Case Management, Indications, Contraindications, and Safety
Case Management
Documentation and consent
Chart in a consistent format (subjective, objective, assessment, plan) with measurable findings, skilled interventions, and response to treatment - this is what supports medical necessity. Informed consent requires capacity, disclosure of risks and alternatives, understanding, and voluntariness; it is an ongoing conversation, not a signature.
Goal setting and outcomes
Write goals that are specific, measurable, achievable, relevant, and time-bound, stated in functional terms (for example, walk 400 m without a cane in 4 weeks). Pair them with validated outcome measures such as the numeric pain rating scale, patient-specific functional scale, Oswestry or Neck Disability Index, DASH, Berg Balance Scale, Timed Up and Go, and 6-minute walk test.
Referral and red flags
Case management questions test whether you know when to stop and refer. Escalate for suspected cauda equina (saddle anesthesia, bowel or bladder change, bilateral lower-extremity weakness), progressive neurologic deficit, unexplained weight loss, night pain unrelieved by rest, fever with spinal pain, history of cancer, significant trauma, or suspected fracture or infection.
Communication
Use plain language, teach-back, and motivational interviewing for behavior change. Coordinate with the referring provider, and plan discharge from the first visit: what the patient must be able to do, and how it will be measured.
Traps
Non-measurable goals, treating beyond a plateau without revising the plan, and missing a red flag hidden in a routine-sounding vignette.
Rule of thumb
If a new finding would change the medical workup, it is a referral issue - document it, communicate it, and continue only within your scope.
Indications, Contraindications, and Safety
Screen before you treat
The same pre-treatment screen applies to nearly every modality and procedure: sensation, skin integrity, circulation, cognition and ability to communicate, pregnancy status, malignancy history, bleeding risk or anticoagulation, implanted devices (pacemaker, defibrillator, spinal cord stimulator, metal hardware), and infection.
Contraindication clusters
- Cold: cold hypersensitivity, Raynaud phenomenon, cold urticaria, cryoglobulinemia, paroxysmal cold hemoglobinuria, over regenerating peripheral nerve, impaired circulation or sensation.
- Heat and diathermy: acute inflammation or hemorrhage, impaired sensation, ischemic tissue, malignancy, over the pregnant uterus, and - for diathermy - pacemakers and metallic implants in the field.
- Electrical stimulation: across the heart or chest, over the carotid sinus or anterior neck, transcerebrally, over the abdomen or pelvis in pregnancy, over the eyes, and over areas of active infection, thrombophlebitis, or malignancy.
- Ultrasound: over the eyes, heart, pregnant uterus, reproductive organs, malignancy, thrombophlebitis, epiphyseal plates in children, and laminectomy sites.
Procedural safety
Inspect equipment and cords, keep the patient dry and remove jewelry, never leave a patient unattended with an active thermal or electrical agent, and check the skin before, during, and after treatment. Ask about pacemakers before any electrical device, and confirm sensation with a light touch screen when the patient cannot report symptoms.
Traps
The exam often offers a legitimate indication as a distractor for a contraindication question, or describes a patient with neuropathy receiving a hot pack. Absent or unreliable sensation is an absolute reason to avoid thermal agents.
Rule of thumb
If the patient cannot feel it, report pain, or move away from it - do not apply heat, cold, or electricity at a dose you cannot monitor.