Electrophysical modalities (FS-08)

Focused symposium
Saturday 11 May 2019, 16:00-17:30
Room B

Watson T1Laakso L2Hoens A3Ronzio O4Ramalingam K5 
1University of Hertfordshire, Allied Health Professions & Midwifery, Hatfield, United Kingdom, 2Allied Health Mater Research/Mater Health, Mater Research, Brisbane, Australia, 3University of British Columbia, Physical Therapy, Vancouver, Canada, 4Universidad Maimónides, Carrera de Kinesiología y Fisiatría, Buenos Aires, Argentina, 5Divine Word University, Rehabilitation Sciences, Madang, Papua New Guinea

Learning objective 1: To evaluate the scope and quality of the evidence for EPA integration into treatment programmes
Learning objective 2: To identify examples of Electrophysical interventions making a significant contribution to treatment outcomes as an integral component of PT
Learning objective 3: To be able to critically interpret recommendations in EPA related systematic reviews and guidance in the light of the evidence
Description: This symposium aims to tackle two issues in the context of EPA use in contemporary PT practice: (a) the recommendation from some recent systematic reviews & clinical guidelines that EPA's lack robust evidence and should not be employed in particular clinical scenarios (b) that on the basis of economics, EPA use is only attainable in first world (rich) countries. We aim to explore both issues in this integrated, evidence based programme.
Several systematic reviews identify insufficient evidence to support the use of EPA's in clinical practice whilst others have been supportive for the same interventions in the same patient group (e.g. Bayat et al 2018 (support) Schandelmaier et al 2017 (no support) for LIPUS in fracture healing). Similarly, some guidelines have advocated that EPA's should not be employed for a clinical presentation whilst others are supportive (e.g. UK National Clinical Guidance Osteoarthritis 2014 (supports TENS); OARSI 2014 Guideline (no TENS support). These reviews and guidance documents ostensibly evaluate the same evidence. It is the presenters' contention that the critical analysis methodology employed to evaluate the evidence can have a highly significant influence on the conclusions reached. Studies are sometimes considered equally though in reality they may be very different (e.g. Hurlow et al, 2012 TENS in cancer pain). Some appear to disregard treatment parameters with highly variable doses being treated equally (e.g. Page et al 2014), though acknowledged by others (e.g. Beckwee et al 2014).
Whilst systematic reviews are regarded as being at the pinnacle of the evidence hierarchy, considering the abstract in isolation may lead the reader to an over-simplistic conclusion and the patient may be denied an effective intervention. The use of EPA's as an integrated component of healthcare provision would be consistent with the evidence. Used in isolation, they are unlikely to constitute best practice.
Using 3 EPA´s, some of the subtleties pertaining to these issues will be explored (TENS for Osteoarthritis pain, NMES for muscle function and Shockwave in Tendinopathy).
EPA devices have a cost implication. It is suggested that these applications are biased towards use in the high income countries. Both TENS and NMES devices are low cost and are almost universally available. Their evidenced employment by therapy services in low income countries is attainable and their judicious use can enhance patient care without placing an undue burden on healthcare services nor on the patient/their family.
EPA's are not 'better' than other modes of therapeutic intervention. Their integration into care/management programmes is evidenced as adding value from the patient care perspective. There is sufficient robust evidence to enable the critical therapist to make clinical decisions based on this resource. Consulting review abstracts in isolation may not be sufficient to enable best evidenced decisions.
Topic 1: An example (Australia) under the auspices of Choosing Wisely initiative in which it is proposed “Don't use electrotherapy such as ultrasound, laser or TENS …. for an older person with pain due to knee or hip osteoarthritis”. We will examine the proposed draft recommendation highlighting their strengths/weaknesses as an exemplar of the movement towards abandoning EPA in physiotherapy.
Topic 2: A review of the compelling evidence supporting NMES for improving outcomes for patients with musculoskeletal, cardiorespiratory neurological conditions and critical illnesses. Rigorous literature provides direction for optimal treatment parameters.
Topic 3: Electrophysical Modalities for Tendinopathy - with emphasis on Shockwave as a 'new' modality with a strong evidence base - discriminating between the hype and the evidence.
Topic 4: Studies in numerous countries show that physiotherapists use at least one EPA in patient management on a regular basis. Developed nations use EPA's due to high availability and affordability. The use of EPA´s in developing countries is less well known or documented. It is found that physiotherapists also use EPA´s in their management. This session explores issues of therapist knowledge, skills and funding.
Implications / Conclusions: The evidence base to support the use of EPA's in contemporary practice is strong and identifies optimal treatment parameters. Recent reviews sometimes miss the important 'dose effect' relationship and readers who only consider the review abstract may not pick up on this important point. Expedient use of EPA´s can be cost effective in low income healthcare systems whilst retaining an evidence based approach 
Key-words: 1. Electrophysical 2. Electrotherapy 3. Evidence Based
Funding acknowledgements: This work is not funded
Relevance to physical therapy globally: Electrophysical agents (EPAs) have been historically integral to physiotherapy practice and included as a core component of practice within many WCPT countries. Recent systematic reviews and patient management guidelines have questioned their effectiveness. Methodological issues have coloured the literature interpretation, and thus jeopardized EPA evidence-informed utilization. Application of EPAs, like all interventions, should be predicated on critical analysis to determine the effective ‘dose’ rather than excluding their use, thereby denying patients access to optimal care.
Target audience: Physical Therapists involved in Education, Research, Practice, Policy and Strategy and those with an interest in the evidence based scope of contemporary practice.