Development and Development and Delivery of Treatment Delivery of Treatment

ProtocolsProtocols

Chapter 3Chapter 3

►Remember from chapter one Therapeutic Remember from chapter one Therapeutic Modalities are used to create the proper Modalities are used to create the proper environment for healing.environment for healing.

►Many components of the injury response Many components of the injury response process are intertwinedprocess are intertwined Edema causes painEdema causes pain Pain causes spasmPain causes spasm Spasm causes painSpasm causes pain

►Although pain may be your patients Although pain may be your patients primary complaint, simply focusing your primary complaint, simply focusing your tx on pain relief does little to resolve the tx on pain relief does little to resolve the underlying cause of discomfort or underlying cause of discomfort or dysfunction.dysfunction.

►The ability to plan a Tx and The ability to plan a Tx and rehabilitation program is perhaps the rehabilitation program is perhaps the most complex skill that rehabilitation most complex skill that rehabilitation clinicians must master.clinicians must master.

►This process integrates This process integrates Physical evaluation skillsPhysical evaluation skills Knowledge of pathologyKnowledge of pathology Knowledge of applicable therapeutic Knowledge of applicable therapeutic

techniques and principlestechniques and principles Goal settingGoal setting And patient motivation and educationAnd patient motivation and education

►No one source is sufficient to gain No one source is sufficient to gain proficiency in this skill.proficiency in this skill.

►Your ability in this area will grow and Your ability in this area will grow and be perfected with experiencebe perfected with experience

►The Problem-solving Approach (PSA)The Problem-solving Approach (PSA) Is a logic-based technique used in Is a logic-based technique used in

developing the patient’s Tx plan to developing the patient’s Tx plan to achieve a long-term goalachieve a long-term goal

The Problem-solving The Problem-solving ApproachApproach

►Although “logical thinking” is something Although “logical thinking” is something that we usually do not do consciously, that we usually do not do consciously, we practice it as part of our daily we practice it as part of our daily routine.routine.

► It involves basic skillsIt involves basic skills For example getting dressedFor example getting dressed

►And more complicated tasksAnd more complicated tasks Such as finding one’s way around an Such as finding one’s way around an

unfamiliar city for a job interview.unfamiliar city for a job interview.►Either way, you use logical thinkingEither way, you use logical thinking

Extending the logical thinking Extending the logical thinking into treatment of the patientinto treatment of the patient

►As described in Chapter 1, each As described in Chapter 1, each individual responds differently to individual responds differently to trauma.trauma.

►This fact alone illustrates the need to This fact alone illustrates the need to treat each patient differently, based on treat each patient differently, based on his or her own needshis or her own needs

►Generalized Tx protocols should not be Generalized Tx protocols should not be viewed as, or used as, unyielding viewed as, or used as, unyielding individual treatment plans.individual treatment plans.

► Individual Tx plans that specify each Individual Tx plans that specify each patient’s case leads to a more efficient patient’s case leads to a more efficient and successful outcome. and successful outcome.

► PSA describes an ongoing process of PSA describes an ongoing process of evaluation, analysis, and planning.evaluation, analysis, and planning.

► It is comprised of four stepsIt is comprised of four steps Recognition of the patients problemRecognition of the patients problem Prioritization of the problemsPrioritization of the problems Goal settingGoal setting Treatment planningTreatment planning

► Although our focus is on Therapeutic Although our focus is on Therapeutic Modalities, the role of these devices is to Modalities, the role of these devices is to prepare the patient for Therapeutic exercise prepare the patient for Therapeutic exercise and manual techniques.and manual techniques.

►Modalities are also used after these Modalities are also used after these techniques as a way of controlling exercise-techniques as a way of controlling exercise-induced inflammationinduced inflammation

► Regardless of expertise and the number of Regardless of expertise and the number of years of experience, not every clinician is years of experience, not every clinician is capable of managing every condition.capable of managing every condition.

► You as clinicians should not hesitate to seek You as clinicians should not hesitate to seek the input and advice of others who possess the input and advice of others who possess more knowledge or have more experience more knowledge or have more experience managing a specific condition.managing a specific condition.

► The knowledge of when to refer a patient to The knowledge of when to refer a patient to a more appropriate rehabilitation setting or a more appropriate rehabilitation setting or to another healthcare or medical professional to another healthcare or medical professional should be considered a high ethical priority.should be considered a high ethical priority.

► Its also an important element in your Its also an important element in your learning process.learning process.

Components of the Problem-Components of the Problem-solving Approachsolving Approach

►Recognition of the problems:Recognition of the problems: Identify the type and depth of the Identify the type and depth of the

involved tissuesinvolved tissues Identify the nature of the pathologyIdentify the nature of the pathology Determine the stage of healingDetermine the stage of healing Recognize any contraindications to the Recognize any contraindications to the

use of modalities or exercisesuse of modalities or exercises

►Prioritization of the problemPrioritization of the problem Develop the logical treatment order based Develop the logical treatment order based

on a cause-and-effect relationship on a cause-and-effect relationship between the pathology and the signs and between the pathology and the signs and symptomssymptoms

►Goal SettingGoal Setting Develop structure and sequence in the Develop structure and sequence in the

treatment plantreatment plan►Treatment planningTreatment planning

Determine the modalities and exercises to Determine the modalities and exercises to be used and their sequence based on the be used and their sequence based on the patient’s problems and treatment goals.patient’s problems and treatment goals.

Recognition of the ProblemsRecognition of the Problems►To provide proper care, you must know To provide proper care, you must know

what condition(s) you are treating.what condition(s) you are treating.►However, again recalling Chapter 1, you However, again recalling Chapter 1, you

are treating more than a “sprained are treating more than a “sprained ankle”.ankle”.

►This stage is designed to identify:This stage is designed to identify: The type of tissues involvedThe type of tissues involved

►Anatomy, function, size, depthAnatomy, function, size, depth The effects of pathologyThe effects of pathology

►Pain, Pain, ↓ROM, Strength loss↓ROM, Strength loss The stage of the healing processThe stage of the healing process

►Acute inflammation, proliferation, Acute inflammation, proliferation, maturationmaturation

► Each type of tissue responds differently to Each type of tissue responds differently to various modalities.various modalities. The properties of the traumatized tissuesThe properties of the traumatized tissues Their depth below the skinTheir depth below the skin Their stage in the inflammation and healing processTheir stage in the inflammation and healing process

► All of these will dictate which modalities can All of these will dictate which modalities can effectively stimulate them.effectively stimulate them.

► Using a superficial modality to treat structures Using a superficial modality to treat structures that are deep within may produce little or no that are deep within may produce little or no benefitbenefit

► Using a modality that can accelerate the Using a modality that can accelerate the inflammatory response on tissues that are inflammatory response on tissues that are already actively inflamed can result in further already actively inflamed can result in further cell destructioncell destruction

► Always begin the problem identification by Always begin the problem identification by reviewing any existing medical records reviewing any existing medical records describing the course of the patient’s describing the course of the patient’s condition.condition.

► Valuable information is stored in these Valuable information is stored in these records on your patient.records on your patient. Some records includeSome records include

►Treatment notesTreatment notes►Operative notesOperative notes►Diagnostic test resultsDiagnostic test results►Physicians referral or prescription notesPhysicians referral or prescription notes

► All potential contraindications to treatment All potential contraindications to treatment approaches, devices, and modalities should approaches, devices, and modalities should also be identified.also be identified.

► Formal patient evaluations and re-evaluations Formal patient evaluations and re-evaluations should be conducted at timely intervals.should be conducted at timely intervals.

Patient InterviewsPatient Interviews

►Less detailed patient interviews should Less detailed patient interviews should be done prior to each Tx session to be done prior to each Tx session to identify the patientsidentify the patients Physical statusPhysical status Mental statusMental status As well as to gain the patients overall As well as to gain the patients overall

perspective of the Tx protocol. perspective of the Tx protocol.

Info gained during patient Info gained during patient interviewinterview

► Subjective informationSubjective information Chief complaintChief complaint Medical historyMedical history MedicationsMedications MOIMOI

►Nature of the traumaNature of the trauma► Types of tissues involvedTypes of tissues involved► Stage of injury responseStage of injury response► Patient goalsPatient goals► Contraindications to purposed Tx’s.Contraindications to purposed Tx’s.

► A wealth of information can be obtained A wealth of information can be obtained during your formal interview as well as an during your formal interview as well as an informal discussion.informal discussion.

►Good clinicians require a keen listening skill Good clinicians require a keen listening skill and the ability to identify and solicit and the ability to identify and solicit pertinent information offered by the patient.pertinent information offered by the patient. Example: Your patient comment is “I am unable Example: Your patient comment is “I am unable

to tuck my shirt tail in” what can this identify to to tuck my shirt tail in” what can this identify to you as a clinician??you as a clinician??►Restricted internal glenohumeral rotation.Restricted internal glenohumeral rotation.

Post treatment the patient complains of feeling Post treatment the patient complains of feeling “worse” what does this indicate to you as a “worse” what does this indicate to you as a clinician?clinician?►The exercise and/or treatment protocol was too The exercise and/or treatment protocol was too

intense.intense.

►When applicable these comments should be When applicable these comments should be noted in the patients file.noted in the patients file.

► Avoid the temptation to focus on observable Avoid the temptation to focus on observable signs such assigns such as SwellingSwelling Discoloration Discoloration Decreased ROMDecreased ROM And the reported symptom of painAnd the reported symptom of pain Numbness, etc.Numbness, etc.

► Although the short-term objective Tx of any Although the short-term objective Tx of any given Tx session is to provide symptomatic given Tx session is to provide symptomatic relief, the long-term foal of proper healing relief, the long-term foal of proper healing and return to normal lifestyle will not be met and return to normal lifestyle will not be met until the underlying pathology is identified until the underlying pathology is identified and managed.and managed.

► As we will see in the following sections, As we will see in the following sections, symptomatic Tx are required in the early Tx symptomatic Tx are required in the early Tx phases, but only as a transition to curative Tx.phases, but only as a transition to curative Tx.

►Many conditions may be identified during the Many conditions may be identified during the evaluation process.evaluation process.

► The use of valid and reliable tools, correct The use of valid and reliable tools, correct measurement techniques, consistency during measurement techniques, consistency during re-evaluation, and proper documentation of the re-evaluation, and proper documentation of the results contribute to the accumulation of results contribute to the accumulation of documented evidence of the patients progress.documented evidence of the patients progress.

►However, all of these tools are not appropriate However, all of these tools are not appropriate for every condition, and the patient may have for every condition, and the patient may have one or more contraindications to their use, see one or more contraindications to their use, see table 3.4 on handouttable 3.4 on handout

► You should also assess your patients mental You should also assess your patients mental and emotional state.and emotional state.

► The patient should be educated regarding The patient should be educated regarding The nature of the injuryThe nature of the injury The Tx planThe Tx plan And the goalsAnd the goals

► To maximize participation, the patient must To maximize participation, the patient must be able to understand and comprehend be able to understand and comprehend The nature of the injuryThe nature of the injury The Tx planThe Tx plan The Tx goalsThe Tx goals And the expectations for recovery And the expectations for recovery

► Also assessing the patients motivational Also assessing the patients motivational level is a must.level is a must. Patients who lack motivation or disinterest in Patients who lack motivation or disinterest in

recovery may need the assistance of a mental recovery may need the assistance of a mental health care providerhealth care provider

► The info collected during evaluation and the The info collected during evaluation and the Tx sessions should be identified and recorded Tx sessions should be identified and recorded in the patients file using measurable and in the patients file using measurable and objective termsobjective terms This allows you to track the patient’s progress This allows you to track the patient’s progress

toward recoverytoward recovery► Although each Tx session should begin with a Although each Tx session should begin with a

patient interview, a full re-evaluation of the patient interview, a full re-evaluation of the patients condition should be conducted at patients condition should be conducted at regular intervals.regular intervals. IE. At the end of a goal period.IE. At the end of a goal period.

► This allows for comparative baseline info and This allows for comparative baseline info and a determination can be made whether a a determination can be made whether a patient has improved as expected or if the Tx patient has improved as expected or if the Tx plan needs to be modified because of a lack of plan needs to be modified because of a lack of progressprogress

Case Study #1Case Study #1See handout and answer why See handout and answer why

each of the problem recognitions each of the problem recognitions are importantare important

DUE THURSDAY!!!!DUE THURSDAY!!!!

Prioritization of the Prioritization of the ProblemsProblems

► Prioritizing the patients problems assists you Prioritizing the patients problems assists you in developing the logical order of treatment.in developing the logical order of treatment.

►Determining the logical order of treatment Determining the logical order of treatment requires knowledge of the pathophysiology, requires knowledge of the pathophysiology, the events associated with each stage of the the events associated with each stage of the healing process, and the beneficial effects healing process, and the beneficial effects (or hazardous effects) that each modality (or hazardous effects) that each modality has on the injury response process.has on the injury response process.

► Prioritize problems based on their cause-and Prioritize problems based on their cause-and effect relationship to the chief complaintseffect relationship to the chief complaints This gives you an orderly treatment sequenceThis gives you an orderly treatment sequence It also helps prevent mistakes and allows the It also helps prevent mistakes and allows the

patient to return to preinjury state in the safest patient to return to preinjury state in the safest most expedient mannermost expedient manner

►Multiple chief complaintsMultiple chief complaints Usually all are intertwinedUsually all are intertwined The key find the patients functional deficit that is The key find the patients functional deficit that is

triggering all of the problemstriggering all of the problems A question that can be used to do this is A question that can be used to do this is

►““what other signs and symptoms will be reduced if this what other signs and symptoms will be reduced if this problem is resolved?”problem is resolved?”

Consider a patient who can not bear weight Consider a patient who can not bear weight secondary to pain, secondary to pain, ↓ ROM, and swelling in the ↓ ROM, and swelling in the left ankle.left ankle.►Which treatment should receive the highest priority?Which treatment should receive the highest priority?

Pain?Pain?► Pt would still be unable to walk properly because of Pt would still be unable to walk properly because of

swelling, ↓ ROM, and lack of strengthswelling, ↓ ROM, and lack of strength ↓ ↓ ROM?ROM?

► Can not be adequately preformed because of pain and Can not be adequately preformed because of pain and swelling.swelling.

Swelling?Swelling?► This would be the highest priority This would be the highest priority

►Once the anti-inflammatory process Once the anti-inflammatory process has been controlled, swelling is has been controlled, swelling is reduced, and limited pain-free ROM reduced, and limited pain-free ROM has been restoredhas been restored Functional exercises should be initiatedFunctional exercises should be initiated

►ROM exercisesROM exercises►StretchingStretching►BalancingBalancing►ProprioceptionProprioception►And finally a strengthening protocolAnd finally a strengthening protocol

All of these will lead to a normal gait and All of these will lead to a normal gait and return to the pre injury activity levelreturn to the pre injury activity level

Case Study #1Case Study #1

Prioritize your problemsPrioritize your problems

Goal SettingGoal Setting

►Clear, concise, and measurable goals Clear, concise, and measurable goals translate the prioritized problem list translate the prioritized problem list into a well-constructed treatment plan.into a well-constructed treatment plan. 2 types2 types

►Short term (1-14 days)Short term (1-14 days)►Long term (> 14 days)Long term (> 14 days)

These types of goals will identify your These types of goals will identify your outcomes, establish timelines, and outcomes, establish timelines, and measure the effectiveness of the measure the effectiveness of the treatment protocoltreatment protocol

► Patients ability to meet the established goals Patients ability to meet the established goals indicates advancement to the next stage.indicates advancement to the next stage.

►While a patients inability to progress indicates While a patients inability to progress indicates a modification in treatment is necessarya modification in treatment is necessary

► Also, properly written and documented goals Also, properly written and documented goals are used for insurance and legal purposes and are used for insurance and legal purposes and demonstrates the criteria used to decide when demonstrates the criteria used to decide when to discharge you patient from careto discharge you patient from care

► Tx goals are an estimation of where you Tx goals are an estimation of where you expect the patients progress to be at a expect the patients progress to be at a specific point in timespecific point in time Should be consistent with the patients priorities, Should be consistent with the patients priorities,

lifestyle, and expectations (when feasible)lifestyle, and expectations (when feasible) The patient should be encouraged to participate The patient should be encouraged to participate

in the treatment goalsin the treatment goals Compliance with the protocol and the programs Compliance with the protocol and the programs

effectiveness are effectiveness are ↑ when the goals are fully ↑ when the goals are fully understood and agreed upon by everyone understood and agreed upon by everyone involvedinvolved

► The most important reason to establish The most important reason to establish goals is to motivate the patientgoals is to motivate the patient Each goal that is met marks another milestone Each goal that is met marks another milestone

on the road to recoveryon the road to recovery

Measurable GoalsMeasurable Goals► ProblemProblem

The patient has an inversion ankle sprain. Active The patient has an inversion ankle sprain. Active ROM produces 2ROM produces 2°° of dorsiflexion and the patient of dorsiflexion and the patient cannot ambulate with a normal gaitcannot ambulate with a normal gait

►Nonobjective goalNonobjective goal To ↑ active dorsiflexionTo ↑ active dorsiflexion

►Objective goalObjective goal To ↑ active dorsiflexion to 10°To ↑ active dorsiflexion to 10°

► Re-evaluation Re-evaluation The patient has 8° of active dorsiflexionThe patient has 8° of active dorsiflexion

► AssessmentAssessment The patient has met the nonobjective goal to ↑ The patient has met the nonobjective goal to ↑

active dorsiflexion but has not met the active dorsiflexion but has not met the objectively stated goal. Because a min. of 10° of objectively stated goal. Because a min. of 10° of dorsiflexion is required for normal gait, we can dorsiflexion is required for normal gait, we can assume that the patient still has an altered gait.assume that the patient still has an altered gait.

Goal PyramidGoal Pyramid

Developing Written Developing Written GoalsGoals

►You should start by taking all of the You should start by taking all of the prioritized problems, and in an orderly prioritized problems, and in an orderly fashion, formulate the final treatment fashion, formulate the final treatment outcomes, a list of long term goals, outcomes, a list of long term goals, and a list of short term goalsand a list of short term goals Note on short term goal may apply to Note on short term goal may apply to

more than one long term goalmore than one long term goal

►Final step determining what goals Final step determining what goals should be reasonably accomplished in should be reasonably accomplished in the given time framethe given time frame

►Use the ABCD formatUse the ABCD format This is stated in terms of what will be This is stated in terms of what will be

accomplished in the estimated time periodaccomplished in the estimated time period Rather than what limitations will be presentRather than what limitations will be present

►This serves to motivate the patient and also keep This serves to motivate the patient and also keep you focused on how the plan must be altered to you focused on how the plan must be altered to facilitate the patients progressfacilitate the patients progress

Last, to avoid confusion, the goals should be Last, to avoid confusion, the goals should be written in precise vs general terms for each written in precise vs general terms for each problemproblem

Long term goalsLong term goals► Provide direction to the treatment plan byProvide direction to the treatment plan by

Identifying and quantifying the final outcomes of Identifying and quantifying the final outcomes of the treatment programthe treatment program

Are often used as outcome measuresAre often used as outcome measures► In most cases the long-term goal is to return In most cases the long-term goal is to return

to the preinjury level of functionto the preinjury level of function But is not always feasibleBut is not always feasible

► Although long term goals are subject to Although long term goals are subject to modification throughout your rehab, they modification throughout your rehab, they are revised less often than short term goals.are revised less often than short term goals.

► Last, but most important, these goals should Last, but most important, these goals should identify the patients needs as the focus of identify the patients needs as the focus of their treatment rather than in individual their treatment rather than in individual pathologies afflicting the personpathologies afflicting the person

►You should make every attempt to You should make every attempt to make long term goals measurable, make long term goals measurable, however they should also be however they should also be functional.functional. ExampleExample

►To return to full competition in college footballTo return to full competition in college football►Or, To return to the preinjury level of activity Or, To return to the preinjury level of activity

at the sawmillat the sawmill These define the final outcome of the patients These define the final outcome of the patients

therapy, and their use should be encouragedtherapy, and their use should be encouraged

Because LTG attempt to describe the final Because LTG attempt to describe the final outcome the number of these goals outcome the number of these goals should be less than the number of short should be less than the number of short term goalsterm goals

Case Study #1Case Study #1

Write some long term goalsWrite some long term goals

Short term goalsShort term goals

►Describe the functional progression that Describe the functional progression that the patient will obtain in a specific time the patient will obtain in a specific time frame.frame. Usually focus on the specific problems Usually focus on the specific problems

identifiedidentified If met, will achieve the long term goalsIf met, will achieve the long term goals In general, the time established for meeting In general, the time established for meeting

these goals is the time that you feel is these goals is the time that you feel is needed to produce a measurable change in needed to produce a measurable change in the patients conditionthe patients condition

►STG’s serve as a measuring stick for STG’s serve as a measuring stick for the treatment plan.the treatment plan.

►During re-eval, you should be able to During re-eval, you should be able to determine that goals are being met determine that goals are being met and progress is being made.and progress is being made.

► If STG’s are not being met, you should If STG’s are not being met, you should re-evaluate the treatment program re-evaluate the treatment program and change it accordingly.and change it accordingly.

Case Study #1Case Study #1

Write some short term goalsWrite some short term goals

Treatment PlanningTreatment Planning

►Once the problems have been determined, Once the problems have been determined, prioritized, and goals have been established, prioritized, and goals have been established, the planning of treatment follows naturallythe planning of treatment follows naturally

► The stage of healing and the choice of The stage of healing and the choice of therapeutic technique largely determine therapeutic technique largely determine what modality types will be usedwhat modality types will be used

►Once the type of modality to use has been Once the type of modality to use has been determined, the application is determined determined, the application is determined based on physical characteristics of the based on physical characteristics of the surface being treatedsurface being treated

►ExampleExample If a chronic ankle sprain is being treated and If a chronic ankle sprain is being treated and

there is little or no swelling, the modality of there is little or no swelling, the modality of choice would probably be heat.choice would probably be heat.

► In this scenario, the physical In this scenario, the physical characteristics of an ankle sprain would characteristics of an ankle sprain would most likely call for the use of a warm most likely call for the use of a warm whirlpool rather than a moist heat pack.whirlpool rather than a moist heat pack.

►A common area of frustration is that in A common area of frustration is that in many cases there is no one “best” many cases there is no one “best” choice modality.choice modality.

►Often the final decision on which one to Often the final decision on which one to use is based on personal comfort, past use is based on personal comfort, past experience, and patient input.experience, and patient input.

►However this frustration can work to However this frustration can work to your advantage, if satisfactory results your advantage, if satisfactory results are not being obtained from the 1are not being obtained from the 1stst modality, the treatment protocol can modality, the treatment protocol can easily be modified to incorporate an easily be modified to incorporate an alternate one.alternate one.

Case Study #1Case Study #1

Plan treatmentsPlan treatments

Always consider the Always consider the healing stagehealing stage

Acute Inflammatory stageAcute Inflammatory stage

Proliferation phaseProliferation phase

Maturation PhaseMaturation Phase

Evaluation of the Evaluation of the treatment plantreatment plan

►Re-evaluation of the patient serves as an Re-evaluation of the patient serves as an evaluation of the treatment plan.evaluation of the treatment plan.

►You assess the findings of the re-eval to You assess the findings of the re-eval to determine if the plan has been determine if the plan has been successfulsuccessful Have you been successful in meeting STG’sHave you been successful in meeting STG’s Are you progressing towards your LTG’sAre you progressing towards your LTG’s

►If your goals are not being met you must make If your goals are not being met you must make necessary adjustments and you must identify necessary adjustments and you must identify why they were not successful.why they were not successful.

Case study #1Case study #1

Identify changes that can be Identify changes that can be made in the program if the 1made in the program if the 1stst

treatment was not workingtreatment was not working

Consider workplace Consider workplace influencesinfluences

DocumentationDocumentation

►Medical records serve a wide range of Medical records serve a wide range of purposespurposes

►Evaluation findings should be Evaluation findings should be documented as specifically as possible, so documented as specifically as possible, so continuity of care can be established in continuity of care can be established in the event of more than one person is the event of more than one person is treating the patienttreating the patient

►Even minor changes in a modality’s Even minor changes in a modality’s application parameters can produce application parameters can produce drastically different physiological effectsdrastically different physiological effects

►Morale of the story…. Always document!!!Morale of the story…. Always document!!!

Legal ConsiderationsLegal Considerations

►Scope of practiceScope of practice► Informed consentInformed consent►NegligenceNegligence

Patients have the right to receive safe and Patients have the right to receive safe and proper tx without exposure to undue proper tx without exposure to undue hazards.hazards.

►Negligent delivery of TreatmentNegligent delivery of Treatment OmissionOmission CommissionCommission

►Negligent care of facilitiesNegligent care of facilities

Considerations for safe Considerations for safe facilitiesfacilities

► All electrical modalities should be connected All electrical modalities should be connected to a GFI. Whirlpools and jacuzzis must be to a GFI. Whirlpools and jacuzzis must be connected to these devices alsoconnected to these devices also

► Patients must not be permitted to turn Patients must not be permitted to turn on/off whirlpools while they are in the water. on/off whirlpools while they are in the water. Ideally, the switches should be located so Ideally, the switches should be located so that they cannot be reached from these tubsthat they cannot be reached from these tubs

► All modalities should be inspected and All modalities should be inspected and calibrated by a licensed professional at calibrated by a licensed professional at intervals prescribed by the manufacturer.intervals prescribed by the manufacturer.

► Flooring should be made of nonslip materialFlooring should be made of nonslip material

On to Chapter 4On to Chapter 4

Thermal AgentsThermal Agents