why SWD and IFT in sciatica?

[sharmaphysio]

hi guys,
normally we give SWD and IFT in sciatica.my question is y so?
ok fine SWD is a deep heating modality,then y deep heating only,and also y swd only?
when sciatica is a radiating pain why ift is more often used then tens?

Similar Threads:

• IFT and Vibrator Machines
• why SWD is being criticised in some localities?
• SWD
• swd and blood pressure
• IFT,Electric Up/Down Bed and Traction, Ultrasound etc

[alophysio]

Good question.

In fact, I ask why is SWD and I/F used as first line treatments?

I like to treat the causes of whatever caused the pain. That is sometimes their hip or SIJ causes the L/S to take more strain and then their disc wears out. I like to look for the hip or SIJ problem because a monkey can help their symptoms (just wait 6 weeks and most people will feel better) but their pain will reoccur unless you treat the problem.

My point is that SWD and I/F, as far as I know, do not address the causes of pain, only the symptoms.

Besides, anyone can put a machine on someone, it really isn't that hard to learn that. What is difficult is to put your hands on someone, diagnose and make a patient who couldn't walk straight do so in less than 10 mins. Now that's impressive right? That's where we should invest our time, energy, research and skills.

Otherwise we are just machine technicians...

[neurospast]

What means the abbreviation SWD and IFT. I feel it is extremely annoying that people seem to think that everyone is familiar with these abreviations. By the way a lot of abreviations can mean different things even within physiotherapy and for shure within the medical world so please get customed to avoid them. Furthermore the use of abreviations is more and more abandonded within physiotherapy so please get into the 21st century! and avoid misunderstandings.
Personaly I think it is a strange idea to use deep heat in sciatica since the cause of pure sciatica is a compression of a nerve with as a result, nerves do that, inflamation. I do not think that it is a good idea to stimulate an inflamation unless you want to treat your patient forever. Also there are big doughts about the use of 'electrotherapy and alike' as being useful in the first place. As far as I know research is very unclear about it and a placebo effect, which can be upto 70% of physiotherapy treatment should be taken into account.
I feel that use of e.g. electro therapy is an easy way out to avoid hands on and avoiding claims of malpractice. In general more experienced people will not have as their first choice electro therapy but hands on, exercise therapy and re-education. When electrotherapy is used it will only be a support of the treatment or maybe.... if you just don't know anything else to do.
But I am curious why you have come to the conclusion that SWD and IFT is a first choice of treatment. Did you readr this, did anyone told you that?
Cheers.

[Physiobase]

SWD - Short Wave Diathermy.
IFT - Interferrential Therapy.

Both are very commen abbreviations and something that should have been taught in an undergraduate course. I tend to agree with the random use of abbreviations however these are really standard and I welcome their use in this forum.

As for there use in sciatica. Why indeed? I thought that SWD machines were the realm of the creatures in a Dr Who episode. Perhaps they have made another earthly invasion 8o

[sdkashif]

Whether to use the heat treatment or cold treatment as dealing with the inflammation, it depends upon the nature of inflammation. As in acute trauma or inflammation or during the first 72 hours the principle is R I C E - Rest, Ice, Compression and elevation. And afterwards or in sub acute or chronic inflammation you have to shift the treatment to heating modalities. And Why do therapist prefer SWD, is the reason because the lesion is situated deep and superficial heating agents or superficial modalities do not produce effects in deep tissues at the site of pathology. Both SWD and Interferential therapy produce effects in the deep tissues. That is why they are preferred to the other agents regarding the application. Let us have a look over the effects produced by the SWD and Interferential therapy.

The Use of Heat and Cold in Pain Modulation

Thermal modalities are passive modalities, whether they are applied by the patient or the nurse, physical therapist,
athletic trainer, or parent. It is essential that each patient is evaluated for the cause of pain in order to make an
appropriate clinical decision about the use of passive modalities. The passive role may be appropriate for patients
in acute pain, for those with recurrent pain from reinjury or exacerbation of disease, or for palliative care. Some
modalities may be appropriate for chronic pain, but only if their application is associated with a functional goal, and
are best applied by the patient himself. Self-application of heat or ice can be used to provide symptomatic relief
from pain which permits a more active treatment approach, and can be used as a reward for accomplishing a
functional goal. These modalities are easy to apply, and can be used effectively in an overall plan of care for a
variety of pain patients. They are most often effective in conjunction with techniques of soft tissue mobilization,
exercise, stretching, and stabilization.

Heat

There are three theories of pain relief using heat. The vascular theory is based on the finding that heat application
induces vasodilatation, which can increase tissue blood flow up to 30 ml per 100 g of tissue. The increase in blood flow reduces pain by effectively supplying oxygenated blood and nutrients while washing out metabolites (including those that contribute to nociception, such as K+) accumulated during
muscular activity. Through this mechanism it is expected that there will be an increased potential for edema formation due to the increase in capillary permeability induced by heat.

The counterirritation theory is based on the gate control mechanism originally proposed by Melzack and Wall
(1965). Pain may be modulated by thermoreceptor afferent input which can act as a gating mechanism in the dorsal
horn of the spinal cord at the spinal level of the pain and thermal sensory input. The dual affective stimulation is
said to block pain transmission to higher centers. Also, heating of a painful part can induce whole body relaxation,
perhaps through a descending pain inhibitory pathway which influences the same gate in the dorsal horn, and helps
to inhibit painful muscle spasm or muscle tension.

The third theory involves the direct influence of heat on neuromuscular tissue, including muscle spindles and on
sensory nerve conduction. When animal muscle spindles and exposed nerve endings are directly heated, a
significant decrease in neuronal activity of the secondary endings and an increase in activity of primary endings and
Golgi tendon organs have been measured. This produces a net inhibitory influence of the motor neuron pool that
breaks the vicious circle of pain-spasm-pain. It presumably takes a very intense amount of heat to achieve direct heating of nerves in situ.

Many people associate better penetration with wet heat, rather than dry. Examples of wet heat include hot packs
and whirlpool and dry heat include an infra-red heating lamp, and ultrasound. Dry heat actually elevates skin
temperatures more than deeper structures, while wet heat elevates both skin and deeper tissues slightly more.
A variety of hot packs are commercially available for self-application of heat. Each type has advantages and
disadvantages in terms of price, ease of reuse, temperature control, length of heating, and portability. Patients are
instructed in the use of superficial heat to warm muscles before stretching and exercise, for relaxation, and for
transient pain reduction when there is no edema present. Once patients are instructed in the safe use of superficial
heat, including the appropriate use of a protective barrier such as toweling to prevent burns, patients may be invited
to use heat independently before or after exercise or functional activities.

For acute injuries, heat is contraindicated.Many physical therapists apply ultrasound as a heating modality. It has deeper heating effects, as well as nonthermal benefits, and penetrates to structures such as joints, muscle, and bone. It has been shown in experimental studies to stimulate tissue regeneration and bone growth and increase pain threshold and collagen extensibility.

In a meta-analysis of 22 studies on the effect of ultrasound application in the treatment of musculoskeletal disorders, however, no significant effect of ultrasound on pain reduction was found.

Cold

Cold therapy can be delivered in three basic forms: cold packs, ice massage, or vapocoolant spray. Cold packs are
commercially available or can be made at home with crushed ice, ice cubes, or bags of frozen vegetables (not to be
eaten after use!). Cold packs are useful for postexercise soreness, acute inflammation, or inflammation associated
with edema, and transient reduction of pain (symptomatic relief).

In ice massage, ice is rubbed directly over the skin until numbness is felt. Ice massage delivers cold to a more focal
area with greater efficiency than a cold pack and may also provide more effective counterirritant therapy for pain
relief. Patients are instructed in the safe use of ice massage, the warning signs of frostbite, and the four stages of
sensation during ice massage (cold, burning, aching, and numbness). Ice massage is useful for relaxation, transient
pain reduction, and treatment of local inflammation.
Cold application for pain relief can achieve peripheral or central responses. Brief, intense cold such as that delivered with a vapocoolant spray most likely produces peripheral receptor adaptation. The counterirritation discussed in the section on heat therapy also applies to cold therapy. Brief, intense cold can slow conduction velocity in C fibers carrying nociceptive input to the spinal cord. This action and receptor
adaptation may be the mechanism of the trigger point therapy advocated by Travell and Simons (1983).

For every 1°C decrease in intramuscular temperature, a decrease of 1.2 m per second in motor nerve conduction
velocity and a 2 m-per-second drop in sensory nerve conduction velocity has been rcorded. The “hunting response,” characterized by cold-induced vasodilatation
after an initial vasoconstriction, occurs in the ears, nose, fingers, and toes. This phenomenon is seen when tissue
temperature is reduced by more than 10°C. Under conditions of continued intense cold, this reversal continues as a
cycling of vasoconstriction-vasodilatation, permitting tissue temperature to be kept somewhat constant, although
lower than precooled temperatures.

Prlonged cold can also produce vasodilatation in deeper
muscle tissues and stimulate profound hyperemia (increased blood flow to the effected area) after withdrawal of the
cold .

Which is best, heat or cold?

The choice between using heat or cold for pain should take into account several factors. Heat decreases pain and
induces relaxation. Therefore, it may have a ounterproductive sedative effect if used before exercise. It increases issue extensibility (softer and easier to stretch—think of what happens when mozzarella cheese is warmed), which is advantageous when addressing stiff joints through self-mobilization and stretching. Heat decreases overall
stiffness of musculoskeletal tissues. It may result in edema and should be used carefully if swelling is already a
component of the patient’s problem.

Cold decreases pain and swelling and is especially indicated in an acute injury; however, it increases overall stiffness and decreases tissue extensibility. Some patients have a profound aversion to cold and experience anxiety with its use. Many patients with neuropathic pain do not tolerate cold well.

The clinician should choose a modality based on the patient’s preferences and, in the case of chronic pain, convenience for self-treatment. In pain that has persisted well beyond an expected healing time, the emphasis is not on pain relief, but on using the modality as a method of coping with pain. It should be possible for a patient to learn to safely apply a modality as a specific part of the total pain rehabilitation program.

Interferential Therapy

The basic principle of Interferential Therapy (I/F) is to utilise the strong physiological effects of low frequency (@ <250pps) electrical stimulation of muscle and nerve tissues without the associated painful and somewhat unpleasant side effects of such stimulation.

To produce low frequency effects at sufficient intensity at depth, most patients experience considerable discomfort in the superficial tissues (i.e. the skin). This is due to the resistance (impedance) of the skin being inversely proportional to the frequency of the stimulation. In other words, the lower the stimulation frequency, the greater the resistance to the passage of the current & so, more discomfort is experienced. The skin impedance at 50Hz is approximately 3200W whilst at 4000Hz it is reduced to approximately 40W . The result of applying this latter frequency is that it will pass more easily through the skin, requiring less electrical energy input to reach the deeper tissues & giving rise to less discomfort.

Interferential therapy utilises two of these medium frequency currents, passed through the tissues simultaneously, where they are set up so that their paths cross & in simple terms they interfere with each other. This interference gives rise to an interference or beat frequency which has the characteristics of a low frequency stimulation.

The exact frequency of the resultant beat frequency can be controlled by the input frequencies. If for example, one current was at 4000Hz and its companion current at 3900Hz, the resultant beat frequency would be at 100Hz, carried on a medium frequency 3950Hz amplitude modulated current.

By careful manipulation of the input currents it is possible to achieve any beat frequency that you might wish to use clinically. Modern machines usually offer frequencies of 1-150Hz, though some offer a choice of up to 250Hz or more. To a greater extent, the therapist does not have to concern themselves with the input frequencies, but simply with the appropriate beat frequency which is selected directly from the machine.

Excitable tissues can be stimulated by low frequency alternating currents. Although to some extent, all tissues in this category will be affected by a broad range of stimulations, it is thought that different tissues will have an optimal stimulation band, which can be estimated by the conduction velocity of the tissue, its latency and refractory period. These are detailed below:

Sympathetic Nerve 1-5Hz

Parasympathetic Nerve 10-150Hz

Motor Nerve 10-50Hz

Sensory Nerve 90-100Hz

Nociceptive fibres 90-150Hz (?130Hz specific)

Smooth Muscle 0-10Hz

The clinical application of I/F therapy can be based logically on this data together with a knowledge of physiological behaviour of stimulated tissue. Selection of a wide treatment band can be considered less efficient than a smaller selective band in that by treating with a frequency range of say 1-100Hz, the appropriate treatment frequencies can be covered, but only for a relatively small percentage of the total treatment time. Additionally, some parts of the range might be counterproductive for the primary aims of the treatment.

The are 4 main clinical applications for which I/F appears to be used:

Pain relief

Muscle stimulation

Increased blood flow

Reduction of oedema

In addition, claims are made for its role in stimulating healing and repair.

As I/F acts primarily on the excitable tissues, the strongest effects are likely to be those which are a direct result of such stimulation (i.e. pain relief and muscle stimulation). The other effects are more likely to be secondary consequences of these.

Pain Relief:

Electrical stimulation for pain relief has widespread clinical use, thought the direct research evidence for the use of I/F in this role is limited. Logically one could use the higher frequencies (90-150Hz) to stimulate the pain gate mechanisms & thereby mask the pain symptoms. Alternatively, stimulation with lower frequencies (1-5Hz) can be used to activate the opoid mechanisms, again providing a degree of relief. These two different modes of action can be explained physiologically & will have different latent periods & varying duration of effect. It remains possible that relief of pain may be achieved by stimulation of the reticular formation at frequencies of 10-25Hz or by blocking C fibre transmission at >50Hz.

Muscle Stimulation:

Stimulation of the motor nerves can be achieved with a wide range of frequencies. Clearly, stimulation at low frequency (e.g. 1Hz) will result in a series of twitches, whist stimulation at 50Hz will result in a tetanic contraction. The choice of treatment parameters will depend on the desired effect, but to

combine muscle stimulation with an increase in blood flow and a possible reduction in oedema, there is some logic in selecting a range which does not involve strong sustained tetanic contraction & a sweep of 10-25Hz is often used.

There is no primary nervous control of oedema reabsorption & the direct electrical stimulation of blood flow is limited in its effectiveness. It is suggested therefore that in order to achieve these effects, suitable combinations of muscle stimulation can be made.

Short Wave Diathermy

Short wave diathermy is the therapeutic application of high-frequency currents; it uses radiofrequency electromagnetic fields for therapeutic heating of tissues. For application, it uses capacitor plates or inductive coil applicators.

Continuous shortwave diathermy is the technique of choice when uniform marked elevation of temperature is required in the deep tissues. This heating can be targeted accurately by using an appropriate applicator positioned correctly. SWD also allows superficial structures to be heated selectively, although for this the various methods of surface heating are usually preferable. Sub-acute or chronic conditions respond best to continuous shortwave diathermy which, when used properly, can be as effective as ultrasound. Acute lesions are better treated with pulsed shortwave diathermy. Continuous shortwave diathermy can help to relieve pain and muscle spasm, resolve inflammatory states and reduce swelling, promote vasodilation, increase the compliance of connective tissue, increase joint range and decrease joint stiffness.


Common Indications

Localized musculoskeletal pain

Inflammation (joint or tissue)

Pain/spasm

Sprains/strains

Tendinitis

Tenosynovitis

Bursitis

Rheumatoid arthritis

Periostitis

Capsulitis

Precautions or Contraindications

Malignancy

Sensory loss

Tuberculosis

Metallic implants or foreign bodies

Pregnancy

Application over moist dressings

Ischemic areas or arteriosclerosis

Thromboangiitis obliterans

Phlebitis

Use extreme care with pediatric and geriatric patients

Cardiac pacemakers

Contact lenses

Metal-containing intrauterine contraceptive devices

Metal in contact with skin (eg, watches, belt buckles, jewelry)

Use over epiphyseal areas of developing bones

Active menses


Types of Applications

The condenser field method (commonly used)
Cable method


Where useful?

Inflammation of shoulder joint
Inflammation of Elbow Joint (Tennis Elbow)
Degeneration of joints of neck (Cervical Spondylosis)
Degeneration of joints like knee and hip (Osteoarthritis)
Ligament Sprains in knee joint
Low Back Ache
Plantar fascitis (Heel Pain)
Sinusitis

Where it should not be used?

General

High Fever
Fluctuating Blood Pressure
Very sensitive Skin
Persons with Untreated Fits
Persons using Cardiac Pace Maker
Severe kidney and heart problems
Pregnant Women
Mentally Retarded Individuals
Tuberculosis of Bone
Malignant cancer


These can be basically divided into two types - those of the electric field & those of the magnetic field. There appears to be almost no literature/research concerning the effects of pulsing the electric field, & almost all the research revieved is concerned with the therapeutic effects of the magnetic field. This is not to say that pulsing the electric field has no effect, but that the research evidence for such an effect is lacking. The information which follows relates therefore to the effect of pulsing the magnetic field.

The primary effects of the pulsed magnetic field appears to be at the cell membrane level & is concerned with the transport of ions across the membrane.

Normal cell membranes exhibit a potential difference due to the relative concentration differences of various ions on either side of the membrane (reviewed in Charman 1990). Of these ions, sodium (Na+), potassium (K+), calcium (Ca++), chloride (Cl-), & bicarbonate (HCO3-) are probably the most important. Cell membrane potentials vary according to the cell type, but a typical membrane potential is -70mV, internally negative. It is actively maintained by a series of pumps & gated channels, & cellular energy (ATP) must therefore be utilised to maintain the potential.

A cell involved in the inflammatory process demonstrates a reduced cell membrane potential & consequently, the cell function is disturbed. The altered potential affects ion transport across the membrane, & the resulting ionic imbalance alters cellular osmotic pressures. It is suggested that the main clinical effects of this are pain & oedema (probably indirectly).

The application of pulsed SWD to cells affected in this way is claimed to restore the cell membrane potential to their normal values & also restores normal membrane transport & ionic balance. The mechanism by which this effect is brought about is not yet established, but the two theories suggest that this is either a direct ionic transport mechanism or an activation of various pumps (sodium/potassium) by the pulsed energy

It is claimed that the energy has little or no effect on normal cells as `sick' cells respond to lower energy levels than normal cells. A time period of 4 days has been attributed to this process (see Hayne 1984 for a useful review).

The following are the primary effects of pulsed SWD:

1) Increased number of white cells, histocytes & fibroblasts in a wound.

2) Improved rate of oedema dispersion.

3) Encourages absorption of heamatoma.

4) Reduction of the inflammatory process.

5) Prompts a more rapid rate of fibrin fibre orientation & deposition of collagen.

6) Encourages collagen layering at an early stage.

7) Stimulation of osteogenesis.

8) Improved healing of the peripheral & central nervous systems.

With respect to the effects of pulsed SWD, there is an element of tissue heating which occurs during the `on' pulse, but this is dissipated during the prolonged ‘off' phase & therefore, it is possible to give treatment with no NET increase in tissue temperature. The `non thermal' effects of the modality are generally thought to be of greater significance. They appear to accumulate during the treatment time & have a significant effect after a latent period. It is suggested that the energy levels required to produce such an effect in humans is low.

An active research programme has been conducted for several years now relating to the thermal nature of PSWD. It was unclear just what power levels were required to bring about a real tissue heating, and in fact, there has been some opinion that PSWD was a non thermal modality per se. Recent work from this research unit has demonstrated that PSWD does have a thermal component, and real tissue heating can occur under different treatment settings. This is important in that if the modality is to be applied in circumstances where the heating would be inappropriate or contraindicated, it is essential to know then power / energy levels where the thermal effects begins. The pages on PSWD Research include the experimental details and summary results of the work we have done over the last 5 years. In essence, it has been shown that a measurable heating effect can be demonstrated at power levels over 5 watts, though on average, it will become apparent at some 11 watts mean power.

If a ‘non thermal’ treatment is the intended outcome of the treatment, it is essential that the mean power applied remains below this level. If a thermal effect is an intentional outcome of the intervention, then it may be perfectly appropriate to deliver power levels in excess of 5 watts, but if doing so, the therapist must ensure that the precautions are taken as for any other thermal intervention.

Cholnoky's Indication's for SWD: See Cholnoky

The table below, as the rest of similar tables below are given for comparison and scientific research only.

Infectious Diseases: The Common Cold
Pneumonia
Pulmonary Tuberculosis
Erysipelas (pre gangrenous condition)
Erysipeloid (infective dermatitis)
Actinomycosis (infects soft tissues & bone of lower jaw)
Allergic Diseases
Bronchial Asthma

Metabolic Diseases:

Gout
Obesity
Diabetes Mellitus
Disorders of the Endocrine Function

Disease of the Respiratory Tract:

Laryngitis
Bronchitis
Bronchiectasis
Emphysema
Pleurisy
Empyema
Abscess of the Lung
Pulmonary Gangrene
The Oral Cavity:

Dental structures:

dental granulomas, parodontitis
Tonsillitis
Spasm of the Esophagus

The Stomach:

Gastritis
Peptic ulcer
Gastric neuroses

The Intestines:

Tuberculous colitis
Chronic appendicitis
Abdominal adhesions
Spastic colitis
Perityphlitis
Peritonitis

The Biliary Passages:

Cholecystitis
Cirrhosis of the liver
Hepatitis
The Urinary Tract:
Cystitis (Tuberculous)
Puelitis
Nephritis
Perirenal Abscess

Diseases of the Skin:

Furuncle
Carbuncle
Axillary Sweat-gland Infection and Abscess
Phlegmon
Streptococcus
Eczema (chronic ulcers, lupus)
Acne vulgaris
Pruritus


Diseases of the Head:

Sinusitis (acute and chronic)
Empyema of the antra, adjacent, and ethmoid sinuses

The Female Genital Tract: Pelvic Inflammation and Infections:
Old Adnexal Tuberculosis
Acute salpingitis
Adnexal tumors
Peritonitis
Gonococcal adnexitis
Adnexal swelling due to infection following miscarriage or pregnancy
Chronic adnexitis
Metro endometritis
Bartholin's Gland Abscess
Dysmenorrhea

The Male Genito-Urinary Tract:

Gonorrheal Urethritis
Epididymitis
Diseases of the Prostate
Tuberculous disease of the testicles, bladder, and kidney

Diseases of the Locomotor System:

The Muscular System:
Myalgia
Lumbago
Spastic contractures
Rheumatism, etc.
Tendovaginitis
Bursitis

The Bones:

Periostitis
Osteomyelitis

The joints:

Arthritis
Gonorrheal arthritis
Traumatic arthritis
Atrophic arthritis
Hypertrophic arthritis
Tuberculosis

Traumatic injuries:

Hematoma, Sprain, Lesions, Lacerations

Diseases of the Nervous System:

Neurosyphilis
Neuritides
Neuralgia of the Lumbosacral Plexus
Trigeminal, Brachial, Exipital, and Intercostal Neuralgias
Polyneuritis
Migraine
Parkinson's Disease
Epilepsy
Hiccup
Urinary Incontinence of Nervous Origin (due to multiple sclerosis, syphilis, traumatic hematomyelia, enuresis nocturna)
Neuroma (e.g., amputation neuroma)

Diseases of the Eye:

Atrophy of the optic nerve
Corneal ulcer
Orbital phlegmons
Iridocyclitis, tuberculous lesions, inflammatory disorders, and palsies of the ocular muscles

Diseases of the Ear:

Otitis media
Mastoiditis
Mastitis
Malignant Diseases


See further

Short-wave diathermy: current clinical and safety practices.

[billyzaf]

Hello, I'm new to this site.Very interesting views. I just want to say about the abbreviations, I'll have to agree with neurospast. Some people were not trained in English so those abbreviations are different over there. If you want to use such "long" terms a lot of times then I suggest that you add a definition of them just once. Thank you
p.s.Great post sdkashif

[sharmaphysio]

hey thanks alot for such a nice reply sdkashif.

[alophysio]

Hi.

Nice bit of information sdkashif.

However the question remains - why would you want to do all that in the first place?

From what I read in the information provided above, these electrotherapy modalities are utilised to interfere with nerves, their conduction velocities and pain transmission. They are also used as pain relief and the various listed benefits of Short Wave Diathermy. BUT what is causing all this pain in the first place?

I can tell you that in Australia (where I was trained and still work), you would find it difficult to find a short-wave machine. Interferential is still used but as pain relief. The best physios use advanced manual therapy techinques and exercises to achieve quick, long lasting results.

Just today, I had a patient with a 4 month history of low back pain (LBP). He was on an elliptical machine (low impact aerobic machine) when he fell off and landed heavily onto his back. He had terrible back pain and sciatica down both legs. He had 11 sessions with another physio who used ice, heat packs (H/P), ultrasound (U/S), Interferential (IFT), traction (Tx) and massage. This treatment (Rx)lasted 1.5hrs and he actualy couldn't walk the next day because of the Tx. He ceased Rx and actually began to get better but still had lingering pain.

He came to me on a referral from a friend who I have helped get better. His problem was simple - mechanical low back pain. His pain was reproducible on extension (E), lateral flexion (LF) left (L) and right (R). Forward Flexion (FF) was generally pain free but he could still feel that things were not right.

Segmental motion was blocked at L4/5 and L5/S1. Straight leg raise (SLR) was negative as were reflexes.

Rx: Mainipulation (with consent) of L4/5 and L5/S1. Immediate restoration of segmental motion. Immediate pain relief to ZERO. Increased range of motion (ROM) in FF, E and LF - all pain free. No leg symptoms. Exercises given to maintain restored ROM.

Total Rx time including assessment = 20 mins.

For $60, he walked in with chronic pain (4 months) and walked out pain-free. Addressing the problem is the first step to curing someone's pain. If his other physio had addressed his jammed-up facet joints, he would not have had all this long and painful Rx, although he liked the massage .

I grant you that his condition was simple but his story is the norm, not the exception.

I love having competitors use electrotherapy in their practices around mine because it makes it easy for me to distinguish myself from them.

However, for the good of physio, please consider treating the problem, not just giving someone an expensive pain-relief treatment session.

Electrotherapy has its place and I use U/S but it is usually for "price-sensitive" or "time-sensitive" patients who feel they aren't getting their money's worth if they spend their 20-30mins with me, never mind that they feel 85% better after 10 mins of Rx!

Let's bit the bullet and throw money into researching how manual therapy combined with exercise is best utilised.

As sdkashif's information from the unnamed source puts it - U/S has no effect on pain disorders...I also believe that IFT and SWD are also not that effective...

Use your hands - God gave them to you as a gift to help others

Please let me know if you agree or disagree

[chaitanyamohansuri]

SWD (Short wave Diathermy) and IFT(Interferential current) these 2 have a mode of action.
see for the case of LBA with sciatica we need to go deeper to the nerve root level where the compression is? IFT is also giving the choice as the 2 carrier waves takes care of the superficial structute and the interference zone produced of low frequency penetrates to the deeper structure without getting the enery lost in the superficial structure. the penetration of anythig decreases with depth and hence to avoid this loss the carrier waves are used and for the pain relief the interference zone do the rest.

[sdkashif]

Thanks for positive feedback alophysio. I fully agree that once the patient comes to for physiotherapy, its problem should be analysed by routine subjective and objective examination to analyse the disorder to provide a rational basis for addressing the right treatment for physiotherapy. There are cases out there which do not simply require physiotherapy and receive the sessions without getting their problems fully diagnosed. But this seldom happens. A proper physiotherapy referral is necessary. In addition physiotherapist should also avoid treating patients who simply don't need Physiotherapy. For example let us have a look over the possible causes of Back Pain. These are

Traumatic

These include fractures and other associated injuries

Mechanical

Muscular Pain
Postural back pain
Prolapsed Disc
Lumbar Sponylosis +/- Spinal Stenosis
Disseminated Idipathic Skeletal Hyperostosis
Spondylolisthesis

Inflammatory

Infective Lesions of the Spine
Ankylosing Spondylitis

Metabolic

Osteoporis + Fractures
Osteomalacia
Paget's Disease

Neoplastic

Metastases
Multiple Myeloma
Primary Bone Tumours

Referred Pain

Only Mechanical Disorders, among inflammatory disorders (non Infective) ankylosing Spondylitis, traumatic disorders like spains/strains, metabolic disorders requiring other therapies or referral in conjuction with physiotherapy come under the appropriate referral for physiotherapist. The rest of the disorders require referral to the other clinicians.

I was just highlighting the importance of the modalities where they are required to be applied along with other popular regimes of physiotherapy like different forms of exercises, mobilizations and manipulation where indicated ( not every care require manipulation). Analysing the cause and addressing the right management plan is all that is required. I was just discussing where the superficial modalities should be applied and where deep modalities or agents should be applied. Which modality or agent is better to be applied when required to be prescribed.

Among the different treatment approaches, there are different school of thoughts each having its merits and demerits & rational use where they are required to be used. There are certainly many good manipulative therapists there in Australia, England and in America with their originators. But certainly manipulation has its own role where it is required having good results & where not required having no results giving no benefits. Also there are other approaches like McKenzie Method etc where required to be indicated. So it is important to see where that particular approach is required and where not required. I guess you would agree in many aspects.

[alophysio]

Thanks for the reply sdkashif.

I do agree with all that you say in the post and I do understand that you were answering a question about the use of IFT and SWD in sciatica.

My point is that I believe that the role of electrotherapy is quite small compared to manual therapy and exercise. Sometimes i go days without touching my U/S (ultrasound)and weeks/months without my IFT (interferential).

Whilst all the elaborate reasons about why you need this frequency or that is interesting, the bottom line is that it is just a band-aid in the end.

A comparison might be this...
You get stabbed in the leg(heaven forbid). You have a knife wound that is bleeding and lots of pain but neither is life-threatening (no arteries cut). You take a pain-killer. The pain stops. When the pain killers wear off, you are in pain again. You can take another pain killer or not. This goes on until there is no longer any pain - that is the wound heals itself. The pain-killer did not fix the problem, it just made the process more bearable. However, if you had the wound cleaned up and stitched up, the healing would be a lot faster (that is, taking measures to fix the problem).

In physio terms, treatment of sciatica with IFT or SWD is like this...
You have a lesion causing sciatica. You give the patient a pain-killer (IFT, SWD, electrotherapy). They keep coming back for about 6 weeks. During this time, most people with back pain will have their pain spontaneously resolve within 6 weeks. No matter how much we would like to think we helped, I am fairly sure the research supports the notion that electrotherapy is not that beneficial for low back pain. Of course, if you addressed the problem - pinched nerve, trapped meniscoid, motor control problem, global hyperactivity, etc, then they can better faster.

What do you think?

[sharmaphysio]

i totally agree with you, even i used to diagnose the proble and try to treat it.

my topic in final year was neural mobilization for sciatica.

actually this Q was asked by my juniour, i answered him but just wanna take ur expert views.

thanks alot for ur reply

[neurospast]

I am still wondering and with me, after reading the responses, other authors why someone would choose SWD or IFT in the first place. Some contributors were so kind to give the theoratic back ground but within what time scale do you actualy have results? On average 3 treatments 70% improvement? Less?
One has to consider that if I put e.g. a wand on somebodies back this already has an effect because of you actualy have started a treatment with a neurological response which has nothing to do with all the theoratical back ground of SWD/IFT the same response you might find with massage or grd1-2 mobilisations. (the latter I think personally to have a far bigger effect). But how much improvement is there with these applications after 3 sessions, including assessment, on average when one take in account objective measurements (like increased mobility) as well subjective (like less pain)? Is this 70%? If it would be less than 40% improvement on average (taking in account that the client receives 1 treatment a week) research shows that natural healing processes would most likely be accountable for the improvement.
Any figures? If it is so good please give some sort of evidence why it would be better than other modalities like acupuncture, manipulation and exercise/posture education.
Cheers

[alophysio]

Hi Neurospast,

Can i just clarify your last post...

1. You are still wondering who/why someone would choose SWD or IFT as a first-line treatment against sciatica, especially after some of the above posts.

2. You would like to know the results of using SWD and IFT to see if it is above natural recovery rates.

3. You would like someone who can give a reasoned argument as to why electrotherapy should be used before mobliisations, exercise and education.

Is this right???

[neurospast]

Yes I am very interested in why it should be the first choice.

[briganjo]

hi

[briganjo]

hallo everybody,
to my understanding, sciatica is due to the compression of the sciatic nerve,it may be at the sij level or at spinal level.
the goal should obviously be to release the nerve from compression.it can be through neural mobilisation tech or by using faradic current stimulation on either side of the compression,which can force the neuropraxia to release.this is possible, if the compression is at the sij level.if it is in the spinal level, it can be released by traction tech and faradic currents can be used for better conduction of nerves.badsitting postures are also sometimes reponsible for the compression of the nerve ,in such cases postural awareness should also be given,if not ,tne nerve gets compressed repetedly.
due the inflamation of the nerve ,there would be a genral spasm ,which results in pain.it is important to release the nerve. at the same time it is also important to consider pain psychology.so ,it definately important to deal with the patients pain also.the choice of modality is definately of therapists choice, i choose swd against muscle spasm.ift to block pain through spinothalamic tract and tens for the local release of b-morphins,encephalin and other analgesic and anasthetics.
when the therapist can use his option properly ,i'm sure he can do his best to the patient.atleast the nerve can be stopped from the danger of getting degenerated, which may happen on severe compression

[briganjo]

it was very nice to hear to use the wonderful god given hands ,i completely agree with alophysio when he says to use our hands.i would be very grateful ,if any body can tell me,guide me or refer me any book,where i can find how to decompress the nerve manually at sij level.i would glad to read your explanation than books to be referred,frankly ican't afford them.thanking u...bye

[alophysio]

Hi.

I will try to explain but I do not have access to my resources at the moment...

First of all, it is probably not the compression of the nerve that is causing symptoms. Studies have shown that people with compression of a nerve on MRI can be completely symptom free. Rather, it is thought that the noxious chemicals from the disc sensitise the nerves to pressure and therefore pain results.

A good review of the disc is given for free by Urban and Roberts 2003 -

Urban JP and Roberts S (2003) Degeneration of the Intervertebral Disc. Arthritis Research and Therapy 5: 120-131

Next, I would be hesitant to blame the SIJ for the compression of the nerve causing sciatica. However, I do believe that dysfunction of the SIJ will lead to factors that will lead to sciatica and the perpetuation of pain.

Explaining how to treat the SIJ is really not possible to do on a forum. I understand that it is difficult to purchase the books - perhaps you can get your employer to purchase it or get the hospital library to buy them. I would recommend "The Pelvic Girdle - 3rd Edition" by Diane Lee.

A key idea from the book is the "Intergrated Model of Function". You can get the chapter on this from Diane Lee's website - www.dianelee.ca - for free as a download...

The integrated model of function looks at:
1. Form Closure - how do the joints work - This involves assessment of the L/S, SIJ and Hips.

2. Force Closure - how do the local and global muscles work? Are the joints adequately supported during movement? Are the muscles able to stabilise the joints during motion?

3. Motor Control - How does the body/brain co-ordinate the muscles and joints? Your joints might be fine and intact. Your muscles might be strong and uninjured. But if the muscles don't co-ordinate their action, dysfunction can result.

4. Emotions - This area is more about how the body is affected by the brain. Less about "hands-on" in this area!

Plan your professional development along these lines - that is, work out if you know how to assess and treat along these lines. Work out where you are deficient and aim your development there.

For instance, my strength is in my form and force closure as well as emotions (I really am a "joint-man" at heart!). My weakness *was* motor control. So I have been working hard at learning and understanding motor control better so I can help my patients.

Lastly, please don't get caught up with finding the "pain-producing structure". People often try to find what is causing the pain and try to fix it to fix the problem. A better question to ask is "why did this structure breakdown in the first place?".

That way, you are looking for why the L4/5 disc is severely degenerated when the others look fine. Yes it may have a big bulge there compressing the nerves but what is the patient doing to stress that L4/5 disc in the first place? Adressing that reason is often better than trying to get an overworked disc to settle down (which most do within 6 weeks anyway!).

So although the pain may be coming from the back or SIJ, or wherever, we should treat the reason why it broke-down...

I hope that helps.

Now about your electrotherapy for sciatica.
1. Are you suggesting that preservation of the nerve/prevention of degeneration occurs if you use electrotherapy? Any References?

2. How quickly do your patients improve with Electrotherapy? Is it long lasting? Does it take longer than 6 weeks? Can you get them better with 3 treatments within 7-10 days?

I ask qu2 because i haven't been able to in the past and i was wondering if other people do it regularly - if so, I am more than happy to try

THanks

[arkesh_physio]

hi
even i believe electro is a waste of time and it only gives placebo effects.
hands on approach is more imp for a physio instead of the technicians job of electrotherapy

[jebapt]

Hi,
I think electro modalities have lots of scope because I don't think that mobilizations or manipulations whatever it may be.. doesn't always have positive results (They are always DOUBLE EDGED SWORD..) Sometimes those hands on stuff might worsen the condition.. My point is Traditional Physical therapy definetely has valuable role in pain relief... Thanks..

[alophysio]

Hi jebapt,

I agree with you the mobilisations and manipulations don't always have good results - we should be using the appropriate treatment approach for each condition we come across.

My question is: Does electrotherapy really need to be used so often?

There is plenty of evidence to support manual therapy (mobilisations & manipulation) with exercises (force closure, form closure & motor control - see above post). There doesn't seem to be much recent evidence to support the use of electrotherapy in the treatment of musculoskeletal conditions.

If anyone has any recent reviews to support the use of electrotherapy I'd love to read them.

Thanks

[sdkashif]

Exercises, mobilization and manipulation are no doubt effective mean of treating musculoskeletal disorders but they are only one of the possible mean of treating the musculoskeletal problems. Clinicians having expertise in them are no doubt very enthusiastic in emphasizing their ways of treating them. But other aspects of dealing with musculoskeletal problem should also not be ignored or suppressed.

Here are some evidence based studies showing the efficacy of electrotherapy. But here also remember that electrotherapy is one of the possible way or mean of treating the disorders along with other means included in the management plan of the problem.

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

Clinical effectiveness of commonly used electrotherapy modalities page 21

National practice guidelines for physical therapy in
patients with low back pain

Evidence In Practice -Is low-level laser therapy effective in the management of lateral epicondylitis?

Evidence for the treatment of shoulder disorders with physiotherapy modalities

Electrotherapy for neck disorders

Electrical stimulation for Pain

Self care techniques for acute episodes of Low back pain

[alophysio]

Hi sdkashif.

Thank you for providing those links.

I took these from your references above.

Ref #1 (Spine - Cochrane on TENS)

The results of the meta-analysis present no evidence to support the use or nonuse of TENS alone in the treatment of chronic low back pain.

Ref #2 (CSP on U/S)

What is the potential effectiveness of the intervention / impact of the issue?
The current state of evidence suggests that the physiological effects of US observed in vitro,
either do not occur in vivo, or have not been proven to have a clinical effect under these
conditions.1 There is therefore insufficient evidence to support the use of US in the treatment of
musculoskeletal injury. It has been argued that knowledge of cellular mechanisms and results
from in vitro studies coupled with judicial use of clinical reasoning constitutes good practice.9 It
is however important to establish its clinical effect, both related to different types of injury, and
with regards to the exact application of the treatment. This will allow for the most optimal
treatment and recovery, and should help to eliminate unnecessary costs both of equipment and
treatment time.

Ref #3 didn't link - don't know why (??????)

Ref #4 (A report on researching laser effectiveness on lateral epicondylalgia)

Based on the available evidence, especially
the studies by Basford et al and Papadopoulos et al, I
decided that LLLT would not be an effective intervention
for my patient with lateral epicondylitis.

Ref #5 (APA shoulder position statement)

Evidence for...
* Laser and pulsed electromagnetic field for RC tendinopathy
* U/S for short term pain relief for adhesive capsulitis
* U/S and pulsed electromagnetic field for calcific tendinitis
Evidence against...
* U/S not better than exercise for general shoulder pain
Insufficient Evidence...
*Any modality for RC tear, Instab/Hypermob of GH joint, RA or OA of the shoulder, AC joint injuries

Ref #6 (research report into C/S electrotherapy)

Overall, it can be concluded that, at present, there is no evidence on the effectiveness of electrotherapy in treating mechanical neck disorders.

Ref #7 (?insurance company's summary of the evidence of elect stim for pain)

There are too many quotes from this website but the general gist of it is that there is not much evidence to support its use or that it is to be used when every else has failed to alleviate the pain.

Ref #8 (Self care article 2002)

There is no proof that modalities improve the outcome of low back pain. However, as a short term relief and as an aid for activity resumption some of them, such as moist heat and ice can be easily taught to the patient. It is important that patients (and therapists) understand that these modalities are for controlling symptoms only and that an active approach will produce the best results.

.

So, the above "evidence" actually doesn't present any evidence at all supporting the use of Electrotherapy for most musculoskeletal conditions. There is some reported evidence for some shoulder conditions. Otherwise the evidence is equivocal at best or non-supportive at worst. Electrotherapy, as summed up in the last reference, is about symptom control, not improving the actual condition of the patient.

I am happy for people to show me where i am wrong but take the time to look these references up yourself to see that i am not being biased about this.

By the way, i do believe that the absence of evidence does not equate to evidence of failure but in this case, the available evidence shows that electrotherapy use is not supported.

Also, would it be fair to say that in Western countries, electrotherapy is less of a focus than from countries in asia, mid-east etc? Or is that a terrible generalisation? I am only garnering this information from reading the responses of participants on this forum (in other posts)...

Your thoughts would be appreciated...

Edited for poor formatting!

[sdkashif]

There are studies which support the use of electrical modalities and there are studies which do not. The findings of these studies have been questioned as they contrast with clinical experience and it would be inappropriate to dismiss the use of electrical modalities painful musculoskeletal disorders until the reasons for the discrepancy between experience and published evidence is fully explored.