Re: Aged Care Funding Instrument revision - Physiotherapy · PDF fileThe ACFI should be changed to reflect the following: Section 2 – Mobility should include a mandatory physiotherapy

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14 May 2012 Keith Tracey-Patte Assistant Secretary Policy and Evaluation Branch Ageing & Aged Care Division GPO Box 9848 Canberra ACT 2601 Dear Keith Re: Aged Care Funding Instrument revision I am writing with regards to the revision of the Aged Care Funding Instrument (ACFI). As the APA has been excluded from any recent discussions on the revision to ACFI, we are concerned about the potential implications that may arise from changes to ACFI that can affect the care provided to older Australians and be detrimental to their health and wellbeing. Our members are gravely concerned with rumours that some aged care providers may significantly reduce or altogether remove services provided by physiotherapists should there be changes to ACFI that do not support therapies that reduce pain, and maximise function and independence. Whilst we acknowledge that as revisions to ACFI remain unannounced and the above concerns are driven by speculation within the industry, we need to ensure that any change does not inadvertently reduce the access of aged care residents to physiotherapy. Physiotherapy is a vital component in aged care and one of the key treatments that can optimise function and improve the health of older Australians – this is acknowledged by the Productivity Commission in its report Caring for Older Australians. We are fully aware of the issues with the current ACFI model. Some of the changes that were recommended in our earlier submissions to the Department of Health and Ageing (please refer to attachment) are:

To help support older Australians gain and maintain independence and in the case of home care (when ACFI will eventually be used for older Australians in the community as proposed in the Living Longer, Living Better package) help them remain and receive care at home, restorative assessment and treatment should be included as a section in the ACFI. This care should encompass

o maximising physical functionality o falls and balance o continence – especially functional incontinence o pain management

No funding levels should dictate the frequency of treatment, other than requiring that they be

based on clinical best practice.

Treatment options should support the clinical judgement of the most suitably qualified health professional, and should be based on the most up-to-date evidence and guidelines available. The Complex Health Care section should be amended to support the most appropriate clinician’s clinical decision, rather than focusing on particular modalities and frequencies.

Perverse incentives that currently encourage behaviour leading to further functional decline instead of promoting maintenance of function and mobility must be addressed. An example is when a resident who is slow and requires supervision is placed in a wheelchair as it attracts a higher level of funding and requires less staff time, despite assisted walking being able to improve mobility.

We are also acutely aware that there is currently a lack of a rehabilitative or restorative focus in residential aged care where specific physiotherapy interventions are evidenced to improve or maintain function, and we believe this is partly influenced by the existing ACFI funding model. The APA believes that we need to be directly involved with any review of ACFI. As one of the main health professions in the aged care sector, it is crucial that we are able to directly advise points such as the above, as well as ensuring that, as previously mentioned, changes to ACFI does not inadvertently reduce the access of aged care residents to physiotherapy. Please feel free to contact Darren Li, Senior Policy Officer, at (03) 9092 0840 or email [email protected] should you require any clarification or more information about the points made above, or any matters related to the provision of physiotherapy for older Australians. Thank you for your consideration and I look forward to your response. Yours faithfully,

Cris Massis Chief Executive Officer

Submission to the Review of the Aged CareFunding Instrument

Presented to the Department of Health andAgeing

April 2010

Authorised by:

Patrick MaherPresidentAustralian Physiotherapy Association1/1175 Toorak RdCamberwell VIC 3124Phone: (03) 9092 0888Fax: (03) 9092 0899www.physiotherapy.asn.au

http://www.physiotherapy.asn.au/

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Executive Summary

The APA advocates that any aged care system should aim to maximise mobility and functionalindependence in older people, and that such a system would greatly contribute to improving qualityof life for its participants and reduce the burden of care.

The APA makes the following recommendations:

That the requirement for residents to be reassessed under the ACFI six months afterreadmission from extended hospital leave be removed.

That restorative assessment and treatment be included as a section in the ACFI. Treatmentshould be available for both low and high care residents. This care should encompass

o maximising physical functionalityo falls and balanceo continence – especially functional incontinenceo pain management

No funding levels should dictate the frequency of treatment, other than requiring that they bebased on clinical best practice.

Treatment options should support the clinical judgement of the most suitably qualified healthprofessional, and should be based on the most up-to-date evidence and guidelines available. Amechanism should be implemented, that ensures funding for the incorporation of new,evidenced based guidelines as they are released.

Funding incentives that are built into the current ACFI that encourage providers to improve andmaintain the physical function of residents should be explicit in the ACFI documentation.

The Complex Health Care section should be amended to support the most appropriateclinician’s clinical decision, rather than focusing on particular modalities and frequencies.

Funded pain management modalities should include current modalities such as therapeuticexercise programs supervised by physiotherapists.

The ACFI should be changed to reflect the following:

Section 2 – Mobility should include a mandatory physiotherapy falls assessment (as per theACSOHC Guidelines). Where clinically indicated, residents should be enrolled in aphysiotherapist supervised falls and balance program that is based on current clinicalpractice guidelines

Section 5 – Continence should include a physiotherapy assessment to determine suitabilityfor physiotherapy intervention to improve function.

Section 12 – Complex Health Care should:o define an ‘allied health professional’, and the list should be kept up to dateo require all staff (other than physiotherapists and medical practitioners) administering

heat packs, therapeutic massage or pain management involving technicalequipment specifically designed for pain management to have undergone aminimum training requirement specific to the modality being applied. Training mustinclude (but should not be limited to) such areas as: contra-indications;complications; tests required prior to treatment; required warnings; supervision ofthe resident during application; and familiarity with the APA’s guidelines for theclinical use of electrophysical agents.

o move the funding criteria away from the focus on duration of treatment. Fundingshould match the severity of the condition, rather than prescribing treatmentcategories

o require that interventions used are based on the clinical requirements of the resident

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That the Department of Health and Ageing (DoHA) work with Medicare to ensure that thesystems are integrated effectively, and that the mandatory requirement for GP contribution tocare plans be removed.

Residents of RACFs with a complex condition should be recognised as needing more than fivesessions, and should be entitled to additional consultations with specified allied healthprofessionals under the program.

That a pool of funding be allocated to people who move from an acute hospital bed to an agedcare bed. This funding should be used for rehabilitation for a set period of time.

That the ACFI include a mechanism to ensure that incentives are offered to fund implementationof new evidence based guidelines into residential aged care facilities.

It is extremely difficult for aged care providers to balance budgets based on medium to long termcost savings and intangible improvements in resident well-being. With slim day to day profit margins,providers find it difficult to invest in therapies which will provide long term cost savings.

It is up to the Government of Australia to ensure that care to older people is not focused onmaximising dependency in order to maximise funding, but instead focused on prevention of decline,maximisation of function and clinical best practice.

If the focus on resident dependence is allowed to continue without an equal focus on the preventionand improvement of ill health, then the ‘burden’ of Australia’s ageing population will soon becomeunmanageable. This submission provides recommendations that aim to change the focus ondependency to ensure that people who have the potential to improve function are empowered to doso.

Australian Physiotherapy Association

The Australian Physiotherapy Association (APA) is the peak body representing the interests ofAustralian physiotherapists and their patients. The APA is a national organisation with state andterritory branches and specialty subgroups. The APA corporate structure is one of a company limitedby guarantee. The organisation has approximately 12,000 members, some 70 staff and over 300members in volunteer positions on committees and working parties. The APA is governed by aBoard of Directors elected by representatives of all stakeholder groups within the Association.

The APA vision is that all Australians will have access to quality physiotherapy, when and whererequired, to optimise health and wellbeing. The APA has a Platform and Vision for Physiotherapy2020 and its current submissions are publicly available via the APA websitewww.physiotherapy.asn.au.

http://www.physiotherapy.asn.au/

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The Aged Care Funding Instrument (ACFI)

Introduction

The APA advocates that any aged care system should aim to maximise mobility and functionalindependence in older people, and that such a system would greatly contribute to improving qualityof life for its participants and reduce the burden of care. This submission contains recommendationsthat the APA believes would help the Australian residential aged care system to achieve thesegoals.

Physiotherapists have been concerned about the effects of the ACFI on residents of ResidentialAged Care Facilities (RACF) since the inception of the new funding instrument, and observations ofits wide implementation have shown that these concerns remain valid.

The Aged Care Funding Instrument (ACFI) is ‘based primarily on the resident’s need for care anddependency’

1and does not provide incentives for residential aged care providers (‘providers’) to

offer interventions that reduce dependency and decline. Instead, it rewards premature increase infunctional decline, meaning that residents need more care, more staff and more funding.

The APA’s concerns continue to revolve around the negative incentives that form the basis of theinstrument, namely that maximal dependency is equated with maximal funding, and we believe thatthere are no effective incentives for providers to focus on improving independence and functionality.These financial incentives steer providers and residents towards unintentional premature disability –maximum dependency and maximum financial reward are linked.

The Department of Health and Ageing (‘the Department’) has responded to these concerns bysaying that providers do have an incentive to reduce dependence, as ongoing ACFI assessmentsare not required, and if an RACF is able to improve the condition of a resident who has beenassessed as high care, they will still receive funding for that resident at a high care level.

During the first year of the ACFI however, the APA has noted several problems with the operation ofthis incentive, primarily as the incentive is not made clear in any literature around the ACFI.Providers and staff may therefore not be aware of it at all.

Even if this incentive was clear to providers, the APA believes that the initial outlay on professionalstaff may mean that busy providers and care staff do not see future potential cost savings as a highpriority. Therefore potential improvements in residents’ quality of life can be lost to more immediatefactors – such as getting to the dining room quickly in a wheel chair rather than being provided withwalking assistance, or the provision of continence pads, rather than be provided with physiotherapyto improve toileting control.

Physiotherapists believe that low care residents have a great potential to benefit from physiotherapyto maximise mobility and independence. There is no funding for this in the ACFI even thoughphysiotherapy could actively prevent these low care residents from prematurely drifting into highcare. Funding for treatment for these residents should be incentivised through the ACFI.

While the Federal Government contributes significant amounts to the residential aged care sector,the APA believes that physiotherapy is still under-utilised in facilities. The result is that manyresidents are not able to gain access to physiotherapy services that could improve such factors as:

incidents of injury from falls pain management management of osteoarthritis management of osteoporosis management of type 2 diabetes improvement in mobility and dexterity management and improvement of incontinence

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Factors such as perceived cost, supply and lack of awareness about physiotherapists’ skills have arole in this under-utilisation, and the APA urges the government to ensure that its funding instrumentsupports aged care residents to access care that facilitates restorative treatments.

The 2009 Aged Care Survey

In 2009 the APA undertook a survey to ascertain the changes to the provision of physiotherapyservices within the residential aged care sector. The key findings were:

Optimal pain management has been compromised since the introduction of the ACFI

Exercise programs in most facilities have either decreased or failed to expand since theintroduction of the ACFI

A significant proportion of physical therapy is delivered by staff members who are notappropriately qualified or experienced

There is a poor rate of uptake of Medicare items for physiotherapy services

There appears to have been a decline in the ratio of physiotherapists to residents withinresidential aged care facilities (RACF)

The survey indicates that there has been an increase in the number of unpaid hours workedby physiotherapists since the introduction of the ACFI

Half of the physiotherapists surveyed believe that the therapy needs of residents in RACFsare not adequately met

Just under half of the physiotherapists surveyed believed that optimum levels of mobility anddexterity were not achieved for all residents, meaning that nearly half of all RACFs are notfully meeting accreditation standards.

Elderly residents of RACFs need sufficient care to maintain wellbeing and the best possible level ofmobility. The Australian Physiotherapy Association believes that the ACFI review must urgentlyaddress the problems identified in the survey, to ensure that Australia’s aged care residents receivethe most appropriate level of treatment from skilled practitioners.

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A full copy of the report is appended to this submission.

Matching funding to care needs

The APA believes that RACF residents, like all Australians, are entitled to care that maximiseswellbeing and quality of life. The APA believes that there are a number of specific care needs thatare not well captured by the ACFI, resulting in poorer quality of life for older people in RACFs.

In the APA’s 2009 Aged Care Survey, an alarming 50 per cent of physiotherapists did not believethat residents’ therapy needs were adequately met in their RACF, indicating that the ACFI has donelittle to improve access to the therapy residents require.

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The three primary areas in need of funding through the ACFI are restorative care, preventative care(particularly falls prevention), and pain management. The APA believes that funding must bematched more carefully to the needs of the whole person.

Restorative care

Aged Care Assessment Teams (ACAT) comprehensively assess people for the restorative, physical,medical, psychological, cultural and social dimensions of a person’s care needs

4, yet the ACFI

literature says that restorative care is explicitly excluded from the ACFI. This is despite restorativecare and rehabilitation being greatly needed by many residents of RACFs. It also has the potential toreduce costs for providers in the mid and longer terms.

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The Quality of Care Principles specifically excludes providers from providing their residents withrehabilitation after serious illness, injury or trauma. These principles made under the Aged Care Act1997 say that low care residents are not provided with this level of physiotherapy. While not withinthe scope of this review, the APA believes that these principles should urgently be amended toensure that they do not preclude rehabilitation after an acute event.

After hospitalisation

Lack of any rehabilitation for residents after hip fracture is one example of the problem experiencedwhen returning to a RACF after a period of hospitalisation. It is a fact of life that busy staff in ourhospitals need to prioritise some patients over others, and identify those most at risk after discharge.Consequently elderly patients who will return to the community are often the first to receiverehabilitation, and there is an assumption that those returning or going to an RACF will be providedwith both maintenance and rehabilitation by facility staff.

Unfortunately this does not usually occur, and busy staff can often provide only basic maintenancecare, which does not take into consideration the potential for considerable improvement during thesub-acute phase. Were adequate funding available, physiotherapists could provide rehabilitationservices to people in RACFs after an acute episode requiring hospitalisation such as a hip fracture.Such services could prevent residents from becoming bed or chair bound and so reduce the burdenand cost of care after a few shorts weeks of rehabilitation. A further disincentive to providing carethat improves a resident’s independence is the mandatory requirement that facilitates re-assessresidents six months after an extended hospitals stay. Physiotherapists working in RACFs feel thatthis is a barrier to the improvement of residents’ condition after an acute episode.

APA members have reported their frustrations when seeing resident’s potential for improvement, butnot having the opportunity to treat them. When asked about her experiences working in an RACFunder the old funding model and then under the ACFI, one physiotherapist had the following to sayabout one of her private patients.

1. [I treated] a 58 year old man with a wife with Parkinson’s disease. He was hospitalised withbowel cancer, had surgery and chemo. He then had Guillain–Barré syndrome, probablyfrom an infection while on chemo and then after some rehab ended up with a lot of muscleremoved from his leg when a melanoma was eventually surgically excised. He was then toldhis “paralysis” was permanent, he wasn’t for rehab and placed in a Nursing home… Afterour rehab he walked out of the home on 2 walking sticks, started driving and looked after hiswife at home.

This level of physiotherapy intervention provided was not funded through the ACFI. The Quality ofCare Principle that removes the obligation to provide rehabilitation after surgery also forms a barrierto RACFs providing this level of care.

Another physiotherapist told a similar story about a client that she treated residing in an RACF.

An elderly woman who had a severe stroke, was initially unable to sit, was full assist withhoist. [She] was not given rehab in hospital. She was very keen to walk again even though itseemed unlikely. She was given lengthy rehab in [the] nursing home by physios for manymonths and is now able to walk with a FASF [forearm support frame] with staff and uses astand up hoist instead of the full hoist which is more dignified for her and easier for the staff.

For each person who can afford to privately fund physiotherapy to improve their independence andmobility, there must be many more unable to access this kind of care. Statistics from the PrivateHealth Insurance Administration Council (PHIAC) indicate that around 85,000 people aged over 85years held general treatment coverage (‘extras’) in December 2009.

5When compared to Australia’s

population of 515,000 males and females aged 85 or over6, it becomes apparent that very few

people in RACFs would have the assistance of private health insurance to assist them in accessingprivate physiotherapy rehabilitation.

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National Physical Activity Guidelines for Older Australians

The Australian Government published the National Physical Activity Guidelines for Adults, and hasdeveloped further recommendations for older Australians. These recommendations encompass allolder Australians, including people living in residential care. The guidelines make fiverecommendations but the first two are most relevant to older people living in RACFs:

1. Older people should do some form of physical activity, no matter what their age, weight,health problems or abilities

2. Older people should be active every day in as many ways as possible, doing a range ofphysical activities that incorporate fitness, strength, balance and flexibility.

By funding only dependency and failing to offer any funding for treatments that would improve olderpeople’s capacity to participate in physical activity (such as assistance to walk to meals) the ACFI isfailing to follow the Guidelines. The ACFI provides more funds for pushing a person in a wheel-chairthan it does to assist the same person to walk to meals, despite walking assistance taking more timebut being more beneficial for the resident.

The Guidelines also outline the following benefits of regular physical activity. These include helpingto:

maintain or improve physical function and independent living improve social interactions, quality of life, and reduce depression build and maintain healthy bones, muscles and joints, reducing the risk of injuries from

falls reduce the risk of heart disease, stroke, high blood pressure, type 2 diabetes, and some

cancers7

A mechanism to assist RACFs to provide activities that work towards fulfilling the recommendationsshould be developed for all residents, including those with decreased mobility, at risk of falls, chronicdisease and pain.

Continence in older people

Treatment delivered by a physiotherapist with expertise in continence issues to patients who haveimpaired bladder control can reduce dependence, thus helping to improve residents’ physical andmental wellbeing. Active management of incontinence rather than passive acceptance of thecondition is in the best interests of residents and care facilities alike.

Unfortunately this is not acknowledged by the ACFI. The ACFI funds dependency by providingmoney only for the supply of services and products such as incontinence pads and assisted toileting.It fails to support physiotherapy services which aim to increase residents’ ability to control andimprove functional continence.

Preventative care and falls prevention

Falls have a huge economic and quality of life cost to the community. It is estimated that if nothing isdone to prevent falls, by 2051 the total health cost attributable to falls-related injury will nearly triplefrom $498.2 million in 2001 to $1,375 million per year in 2051. In addition, an extra 3320 additionalRACF beds will be needed.

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Work has already been done by the Australian Commission on Safety and Quality in Healthcare(ACSQ) in producing guidelines around falls prevention in RACFs, however more must be done bythe Australian Government to encourage providers to read and adopt the recommendations intotheir facilities – no small task considering the full report runs for 189 pages.

While expensive to implement in the short term, falls prevention programs that follow best practiceguidelines are vital to the continued viability of both the aged care and health systems. To do this,falls and balance assessments and programs must be factored into the ACFI.

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Rather than doing this however, ACFI is diverting such needed physiotherapy time with its selectivefunding of only some modalities of physiotherapy treatment.

Guidelines

Multi-factorial multidisciplinary falls prevention programs are recommended by the ACSQ guidelines.Yet the APA’s data actually shows that there has been a decline in falls prevention programs run byphysiotherapists within RACFs. The APA’s Aged Care survey shows that there has been an over-alldecline in physiotherapy led falls and balance classes in RACFs of 20 per cent.

9Physiotherapists

who participated in the survey commonly attributed this to the perception that such classes are notfunded.

As part of the survey, physiotherapists were asked to make recommendations that would improvetheir RACF. The second most common response (below an increase in physiotherapy hours) wasaround the funding and provision of exercise programs for balance and mobility.

It is important that appropriately trained health professionals run these programs, as to be effectiveat falls prevention, programs need to be designed at a level that will produce physiological changeand challenge balance. This requires higher level skills and knowledge of pathology to be safelyimplemented. Physiotherapists are trained in these skills, and these programs should be deliveredby physiotherapists in all residential aged care facilities.

Other recommendations in the Guidelines include:

As many falls occur during toileting, and physiotherapy intervention should be utilised tomaximise continence (Section 8.2.2)

For women in RACFs who have a history of fracture associated with osteoporosis, ongoingphysiotherapy assessment and management is particularly important. (Section 19.2.1)

Pain management

The APA applauds the Department’s recognition that chronic pain is a poorly understood andundertreated condition in aged care facilities. However the APA is still concerned about the way inwhich pain management funding has been included in the ACFI.

The ACFI supports only specific, passive modalities of pain management. This encouragesproviders to reduce or eliminate funding for other evidenced-based interventions, and underminesthe independence of clinical decision making by physiotherapists.

Funding for the management of pain which encourages the use of physiotherapy treatmentmodalities is dangerous. In 2009 a physiotherapist told the APA of her experiences in unqualifiedstaff carrying using heat packs:

I have seen severe burns in my facility where [untrained] staff applied hot packs to residentswith sensation loss… [They] did not understand that this could happen.

Guidelines

Pain management requirements under the ACFI should have reference to the Australian PainSociety’s Pain in Residential Aged Care Facilities: Management Strategies – The Pain ManagementGuide Kit for Aged Care.

Guideline 19 of this document says that ‘Physical therapies, such as superficial heat andTranscutaneous Electrical Nerve Stimulation (TENS) can be helpful in reducing pain intensity in theshort term, for residents who are able to provide feedback on their experience.’

10The guideline goes

on to say that such modalities are not indicated for the management of persistent pain, and mostimportantly for high care geriatric residents, that these modalities are contra-indicated for peoplewith impaired cognition (ie dementia or Alzheimer’s) or for those otherwise unable to communicate.Residents need to be able to relate any discomfort to staff, and treatments must be carefullymonitored. This is also stated in the APA’s Guidelines for the Clinical use of ElectrophysicalAgents

11(which are appended to this document).

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The ACFI ignores Guideline 18 from the Australian Pain Society, which says that ‘Therapeuticexercise can decrease pain. Strengthening, stretching and aerobic exercises can be beneficial inincreasing function and improving mood, as well as reducing pain intensity.’ Pain intensity can bereduced by up to 30 per cent, and has been shown to improve mood in older people withdepression.

Complex health care items

There are some specific issues that physiotherapists have identified around the complex health caresection of the funding. These are outlined below.

Item 4a – Complex pain management and practice undertaken by an allied healthprofessional or registered nurse. This will involve therapeutic massage and/or painmanagement involving technical equipment specifically designed for pain management ANDFrequency at least weekly, AND involving at least 20 minutes of staff time in total.

This item precludes the use of prescribed supervised exercise for the management of pain, amodality that is well accepted, evidence based, and not contra-indicated for patients with a cognitiveimpairment such as dementia.

Item 4b – Complex pain management and practice undertaken by an allied healthprofessional which involves therapeutic massage and/or pain management involvingtechnical equipment specifically designed for pain management AND Frequency at least 4times per week.

In addition to the problem of exclusion of some modalities of pain management, physiotherapists areconcerned that this level of intervention could be clinically justifiable in only extremely severe cases.Further more, in small facilities or outside major cities, adequate staffing to provide this care wouldbe nearly impossible to find or fund.

RECOMMENDATIONS

That the requirement for residents to be reassessed under the ACFI six months after readmissionfrom extended hospital leave be removed.

That restorative assessment and treatment be included as a section in the ACFI. Treatment shouldbe available for both low and high care residents. This care should encompass

maximising physical functionality falls and balance continence – especially functional incontinence pain management

No funding levels should dictate the frequency of treatment, other than requiring that they be basedon clinical best practice.

Treatment options should support the clinical judgement of the most suitably qualified healthprofessional, and should be based on the most up-to-date evidence and guidelines available.

A mechanism should be implemented, that ensures funding for the incorporation of new, evidencedbased guidelines as they are released.

Funding incentives that are built into the current ACFI that encourage providers to improve andmaintain the physical function of residents should be explicit in the ACFI documentation.

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Funding outcomes and impact on aged care providers

The ACFI specifically funds some modalities. This has resulted in a perception by providers thatcertain modalities of treatment are not funded. This is particularly evident in the pain managementsection of Complex Health Care under which only massage, electrotherapy (eg. TENS, lasertherapy, ultrasound therapy etc.) and heat packs can be funded, to the detriment of exerciseprograms for pain management.

In 2009, the APA’s Aged Care survey found that under the ACFI system, 32 per cent ofphysiotherapists have experienced a decrease in exercise programs delivered in RACFs with 2 percent reporting that exercise programs have ceased completely. This is in comparison with 14 percent of physiotherapists saying that exercise programs have increased under ACFI.

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In contrast to this, 35 per cent say that the number of hours that are spent on deliveringelectrotherapy and massage for pain relief have increased, compared to 6 per cent reporting adecrease in these modalities.

Some physiotherapists reported facing pressure from aged care providers to use techniques thatattract funding, regardless of the suitability of the resident for that particular type of care. Forinstance TENS is contra-indicated for patients with cognitive impairment such as dementia, andheat-packs can be dangerous when applied to people with sensation loss and poor circulation (forexample people with diabetes).

RECOMMENDATIONS

The APA recommends that the Complex Health Care section be amended to support the mostappropriate clinician’s clinical decision, rather than focusing on particular modalities and frequencies.

Funded pain management modalities should include current modalities such as therapeutic exerciseprograms supervised by physiotherapists.

Documentation and administrative arrangements

Despite the ACFI not requiring regular re-assessment for funding reasons, annual review of aresident’s condition is normal clinical practice. For this reason, physiotherapists do not feel that theadministrative burden has improved in RACFs with the introduction of ACFI.

Design issues including the roles of health professionals

Physiotherapists are frustrated with the ACFI, as they feel that it limits their input into the care ofresidents of RACFs, despite the potential for improvement that some of these residents display.Some physiotherapists face a battle to convince RACF managers that they are able to do more thanprescribe the pain management treatments outlined in the ACFI documentation.

The ACFI needs to acknowledge that physiotherapists can run falls prevention programs, active painmanagement classes, can assist with improving continence and are imperative to assist residentsachieve optimum levels of mobility and dexterity.

Residents in RACFs often have multiple pathologies that impact on therapy options.Physiotherapists have the training and skills to treat these complex and co-dependent conditions.For instance there is a great deal of evidence for the efficacy of physiotherapy exercise programs forpeople with knee osteoarthritis, however residents may have co-morbities such as osteoporosis,which could limit mobility and increase the risk of fracture. Physiotherapists can tailor programs tothe individual, so that programs are not only safe for people with these complex co-morbities andpathologies, but are effective in improving function, reducing pain and preventing injury.

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RECOMMENDATIONS

The ACFI should be changed to reflect the following:

Section 2 – Mobility should include a mandatory physiotherapy falls assessment (as per theACSOHC Guidelines). Where clinically indicated, residents should be enrolled in aphysiotherapist supervised falls and balance program that is based on current clinical practiceguidelines

Section 5 – Continence should include a physiotherapy assessment to determine suitability forphysiotherapy intervention to improve function.

Section 12 – Complex Health Care should:o define an ‘allied health professional’, and the list should be kept up to dateo require all staff (other than physiotherapists and medical practitioners) administering

heat packs, therapeutic massage or pain management involving technicalequipment specifically designed for pain management to have undergone aminimum training requirement specific to the modality being applied. Training mustinclude (but should not be limited to) such areas as: contra-indications;complications; tests required prior to treatment; required warnings; supervision ofthe resident during application; and familiarity with the APA’s guidelines for theclinical use of electrophysical agents.

o move the funding criteria away from the focus on duration of treatment. Fundingshould match the severity of the condition, rather than prescribing treatmentcategories

o require that interventions used are based on the clinical requirements of the resident

Interface with other elements of aged care

Medicare Enhanced Primary Care program

The APA believes that the ACFI is very poorly integrated with other elements of care for agedpeople, particularly those with complex and chronic conditions. APA research has found that despiteits potential, the Enhanced Primary Care (EPC) program is under-utilised by residents of aged carefacilities.

Physiotherapists reported that 70 per cent of RACFs do not utilise Medicare EPC funding for alliedhealth at all. Physiotherapists reported that the main reasons were that doctors are too busy tocontribute to care plans (27 per cent of respondents), RACF staff were not aware of Medicarefunding (25 per cent) and doctors were not prepared to contribute to care plans (20 per cent). TheAPA believes that this rate of utilisation is unacceptably low, given the benefits that residents couldgain from restorative care by physiotherapists.

Another barrier that clinicians see to accessing these rebates is the number of visits available eachyear. Five sessions with an allied health profession is sometimes seen by providers and medicalpractitioners as not worth the administrative requirements to access. Compounding the issuesencountered by RACFs and health professionals is that these five sessions must be shared amongstthe allied health professions. This funding applies to people with chronic and complex conditions(such as many older people residing in RACFs) and this population is often in need of a range ofhealth professionals.

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47 per cent of respondents felt that the requirement for GPs to contribute to care plans was a barrierto their utilisation. The APA believes that the mix of healthcare professionals in aged care facilities isadequate to assess the need for physiotherapy treatment within RACFs, and health professionalssuch as physiotherapists and nurses are already well accustomed to involving a GP when they arepresented with conditions that are outside of their own scope of practice. GP involvement shouldtherefore not be mandated as a condition of Medicare funding. In addition, all RACF residents havealready been assessed by an ACAT team to have been admitted to a RACF.

RECOMMENDATIONS

That the Department of Health and Ageing (DoHA) work with Medicare to ensure that the systemsare integrated effectively, and that the mandatory requirement for GP contribution to care plans beremoved.

Residents of RACFs with a complex condition should be recognised as needing more than fivesessions, and should be entitled to additional consultations with specified allied health professionalsunder the program.

Acute and sub-acute care

Residents of RACFs are likely to interact with acute and sub-acute services, yet ACFI does notrecognise the need for rehabilitation after an episode of acute care. This results in problems whereresidents miss out on the rehabilitation that they need after an acute injury or condition.Rehabilitation workers within the hospital system often need to prioritise the rehabilitation of patientswho will return to the community rather than RACFs, as patients who are in residential care haverecourse to care within the facility. It has been physiotherapists’ experience that hospital staff mayexpect RACFs to provide some level of rehabilitation services. Unfortunately the reality is that thelow level of functionality that is seen in the acute setting may never improve due of lack ofphysiotherapy time within many facilities.

RECOMMENDATION

That a pool of funding be allocated to people who move from an acute hospital bed to an aged carebed. This funding should be used for rehabilitation for a set period of time.

Best practice guidelines

The Australian Government has released several excellent evidence based guidelines for olderpeople in both the community and residential care. However the ACFI system does support theimplementation of guidelines such as Choose Health: Be Active, A physical activity guide for olderAustralians, or Preventing Falls and Harm From Falls in Older People: Best practice Guidelines forAustralian Residential Aged Care Facilities 2009.

RECOMMENDATION

That the ACFI include a mechanism to ensure that incentives are offered to fund implementation ofnew evidence based guidelines into residential aged care facilities.

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Conclusion

It is extremely difficult for aged care providers to balance budgets based on medium to long termcost savings and intangible improvements in resident well-being. With slim day to day profit margins,providers find it difficult to invest in therapies which will provide long term cost savings.

It is up to the Government of Australia to ensure that care to older people is not focused onmaximising dependency in order to maximise funding, but instead focused on prevention of decline,maximisation of function and clinical best practice. The Government also needs to ensure that thetreatment of pain in older Australians is based on the appropriate evidence base and clinicalexpertise of physiotherapists.

If the focus on resident dependence is allowed to continue without an equal focus on the preventionand improvement of ill health, then the ‘burden’ of Australia’s ageing population will soon becomeunmanageable. This submission provides recommendations that aim to change the focus ondependency to ensure that people who have the potential to improve function are empowered to doso.

References

1Department of Health and Ageing, (2009). Review of the Aged Care Funding Instrument, CanberraDoHA

2Australian Physiotherapy Association, (2009). APA Aged Care Survey 2009, Melbourne, APA

3Ibid

4Department of Health and Ageing, (2009). Review of the Aged Care Funding Instrument, CanberraDoHA

5Private Health Insurance Administration Council, (2010), Membership and Coverage Data TablesDecember 2009, Canberra, PHIAC

6Australian Bureau of Statistics, (2009). Population by Age and Sex, Australian States andTerritories, Jun 2009, Cat No: 3201.0, Canberra, ABS

7Department of Health and Ageing, (2009). Recommendations on physical activity for health forolder Australians, Canberra, DoHA

8Australian Commission on Safety and Quality in Healthcare, (2009). Preventing Falls and HarmFrom Falls in Older People: Best practice Guidelines for Australian Residential Aged Care Facilities2009, Sydney, ACSOHC


10Australian Pain Society (2009). The Pain Management Guide Kit for Aged Care, Sydney, APS

11Australian Physiotherapy Association (2001). Guidelines for the Clinical use of Electrophysical

Agents, Melbourne, APA


ApA Aged Care Survey 2009

A G E d C A R E S U RV E Y 2 0 0 9

1

FOREWORd

The Australian Physiotherapy Association (APA) advocates for equitable access to quality physiotherapy and optimal health care for all Australians and is committed to ensuring that

government policy decisions do not adversely affect the delivery of physiotherapy within our communities.

Gerontology Physiotherapy Australia (GPA) is a national group of the APA whose philosophy of care is centred on maximising functional ability, which physiotherapists strongly promote in the residential aged care sector.

The introduction of the Aged Care Funding Instrument (ACFI) by the Federal Government has been of great concern to Gerontology Physiotherapy Australia since its proposal in 2005. In response to these concerns the APA undertook a survey to gauge the level of physiotherapy provided to clients in residential aged care facilities (RACFs).

The first survey in 2007 established important benchmarks of the level of physiotherapy service delivery prior to the introduction of the ACFI. The 2009 survey discussed in this report establishes what the effect of the introduction of the ACFI has been on the provision of physiotherapy services in our aged care facilities.

Patrick Maher Shylie MackintoshAPA President Chair – Gerontology Physiotherapy Australia

ABN 890 042 65150NATIONAL OFFICE • PO Box 437, Hawthorn BC, VIC 3122 • Level 1, 1175 Toorak Road, VIC 3124

Tel: (03) 9092 0888 • Fax: (03) 9092 0899 • www.physiotherapy.asn.au • Email: [email protected]


2

ACknOWlEdGEmEntS

Authors: Paula Johnson (Senior Policy Officer, APA National Office), Shylie Mackintosh, Chair, Gerontology Physiotherapy Australia and Jane Louis, Gerontology Physiotherapy Australia.

The APA wishes to acknowledge the work of the members of Gerontology Physiotherapy Australia, and the APA members who completed the survey.

First published 2010

© Copyright Australian Physiotherapy Association 2009

This work is copyright. Apart from any use permitted under the Copyright Act 1968, no part may be reproduced by any process without prior written permission from the APA.

Australian Physiotherapy Association PO Box 437, Hawthorn BC Victoria 3122 Phone +61 3 9092 0888 Fax +61 3 9092 0899 Email: [email protected] Web site: www.physiotherapy.asn.au


3

EXECUtIVE SUmmARY

Key findings from the report

Optimal pain management has been • compromised since the introduction of the Aged Care Funding Instrument (ACFI)

Exercise programs in most facilities have • either decreased or failed to expand since the introduction of the ACFI

A significant proportion of physical therapy • is delivered by staff members who are not appropriately qualified or experienced

There is a poor rate of uptake of Medicare • items for physiotherapy services

There appears to have been a decline in • the ratio of physiotherapists to residents within residential aged care facilities (RACF)

The survey indicates that there has been • an increase in the number of unpaid hours worked by physiotherapists since the introduction of the ACFI

Half of the physiotherapists surveyed believe • that the therapy needs of residents in RACFs are not adequately met

Just under half of the physiotherapists • surveyed believed that optimum levels of mobility and dexterity were not achieved for all residents, meaning that nearly half of all RACFs are not fully meeting accreditation standards.

Elderly residents of RACFs need sufficient care to maintain wellbeing and the best possible level of mobility. The Australian Physiotherapy Association believes that the ACFI review scheduled for 2009–2010 must urgently address the problems identified in this report, to ensure that Australia’s aged care residents receive the most appropriate level of treatment from skilled practitioners.


4

IntROdUCtIOn

OVERVIEW

It is now well established that Australia has an ageing population with the number of people aged 65 or more projected to double within thirty years. As a consequence, residential aged care facilities (RACFs) and the care requirements of older people have become a high priority for Australia. Previous funding for residential care

was based upon the Resident Classification Scale (RCS); however, in 2008 the Aged Care Funding Instrument (ACFI) replaced the RCS. Funding under the ACFI system targets the individual resident’s care needs rather than focusing on the care delivered.

The ACFI is a resource allocation instrument that uses the assessment of core care needs as a basis for allocating funding (Department of Health and Ageing, 2009). The ACFI was produced to replace the RCS. In 2002 a review of the previous RCS funding model took place and determined that care assessment and documentation were driven by ensuring maximum funding for an RACF.

The ACFI was intended to function very differently to the RCS. The ACFI focuses funding on dependency (need for care) and thus, the ACFI does not explicitly or implicitly prescribe particular health care interventions (including allied health services and therapies) to maximise mobility and dexterity. According to the Department of Health and Ageing (DoHA), it was designed to be simpler, shorter and easier to use than the RCS and intended to streamline and simplify the funding system so that aged care homes spend less time on paperwork and more time providing care. This new funding model was implemented on 20 March 2008, it did not negate the responsibility of aged care providers to provide care planning and care intervention programs, however ongoing care documentation which was required to secure funding under the RCS is not required for the ACFI.

As outlined in the ACFI User–Guide, 12 care needs questions are used to determine the level of care necessary for the individual and thus the funding requirement (DoHA, 2009). With the ACFI, the number of funding categories for basic care has been reduced from eight to three, which are outlined below.

Activities of Daily Living• (ratings on Nutrition, Mobility, Personal Hygiene, Toileting and Continence questions are utilised to determine the level of the basic subsidy)

Behaviour Supplement• (ratings on Cognitive Skills, Wandering, Verbal Behaviour, Physical Behaviour and Depression questions are utilised to determine the behaviour supplement)

Complex Health Care Supplement• (ratings on Medication and Complex Health Care Procedure questions are utilised to determine the complex health care supplement).

The amount of each of these that is payable in respect of a particular resident depends on the ratings (A, B, C or D) for each of the ACFI questions (1 – 12). Diagnostic information about mental and behavioural disorders and other medical conditions is also collected.


5

tHE CASE FOR REVIEW

The Australian Physiotherapy Association (APA) has voiced concerns to the Federal Government since the ACFI pilot in 2005. Concerns were raised when a number of aged care facilities indicated that there would be a reduction of the level of physiotherapy available to the residents once the ACFI was introduced. APA members expressed alarm about the potential impact on residents and standards of care in RACFs. In particular, members were concerned that the proposed funding instrument may encourage premature dependency to maximise the facility’s funding. The Department of Health and Ageing (DoHA) assured the APA that if this was to occur it would be a breach of Accreditation Standards. The Accreditation Standards state

that residents must be referred to appropriate health specialists in accordance with the resident’s needs and preferences. The Standards do not explicitly state that the services the resident needs must be provided for low care residents.

For these reasons the APA conducted a survey with physiotherapists working in RACFs in 2007 to determine the baseline level of physiotherapy service prior to the introduction of ACFI and then a second survey in 2009, to evaluate current trends in the care of residents, in particular the impact (if any) the ACFI has on physiotherapy services in RACFs.

mEtHOdOlGY

Sampling

The second survey was conducted online from 29 May 2009 through to 24 July 2009. All members of the APA’s Gerontology Physiotherapy Australia (GPA) and Physiotherapy Business Australia (PBA) were invited, via email, to participate in the survey and encouraged to forward the survey to other physiotherapists working in RACFs who may not be members of these groups.

Survey Design

The survey was developed by the APA’s Senior Policy Officer in consultation with its executive management team and the GPA Committee. The survey was composed of a series of closed questions, mostly with Likert scale response categories, as well as a number of open ended sections inviting comments. The instrument was converted to an online tool which could be accessed via a link through the emailed survey invitation.

Data Analysis and Reporting

After the closing date (24 July 2009) of the online survey the raw data was downloaded to Microsoft Excel. After cleaning, the data was then pooled and analysed descriptively, with comparison to the previous survey in 2007.


6

RESUltS

In 2009, responses were received from 206 physiotherapists, compared to 157 in 2007. The number of responses varies for different questions, as it was not compulsory to respond to all questions in the survey.

Table 1: Employment Status in RACFs

(204 respondents) Number percentage Change since 2007

Ongoing, permanent 81 40% +3%

Contract employment 111 55% 0%

Other* 12 6% –2%

*Of those that answered “other”, the majority of respondents worked through a consultant/agency/contractor agreement.

Table 2: Number of hours of employment per week*

(205 respondents) Number Average per facility Change since 2007

total number 2,495 12.1 hours per week – 0.4 hours per week

Paid 2,275.5 91% –4%

Unpaid 219.5 9% +4%

*It was assumed that where it was not indicated whether employment was paid/unpaid, that the employment hours were paid.

Table 3: Number of physiotherapists employed at RACFs


One physiotherapist employed 172 83.5% –3%

2 or more physiotherapists employed 34 16.5% +2.5%

Table 4: Number of beds in RACFs

(205 respondents) Number Average bed per facility Change since 2007

total number 21,775 106 +14 beds

High–Care 12,406 57% –3%

low–Care 6,761 31% +5%

no indication of bed type 2,608 12% –2%

Table 5: Since the introduction of the Aged Care Funding Instrument, physiotherapy hours at aged care facilities have

(193 respondents) Number percentage

Increased by 10 or more hours per week 8 4%

Increased by between 5 & 9 hours per week 15 8%

Increased by between 1 & 4 hours per week 45 23%

Remained unchanged 114 59%

decreased by between 1 and 4 hours per week 4 2%


decreased by 10 or more hours per week 2 1%


7

Table 6: Since the introduction of the Aged Care Funding Instrument, physiotherapy assistant hours at aged care facilities have


Increased significantly 9 5%

Increased slightly 20 11%


decreased slightly 16 9%

decreased significantly 17 9%

Ceased completely 3 2%

Table 7: Assuming that all clients require physiotherapy care in the RACF setting, in a normal week the amount of time spent with clients in a clinical setting was

(195 Respondents) 2009 2007

Average time spent per client per week 5 minutes 4.45 minutes

Range 2 seconds – 27.8 minutes 24 seconds – 30 minutes

Table 8: In a normal week the amount of time spent discussing care plans with staff was

(202 respondents) 2009 2007

Average percentage of weekly hours spent on care-planning per week

25% +10%

maximum time 100% 0%

minimum time 0% 0%

Table 9: proportion of physiotherapy services carried out by non physiotherapy staff

(193 respondents) 2009*

Average 37%

maximum response 0%

minimum response 100%

* No data was collected in 2007

Table 10: The number of hours per week that non–physiotherapist staff members undertake tasks that are most appropriately undertaken by a physiotherapist)

Number percentage Change since 2007

less than 1 hour per week 51 26% +7%

1 – 2 hours per week 32 17% 0%

3 – 4 hours per week 34 18% 0%

5 hours or more per week 76 39% –7%

RESUltS


8

Table 11: The facility uses Medicare funding for allied health


Yes 55 30% +10%

no 126 70% –10%

Table 12: If the facility did not use Medicare items, the primary barrier to their use is thought to be

(159 responses; individuals could choose more than one response)

Number percentage Change since 2007

doctors are too busy to contribute to care plans 43 27% +2%

RACF staff are not aware of medicare funding 40 25% 0%

doctors are not prepared to contribute to care plans 32 20% –3%

medicare system is too hard to understand 16 10% +1%

Other 28 18% 0%

Table 13: Since the introduction of the Aged Care Funding Instrument, on average, the number of hours per week that are spent on delivering electrotherapy and massage for pain relief have


Increased by 10 or more hours per week 8 4%

Increased by between 5 and 9 hours per week 15 8%

Increased by between 1 and 4 hours per week 45 23%




decreased by 10 or more hours per week 2 1%

Table 14: Since the introduction of the Aged Care Funding Instrument, exercise programs at aged care facilities have


Increased significantly 6 3%

Increased slightly 20 11%


decreased slightly 31 17%

decreased significantly 27 15%

Ceased completely 3 2%

RESUltS


9

Table 15: physiotherapists are valued


Strongly agree 75 39% –3%

Agree 85 44% +5%

neutral 17 9% –3%

disagree 12 6% +1%

Strongly disagree 4 2% 0 %

Table 16: physiotherapists are able to practise as autonomous practitioners and their professional opinion is respected*


Strongly agree 67 35%

Agree 93 48%

neutral 18 9%

disagree 9 5%

Strongly disagree 6 3%


Table 17: Every client in this RACF receives the physiotherapy treatment they require from a qualified physiotherapist


Strongly agree 17 9% +6%

Agree 41 21% +4%

neutral 28 15% +1%

disagree 78 40% –1%

Strongly disagree 30 16% –9%

Table 18: Clients’ therapy needs are adequately met in the RACF



Agree 53 28% +4%

neutral 31 16% –4%

disagree 72 37% –3%


RESUltS


10

Table 19: Clinical consultation time is adequate for residents



Agree 52 27% –1%

neutral 26 13% –2%

disagree 75 39% 0%


Table 20: Generally, communication is good between physiotherapist and other RACF staff regarding client care planning



Agree 94 49% +1%

neutral 20 10% –7%

disagree 13 7% +3%

Strongly disagree 2 1% 0%

Table 21: physiotherapists have adequate input into the planning and implementation of resident care*



Agree 90 47%

neutral 26 13%

disagree 29 15%



Table 22: The Aged Care Funding Instrument has compromised evidence–based practice in the management of pain*



Agree 53 27%

neutral 56 29%

disagree 19 10%



RESUltS


11

Table 23: Optimum levels of mobility and dexterity are achieved for all residents (Accreditation Standard 2.14)



Agree 55 28%

neutral 36 19%

disagree 66 34%



Table 24: The biggest problem faced by the provision of physiotherapy to residents of RACFs was


lack of funding for physiotherapy 43 32%

lack of physiotherapist hours 29 22%

low value placed on physiotherapy 19 14%

lack of freedom to exercise clinical discretion due to funding tool

8 6%

lack of exercise programs (falls prevention, balance, mobility)

7 5%

High administration requirements 7 5%

Other 21 16%

Table 25: Changes physiotherapists would like to see over the next 2 years in their RACFs are


Increased hours for physiotherapists 32 23%

more emphasis on the funding and provision of exercise programs for balance and mobility

24 17%

the introduction of physiotherapy assistants or increased hours for physiotherapy assistants

24 17%

Increased staffing (nursing, carers) 7 5%

Promotion of independence 6 4%

Increased compliance with care plans 6 4%

Utilisation of Extended Primary Care programs/ medicare benefits

5 4%

Equipment/ improved facilities 5 4%

no change needed 5 4%

lowered administrative requirements 4 3%

more government support for aged care 3 2%

Other 21 15%

RESUltS


12

dISCUSSIOn

Physiotherapy treatment in aged care facilities

The results indicate that there may have been a decline in physiotherapists’ working hours in RACFs, with an average decline of just under half an hour (12.1 hours per week down from 12.5 hours per week in 2007) (Table 2). This is despite an apparent rise in the average number of beds per facility (106 beds per facility up from 92 in 2007) (Table 4). The 12.1 hour average includes unpaid hours worked in facilities, which has increased from 4% of all hours worked to 9%, an indication that the new funding instrument is failing to provide for an adequate physiotherapy presence within RACFs. An issue with response bias may have occurred as physiotherapists who have left the aged care sector were not easily accessible for this survey. No reports of termination of hours in this survey occurred, despite a number of anecdotal reports to the APA.

Of major concern in the 2007 survey was the low allocation of clinical physiotherapy time per resident. Data supplied in 2007 indicated that although time was not split evenly between low and high care residents, the minimum time allocated per patient was 24 seconds. Data from the 2009 survey indicates that this situation has intensified, with the minimum time allocated per patient being two seconds, however the average rose slightly to five minutes, and the maximum time allocation fell by just over two minutes at 27.8 mins (Table 7). On average 25% of a physiotherapist’s time was spent discussing care plans with staff (Table 8).

Physiotherapists’ concerns about residential aged care

Physiotherapists’ two most significant concerns were the lack of funding for physiotherapy in aged care facilities (32% of respondents) followed closely by the lack of physiotherapist hours (22%) (Table 24).

30% of physiotherapists said that residents received the physiotherapy treatment they needed from a physiotherapist, which represents an increase from 2007. However the majority (56%) still felt that patients were not getting the treatment they needed from qualified staff (Table 17). This poses problems for the safety and reliability of treatment for some of the most fragile people in our communities, and remains a problem for physiotherapists in implementing care plans and ordering interventions under the Complex Health Care section of the ACFI.

In addition, 51% of physiotherapists believed that the therapy needs of residents in RACFs were not adequately met (Table 18). Adequately met needs are likely to result in decreased dependence on care workers, decreased incidents of falls and increased wellbeing, so it is vital that adequate services are available to residents.

The survey showed that the importance of physiotherapy within aged care facilities is well recognised, with 83% of respondents saying that they feel valued within their RACF (Table 15). Yet comments indicate that physiotherapists remain frustrated by inadequate time to see residents in RACFs or to run exercise programs that would help manage pain, reduce falls and improve well–being.

Pain management in aged care facilities

ACFI allocates funding for specific modalities of pain management, and it has been the APA’s experience that many physiotherapists feel that this undermines their choice of efficacious pain management modalities. Survey data has supported this anecdotal evidence, with 59% of physiotherapists indicating that the ACFI has compromised their evidence–based practice in the management of pain (Table 22). Only 12% disagreed with the statement that ‘ACFI has compromised evidence based practice in the management of pain.’


13

Electrotherapies and massage to manage pain (two of the three modalities for which funding is specifically allocated) have increased by 35% within RACFs (Table 13). Given that overall services have decreased in the aged care facilities, this result is concerning, as other active modalities with good evidence to support their use (such as exercise therapy) must have been cut to provide such an increase in the level of passive therapies with little evidence to support their use.

Residents’ mobility and dexterity

A total of 44% of respondents believed that optimum levels of mobility and dexterity were not achieved for all residents (Table 23), meaning that in the opinions of those most qualified to assess mobility and dexterity, nearly half of all RACFs were not meeting accreditation standards.

One way to assist with the delivery of certain physiotherapy services within RACFs would be to increase the hours of trained physiotherapy assistants (PTA), however the survey found that in 20% of cases, PTA hours have been reduced. In some of these cases, PTA hours have ceased entirely (Table 6).

Medicare funding in aged care facilities

One of the concerns raised in the 2007 survey was a lack of utilisation of Medicare rebates available for allied health treatment of chronic and complex conditions. This has improved somewhat with 10% more facilities now utilising the items, however the vast majority of RACFs are failing to utilise this funding (70%) (Table 11).

The top three reasons cited for this is that doctors were too busy or not prepared to contribute to care plans (47%) and that RACF staff were not aware of the funding (25%) (Table 12). This correlates with GPs claims since the introduction of the Enhanced Primary Care (EPC) program – that administrative requirements for the scheme are a disincentive to its use. This finding also suggests that the placing GPs in the role of ‘gatekeeper’ to allied health services within RACFs is ineffective, and arrangements should be changed to better facilitate access to physiotherapy for residents of RACFs.

Other issues that could contribute to decisions not to utilise the items are the relatively few treatments allowed under the scheme in contrast to the long term treatment required for residents of aged care facilities.

dISCUSSIOn


14

COnClUSIOnS

The results of this survey show that there has been a decline in the ratio of physiotherapists

and PTAs to residents within RACFs since the introduction of the ACFI.

Physiotherapists have also expressed concern about the impact of funding for selective modes of pain management and the subsequent decline in exercise programs that otherwise would have the potential to reduce falls and improve residents’ mobility and dexterity.

The survey found that a significant proportion of physical therapy continues to be delivered by staff members who are not appropriately qualified or experienced. This is problematic on a number of levels, as the quality of such treatment is questionable and has the potential to compromise patient safety.

The poor rate of uptake of Medicare items indicates that more needs to be done to encourage GPs and RACF staff to utilise EPC funding. Improvements could include reducing administrative work associated with the items and increasing the number of services available to residents.

First published 2010

© Copyright Australian Physiotherapy Association 2009

This work is copyright. Apart from any use permitted under the Copyright Act 1968, no part may be reproduced by any process without prior written permission from the APA.

Australian Physiotherapy Association PO Box 437, Hawthorn BC Victoria 3122

Phone: +61 3 9092 0888 Fax: +61 3 9092 0899

Email: [email protected] Web site: www.physiotherapy.asn.au

ApA Aged Care Survey 2009

VJ Robertson

LS Chipchase

EL Laakso

KM Whelan

LJ McKenna

GUIDELINESFOR THE CLINICAL USE OFELECTROPHYSICAL AGENTS

2001

GUIDELINES FOR THE CLINICAL USE OF ELECTROPHYSICAL AGENTS

1

INTRODUCTION ..............................................................................................................................................2Duty of care ................................................................................................................................................2Disclaimer...................................................................................................................................................2Invitation to provide feedback....................................................................................................................2Legislative differences between states........................................................................................................2Authors and acknowledgements.................................................................................................................2

SECTION 1: CONTRAINDICATIONS, PRECAUTIONS, TESTS AND WARNINGS ..............................3Contraindications and precautions .............................................................................................................3Table 1. Contraindications (C/I) and precautions (P).................................................................................3Tests conducted prior to treatment .............................................................................................................4Table 2. Specific tests.................................................................................................................................5Recommended warnings ............................................................................................................................5

SECTION 2: EPA PRACTICE STANDARDS AND NOTES ON SPECIFIC EPAs.....................................8EPA practice standards ...............................................................................................................................8Table 3. Practice standards .........................................................................................................................8Notes on specific EPAs ..............................................................................................................................9Ultrasound ..................................................................................................................................................9Thermal - superficial heating and cooling ...............................................................................................10Thermal - deep .........................................................................................................................................10Electrical stimulation................................................................................................................................11Ultraviolet .................................................................................................................................................12Laser .........................................................................................................................................................13Low frequency magnetic fields ................................................................................................................13

SECTION 3: INFECTION CONTROL PROCEDURES ..............................................................................14Routine care..............................................................................................................................................14Non-critical treatment...............................................................................................................................14Semi-critical treatment .............................................................................................................................14Critical treatment ......................................................................................................................................15Cleaning....................................................................................................................................................15Disinfection ..............................................................................................................................................15Sterilisation...............................................................................................................................................15

SECTION 4: EPA EQUIPMENT SAFETY...................................................................................................16Basic EPA equipment safety requirements...............................................................................................16

SECTION 5: BIBLIOGRAPHY ....................................................................................................................17Authors’ affiliations..................................................................................................................................20Contributors ..............................................................................................................................................20

APA Australian Physiotherapy Association

C/I Contraindication

EPA Electrophysical agent

EPAGs Electrophysical agent guidelines

EStims Electrical stimulation

E1 Erythema first degree

IR Infra-red

MW Microwave

P Precaution

SWD Shortwave diathermy

US Ultrasound

UV Ultraviolet

ABBREVIATIONS

TABLE OF CONTENTS

The Electrophysical Agents Guidelines outline thebasic standards of clinical practice for applyingelectrophysical agents (EPAs) safely and effectively.

The booklet has 5 sections.

• Section 1. Tables of contraindications andprecautions, specific tests, and patient warnings

• Section 2. EPA practice standards and notes onspecific EPAs

• Section 3. Infection control procedures whenusing EPAs

• Section 4. EPA equipment safety requirements

• Section 5. Bibliography.

This booklet is not a treatment manual or a textbook.A qualified physiotherapist will use such resourcesand relevant recent publications plus their ownprofessional knowledge and experience in order toplan and implement effective treatments for theirpatients. The Guidelines outline basic clinicalstandards for using EPAs by indicating what isnecessary to ensure patient and therapist safety. Theyare aimed at reducing the risks associated with usingEPAs and do not address issues of the clinicaleffectiveness of modalities. While not mentioning allEPAs, or combinations of EPAs that physiotherapistsmight use, the Guidelines provide general principlesapplicable to all. The most commonly used EPAs atthe time of publication are addressed specifically andadditional notes provided on them.

The main changes in this edition are an updating ofinformation and a reorganisation to facilitate accessfor both physiotherapy practitioners and students.These Guidelines, however, suffer from the sameproblems as those preceding them because of the lackof an adequate database to substantiate some of theaccepted contraindications and methods of usingsome EPAs. When in doubt we have erred on theconservative side. We remind readers that theGuidelines must always be read in the context ofcurrent research findings.

Duty of care

Physiotherapists have a duty of care which includesan obligation to take all reasonable steps to avoid therisk of damage or harm being caused to their patients.One part of this obligation includes explanationsbeing given to patients of both the benefits andpotential dangers of treatments. Patient consentfollowing a detailed explanation of benefits and

potential dangers does not absolve a physiotherapistfrom liability if a reasonable physiotherapist wouldhave acted in such a manner as to avoid the damagewhich ultimately arises ( see Vines 1996 and Delany1996).

Disclaimer

No person should rely solely on the contents of thispublication. This publication is of a general natureand is not intended to be a comprehensive statementof minimal standards of care covering all individualcircumstances. The Australian PhysiotherapyAssociation, the authors and other contributorsexpressly disclaim all and any liability andresponsibility to any person in respect of anything,and of the consequences of anything done or omittedto be done by any such person in reliance, whetherwholly or partially, upon the whole or any part of thecontents of this publication.

Invitation to provide feedback

The Australian Physiotherapy Association invitesreaders to forward any comments or feedback on thecontents of this document or suggestions as to howfuture editions might be improved.

Copyright in this document and the concepts itrepresents are strictly reserved to the AustralianPhysiotherapy Association 2001. No unauthorised useor copying of this document is permitted.

Legislative differences between states

All physiotherapists have an obligation to be aware ofany legal requirements in their state of practice thatalter any requirements stated in these Guidelines.

Authors1 and acknowledgements

Authors: VJ Robertson PhD (convenor); LS Chipchase; EL Laakso PhD; KM Whelan; LJ McKenna.

Contributors: A Ward PhD; D Bastians

Physiotherapy in Australia owes a considerable debtto those who wrote the first edition of theseGuidelines. By detailing and setting standards of carein using EPAs they provided incommensurable help tothe physiotherapy profession in ensuring patient andtherapist safety. The current edition is intended tocontinue their lead.

© Australian Physiotherapy Association 20012

INTRODUCTION

1 Details follow bibliography.

Table 1. Contraindications (C/I) and precautions (P)

Modality Pregnancy2 Inbuilt Circulatory Risk of Exacerbation Unable to To eyes Sensorycategory stimulator, insufficiency4 dissemination5 of existing communicate or loss7

e.g pacemaker3 conditions6 testes

Heating - C/I SWD C/I C/I C/I C/I C/I C/I8 MW anddeep within 3m SWD C/I[SWD*, MW and MW* US] US C/I over

stimulator

Heating - - - C/I C/I C/I P C/I Psuperficial [wax*, infra-red, hot packs]

Cold - - C/I - C/I P - P

EStims* C/I vicinity C/I over P P P P - Pof uterus stimulator

US [no/ C/I vicinity C/I over P P P P C/I Plow heat] of uterus stimulator

Ultraviolet* - - P - P P C/I -to eyes

Laser* C/I vicinity - - P P P C/I -of uterus to eyes

KEYAbbreviations: SWD, shortwave diathermy; MW, microwave diathermy; US, ultrasound; EStims, electrical stimulation; C/I, contraindication; P,precaution; m, metres.*See modality specific information on the next page for further details and the relevant notes on specific EPAs in Section 2.


3

Contraindications and precautions

The table below provides a general guide to whendifferent categories of modalities are alwayscontraindicated or should be used only withappropriate precautions. The table errs on theconservative side and repeats some historicallyaccepted contraindications and precautions in theabsence of an adequate database or research findingsto exclude them.

Modality specific information follows on the next

page. Physiotherapists should use this information inconjunction with individual patient assessments andtreatment decisions.

Note: Possible interactive effects of modalities usedconcurrently or sequentially may increase the dangersusually associated with an individual modality.Therapists using modalities in this manner incur anadditional obligation to ensure any risks of damage orharm to their patients are avoided. For example, usingice prior to another modality can reduce a patient’scapacity to distinguish the level of heating or currentflow.

SECTION 1: Contraindications, precautions, tests and warnings

2 Pregnancy: in the absence of reliable information pregnancy isconsidered a contraindication to any applications ofradiofrequency modalities (MW & SWD) and to applicationsof some other modalities in vicinity of the uterus (US, EStims,laser).

3 Inbuilt stimulators: most commonly used are pacemakers.Unless the specific risk has been evaluated by the relevantmedical specialist, must be considered contraindicated (seeChen et al 1990, Low and Reed 2000, Rasmussen et al 1988).

4 Circulatory insufficiency: identified using objective testingand/or clinical findings including presenting symptoms, pasthistory and skin discolouration.

5 Dissemination: conditions with known or accepted risks

include acute infections, tumours (benign or malignant), TB,osteomyelitis.

6 Exacerbation: existing conditions with known or acceptedrisks include acute infective or inflammatory conditions, skindisorders such as eczema and dermatitis, areas of increasedfluid tension, regions treated within 3 to 6 months byradiotherapy, haemorrhagic conditions, and severe organ statessuch as cardiac failure (Lorenze et al 1960, Low and Reed2000, p.272, Stanghelli and Nilsson 1983).

7 Any relevant sensory loss for each EPA listed in table ofspecific tests (Table 2).

8 Mesh goggles are not always effective eye protectors (Delpizzoand Joyner, 1987).


Modality specific information

Read in conjunction with table of contraindicationsand precautions (Table 1).

Wax

Contraindicated if skin is broken.

Microwave/Shortwave Diathermy (MW/SWD)

Contraindicated if metal within field (any deepor superficial internal, or external within 30cm).(Note that metal objects can act as aerials egceiling wiring to smoke alarms and otherequipment.)

Contraindicated if unable to accurately detectheat in area to be treated (see specific tests,Table 2).

Contraindicated within 3m of operatingEStims or biofeedback.

Precaution: remove hearing aid(s).

Precaution: turn off mobile phones within 3m.

Precaution for SWD operators: ensure aminimum distance of 1m from applicators and0.5m from leads.

Ultraviolet Light (UV)/Laser

Precaution: with UV or Class 3B lasers9 eyeprotection is required for therapist and patientand recommended with other classes of laser.Use only safety glasses/goggles designed toscreen relevant wavelengths.

Precaution: for UV therapy confirmphotosensitivity status is unaltered ie medicalcondition and medical status unaltered, no skinlotions applied.

Electrical Stimulation (EStims)

Contraindicated: trans-thoracic applications(antero-posterior thorax, arm to arm, leg to arm).

Contraindicated: long duration direct current(ie monophasic pulses of at least 10msecduration) in absence of sharp/bluntdiscrimination under electrodes (see nextsection).

Contraindicated: use within 3m of operatingSWD equipment (risk is to person havingEStims).

Precaution: if reduced sharp/bluntdiscrimination can, with care, apply low andmedium frequency currents and interruptedgalvanic and high voltage pulsed currents, eg usenew self-adhesive electrodes or electrodesponges and lowest intensity output practicable.

Precaution: avoid applications over brokenskin. Marked reduction in impedance will causeconcentrated current flow. EXCEPTION: whensuitably low intensity current applied for woundtreatment.

Precaution: repeated uses of self-adhesiveelectrodes, electrode sponges and covers canreduce their conductivity and necessitate higherstimulus intensities (see manufacturers’guidelines).

Tests conducted prior to treatment

The tests listed in Table 2 are for thermal sensitivity,reaction to ice, sharp and blunt discrimination anderythemal levels. Testing should always be conductedif the history indicates the patient has a problemwhich may increase the risks associated with usingEPAs. Testing is otherwise strongly advised routinelyat the first treatment and, subsequently, after anyrelevant change in a patient’s condition. Which test isselected depends on the modality to be used.

Note: always record all tests undertaken and results.

General guidelines:

• if the modality produces or can produce heat (ieSWD, MW, wax, infra-red, hot packs,ultrasound) use the test for thermal sensitivity;

• if the modality might cause a reaction to cold (iethe application of ice) test for a reaction to ice;

• if the modality might cause skin irritation, pain,or electrolytic burns (eg the different types oftranscutaneous electrical stimulators) test forsharp/blunt discrimination; and

• if the skin will be exposed to ultraviolet rays (ieUV) establish the erythemal level (E1) prior totreatment.

9 AS/NZS 2211.1 Suppl.1 (1999): Laser safety. Part 1;Equipment classification, requirements and user’s guide.Supplement 1: Application guidelines and explanatory notes.“Class 3B laser products are unsafe for eye exposure.

Usually only ocular protection would be required. Visible Class3A laser products are safe as long as staring is not required.”p.12.


5

Thermal sensitivity

Test patient’s ability to discriminate hot from coldobjects at site to be treated. Typical items used areappropriately heated and cooled dry test tubes (filled)or metal spoons.

Look for: inability to reliably discriminate hot fromcold.12

Ice reaction test

Test by either performing an ice cube massage for aminimum of 30 seconds or apply an ice pack andexamine local response under the pack after 5 minutesand be aware of the possibility of latent effects.

Look for: an excessive redness, an inflammatory wealor a systemic reaction, including increased bloodpressure or heart rate.13

Sharp/blunt discrimination

The area under the electrodes is tested using,typically, a new toothpick, a partially unfoldedpaperclip, or sharp pin. The skin must not be piercedand any test instrument only reused following thecleaning procedures outlined for non-criticaltreatment in Section 3 of this document.

Look for: inability to reliably differentiate sharp fromblunt.

See table of contraindications and precautions and themodality specific information following it (Table 1).

Erythemal skin test (E1)

Always conduct an E1 skin test prior to commencingtreatment with UV or after lamp bulb/tube is changed.See Section 2, notes on specific EPAs, UV page, andconsult a standard textbook for further details.

Recommended warnings

The therapist is responsible for ensuring the patienthas the information required to make an informeddecision and consent to treatment. This informationshould include the relative risks and benefits of theproposed treatment as well as what the patient shouldusually expect and their responsibilities regardingnotifying the physiotherapist of undesirable effects.The following warning statements are recommended,bearing in mind that each will need to be tailored toeach patient’s specific needs.14

The first is a general warning intended to covermodalities not specifically addressed.

Note: record details of warnings given and documentinformed verbal consent.15

10 Therapeutic ultrasound: risks are typically thermal burns andpain.

11 Skin irritation, either an allergy or, more likely, electrolysiswill occur at electrode site with long duration monophasicpulses (direct current) and possibly with unbalanced biphasicpulses (time averaged current not zero).

12 Odia and Aigbogum 1988.13 Knight 1995.14 Delany 1996, p. 252.15 Vines 1996, p. 246.

Table 2. Specific tests

Modality Risk Test

Wax baths Thermal burns Thermal sensitivityHot packsInfrared radiation Microwave diathermyShortwave diathermy Ultrasound10

Cryotherapy Adverse reaction to ice Ice reaction test

Sensory stimulation (TENS)Motor stimulation (FES, NMES, FNS) Skin irritation11 Sharp/blunt discriminationInterferential therapy Electrical burnsHigh voltage pulsed stimulation PainDirect currentUltrasound

Ultraviolet Light UV burns Erythemal skin test (E1)


General warning

When having …. [magnetic field therapy or anEPA not covered below], what you should feel is….

If you feel anything other than that call …. [yourphysiotherapist] immediately: otherwise, youmay be in danger of ….. [details if known].

If in doubt, call …. [your physiotherapist].

Please do not move or touch any of theequipment during treatment. If you becomeuncomfortable, call …. [your physiotherapist].

Do you understand what I have said?

Do you have any questions?

Are you happy for me to proceed?

Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Heat treatments: includes wax, IR, hot packs, MW,SWD16

When having ….. [a heat treatment], all youshould feel is a mild comfortable warmth. Ifyou feel any more than this or if the heatconcentrates in any particular spot or it starts tofeel uncomfortable you must call ….. [yourphysiotherapist] immediately: otherwise, youmay be in danger of being burnt.

If in doubt, call ….. [your physiotherapist].





Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Ultrasound treatments

When having ultrasound you will usually feel…. [nothing other than the applicator pressure/very little/ some heat]. If you feel any discomfortor it feels hot under the applicator you mustimmediately tell …. [your physiotherapist]:otherwise, you may be in danger of being burnt.




Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Cryotherapy treatments

When having an ice treatment you will usuallyfeel gradually increasing cold, which may befollowed by a period of discomfort. The areashould then go numb. If you feel any extremediscomfort or pain you must immediately tell ….[your physiotherapist]: otherwise, you may bein danger of an ice burn.

Please do not move during treatment. If youbecome uncomfortable, call …. [yourphysiotherapist].




Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

16 Ultrasound is listed separately given its extensive use inAustralian physiotherapy practice.


7

Electrical stimulation treatments: includes TENS(sensory or motor), interferential, etc

When having electrical stimulation you shouldfeel …. [tingling or similar if for sensorystimulation, pain relief or wound healing; and/ormuscle contractions if motor level stimulationsuch as FES, NMES, or oedema control]. If youfeel anything other than [...] or any pain ordiscomfort you must call …. [yourphysiotherapist] immediately: otherwise, youmay risk skin and other tissue damage under theelectrodes.






Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Laser treatments

During laser treatment you should feel nothing(other than the pressure of the applicator againstyour skin). If you do feel any discomfort youmust immediately tell….. [yourphysiotherapist] and the treatment will beterminated. Side effects from laser therapy caninclude dizziness, nausea or an initial increase inpain. They are short term only and usually onlyoccur if the treatment dose is too high.





Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

UV treatments

Initial treatment: During a UV treatment youmay feel nothing or you may notice a little heat.If you do feel any discomfort or notice any otherchange you must call…. [yourphysiotherapist] immediately: otherwise, youmay risk skin damage.



Subsequent treatments: If you have changedyour medication or noticed any differences inresponse following the last treatment it isimportant you tell me as this may mean today’sdosage should be changed.




Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


EPA practice standards

The table of EPA practice standards (below) indicatesthe usual sequence that follows a patient assessmentwhen an EPA has been selected for use in thetreatment. The physiotherapist is assumed to befamiliar with the specific equipment selected and therelevant manufacturer’s instruction manual. Thetherapist is required to ensure that the equipment

satisfies the relevant Australian Standards (AS/NZS3200.1.0:199817; and AS/NZS 3003:199918). SeeSection 4 for a summary of safety requirements forelectro-medical equipment, based on AS/NZS2500:199519).

Notes on specific EPAs follow these practicestandards. They give details for the specificmodalities most commonly used by physiotherapistsat the time of writing these Guidelines.

SECTION 2: EPA practice standards and notes on specific EPAs

Table 3. Practice standards

Check modality specific risks in table of contraindications and precautions (Table 1).

Select modality 1. selection based on assessment of the patient, clinical knowledge, and known effects of individual EPAs.

Check 1. read table of contraindications and precautions and modality specific information (Table 1)contraindications 2. if together with clinical assessment, specific risk(s) are identified, conduct relevant test(s) shown in table of specific

tests (Table 2) prior to use of modality.

Explain to patient 1. reasons for selecting a particular modality, how it works and how it will be applied2. expected effects of the modality3. possible risks of using the modality in the specific circumstances4. ensure patient understands and consents to use of EPA.

Treatment Patientpreparation 1. fully expose area to be treated by EPA and check skin for damage, wounds, scars, condition, colour etc.

2. position patient appropriately for treatment and comfort 3. drape to minimise threat to modesty

Treatment area1. eliminate sources of possible electrical interference (eg no operating SWD within 3m of operating EStims or

biofeedback)2. ensure no metal furniture used or in vicinity if MW or SWD

Equipment1. test machine output prior to use20 and also safety switch if applicable2. set adjustable output controls at zero (except: UV lamps – cover during warm up).

Warnings On each occasion the patient should be advised:See Section 1. 1. what they can expect to feel during treatment

2. what they should not feel and responses they should not have3. what they are to do if they do feel or have unwanted responses 4. not to move during the treatment 5. not to touch the equipment or applicators

See recommended warnings in Section 1.In conjunction with the warning, teach the patient to use a safety switch if relevant and available.

SignsIf radio-frequency equipment (MW/SWD) is present and might be in use, provide appropriate multilingual signs to adviseall clinic entrants in case any have a pacemaker or other indwelling stimulator. Make every effort to ensure all patientscan understand these signs.

Table continued next page.

17 AS/NZS 3200.1.0:1998 Medical electrical equipment. Part1.0: General requirements for safety – Parent Standard

18 AS/NZS 3003:1999 Electrical installations – Patient treatmentareas of hospitals and medical and dental practices.

19 AS/NZS 2500:1995 Guide to the safe use of electricity inpatient care.

20 See notes on specific EPAs following this section.


9

Table from previous page

Administration Apply

1. as explained to the patient and only after informed consent to proceed is obtained from them2. as advised in most recent manufacturers’ guidelines relevant to specific item of equipment being used 3. see Notes on specific EPAs, Section 2.

Remain within call1. so immediately accessible to patient2. to monitor treatment and make checks as appropriate.

Completion 1. turn equipment off as advised by the manufacturer: usually output to zero first 2. question patient and examine treated and adjacent areas for any abnormal reactions to treatment3. record specific details including:• C/Is checked, results of initial sensation tests and machine tests, that warnings were given and appeared to be

understood, and consent obtained• all treatment details, including intensity and if continuous or pulsed (with on:off ratio), duration, area treated,

location of electrodes, and method used, equipment details including which machine and frequency (asappropriate)

• immediate result of treatment – including any abnormal reactions and any subsequent action taken orrecommended

• all other treatment details.

Subsequent 1. re-evaluate effects and effectiveness of EPA usedtreatments 2. modify treatment parameters/method of application as required.

Notes on specific EPAs

Ultrasound

Check particular risks in table of contraindications and precautions (Table 1).

Output check Set continuous output. While applying one of the following two tests, observe water (or gel) nearapplicator for ripple pattern or marked disturbance which should increase as intensity is increased:1. applicator face covered by water in metal or plastic bowl or bucket of water and angled towards

the surface ( to prevent beam reflection back into itself), briefly turn to high intensity output andthen off OR

2. cover face of applicator with 0.5-1cm of gel, turn on briefly to high intensity and immediately off21

Testing frequency varies with usage level – if high, test each day.Note: these tests indicate only if there is an output, not the level of output.

Dosage Base intensity and frequency selection on the following:parameters 1. stage of the problem (acute/sub-acute/chronic)

2. nature of the tissue (superficial bone or metal implant)3. depth of the tissues being treated4. size of the treatment area 5. the use of pulsed or continuous mode6. coupling medium options7. frequency options available 8. effective size of the radiating surface.

Method of 1. apply appropriate transmission medium (usually gel) directly to skin or, immerse part in water application (preferably degassed) at a comfortable temperature or, use water bag with gel on bag surfaces in

contact with the skin and the applicator2. have applicator in contact with skin (if subaqueous with 1-2cm distance and appropriate increase

in intensity ie 30%-55%22) and moving before turning on output3. maintain full contact with (or if subaqueous, constant distance from) skin and move applicator at

a constant rate4. avoid air bubbles in gel (can markedly reduce transmission) and maintain maximal applicator

contact (if subaqueous method, rapidly remove bubbles manually from skin and applicator face as they develop)

21 This is not the preferred method as it may cause damage to thecrystal in some machines or alter the machine output.

22 Ward and Robertson 1996.


5. move the applicator at all times there is an output to minimise production of hot spots resulting from the beam intensity pattern and standing wave formation, and pain with transmitted and shear waves at bony surfaces.

Records Must be kept and must include the following:1. C/Is checked, results of initial sensation tests and machine tests, that warnings were given and

consent obtained2. treatment details, including intensity and if continuous or pulsed (with on:off ratio), duration, area

treated and method used, equipment details including applicator, machine and frequency3. immediate result of treatment – including any abnormal reactions and subsequent action taken

or recommended4. all other treatment details.

Thermal - superficial heating and cooling

Check particular risks for thermal EPAs in table of contraindications and precautions (Table 1).

Output check Wax: temperature in middle depth of wax bath in range 42-52˚C23

Hotpacks: hydrocollator temperature 76-80˚C24

IR: therapist hand under lamp at approx. 60-75cm distance (750-1,000W), or 40-45cm if lesspower,25 after 5 minute warm upIce: examine skin under ice pack after 5 minutes to ensure no adverse reaction.

Dosage Superficial heatingparameters Guided by patient’s thermal responses - superficial heating modalities should provide comfortably or

perceptibly warm heat to patient. Therapists must limit the max. heating possible for patient withreduced thermal discriminationWax: ask about level of heating immediately after first and last layers of wax application and again at5 minutes and regularly thereafterHot packs and IR lamps: check skin immediately under hot packs26 and infra-red lamps for levels ofheating and adverse reactions and again after 8 minutes and regularly thereafterCoolingIce packs: check skin under ice packs immediately and after 5 minutes for adverse reactions.

Method of Precise distance and methods used to apply cooling or heating vary with the particular EPA. Avoidapplication weightbearing on heating or cooling sources. Consult standard textbook for details

Superficial heating1. wax: usually 6 to 8 layers with first most extensive, cover with plastic or waxed paper and wrap

in towel2. hot packs: place in wrap or towel so there is approximately 1-2cm covering between skin and

pack3. infra-red: lamp with parabolic reflector up to 70cm from and parallel to areaSince these methods do not incorporate safety switches, provide the patient with a bell or similardevice to use if the heat/sensations alter, become localised or uncomfortable, patient’s positionbecomes uncomfortable or they or any equipment movesCooling1. ice pack - methods include R.I.C.E. (rest, ice, compression, elevation).


consent obtained2. treatment details, including the EPA used and specific technique (eg distance of IR applicator

from skin and alignment, distance between hot pack and skin), and duration of application etc 3. immediate result of treatment - including any abnormal reactions and subsequent action taken or

recommended4. all other treatment details.

Thermal - deep

Check particular risks for thermal EPAs in table of contraindications and precautions (Table 1).

Output check SWD: operator’s hand between electrodes prior to use on patient or purpose-designed fluorescenttest tube for SWD MW: operator’s hand under transducer for MW with comfortable warmth settingTesting frequency varies with usage level - see manufacturers’ guidelines.

Dosage Requires patient has accurate thermal discrimination. See standard textbook for details of different parameters electrode arrangements (SWD). Check level of heating throughout the application.

23 Low and Reed (2000), p.244.24 Low and Reed (2000), p.246.

25 Low and Reed (2000), p.352.26 Fyfe 1982.


11

Method of Precise distance and methods used to apply heating vary with the method of deep heating. Consultapplication standard textbook for details.

Do not weightbear on heating or cooling source. Always expose the area fully prior to applying heatand ensure the area is, and remains, dry. See manufacturers’ guidelines for separation distances ofleads and ensure towel layer separates leads from any surface. If the equipment has a safety switch(eg MW or SWD) instruct the patient on its use. If no safety switch, provide the patient with a bell orsimilar device to use if the heat/sensations alter, become localised or uncomfortable, patient’s positionbecomes uncomfortable or they or the equipment moves.SWD - distances and relative sizes of capacitive pads and plates or inductothermy coils used varywith aims. Capacitive: min. electrode to skin distance 2-4cm. Inductothermy: min. distance to skin, onelayer of towel. See standard textbook for details of methods. SWD operator distance 0.5-1m fromoperating equipment27, treatment area free of metal.MW - usual transducer distance to skin 4cm. See standard textbook.


consent obtained2. treatment details, including the EPA used and specific technique (eg space plate arrangement,

distance from skin and alignment), duration of application and any available details of output intensity etc

3. immediate result of treatment - including any abnormal reactions and subsequent action taken orrecommended

4. all other treatment details.

Electrical stimulation

Check particular risks with electrical stimulation in table of contraindications and precautions (Table 1).

Output check Stimulator outputSet appropriate treatment parameters. With therapist’s hand or forearm across connected electrodes,gradually increase output with other hand until tingling sensations are felt. [If using non-reusableelectrodes, hold pre-gelled ends of leads 5mm apart and test as above].This test indicates only that there is an output and electrical continuity of the leads and electrodes.Testing frequency – prior to use on a day and otherwise on first treatment occasion for each patient.

Dosage parameters Consult appropriate research papers and recent textbooks for details.

Method of Skin impedanceapplication Wash skin with warm soapy water and rinse or, clean with alcohol swab before attaching electrodes.

ElectrodesAn even contact between the electrode surface and the skin is required for transcutaneous electricalstimulation. Electrodes: disposable or reusable1. if reusable electrode, reject if any cracks or signs of damage, if pads or sponges ensure they are

thoroughly rinsed after cleaning2. apply electrodes to skin with firm and even pressure, avoiding or minimising weightbearing on

sponges and pads. If using longer duration monophasic currents (eg greater than 10msec) use purpose designed electrodes or 2cm thick clean pads under reusable electrodes to reduce electrolytic effects on skin

3. electrode size, number and shape relate to method, area treated and aims. A high current density (mA/cm2) can produce skin damage: do NOT use small electrodes especially with MFAC28 currents such as interferential current.

4. position electrodes considering current path - must not be transthoracic, possibly also not through antero-lateral aspect of neck or either side of head. For interferential, position so interference pattern will develop in chosen area.

5. electrodes (some types) can be moved while current flows but only if kept in effective contact at all times with the skin.

StimulatorAfter setting output and checking parameters increase intensity slowly (if motor, only during ‘on time’)to allow the patient adequate time to adapt to the sensory effects. Increase until required effects (iedegree of sensory stimulation, of torque, etc) are achieved.If a patient safety switch is available, instruct the patient in its use. If not, provide them with a bell orsimilar warning device.Suction devicesEnsure such devices are used at sufficiently low pressure so no skin bruising, damage, or swellingoccurs under the suction cups.

27 Delpizzo and Joyner (1987).28 MFAC: medium frequency alternating currents (usually 1kHz

to 10kHz frequency) includes interferential and ‘russian’currents.



consent obtained2. treatment details, including machine, current type (frequency, pulse width), intensity (V or I),

options (eg modulations), duty cycle or on: off ratio, responses (sensory, motor, pain), duration oftreatment, location and type of electrodes, etc



Ultraviolet

Check particular risks for using UV in table of contraindications and precautions (Table 1).

Output check 1. requires professional testing2. keep records with UV lamp of time for E1 with successive patients - list distance and skin type,

time, and area of body tested. Adjust stabiliser only if marked increases documented in E1 times as necessitates re-establishing the E1 dosages for all patients currently being treated with that lamp

3. replace distilled water in water cooled lamp (eg Kromayer) at least annually.

Testing and Erythemal testingdosage 1. test either an area of skin adjacent to the area to be treated and with similar exposure to sunlight parameters or, the inner surface of a forearm

2. categorise patient’s skin type, check for medications that might alter sensitivity to UV and ascertain the patient’s usual reaction to exposure to sunlight

3. estimate appropriate test exposure times and apply exposure range to be slightly above and below expected E1 level using same lamp as for future treatments

4. provide patient with card at end of test and instructions to observe test area, and record reactions to report at the subsequent visit.

Dosage parameters1. see a standard textbook for details of factors that alter UV sensitivity and erythemal definitions

and recommended dosage levels2. do not treat if the skin over the area to be irradiated is peeling3. breaks between treatment

• if 10 or more days, reduce or repeat the previous exposure time• if 3 or more weeks, restart dosage on basis of original E1.

Method of Generalapplication 1. check for changes in any systemic or applied photosensitising agents (eg some medications)

prior to treatment2. apply UV in enclosed area - all who are exposed must wear UV protective goggles3. cover areas of patient not to be exposed with non-UV penetrating material, eg fine cotton

sheeting 4. select comfortable treatment position that gives appropriate UV access5. calculate treatment dose based on initial E1 for first session, and then on previous session for

subsequent treatments, and time precisely 6. warmup lamp for recommended period prior to treatment (usually 5 minutes for hot quartz

mercury vapour lamps) 7. inspect area after exposure and advise patient what to expect.Wounds1. remove dressings and clean area using a sterile technique 2. on completion of treatment, inspect irradiated area and dress wound as necessary.

Records Must be kept and must include the following:1. that warnings were given and consent obtained 2. check made for presence of any photosensitising agents prior to treatment3. the E1 test results for patient and the test and treatment lamp used 4. distance from the lamp, dose selected and exposure time given in each treatment session, time

of day and date5. immediate result of treatment - including any abnormal reactions and subsequent action taken or

recommended6. if treating a wound: the shape, size and depth of wound7. all other treatment details.


13

Laser29

Check particular risks for using laser in table of contraindications and precautions (Table 1).

Output check 1. check probe output using appropriate testing meter or photoelectric device 2. alternatively, ensure frequent testing by appropriate electromedical technician.

Dosage Regardless of acuteness/chronicity of the condition being treated:parameters 1. commence treatments with a low dose

2. base any dosage increase on the results of previous treatments of that patient.

Refer to textbook for further advice on dosage.

Method of 1. clean skin and applicator/probe with an alcohol wipe prior to use; clean open wounds with application normal saline solution

2. apply laser so the beam strikes the skin at a right angle3. use applicator in contact with intact skin, and with open wounds, as close as possible without

contact.

Records Must be kept and must include the following:1. that warning was given, consent obtained, that goggles worn 2. treatment details, including the particular equipment (class and type of laser) and applicator used

(single probe, scanner, multi-diode probe), the specific technique (eg in contact or held over skin,gridding, scanning), energy density, size of area treated, number and location of points treated and duration per point



Low frequency magnetic fields

Output check Test output according to manufacturers’ instructions eg small magnet supplied will pulse at test frequency (eg 1 Hz) when held inside the applicator.

Dosage Refer to textbook and current research.parameters

Method of 1. position applicators close to the area being treated to ensure that the pulsed magnetic field application adequately affects the tissues

2. connect applicator to machine, set frequency and intensity, then switch on3. do not cover part being treated and/or applicator or apparatus, with any form of covering – heat

may be generated if the treatment time is protracted.

Records Must be kept and must include the following:1. that warning was given and consent obtained2. treatment details, including the frequency used (Hz), intensity (Gauss), duration of treatment,

applicator used and its position/polarity as appropriate3. immediate result of treatment - including any abnormal reactions and subsequent action taken or

recommended4. all other treatment details.

29 Laser: Light Amplification by Stimulated Emission ofRadiation.


Physiotherapists have a responsibility to be cognisantof and to apply principles of infection control in theirclinical practice. This section lists items of routinecare, followed by care appropriate to the differentlevels of risk relevant when using EPAs.

Users of EPA equipment should:

1. always apply standard precautions and, whennecessary, additional precautions (NHMRC1996 and 2000 draft)

2. perform a risk assessment to ascertain the levelof precautions necessary.

Routine care

1. Hand washing

• is essential immediately before and immediatelyafter every patient to prevent cross infectionbetween patients and protect physiotherapistsfrom pathogenic micro-organisms (Bryan et al1995, Horton 1995, Larson 1995).

2. Disposal of sharps

• requires a sharps container (thick yellow plasticpurpose built and must meet AustralianStandards AS 4261, AS 4031)

• sharps container must be in safe and accessibleplace

• sharps container must not be filled abovecapacity.

Levels of care

Non-critical treatment

EPA treatment involving contact with intact skin isconsidered a low risk procedure (non-critical).

EPA probes, electrode covers or sponges

• routinely wipe this equipment with 70% alcohol(alcohol wipes) or soak regularly in fresh Milton(sodium hypochlorite) solution between patients(according to manufacturers’ guidelines) eg seeLambert et al (2000)

• dry electrode covers and sponges completely

overnight to enhance disinfection

hot or cold packs

• use fresh towels with each new patient

self-adhesive electrodes

• re-use only with same patient (see modalityspecific information following Table 1) providedtheir skin is intact and store as suggested by themanufacturer

other EPA equipment

• if not in contact with patients, EPA devicesshould be wiped routinely with hot water, aneutral detergent, a disposable cloth and allowedto dry. The frequency of this environmentalcleaning should be determined by the level ofrisk of the clinical area eg where there is a highrisk of infection, such as a burns unit,environmental cleaning should occur daily.

Semi-critical treatment

Where there is an open wound or the potential forcontact with blood or body substances, non-intactskin or mucous membranes, physiotherapists shouldapply Standard Precautions (NHMRC 1996, 2000draft)

• wear gloves and ensure contaminated gloves donot contact the EPA control panel or equipment.

• ensure gloves, single use covers, vaginalelectrodes, etc. are removed without inadvertentflicking of gel onto other surfaces and dispose ofin double plastic bagging

• wash hands thoroughly with soap and waterbefore and after each procedure

• use probes (laser, UV), electrodes (vaginal andother), perineometer and US applicator withsingle use (eg vaginal electrodes) or sterile cover(eg laser). Following this any covers must bedisposed of carefully and all equipment cleanedthen disinfected (see definitions next page). Ifsingle-use sterile covers are not available, anyequipment that comes in contact with intactmucous membranes or non-intact skin must besterilised eg UV Kromayer probes

SECTION 3: Infection control procedures


15

gel

• possible source of infection when used in semi-critical treatments

• single use sterile gel packets are preferred sincethey remove any risk of contact between thesource of infection and the nozzle or outercontainer.

Critical treatment

Treatment that involves submucosal invasion

acupuncture or needle EMG electrodes

• sterile needles must be used

• use alcohol wipe on skin prior to insertion of anyneedle to reduce the bacterial load on the skin tolessen the risk of infection.

Definitions

Cleaning

Cleaning of applicators and non-electrical equipmentis essential prior to disinfection and sterilisationprocesses (NHMRC 2000 draft). The followingcleaning technique is recommended (NHMRC 2000draft):

1. gloves, face protection and a plastic apron mustbe worn

2. flush in running water

3. fully dismantle instrument and immerse in warmwater (45 degrees) and a neutral detergent

4. scrub gently with a brush. Cleaning instrumentsshould be stored dry

5. rinse in hot water to assist the drying process

6. inspect instrument to ensure that it is free fromprotein residues and other stains

7. dry mechanically in drying cabinet or hand drywith a clean lint free cloth (NHMRC 2000 draftguidelines recommend that items are NOT left todry in ambient air).

Disinfection

Disinfection is the inactivation of non-sporingorganisms using either thermal or chemical means(AS 4187). Chemical disinfection involves chemicalssuch as hyperchlorites and aldehydes. Theeffectiveness of these agents is dependent on severalfactors including temperature, pH, concentration, thepresence of organic material, and the relativeresistance of any infectious agents involved (NHMRC2000 draft).

Suitable agents include those containing chlorine,gluteralderhyde or alcohol. Gluteraldehyde (2%) isthe most readily available chemical disinfectant formanual use and has a demonstrated effectivenessagainst a range of viruses and bacteria (Hanson et al1994). However, gluteraldehyde must be used only incontrolled circumstances and with carefulmonitoring. Gluteraldehyde is unlike sodiumhypochlorite or alcohol which are relatively safe.Alcohol assists in drying but has limited efficacy as adisinfectant. Thermal disinfection can be used if theEPA device can tolerate boiling. Also, manufacturers’recommendations should be sought prior to the use ofspecific agents.

Sterilisation

Sterilisation is a validated process used to render aproduct free of all forms of viable micro-organismseg autoclaving, dry heat and high level or automatedchemical process systems (eg ethylene oxide gas).Manufacturers’ recommendations regarding thesterilisation process suitable for each EPA devicemust be sought to prevent damage.

Recommendation: That each practice/clinic have awritten set of procedures detailing the agents andprocesses used for infection control in each situation.


Basic EPA equipment safetyrequirements

Physiotherapy treatment areas should be electricallywired as body protected areas (Type BF), to protectthe therapist and patient from electrical macroshock,unless only Type CF or BF patient equipment is usedin them.30 The EPA user, however, is responsible forensuring the level of equipment safety established bydesign and manufacture. The following points arebasic and apply to any electrical equipment. Moredetailed information can be obtained from therelevant Australian/New Zealand Standardspublication.31

1. All electromedical equipment is required to betested at least every 12 months32 for basicelectrical safety by suitably qualified technicalstaff competent in the area of biomedicalengineering and a label affixed which indicatesthe date, tester, and period covered by the safetytest. All electromedical equipment is to becalibrated at least every two years.33 Whereelectromedical equipment is used heavily anddaily it is recommended that servicing should beconsidered more often, at least six-monthly.34

All new electromedical equipment purchasedshould be electrical safety tested and clearedprior to commissioning.

2. Inspect the supply cord and plug before pluggingequipment into the power outlet. Check for anyphysical damage such as a cracked or split plugcasing or damage to the outer sheath of thepower cord. Look for loose screw connections,frayed wires, signs of overheating and loose cordclamps. Ensure the earth wire is intact(green/yellow or all green). The use oftransparent plugs (now mandatory) facilitatesthis.

3. Fault tag any suspected faulty leads andequipment, disconnect from the power, andremove from use. Fault tags should be readilyavailable and identifiable and have space for adescription of the fault symptoms. Ensure faultyequipment is not re-used until tested byappropriately qualified engineering staff.

4. Double adaptors and extension cords are notpermitted. Both can lead to overloading of a leador wall socket and, extension cords arehazardous in a work environment. Power boardsare permitted but only if used with cautionbecause of the risk of overloading either theboard or wall socket. Consider installingadditional wall sockets.

5. Inspect patient leads (or cables) and electrodesprior to use for damage. Frequent flexing ofleads can result in broken wires in the lead or atthe machine or electrode connections and candisrupt the output. With ultrasound machines,inspect the cable to the applicator and the cableinsulation. Ensure the applicator remainswaterproofed. With shortwave diathermyequipment check accessories including leads,pads, space plates, and coils. Damage can lead toarcing within an accessory or at the socket.

6. Connecting patients to more than one item ofelectrical equipment at a time increases theelectrical hazard as well as possibly creatingadditional risks because of interactive effects(see Note on possible interactive effects, Section1).

7. Space needs to be left around machines forventilation as most electrical equipmentgenerates some heat during use. Should theequipment emit an unusual odour or be too hotto touch, switch off immediately, fault tag it, anddo not re-use until checked and cleared.35

8. Loose switches, controls, dials or non-functioning indicator lights/meters requirerepairing before the equipment is safe to use.

9. If, during use, any unexpected disturbance in theoutput or an uncontrolled surge/shock occurs,turn off equipment immediately. Fault tag it andhave it checked before further use.

10. The wax bath temperature should be checkedregularly to prevent fire and, the bath shouldhave a metal lid. Have a fire extinguishersuitable for electric fires present and a fireblanket.

SECTION 4: EPA equipment safety

30 AS/NZS 3003:1999, pp.8, 15-19. 31 AS/NZS 2500:1995, Guide to the safe use of electricity in

patient care.32 AS/NZS 3551:1996, p.19.

33 May need updating when the AS/NZS currently beingdeveloped for ultrasound equipment becomes available.

34 AS/NZS 3551:1996, p.19.35 All equipment checking and testing must be done by qualified

technical staff competent in biomedical engineering.


17

General

Cameron MH (Ed.) (1999): Physical Agents inRehabilitation. Philadelphia: WB Saunders Co.

Delany C (1996): Should I warn the patient first?Australian Journal of Physiotherapy,42: 249-255.

Low J and Reed A (2000): Electrotherapy Explained.(3rd ed.) Oxford: Butterworth-Heinemann Ltd.

Nelson R, Hayes K and Currier D (Eds) (1999):Clinical Electrotherapy. (3rd ed.) Stamford:Appleton and Lange.

Vines P (1996): Informed consent: From paternalbenevolence to trust mediated by truthfulness.Australian Journal of Physiotherapy 42: 245-246.

Ultrasound

Baker K, Robertson V and Duck F (2001): A reviewof therapeutic ultrasound. Part 2: Biophysicaleffects. Physical Therapy 81.

Ebenbichler GR, Erdogmus CB, Resch KL, FunovicsMA, Kainberger F, Barisani G, Aringer M,Nicolakis P, Weisinger GF, Baghestanian M,Priesinger E, Fialka-Moser V and Weinstabl R.(1999): Ultrasound therapy for calcific tendinitisof the shoulder. New England Journal ofMedicine 340: 1533 -1538.

Ebenbichler GR, Resch KL, Nicolakis P, WeisengerGF, Uhl F, Ghanem AH and Fialka V (1998):Ultrasound treatment for treating the carpaltunnel syndrome: randomised “sham” controlledtrial. British Medical Journal 316: 731-735.

Robertson V and Baker K (2001): A review oftherapeutic ultrasound. Part 1: Effectivenessstudies. Physical Therapy 81.

Ward AR and Robertson VJ (1996): Dosage factorsfor the subaqueous application of 1MHzultrasound. Archives of Physical Medicine andRehabilitation 77: 1167-1172.

Heat Therapy

Ayling J and Marks R (2000): Efficacy of paraffinwax baths for rheumatoid arthritic hands.Physiotherapy 86: 190-201.

Fyfe M (1982): Skin temperature, colour, and warmthfelt, in hydrocollator pack applications to thelumbar region. Australian Journal ofPhysiotherapy 28: 12-15.

Kallen B, Malmquist G and Moritz U (1992):Delivery outcomes among physiotherapists inSweden: Is non-ionising radiation a fetal hazard?Physiotherapy, 78: 15-18.

Logue JN, Hamburger S, Silverman PM andChiacchierini RP (1985): Congenital anomaliesand paternal occupational exposure to shortwave,microwave, infrared and acoustic radiation.Journal of Occupational Medicine 27: 451-452.

Low J and Reed A (2000): Electrotherapy Explained(3rd ed.) Oxford: Butterworth-Heinemann Ltd,pp. 212-254.

Martin CJ, McCallum HM, Streelley S and Heaton B(1991): Electromagnetic fields from therapeuticdiathermy equipment: A review of hazards andprecautions. Physiotherapy 77: 3-7.

Odia G and Aigbogun O (1988): Thermal sensationand the skin sensation test: Regional differencesand their effects on the issue of reliability oftemperature ranges. Australian Journal ofPhysiotherapy 34: 89-93.

Cold Therapy

Belitsky RB, Odam SJ and Hubley-Kozey C (1987):Evaluation of the effectiveness of wet ice, dry iceand cryogen packs in reducing skin temperature.Physical Therapy 67: 1080-1084.

Day MJ (1974): Hypersensitive response to icemassage. Report of a case. Physical Therapy 54: 592-593.

Ho SSW, Illgen RL, Meyer RW, Torok PJ, Cooper MDand Reider B (1994): Comparison of variousicing times in decreasing bone metabolism andblood flow in the knee. American Journal ofSports Medicine 23: 74-76.

Knight KL (1995): Cryotherapy in SportManagement. Champaign (Illinois): HumanKinetics.

Lorenze EJ, Carontonis G and De Rosa AJ (1960):Effect on coronary circulation of cold packs tohemiplegic shoulders. Archives of PhysicalMedicine and Rehabilitation 41: 394-399.

SECTION 5: Bibliography


Meeusen R and Lievens P (1986): The use ofcryotherapy in sports injuries. Sports Medicine3: 398-414.

Rasmussen M, Hayes D, Vlietstra R andThorsteinsson G (1988): Can transcutaneouselectrical nerve stimulation be safely used inpatients with permanent cardiac pacemakers?Mayo Clinic Proceedings 63: 443-445.

Stanghelle JK and Nilsson S (1983): Angina pectorisand cold. International Journal of RehabilitationMedicine 5: 189-191.

Taber C, Contryman K, Fahrenbruch J, LaCount Kand Cornwall MW (1992): Measurement ofreactive vasodilation during cold gel packapplication to non-traumatised ankles. PhysicalTherapy 72: 294-299.

Electrical stimulation

APTA Electrotherapy Standards Committee (1990):Electrotherapeutic Terminology in PhysicalTherapy. Virginia: American Physical TherapyAssociation.

Nelson R, Hayes K and Currier D (Eds) (1999):Clinical Electrotherapy. (3rd ed.) Stamford:Appleton and Lange.

Selkowitz DM (1999): Electrical currents. InCameron MH (Ed.): Physical Agents inRehabilitation. Philadelphia: WB Saunders Co.,pp. 345-427.

Ultraviolet

Low J and Reed A (2000): Electrotherapy Explained.(3rd ed.) Oxford: Butterworth-Heinemann Ltd,pp. 376-412.

Stern RS, Nichols KT and Vakeva LH (1997):Malignant melanoma in patients treated forpsoriasis with methoxsalen (psoralen) andultraviolet A radiation (PUVA). New EnglandJournal of Medicine 336:1041-1045.

Laser

Kleinkort JA and Foley RA (1984): Laseracupuncture: Its use in physical therapy.American Journal of Acupuncture 12: 51-56.

Kramer JF and Sandrin M (1993): Effects of low-power laser and white light in sensory nerveconduction rate of the superficial radial nerve.Physiotherapy Canada 45: 165-170.

Laakso L, Cramond T, Richardson C and Galligan JP(1994): Plasma ACTH and beta-endorphin levelsin response to low level laser therapy (LLLT) in

myofascial trigger points. Laser Therapy6: 133-142.

Laakso EL, Richardson C and Cramond T (1997):Pain scores and side effects in response to LowLevel Laser Therapy (LLLT) for myofascialtrigger points. Laser Therapy 9: 67-72.

Mester E, Mester AF and Mester A (1985): Thebiomedical effects of laser application. Lasers inSurgery and Medicine 5: 31-39.

Magnetic field therapy

Leclaire R and Bourgouin J (1991): Electromagnetictreatment of shoulder periarthritis: A randomizedcontrolled trial of the efficiency and tolerance ofmagnetotherapy. Archives of Physical Medicineand Rehabilitation 72: 284-287.

McMeeken J (1992): Magnetic fields: Effects onblood flow in human subjects. PhysiotherapyTheory and Practice 8: 3-9.

Railton R and Newman P (1983): Magnetic fieldtherapy - does it affect soft tissue? Journal ofOrthopaedic and Sports Physical Therapy 4: 241-246.

Ramey DW (1998): Magnetic and electromagnetictherapy. Scientific Review of AlternativeMedicine 2: 13-15.

Sharrard WJW (1990): A double blind trial of pulsedelectromagnetic fields for delayed union of tibialfractures. Journal of Bone and Joint Surgery(British) 72B: 347-355.

Vallbona C and Richards T (1999): Evolution ofmagnetic therapy from alternative to traditionalmedicine. Physical Medicine and RehabilitationClinics of North America 10: 729-754.

Hazards with EPAs and Australian/NewZealand Standards

Australian and New Zealand Standard AS/NZS 2500(1995): Guide to the safe use of electricity inpatient care. Sydney: Standards Association ofAustralia.

Australian and New Zealand Standard AS/NZS 3551(1996): Technical management programs formedical devices. Sydney: Standards Associationof Australia.

Australian Standard AS 3200.2.6 (1992): Approvaland test specification - Medical electricalequipment. Part 2.6: Particular requirements forsafety - Microwave therapy equipment. Sydney:Standards Association of Australia.

Australian and New Zealand Standard AS/NZS


19

2211.1 Suppl.1 (1999): Laser safety. Part 1;Equipment classification, requirements anduser’s guide. Supplement 1: Applicationguidelines and explanatory notes. Sydney:Standards Association of Australia.

Australian and New Zealand Standard AS/NZS 4173(1994): Guide to the safe use of lasers in healthcare. Sydney: Standards Association of Australia.

Australian and New Zealand Standard AS/NZS 3003(1999): Electrical installations - Patient treatmentareas of hospitals and medical and dentalpractices. Sydney: Standards Association ofAustralia.

Australian and New Zealand Standard AS/NZS3200.1.0 (1998): Medical electrical equipment:General requirements for safety - ParentStandard. Sydney: Standards Association ofAustralia.

Chen D, Philip M, Philip PA and Monga TN (1990):Cardiac pacemaker inhibition by transcutaneouselectrical nerve stimulation. Archives of PhysicalMedicine and Rehabilitation 71: 27-30.

Delpizzo V and Joyner K (1987): On the safe use ofmicrowave and shortwave diathermy units.Australian Journal of Physiotherapy33: 152-162.

Hocking B and Joyner K (1995): Re: Miscarriagesamong female physical therapists who reportusing radio- and microwave frequencyelectromagnetic radiation [letter to editor].American Journal of Epidemiology141: 273-274.

Kitchen S (2000): Audit of the unexpected effects ofelectrophysical agents. Physiotherapy86: 152-155.

Lerman Y, Caner A, Jacubovich R and Riback J(1996): Electromagnetic fields from shortwavediathermy equipment in physiotherapydepartments. Physiotherapy 82: 456-458.

Lundstrom R (1985): Effects of local vibrationtransmitted from ultrasonic devices onvibrotactile perception in the hands of therapists.Ultrasonics 28: 793-803.

Ouellet-Hellstrom R and Stewart W (1993):Miscarriages among female physical therapistswho report using radio- and microwavefrequency electromagnetic radiation. AmericanJournal of Epidemiology 138: 775-786.

Partridge C and Kitchen S (1999): Adverse effects ofelectrotherapy used by physiotherapists.Physiotherapy 85: 298-303.

Taskinen H, Kyyronen P and Hemminki K (1990):Effects of ultrasound, shortwave, and physicalexertion on pregnancy outcome inphysiotherapists. Journal of Epidemiology andCommunity Health 44: 196-201.

Infection control procedures

Australian Standard AS 4031 (1992): Non-reusablecontainers for the collection of sharp medicalitems used in healthcare areas. Sydney:Standards Association of Australia.

Australian Standard AS 4187 (1998): Cleaning,disinfecting and sterilizing reusable medical andsurgical instruments and equipment, andmaintenance of associated environments inhealth care facilities. Sydney: StandardsAustralia.

Australian/New Zealand Standard AS/NZS 4261(1994): Reusable containers for the collection ofsharp items used in human and animal medicalapplications. Sydney: Standards Australia andStandards New Zealand.

Bryan J, Cohran J and Larson E (1995): Handwashing: A ritual revisited. Critical Care NursingClinics of North America 7: 617-625.

Hanson PJ, Bennett J, Jeffries DJ and Collins JV(1994): Enteroviruses, endoscopy and infectioncontrol: an applied study. Journal of HospitalInfection 27: 61-67.

Horton R (1995): Hand washing : the fundamentalinfection control principle. British Journal ofNursing. 4: 926-933.

Lambert I, Tebba S, Hill D, Moss H, Davies A andElliott T (2000): Interferential therapy machinesas possible vehicles for cross-infection. Journalof Hospital Infection 44: 59-64.

Larson E (1995): APIC guidelines for hand washingand hand antisepsis in health care settings.American Journal of Infection Control. 23: 251-269.

NHMRC (1996): Infection control in the health caresetting. Canberra: Commonwealth of Australia.

NHMRC (2000): Infection control in the health care setting - draft guidelines for the prevention of transmission of infectious diseases. Canberra: Commonwealth of Australia.www.health.gov.au/pubhlth/strateg/communic/review.


Authors’ AffiliationsValma J Robertson PhD, BAppSc(Phty), BA(Hons), CertElectronics, MAPAAssociate Professor, La Trobe University, Bundoora, Victoria 3086. [email: [email protected]]

Lucy S Chipchase, MAppSc(Phty), MAPALecturer, University of South Australia, North Terrace, Adelaide, South Australia 5000.[email: [email protected]]

E Liisa Laakso PhD, BPhty, GradCertHealthMgmt, MAPAConjoint Lecturer/Senior Physiotherapist, The University of Queensland/Royal Brisbane Hospital, Queensland.

Karyn M Whelan BAppSc(Phty), MAppSc(Phty), MAPALecturer, School of Physiotherapy, The University of Sydney, Lidcombe, New South Wales 2141.

Leanda J McKenna BAppSc(Phty), PGradDip(Sports), MAPALecturer, Curtin University of Technology, Shenton Park, Western Australia 6008. [email: [email protected]]

ContributorsAlex R Ward PhDSenior Lecturer, La Trobe University, Bundoora, Victoria 3086. [email: [email protected]]

David Bastians BAppSc(Phty)Lecturer, Charles Sturt University, Albury , New South Wales 2640.[email: [email protected]]

Published by: Australian Physiotherapy AssociationPO Box 6465 St Kilda Road Central, Victoria 8008Ph. 03 9534 9400 Fax 03 9534 9199E-mail: [email protected]

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Re: Aged Care Funding Instrument revision - Physiotherapy · PDF fileThe ACFI should be changed to reflect the following: Section 2 – Mobility should include a mandatory physiotherapy