Why we do not offer stim, ultrasound, heat or ice in the clinic?

Many of my patients say that my practice is the first PT clinic they have been to where we do not include electrical stimulation, TENS, iontrophosis, laser treatments, ultrasound, heat, ice, etc. as part of their treatment at the end of the session. The short answer for why we do it this way is the use of these modalities is not recommended across research for the management of musculoskeletal back pain. The long answer of our approach is more complicated.

When you decide on a treatment plan, it is best to compare the pros and cons. The pros of these modalities are limited (as demonstrated by multiple clinical practice guidelines), but the risks associated with them is also not high. What I mean by this is the odds of something bad happening for this choice of treatment is really limited to loss of time, costs and the possibility of delayed progress from not utilizing more effective interventions. This is a stark contrast to the potential risks of any pharmaceutical or surgery for low back pain.

These interventions feel good. If you get hit by a baseball, naturally you are going to want to rub the area so you feel the sensation from you rubbing your skin as opposed to the sensory input from getting hit by the ball.

When it comes to ice, most “old-school” practices will tell you it is key for controlling inflammation. The newer thought is ice is not nearly as effective as controlled movement. Again, the risks associated with using ice is slim to none. If you prefer to use ice, I have nothing against it. I just prefer not to utilize your time on it when pretty much everyone has access to ice at home.

My long answer to the above question is stim, heat, etc. can have a place in your rehab. Let’s say you are in so much pain that you cannot sleep. There is research showing less than six hours of sleep results in greater amounts of reported pain. So why not put some feel good stim on right before bed, drop your pain levels and allow yourself to get more sleep?  I absolutely have no objection to this approach and often recommend this to patients. But these modalities are limited to just that. They are good for short-term pain reduction while you are using them. They do not break up scar tissue, reduce inflammation, help fluid flow better or any of the other claims made.

In conclusion, while the use of stim, ultrasound, etc. is not recommended across multiple clinical practice guidelines they do have a place for an immediate reduction in pain while  using it. If this immediate reduction allows you to participate in an activity that can have greater long-term benefit (such as exercise or sleep), then it can be meaningful. I do not use these modalities as I feel it is not worth the effort when we can do more effective treatments in the clinic instead. The very cheap home stim units are not less effective than the fancy units owned by some PT clinics so there is no reason to use clinic time when it can be used at home when you need it the most.

References:

1. Zadro, J., O’Keeffe, M. and Maher, C., 2019. Do physical therapists follow evidence-based guidelines when managing musculoskeletal conditions? Systematic review. BMJ Open, 9(10), p.e032329.

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