“Why would you still use ultrasound when the research shows it doesn’t work?”

I had this question emailed to me recently from a well-intentioned and curious newer graduate. He had recently seen an old client of mine who said I had used this modality with them and he was interested, considering my years of experience and advanced orthopaedic training, why I would do this.

I wanted to respond thoughtfully and decided this blog post might be an effective way to reply to an honest question…as well as express some of my concerns of my own about some tendencies that I see developing in our community.

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Physiotherapy has evolved over the past 20 years, as any science-based profession should. Our practices, as critical thinkers, should always be based on what treatment choices are most effective and evidence-based currently, but also take into consideration the bigger picture of our client’s care and goals.

For any non-physiotherapists reading this, modalities (such as ultrasound and interferential current) serve primarily as pain-relief and to assist in settling acute symptoms. Since the shift towards evidence-based practice, there has been an increasing tendency of some groups to look down the use of modalities whatsoever as “bad practice.”

Since I no longer accept new clients I rarely see acute injuries, but I do on occasion see my long-standing clients for acute injuries. After 18 years of practice, my assessments are shorter and more to the point – one of the values of experience is that, usually, it allows you to identify a problem more quickly and with less assessment than a newer practitioner, though we also need to be aware that we are more prone to jumping to a diagnosis based on our experience.

And yes, I still use ultrasound on occasion as well as a couple of other modalities for pain-relief, and will continue to use them, if available and appropriate.

Here are my top three reasons why:

1. My client’s goals matter and sometimes those include pain-relief.

Many of my clients are coming in to see me with the goal to walk out of there in less pain. Yes, they are looking for the problem to be “fixed” but being in less pain in the short-term would also make their life a whole lot easier right now. This might allow them to sleep better that night, spend time with friends without being distracted by the pain or maybe breastfeed their baby more comfortably that day.

That is what is important to them, so it is important to me.

And for me, that is the most essential element of client-centered care.

2. Sometimes my physio tools create more discomfort and pain.

Many of the techniques and tools that I have in my toolbox at this stage in my career, though they can be very effective in remedying certain problems quickly, do involve the potential for a temporary increase in pain following the treatment, such as joint manipulation and dry needling/IMS.

I can treat clients more quickly with these tools than if I didn’t have them, so I have the luxury of sometimes finding myself with a spare few minutes at the end of the session to devote to pain-relief. This definitely wasn’t the case for many years of my practice when I doubted my assessments and skills more and needed the full treatment time to devote to figuring out what was wrong, gaining the trust of a new client and providing them with effective and quality care. In those instances, I would have rarely had time to devote to ultrasound.

3. A few minutes of ultrasound can also often prevent me from falling into the tendency to over treat, something I did a lot in my earlier years of practice.

Some might argue that that time would be better spent adding more exercises to their regime than the 1-2 I tend to give or going over more self-care. Sometimes I do this, but often giving a client a few minutes of relaxation at the end of their session and doing the educational piece I always try to include during that time is a nice way to wrap up the session and they leave happier and more comfortable.

Don’t get me wrong – I’m definitely not a proponent of regular ultrasound use and strongly feel it should neither be an essential nor go-to treatment in any Physiotherapist’s toolbox. I have had practitioners at our clinic in the past whom I felt used it too much and I made a point of sitting down with them to find out why this was happening and how we could change it.

Additionally, my advice to clients has always been if you see a Physiotherapist and all they do is ultrasound, don’t go back unless they have explained very clearly and reasonably WHY this is all they did.

But as an adjunct to treatment, I disagree that it is worthless.

I also understand why many of the newer genre of Physiotherapists opening smaller clinics have chosen not to purchase modalities and advertise themselves as “no-machine clinics”. Ultrasound machines are very expensive and I agree that you absolutely can do without them in quality care, especially if you are focussed on a niche area such as pelvic health, Clinical Pilates, etc. The small second clinic I am currently in the process of opening won’t have an ultrasound machine – for these exact reasons. But there are going to be some days I think I might miss it.

Lastly, I was quite apprehensive to write this post. Sadly, there seems to be a growing tendency in our Physiotherapy community for some groups to openly criticize other members of our community and their practices. I’m not sure where this need comes from. I’m all for open conversations, honest and curious questions, and healthy growth as a community, but I honestly find the need to put others down unprofessional.

I believe there are no bad Physiotherapists, just poor clinical reasoning…and sometimes some poor behaviour in respecting your fellow professionals.

My hope is that if this past pandemic year has taught us anything, it has shown us how much community matters and that we all need to be a little gentler and kinder to each other and know that we are all doing the best we can – in every area of our life.

I’m open to kind, honest and constructive comments, feedback or discussion and can be reached at info@alaia.ca

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Katrina Sovio, Physiotherapist & Clinic Director