Anatomy In Action Series: A Review of Modality Contraindications
Educational articles designed to help CAs understand the underlying anatomy and physiology of conditions presenting to the chiropractic office
Laurie Mueller
Remember to "STIM" before Electric Muscle Stim!
In this segment, we are going to review some of the major contraindications to using modalities such as electric muscle stimulation (EMS). Even with our most regular patients, it is important not to get complacent. Changes could have occurred between visits that they simply forgot to mention. We all try our best when providing care to ask things before adjusting, such as, "Have you had any surgeries, traumas, illnesses, or other medical or medicine changes since the last visit?" When the doctor asks this type of question, often referred to as STIM (surgeries, traumas, illnesses, medical/medicine changes), it helps prompt the patient to remember and report changes in his or her health status.
Does Your Physiotherapy Suite Have Signage?
Along with cognizant observations and possible screening questions from CAs as a second line of defense, having signage in the physiotherapy suite can also help remind patients to report their health status.
The following list provides some of the most common contraindications that we might find before administering a modality. It includes but is not limited to:
• Mental status: The patient must be able to provide reliable and accurate feedback to you regarding the procedure.
• Causes pain: EMS should not cause pain. If it does, stop immediately and get the doctor. If the pain is "burning in nature," also check the pads and ensure they have adequate adhesive!
• Cancer/disease: Never use EMS over a cancerous lesion or area of disease/infection.
• Pregnancy: Current should always be kept far away from a pregnant uterus.
• Implants: Some implants can't handle modalities. Always double check with your doctor if asked to perform a procedure over an implant.
• Pacemakers: Electrical devices working to regulate an electrical organ like the heart do not mix with EMS. Keep the current away.
• Neuropathies/lack of sensation: Again, a patient must be able to provide reliable and accurate feedback to you regarding the procedure
and what they are feeling. Do not perform EMS over areas that the patient "cannot feel."
• Recent surgery: Sensitive areas, pulling at the incision site, stimulating bleeds, or irritating staples are just a few of the reasons that EMS after a recent surgery is a very bad idea.
ATTENTION ALL PATIENTS
Tell the Doctor/Assistant about:
• Pregnancy
• Recent surgery/medication changes
• Open wounds
• Lack of sensation
• Any implants/joint replacements
• Pa ce m a kers/defib dilators
• Circulatory issues
• Other?
These conditions could affect your treatment.
Thank you!
Quick Tests
If you have a patient with questionable sensation, performing a couple of quick tests before administering a modality is a good decision. If you perform these tests, don't forget to document them in the patient file. If the patient fails a test, you will need to inform the doctor so that he or she can reassess the idea of using a modality on that area.
• Has patient had sharp/dull test? This is a great general test to assess if a patient can differentiate different sensations. For example, someone with diabetic neuropathy can still get EMS treatments if they can adequately provide feedback. This can be performed all around the area you intend to treat. First, show the patient what you are using. It could be the end of a toothpick and a Q-tip. Demonstrate on their hand what "sharp" and "dull" should feel like. Then tell them that you will have them close their eyes and when you touch the treatment area with one of the implements, they should state "sharp" or "dull." You can then perform the test and chart the results.
• Has patient had hot/cold test? This is good for heat and cryotherapy, but not limited to those modalities. EMS can generate burns (with faulty pads, for example), ultrasound has the potential to get hot, diathermy, etc. If testing sensation, it is prudent to include hot/cold to be thorough. This test is similar to the previous test, but you will use something hot (not too hot!) and cold. If you have glass test tubes in the office, these are great and can be filled with hot and cold water from the tap to easily perform the test over the area you plan to treat. If you use a hydrocollator
in the office, you might also just fill a tube with some of the hot water from there.
Lack of sensation can come from a variety of causes, including nerve damage, diabetic neuropathy, multiple sclerosis, or even a history of frostbite.
Areas/Conditions to Avoid
There are several areas and conditions when we will never apply EMS, which include but are not necessarily limited to:
• Pregnant uterus
• Circulatory insufficiency
• Epilepsy (head or neck region)
• Cancerous area
• Eyes
• Genitals
• Tra nsce re b rally
• Active epiphysis (bone growth center—i.e., watch it with kids!)
• Active implants (pacemaker/defibrillator)
• Across the heart
• Areas of bleeding tissue
• Over the thyroid gland
• Over the carotid sinus: A special note about the carotid sinus. It has baro receptors, which are special nerves that help regulate blood pressure. If you stimulate that area, the patient could get faulty signals and actually pass out. It is important you know how to find it so that you can avoid it. The diagram on this page shows its location. It's in the same place where you would take the carotid pulse! You may often perform EMS on the SCM muscle, scalenes, or other tight neck muscles, so making it a habit to avoid the sinus is very important.
Education Fosters Understanding
An understanding of anatomy and clinical applicability helps all health-office employees better communicate with patients and provide care more
Even with our most regulor patients, It Is Important not to get complacent. Changes could have occurred between visits that they
simply forgot to mention. 33
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CERTIFIED CHIROPRACTIC CLINICAL ASSISTANT
Laurie Mueller, BA, DC, CFMP, served in private practice in San Diego, California. She was the postgraduate director at Palmer College from 2000-2010; served as the ACC postgraduate subcommittee chair for six y ears; peer-reviewedfor the Research Agenda Conference; and wrote the informal role determination study that aided in the development of FCLB ’s guidelines for chiropractic assistants. Dr. Mueller currently works as a private eLearning consultant with a focus on healthcare topics and functional medicine through her company, Impact Writing Solutions, and the subsidiary, www.CCCAonline.com. She is a clinician, an educator, and an expert in online educational pedagogy.
