Introduction: current concepts and clinical decision making in electrotherapy

Tim Watson

INTRODUCTION
CHAPTER CONTENTS Introduction 3

Current concepts in electrotherapy 5 Models of electrotherapy Electrotherapeutic 5

windows 6

Clinical decision making in electrotherapy 9 Conclusion References 9 10

Electrotherapy has a long-established place in therapy practice, being one of the mainstays of professional activity over many years. The emphasis on this mode of intervention has gone through significant changes over time and, in current practice, it is seen for the most part as an adjunct to treatment rather than as a means to an end in isolation. There are instances where it can be rightly considered to be the focus of the treatment but this is unusual and, arguably, the exception rather than the rule. Given that many of the modalities that have been used in the past have waned in popularity, and that every year new machines and new 'treatments' come to the marketplace, it can be difficult for the therapist to know whether this 'new' treatment is in fact new or just a revamped version of an already existing intervention. There are undoubtedly new interventions and certainly new approaches to existing treatments, driven by a demand from patients,from manufacturers and from research. To claim that all current electrotherapy practice is 'evidence based' would be naive, although there is room. for debate as to what actually constitutes evidence-based practice, from where the evidence is sourced and the role of individual experience and that of colleagues in that process. Some of these issues will be explored in this introductory chapter.

INTRODUCTION

AND SCIENTIFIC

CONCEPTS

From the published and experiential evidence, it appears that electrotherapy can be clinically effective and need not be written off as something that is 'old fashioned' and that no longer deserves a place in the therapeutic tool kit. That it can be applied in a clinically effective manner is evidenced in the chapters that follow. That it can also be delivered in an ineffectual manner is something that will be recognised by practitioners from many disciplines. The evidence would suggest that when the appropriate modality is applied at the 'right' dose for the presenting problem, it can make a significant contribution to the improvement and well being of the patient. The fact that it does not work in all cases is not surprising at all. This would be a common feature of any therapy - whether manual therapy, exercise or drug therapy. If one were to use a particular manual therapy technique for patient X, and the next day or the next week, when X returns, there was no improvement, it would not mean that all manual therapy was a waste of time, or even that the therapist was incompetent. There are patients who fail to respond to therapy A, but do very well with therapy B. The reasons for these individual differences are poorly understood, but certainly add to the richness of clinical experience. If therapy was simply a matter of applying the right recipe to the patient presenting with a given problem, clinical practice would lose a deal of its attractiveness. For any therapeutic intervention to be effective there is the need for a clear assessment, a rationalisation of the problem(s), and the construction of a proposed treatment plan that matches the needs of the individual taking into account their holistic circumstances, not just their presenting signs and symptoms. The applied intervention is that which is deemed to be most likely to be effective. This is no guarantee that there will be 100% success, but the best odds for a beneficial outcome. The thinking therapist then re-evaluates the outcomes as the treatment progresses, modifying the treatment package in the light of these results. . One of the problems with the application of research in electrotherapy, as well as in other fields, is that the research tends to be somewhat reductionist in approach. A clinical trial that evaluates, for example, the effect of ultrasound for patients with a tear of the medial collateral ligament of the

knee, aims to construct a methodology that readily identifies the contribution that ultrasound makes to the clinical outcome. By keeping all other treatment parameters' constant' - the advice, exercise, manual therapy, environment, number of treatment and treatment intervals - the real effect of the ultrasound therapy can be evaluated. The clinical reality is that it is the package of care that is clinically effective (or not), rather than any one individual component of it. If a patient has received several forms of intervention (e.g. some advice, electrotherapy, manual therapy and exercise coupled with appropriate advice and education) and comes back for the next session with an improvement, it is extraordinarily difficult to know which elements of the treatment package (if any) were responsible for the change. It could be that all were necessary in that particular combination; it could be that one could have been safely omitted and the equivalent outcome would have been achieved. . When making a clinical decision, practitioners will put together the package that in their opinion is most likely to be effective for that patient. Some patients will not take advice well, others will almost certainly not undertake the exercises that are suggested, and others might have a strong aversion to the idea of electrical stimulation. The effective package is the one that matches the patient's presentation and the treatment context. Some patients might be treated several times a week whereas others can only be seen once every 2 or 3 weeks on a 'check-up' basis. Package tailoring is an essential skill for any therapist. The current stage of research in electrotherapy and many other therapeutic fields is still at the point where the building blocks of these packages are being evaluated. We might know, in absolute terms, the effect of this particular treatment, at this particular dose on a specific problem in a controlled research environment. We might not know what happens when the same therapy is used in a different combination - there are almost too many variables to evaluate at the current time. The research evidence suggests that electrotherapy can be effective as an element of treatment. Further work is needed to evaluate the combinations or treatment packages - that are most effective. Practitioners will have, from their own experience,

Introduction:

current

concepts and clinical

decision

making

in electrotherapy

ideas about combinations that are more or less effective. This is the source of the richness of therapeutic experience and until substantially more work has been completed - both in the laboratory and in clinical practice, usingreductionist, holistic and pragmatic methodologies - the full story is unlikely to emerge. The intention of this publication is to provide a review of the background, evidence and clinical applicability of various modalities in use. The authors of each chapter are writing because they know their subject and, although there might be gaps in the knowledge that deserve to be filled, there is sufficient evidence out there from which clinical decision making can be enhanced and further developments achieved.

incorporated with some forms of shortwave that employ and electromagnetic field? The modalities covered in this text include those that are in common clinical use, and have been divided into sections that reflect the type of energy employed, for example, the thermal energies are grouped as are various forms of electrical stimulation. The grouping of laser, ultrasound and biofeedback does not imply a common energy type or mode of action, but rather their individuality.

MODELS OF ELECTROTHERAPY
All electrotherapy modalities - whether in current use, abandoned from the past or yet to be 'invented' - actually follow a very straightforward model that is presented below. It is sufficiently robust to explain current practice, yet sufficiently flexible to incorporate future developments. It has been refined over the years and will almost certainly be subject to further refinement in the future. In principle, the model identifies that the delivery of energy from a machine or device is the start point of the intervention (Fig. 1.1). The energy entry to the tissues results in a change in one or more physiological events. Some are very specific whereas others are multifaceted. The capacity of the energy to influence physiological events is key to the processes of all electrotherapy modalities and will be reflected throughout this publication. The physiological shift that results from the energy delivery is used in practice to generate what is commonly referred to as a therapeutic effect. This is a fairly classical learning sequence for many therapists. One learns what the energy is, where it goes, what it does when it gets there and

CURRENT CONCEPTS IN ELECTROTHERAPY

, 0 matter which classification one uses, there is no one correct way to divide and categorise the range of electrotherapy modalities available. One could for example use a thermal/non-thermal division, but reading the literature on thermal vs. non-thermal vs. microthermal will soon demonstrate that this is an almost certainly flawed proposition. One could attempt to categorise by type of applied energy: light (e.g. laser, ultraviolet) versus electricalstimulation (e.g. transcutaneous electrical rve stimulation [TENS],interferential) versus the gh-frequency radiations (shortwave, microwave). trasound would have to sit in a category of its m and biofeedback would not belong anywhere that, for the most part, it does not involve the elivery of energy but enables the patient to spond to the behaviour of his or her body. This ~ -ision could also be challenged in that, for ample, the effects of continuous shortwave are ~illli.lar but clinically different from those of pulsed _ ortwave. The fundamental energy might be the same but the mode of delivery makes a substantial .. erence to the treatment outcome. Furthermore, there is an issue with the inclusion ~ new' therapies into the classification. Magnetic erapy is a swiftly developing field although, e would suggest, still in its clinical infancy. uld it have a category of its own or should it be

Theory Deliver energy Physiological effect(s) Therapeutic effect(s)

Figure 1.1 A simple model of electrotherapy.

INTRODUCTION

AND SCIENTIFIC

CONCEPTS

has effects that are harnessed by therapists when what the outcome might be. One has to learn the treating a variety of open wounds and musculomaterial somehow, and this is possibly as good a skeletal tissue problems. Applied at a higher dose, way as any. the same light energy is used by the surgeon as a The clinical application of the .model is best means to ablate or vaporise tissue. The energy' achieved by what appears to be a reversal of might be the same, but the dose is different and this process. Start with the patient and his or her the outcome is easily distinguished. problems, which are identified from the clinical One might argue that this is an extreme examassessment. Once the problems are known, the ple, which in some ways it is, but the point is that treatment priorities can be established and the the effects of the therapy are both modality and rationale for the treatment determined. Knowing dose dependent. There are 'therapeutic windows' what it is that is intended to be achieved generates in electrotherapy (as there are in almost all therathe target for the intervention. Moving one step back through the model, the question then arises: . peutic interventions) and, to achieve the 'best' outcome, it is essential to get as close to this window 'If that is the intended outcome or therapeutic as one possibly can. The theory of these windows effect, which physiological process(es) need to be will be briefly explored in the next section, but stimulated, modified or affected in order for the the principle is introduced here (see the section outcome to be achieved?' Once the physiological 'Electrotherapeutic windows', below) . . changes are established, one further step back This fundamental model of electrotherapy through the model will enable the determination of could be applied to many interventions: drug therthe most appropriate modality that can be used to achieve this effect, based on the best available eviapy, manual therapy, exercise therapy. All involve the use of an intervention to achieve a physiologidence. If, for example, the patient presents with a chronic hamstring muscle tear, with pain, disturbed cal shift or change. It is this change that is the therapeutic tool. The treatment - whether a drug movement patterns and functional difficulty, then and exercise! or the energy from a machine - is what needs to be changed, stimulated or activated to get a clinically beneficial outcome? Once this is just a tool to stimulate the physiological change. Electrotherapy is therefore little different from decided, it is a matter of deciding from the evidence manual therapy or anything else in the treatment which modality, if any of them, is best able to realm. It is a tool that, when applied at the right achieve these results? If there is no electrotherapy modality capable of stimulating this/these physiotime, at the right dose and for the right reason, has logical change(s) in the tissue in question, then the capacity to be beneficial. Applied inappropriately, it is not at all surprising that is has the capacwhat place does electrotherapy have in the management of this particular patient? ity to achieve nothing or in fact to make things The effectsof electrotherapy appear to be modalworse. The skilful practitioner uses the available evidence combined with experienceto make the best ity dependent. The primary decision that has to be possible decision taking into account the psychomade is critical, in that some modalities have a social and holistic components of the problem - it is limited subset of effects that are fundamentally not cl simple reductionist solution. different from another modality, They are not necessarily interchangeable, although they might be. Having identified the modality that is best able to achieve the effects required, the next cliniElECTROTH ERAPEUTIC WIN DOWS cal stage is to make a 'dose' selection. Not only is Windows of opportunity are topical in many areas it critical to apply the right modality, but it needs of medical practice and are not a new phenomenon to be applied at the appropriate' dose' for maximal at all. It has long been recognised that the 'amount' benefit to be achieved. There is a substantial and of a treatment is a critical parameter. This is no less growing body of evidence that the same modality true for electrotherapy than for other intervencan be applied at different doses and the results tions. Literally hundreds of research papers illuswill not be the same. An obvious example might trate that the same modality applied in the same be laser therapy. Applied at a low dose, laser

Introduction:

current

concepts

and clinical

decision

making in electrotherapy

circumstances, but at a different 'dose', will produce a different outcome. The illustrations used in this section are deliberately taken from cell, animal and clinical research studies with various modalities to illustrate the breadth of the principle. Furthermore, the examples used are not intended to criticise the researchers reporting these results. Knowing where the window 'is not' is possibly as important as knowing where it is. Given the research evidence, there appear to be several aspects to this issue. Using a very straightforward model, there is substantial evidence, for example, that there is an amplitude, window or strength window. An energy delivered at a particular amplitude has a beneficial effect, whereas the same energy at a lower amplitude-might have no demonstrable effect. The laser example above is a simple extension of this case - one level will produce a distinct cellular response whereas a higher dose can be considered to be destructive. Karu (1987)demonstrated and reported these principles related to laser energy and the research produced since has served to reinforce the concept (Vinck et a12003). There are many examples of amplitude windows in the electrotherapy-related literature, and in some instances, the researchers have not set out to evaluate window effects but have none the less demonstrated their existence. Papers by Larsen et al (2005)measuring ultrasound parameter manipulation in tendon healing, Aaron et al (1999)investigating electromagnetic field strengths, Goldman et al (1996)considering the effects of electrical stimulation in chronic wound healing, Rubin et al (1989) investigating electromagnetic field strength and osteoporosis and Cramp et al (2002)comparing different forms of TENS and its influence on local blood flow all provide evidence in this field. Along similar lines, frequency windows are also apparent. A modality applied at a specific frequency (pulsing regimen) might have a ineasurable benefit, whereas the same modality applied using a different pulsing profile might not appear to achieve equivalent results. Electrical stimulation frequency windows have been proposed and there is clinical and laboratory evidence to suggest that there are frequencydependent responses in clinical practice. TENS applied at frequency X appears to have a different

outcome to TENS applied at frequency Y in an equivalent patient population. Studies by Han et al (1991),Kararmaz et al (2004)and Sluka et al (2005)are among the many that have demonstrated frequency-dependent effects of TENS. Several authors have appeared to demonstrate that frequency parameters are possibly less critical, especially in clinical practice, and Chapters 16 and 17, on TENS and interferential therapy, include useful discussion on these issues. Frequency windows 'are not confined to TENS treatments and there are examples from other areas, including electromagnetic fields (Blackman et al 1988), ultrasound (Schafer et al 2005) and interferential (Noble et al 2000). A simple therapeutic windows model is illustrated in Figure 1.2, using amplitude and frequency as the critical parameters. The figure shows that the 'ideal' treatment dose would be that combination of modality amplitude and frequency that focuses on the central effective zone. It can be suggested (from the evidence) that if the right amplitude and the right frequency are applied at the same time, then the maximally beneficial effect will be achieved. Unfortunately, there are clearly more ways to get this combination 'wrong' than 'right'. A modality applied at a less than ideal dose will not achieve best results. Again, this does not mean that the modality is ineffective, but more likely, that the ideal window has been missed. The same principle can be .applied across many, if not all areas of therapy. In Figure 1.3, the most effective treatment window (black box, lower central) has clearly been

Frequency

Figure 1.2 Basic windows of opportunity.

INTRODUCTION

AND SCIENTIFIC

CONCEPTS

missed by the delivered treatment (upper left) and hence whatever the effect of the therapy, it will fail to be maximally effective. The situation is complicated by the apparent capacity of the windows to 'move' with the patient's condition. The position of the therapeutic window in the acute scenario appears to be different from the window position for the patient with a chronic version of the same problem. A treatment dose that might be very effective for an acute problem may fail to be beneficial with a chronic presentation. In Figure 1.4, the effective 'acute window' shown in the left-hand picture is in a different position to the most effective 'chronic window' shown in the right-hand picture. Given the rapidly increasing complexity seen in this simple two-parameter model (amplitude and

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Frequency

Figure 1.3 Treatment dose 'missing' the window.

frequency) with two levels of condition (acute and chronic), it is easy to see how difficult clinical reality might be. As the volume of published work continues to increase, new results can be included in the existing framework, and this helps to identify where the windows are (positive research outcomes) and where they are not (negative outcomes). If this methodology is pursued, it is interesting to note how the effective treatments cluster when plotted, adding weight to the therapeutic windows theory. Assuming that there are likely to be more than two variables to the real-world model, some complex further work needs to be invoked. There is almost certainly an energy- or time-based window (e.g. Hill et al 2002)and then another factor based on treatment frequency (number of sessions a week or treatment intervals). Work continues in our own, and other, research units to identify the more and less critical parameters for each modality across a range of clinical presentations. One research style that has proved to be helpful in this context is to test a treatment on non-injured subjects in the laboratory using a variety of doses, and then to take the same protocol out into the clinical environment and repeat the testing procedure with real patients with particular clinical problems. Preliminary results indicate that there are distinct differences between the responses on 'normal' and 'injured' tissues at equivalent doses and further work is essential to maximise our understanding of these behaviours. Research that demonstrates significant effect in a laboratory study might, or might not, transfer directly to

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~ 0.

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Frequency

Frequency

Figure 1.4 Moving acute (A) and chronic (B) windows.

Introduction:

current

concepts

and clinical

decision

making in electrotherapy

the clinical environment. Recent work with pulsed shortwave therapy (AI Mandil & Watson 2006) clearly demonstrated a different magnitude of physiological effect when the same 'treatment' was delivered to asymptomatic subjects in the laboratory and real patients in a clinical setting: the physiological changes were similar, but of a different magnitude.

CLINICAL DECISION MAKING IN ELECTROTHERAPY

When it comes to making a clinical decision with regard to electrotherapy as a component of treatment (and taking into account the preceding sections), it can be seen that the effects of the intervention appear to be both modality and dose dependent (at least to some extent), and thus both elements need to be taken into account. The first decision needs to be with regards to the modality, as this is the primaryconcem; the secondary deciion, although still of importance is that of dosage. This having been said, it is important to remember that the use of electrotherapy in clinical practice is a matter if its integration into the whole treatment programme. Rarely is electrotherapy alone the most beneficial way forward. There are times when this might be the case, but they are the exception rather than the rule. Some patients -'ould gain nothing significant from the addition of a modality into their treatment programme, "hereas others would derive considerable gains. Electrotherapy has, in the past, probably been an o 'erused intervention. Its current incorporation into clinical practice is more e.vidence based and selective, and hence should be more effective. The detailed chapters in this text examine the -idence base for each of the modalities covered and, within that evidence, the areas where the modality has the capacity to be effective and those .here there is insufficient evidence at the present nme. A commonly cited phrase that is important this context relates to the difference between a k of evidence as opposed to an evidence of lack; in ther words, there are many areas of practice, . eluding several areas in electrotherapy, where there is a substantiai lack of evidence - it is simply t there - whereas in other areas there is evidence

that demonstrates a lack of effect. In the former circumstance, the clinician might have to make a clinical decision based on experience and expert opinion in the absence of published research. In the latter circumstances, the clinician who takes account of the available evidence would refrain from adopting that particular clinical approach in favour of another. If it were simply a matter of learning a set of rules or guidelines, the use of electrotherapy in practice might appear to be somewhat simpler but, in reality, there are (at present at least) no rule sets that would govern any possible clinical scenario, and therefore clinical decision making remains an art with a scientificbias, or a science with an integrated art, depending on which philosophy you follow. Whichever one of these it is, the employment of electrotherapy into current clinical practice cannot be reduced to a simple rule set, and possibly it never will. The evidence will continue to close the gaps, although, inevitably, by closing down one gap, another will become apparent, and hence further research will be needed. The individual chapters in this text aim to identifythe key issues about each modality, examine the evidence for their effects and relate this to clinical practice. None of the chapters aims to provide clinical recipes, but will enable practitioners to evaluate the available evidence in order to facilitate their clinical decision making.

CONCLUSION
Incorporation of electrotherapy modalities into clinical intervention programmes can result in significant benefit for the patient. Used unwisely, it is at best an inefficient use of resources and at worst, can easily have effects that are neither wanted nor beneficial. Critical clear thinking, an understanding of the capacity of the various modalities to influence the tissues combined with the joined-up thinking that links this aspect of practice with others such as manual therapy and exercise therapy can result in gains for the patient. Patients who are routinely denied electrotherapy because the clinician does not believe it to be effective would seem, based on the evidence presented in this text, to be denied potential benefit.