----- Original Message -----

From: [log in to unmask] href="mailto:[log in to unmask]">RIDDELL, David

To: [log in to unmask] href="mailto:[log in to unmask]">[log in to unmask]

Sent: Friday, August 24, 2001 12:00 AM

Subject: Re: ultrasound

Hi Henry

I was trying to be a bit challenging?! Like you I have spent all my time in private albeit somewhat longer and I am aware of the issues you face (financial vs professional etc).

My last word on US (I hope). I actually completed a RCT way back in 1991 for my University thesis (which I didn't publish) - too busy/idle? anyway we looked at a very specific injury (acute lat lig sprains of the ankle with only specific ligs injured + a whole lot of exclusion criteria, time of injury within a tight window period, rigorous regime of 5 treatments over a 7 day period etc etc - it was extremely tightly controlled, dosages frequency etc was based on the best available evidence at the time mainly work by Dyson and ? (can't remember off the top of my head). We objectively measured outcome i.t.o digital goniometer, water displacement and subjective VAS. Control group got sham otherwise everything else the same.

The EXpt. group improved significantly on two of the three measures and had a clinically but not statistically significant improvement on the third. HOWEVER the problem was that because dosage was based on an 'accurately measured' area using a grid, we found that the average time of insonation was in the region of about 18 minutes and that some patients - large gents required up to 25 minutes - not very practical!!!

Anyway keep well

Dave Riddell

-----Original Message-----
From: Henry Tsao [mailto:[log in to unmask]]
Sent: 23 August 2001 13:38
To: [log in to unmask]
Subject: Re: ultrasound

David,

Sorry I didn't answer your questions... I took it that you were making more
a comment than a serious question toward myself. I will answer your
questions now :)

>i       Firstly, you didn't anwer my question - what's the evidence like on
>Interferential?

**LIke any electrotherapy, the evidence on the interferential is not very
good. There was an article in Physiotherapy June 1999/Vol85/No6 p294 - "The
Mystiqe of Interferential Currents when used to Manage Pain" - which stated
that with regards to pain relief, "...there is little consistent information
about the different effects of varying dosages. In fact, there is scanty
proof that it works at all."

Also, in The Clinical Journal of Pain Vol 17 No 1 2001, p33 "
Nonpharmacological treatments for musculoskeletal pain" (which is an article
I'd recommend all Physiotherapists to read!), it stated that "the evidence
base to allow us to properly determine the effectiveness of this treatment
modality is inadequate. Those studies that have been reported do not suggest
significant therapeutic benefit." However, they do state the need for more
high-quality trials, but found TENS to be more effective than interferential
according to the evidence available.

>ii.  If the patient has '..been coming in for a long time ..' - have you
>not
>considered that perhaps you not doing doing something right and the other
>physio with the 'tingling machine' was treating symptomatically instead of
>looking for, and correcting the underlying cause(s) of the problem?

**I will answer your question in two parts. Firstly, I have only been a PT
for the last 1.5 years, and I took over from another Physiotherapist who was
there for 3 years and who built a good reputation in the community. When I
first started, it was difficult to change your treatment protocol, more
because the clients did not have as much confidence in you. As I have stated
in previous posts, if the patients do not have confidence in you, why would
they let you try something different. I remember a number of patients where
I did not put the interferential on them, and they told my boss that "I did
not do anything at all." As I said, they have been well trained by the old
Physiotherapy "way". I even know Physio practices around my area now who put
the interferential and heat pack BEFORE the Physio does anything at all!!!
You are in marketing terms satisfying consumer demand.

Secondly, I would have to say that when I first graduated, I was thrown into
the deep end of private practice. My boss had a sick wife with CFS, so I had
to look after a practice independently without any prior physio or clinical
experience. Of course my treatment back then would have been fairly poor,
but as I gain more experience and confidence, and learn more from physio
lists such as this one, I gradually reduced the amount of electrotherapy
used. As well, patients and referring physicians had more confidence in what
I was doing - so I am slowly getting rid off electrotherapy. As much as I
hate it, I still am forced to use it on certain patients (see next question)

>iii. Do you always give the patient 'what they want' - if you weren't in
>private practice would you do this and if not why not? Shouldn't this be an
>appropriate treatment/professional issue not what sounds like a practice
>income issue?
>

**I guess I answered part of this question in my previous response. The
answer is no, I do not usually give the patient what they want, unless they
have been "trained." I have learnt that yes, you have to be a
Physiotherapist and practice EBM, but sometimes, you also have to be a
businessman. I learnt this the hard way once again through some bitter
experiences. You will always get patients who come in and demand that they
want this and that done on them. If you go against it, then no matter how
good a job you do, they will always think you are a bad physio. I think this
is one of the biggest lessons I got out of private practice. As much as I
hate it, private practice in Australia is about balancing your role as a
Physiotherapist, the patients expectations and the business side - and these
three do not always go together. Plus it is not my practice, so I have a
responsibility towards my boss for keeping the clients happy. But if I had
my own practice, perhaps I may do things differently...

>Alternatively, I need treatment so when next I'm in Oz, I'd like some
>cocaine as that's what I want!!

**I know the government here are trying hard to resist legalisation of
cocaine, but they are getting a lot of pressure from different groups. Once
it becomes legalised, I will let you know :D

I hope I have answered your questions this time.

Henry***

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