by Elisio Pereira Neto
Ultrasound and TENS: why do we no longer use them?
If you have ever been to a physiotherapist, especially around 10 years ago, you probably heard of and maybe used an ultrasound or TENS machine. They used to be very common in physiotherapy practice, especially for recent injuries or in the early stages of a condition. A lot of people used to report pain and injury improvement after using them. We often have people walk by our clinics and pop in to ask if we have them. So you may be thinking… why don’t physiotherapist’s use ultrasound and TENS anymore?
And the answer is: research.
When choosing the most appropriate technique, a physio uses – among other things – results from high quality research, which is what we call evidence-based practice. As a clinic we only use techniques and practices that are evidence-based and up to date.
So what do we know about ultrasound and TENS? What does the evidence say? To begin with…
Research can be complicated, there’s no doubt about it. There can be a lot available – sifting through research to find the reliable articles, the most recent, and the quality evidence can be hard.
Luckily, practitioners throughout the world are best fit to do the complicated work that means you as the patients receive the best quality care. In several Universities around the world, highly qualified physiotherapists have completed research by gathering people with different conditions — some would be treated with ultrasound or TENS, and others would not receive any treatment or receive basic treatment. The results might surprise you!
Firstly, let’s discuss ultrasound.
Ultrasound was and is still sometimes used as a therapeutic practice for a number of conditions for physiotherapy treatment.
Ultrasound has been used for over 50 years in the physiotherapy industry (this alone makes it sound outdated!). It is said to work by providing heat to areas of the body that could not be provided through a standard heat pack. The ultrasound instrument creates ultrasonic waves that can pass through your body’s surface and penetrate the targeted tissues. The ultrasonic waves are said to produce microscopic gas bubbles around the injury that expand and contract rapidly, causing localised internal heat. This is thought to speed up the healing process of your injured body part because the heat can cause muscle relaxation and increases in local blood flow. This in turn can induce tissue regeneration and reduction of inflammation.
But as you may know, we cannot rely solely on heat or cooling agents to treat an injury (see our previous blog post on topical pain relief HERE). Whilst they are good for temporary pain relief, our goal is to get you fixed up long term!
Along these lines, recent studies have determined that ultrasound may not provide any additional benefit for the presenting conditions.
A 2014 randomised control trial (RCT) compared two groups of people presenting to physiotherapists with knee osteoarthritis. The test group received ultrasound as part of their therapy, the control group received a fake ultrasound, and the participants did not know which group they were allocated to. All treatments were applied five times a week for 2 weeks. All participants also followed a home exercise program that included isometric exercises, strength exercises, and stretching exercises to be completed at least three times per week. The researchers collected data at 4 follow up points throughout the study, with the last being a 6 month follow up. All groups showed a significant improvement following their physiotherapy treatment. However, there was no significant difference between the groups. What this means is that the home exercise program did wonders for their knee osteoarthritis! The fact that there was no significant difference between the groups, showed that the ultrasound played no part in the recovery and improvement in the pain and the condition itself.
Like many other topics of research, there can be mixed results. When researching things like pain due to injury and or disease, often the results obtained are subjective. This means that the results can vary depending on the person. Two different people do not experience pain in the same way. One may be more susceptible to a placebo effect. Or, if you firmly believe that your condition won’t get better then the results may be skewed to favour that perspective when self-reporting pain levels. This is a well-considered limitation of this kind of research. However, the majority of the research into therapeutic ultrasound is quite heavily favouring the results that say it is inferior to its therapeutic technique counterparts.
For example, another study determined that 7/7 shoulder participants felt a reduction in their pain when using ultrasound as a treatment method. However, 4/7 of those shoulder participants results demonstrated that ultrasound was inferior to the other physiotherapy techniques used. What this means, as mentioned above, is that ultrasound can sometimes be used for pain relief, but the effects are only temporary. If it was used as a primary therapeutic strategy, your condition will not improve significantly, nor will that improvement be maintained long term.
When our physiotherapists prescribe a home exercise program and a product like Fisiocrem, you are receiving a better, evidence-based therapeutic strategy than if you see someone for ultrasound. With the Fisiocrem, you get that heat component for the temporary pain relief (plus, it is less than $20 AND you can use it at home whenever you need). The home exercise program ensures that the problem is fixed at the root and aims to maintain that improvement long term. Education and practical application on how to manage your condition and treat your injury is the best quality care you can get. As they say, give a man a fish and he eats for a day, teach a man how to fish and he eats for a lifetime! THAT is how we want to make an impact in our clients lives.
You may be shocked by the results, but the changes in pain for study participants receiving ultrasound and the ones receiving no treatment was the same! So that is the good reason why we don’t use ultrasound as a technique anymore.
A shortcoming of some healthcare practices is that the evidence-based research into practice. It is a well documented gap between research and practice. Our clinic and practitioners don’t want to be a part of this, so we prioritise putting the quality research into practice.
Secondly, let’s discuss TENs machines.
The research is quite similar.
If you don’t know what a TENs machine is, it stands for transcutaneous electrical nerve stimulation. Put simply, this means electric stimulation applied over the skin. A standard portable TENS machine is small with a couple of leads connected to patches that adhere to the skin. From the machine down to the patches, the electrical stimulation is passed through the skin into the body. TENs machines are often used in labour rooms for pregnancy and birth related pain relief. It is also sometimes used in physiotherapy clinics for temporary pain relief.
So, what does the electrical stimulation actually do? It’s generally accepted that electrical pulses given off by the TENS machine prevent pain signals from reaching your brain. It works in a similar way to rubbing you leg after you bump it. Essentially distracting yourself from the pain. Also TENS pulses stimulate your body to release its own, natural, feel-good substances, called endorphins. Endorphins can also decrease pain levels temporarily (but, there are many ways to get those endorphins flowing!).
A study on TENs machines showed that the participants did have some improvement in pain, but that was only for two or three days. Also, you require at least 20 minutes of TENS application to perceive any benefit. If a session with a physio goes for 30 minutes, almost 70% of it would go towards using a TENS – and you probably don’t want to come to the clinic to have someone putting a machine on your back for 20 minutes. This limits the time for other adjunct therapies, manual therapy, education and developing the long-term strategy. Plus, we don’t want you to have to take time out of your busy schedules to come in 3 times a week every week for pain relief, when we know that this can be achieved in more sustainable and contemporary ways.
We know that TENs machine are safe, non-invasive options with minimal risks or side effects. When compared with pharmaceutical pain relief, with high risks, addiction potential and a long menu of side effects, we know which we would prefer our clients to choose. But there are also arguments against using TENs machines because of their variability in effectiveness. If used at a certain dosage too long or too often, the client may build up a tolerance, meaning they will continually need more and more to feel the benefits. Trying to out-treat the tolerance can be quite harmful, so more research is needed to address this. There is also more research needed to determine the most effective site selections, optimal daily use, and much more.
However, the nature of the technique really shows just why it’s not our first choice for pain relief. It is essentially a distraction from your pain. It can help in the moment, there’s no doubt about this. But this isn’t because the problem is being fixed, it’s because the problem can’t tell you it’s a problem. As physiotherapists we want you to feel better every day, not just at the clinic. The TENs machine can provide a mild distraction from the patients pain, but it will in no way cure or improve the pain long term. Because our focus is on education and long-term positive outcomes, we choose not to use this technology in our clinic. Instead, we follow evidence-based practices that provide short-term AND long-term benefits and positive outcomes for our clients.
Repeat after me – MOTION IS LOTION!
We want to remind you that there is nothing wrong with a clinic that uses these machines still – but it may be an indication that they haven’t put in to practice the most up to date evidence.
You may be thinking ‘I used this once and it helped!’. Well I’m pretty sure it did, but it’s very likely that it was not only because of the ultrasound or TENS, but because of all the other amazing evidence-based treatments your physiotherapist did with you. And, based on research, probably your improvement would have been the same if you have not used ultrasound or TENS.
Hopefully you understand why we don’t use ultrasound or TENS anymore, but if you still have any questions we’re here to help! And if you think that ultrasound or TENS are the only things that would make you feel better, come and see one of your physiotherapists and we can have a chat about other much more amazing options for you. We use a variety of evidence-based therapeutic strategies and we would love to discuss them with you!
If you are wanting to book an appointment with one of our experienced and amazing physiotherapists, click the link in the top right corner or below to book online! Or, call us on 8352 3582 to book with our client services team. We look forward to hearing from you!
References:
1. https://academic.oup.com/painmedicine/article/21/7/1437/5490299?login=false
2. https://journals.lww.com/ajpmr/Abstract/2014/05000/Efficacy_of_Therapeutic_Ultrasound_for_the.6.aspx
3. https://www.verywellhealth.com/does-ultrasound-really-work-2696629#citation-1
4. https://www.sydneyphysioclinic.com.au/treatment-modalities/tens-machines-and-pain-relief/
