335
Electrophysical Agents:
lmplications of their Avai labiIity and
Use in Undergraduate Clinical Placements
Valma J Robertson
Diana Spurritt
Key Words
Electrophysicalagents, electrotherapy, ultrasound, interferential,
shortwave diathermy.
Summary
Aim
This study investigated the availability and use of electrophysical
agents (EPAs) in the clinical placements used by all four years of
undergraduate students from two universities with a combined
annual intake of approximately 180 students.
Method
The 206 facilities surveyed were asked to complete and return a
questionnaire asking for details of the EPAs available, their use,
and reasons for use.
Results
Over half the 160 responding facilities (78% return rate) used
EPAs in at least 50% of all treatments. Ultrasound, hot packs,
TENS and interferentialwere most commonly available and used.
Shortwave was relatively commonly available but few facilities
used it daily.
Discussion
The frequent use of modalities unsubstantiated by independent
clinical research raises important questions for the profession.
In particular, if the modalities have the effects claimed, why is
there so little independent evidence of clinical effectiveness;
and should educators continue to allocate time and resources to
teaching about EPAs not demonstrated as effective? Two
approaches for addressing this dilemma are discussed.
Introduction
Electrophysical agents (EPAs) have been used by
physiotherapists since early times. The thera-
peutic effectiveness of some was questioned
decades ago in a major report (Tunbridge, 1972)
and, more recently, in studies of individual modal-
ities (eg Gam and Johannsen, 1995; van der
Heijden et al, 1997) and in a general overview of
developments in electrotherapy (Ide, 1990).
EPAs are apparently used frequently. Our know-
ledge of which EPAs are used, how frequently,
why, and for what, is limited. This information
has implications for reviewing the role of research
in practice, and for planning and implementing
undergraduate and continuing education
programmes. This study will investigate the
EPAs used in the Australian facilities in which
Victorian undergraduate physiotherapy stud-
ents have clinical placements. Specifically,
this study will investigate the availability of
~~~~~
different modalities, their frequency of use, and
the reasons given for selecting them.
Changing EPAs
The term ‘EPA’ implies a number of different
physical agents. New methods for applying phys-
ical agents are continually being developed.
Chemical cold packs provide a n alternative to
crushed ice packs. Portable and programmable
stimulators have replaced some clinical stimula-
tors. Miniaturised components have increased
the portability of some equipment and techno-
logical changes mean a n applicator can output
ultrasound of different frequencies.
Some changes are a consequence of research. For
example, a n increased understanding of pain
mechanisms in the 1960s coincided with the
development of small battery-powered stimula-
tors (Walsh, 1997). Since then a range of means
of electrically stimulating afferent fibres for pain
control have been developed. Some changes are
not research based. The development of 45 kHz
ultrasound equipment is not supported by the
known physical properties of ultrasound, nor
yet by existing clinical or laboratory studies
(Robertson and Ward, 19971, but it is used by
physiotherapists. Similar examples exist with
other physical agents. Many current practices
using lasers are unsubstantiated (Baxter, 1994,
page 2381, as are those using magnetic field
therapy for pain; yet these agents are used and
new machines are regularly released.
EPAs and Education
For clinicians, ongoing changes in EPAs require
them to constantly update their knowledge of
relevant research and of technique and machine
options. This has implications for undergraduate
physiotherapy teaching.
Entry level physiotherapy education is a heavy
user of clinical placements. In clinical placements,
students learn how to assess and treat patients,
applying the theory and practical skills learnt in
the university context. This assumes a certain
level of continuity in clinical skills and knowledge
base between the university and clinical facilities.
For this reason, university-based staff need to
be aware of the skills and equipment to which
students will have access during their clinical
placements.
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Physiotherapy,July 1998, vol84, no 7
336
Use of EPAs
Existing surveys of EPA usage tend t o have a
narrow focus. Either they focus on one o r two
types of modalities such as electrical stimulation
and ultrasound (Robinson and Snyder-Mackler,
1988), or ultrasound (ter Haar et at, 1988), or they
focus on a type of service provider such as private
practices in Brisbane, Australia (Lindsay et al,
1990), and in Alberta, Canada (Lindsay et al,
1995). Another surveyed the senior physio-
therapists in the out-patient departments of
District hospitals in the NHS in England (Pope
et al, 1995). A similarly narrow extension of
our knowledge can be garnered from studies
on related topics, such as a survey of treatments
used in private practices in Victoria, Australia
(Dennis, 1987).
Specific Modalities
The most consistent finding in previous studies
concerns ultrasound. Ultrasound is the modality
apparently most consistently available to, and
used by, physiotherapists. The availability ranges
from availability in 100% of surveyed practices
and used at least daily by 93.7% in Brisbane
(Lindsay et al, 1990), t o availability in 98.5% of
practices and used at least daily by 93.7% of
respondents in Alberta (Lindsay et al, 1995). Both
studies surveyed private practices, anecdotally
high users. Extrapolations from a study of phys-
iotherapists in the north-eastern area of the
United States suggest 100% availability in the
responding facilities, and a usage rate of 64%
t o 79% (Robinson and Snyder-Mackler, 1988).
Similarly, extrapolations from the data provided
of the NHS survey in England indicate a near
100%availability to the 213 respondents (from 116
facilities) who reported a n at least daily usage
rate of 88%.
Some idea of the extent of use across all treat-
ments is provided by a survey covering a
one-week period in 1985 in the United Kingdom.
In that week, ultrasound was used in 20% of the
94,500 treatments carried out in 204 NHS facili-
ties surveyed, and in 54% of the 5,290 treatments
in the private practices (ter Haar e t aE, 1988).
These findings suggest differences between types
of practices and possibly changes over time.
Other findings suggest considerable differences
in practices between countries. The use of TENS
appears t o vary considerably: daily by 19.4% of
respondents in Brisbane, Australia (Lindsay et al,
1990),27%in England (Pope et al, 1995),62.4%in
Alberta, Canada (Lindsay et al, 1995), and over
67% in north-eastern United States (Robinson and
Snyder-Mackler, 1988). Interferential therapy is
apparently used frequently in Brisbane (76.4%
Physiotherapy, July 1998, vol 84, no 7
of respondents) and not quite so often in Alberta
(56.2% of respondents) (Lindsay et al, 1995) or in
the NHS in England where it was used by 53%
(with suction) and 63% (with electrodes) (Pope et
al, 1995). In north-eastern United States, 89% of
surveyed facilities did not have access to inter-
ferential, and only 3%of respondents used it more
than six times per week (Robinson and Snyder-
Mackler, 1988). These findings indicate con-
siderable national differences in the preferred
methods of applying electrical stimulation for
pain control. They also raise important questions
about the quality and strength of the research on
the parameters of electrical stimulation that can
lead to such differences.
Other differences are apparent in the rates of use
made of laser (lower in Brisbane than in England,
and yet higher in Alberta) and magnetic field
therapy and microwave (higher in Brisbane than
in England or Alberta). Modalities which in
general appear to be used relatively infrequently
include biofeedback, diadynamic currents, infra-
red radiation, and ultraviolet therapy (Lindsay
et al, 1990,1995; Pope et al, 1995).
Relevance of Different EPA Usage Patterns
Why clinicians use a particular EPA is not well
understood. The reasons are possibly not uniform
and may be based on factors other than scientific
evidence. Whatever the reasons, research
suggests that EPAs are used for a large part of
treatment time in at least some physiotherapy
practices. This is in spite of previously expressed
concerns about their reliability, safety, and effec-
tiveness (Ide, 1990). A survey of private practices
(Dennis, 1987), reported that EPAs were used for
up to 61% of clinical treatment time. That study
did not investigate what was used, nor how
representative these findings were of levels
of EPA use in other types of clinical facilities.
Together with the already discussed findings,
they do suggest that physiotherapists use EPAs
often.
Physiotherapy students are expected to be
familiar with a range of EPAs as a result of their
undergraduate coursework. Questions of precisely
which modalities, and how much time should be
devoted t o learning them, plague curriculum
developers. One source of information is text-
books. The current version of a textbook (Low and
Reed, 1994) used in both Victorian undergraduate
programmes devotes 30 pages (148-178) to ultra-
sound, 39 (239-278) t o shortwave diathermy, 41
(330-371)to ultraviolet radiation and 133 (1-133)
t o electrical stimulation. The number of pages
devoted t o different topics in a textbook could
possibly provide a very rough guide to the impor-
tance of a topic. But this ignores differences in the

relative complexity of topics and assumes that the
books drive, o r at least rapidly reflect, the most
current practices and research. Another option is
t o monitor regularly and directly what clinicians
have available and use. For those modalities
which have little research-based support, an
accurate knowledge of their current clinical
uses could provide additional information for
making decisions about curriculum content
and emphases.
The obvious method for ascertaining the current
availability and use of EPAs is to survey an appro-
priate sample of clinical facilities. A limitation of
this method is defining the sample and obtaining
a n adequate return. Existing surveys have a
return rate of from 41% of 208 questionnaires
(Lindsay et al, 1990, 1995), to 45% of 490
(Robinson and Snyder-Mackler, 19881, to 70% of
105 (Lindsay et al, 1990, 1995), and t o 83.5% of
139 (Pope et al, 1995). No return rate was
provided in one survey (ter Haar et al, 1988). The
findings of studies with a less than 60% return
rate must be viewed with considerable caution,
especially in categories which attracted few
answers. Similarly, the findings of a study (Pope
et al, 1995) which included multiple, unspecified
recipients from some facilities must be used
with caution, given the extent of biasing of
the data that this may have introduced.
This study will use a questionnaire survey aimed
at identifying the EPAs to which students will
have access in their undergraduate placements.
This study will also investigate the reasons phys-
iotherapists give for selecting particular EPAs, for
a specified clinical indication. The findings are
expected to provide a rational basis for aligning
undergraduate course content with current clin-
ical practices and a baseline for monitoring
changes in the patterns of use of EPAs in future
years.
Method
Following approval from the university ethics
committee, a questionnaire was administered by
mail to 206 clinical facilities within Australia.
These facilities provided all Australian-based clin-
ical placements used by the approximately 180
undergraduate students in each of the four years
of the two courses run by Victorian universities in
1993. These placements covered a broad range of
physiotherapy services: private practices, commu-
nity health centres, general hospitals, and
specialist facilities including obstetric, paediatric
and geriatric centres. The placements were in
city, suburban and country locations.
The questionnaire comprised ten questions, some
open and some closed. It was piloted early in 1993,
337
in six facilities of different types and sizes.
Following feedback, the questionnaire was
modified and the final version was sent to the
chief physiotherapist in each placement in Sept-
ember 1993 t o be distributed to and answered
by appropriate staff. Follow-up telephone calls
resulted in a final return of 160 completed
questionnaires by early 1994.
The questions asked for details of the following:
the types of modalities available within each
facility and details of their frequency of use. It
also asked which modalities were most frequently
selected to achieve specific effects and the thera-
pists’ reasons for selecting those modalities. Other
questions asked why not all available modalities
were used, and which modalities not currently
available within their facility at that time they
would like to have available, and why. The ques-
tionnaire also asked about the total number of
physiotherapy treatments conducted in each
facility and the percentage which included the use
of an EPA. The final question asked about the
distribution across the different categories of
problems, such as orthopaedic, neurological,
cardiothoracic and geriatric, in the total physio-
therapy case-load of each facility.
Data Analysis
Data were analysed using Statview 4.5 (Abacus
Concepts, Inc). The data from the question on the
distribution of use across treatment categories
were not analysed. The relevant data are not
included in physiotherapy records and this
question was answered infrequently and too
poorly to permit a meaningful analysis.
Results
Questionnaires were returned by 160 facilities, a
return rate of 78%.Of these, 51% were suburban,
28% city, and 21% country settings. They included
51 general hospitals, 36 private practices, 20
community health facilities, 19 geriatric facilities,
seven paediatric facilities, seven general rehabil-
itation centres and 20 ‘other’units which included
obstetric facilities, special resource centres and
hydrotherapy units.
Use of EPAs
Figure 1(overleaf) indicates the extent of use of
EPAs in student clinical placements. A slight
majority (75 of the 149 respondents to this ques-
tion), estimated that they were using EPAs in over
50% of all treatments. Further examination
showed little correlation with type of facility. The
four clinics which reported using EPAs in less
Physiotherapy, July 1998, vol84, no 7
 338
Other private facilities
Other public facilities 0 0 mm
Private practices 0 0
Public paediatric facilities
Private paediatric facilities
Public geriatric rehabilitation units 0 0
Private general geriatric units -
Public general geriatric units - 0 0
Private general rehabilitation centres - n o
Public general rehabilitation centres - 0 0
Public community health centres -
Private general hospitals -
Public general hospitals - 000
I I
than 10% of treatments were predominantly
either paediatric or geriatric facilities. But for the
remainder, the type of facility was clearly not a
major determinant (rz= 0.016). Use of EPAs in
public general hospitals ranged from in less than
10% of treatments t o over 90%. The community
health centres used EPAs in 25% to 90% of treat-
ments, and private practices in 0 to 100%.
Patterns of using EPAs did not vary with the
geographical location of a facility. The percentage
of treatments including EPAs in each location
category - city, suburban and country - ranged
from less than 10% t o over 90%. The consequent
correlation between use and location was
extremely low (r2= 0.002).
Modality Availability and Usage
Available Frequently
Respondents were asked to indicate which modal-
ities they had available. They were then asked
which of those they used, and their frequency of
use. Table 1shows the modalities that were avail-
able in over 40% of responding facilities. The table
shows that ultrasound was the most commonly
available (in 96% or 154 of the 160 responding
facilities) and the most frequently used EPA. More
specifically, the types of ultrasound units that
were used most frequently had both continuous
and pulsed options (89%).
Hot packs were the second most commonly avail-
able EPA, in 88% of facilities (141 of the 160
facilities), and used at least daily by over 73% of
Physiotherapy, July 1998, vol84, no 7
o 0
0
o n o n 0 0 0 0 0
0
0 0
0
0
0
o n 0 0 0 0 0 0 0 0
0
no 00 000 0 o n 0 0 0 0 0
I I 1
all respondents. TENS was the third most avail-
able modality, available in 86% of facilities
and used at least daily by 31% of respondents.
The type of most frequently used trans-
cutaneous electrical neuromuscular stimul-
ation (TENS) units had multiple output options.
The table also shows most facilities had inter-
ferential available (77%), and those used most
frequently had suction. Another 34 facilities
(21%) had interferential units without suction,
but 19 of these also had units with suction
available.
Table 1shows that two methods of cooling (ice and
cold packs) and of heating (wax and shortwave
diathermy CSWD)) were also commonly available.
Those who used cooling, typically had two of ice
packs, coolant spray o r cold packs available.
Although ten of the 84 facilities with shortwave
diathermy had at least one type of machine
available, neither type was available in more
than 40% of facilities. As table 2 shows, pulsed
shortwave was less commonly available than
continuous-only equipment and, altogether,
shortwave was only used by approximately 30% of
respondents, and of them only 6%used it at least
once a day.
Available Infrequently
Table 2 shows the estimated use of modalities
available in less than 40% of the responding facil-
ities. Some of these represent the less common
types of the modalities shown on table 1,such as
 339

Table 1: Use and frequency of use of modalities available in more than

40% of responding facilities * All types of options combined,
eg continuous only and continuous
Facilities Facilities Frequency of use (all respondents) and pulsed (ultrasound, shortwave
available used diathermy), intensity only and
(total 160) (n) At least At least At least Daily users different protocols (TENS), suction
Modality No (%) daily (n) monthly (n) yearly (n) (% of 160) and electrodes only (interferential).
Specific options are listed
Ultrasound* 154 (96) separately.
Ultrasound: t Included because more than
Continuous and pulsed 142 (89) 141 129 11 1 81 40% of respondingfacilities
Hot packs 141 (88) 135 117 15 3 73 have SWD machines of at least
one type (continuous only or
TENS* 138 (86) continuous and pulsed) available.
TENS: different protocols 132 (82) 130 49 66 15 31 Table 2 gives details for each
Interferential* 124 (77) type.
Interferential: suction 109 (68) 105 84 18 3 53
Cold packs 103 (64) 96 30 47 19 19
Wax 100 (62) 93 45 38 10 28
Ice 92 (57) 89 47 32 10 29
SWD*t 84 (52)

Table 2: Usage of modalities available in less than 40% of responding Is frequency of use only where
f aciIities available (cf table 1 where
percentage is of all respondents).
Frequency of use (where available %)
t A breakdown of options typically
% % At least At least At least available (eg SWD has continuous
Modality available used * daily monthly yearly
only or pulsed and continuous).
Numbers of options do not all add
Pressure pumps 39 35 19 49 21
directly as some facilities had both
Infra-red lamps 38 33 25 20 55 types available.
Shortwave:
continuoust 36 86 43 30 26
Biofeedback: EMG 32 94 38 44 18
Shortwave:
pulsed and continuoust 30 70 51 39 10
Stimulator: faradic 22 81 28 49 24
Stimulator:
IFT electrodes onlyt 21 100 65 33 2
Stimulator:
TENS intensity onlyt 15 96 46 40 14
Magnetic field units 12 82 50 36 14
Laser: GaAs 12 100 70 30 0
Ultraviolet: air-cooled 10 50 12 25 63
Laser: HeNe 9 86 75 25 0
Ultrasound: continuoust 8 100 70 30 0
Stimulator: multi-currents 8 83 40 20 40
Stimulator: HVPS 8 92 50 42 8
Ultraviolet: water-cooled 8 50 0 34 66
Stimulator: galvanic 7 73 38 38 24
Laser: GaAlAs 7 100 67 33 0
Microwave 5 75 83 17 0
Coolant sprays 4 50 0 66 34
Ultraviolet: cabinet 4 86 100 0 0
Stimulator: diadynamic 2 75 66 0 34
Biofeedback: temperature 1 100 0 100 0

continuous-only types of ultrasound machines.
Table 2 also shows that many students would be
unlikely to use infra-red lamps, ultraviolet, laser,
coolant sprays, temperature biofeedback, and
stimulators with galvanic, diadynamic or multiple
current options. The table also shows that use of
the less available modalities was extremely vari-
able. For example, of those who had GaAlAs
lasers (7% of respondents), the majority (67%)
tended to use them at least once a day. Of these,
four had more than one type of laser. By contrast,
of those who had an infra-red lamp (38%),only a
small percentage (25%)reported using them once
a day, or even monthly (20%).

Physiotherapy, July 1998, vol84, no 7

340

Table 3: Frequency of selection of modalities for a required outcome

Modalities in order of selection (n)*

Required outcome 1 2 3 4 5

Superficial heating Hot packs 128 Infra-red 5 Ultrasound 3 Wax 2 Microwave 1

Deep heating Ultrasound 78 SWD 38 Microwave 3 Hotpack 1 Hotpacks 1
Muscle re-education Motor stimulation Biofeedback 27 lnterferential 19 TENS 8 Pressure
IFES 41 pumps 1
Pain management TENS 52 lnterferential 48 Hot packs 14 Ultrasound 13 ice 12
Oedema reduction Interferential 47 Pressure Ice 28 Ultrasound 6 Electrical
pumps 31 stimulation2
Muscle relaxation Hot packs 92 Interferential 10 SWD 7 Biofeedback 5 Infra-red 1
Ultrasound 5 TENS 1

* 1 = most frequent, 5 = least frequent

Selection of EPAs Reasons for Selection

Available and Selected
Table 3 shows the modalities preferred for
obtaining a required outcome. The table shows
that for some required outcomes, most of those
who responded gave the same answers. For
example, the majority clearly preferred hot packs
for both superficial heating and muscle relax-
ation. Similarly, a clear majority (78 respondents)
favoured ultrasound over shortwave diathermy
(38) for deep tissue heating. For pain manage-
ment, the differences between the two preferred
options of TENS and interferential were minimal.
Figure 2 indicates the reasons given for selecting
a particular modality for a specified indication.
The figure shows, for example, that the ‘known
effects’ and ‘ease of application’ were nominated
as the most important reasons for selecting a
modality. By contrast, research was nominated by
very few as a reason for any selections, except
perhaps muscle stimulation.
Fig 2 (below): Reasons provided by respondents for
their choice of particular modalities for specified
indications

Superficial
heating

Deep
heating

Pain
management

Muscle
re-education

Oedema
reduction

Muscle
relaxation

0 20 40 60
Number of respondents

Research Available Ease Effects

Physiotherapy, July 1998, vol 84, no 7


Reasons for Non-selection
The most common reasons given for not using
particular modalities were t h a t alternative
methods were easier t o apply (as%), or were
perceived as more effective (25%). Safety was an
issue for 25% of respondents, with particular
reference to both shortwave and infra-red. Sixty-
three facilities did not give any reasons for not
selecting modalities.
Not Available but Preferred Options
The questionnaire also asked which modalities
they did not have available in their facility
but would like as a treatment option for the indi-
cations specified. In response 17% listed
biofeedback, t o help with muscle re-education,
and 14% laser, for the treatment of acute pain.
Both were selected in all cases because of
‘expected effectiveness’ and their ‘ease of appli-
cation’. Table 2 shows that both were available
in less than 40% of the facilities surveyed.
Discussion
The results indicate that EPAs are used at least
daily in the majority of physiotherapy facilities in
more t h a n half of all treatments. The most
commonly available and used modalities are
ultrasound, hotpacks and TENS (pain control).
The least commonly available and used modalities
include lasers, some types of electrical stimula-
tors, microwave and ultraviolet equipment. The
findings indicate that ‘ease of application’ and
‘known effects’ are the major reasons for selecting
most modalities.
Responses
The present study had a higher return rate (78%)
than most previous studies of EPA availability
and use. The exception is a study of NHS facil-
ities in England (Pope et al, 1995). However, the
results of t h a t particular study are difficult t o
interpret as more than one reply was received
from many facilities and some Districts provided
proportionately more replies. For example, 12
were received from four facilities in one District,
but only eight from five facilities in another, with
the result that the 116 responding facilities had
a 183.6% response rate. Without additional
information it is not possible to know the effect
of this on the usage data.
The 160 responding facilities in this present
study all provide clinical placements for the
two Victorian universities with undergraduate
physiotherapy programmes. They represent a
wide cross-section of the types of facilities
in which physiotherapy is conducted within
Australia, and most were in Victoria o r Tasmania.
341
The number of facilities reflects the combined
first-year intake of approximately 180 students
and the fact that students in all four years of each
course visit clinics at some stage in each year.
Asking people to estimate what they use and how
often always carries a risk. Either they answer
the relevant questions as accurately as they can,
or they do not. Some attempts t o answer accu-
rately will include errors about what is used
and, particularly, the frequency of use. Other
responses will be accurate. Respondents who do
not try to answer accurately or with care may still
provide answers that are useful. Reliability can be
demonstrated to some degree by cross-checking.
The findings of this study are consistent with
those of another survey conducted elsewhere in
Australia, whose response rate was 70% of 105
(Lindsay et al, 1990, 1995). In the present study,
we surveyed more facilities and had a higher
response rate, suggesting that the responses are
at least as credible.
Specific Modalities
Ultrasound
The availability of ultrasound was high (96%)and
it was used at least daily in over 81% of the
responding facilities. This is consistent with find-
ings made of physiotherapists in Brisbane,
Australia (Lindsay et al, 1990) and in Alberta,
Canada (Lindsay et al, 1995).It is also consistent
with the high use reported in private practices
in the United Kingdom (ter Haar et al, 1988) and
the NHS in England (Pope et al, 1995).
This finding is interesting. Therapeutic ultra-
sound is clearly used extensively by physiother-
apists in different countries. This occurs although
there is limited clinical research support for
using it (Holmes and Rudland, 1991). A recent
meta-analysis of clinical trials of ultrasound
covering the period 1950 to 1992 commented
on the lack of research based support for
using ultrasound (Gam and Johannsen, 1995).
We can criticise and ignore that study, but we
must seriously consider their comment.
A more recent meta-analysis of the physiotherapy
treatment of soft tissue lesions of the shoulder
also comments on the use of ultrasound (van der
Heijden et al 1997). Their examination of existing
studies led the authors to say that ‘[as] ultrasound
therapy is not effective, any further application
in patients with shoulder disorders should
be discouraged’ (van der Heijden et al, 1997,
page 29).
Meta-analyses have inherent problems, given
the assumptions needed t o equate studies with
different procedures and methods of measuring
outcomes. However, they make a telling point:
~~~ ~
Physiotherapy, July 1998, vol84, no 7
342
ultrasound is widely available and regularly used
in the relative absence of supporting clinical
research. Research which suggests effectiveness
is typically based on in uitro or animal studies (eg
By1 et al, 1993; Enwemeka, 1989; Fyfe and Chahl,
1984; Jackson et al, 1991; Maxwell 1992; Rubin
et al, 1990; Sicard-Rosenbaum et aE, 1995) and
extrapolations require the utmost care (Robertson
and Ward, 1996).
Either ultrasound is effective and physiothera-
pists are not doing the clinical research necessary
to demonstrate this, or ultrasound is not effec-
tive o r has only minimal and possibly clinically
non-significant effects. If so, we should rethink
our use of ultrasound and make the necessary
changes in treatment regimes and undergraduate
courses. We cannot allow the clinical effectiveness
of such a heavily used modality t o continue t o
remain in question. That it has, is evident in the
vast array of ideas about dosage. This is captured
most succinctly in the title of a recent review of
work on ultrasound: ‘Ultrasound: To heat or not
to heat - That is the question’ (Nussbaum, 1997).
For educators, the schism between practice and
the supporting research on therapeutic ultra-
sound is problematic. We are increasingly
required to justify practice through demon-
strating the effectiveness of physiotherapy.
Concurrently, there is a n obligation t o devote
considerable time to teaching undergraduates the
safe use of a modality for which there is little
independent evidence of clinical effectiveness.
If demonstrated clinical effectiveness was the
sole criterion for continuing inclusion in curr-
icula, then ultrasound would not be included.
TENS and Interferential
TENS was used daily in 30%of clinics surveyed in
this study. This contrasts with practices in
Alberta (62.4%) and in north-eastern United
States (67%),but is similar to those in Brisbane
(19.4%)and the NHS in England (27%)(Pope et al,
1995). Similar numbers of the facilities we
surveyed considered TENS and interferential as
almost equivalent methods of providing pain
relief. This difference is consistent with a concur-
rent higher use of interferential in Australia and
England than elsewhere. Over 50% of respon-
dents in this study used interferential machines
with suction at least daily. A smaller percentage
(41%) used it at least daily with electrodes. A
similarly high level of use was reported in
England, but users there preferred electrodes
(63%) to suction (53%).The total percentage of
interferential users from England and Australia
is clearly higher than in Canada (where for all
users it was 56.2%) or the USA (3%).
This difference between countries in their use of
Physiotherapy,July 1998, vol84, no 7
TENS and interferential raises questions about
the relative effectiveness of different modalities.
The absence of research demonstrating the
clinical effectiveness of interferential is long
recognised (Roche, 1982; Taylor et al, 1987). Most
studies of interferential examine the effect of beat
or carrier frequency or of current distribution in
the tissues (Green and Laycock, 1990; Laycock
and Green, 1988, 1993; Nussbaum et al, 1990).
This situation continues, although interferential
has been used clinically for decades. By contrast,
clinical support for the use of TENS has continued
t o accumulate since development in the mid
1960s.
The cross-country difference, in the absence of
relevant research, raises questions. Why is inter-
ferential so frequently available in some surveyed
countries and yet used so differently? Is this a
consequence of marketing, of respected advocates
for a modality living within in a country, of the
direct and indirect influence of a controlling
health authority in one country, or is it more
prosaic? Perhaps the ease of applying interferen-
tial helps explain its popularity in Australia at
least, given the predilection there for using
suction in conjunction with interferential.
However, this does not explain the use in
England, nor why there is little clinical research
explicitly addressing the clinical effectiveness of
what is, in some places, a very popular modality.
Nor does it provide support for continuing to
include teaching of interferential in undergrad-
uate curricula.
Heating
Hot packs were used at least daily in 73% of
facilities surveyed. Most respondents preferred
them for superficial heating and for their ease of
application. For deeper heating, ultrasound
was preferred by most, followed by shortwave
diathermy. Use of these modalities in this manner
is, as Pope et al(l995)noted, typical in Australian
physiotherapy and quite different from usage in
England.
The results of this study also indicate that approx-
imately half the respondents had shortwave
available but that very few used it daily, and of
those who did, more used continuous shortwave
diathermy. By contrast, in England, pulsed short-
wave is used a t least daily by the majority of
respondents surveyed and only a small per-
centage use continuous shortwave or hot packs
(Pope et al, 1995).
Anecdotally, the low rate of using shortwave
diathermy in Australia is part of a general trend
that has developed as the range of EPA options
has increased. This might suggest therapists are
possibly now more aware of the possible dangers

to operators of this modality (Kallen et al, 1992;
Martin et a l , 1991; Wood, 1993). However, this
does not explain the English results. Pope et a1
(19951, in a discussion of similar findings by
Lindsay et a1 (1990), suggested it could relate to a
change based on new knowledge or that it was
just a difference between the two countries. The
findings of the present study confirm the inter-
country difference but cannot account for it.
Nor can the present study suggest why more
of the Australian facilities surveyed use hot
packs. As with the use of ultrasound and inter-
ferential, these differences raise more questions
about the basis of EPA use than they answer.
Other Modalities
Modalities such as microwave, ultraviolet and
laser were typically used frequently in the small
percentage of clinics in which they were available.
Of these, the reasons for using ultraviolet are well
understood. The dangers, including the long-
term use of ultraviolet A, are still being identified
(Stern et al, 1997). With microwave, the general
availability of only one frequency (2,450 MHz),
which is relatively inefficient for diathermy, helps
explain the limited availability and unpopularity
of this modality. For lasers, their usefulness for
treating lesions less than a few millimetres deep
is consistent with their limited availability,
as presumably most facilities would not treat
this type of lesion frequently enough to justify
the outlay on equipment.
Apparatus for obtaining motor responses with
electrical stimulation, and for biofeedback, was
reported as available and used in less than 40% of
facilities. This is likely to change as more physio-
therapists become aware of the possibilities of
more recently developed equipment, and are able
to use it. This possibility was also anticipated by
Pope and colleagues (1995) for lasers and biofeed-
back in England.
Educational Implications
There is little evidence to support the claimed
effects of some EPAs. This includes ultrasound
and interferential, the most frequently available
and used EPAs. This means students in clinical
placements will have routine access to them and
be expected to use them safely. If not, patients
may be burnt or suffer other equally or more
serious consequences. Because of these possible
consequences, we cannot overlook this as just
another of the ‘many areas of physiotherapy [in
which there is limited evidence] t o support the
efficacy of current treatment regimes’ (Robertson,
1996, page 536).
Two approaches might be relevant to resolving
the contradictions between high levels of clinical
343
use and low levels of clinically based research
support. Neither offers a solution with an imme-
diate prospect of change. The first approach is to
ensure that EPA curricula focus on research and
students are made aware of the limited research
justifying the clinical use of many modalities. This
also requires students to know about research,
how t o do it, evaluate it critically, and use it in
their professional practice.
The second approach is to ensure a strong scien-
tific basis for EPA practice. Graduates need a n
in-depth knowledge of the biophysical bases and
effects of the different forms of energy that can be
used. Perhaps an emphasis on this, together with
an increased awareness of the importance of
research, may eventually result in more clinical
research that examines our uses of EPAs. Even if
more research is not produced, then physio-
therapy should still benefit from having more
practitioners who are at least able to distinguish
the optimistic claims made by some manufac-
turers from real possibilities. This might also
affect some of the more blatant differences in
inter-country uses of some modalities.
In the meantime, educators are left with the
dilemma: spend the time necessary t o produce
safe practitioners who are able t o use convention-
ally accepted EPAs irrespective of their probable
clinical effectiveness, or risk students not meeting
currently accepted practice standards. A self-
described ‘fringe watcher’ of physiotherapy
recently presented this problem in a parable on
‘kissotherapy’ (Sala, 1997). He described an imag-
inary treatment for brain-injured patients that he
called ‘kissotherapy’.This treatment he described
as having developed into a well accepted and
funded practice, learnt by many eager students,
used on many patients, and accepted by practi-
tioners as working. In the end, Sala asked, what
should scientifically literate aliens, asked to
organise the health system, do about it? Similarly,
is it perhaps time for us to consider the implica-
tions for physiotherapy practice, and credibility,
if we do not reconsider our use of some EPAs.
Conclusion
The main finding of this study concerns the
generally high levels of use of particular EPAs.
Given the breadth of facilities and the high
response rate, the findings provide a detailed
picture of what was available and what was used
in placements attended by undergraduates at
the time of the survey.
The findings have important implications for
those designing undergraduate curricula. In
particular, they highlight the need for a strong
biophysical base from which students can develop
a set of principles regarding safety, methods of
Physiotherapy, July 1998, vol84, no 7
344
applying existing and new modalities, and their
possible effects. Students should be made aware
of the research base of existing EPA use, and
helped to develop high levels of skill in using
research, in finding it, critically reading it, and
incorporating it into their practice. Given the use
of EPAs in approximately half of the treatments in
responding practices, and the limited justification
for much of this, we must increase our emphasis
on the importance of research on EPAs in clinical
practice.
Acknowledgments
The authors gratefully acknowledge the financial assistance
received from the Australian Physiotherapy Association without
which the study could not have proceeded, and the time and
effort of each respondent who completed and returned the
questionnaire.
This article was received on November 3, 1997, and accepted on
March 13, 1998.
Authors
Valma J Robertson PhD BAppSc(Phty) BA CertElectrncs is an
associate professor and Diana Spurritt MEd BAppSc(Phty)is an
associate lecturer in the School of Physiotherapy, La Trobe
University, Melbourne, Australia.
Address for Correspondence
Dr Val Robertson, School of Physiotherapy, La Trobe Univer-
sity, Bundoora, Victoria, Australia 3083.
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