Australian physiotherapists banning electrotherapy for LBP

The expression by the APA seems to recognise that LBP has a mechanical origin and ignores the psycho-social effects of pain. I both agree and disagree with their statement. The 'cure' is basically physical but the client has to be able to participate in the process. If they view their pain as precluding participation in therapy then they will need a modality to reduce pain to the point they can participate. This could vary from encouragement to opiates and includes EPA's, Many patients react positively to EPA's e.g. IFT and need this input to gain the confidence to participate. After thirty odd years of practising I am of the opinion getting people better is about getting them to participate and if the machine that goes BING is needed, use it. Theory is fine but putting your patient into the equation is essential as a therapist you must treat both the physical problem and the patients outlook. Ignoring the client's personality and reaction to pain is at your's and their peril. They need to be able to relax and listen to your explanation and therapeutic reasoning because if they don't hear it and appreciate it they react on a primal basis guarding and protecting. They will trust you more if they experience pain relief however this is generated; IFT will relieve pain and, perhaps decrease spasm, as much as gentle manual therapy, its the outcome not the means that matters.

Dear Colleagues

Joining this interesting discussion late and I am aware of this Statement by APA , Not sure - how many of you have actually read the statement that reads below :

The APA list of recommendations is as below - Extracted from its WEBSITE - pls read 5 below - that says work AVOID ... not BAN or Dump ... Interesting - how words are TWISTED as discussions go along. ANYWAY - Making such BROAD Statement by APA - is not justifiable ..? It is SAD to see - how little emphasis is given to EPA in AUSTRALIA - My daughter just graduated from a Leading Aussie Univ with Bachelor of PT - and when I asked bout how much of EPA they cover - I was shocked..........

BELOW FROM APA Website : 1.Don’t request imaging for patients with non-specific low back pain and no indicators of a serious cause for low back pain 2.Don’t request imaging of the cervical spine in trauma patients, unless indicated by a validated decision rule

3. Don’t request imaging for acute ankle trauma unless indicated by the Ottawa Ankle Rules (localised bone tenderness or inability to weight-bear as defined in the Rules)
4. Don't routinely use incentive spirometry after upper abdominal and cardiac surgery
5. Avoid using electrotherapy modalities in the management of patients with low back pain
6. Don’t provide ongoing manual therapy for patients with adhesive capsulitis of the shoulder

Two other pearls!

Transcutaneous electrical nerve stimulation: current status of evidence Pain Management January 2017 ,Vol. 7, No. 1, Pages 1-4 , DOI 10.2217/pmt-2016-0030 (doi:10.2217/pmt-2016-0030) http://www.futuremedicine.com/doi/full/10.2217/pmt-2016-0030?src=recsys

Evidence based medicine manifesto for better healthcare BMJ 2017; 357 doi: https://doi.org/10.1136/bmj.j2973 (Published 20 June 2017)

Last updated 10 months ago

Hi Esther. Interesting debate indeed and in terms of Wendy’s raising blood pressure, mine got sky high with signs of cooking blood. Like so many here on this forum I can look back on years of experience with EPA and treating patients suffering from a wide variety of painful conditions. A lot of them were in pain clinics where a multidisciplinary team fights every day for these patients in order to give them a worthy life again. Like so many of you I spent hours and days (and sometimes sleepless nights) reading and discussing articles with others. I can’t count the amount of articles on a wide range of electrotherapy subjects that I’ve got in my private library, so many of them with positive outcome. Like so many of you I used this knowledge in these discussions to defend the multiple attacks on the effects of electrotherapy leaving people behind with a stack of papers they should read first and then debate. Like so many of you I teach electrotherapy at a physiotherapy school and we don’t do this because they needed someone to do it but because we know something about it. And after all this I wonder who these APA people are and if they shouldn’t better be acquiring our level of knowledge before saying things like they did. And in the end I would like to add a publication too, one I liked very much and have been reading over and over again: https://www.ncbi.nlm.nih.gov/pubmed/24953072

Patrick De Bock, PT, Physiotherapy school, University of Antwerp, Belgium.

Interesting debate - and I agree totally with the fact that EBP, as it was originally postulated, did NOT mean that there must be an exact RCT to support Intervention X for Patient Y with Clinical Presentation Z - we would simply stop work. The article in The Australian says ' . . . . the Australian College of Physiotherapy, the APA has recommended physiotherapists no longer: . . . . . . . use electrotherapy in cases of lower back pain . . . . . (one of 6 things). I am not sure of the context in which they use the term 'electrotherapy' - whether they mean the wider range of applications which we would rather call the Electrophysical Agents or Modalities or whether they are taking electrotherapy to mean the use of electrical stimulation - another interesting debate. In the context of TENS and low back pain, an absolutely essential read in this regard is the recent Editorial by Johnson and Jones which I put out on the electro Twitter feed some weeks back (Pain Management 7(1);1-4 (see www.futuremedicine.com/doi/full/10.2217/pmt-2016-0030) . Similar 'advice' has been issued by NICE in the UK - not using TENS for low back pain - so the Australians are not alone - though there may be a common flaw in their respective arguments. I look forward to the continuing debate

Hi Ester, I share the opinion of Wendy and Estherderu and others. In my 33 years of practice, reading and teaching I’ve came across of similar fights. Lat me add some thoughts to this issue:

1 – EBP is not to obey rules, EBP is to obey to reasoning. So one must read and ratiocinate on the the APA document.

2 – Brushing the opinion of professionals and patients, and only “read the articles”, is brushing reasoning and brushing EBP (PICO)!

3 – The APA recommendation is sported, I presume, by, at least, this 2 articles:

Transcutaneous electrical nerve stimulation (TENS) versus placebo for chronic low-back pain. (Cochrane)

Assessment: efficacy of transcutaneous electric nerve stimulation in the treatment of pain in neurologic disorders (an evidence-based review): report of the Therapeutics and Technology Assessment Subcommittee of the American

If you (they) read them to is very end, you (them) can find these recommendations from the authors: “Further research is encouraged” and “Further research into the mechanism of action of TENS is needed, as well as more rigorous studies for determination of efficacy.”, respectively.

So, how can we do further research if the technic is “banned”? No reasoning no EBP!!!!

4 – in accordance to your request some recent publications on this matter:

Short-term effects of interferential current electro-massage in adults with chronic non-specific low back pain: a randomized controlled trial. (https://www.ncbi.nlm.nih.gov/pubmed/23035006)

Effects of transcutaneous electrical nerve stimulation (TENS) and interferential currents (IFC) in patients with nonspecific chronic low back pain: randomized clinical trial. (https://www.ncbi.nlm.nih.gov/pubmed/21971895)

[Comparison of the analgesic effect of interferential current (IFC) and TENS in patients with low back pain]. (https://www.ncbi.nlm.nih.gov/pubmed/26094328)

Effect of interferential current therapy on pain perception and disability level in subjects with chronic low back pain: a randomized controlled trial. (https://www.ncbi.nlm.nih.gov/pubmed/26975312)

Be patient with them and, with my English writing . :-)

Last updated 10 months ago

Hi Esther. I concur with my EPA colleagues - especially Professor Chipchase who live sin Australia! I find it interesting groups such as MSK or manual therapists will want to ban the use of EPA for LBP yet there is no strong evidence that manual therapy works, and give the varieties of manual therapy out there, I find it incredulous they would suggest banning a part of physiotherapy scope of practice such as EPAs. And as someone else stated - how can the professional organization ban a part of practice? Use Tim's electrotherapy.org website and you'll find lots of evidence for EPAs for LBP. Cheers, Sandy

Is this helpful? there are more. Just search the literature on NMES and LBP.

Hicks, G. E. Sions, J. M. Velasco, T. O. Manal, T. J. Trunk Muscle Training Augmented With Neuromuscular Electrical Stimulation Appears to Improve Function in Older Adults With Chronic Low Back Pain: A Randomized Preliminary Trial. Clin J Pain 2016;32:898-906. OBJECTIVES: To assess the feasibility of a trial to evaluate a trunk muscle training program augmented with neuromuscular electrical stimulation (TMT+NMES) for the rehabilitation of older adults with chronic low back pain (LBP) and to preliminarily investigate whether TMT+NMES could improve physical function and pain compared with a passive control intervention. MATERIALS AND METHODS: We conducted a single-blind, randomized feasibility trial. Patients aged 60 to 85 years were allocated to TMT+NMES (n=31) or a passive control intervention (n=33), consisting of passive treatments, that is, heat, ultrasound, and massage. Outcomes assessed 3- and 6-month postrandomization included Timed Up and Go Test, gait speed, pain, and LBP-related functional limitation. RESULTS: Feasibility was established by acceptable adherence (>/=80%) and attrition (<20%) rates for both interventions. Both groups had similar, clinically important reductions in pain of >2 points on a numeric pain rating scale during the course of the trial. But, only the TMT+NMES group had clinically important improvements in both performance-based and self-reported measures of function. In terms of the participants' global rating of functional improvement at 6 months, the TMT+NMES group improved by 73.9% and the passive control group improved by 56.7% compared with baseline. The between-group difference was 17.2% (95% confidence interval, 5.87-28.60) in favor of TMT+NMES. DISCUSSION: It seems that a larger randomized trial investigating the efficacy of TMT+NMES for the purpose of improving physical function in older adults with chronic LBP is warranted.

Hi Ester again! Can the APA actually ban/dump a treatment? Surely that is down to the individual physio or is it that they won't get paid, or can it affect their Professional Indemnity if they "harm" a patient using a modality that is not recommended by the APA? It's a bit rich when doctors are far worse at "treating" back pain with NSAIDs and analgaesics. In my book, they are directly responsible for creating thousands of chronic pain patients and huge numbers of patients becoming addicted to prescription opioids!

Hi Ester. Difficult one as I am not directly involved in research. We had 2 uni students University of Hertfordshire) who independently showed that IFT is a better broncho-dilator than ventolin, but that was undergrad papers. I suspect that I have treated more patients with IFT than anyone else world wide, on the basis that at a conservative estimate, I have done in excess of 100,000 treatments. I was involved with the development of the first British machine back in the day when I was Superintendent at St Bartholomew's Hospital and the Bioengineering department in the Wolfson Centre wanted a project for their MSc students. That resulted in the Medeci machine and then I worked with the guys again when they left and formed their own company - SNS Bioengineering Ltd. I used to lecture across the UK on IFT, but had to stop as there were no new machines that allowed me treat in the ways that I have developed over the years (SNS Bioengineering ceased trading when their main director died some years ago). I am looking to start again as I may have found a machine that will work for me, hence the second edition of the textbook. I am also collating single case studies that will go into that book. I have 8 IFT machines - all of which are more than 20 years old, but still work! Interestingly, this company export 70% of all their electrotherapy equipment as the market has all but dried up. We take uni students on clinical placement from 5 unis here and show them all the value of IFT and without exception they are staggered by the results they can actually observe and cannot understand why they are taught so little electrotherapy these days and there's the other problem - we now have generations of physio who have no real idea of the value of electrotherapy. Why are they still teaching SWD?! Our website www.stortphysio.com may help you. Other than that, I have written articles on the treatment of asthma with IFT in Positive health mag, but that was a while ago. Please feel free to use me in anyway that you think might help the cause. Other than that - I am hoping that the textbook may wake some people up!

dear Wendy, thank you, I too understand your reaction... that is why I am bothering to try to get people to be more open minded. Can I cite you in some way???

Hi Ester. Discussions like this always manage to raise my blood pressure! I have worked with IFT since 1978. I have worked in private practice since 1980 and most of our patients have spinal conditions - backs and necks etc. Our results would be nowhere near as good if we did not incorporate IFT into the treatment protocols - and thereby hangs the argument. All of us here carry out a full clinical exam as per Orthopaedic Medicine, and then treat from a range of techniques using manipulation, mobilisations, acupuncture, rehab protocols specific for the patient etc etc and IFT. The key point is that electrotherapy is a PART of the WHOLE treatment recipe. Even the way we interact with the patients is going to have an effect on their recovery. IFT is taught to undergrads as an analgaesic and nothing else. That's a very expensive paracetamol! I am currently writing my second textbook on IFT and have so far gathered over a thousand research papers on the effects of low frequency currents in isolation from any other treatment. And yet - for example, I have treated a large leg wound only with IFT and reduced the healing time by half that expected by the Tissue Viability unit. I have treated, and cured a case of micronodular cirrhosis. I have treated, and cured 2 cases of onycholysis, which is supposed to be incurable. I have treated endless cases of acute injuries with significant haematomas and reduced the recovery time by at least 50%. You may begin to understand my frustration! The problem is that in a hospital setting in particular, physios are being pressured into shorter treatment times and they don't have the time to treat patients effectively - so getting rid of electrotherapy is seen as one way of getting through more patients in the shortest possible time. The other problem is that there is no consistency in frequency selection across the research. So you cannot compare like with like, or make an informed decision to drive your clinical practice. So much for EBP - good principle, but questionable in physiotherapy. This is why I am working on this next textbook to demonstrate the clinical effectiveness of how I have been treating patients over the last 39 years, as well as to hopefully stimulate research into why these clinical effects are possible ie EBP should follow practised based evidence and not the other way round. The other issue is of course - electrotherapy has simply fallen out of medical fashion, but watch this space as there are drug companies now seriously developing small electrical devices as implants. Is this another example of how we, as a profession, are throwing out treatments techniques for others to pick up and run with, leaving us with a very dubious future? Let's not forget that physiotherapy is a profession and not a treatment. There are too many variables in what we do; how we treat the patient; how we interact with the patients; their fears and worries etc. and this all adds up to a very difficult subject to research. What would happen if we tried to research medicine!

Thank you, I agree with you completely, that is why I have been 'defending the honour'. But I would love some good advice on articles showing that electrotherapy does work on LBP. It seems this is the only thing the authors of this post is interested in. Patients opinion and expert opinions are brushed away as being 'open to unconsious bias'.

Hi Esther I think like everything we should use evidence based practice - our clinical judgment, research and what the patient wishes. That should guide your treatment not mandates from the APA. Electrotherapy is always an easy target to say not to use. The argument has been going on for the last 15 years or so. Its nothing new! As long as you come back to EBP, then you cannot go wrong. Kind Regards Lucy

Hi Esther I think like everything we should use evidence based practice - our clinical judgment, research and what the patient wishes. That should guide your treatment not mandates from the APA. Electrotherapy is always an easy target to say not to use. The argument has been going on for the last 15 years or so. Its nothing new! As long as you come back to EBP, then you cannot go wrong. Kind Regards Lucy