Dear Henry,

Thank you for reply.  I must apologise to you and members of the list if I
gave the impression that Bruce and I were having a discussion.  We weren't.
But perhaps the two of us can start again....
Henry:
> I found an interesting article the other day in the Pain journal on the
> effectiveness of ultrasound therapy on musculoskeletal pain (Pain 81, 1999
> 257-271). It basically evaluated the use of US, and looked at the existing
> research on the topic. They basically concluded that for lateral
> epicondylitis, soft tissue shoulder disorders, deegn rheumatic disorders,
> ankle distorsions and TMJ disorders, US showed no significant clinical
> effect. Even when they combined US with exercise therapy, there was
> clinically important or statistically significant differences in favour of
> US (which I was surprised to read, as we always thought that US was
> effective only when it is used as an adjunct!!). Even though this does not
> totally rule out the uselessness of US therapy, it definitely has some
> strong gound to stand on!
> On the contrary, I found in the Am J of Physical Medicine and Rehab(79, 1,
> p48-52, 2000) an article that looked at the use of US, dry needle, and
> stretches of myofascial trigger points in the Upper Trap muscles. They
found
> that US combined with stretches and dry needle combined with stretches
> produced significant results compared to simply stretching alone. However,
> there was no difference between dry needle and the use of US in
combination
> with stretches.
Cheng:
There are 24 references on my web site that relates to clinical studies on
ultrasound (http://health.shinshu-u.ac.jp/PT/electro/usstudies.htm)  From
the summary table, you can see that for acute injuries, Ultrasound has been
shown to be effective for acute injuries in only one study by Middlemast and
Chatterjee (1978).  The dosage they used was 1.5MHz, 0.5 to 2.0 watt/cm2
(pulsed) 5X/week.  For sub-acute, and chronic injuries, Ultrasound was not
effective.  In the treatment of wounds and ulcers, ultrasound was shown to
be very effective in quite a few studies.
However, lets take this further.  In the management of pain, there have been
other more effective modalities compared to US.  For instance, if you looked
under electrical stimulation for pain modulation
(http://health.shinshu-u.ac.jp/PT/electro/electrostudies.htm), you will find
several good studies there that demonstrates clinical effectiveness.  The
dosage parameters are also given next to the study.  In addition, if you
looked at Lasers (http://health.shinshu-u.ac.jp/PT/electro/laserstudies.htm)
you'll find an overwhelming majority of the studies show that it does NOT
work for pain.
I guess what I am getting at here is that it is pointless to look at a few
studies randomly and conclude from there that electrotherapy is effective or
ineffective.  You would have to go a bit deeper than that in order to do the
subject some justice.  I have attempted to do that by putting it on a web
site.  Another member of this list Hamish Ashton ([log in to unmask])
recently completed a lit review on Ultrasound and wrote in to support its
use for ulcers but no one has acknowledged his message.  (Why are we so hung
up on pain).
Secondly, as the evidence has shown, you would have to select the
appropriate modality for the specific clinical effect that you want to
achieve for your patient.  If pain modulation was your goal, the evidence
suggests that electrical stimulation is far more effective than ultrasound.
The latter being effective only for acute injuries.
Thirdly, the whole discussion so far has centred around PAIN and the
alleviation of pain using electro-modalities.  While this is one of the
benefits of EPA, it is not the ONLY effect we achieve with EPA.  EPA covers
a lot of ground including thermotherapy (SWD, MW, US, IR, etc..),
cryotherapy, electrotherapy (for pain modulation, muscle re-education, and
tissue healing), phototherapy (for dermatological conditions),
mechanotherapy (traction, CPM, intermittent pneumatic pressure), and even
pharmacotherapy (phonophoresis and iontophoresis).  That is a lot of ground
to cover and any discussion on EPA would be pointless without being
specific.  You can't just look at one or two effects (eg. fibroblasts and
and leucocytes) and one or two modalities (eg ultrasound) and conclude from
there that the entire field of EPA is ineffective.  This ignores the
evidence of so many other good studies that have demonstrated clinically
effective results such as the use of ES for the treatment of incontinence
(http://health.shinshu-u.ac.jp/PT/electro/electrostudies.htm), the use of
intermittent pneumatic pressure for oedema
(http://health.shinshu-u.ac.jp/PT/electro/pressurestudies.htm) , the use of
US, ES and UV for wound healing, the use of ES and thermotherapy for pain
modulation, the use of phonophoresis
(http://health.shinshu-u.ac.jp/PT/electro/phonostudies.htm) and
iontophoresis (http://health.shinshu-u.ac.jp/PT/electro/iontostudies.htm) in
the treatment of various disorders including pain and inflammation, the use
of cryotherapy for the treatment of swelling and pain
(http://health.shinshu-u.ac.jp/PT/electro/cryostudies.htm), the use
of.......  Sure, not all of them were success stories, but not every one of
them were dismal failures either.  If you were to look at the evidence
across the board, you will find some modalities that have very strong
evidence for its effectiveness (eg. electrical stimulation for pain and
wound healing) and some not so strong evidence (eg. ultrasound for pain).
Conversely, you will also find very strong evidence that shows it is
INEFFECTIVE (eg. lasers for pain), and some not so strong evidence of
ineffectiveness (eg. ultrasound for pain).  Surely, any school that boasts
of being an evidence based practice champion should have included this in
its EPA curriculum.  It is not possible to discuss the subject fully with
just a few emails going back and forth.  The web site I created itself needs
more than a few visits just to digest the evidence.  It cannot be reduced to
a "postage stamp" size dialogue.  Incidentally, we haven't even been able to
discuss other issues such as dosimetry (including frequency of treatment),
technical competency during its applications (some depts even let patients
apply the treatment themselves!!), machine reliability (the power output
from ultrasound has been shown to be unreliable if it is not calibrated
regularly. That means that many physios are giving US treatment at a
pre-selected intensity which is not the actual output from the transducer).
So, while we may be able to demonstrate effectiveness of ultrasound (for
example) in the treatment of acute pain experimentally, the duplication of
these same effects in the clinics is difficult to achieve because the dose
was inappropriate, or the application was sloppy, or the output of the
ultrasound itself has drifted and readings that you see on your meter isn't
what is coming out of the transducer.  How many of you actually send in your
ultrasound for calibration even once a year??

Henry:
>
> I find it interesting that even though Mr Cheng has noted a few articles
> that claim to have clinical evidence of electrotherapy, most of the
> literature out there disproves the effectiveness of electrotherapy, and
> these should not be ignored.

Cheng:
I have tried to give you information from more than 130 references from my
web site.  If you consider that "a few", then how many is enough?

Henry:
 However, this issue will still continue to be
> contraversial, the research will go on, and physiotherapists will form
their
> own opinions of what electro to use. Despite this, I support Bruce's
> statement that time and cost is a big factor in this, and should not be
> ignored. Unless we are in the field of sport physio and see athletes 3x a
> day, 5x a week, I don't see the point of 15min/2x/week - how much
difference
> is it going to make because that is less than 1% of their week's time!!

Cheng:
But isn't this issue separate from clinical effectiveness.  If you insist on
treating your patient for 15min at 2X/week, when the evidence says that you
should be treating the patient for 5X/week (for example), do you blame the
electromodality or the sloppy application of the modality.  The same can be
said about drugs.  If the dosage says take "two pills and call me in the
morning" and you only took half a pill, would you tell your doctor that the
medicine was ineffective?

Henry:
> Emphasis in this case should be on teaching the patients ultimately how to
> look after themselves thus preventing future injury. Most people want to
get
> better, but also want to know how to keep themselves better, and
> electrotherapy does not do this.

Cheng:
Whether we choose to use EPA or mobs or spray and stretch or whatever
treatment options we have, doesn't it NOT preclude teaching our patients to
look after themselves, how to prevent relapses, how to etc.....  Just
because EPA was one of the treatment options does not mean we FORGET how to
be Physical Therapists like everyone else.

Henry:
> Going through an undergraduate degree whereby electrotherapy was focused
so
> much and yet despised by most students(including myself), I am not for or
> against electrotherapy. However, I believe (and this is only my opinion)
> that unless there is more research for the efficacy of electrotherapy, not
> too many future physiotherapists will include it in their treatment
regime.

Cheng:
I have no idea why students from UQ despise their EPA so much.  Perhaps,
therein lies the problem.

Regards,
Cheng



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