Modalities: They work some of the time, all the time.

Just like many of my colleagues I had at least some part of my academic curriculum dedicated to the learning of modalities. In school it was mainly about ultrasound, muscle stim, TENS, as well as heat and ice. Coming out of school it seemed like that would be a large portion of my treatment options. Then I began to get exposed to differing view-points regarding their effectiveness. Most clinicians have probably heard of a story along the lines of, “I used the ultrasound on a patient, only to realize as the timer went off that I hadn’t turned the machine on. Yet the patient still felt better”. This is one thing that really stuck with me. How is that possible? If it can be effective without being turned on then what is actually happening? This has led me to look more and more into the efficacy of my treatment approach.

Many of these modalities have a lot of research out there that looks at their viability. Over the last decade or so, what we once thought was effective may not be so it seems. This includes things learned after school. This includes, shockwave, acupuncture, various taping methods, cupping and so on. On one hand the science behind how they work suggest it’s not the particular modality that is causing an effect, it’s the application of any modality, although inconsistently. A quote that always comes to mind is “everything works on someone, but nothing works on everyone”. Think about that, if something is specifically effective because of its use then wouldn’t there be some consistency? This doesn’t seem to be the case.

Although I started out my career using many of these modalities and paying money to take courses on learning them I have almost stopped using them completely except in specific individual cases but that is rare. So let’s take a dive into what the research says regarding these things.

First let’s take a look at good ol’ therapeutic ultrasound. This modality has been around a long time in terms or the physiotherapy profession. An analysis of 293 papers concluded that ultrasound treatment for musculoskeletal issues was only based on empirical evidence and lacked strong evidence that included controls(1). As I stated earlier, the fact that some people felt better after it do not necessarily give it merit automatically especially if not compared to controls. Another analysis looked at the effects on bone healing, in which it showed that there was no difference in return to work time, pain at 6 weeks and a few other measures(2). One of the more common applications of ultrasound is for tendinopathies (tendonitis), even though multiple studies show that it adds no benefit over exercise alone (3). Another review looked at 10 studies, with 8 showing the ultrasound showed no statistical difference compared to placebo(4). So although on it’s own it may seem effective, when compared to control groups it does not seem to improve outcomes. It seems that ultrasound has had its time and failed to show usefulness, it is not something that should be taught or used in practice.

Next I will take a look at cupping. Again, something I have used in the past. Cupping has been around a long time but gained popularity largely in part due to the visible cupping marks on Michael Phelps during the Olympics in 2012. In terms of the research and science behind it, it is still very unclear. There is support that cupping can help with pain, as do most modalities, as can many things outside of treatments(5). When looking at analysis of the research it seems that cupping can only be validated to have short term improvements in pain. There does not seem to be any conclusive research for cupping as most of the rationale for it is anecdotal. What I don’t understand is when I hear things such as “breaking up fascia” etc, despite no evidence that it is possible and little to no logical plausibility. I believe we should not give patients explanation that are implausible and pass them off as scientific fact, at the very least they should be framed as theoretical.

Acupuncture is an interesting one. This one takes the added risk of puncturing of the skin. My first personal experience with acupuncture was in high school when I was having some significant back pain. It definitely seemed to help, but those effects were always temporary. The research seems to be aligned with this notion in regards to musculoskeletal issues. The reviews tend to suggest that it again has a temporary effect on pain and some studies even show temporary effects on function, most likely due to the decreased pain (7,8). Another more recent use of needles is dry needling, which is typically used on what are called “trigger points”, although it seems there is no clear cut evidence as to what trigger points are or how they form. A review of dry needling studies showed again a temporary improvement in function when compared to no treatment, but no significant difference when compared to other physiotherapy treatments(9). More recently a new guideline for treatment of recent onset back pain actually recommends against the use of acupuncture, injections and routine use of imaging (10). Another modality/treatment method that reliably shows only temporary effects and may even be not recommended for certain conditions.

Lastly, I will look at k-tape. Again another treatment method that was popularized when people began to see athletes on TV wearing the various colors of tape. One review looked at 13 articles and found that k-tape did not have any significant improvement in pain over other typical modalities (11). Another review of 10 articles showed that there were two studies that showed k-tape increased pain free range of motion in the shoulder (12) although the paper suggests that there was a high risk of bias with both studies. The other studies were inconclusive to it’s affects. There is some evidence that it may improve proprioception, but so can exercise and general movement.

So with all that being said, should a therapist spend valuable time with a patient using these treatments? More importantly should patients be spending their time and money on treatments that may be nothing more than a temporary input to the nervous system or even placebo in many cases? These seem to be band aid treatments. I feel I would almost be doing a disservice using something passive to temporarily decrease pain knowing the pain will return shortly, it’s the same reason I am relatively strong against any type of pain medication except in specific situations. The temporary masking of pain may actually do more harm than good for people as pain is your body sending you a message, you don’t always need to silence the message.

So what does that all mean? By no means am I saying these methods are useless, they can again definitely help when it comes to pain but so can exercise. My opinion and belief in the research is that as most practitioners can agree, that most things can benefit from simple exercise and education. It also seems that one would have a hard time proving that a therapist would not be able to be as effective without the use of these modalities. On top of that is the concern that psychologically people can feel that they have become dependent on these forms of treatment. On the other side some therapist may feel that they would have a hard time having a patient come in more frequently without the use of these modalities. So if I can be a great therapist without them, then why complicate my treatment with theoretical explanations of why something works along with the added costs and time.

Thanks for reading, Vitas

References:

1. Gam et al. “Ultrasound therapy in musculoskeletal disorders: a meta-analyisis” Pain. 1995.

2. Schandelmaier et al. “Low intensity pulsed ultrasound for bone healing: a systemic review of randomized controlled trials” BMJ. 2017.

3. Warden et al. “Low-intensity pulsed ultrasound for chronic patellar tendinopathy: a randomized, double-blind, placebo-controlled trial” Rheumatology. 2008.

4. Robertson et al. “A Review of Therapeutic Ultrasound: Effectiveness Studies” Physical Therapy. 2001.

5. Wang et al. “The effect of cupping therapy for low back pan: A meta-analysis based on existing randomized controlled trials.” J Back Musculoskeletal Rehabil. 2017.

6. Cao et al. “Cupping therapy for acute and chronic pain management: a systemic review of randomized clinical trials” J of Traditional Chinese Med Sci. 2014.

7. Liu et al. “Acupuncture for Low Back Pain: An Overview of Systemic Reviews” Evidence-Based and Contemp Alt Med. 2015.

8. Furlan et al. “Acunpuncture and dry-needling for low back pain: an updated systematic review within the framework of the Cochrane collaboration.” Spine. 2005.

9. Gattie et al. “The effectiveness of Trigger Point Dry Needling for Musculoskeletal Conditions by Physical Therapists: A Systemic Review and Meta-Analysis.” J Orthop Sports Phys Ther. 2017.

10. Stochkendhal et al. “National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy” Eur Spine J. 2017.

11. Montalvo et al. “Effects of Kiniesiology Taping on Pain in Individuals With Musculoskeletal Injuries: Systematic Review and Meta-Analysis” The Physician and Sportsmedicine. 2014.

12. Desjardins-Charbonneau et al. “The Efficacy of Taping for Rotator Cuff Tendinopathy: A Systematic Review and Meta-analysis” Int J Sports Phys Ther. 2015.