EPA - Are we wasting our time?

Is there any strong evidence to support the continued use of ultrasound or interferential for our clients?

The Dutch Health Council recently published a report on the efficacy of electrotherapy, laser therapy and ultrasound treatment for musculoskeletal disorders. The assessment was based on three systematic reviews, including 169 randomized clinical trials, and focused on a best-evidence synthesis. Virtually no conclusive clinically relevant effects of the three forms of physical therapy were found. Possible exceptions are electrotherapy for osteoarthrosis of the hip or knee, laser therapy for pain treatment and rheumatoid arthritis, and ultrasound treatment for epicondylitis lateralis. But even for these putative indications, further research is clearly needed before implementation in practice is justifiable. It is strongly recommended that the current widespread use of electrotherapy, laser therapy and ultrasound treatment should be reduced, preferably by self-regulation within the profession itself.

I am relatively new to this forum, but I am assuming this topic has probably been debated ad nauseam. I would like to offer my opinion - YES, we are wasting our time!!! Although EPA's are trendy, being popular with the general public, there is next to no research supporting their use (except some specific cases, as mentioned, e.g. TENS for knee OA).

Ultrasound has been used therapeutically for the past 60 years. Research on the physiological and therapeutic effects of ultrasound has been conducted for nearly as long. To date the majority of research doesn't support the effectiveness of ultrasound as a physiotherapy treatment. You would think that if ultrasound was an effective treatment we would have produced enough research evidence over the last half century to justify its use. Either we are really bad at conducting research or perhaps ultrasound doesn't work.

It is often commented that lack of research evidence for a treatment shouldn't be interpreted as a lack of treatment effect. Most often, researchers will claim that more research is needed, and future studies require higher statistical power to detect treatment effects (to reduce the chance of a type II error). In my opinion, the more research conducted concluding no treatment effect, the higher the probability that the treatment is actually ineffective. Experiments are conducted in order to test the null hypothesis (i.e. to disprove that the treatment had no effect, to prove the possibility the treatment had an effect). If the null hypothesis is never falsified (as researchers claim that more research is always needed) then how can treatment ineffectiveness be concluded - it can't. In this case science turns it's head on itself. Karl Popper's falsifiability principle (no empirical hypothesis, proposition, or theory can be considered scientific if it does not admit the possibility of a contrary case) is thrown out the window.

That being said, many therapists have adamantly supported the use of one modality or another. When asked why no reasearch supports its use, the common reply is that the reasearch hasn't used the proper parameters. Just once, I would beg the advocate to perform some reasearch using these "magical settings" so that, the long sought after evidence would finally materialize. One and all could be justified in their use.

Clinical experience is not enough to support the use of a treatment that is used so pervasively in the profession. Of course, physiotherapy is both an art and a science, however our artistic freedom has limits - limits of sensibility. I hope the following passage explains why.

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"A large part of the history of science, especially medical science, has been a progressive weaning away from the superficial seductiveness of individual stories which seem, but only seem, to show a pattern. The human mind is a wanton storyteller and, even more, a profligate seeker after pattern. We see faces in clouds and tortillas, fortunes in tea leaves and planetary movements. It is quite difficult to prove a real pattern as distinct from a superficial illusion. The human mind has to learn to mistrust its native tendency to run away with itself and see pattern where there is only randomness. That is what statistics are for, and that is why no drug or therapeutic technique should be adopted until it has been proved by a statistically analyzed experiment, in which the fallible pattern-seeking proclivities of the human mind have been systematically taken out of the picture. Personal stories are never good evidence for any general trend.

In spite of this, doctors have been heard to begin a judgments with something like, “The trials all say otherwise, but in my clinical experience . . .” This might constitute better grounds for changing your doctor than a suable malpractice! That, at least, would seem to follow from all that I have been saying. But it is an exaggeration. Certainly, before a medicine is certified for wide use, it must be properly tested and given the imprimatur of statistical significance. But a mature doctor’s clinical experience is at least an excellent guide to which hypotheses might be worth going to the trouble and expense of testing. And there’s more that can be said. Rightly or wrongly (often rightly) we actually do take the personal judgments of a respected human individual seriously. This is so with aesthetic judgments, which is why a famous critic can make or break a play on Broadway or Shaftesbury Avenue. Whether we like it or not, people are swayed by anecdote, by the particular, by the personal."

"The Devil's Chaplain" (Richard Dawkins)

Quite simply put, no one would deny that when one has a head ache, they pop a pill, and 'walla' magic, the individual can get on with their day and do the activity that they weren't able previously.

What is the purpose of any 'therapy'? To allow people to 'get on with [it]'.

Unless I am mistaken.

If a toxic medical drug may be prescribed to allow one to return to activity,

then the question must be asked why not a non-toxic therapy (such as complementary therapies including epa, acu, relaxation techniques), all of which produce the exact same physiologicaly response (that is reduction of pain receptors via some substance P type pathway not yet deciphered by research!)

Indeed, absorb what is useful, and leave that which is not. As well, utilize where required rather than over-utilizing/selling/hyping

I am not denying the importance of the placebo effect (which does indeed have a physiological mechanism currently under investigation) I am just emphasizing that it is time we strive for something more effective.

Many texts have been written examining the mechanism and amplitude of the placebo effect. One consistent finding is that the strength of a placebo is intimately related to the degree of patient expectation. In turn expectation is closely related to invasiveness. That is to say certain placebo therapies may be more effective than others because they are invasive, therefore, the patient identifies this with a high expectation that the treatment will have a therapeutic effect. For example acupuncture, saline injections and sugar pills are all forms of therapy with a high level of perceived invasiveness and therefore result in high expectations that the treatment will be beneficial (in turn stimulating the mind-body connection, i.e. placebo effect). Now, this is still an unsubstantiated theory but it does have interesting implications. For example, why perform true acupuncture (following meridians) when sham acupuncture (random application) is often equally effective. The placebo effect can be produced by any form of treatment as long as the client can be persuaded that the treatment may have an effect (i.e. as long as a positive expectation can be formed).

I think there is two ways of looking at this issue: (1) from the perspective of a health care professional with the duty of beneficence and (2) at the level of policy. In (1), a physiotherapist should act in the best interest of each and every patient to ease their pain, facilitate healing, and improve function. On the other hand, at the level of policy management, the whole population is considered and not just the individual. Perhaps, it could be concluded that resources are being squandered by supporting a placebo therapy rather than allocating resources to R&D to discover novel, more effective (above and beyond placebo) forms of treatment.

Furthermore, it is my opinion that one must consider the veracity of using a modality with little to no best research evidence supports its use (e.g. most electrophysical agents). Reminds me a little of selling snake oil.

The main problem with electrophysical agents is that although they may reduce subjective pain responses, they rarely if ever improve function. This is the primary reason that most worker compensation boards vehemently disaprove of their use - they don't facilitate return to work.

I'm sorry if I come across skeptical or close minded. My true intention is to stimulate discussion.