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BOOK REVIEWS
Electrotherapy: evidence-based
practice (12th edition)
Edited by Tim Watson. Published by Churchill Livingstone,
Edinburgh, 2008, £41.99. ISBN 978-0-443-10179-3
Edward B Clayton’s Electrotherapy and acti-
notherapy was first published by Baillière,
Tindall and Cox in 1949, an amalgamation of
Electrotherapy with the direct and low frequency
currents (1944) and Actinotherapy and diathermy
for the student (1939). It still bore the title
Clayton’s electrotherapy in its 10th edition,
edited by Sheila Kitchen and Sarah Bazin
(Saunders, 1996). In the meantime, though,
the fashionable catchphrases ‘‘evidence-based’’
and ‘‘evidence-based medicine’’ had been
introduced (in 1990 and 1996, respectively),
and the book’s next incarnation was
revamped to its current title, with Kitchen
as sole editor. The current edition has again
been edited single-handedly, by Tim Watson,
Professor of Physiotherapy at the University
of Hertfordshire, and was published in 2008
by Elsevier under the Churchill Livingstone
imprint. Associated material can be accessed
(and downloaded) by purchasers at http://
evolve.elsevier.com/productPages/s_1451.html
(accessed 12 May 2009). Further useful infor-
mation is available at Watson’s own website,
Electrotherapy on the web, at http://www.
electrotherapy.org/ (accessed 12 May 2009).
Watson’s emphasis throughout, as shown
in his own thorough and well constructed
contributions to this volume, is on evidence-
based practice as an integration of ‘‘indivi-
dual clinical expertise with the best available
external clinical evidence from systematic
research’’ (p vii). Not all his co-contributors
have been so careful, however, and there is
still room for improvement if the book’s
contents are to conform consistently with
its title.
The book contains 21 chapters in five
section: (1) Introduction and scientific con-
cepts (8 chapters); (2) Thermal and non-
thermal modalities (4 chapters); (3)
Electrical stimulation modalities (7 chap-
ters); (4) Ultrasound imaging (1 chapter);
and (5) Contraindications, dangers and
precautions (1 chapter, ‘‘Guidance for the
clinical use of electrophysical agents’’, pub-
lished in 2006 by the Chartered Society of
Acupunct Med September 2009 Vol 27 No 3
Physiotherapists). Comparison with my
battered and much read copy of the 10th
edition (I have not seen the 11th) gives some
surprising results:
In Section 1, for example, many of the
chapters have been little changed, apart
from excluding some historical accounts of
the development of particular modalities, re-
ordering bits and pieces within chapters or
sections, updating references and illustra-
tions (the latter mostly through a judicious
use of colour rather than anything else) and
in some cases altering author attributions.
Here only one chapter (ch. 6, ‘‘Physiology of
pain’’, by Leslie Wood) is significantly
different from the same contributor’s earlier
version (referencing in both is disappoint-
ing). Thus it would seem that the scientific
underpinnings of electrotherapy have not
altered that much within the last 12 years or
so, despite a clear acceleration of change in
many other areas of scientific research.
In Section 2, on the other hand, apart
from the complete omission of two chapters
on the currently unfashionable modalities of
microwave diathermy and ultraviolet, there
are also considerable changes and improve-
ments in Sheila Kitchen’s chapter on ‘‘Heat
and cold application’’ (which already, back
in 1996, included a brief disquisition on
‘‘evidence for clinical efficacy’’), a much
improved presentation on ‘‘Pulsed and con-
tinuous shortwave therapy’’ by Maryam Al-
Mandeel and Tim Watson, and a very
informative chapter on ‘‘Therapeutic ultra-
sound’’ by Watson and Stephen Young. These
last two chapters contain a wealth of new
evidence for efficacy, whereas ‘‘Low-intensity
laser therapy’’ by David Baxter, the other
chapter in this section, is relatively little
changed, apart from more precise indications
on the power and energy per point that
should be used for best results. Curiously,
Baxter no longer includes references to
Semion Rochkind’s research on tissue repair.
Section 3, in many ways of most relevance
to acupuncturists, starts with a completely
rewritten ‘‘Introduction to low-frequency
currents’’ by Deirdre Walsh, based solely on
up-to-date references, followed by a rather
technical chapter on ‘‘Neuromuscular elec-
trical stimulation’’ by Mary Cramp and
Oona Scott (with much new material, but
only a page on clinical studies—on Bell’s
palsy, rheumatoid arthritis, chronic heart
failure and Duchenne muscular dystrophy).
This is followed by a more clinically oriented
‘‘how-to’’ chapter on ‘‘Neuromuscular and
muscular electrical stimulation’’ by Suzanne
McDonough, with a good evidence base
(although it only consists of a relatively
small number of studies). After this comes
the longest and most ambitious chapter in
the book, Mark Johnson’s contribution on
TENS. His approach is comprehensive and
critical (sometimes perhaps overly judgmen-
tal), based on a wealth of recent research
studies, both experimental and clinical. He
even briefly mentions various ‘‘TENS-like
Media reviews
devices’’, such as Alex Macdonald’s transcu-
taneous spinal electroanalgesia and hand-
held piezoelectrical stimulators such as the
PainGone device.
While acknowledging that some opinion
leaders define acupuncture-like TENS (AL-
TENS, or low frequency, high amplitude
TENS), without reference to muscle contrac-
tions, and that many research reports also
do not mention motor effects, Johnson
characterises it as ‘‘the induction of forceful
but non-painful phasic muscle contractions
at myotomes related to the origin of the
pain’’ (p262). He thus feels justified in
explaining—somewhat dogmatically—that
AL-TENS operates by selective activation
of Aa (Group I) efferents (mistyped as Ad),
resulting in activity in ergo-receptors and
Group III (Ad) afferents, as opposed to
‘‘intense TENS’’ (high frequency, high inten-
sity TENS) that activates Ad fibres directly.
In both cases, Ad activation leads to extra-
segmental analgesia, and the concomitant
Ab afferent activation to segmental analge-
sia. As he says, ‘‘there is a lack of good-
quality and systematic experimental work
that has directly compared the clinical
effectiveness and analgesic profiles of these
types of TENS’’ (p263)—perhaps because, in
essence, there is not a huge difference
between them in terms of final common
neurological pathways.
Chapter 17, by Shea Palmer and Denis
Martin, is a complete rewrite of the latter’s
earlier version of the chapter on ‘‘Interferential
current’’ (IFC), taking theoretical, laboratory
and clinical evidence into account. As its
authors conclude, ‘‘it is still not clear whether
IFC is, indeed, efficacious or which aspects of
clinical conditions are affected. There is also
the key question of whether IFC is any more
effective than other, more accessible, forms of
electrical stimulation such as TENS’’ (p311).
As in so many forms of physiotherapy, the
attempt to squeeze positive results from
research is laborious and still all too often
quite unproductive.
The next chapter, ‘‘Functional electrical
stimulation’’ (by David Ewins and Sally
Durham), covering the application of elec-
trical impulses to the body to restore lost or
impaired functions, is less relevant to those
practising acupuncture than Watson’s final
chapter in this section (‘‘Electrical stimula-
tion for enhanced wound healing’’), and
more an account of methods used than of
the evidence for their usefulness. Watson’s
chapter, on the other hand, like his other
contributions to this volume, is very much
evidence-based. Yet, as he comments,
despite the drive towards evidence-based
practice, and ‘‘although there have been
many publications in this research area,
especially in more recent years, there appears
to be a reluctance to use the therapy in the
clinical environment’’ (p329).
The single chapter in Section 4
(‘‘Musculoskeletal ultrasound imaging’’), by
John Leddy, is disappointingly not particularly
135
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Media reviews
evidence-based, and does not fit easily with
the rest of the book. In part this is because
‘‘the use of ultrasound imaging in physiother-
apy is still in its infancy’’ (p349), in part
because this chapter was not included in
previous editions of the book, in part because
it is about a method of evaluating and
monitoring change rather than about actual
treatment.
The final chapter, which covers much more
than the title of Section 5 would suggest, will
be essential reading for all those practitioners
whose patients receive electrotherapy,
whether from themselves or elsewhere.
In conclusion, this book is both compre-
hensive and an extremely useful summary of
current knowledge in electrotherapy that
will be of use to all clinicians whose patients
have undergone (or are currently receiving)
such treatment or who wish to clarify
whether referral for electrotherapy might
be appropriate. It will be of particular
interest to acupuncture practitioners, whose
interventions often overlap with those of
physical therapy, both theoretically and in
effect. For those who use electrotherapeutic
acupoint-based modalities such as electro-
acupuncture, TEAS (transcutaneous electri-
cal acupoint stimulation)/TENS, laser
acupuncture or far infrared (‘‘TDP’’) lamps,
this will be a key book, offering a thoroughly
grounded Western context for their treat-
ment as well as an Oriental one.
Two limitations of the book are (1) that
the quality of evidence used is, for the most
part, inadequately analysed (except by
Johnson in his chapter on TENS), and (2)
that the studies cited are virtually all from
English-language publications, despite the
fact that research in some areas is mostly not
available in English. To remedy these defects
will take some hard work, which could
profitably be taken on board for the next
edition. (Hopefully some of the errors in
cross-referencing chapters and boxes will
also be corrected, along with several
instances of ‘‘mA’’ for ‘‘mA’’ in Watson’s
chapter on wound healing.)
It is salutary that the conclusions on
TENS and IFC quoted above are echoed
repeatedly throughout this volume. The
authors of the chapter on shortwave ther-
apy, for example, writing about differences
between pulsed shortwave and pulsed elec-
tromagnetic fields, conclude that
‘‘Demonstration of the similarity or differ-
ence between these modes is an important
issue in the next generation of research in
this field’’ (p156). The chapter on neuro-
muscular electrical stimulation concludes
that ‘‘There is still uncertainty over opti-
mum patterns of electrical stimulation in
different physiological circumstances’’
(p226). On wound healing, Watson writes
of direct current (DC), pulsed DC and
alternating current (AC) modes, that
‘‘Differentiation between these modes of
intervention is currently problematic’’,
although all appear to ‘‘have a clinically
significant effect’’ (p344). As McDonough
136
concludes her chapter, ‘‘as with many other
electrophysiological agents, there are still
major gaps in our knowledge about the
effects of electrical stimulation, the most
effective parameters for its use and its long-
term efficacy’’ (p209). A similar concern
with parameters and what Tim Watson
terms ‘‘treatment dose’’ in the context of
the whole ‘‘package of care’’ is, of course,
evident in the literature of acupuncture and
its many variants as well (see Adrian White’s
editorial in the June 2008 issue of
Acupuncture in Medicine). Knowledge is never
complete, much research remains to be
done, and this book provides a useful over-
view of a field that is developing in many
ways parallel to our own. Those working in
both fields will learn much from each other
in the future.
David Mayor
Correspondence to: Mr David Mayor, 86 Handside Lane,
Welwyn Garden City AL8 6SJ, UK; davidmayor@
welwynacupuncture.co.uk
Competing interests: Tim Watson is academic supervisor
for the reviewer’s project to update the electroacupuncture
clinical studies database now available at http://www.
electroacupunctureknowledge.com/.
Provenance and peer review: Not commissioned; not
externally peer reviewed.
Schizophrenia, sleep, and
acupuncture
Edited by Peggy Bosch, Maurits van den Noort. 348 pages,
Hogrefe & Huber Publishers, 2008, Hardcover, £31.00. ISBN:
978-0-88937-355-8.
Schizophrenia is a complicated mental ill-
ness, which I feel is best left to the
psychiatrists. Patients hate the side effects
of medication. I don’t treat patients with
schizophrenia with acupuncture: would this
book change my mind?
A large collection of international experts
have been drawn together to give their views
on the diagnosis and medical treatment of
the condition with a dedicated chapter on
neuroimaging, which concludes only that
schizophrenia is associated with frontal and
temporal brain dysfunction. One quarter of
the book is taken up with scientific discus-
sion of the disease, which is covered well,
but you have to ask yourself whether you
would prefer to read this in a conventional
medical textbook rather than a book on
acupuncture.
The next two chapters look at sleep
disturbance because ‘‘insomnia is associated
with almost all psychiatric disorders’’ and a
poor quality of life. An increase in total sleep
with anti-psychotic medication, with an
increase in REM (rapid eye movement) sleep
latency, was associated with improvement
of the schizophrenic state. Reduction in
activity of the prefrontal cortex could
‘‘explain the hallucinatory, fantasy-rich nat-
ure of both dreams and the positive symp-
toms of schizophrenia’’. There is evidence to
suggest that melatonin affects dopamine
systems and improves the quality of REM
sleep and schizophrenia, and that acupunc-
ture treatment can increase melatonin levels.
Next is the introduction to Traditional
Chinese Medicine (TCM), its history, philo-
sophy, the inevitable ‘‘medical acupuncture
is rubbish’’ and that Western medical
practitioners do not understand the con-
cepts of TCM and holism. Then the usual
comments about how acupuncture cannot
lend itself to strict research protocols and ‘‘it
is an impossible task to condense several
thousands of years of accumulated knowl-
edge and wisdom on the topic into a single
chapter’’. In an attempt to resolve TCM’s
antipathy to Western medicine, neuroima-
ging is brought out again in a chapter
authored by the editors of the book which
lists all 33 imaging studies between 1998 and
2007. The research does not tell us much
apart from the limbic system may be fired
up by acupuncture. This chapter was
delightfully TCM free.
We know that the neurotransmitter
dopamine is involved in the pathophysiol-
ogy of schizophrenia and that the positive
symptoms may be attributable to an excess
of dopaminergic transmission within the
central nervous system. Is it possible to
control the level of dopamine by acupunc-
ture? Eleven acupuncture on schizophrenia
studies were analysed and five showed a
positive response to one or more aspects of
the illness. Extra Point 1 (Yintang) and GV20
were mostly used, and HT7, GV20, PC6,
SP6, BL62 were used in 18 trials for insomnia
with good results (but small sample num-
bers). No study on sleep disorders caused by
schizophrenia was identified. Experiments
on animals did not find acupuncture
research on the levels of dopamine related
to schizophrenia. Having found very little
research to support TCM principles and in
particular the Yin and Yang Heel Vessels, a
salient chapter considers: Can acupuncture
be used in the treatment of insomnia and
schizophrenia? Well, sort of.
Next comes a very heavy chapter on TCM
and the treatment of psychological disorders
but I’m afraid that the effect of invisible
phlegm, congealed blood, the concept of
syndrome differentiation, and the relation-
ship between body and mind, simply alienate
Acupunct Med September 2009 Vol 27 No 3
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Electrotherapy: evidence-based practice

(12th edition)
David Mayor

Acupunct Med 2009 27: 135-136

doi: 10.1136/aim.2009.000877

Updated information and services can be found at:

http://aim.bmj.com/content/27/3/135

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