior/Dorsal toward the back

Medial toward the middle

Lateral toward the side

Bilateral both sides

Coronal toward the head

Caudal toward the bottom‐tail

Superior above

Inferior below

Proximal closer to the midline

Distal farther away from the midline

Erect standing

Supine lying flat face up

Prone lying flat face down

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Definitions/TerminologyJoint Movement

PronationSupination

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Circumduction

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Abduction Adduction

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Definitions/TerminologyICD‐10 Diagnosis Coding

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International Classification of Diseases 10th version:

M99.0x ‐ Biomechanical lesions, not elsewhere classified:

Includes segmental and somatic dysfunctionM99.00 – Head Region Depends on jurisdictionM99.01 – Cervical RegionM99.02 – Thoracic RegionM99.03 – Lumbar RegionM99.04 – Sacral RegionM99.05 – Pelvic Region

According to Medicare the above represent the chiropractic subluxation

M99.06 – Lower extremitiesM99.07 – Upper extremitiesM99.08 – Rib CageM99.09 – Abdomen and other

Definitions/TerminologyProcedure Coding (CPT)

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HCPCS ‐ Healthcare Common Procedure Coding System

CPT ‐ Current Procedural Terminology

“CPT® is a registered trademark of the American Medical Association”

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Primary Procedure:

1. Chiropractic Adjustment

Supportive Therapies:

1. Modalities (gadgets): Purpose‐to improve sign or symptom

• Supervised No Direct One‐on‐One patient contact required

Not a timed procedure

• Constant Attendance

Requires Direct One‐on‐One patient contact

Timed

2. Therapeutic Procedure: Purpose‐to improve function• Requires Direct One‐on‐One patient contact

• Timed

Evaluation and Management (E/M):

1. Examinations‐Consultations


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Evaluation and Management ‐ E/M (Examinations):

New Patient E/M Codes:99201 – Limited

9902 – Expanded

99203 – Detailed

99204 – Comprehensive.

99205 – Complex

Established Patient E/M Codes:99211 – Minimal

99212 – Limited

99213 – Expanded

99214 – Detailed

99215 – Comprehensive

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Definitions/TerminologyProcedure Coding (CPT )

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Chiropractic Manipulative Therapy:98940 – Spinal, one to two regions

98941 – Spinal, three to four regions

98942 – Spinal, five regions

Modalities – Supervised:97010 – Hot or cold pack

97012 – Mechanical traction

97014 – Electric stimulation (unattended)

97018 – Paraffin bath

97024 – Diathermy

Modalities ‐ Constant Attendance:97032 – Electric stimulation Attended (manual component)

97035 – Ultrasound

97039 – Unlisted modality

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Therapeutic Procedures:97110 – Therapeutic Exercises

97112 – Neuromuscular Reeducation

97116 – Gait training

97124 – Massage

97139 – Unlisted Therapeutic Procedure

97140 – Manual Therapy Techniques

Other:

99070 – Supplies and materials


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Definitions/TerminologyProcedure Coding (CPT and/or HCPCS)

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The 8 minute rule/units


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Bundling v. Unbundling

UnbundlingRationale is for an accepted and non duplicative service

BundlingRationale is for an unaccepted, duplicative or tangential service

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One on OneServices must be performed by a doctor

or other licensed qualified health care provider

Definitions/TerminologyTypes of Chiropractic Patient Management

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Disease/Condition TreatmentDisease/Condition Treatment commonly utilizes Supportive Therapies & Procedures

Health/Wellness/Maintenance CareHealth/Maintenance Care does not routinely utilize Supportive Therapies

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Definitions/TerminologyHealth v. Disease/Condition

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Health is the optimal physical, mental, and social well‐being;

not simply the absence of disease/condition

Disease/Condition (lack of ease) an organ or system that has a loss of physiological balance (homeostasis) causing malfunction, i.e. functions too much or too little

Definitions/TerminologyFive Aspects of Health

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1. Rest

2. Exercise

3. Nutrition

4. Positive Mental Attitude

5. Sound Nervous System

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Definitions/Terminology Science, Art and Philosophy

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Chiropractic Profession:

Science Anatomy and physiology of the human body

Art Techniques of location & removing subluxations

Philosophy The belief the body has the power to heal itself

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Definitions/Terminology Chiropractor

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1. Doctor of Chiropractic (D.C.)

2. Chiropractor

3. Chiropractic Physician

No such words as:

Chiropractry

Chiropractics

Chiropracty

Definitions/TerminologyAdjustment/Manipulation

Chiropractic Manipulative Therapy

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• Adjustment Treatment procedure to remove/reduce subluxations of the spine and associated structures

• Manipulation Common synonym for adjustment, also used by Osteopaths

• CMT Medicare's term for adjustment Chiropractic Manipulative Therapy

• Mobilization General movement of joints commonly performed by P.T.s

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Definitions/TerminologyAdjustment Techniques

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1. Osseous ‐Manual ‐ commonly popping

2. Mechanical ‐Drop Tables ‐ specialized table

3. Instrument ‐Impact Devices ‐ specialized tools

4. Soft tissue ‐Pressure Protocols ‐ with breathing assist

Above may be utilized in combination and with varied amounts of force.


1. Misaligned vertebra

2. Causing nerve interference

3. Resulting in altered function

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General Anatomy

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Anatomy

Anatomy = Greek for "dissection”, the branch of biology concerned with the study of the structure of organisms and their parts.

Gross Anatomy = that which can be seen by the naked eye

Microscopic Anatomy = can only be seen with a microscope

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General AnatomyBody Planes

Sagittal divides left and right where ever

Median or Mid‐Saggittal divides left and right equally

Frontal divides front from back

Transverse divides upper from lower

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General AnatomyBody Planes

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General AnatomyAnatomical Position

• Body erect• Eyes forward• Arms at side• Palms forward• Feet forward

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General Anatomy11 Organ Major Systems

1. Nervous: Master controller. Maintains homeostasis. Computer of the body andWiring connecting brain to the body and the body to the brain.

2. Circulatory: Transports substances throughout body via arteries, veins, and heart.

3. Lymphatic: Transports lymph fluid throughout the body.Removes excess fluid. Fights infection.

4. Respiratory: Brings Oxygen to the blood.

Removes Carbon Dioxide.

5. Skin/Integumentary: Protects, regulates, and senses environment (largest).

6. Endocrine: Secretes and regulates hormones.

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General Anatomy11 Organ Major Systems

7. Digestive: Breaks down food.

Absorbs nutrients.

Removes solid waste.

8. Urinary: Cleans and balances the blood chemistry.

Removes liquid waste.

9. Reproductive: Produces and facilitates procreation.

10. Muscular: Creates movement.

11. Skeletal: Support.Movement. Protection, Production of RBCs. Storage of minerals. Structure of the body.Hormone regulation (glucose regulation).

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Skeletal Anatomy

206 bones in the human skeleton

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Skeletal Anatomy

• Bone rigid connective tissue

• Cartilage tough flexible inelastic connective tissue lining joints

• Tendon tough flexible inelastic fibrous connective tissue that connects muscle to bone

• Ligaments tough flexible elastic fibrous connective tissue that connects bone to bone

• Skeleton pectoral and pelvic girdles and extremities

• Articulations area where two or more bones meet.

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Skeletal Anatomy

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Skeletal AnatomyCommon Names Anatomical Name/LocationHead Skull

TMJ Temporo‐Mandibular Joint

Adam’s Apple Thyroid Cartilage

Collarbone Clavicle

Wing Bone/Shoulder Blade Scapula

Breast Bone Sternum

Funny Bone Medial epicondyle of elbow with nerve

Hip Joint Articulation of femur head (ball) and acetabulum (socket)

Hip Bone Iliac crest of each ilium (just below waist)

Kneecap Patellar

Thigh Femur

Shin Bone Tibia

Arch of Foot Plantar surface (bottom of foot) that is arched

Heel of Foot Calcaneus

Joints Articulations99

Skeletal Anatomy

Articulations (joints):

There are 3 classes of articulations:1. Immoveable (maybe minor movement). Bony surfaces that are almost in direct

contact with only connective tissue in between. Example is the skull2. Slightly movable joints. Two bony surfaces unites by cartilage. e.g. symphysis pubis.

Example is the Symphysis Pubis of the pelvis3. Freely Movable. Boney surfaces that are limited in motion by ligaments. Example is

the fingers, hip

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Clavicle

Scapula

Humerus

Radius

Ulna Hand

Arm

Forearm

Skeletal Anatomy

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Skeletal Anatomy

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Thigh

Leg

Foot

Knee Joint

Skeletal Anatomy

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Skeletal Anatomy

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Normal

KyphosisPosterior/Backward Curve

LordoticAnterior/Forward Curve

Skeletal AnatomyCurves

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Scoliosis:Lateral/Sideways Curve

Skeletal AnatomyCurves

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Spinal Anatomy

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Spinal Anatomy

Spinal Column 31+ bony segments of the spine

Vertebra bony segment of the spinal column

Vertebrae plural of vertebra

Occiput (CO) base of the skull

Cervical neck area

Atlas (C1) first cervical vertebra

Axis (C2) second cervical vertebra

Thoracic (dorsal) mid back area

Lumbar low back area

Sacrum base of spinal column

Coccyx tailbone

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Spinal AnatomyAreas

Area # of Segments Designation

Cervical 7 C1 to C7

Thoracic 12 T1 to T12

Lumbar 5 L1 to L5

Sacral fused 5 S1 to S5

Coccyx 2 to 4

______________________________________________

Total 31 to 33

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Cervical Vertebrae

Spinal AnatomyAreas

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Thoracic Vertebrae

Spinal AnatomyAreas

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Lumbar Vertebrae

Spinal AnatomyAreas

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Spinal AnatomyAreas

Side:Right LeftBilateral

Levels:

upper middle lower

C1 to C2 C3 to C5 C6 to C7

T1 to T4 T5 to T8 T9 to T12

L1 to L2 L3 to L4 L5 to S1

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Spinal AnatomyPelvis

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Spinal AnatomyPelvis

Symphysis Pubis

1 Ilium2 Pubis3 Ischium4 Symphysis Pubis

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Spinal AnatomySacrum

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Spinal AnatomySacro‐Iliac Joint

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Spinal AnatomyCoccyx

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Vertebral Anatomy

ATLAS

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Vertebral AnatomyCO (Occiput) ‐C1 (Atlas)

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Vertebral AnatomyC1 (Atlas) ‐ C2 (Axis)

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Vertebral AnatomyHead Rotation

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Vertebral Anatomy

Vertebral Body

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Vertebral Anatomy

Processes

Transverse Process

Spinous Process

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Vertebral Anatomy

Facet Joints

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Vertebral Anatomy

Foramen

Spinal Canal

IntervertebralForamen

IVF

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Vertebral Anatomy

Intervertebral Disc

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Vertebral Anatomy

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Vertebral Anatomy

Herniated Disc = (Displacement of disc material beyond the interspace.)

• Protruded (contained), (slipped)

• Extruded (non‐contained), (ruptured)

The term “prolapse” has been use to refer to either

without specifying which one this term is too ambiguous.

Best to avoid use of the term prolapse altogether.

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Vertebral Anatomy

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Vertebral Anatomy

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Vertebral Anatomy

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Vertebral Anatomy

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Vertebral AnatomyMotor Unit

2 vertebrae ‐ 1 disc ‐ 2 nerves left and right

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Vertebral AnatomyDegeneration

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Nervous System

• Master Controller of all other aspects of the body

• Function is to maintain balance (homeostasis)

• Interference results in too much or too little function

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Nervous System

Brain and Spinal cord make up the Central Nervous System (CNS)

Nerves from the spinal cord that that exitthe spine through the intervertebral foramenand go to the rest of the body make up the Peripheral Nervous System (PNS)

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1. Misaligned vertebra

2. Causing nerve interference

3. Resulting in altered function

Altered function means too much or too little,

i.e. dis‐ease/condition139

SubluxationFive Components

1. Joint movement too much or too little‐ altered function

2. Muscle movement too much or too little ‐ altered function

3. Hard tissue Wear & Tear too much or too little ‐ altered function

4. Soft tissue Wear & Tear too much or too little ‐ altered function

5. Nerve interference too much or too little – altered function

Chiropractic Adjustments treat all five components.

Supportive Therapies assist the Chiropractic Adjustment in treating one or more of the five components of a subluxation.

If Supportive Therapies are extensively utilized without a Chiropractic Adjustment it approaches Physical Therapy.

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Muscle Anatomy

Types:1. Cardiac/Heart2. Smooth/Organ3. Striated/Skeletal

• Skeletal Muscles move the body.

• Simply, there are 2 places that muscle connect: 1. Origin – Source generally fixed position2. Insertion ‐ Attachment point – part being moved.

• Most muscles are deep to other muscles.

• Muscles are usually named after look or location.

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Muscle Anatomy

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Prime Mover: muscle that carriers out an action

Synergist: muscle that supports the prime mover

Antagonist: muscle that performs the opposite action of the prime mover and synergist muscles

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Muscle Anatomy

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Prime Mover Antagonist

Muscle AnatomySternocleidomastoid (SCM)

Side to front of neck

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Muscle AnatomyTrapezius

Triangular shaped muscle over the neck and midback

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Muscle AnatomyRhomboids

Muscle connecting shoulder blade to the vertebrae

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Muscle AnatomyParaspinals Muscles Along side the spine

Connect to vertebrae to vertebrae and ribs

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Muscle AnatomyLatissimus DorsiUnder the arms

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Muscle AnatomyQuadratus Lumborum

Top of Ilium to transverse processes of lumbar vertebrae

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Muscle AnatomyGluteals

Buttock Muscles

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Muscle AnatomyDeltoid

Top of the ShoulderArm Abduction

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Muscle AnatomyBiceps

Forearm Flexion

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Muscle AnatomyTriceps

Forearm Extension

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Muscle AnatomyHamstringsHip ExtensionKnee Flexion

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Muscle AnatomyQuadriceps

Knee Extension

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Muscle AnatomyGastrocnemius

Leg FlexionFoot Plantar Flexion

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Muscle Anatomy

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Muscle Anatomy

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Muscle Anatomy

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What is X Ray?

Non‐IonizingIonizing

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1. In MA CAs cannot take X‐Rays.

2. Primary importance is patient safety.

3. All female patient must be asked:

“Is there a chance that they are pregnant?”

4. Proper Informed Consent.

5. Use lead shielding to cover areas not needing exposure.

6. Proper instruction to patient, e.g. remove all metal.

7. Proper room protection.

8. Proper use of exposure badges.

9. Equipment properly maintained.

X Ray

Phases of Condition Treatment

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1. Relief acute/highest pain / least function most therapies/most frequent

2. Therapeutic repair/less pain/improved functiondecreased therapies/decreased frequency

3. Rehabilitative healing/little to no pain/most functionminimal to no modalities, some therapeutic procedure/less frequent

4. Supportive chronic management/MMIno therapies/least frequent

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Phases of Condition Treatment

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Phase of Condition Treatment is defined by the DC and

may determine if the services are bundled or unbundled.

• Is the goal/rationale non‐duplicative?

• Is it a Modality or Therapeutic Procedure?

• If Modality is it Supervised or Constant Attendance?

• If Therapeutic Procedure is it One‐on‐One?

• Is it timed based?

CAs need to Know!

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• Contraindications

• Instructions

• Documentation requirements

• Location of First‐Aid kit

• Emergency Procedures

• Your Patient

• X‐Ray Safety

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ContraindicationsCommon to All Therapies

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Absolute: Common for all. e.g. EMS over pace maker

Relative: Specific to the individual patient/condition/past reaction,e.g. ultrasound on pregnant patient

ContraindicationsCommon to All Therapies

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Application of a therapy against contraindications may sometimes apply. This is referred to as “off‐label” use and requires a higher level of knowledge and expertise and carries a greater risk. CAs should never perform Supportive Therapies against contraindications.

The DC must perform all services that are utilized for off‐label rationales.

For purposes of this course the common contraindications for all are:

1. Sensitivity to agent2. Pregnancy3. Children under 104. Area of numbness or decreased sensation5. Open wounds, rashes, burns6. Over heart, head / brain7. Over internal or external implanted devices8. Cancer

Never mate with the eight!

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InstructionsCommon to All Therapies

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P.E.A.C.E. of mind:

P rotocol inform patient of protocol

E xperience inform patient what they will feel

A lterations inform patient about changes in feeling

C omfort inform patient that it should always be comfortable

E mergency inform patient of emergency protocol bell/buzzer, shut‐off switch and/or procedure

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DocumentationCommon to All Therapies

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S.O.A.P.• Subjective Patient presented information

• Objective Doctor derived information

• AssessmentConclusions from above

• Plan Treatment specifics /goals/expectations recommendations

CA Supportive Therapy Notes are in the “P” Section.

L ‐ Location side, area, level

I ‐ Instructions/Informed Consent pt. instructed & consented to Tx

S ‐ Settings time, intensity, frequency etc.

T ‐ Time actual stop and start time

D ‐ Discharge Status “pt. tolerated tx w/o incident”

C ‐ CA Identification signature or initials‐legible

Use of standard abbreviations are allowed.

Use of unique in‐office abbreviations should not be use.


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Vitals

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Gender (M‐F):

• Report male or female or Unspecified

Height (Ht.):

• Report in inches

• Normal based on age and gender

• Inches (in.) or Centimeters (CM) “

Weight (Wt.):

• Report in pounds

• Normal based on age, gender, and Ht.

• Pounds (lbs.)

Vitals

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Respiration:• Report in breaths per minute• Report rhythm• Normal based on age• Adult at rest = 12 to 18 BPM• Breathes per minute /regular

Temperature (temp):• Report in degrees Fahrenheit or Celsius• Normal at rest = 98.6 ° F• °F or °C

Pulse/Heart Rate:• Report beats per minute. • Normal based on age and condition.• Adult at rest = 60 to 100 bpm• Beats per minute (bpm)

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Vitals

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Blood Pressure (BP):

• Report systolic/diastolic in millimeters of mercury. (mmHg)

• Report in even numbers.

• Normal based on age.

• Normal at rest = 118/78 mm Hg to 126/84 mm Hg

Supportive Procedures

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Supportive Therapies:

1. Modalities (gadgets): Purpose‐to improve sign or symptom

• Supervised No Direct One‐on‐One patient contact required

Not a timed procedure

• Constant Attendance

Requires Direct One‐on‐One patient contact

Timed

2. Therapeutic Procedure: Purpose‐to improve function• Requires Direct One‐on‐One patient contact

• Timed

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Cryotherapy (Cold)

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Types:

1. Wet Immersion

2. Cryo‐Chambers

3. Vapor Sprays

4. Wet Packs

5. Dry Packs used by most practitioners

Cryotherapy (Cold)

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Use of Cryotherapy throughout all phases is acceptable however rationale as an unbundled service generally does not exceed Relief Phase without documentation of special circumstances.

• Rationale competes with other “modalities” (except for decreasing circulation)

• Modality ‐ Supervised

• Not One‐on‐One

• Not time based

• CPT ‐ 97010 – Application of a modality to 1 or more areas; hot or cold packs

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Cryotherapy (Cold)

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Effects:

• Decreases local circulation (only therapy that does this)

• Decreases muscle tension

• Decreases inflammation and/or edema

• Decreases pain

• Pre‐adjustment relaxation

Cryotherapy (Cold)

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Contraindications:

Never mate with the eight!1. Sensitivity to Cryotherapy

2. Pregnancy

3. Children under 10

4. Area of numbness or decreased sensation

5. Open wounds, rashes, burns

6. Over heart, head / brain

7. Over internal or external implanted devices

8. Cancer

Specific to Cryotherapy:Fair or sensitive skin

Circulatory disorders

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Cryotherapy (Cold)

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Procedure & Protocol:

Review file for any contraindications

Check equipment (if ice pack, check for leaks)

Check temperature

Patient position: Expose area to be treated Inspect area for any rashes, wounds etc.

Observe area to be treated

Determine size of pack

If wet technique is used; rinse towel under cool water and ring out

Wrap Cold Pack with dry or wet towel

State Instructions

Cryotherapy (Cold)

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Instructions:

P.E.A.C.E. of Mind

Protocol inform patient of protocol

Experience inform patient that they will feel cold

Alterations inform patient that the temperature will decrease

Comfort inform patient that it should always be comfortable

Emergency inform patient as to location of emergency bell/buzzer and if uncomfortable to ring bell/buzzer or call out ASAP

Proceed to Application

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Cryotherapy (Cold)

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Application:

1. Place pack on towels2. Question comfort level3. Set timer 4. Return and check area after 3 to 5 minutes5. Add towels if needed6. After designated time remove packs, place contact towels in laundry7. Inspect treated area8. Document response, time, location

Nevers:

Never have patient lie on packs Never place on patient without a towel Never use against contraindications

Cryotherapy (Cold)

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Monitoring Procedure:

• Have an emergency protocol, e.g. bell or buzzer for patient to ring if needed

• Check patient after 3 to 5 minutes then every 5 to 7 thereafter

Negative Response/Reaction:

• if skin appears frosted remove pack ASAP

• if skin appears excessively red or blistering remove pack ASAP

• if patient complaints of a burning sensation

• if patient complains of increased pain

• Get the doctor

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Cryotherapy (Cold)

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CA Documentation (L.I.S.T. D.C.): CA portion of Supportive Therapy Notes are in the “P” Section

Location to include side, levelInstructions Informed ConsentSettings layers of towels‐wet or dryTime start and end timeDischarge Status post therapyC A Identification Mary Jones, CA

“Patient informed of Cryotherapy and consented to treatment.”Bilateral Mid to Lower Lumbar

2 dry towel layerTime 1:30p‐1:45p

“Patient tolerated treatment w/o incident.”Mary Jones, CA

Body Temperature

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Procedure for Taking Oral Temperature:

May be taken in multiple location‐oral, rectal*, axillary, temporal, auricular.

May use thermometer that needs to be inserted or hand held instrument that measure radiate heat off skin surfaces.

Most common location is oral or forehead:

1. Clean hands

2. Remove thermometer from storage container

3. Clean thermometer

4. Shake down to lowest mark

5. Place under tongue, leave in place for minimum of 3 minutes

6. Remove and record number

7. Re‐clean, shake down and replace in storage container

8. If Temperature is greater than 98.6 ° F, inform doctor if not WNL

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Superficial Heat

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Types:

1. Convection travels through affected medium e.g. Whirlpool

2. Radiation travels through unaffected medium e.g. infra‐red lamps

3. Conduction direct contact skin to heat E.g. Heating Pads, Paraffin Baths, HMP The most common is Hot Moist Packs (HMP) HMP = routinely from a hydrocollator

All types of Superficial Heat carry the risk of skin burns.

Superficial Heat

186

Use of Superficial Heat (especially HMP) Therapy throughout all phases is acceptable however rationale as an unbundled service generally does not exceed Therapeutic Phase without documentation of special circumstances

• Rationale competes with other “modalities”



• Not time based

• CPT ‐ 97010 – Application of a modality to 1 or more areas; hot or cold pack

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Superficial Heat

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Effects:

• Increases local circulation



• Promotes healing

• Decreases pain


Superficial Heat

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Contraindications:

Never mate with the eight!1. Sensitivity to Superficial Heat

2. Pregnancy






8. Cancer

Specific to Superficial Heat: Acute severe inflammation

Fair or sensitive skin

Patients with fever

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Superficial Heat

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Review file for any contraindications Check equipment Check temperature

should be between 125 and 155 degrees Patient position:

Expose area to be treated Inspect area for any rashes, wounds etc.

Observe area to be treated Determine size of pack and towel layers needed based on patient and conditions

minimum 6 towel layers Holders generally count for 4 layers (check manufacturer) if holder is used add 2 towel layers to equal 6 total If only towels use cross method

State Instructions

Superficial Heat

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Instructions:

P.E.A.C.E. of Mind


Experience inform patient they will feel warmth

Alterations inform patient temperature will increase


Emergency inform patient as to location of emergency bell/buzzer and if uncomfortable to ring bell/buzzer or call out ASAP


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Superficial Heat

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Application:

1. Remove Hot Pack from hydrocollator unit away from patient

2. Place pack in holder / on towel layers

3. Place on patient

4. Question comfort level

5. Set timer

6. Return and check area after 3 to 5 minutes

7. Add towels if needed

8. After designated time remove packs, replace in unit, and place towels that had contact with patient in laundry

9. Inspect treated area

10. Document response, time, location

Nevers: Never have patient lay on packs Never use less than 6 layers If a Heating Pad never fold Never use against contraindications

Superficial Heat

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• Have an emergency bell or buzzer for patient to ring

• Check patient after 3 to 5 minutes then every 5 to 7 thereafter


• if skin appears excessively red or blistering remove pack ASAP


• If patient complains of increased pain

• Get the doctor

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Superficial Heat

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Location to include side, level

Instructions Informed Consent

Settings layers of towels

Time start and end time

Discharge Status post Therapy

C A Identification Mary Jones, CA

“Patient. informed of MHP therapy and consented to treatment.”Bilateral Mid to Lower Lumbar

6 towel layersTime 1:30p‐1:45p


Blood Pressure

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Blood Pressure (BP): Pressure in arteries only (not veins)

Systolic: Maximum pressure ‐ heart beat/contraction

Diastolic: Minimum pressure ‐ heart relaxes between beats

Hypertension: High blood pressure

Hypotension: Low blood pressure

BP Cuff: Inflatable portion of instrument

Sphygmomanometer: Meter portion of instrument in mm Hg

Stethoscope: Listening device that magnifies sound

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Blood Pressure

195

Procedure Blood Pressure ‐Manual

Instruments required:

1. Blood Pressure Cuff

2. Stethoscope

Blood Pressure

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1. Patient should be at rest, seated, and arm to be tested is supported (commonly right).

2. Extend arm with slight bend, but keep relaxed.

3. Open valve on pump bulb.

4. Place BP cuff one inch above bend of elbow.

5. Snug cuff tight enough so 2 finger tips can fit under the top of the cuff.

6. Place earpieces end of stethoscope in ears.

7. Place diaphragm end of stethoscope (disc shaped) over anterior bend of elbow.

8. Close valve on pump bulb.

9. Inflate to 30 millimeters above reported normal.

10. Release valve in cuff slowly ‐ 2 millimeters (lines) per second.

11. Listen for the first beat you hear, take note of number. THIS IS THE SYSTOLIC NUMBER.

12. Continue listening until beating stops take note of number. THIS IS THE DIASTOLIC NUMBER.

13. If interrupted and need to start over, first deflate cuff all the way.

14. Do not re‐inflated half filled cuff.

15. If BP is outside normal range inform doctor

Procedure Blood Pressure – Manual ‐May be taken on any extremity, commonly right arm

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Deep Heat

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Types:1. Short Wave light

2. Microwave light

3. Ultrasonic sound

Deep Heat ‐ Diathermy

198

Many variables affect the way tissue responds:

WavelengthIntensity/wattagePlacement of deviceDosageFrequencyAll Deep Heat techniques carry a risk of deep burnsTechnique of application

All force cells to vibrate and create heat by friction, more vibration, more heat

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There are 2 ways to administer Deep Heat:1. Attended Constance Attendance

2. Unattended Supervised

Some insurance companies only reimburse for the attended.

Deep Heat ‐ Diathermy ‐Unattended

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Use of Diathermy throughout all phases is acceptable however rationale as an unbundled service generally does not exceed Therapeutic Phase without documentation of special circumstances

• Rationale/goal competes with other “modalities”



• Not time based

• CPT ‐ 97024 – Diathermy (e.g. microwave)

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Effects:

• Local deep heat on the treated tissue



• Micro massage/vibratory effect

• Increases cell activity


• Decreases pain


Deep Heat – Diathermy

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Contraindications:

Never mate with the eight!1. Sensitivity to Diathermy

2. Pregnancy






8. Cancer

Specific to Diathermy: Over attached hearing aids Over fractures Over metallic implants, dental, orthopedic Over adhesive strapping Over casts Over eyes Over areas of severe acute inflammatory processes, e.g. rheumatoid, TB Varicosities/Phlebitis Over menstruating uterus

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• Short Wave and Microwave techniques require a higher level of understanding and therefore carry a higher risk and will not be reviewed in this class.

• Background, procedures and protocols are fundamentally the same but need to be specifically reviewed by DC

• Most common form utilized in the chiropractic office is attended Ultrasound

• Unattended ultrasound is rare and generally not yet accepted by most insurers.

Deep Heat ‐ Ultrasound

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Use of Ultrasound throughout all phases is acceptable however rationale as an unbundled service generally does not exceed Therapeutic Phase without documentation of special circumstances

• Hand held probe• Modality ‐ Constant Attendance• Timed based• CPT ‐ 97035 – Ultrasound, each 15 minutes

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Effects:

• Local deep heat on the treated tissue



• Micro massage/vibratory effect

• Increases cell activity


• Decreases pain


Deep Heat – Ultrasound

206

Contraindications:

Never mate with the eight!1. Sensitivity to Diathermy

2. Pregnancy






8. Cancer

Specific to Ultrasound: Over attached hearing aids Over fractures Over metallic implants, dental, orthopedic Over adhesive strapping Over casts Over eyes Over areas of severe acute inflammatory processes, e.g. rheumatoid, TB Varicosities/Phlebitis Over menstruating uterus

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Procedure & Protocol ‐ Ultrasound: Review file for any contraindications Check equipment; all controls off Select transducer head size based on anatomical part Check Connections Determine method, i.e. Immersion or direct If direct utilize a coupling agent/medium to maintain conductivity

Maximize heat use a glycerin based agent Maximize vibratory effect use water based agents Medium should be room temperature or cool (Contrary to common thought) When cool this enhances heat removal from surface Best to use more than less

Determine settings per DC instructions, pulsed or continuous Continuous mode generates more heat Pulsed enhances vibratory effects

Table should not be metal Patient Position

Expose area to be treated Inspect area for any rashes, wounds etc.

Make sure skin is clean and free of debris Review file for any contraindications and/or with patient Set power mode (wattage) per instructions from DC Set timer per instructions from DC State Instructions

Deep Heat ‐ Ultrasound Therapy

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Instructions:

P.E.A.C.E. of Mind

Protocol inform patient of protocolExperience inform patient they will feel warmthAlterations inform patient temperature will increaseComfort inform patient that it should always be comfortable

Emergency inform patient as to location of emergency bell/buzzer and if uncomfortable to ring bell or call out ASAP


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Application:1. Turn on device with intensity to zero, wattage as instructed

2. Spread medium on area to be treated

3. Press start (this should start timer also), keep transducer head flat Do not expose transducer head to air while running (may crack the crystal insides)

4. Move transducer head in an up and down, side to side or circular motion over area spreading medium Do not cross the spine Do not apply over boney prominences Do not apply over areas with metal implants Do not hold in one place

5. Slowly increase intensity to instructed level; continuously move transducer head over area being treated

6. Overlap 50% with each stroke of transducer head

7. Question comfort level at each change

8. Question what they are feeling

9. Adjust settings as needed

10.After designated time turn off device, clean head and replace to holder

11.Clean and inspect treated area

12.Document response, time, intensity, location and settings


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Nevers: Never cross the spine

Never apply over boney prominences

Never apply over areas with metal implants

Never stop moving US head

Never place over areas with loss of feeling

Never place over moles, warts

Never place over heart or across chest A to P

Never place over infections of open wounds

Never place over hemorrhaging areas

Never place over front of neck (carotid sinus reflex) or throat

Never use over occlusive vascular conditions

Never place abdomen of pregnant patient

Never place over menstruating uterus

Never place over internal or external implanted electronic devices

Never place on head, eyes or ears

Never use against contraindications

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Deep Heat ‐ Ultrasound Therapy

211


• Observe area being treated during process

• Question comfort level regularly during process


• if skin appears excessively red or blistering


• if patient complains of loss of feeling


• Get the doctor

Deep Heat (Diathermy) / Ultrasound

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Location to include side, levelInstructions Informed ConsentSettings Pulsed or Continuous, IntensityTime start and end timeDischarge Status post therapyC A Identification Mary Jones, CA

“Patient. informed of US therapy and consented to treatment.”Left‐Mid to Lower LumbarContinuous Wave 1.0 watts

Time 1:30p‐1:45p “Patient tolerated treatment w/o incident.”

Mary Jones, CA

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Pulse/Heart Rate

213

Procedure for Taking Pulse/Heart Rate:

1. May be taken anywhere there is a pulse, e.g. radial, axillary, carotid.

2. Most common location is the radial pulse of the right arm.

3. Use your index and middle fingers.

4. Do not use your Thumb.

5. Place two fingers over the artery to be monitored.

6. Counts the number of beats in one minute.

7. Record number in bpm.

8. If Pulse/Heart Rate is outside normal range inform doctor.

Electrical Stimulation (ES)

214

TYPES:

• Low Volt Increased skin resistance, superficial

• High Volt Less skin resistance, deep

• Interferential Medium frequency, broad areas of TX

• Iontophoresis Chemical ions into superficial tissue

• T.E.N.S. Transcutaneous Electrical Nerve Stimulation

• A.C. Alternating Current

• D.C. Direct (galvanic) Current

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Many variables affect the way tissue responds:

Voltage

Frequency

Type of current‐AC/DC

Pulsed Rate

Refractory period

Duration of stimulation

Intensity of stimulation

Number of pads

Placement of pads

Polarity of the pads


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Good News

DC determines the intention & settings of the ES.

The procedures for all ES are similar.

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Combo Units

Electric Stimulation

Infrared Light Therapy

Ultrasound Therapy


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There are 2 ways to administer ES:1. Attended Constance Attendance

2. Unattended Supervised

Some insurance companies only reimburse for the attended.

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Electrical Stimulation (ES) ‐ Attended

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Use of Attended ES Therapy throughout all phases is acceptable however rationale as an unbundled service generally does not exceed Therapeutic Phase without documentation of special circumstances.

• Rational/goal competes with other “modalities”

• Manual ‐ typically hand held instrument

• Modality ‐ Constant Attendance

• Timed based

• Areas treated and time on them must vary

• CPT ‐ 97032 – Application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes

Electrical Stimulation (ES) ‐ Unattended

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Use of Unattended ES Therapy throughout all phases is acceptable however rationale as an unbundled service generally does not exceed Therapeutic Phase without documentation of special circumstances.

• Rational/goal competes with other “modalities”

• Modality ‐ Constant Attendance

• Timed based

• Manual ‐ typically hand held instrument

• Areas treated and time on them must vary

• CPT ‐ 97014 – electric stimulation (unattended)

• HCPCS ‐ G0283 – electric stimulation (unattended), to one or more areas for indication(s) other than wound care, as part of a therapy plan of care

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Effects:




• Passive exercise

• Reduces trigger points

• Promotes nerve function

• Decreases pain



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Contraindications:

Never mate with the eight:1. Sensitivity to ES2. Pregnancy3. Children under 104. Area of numbness or decreased sensation5. Open wounds, rashes, burns6. Over heart, head / brain7. Over internal or external implanted devices8. Cancer

Specific to ES: Over metallic implants Front of neck (carotid sinus reflex) Varicosities/Phlebitis Over menstruating uterus

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• Should not use metal tables

• Review file for any contraindications

• Check equipment; ensure all controls are set to zero with unit on

• Select pads or wand

• Check Connections

• Patient position to expose area to be treated

• Inspect area for any rashes, wounds etc.

• Make sure skin is clean and free of debris, excessive hair may interfere with EMS

• Set ramp up time, current, frequency, contraction time and rate per instructions from DC. Many offices and equipment have routine or pre established settings for the most common areas treated

• Apply pads or wand

• State Instructions


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Instructions:

P.E.A.C.E. of Mind


Experience inform patient that they will feel a tingling feeling

inform patient they may feel muscles move

describe and/or show anticipated movement of muscle

Alteration inform patient that the intensity will slowly increase


Emergency inform patient not to touch the control panel inform patient as to location of emergency bell/buzzer or kill switch and if uncomfortable to ring bell or call out ASAP


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Application:1. Device should be on, if not turn on device with intensity to zero

2. Place pads on patient (keep wires parallel, leads pointing towards machine)

3. Slowly increase intensity

4. Question comfort level at each change

5. Increase to tolerance and then back down or to pre‐instructed level

6. Set timer

7. Reinforce location of emergency bell/buzzer

8. Return and check area after 4 to 5 minutes

9. Adjust settings in needed

10. After designated time turn off device

11. Remove pads and replace all equipment and wires

12. Inspect treated area

13. Document response, time, intensity, location and settings


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Nevers: Never have patient lay on pads

Never place over old scars (decreased sensation)

Never place over areas with loss of feeling

Never place over moles, warts

Never place over metal implants

Never place over heart or across chest A to P

Never place over infections of open wounds

Never place over hemorrhaging areas

Never place over front of neck (carotid sinus reflex) or throat

Never use to treat varicosities

Never use to treat phlebitis

Never place over low back or abdomen of pregnant patient

Never place over menstruating uterus

Never place over internal or external implanted electronic devices

Never place on head


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• Have an emergency bell or buzzer for patient to ring if needed• Check patient after 3 to 4 minutes then every 5 minutes thereafter


• if skin is excessively red or blistering get the doctor, ASAP, do not remove pads



• if patient complains of electrical shock feeling

• Get the doctor


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Location to include side, levelInstructions Informed ConsentSettings ramp up time, current, frequency, contraction

time and rate or established protocolTime start and end timeDischarge status post therapy)C A Identification Mary Jones, CA

“Patient. informed of EMS therapy and consented to treatment.”Left Mid Thoracic

Low Volt‐2 Pad‐Ramped‐Pulsed‐20 contraction/minutes (if defined‐example office MT protocol 1)

To Patient comfort 8/10Time 1:30p‐1:45p


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Respiration

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Procedure for Observing Respiration:

1. Note rise and fall of patient’s chest.

2. Count the number of rising chest observations for one minute.

3. Record number.

4. Observe if respiration has a regular rhythm.

5. Record number in breaths per minute – breaths/min/regular.

6. If rate and/or rhythm are outside normal range inform doctor.

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Traction

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Traction is the drawing or pulling apart sections or parts of the body

Traction can be applied by hand, weights, stretch cords, springs, mechanical devices or gravity

Types:

1. Manual performed with hands and requires doctor

2. Mechanical Involves a “gadget”

Forms – Manual or Mechanical:

• Axial along the spine

• Intersegmental between motor units

Methods – Manual or Mechanical:• Static/Continuous steady pulling

• Intermittent off and on pulling

Traction ‐Manual

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Use of Manual Traction throughout the Therapeutic and initial part of the Rehabilitative Phases is acceptable however rationale as an unbundled service generally does not exceed up to the middle of the Rehabilitative Phase without documentation of special circumstances

• Therapeutic Procedure

• One‐on‐One

• Time based

• CPT ‐ 97140 – Manual Therapy

This service must be provided by a licensed practitioner and is beyond the scope of this course.

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Traction ‐Mechanical

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Use of Mechanical Traction throughout the Therapeutic and initial part of the Rehabilitative Phases is acceptable however rationale as an unbundled service generally does not exceed up to the middle of the Rehabilitative Phasewithout documentation of special circumstances

• Rationale/goal competes with other “modalities”• Modality ‐ Supervised• Not One‐on‐One• Not time based• CPT ‐ 97012 ‐ traction, mechanical

Mechanical Devices:

• Counter weight pully systems.

• Intersegmental Roller Tables

• Flexion Distraction Tables considered an adjusting technique performed by the DC. Treatment utilizing table that flexes with hand contact

• Computerized Axial Decompression is traction utilizing a computer controlled traction device

• Gravity Inversion traction utilizing frame device inverting patient against gravity

Traction ‐Mechanical

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Effects:• Decreases muscle tension

• Stimulates proprioceptive response in joints and tissue

• Stretches adhesions

• Increases circulation

• Decompresses IVF

• Promotes disc hydration

• Decreases pain


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Traction –Mechanical

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Contraindications:

Never mate with the eight!1. Sensitivity to Traction

2. Pregnancy






8. Cancer

Specific to Traction:

Severe joint instability

Uncontrolled hypertension (high blood pressure)

In combination with adhesive strapping

Over areas of severe acute inflammatory processes, e.g. rheumatoid, TB

Traction ‐ Mechanical ‐ Intersegmental Traction (IST)

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Most common form of traction in the chiropractic office is Intersegmental Traction (IST)

Rollers are hourglass shaped

Some carriers considers Intersegmental traction (IST) experimental and will not reimburse for it under any circumstances.

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Traction ‐ Intersegmental (IST)

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Procedure & Protocol: Review file for any contraindications and/or with patient

Review file for height and weight

Check equipment; all controls off

Identify area to be treated per DC

Determine settings of device or weight to be used per DC instructions IST set length of traction rollers per DC instructions IST set height of traction rollers per DC instructions IST if applicable set vibration or no vibration per DC instructions

Many offices have routine settings for the most common areas treated

Table should be off Patient Position Supine for IST Question/ Inspect area for any rashes, wounds etc. Make sure area is free of debris State Instructions

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Traction ‐ Intersegmental Traction (IST)

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Instructions:

P.E.A.C.E. of Mind

Protocol inform patient of protocol.

Experience inform patient they will feel rolling under the spine and to not press into rollers

Alterations inform patient that the degree of rolling will increase

and the rollers will travel up and down the spine.


Emergency inform patient if uncomfortable to call out



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Application:1. Turn on device with intensity to lowest setting2. Slowly increase intensity 3. Question comfort level at each change4. Increase to instructed level5. Start timer6. Question what they are feeling7. Adjust settings if needed8. After designated time turn off device9. Question/Inspect treated area10. If your machine turns off automatically let patient know.11. Document response, time, intensity, location and settings

Nevers: Never perform over areas with loss of feeling Never perform over infections of open wounds Never Perform over recent stitches Never perform over hemorrhaging areas Never perform over fractures Never perform on pregnant patients Never place prone Never use against contraindications

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• Have an emergency bell or buzzer for patient to ring if needed

• Check patient after 3 minutes then every 5 minutes thereafter




• Get the doctor


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Location to include side, levelInstructions Informed ConsentSettings height and spinal level(s)Time start and end timeDischarge Status post therapyC A Identification Mary Jones, CA

“Patient informed of traction therapy and consented to treatment.”Bilateral‐Upper Thoracic to lower Lumbar

Height 5/8, no vibrationTime 1:30p‐1:45p


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Posture Analysis

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Posture may be analyzed from the Anterior, Posterior, or laterally.

Normal depends on viewpoint.

Posterior: Level head‐level shoulders‐level pelvis‐gluteal fold in line with center of occiput‐spinous processes‐evenly center between knees and feet (pointing anterior).

Anterior: Level eyes‐level shoulders‐level pelvis‐nose in line umbilicus (belly button)‐evenly center between knees and feet (pointing anterior).

Laterally: Mid ear‐mid shoulder‐mid‐hip—mid knee‐mid ankle.

Posture Analysis

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Posture Analysis

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Procedure for Analyzing Posterior Posture:

• Unless otherwise instructed, posture will be viewed from the posterior and laterally on the right.

• Unless otherwise instructed report in terms of high side.

• Have the patient stand with hands by their side, feet, shoulder with and pointing forward.

1) Observe if head is level. If not what side is high? Record high side.

2) Observe if shoulders are level. If not what side is high? Record high side.

3) Observe if pelvis is level. If not what side is high? Record high side.

Hints: for pelvis, look at skin folds, garment line.

Posture Analysis

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Procedure for Analyzing Lateral Posture:

• Unless otherwise instructed report observed part anterior or posterior to normal.

• Right Lateral: Have patient stand with back to observer; hand by their side, feet shoulder with and pointing forward.

• Step to the patient’s right side.

• Imagine line from mid‐ear‐shoulder‐hip‐knee‐ankle

• Observe if ear is split by that line. If not is it anterior or posterior to that line. Record.

• Observe if shoulder is split by that line. If not is it anterior or posterior to that line. Record.

• Observe if hip is split by that line. If not is it anterior or posterior to that line. Record.

• Observe if knee is split by that line. If not is ts anterior or posterior to that line. Record.

• Observe if ankle is split by that line. If not is it anterior or posterior to that line. Record

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Posture Analysis

Posture is an outward reflection of the spine’s curves (or lack thereof)

Normal Hump Back Sway Back Flat back Scoliosis

Posture Analysis

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Posture Analysis

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Low Level Laser Therapy (LLLT)Laser Phototherapy

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L.A.S.E.R. Light Amplification by Stimulated Emission of Radiation

Synonymous Names:

Cold Laser

Non‐Thermal Laser

Types:

1. Class 1 No risk to tissue during normal operation

2. Class 1M No known hazards to eye or skin unless collecting optics are used

3. Class 2 & 2b No risk to tissue…low level, bar scanners

4. Class 3a Similar to Class 2 (except collecting optics can be used)

5. Class 3R No known risk to tissue…medium level (replaced Class 3a)

6. Class 3b Risk to retina…medium level…LLLT

7. Class 4 increased risk to tissue…high level


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Use of LLLT throughout all phases is acceptable however rationale as an unbundled service generally does not exceed Therapeutic Phase without documentation of special circumstances.

• Goal competes with other “modalities”• Modality ‐ Constant Attendance• CPT ‐ 97039 – Unlisted modality code. There is no actual CPT code for this service. If

using CPT code for this procedure you use the unlisted modality code 97039 with an explanation describing type and time. Payment is at the discretion of the insurance carrier

• HCPCS ‐ S8948 ‐ Application of a modality (requiring constant provider attendance) to one or more areas; low‐level laser; each 15 minutes

Many carriers considers it experimental and will not reimburse for it.

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LLLT is in the infra‐red spectrum with low wattage beam.

It is not the same as infra‐red heat lamps


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There are 2 ways to utilize LLLT1. Modality for injured area

2. Acupuncture point stimulation

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Effects:



• Reduces trigger points

• Promotes increase cell function and energy

• Decreases pain


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Contraindications:

Never mate with the eight!

1. Sensitivity to LLLT

2. Pregnancy






8. Cancer

Specific to LLLT: Direct exposure to the eyes Over thyroid Patients on light sensitive medications or immune suppressant drugs Patients with heart disease

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Review file for any contraindications

Check equipment; all controls off

Check Connections

Patient position

Expose area to be treated

Inspect area for any rashes, wounds etc.

Set voltage per instructions from DC

Set frequency per instructions from DC

Set intensity per instructions from DC

If separate; set width of beam per instructions from DC

Set time

Make sure skin is clean and free of debris

Laser emitter may be hand held or mounted on a stand

State Instructions


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Instructions:

P.E.A.C.E. of Mind


Experience inform patient that they should not feel anything however on occasion some patients feel a slight warmth or coolness

Alterations inform patient to let you know about any changes


Emergency inform patient if uncomfortable to call out


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Application:1. Place protective goggles on all in the room (including you)2. Set the appropriate levels3. Start therapy4. Question comfort level5. Set timer6. After designated time turn off device7. Inspect treated area8. Document response, time, intensity, location and settings

Nevers: Never perform without safety goggles on all in the room Never place over moles, warts Never place over metal implants Never over heart Never place over infections of open wounds Never place over hemorrhaging areas Never place over abdomen of pregnant patient Never place over internal or external implanted electronic devices Never place on head (except TMJ) Never use against contraindications


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• Question patient if they are feeling anything


• if skin appears excessively red or blistering• if patient complaints of a burning sensation• if patient complains of increased pain• Get the doctor

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Location to include side, level

Instructions Informed Consent

Settings frequency or protocol

Time start and end time

Discharge Status post therapy

C A Identification Mary Jones, CA

“Patient. informed of LLLT therapy and consented to treatment.”Right Upper Trap medial and lateral‐hand held

Time 1:30p‐1:45p“Patient tolerated treatment w/o incident.”

Mary Jones, CA

Therapeutic Procedures

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Types:

1. Manual Therapy (we already discussed this under traction)

2. Therapeutic Exercise (TE)

3. Neuromuscular Re‐Education (NMR)

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Therapeutic Procedures

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Purpose:

• An “attempt to improve function” and are not symptom driven

• Unlike Modalities clinical need must be defined in terms of decreased function.

• There must be a metric to gauge progress, i.e. Outcome Assessments, Exam, History

• Remember, when treating injuries from MVAs the goal is pre‐injury.

• If, as a result of a MVA, Therapeutic Procedures are indicated, an attempt at defining pre‐injury level of function should be part of the protocol

• The documented medical necessity for the service(s), short and long term goals and metrics are expressed in terms that define the patient’s condition and progress in comparison to pre‐injury status or need that otherwise would not allow for recovery.

Therapeutic Procedure ‐ Therapeutic Exercise (TE)

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Use of TE throughout all phases is acceptable however rationale as an unbundled service generally does not exceed Rehabilitative Phase without documentation of special circumstances.

• TE is not the same as exercise

• Direct One‐on‐On

• Require skilled service

• Timed based

• Require specific functional goals expressed by metrics

• Must be performed by a Licensed Physician or Other Qualified Healthcare Professional

• CPT – 97110 – Therapeutic Exercise

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Methods:

• Weights

• Aerobics with or without equipment

• Resistance cords

• Isometric exercises

• Stretching maneuvers


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Effects:

• Develop strength

• Develop endurance

• Increase ranges of motion

• Increase flexibility

When performing this service the intent/rationale

must be quantified as one of the above on any given date.

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Therapeutic Procedure ‐ Neuromuscular Reeducation (NMR)

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Use of NMR throughout all phases is acceptable however rationale as an unbundled service generally does not exceed Rehabilitative Phase without documentation of special circumstances.

• Direct One‐on‐On

• Require skilled service

• Timed based

• Require specific functional goals expressed by metrics

• Must be performed by a Licensed Physician or Other Qualified Healthcare Professional

• CPT‐ 97112 – Neuromuscular Reeducation

Therapeutic Procedure ‐ Neuromuscular Reeducation (NMR)

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Methods:

• Proprioceptive Neuromuscular Facilitation (PNF)

• Balance boards and discs

• Feldenkreis

• Neuro‐Developmental Technique (NDT)

• Hemispheric rehab

• Bobath’s Technique

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Therapeutic Procedure ‐ Neuromuscular Re‐Education (NMR)

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Effects:

• Improve balance

• Improve coordination

• Improve posture

• Increase kinesthetic sense

(bodies sense of it own placement in space)

When performing this service the intent/rationale

must be quantified as one of the above on any given date.

Therapeutic Procedures – TE and NMR

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Contraindications:

Never mate with the eight!1. Sensitivity to TE & NMR2. Pregnancy3. Children under 104. Area of numbness or decreased sensation5. Open wounds, rashes, burns6. Over heart, head / brain7. Over internal or external implanted devices8. Cancer

Specific to Therapeutic Procedures TE and NMR:

Severe joint instability Uncontrolled hypertension (high blood pressure) Aneurysms Over areas of severe acute inflammatory processes, e.g. rheumatoid, TB

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1. Review file for any contraindications and/or with patient

2. Review file for Height and Weight

3. Review BP, respiration, pulse

4. Check equipment if applicable5. Identify area and goal to be treated per DC6. Determine settings of device or weight to be used per DC instructions7. All equipment in a safe and neutral position8. Patient position9. Determined by procedure per DC instructions10. Make sure area is free of debris11. Place patient in appropriate position per instructions from DC12. State Instructions


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Instructions:

P.E.A.C.E. of mind

Protocol inform patient of protocol, breathing, reps, posture etc. Demonstrate exercise/protocol make sure they are clear on what to do

Experience inform patient what they will feel

Alterations inform patient about changes in feeling


Emergency inform patient that if uncomfortable to call out ASAP


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Application:

1. Patient begins

2. Question comfort level during each set

3. Document response, time, intensity, location and settings

Nevers:

Never perform on pregnant patients not use to exercise



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• Monitor breathing and pulse

• Monitor posture, position

• Monitor time, reps, weight

• F.A.S.T.

Negative Response/Reaction: (Assisting the doctor)


• if patient complains of increased pain• if patient complains of shortness of breath• if patient complains of dizziness• If patient complains of weakness; especially one sided

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Location to include side, levelInstructions Informed ConsentSettings type‐weight‐repsTime start and end timeDischarge Status post therapyC A Identification Mary Jones, CA

“Patient informed of Ther. Ex. and consented to treatment.”Lumbar Endurance protocol‐treadmill…..

4 miles per hourTime 1:30p‐1:45p


Emergency Procedures

Disclaimer:

This section is a general overview of Emergency Procedures. It is not intended to replace any certification program.

This section is intended to inform you on those topics that need further instruction.

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Urgent Care Situations:

Procedures that require training:

1. First Aid

2. Severe Bleeding

3. Stoppage of Breathing

4. Choking

5. Stroke

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1. First Aid: Defined as the immediate and temporary survival care given to a person in need due to accident or illness.

Call 911

Vitals‐BP‐Pulse‐Temperature‐Respiration‐Comfort

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2. Severe Bleeding.

Call 911

Apply direct pressure to supplying artery, e.g. Brachial, Femoral using a cloth or compress of some kind

If possible elevate the part

If delay in emergency response, maintain fluids

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3. Stoppage of Breathing.

Call 911

Check to see if there is a pulse

No pulse no breathing‐Do they need CPR (Cardio Pulmonary Resuscitation) if needed (only if properly trained)

Defer to AED (Automatic External Defibrillators)

If pulse are they choking

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4. Choking

Call 911

Check to see if they can talk

If not‐perform Heimlich Maneuver

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5. Stroke

F.A.S.T.

“F” face = Ask person to smile

“A” arms = Ask person to raise both arms. Does one drift down?

“S” speech = Ask person to repeat a phrase to detect slurred speech.

“T” time = If any of the above call 911 immediately

“T” also tongue = Ask person to stick out tongue. Observe if it deviates to one side.

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chiropractic assistants procedures program …...capp september 2019 10 mborc regulations 19 4.02:...

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