why SWD and IFT in sciatica?

Thanks for the reply.

I agree as I have already described that electrotherapy should not be used in isolation but it should be used as a part of treatment plan and shoudl not be used in isolation as a treatment remedy. There are studies out there that supports the use of electrotherapy and there are studies out there that disagree upon the use of electrotherapy modalities. The studies which question the use of electrotherapy modalities are also questioned as they do not corrsponds to the clinical experience. More work is needed to resolve this difference between clinical studies and clinical experience. Let's have a look over that.

TENS- Eveidence based study

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TENS is used extensively in health care to manage
painful conditions because it is cheap, safe
and can be administered by patients themselves.
Success with TENS depends on appropriate
application and therefore patients and therapists
need an understanding of the principles of
application.

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Systematic reviews of RCTs report that
there is weak evidence to support the use of
TENS in the management of postoperative and
labour pain. However, these findings have been
questioned as they contrast with clinical experience
and it would be inappropriate to dismiss
the use of TENS in acute pain until the reasons
for the discrepancy between experience and
published evidence is fully explored.

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Systematic
reviews are more positive about the effectiveness
of TENS in chronic pain. However, betterquality
trials are required to determine
differences in the effectiveness of different types
of TENS and to compare the cost effectiveness of
TENS with conventional analgesic interventions
and other electrotherapies.

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Efficacy of the Transcutaneous Electrical Nerve Stimulation for the Treatment of Chronic Low Back Pain: A Meta-Analysis.

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This meta-analysis lacked data on how TENS efficacy is affected by four important factors: type of applications, site of application, treatment duration of TENS, and optimal frequencies and intensities.

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Randomized Trial Comparing Interferential Therapy With Motorized Lumbar Traction and Massage in the Management of Low Back Pain in a Primary Care Setting.

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This study shows a progressive fall in Oswestry Disability Index and pain visual analog scale scores in patients with low back pain treated with eitherinterferential therapy or motorized lumbar traction and massage.

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Therapeytci Application of electromanetic Power

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Recent research has shown that the use of the industrial, scientific, and medical (ISM) frequency of 915 MHz is more efficient than the currently used 2450-MHz microwave frequency in terms of maximum power transfer to deep tissues. The results also show that in addition to thermal applications, microwave energy can be used for the controlled transcutaneous stimulation of nerve action potentials via implanted miniature microwave diodes.

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Electrical Stimulation for Pain

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The Canadian Coordinating Office for Health Technology Assessment evaluated the clinical value of TENS in pain management and concluded that there is little evidence of the effectiveness of TENS in treating chronic pain

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It has been claimed that IFS is highly effective in reducing (i) pain and use of pain medications, (ii) edema and inflammation, (iii) healing time, as well as in improving (i) range of motion, (ii) activity levels, and (iii) quality of life. However, there are very few well designed studies such as randomized, double blind, controlled clinical trials that support such claims. Low (1988) stated that in spite of widespread agreement among physiotherapists that IFS has a marked pain relieving effect, there is a paucity of objective investigations into this analgesic effect. He claimed that both the therapeutic and physiological effects of interferential currents require further investigation.

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In a Cochrane review on pulsed electric stimulation for the treatment of OA (Hulme et al, 2002), the authors stated that current evidence suggests that electrical stimulation therapy may provide significant improvements for knee OA, but further studies are required to confirm whether the statistically significant results shown in these trials confer clinically significant and durable benefits.

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Here are some more resuorces.

Neck Pain

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The RCT (40 people with acute whiplash who all received
analgesia and a neck collar) compared pulsed electromagnetic field treatment versus
sham pulsing electromagnetic field treatment.68 It found that electromagnetic field
treatment significantly reduced pain compared with sham treatment after 4 weeks
(P < 0.05), but not after 3 months (reported as non-significant, P value not reported;
absolute results for both outcomes presented graphically).

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Management of Osteoarthritis

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Cold application such as ice packs and ice massage might be considered at the time
of disease flare up where there is associated swelling. Hot packs are not effective for OA-related
swelling.

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Pulsed electromagnetic fields or stimulation- Consider electrical stimulation for symptomatic treatment of OA.

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Modalities for therapeutic interventions

Ok, let's leave the "evidence-base" behind because i think we agree that the research is all over the place on the subject - there is no clear, strong support for or against.

However, you have mentioned clinical experience.

From my clinical experience, I find that ice is useful for acute injuries but rather than keep my patient in my clinic to get ice, i either send them home to do it or sell them an ice-pack then send them home to do it.

I find that heat is the same. Fine for pain relief but they can do this at home. There is nothing special about hot packs that a "professional" such as a physio needs to bring a client in to do this.

Interferential. I very rarely use this as i have found that it doesn't make a scrap of difference to my patients if i do use it or if i don't. I tend to use it, ashamedly, when i am running late and i need to "buy time" and treat a couple at the same time.

U/S. I like it for heat and in the very early stages of injuries. I am willing to admit that i use it more because once i do what i need to do to a patient, it might only take 5 mins. I have this feeling that they might want more of "something" but they are painfree with full ROM after treatment so i give them U/S and have a chat. I can't recall a case where i felt that it was the U/S that solved a problem.

TENS. Selling a patient one of these (or renting it to them) is akin to me saying that "I can't help your chronic intractable pain". It is effective in blocking pain just as a paracetamol tablet is. The problem is still there after you stop using it.

That is what I think and how i use electro. In summary, I use U/S, all the others are very sporadic. My main treatments are very specific manual therapy techniques and exercise prescription.

How do other people use electro and why?

If I see in the past few decades about the history of electrotherapy modalities, they were very popular while making a managment plan of the patient with any musculoskeletal disorders. And researchers were very enthusiastic to justify their use in physiotherapy. But now a days with the advent of evidence based practice and studies, it has been claimed as in many studies that electrotherapy is not effective in good sense and so many studies do not support their use today. This difference in research is really need to be questioned.

My view is if today authorities during the research find these ways of treatment of electrotherapy ineffective, there should be a major change withing the syllabus of physiotherapy internationally so that less reliance is made upon electrotherapy modalities and a lot of time of patient and therapist is saved and of course cost effectiveness is enhanced. What do you think about it? Should these ideas of revision be made within the syllabus?

Hi.

I absolutely agree that syllabuses should be changed.

When i went through university, I spent 2 or 3 years doing electro! What a waste of my time. I wish that time was spent on manual therapy skills and clinical reasoning.

I am not sure but i am fairly certain that electro at Uni of Sydney is pretty minimal now. Perhaps this is the case in "Western" countries.

I appreciate that electrotherapy was popular and that it helps many people. It is just that i have found that using manual therapy and specific exercises much more effective. maybe it is the type of client. However when i speak to some people, they have their clients on electro for 6 weeks and claim that it helped the patient get better when it is more likely that time healed that person. I have spent a lot of time and money learning these things when i think that my uni education should have covered it better.

Wouldn't you rather spend time learning what peter O'Sullivan's classification system is and how it works or how retraining of the core stability muscles in various parts of the spine works and how to grade and progress your exercise prescription rather than just give general exercises such as neck retractions or spend countless hours learning a *theory* on why TENS blocks pain (but doesn't solve the problem)?

Are you trained to be clinicians who diagnose musculoskeletal problems then prescribe a course of treatment? In my opinion, i can train anyone to use electro quicker than i can train a physio to be a good manual therapist...

In your countries (wherever all these readers are from), what emphasis does electro have?

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Are you trained to be clinicians who diagnose musculoskeletal problems then prescribe a course of treatment?

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The standards of physiotherapy practice here meets to the international standards and criteria of practice of physiotherapy within Asian countries. A physiotherapist here has the right to assess, diagnose and make a management paln withing the scope of his profession.

Manual therapy while just a part of practice of physiotherapy dealing with musculoskeletal disorders constitute one aspect of dealing the some problems of physiotherapy while profession is very vast dealing many wide aspects of problems that Physiotherapist treats.

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In your countries (wherever all these readers are from), what emphasis does electro have?

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Electrotherapy is studied here in a lot of extensive detail here in Physiotherapy schools as a major subject spending almost two years and more studying it. The scope of electrotherapy with the framework of musculoskeletal problems is just a part of routine management plan and it is not used in isolation as a treatment. So electrotherapy is not bypassed here in the treatment regimes as textbooks have good recommendations regarding their use. So electrotherapy forms a part of treatment regime.

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It is just that i have found that using manual therapy and specific exercises much more effective.

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Manual therapy in good hands has been found to be effective as claimed by many therapists. There are studies which support and argue with that as has been seen in topic discussed in detail else where in this forum. But only where it is felt after assessment that manual therapy is needed gives good results and where it is not needed give no results. Perhaps manual therapy have good justification only in mechanical disorders of musculoskeletal origin only. For example metabolic disorders like Osteoporsis, osteomalasia, inflammatroy arthropathies like AS, arthritis have no justification for passive moment therapies ( Mobilization, manipulation).

Hi.

Just briefly, I basically agree - Manual therapy is not indicated in all conditions. O'Sullivan's work on LBP helps to classify those who will benefit from exercise, who will benefit from manual therapy and those who aren't appropriate for physiotherapy.

The reason I ask the question about the emphasis on electro is because i read questions on this forum and people are so quick to prescribe/recommend/advise the use of electrotherapy when, from my personal experience, it would be more appropriate to use manual therapy or exercise or look for the main cause of a problem elsewhere.

Apparently there is no evidence that electrotherapy does work and I do not use a lot of it anyhow since I found as many others that in general we have a lot of options which give better or faster results.
Having said this I think we all have to understand that we all have our preferances on how to address problems and that for some of us it does work(allthough there is no evidence) I think the reason for it is far more complicated.
One of the modalities, I suppose, the majority of physios do use (now and then) is TENS. We have low TENS and high TENS which ought to stimulate different nerves with different responses (central pain reduction 2-4HZ and perifical pain reduction 100-120HZ) I personaly found that a stimulation of 70HZ and wave amplitude height (mju) of 150 works in many cases far better. Why? it is not supported by theories of conduction (none sheeted nerves versus sheeted). What happens is in principle that a patient feels something is going on and may respond possitive on stimulus. This could well be placebo.
A problem arises here, because how are we going to find out if it is placebo? When looking at the way medication is researched it becomes obvious we are unable to do the same: We cannot give a placebo treatment (no sugarlumps available I am afraid) because as soon as we talk, explain what we are doing and why we influence already the brain (Pain is in the brain!) then the next step is physical assessment and treatment which will give the body a stimulus anyhow. (with acupuncture one could use the handle of a needle or a toothpick and this stimulates as well).
So it seems to me very tricky to say what is placebo and what is not. I read e.g. 2 researches which seemed at the tme sound on the use of short wave for arthrosis of the knee. one claimed a succes rate of 10% the other 90% with more or less the same set up of the machines. 10% was though someone rather sceptical about short wave the other not.
And here lies actualy the problem: do you believe as a therapist what you are doing or do you just do someting?
THere is only, to my opinion, one way out of this mess and to review how research is performed within physiotherapy. It seems to me far better to set up some form of date base where as many physiotherapists put in what they do and why(recepies like in a cooking book) and the results because only then we can exclude the influence on the brain of the patient by the therapist as well as we might be able to understand better how it works.
As many of my colleagues pointed out why do you want to use electrotherapy while there is no evidence to support this choice I would like to respond (note I am not keen on electrotherapy) why do you use mobilisations manipulations and exercises? (as I do as well)? Is there sufficient evidence to support your choice?(on mobilisations there is a dought as well on the effectiveness and it can even be dangerous in some cases (Spinal stroke).
Get the cooking guide ready!

shkadif: Thanks for the great reply to the former posts. I am often frustrated by physios who look down on certain modalities, while maintaining that their particular approach minus modalities is the only one that promotes "professional status". These people, in my opinion, are focused on the diagnosis and not on the holistic treatment of the human being in their care.

1st of all i would like to thank all those who have shown there interst in the topic and those who replied to my post.

now about my question, physioz here are taking my question as my treatment plan,i just asked it bcoz i have seen people using it.

in my case i dont use ift and use tens for radiating pain and also give neural mobilization for it.

i beleve in manual therapy more but electro can help in giving imidiate relief so that we can work to solve the problem.

Thanks for bringing the topic back to earth. I have recently been reading a little on what Lorimer Moseley (aussie PT) has been going about preaching - i.e. pain and what causes it - tissue damage or the brain.

This is an interesting topic in the light of the placebo effect as in some cases it has now been shown that the tissue damage causes the afferent stimulus to the brain that something has happened and the brain decides what to do with that informatiion. In some cases what it decides is PAIN, at other times it ignores it or decides it is worth ache sensation etc. This variance between patients in the brains decision might be what we see as differences in an individuals pain threshold. Mind you it always seems to be those with what they seem to think is a "High Pain Threshold" that come in complaining about pain!

The interesting thing here is that this concept might help explain the placebo effect. e.g. by taking a form of action (swallowing a pill, even seeing a therapist for assessment and advice only) this might make the brain content that someting positive has been done and therefore it can remove the PAIN stimulus.

His work also suggests that the education of patients about pain and whether to promote a tissue damage explanation or a brain response scenario. Thus far some repeatable studies have shown that explaining the situtation from a brain perspective (not tissue damage) in low back pain has been followed by positive results. In the same studies the tissue damage explanation groups were in fact worse off. No actual treatment as such was given in these studies so the effects we limited to the explanation and advice given.

This new insight alone can help us as clinicians to improve on whatever we are currently doing as a treatment approach. It might also help seperate those individuals with more of ann inflammatory issue from those more mechanical. Maybe I will start a new post on this line of thinking.

SWD is needed in sciatica as its a deep heating modality , bcoz there will be a pain induced muscle spasm in and around the region.

In the case of IFT better than TENS , it can be well explained when frequency is more the resistance will be low , so it can reach to deep tissues. So a TENS cannot be used there because the frequency is less so resistance will be more.

Is the condition acute or chronic?

There has been a recent study that concluded effectiveness of the use of electrical modalities/heat/cold treatment in acute stages of musculoskeletal conditions. however, in a patient who presents with a chronic musculoskeletal condition, therapeutic exercises are proven more effective.

thanks to all:)

Evidence Based Physiotherapy.... required so that we can substantiate what we do to the rest of the medical/scientific fraternity but aren't we all smart people with our own ideas? We enter physiotherapy so that we can help people and different people respond to differenct forms of treatment... i.e. some prefer hands-on therapy others prefer electrotherapy. I am definately a hands on therapist who prefers to introduce the patient to self-management techniques (mainly due to my remoteness and the fact that in most cases I may only be able to see that patient once a month). It is all well and good for us to have the studies to support our treatments but in the long run it comes down to that individual patient and the individual clinician. Physiotherapy is never going to be a black and white science.

Is it a science at all?

I have re-read the posts above.

I accept that others like electrotherapy and others (like me) don't.

In context, I think a thorough assessment, examination, diagnosis and classification will lead you towards the most appropriate treatments.

Next, how many of us have actually done post-graduate training (e.g. Masters in Sports pHysiotherapy or Manipulative Therapy)? Perhaps we all should consider improving our skills in this way - i started my masters last year after 10 years of clinical practice. I should have started a little sooner!

Lastly, it is hard to provide research in a double blind RCT for manual therapy because a good manual therapist doesn't apply the one treatment in isolation, nor do they apply only one treatment technique to ALL subjects. Also, you cannot "blind" the therapist to what treatment technique the patient is having. Nor can you have a manual therapist provide a placebo without being blinded.

Obviously for electrotherapy, it is not used in isolation (although you do hear lots of stories about electro without much else...), it forms part of the overall management of the patient. But with these studies, you can have both the patient and therapist blinded because you can just make the machine LOOK like it is working when it is not, especially U/S. So theoretically, the studies on electro should be of a higher standard because the therapist never knows if the machine they are using is actually working or not.

Anyway, more food for thought!

After reading through all the posts, I totaly agree that it not science at all to depend on swd/ift in sciatica. If we were to concentrate on finding the cause of sciatica and release the patient of it, pain relief automatically follows.
As someone has written in one of the posts,

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I am often frustrated by physios who look down on certain modalities, while maintaining that their particular approach minus modalities is the only one that promotes "professional status". These people, in my opinion, are focused on the diagnosis and not on the holistic treatment of the human being in their care.

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it is not looking down on certain modalities, nor is it that our particular approach minus modalities is the only one that promotes "professional status". It is not that we are focused on the diagnosis and not on the holistic treatment of the human being in our care. If my treatment is backed by a good assessment, I do not need any modality to bring relief of pain to any patient. In fact since most of my patients are direct contact patients,I make it a point to tell them to come for their assessment & their sessions without taking any NSAIDS. This lets me know exactly what effect my treatment has had on the patients symptoms. I emphasise on modality on those patients who are a little sensitive and equate the time spend at the clinic to the price they are paying , and do not concentrate on the relief obtained. In these patients again I give the modality according to what is most convenient to me at that point of time.
Regarding alophysio's comment that the therapist never knows if the machine they are using is actually working or not, I think that would be unforgiving. If I do not use my U/S for a period of time, I always make it a point to test it before administering it on a patient. Even if we use the modality for a placebo effect, one must see that they in working condition.

Hi,

Thanks for your comments asha.

My point about the electro machines not working is that when you design a study, it is more likely to be of a higher quality for electrotherapy because you can blind the therapist.

That is, the therapist doesn't actually know whether the machine is working or not and so that level of bias is taken out of the equation.

Therefore, if there is equivocal research on the use of electrotherapy, then it is stronger evidence that it may not work that for manual therapy simply because the research design is different. Because Electro studies can be DOUBLE BLINDED (MT cannot be for reasons discussed earlier), it is more rigorous evidence that is works or not works.

Obviously in the clinic, you would test your equipment and make sure it is working before using it!

I hope that helps!

In modern physiotherapy we do many stupid things. For sciatica why should we use SWD and IFT or such electro theraputic modalities. Is those going to reduce the cause of Sciatica? Is those going to reduce the postero-lateral disc protrution?

Modern Orthopaedic medicine discovered that, There is a period of spontenious cure for Sciatica or pure postero-lateral disc protrution. That is 3-4 month. In this time the protrud disc is reduced automaticly.

So, we have to perform manipolation (Under traction) to reduce the disc protrution. Only SWD and IFT can be used for reduce the protective muscle spasm induced by pain if there is any.

Osman Gony
BPT; PG. Dip. Orthopaedic Medicine

I fully agree with you , SWD and IFT cannot treat the root cause of pain in sciatica . It can be done only to reduce the pain induced muscle spasms. The key in every treatment is the proper diagnosis and treating the root cause instead of trying to mask the pain using any modalities.

Thanks alophysio, You are right. Guess I was reading through it through my ambience vision.
asha

Thanks alophysio. You are right. Guess I was reading through it with my ambience vision.

Hi,
Can anybody please explain how SWD or IFT would treat the root cause of sciatica..?
I guess its just gonna give u temporary relief..n not treat the cause...instead manipulations would help..

have a read of the posts above...

Hello Sir.. great effort on your part to post such a long answer. Really good notes.. but why not to-the-point answer. I am new to the physio forum.. its interesting to read and share the views on all queries and doubts..
thanks for the information provided..