Despite health care changes, e-stim retains a role in PT treatment
BY MIKE LE POSTOLLEC
Surviving the Market Changes
Functional treatment: it's a phrase that's become almost omnipresent in all areas of rehab care. As health care dollars tightened in recent years, the insurance trend has moved toward reimbursement for only those treatments that demonstrate gains in immediate, quantifiable and functional terms. And at the same time, the demands placed on therapists and all health care professionals to heal patients as quickly and cost-effectively as possible have led to an increased focus on function.
The available resources and amount of treatment time is considerably smaller than in years past, and therapists are finding that when it comes to patient care, there is little or no time to waste.
Of all forms of PT treatment, modality use has possibly been dealt the strongest blow by this change in health care. Whereas therapists could take the treatment time to use this resource in years past, manual therapy has taken precedence in many cases, certain modalities such as traction devices and TENS units are more commonly prescribed for home use, and in some cases PTs must defend their efficacy. In one recent and widely publicized example, the APTA successfully lobbied to overturn HCFA's decision to deny the use of electrical stimulation for wound treatment (ADVANCE, (8)37: 6-7, (9)3: 33-34).
Will the use of traditional PT modalities such as electrical stimulation soon be a thing of the past, replaced by patient education and less effective home units?
Not just yet, according to Dave Clement, PT, of Everett Sports Therapy, Orange, CA, a primarily sports medicine and orthopedic clinic. A reassessment of electrical stimulation's role in treatment, coupled with much improved technology, should keep the modality in valuable use for years to come. "I don't think that [e-stim] is used as commonly in the clinic as it was when I first began practicing, but that's not necessarily a bad thing," explained Clement. "I just think that therapists are more selective about how it's used, and between that and all of the improvements in technology, e-stim will be around for a long time."
Indications for E-Stim
Traditionally, Clement said, the most common uses of electrical stimulation are for acute pain management and the reduction of swelling, two benefits that he has put to great use with his primarily athletic population. "I treat a lot of athletes for simple sprains all the way up to knee injuries and anterior cruciate ligament (ACL) reconstruction."
Athletes who see Clement often are experiencing a lot of pain and inflammation. "E-stim is not something I use for every patient, but in acute cases it can help get rid of the pain so that I can get to manual therapy and active treatments faster."
Audrey Kennedy, MEd, PT, clinical director of Rehab Solutions, Cumberland, MD, and of Garrett Rehab Services, Oakland, MD, agreed, adding that sports-related injuries are some of the best areas to gain these results. "Normally, if it's a 15-minute treatment and I'm working on a patient with pain and swelling, I try and use e-stim at the end of treatment with ice to calm the area down," she said. "But if they come in with severe pain, I'll use e-stim right away to try and reduce pain before I work on them."
E-stim can also have positive effects when there is pain without swelling. Although therapists should be wary of having patients rely too heavily on modalities that likely won't be available after discharge, there are some cases where long-term use of e-stim, with the proper instruction from a PT, can be beneficial.
"PTs will sometimes prescribe TENS units, and the nice thing about that is the patient can take it home with them and it's not taking up treatment time," she said. "It's used most often for patients with chronic back pain. Patients will use the TENS unit if they need to be active or at work, and can't take pain relief medication [due to side effects like drowsiness]." By applying a continuous minor voltage to the affected area, a TENS unit can cause metabolic changes within the tissue, speeding the healing process and the reduction of swelling.
Clement said that he also frequently uses TENS in treating injured athletes. "ACL tears might be the most common athletic injury I treat here, and many times the patient's muscles atrophy and become much weaker than the other leg, which can throw off balance and cause problems with mobility," he said. "With e-stim, we can cause those muscles to contract. Athletes are always concerned about losing strength when they are hurt and can't be active, so this is a good way to build up the surrounding muscles, and it also helps educate them on how to contract the muscles."
Although wounds are not a common part of either therapist's caseload, both PTs noted e-stim's effectiveness with wound healing. Of all of the treatments mentioned, wound treatment is probably one of the more current widespread uses of e-stim among PTs, and as mentioned earlier, its acceptance with insurers has been somewhat of a struggle.
However, as the body of research increases, therapists expect the modality's role in wound treatment to do the same. "I don't usually treat wounds, but I work with therapists who do wound treatment, and I've seen some really great results with e-stim," Kennedy said. "E-stim increases the blood flow to the area, and the enzymatic changes that it makes in the tissue promote healing."
Despite these benefits, Kennedy stressed that the use of e-stim, like most modalities, should be limited, and used as an adjunct to manual and more active therapy. "I will use e-stim, but modalities will not make or break a treatment for me," she explained. "I didn't go to PT school just to hook patients up to a machine, and it's a big mistake when therapists just give patients ultrasound, e-stim or ice the whole time; that's not a treatment."
"The important thing is to know when e-stim should be used, and not rely on it as the scope of your treatment," Clement added. "When I first began practicing, I think modalities in general were overused a lot, but with the way health care has changed, PTs are held much more accountable for their treatments, by patients and insurance. I'll use e-stim pretty often, but it's never the focus of my treatment."
Considering this shift in modalities' role, it might seem that the glory days of e-stim are long past, but Clement disagreed. "The big difference today is that PTs are using e-stim much more responsibly, and the equipment has improved so that it's a lot more effective."
Aside from being much safer than the somewhat crude e-stim units of the past, most equipment today offers a range of settings designed for each patient's specific needs, whether it's for swelling reduction, pain reduction, neuromuscular re-education or wound care. Generally, these different settings will affect the waveform of the device's charge, tailoring it to the therapist's specific goals and eliminating the need for more than one piece of equipment. While this can be a great help for therapists who use e-stim for many different conditions, Kennedy warned therapists against marketing ploys.
"Be careful, because there are vendors out there who will give fancy names for all these different settings to sell the product, and a lot of them might be the same thing," she said. "What it really comes down to is a direct current, where there is a buildup of ions, and an alternating current, so there's no buildup. Some vendors will use different names for these parameters, and it's confusing. But if you stick to the basics, you can pretty much figure it out."
As for Clement, his advice, in both using the modality and selecting equipment, is simply to go with what you need. "You really need to look at your clientele to figure out how often you are going to use e-stim and what you'll use it for, and base your decisions [of purchasing equipment] on that," he said. "Electrical stimulation is not the end-all modality for any treatment, but if it's working for your patients and helping them recover faster and with less pain, then I think you should use it."
Mike Le Postollec is on staff at ADVANCE.