The most expensive habit in this profession
What the evidence says about the machines
Ultrasound, electrical stimulation and mechanical traction are on the price list of most physical therapy clinics in this country. They are not on most treatment plans here, and the reason is not taste.
The machines are not the treatment. Ultrasound, most electrical stimulation and mechanical traction do not appear on our treatment plans as a matter of routine. The World Health Organization's 2023 guideline recommends against therapeutic ultrasound in routine care for chronic low back pain, NICE recommends against offering it for back pain with or without sciatica, and the Cochrane review found a small effect that was not clinically important. These machines survive because they bill well and need no clinician in the room, which is precisely the reason to be suspicious of a plan built around them.
There is a particular shape to a physical therapy appointment that a great many people have experienced: fifteen minutes of a heat pack, fifteen minutes of an ultrasound head being moved in circles, fifteen minutes of electrode pads, and a sheet of exercises handed over at the door. Three quarters of the hour is passive and none of it requires a clinician to be watching.
That shape is not an accident and it is not stupidity. It is what the billing rewards. Passive modalities generate units, occupy a room rather than a person, and can be run on several patients at once. The exercise — the part with the evidence — needs somebody qualified standing next to you for an hour, which is the most expensive thing a clinic owns.
What the guidelines actually say about ultrasound
The World Health Organization's 2023 guideline on non-surgical management of chronic primary low back pain recommends against the use of therapeutic ultrasound in routine care for adults, including older adults. That is a recommendation against, not an absence of a recommendation for.
NICE, in its guideline on low back pain and sciatica, tells clinicians not to offer ultrasound for managing low back pain with or without sciatica. Again: an explicit instruction not to, rather than silence.
The Cochrane systematic review of therapeutic ultrasound for chronic low back pain (Ebadi and colleagues, 2020) found low-certainty evidence of a small effect on back-specific function against placebo in the short term, and concluded that the effect did not appear to be clinically important. The certainty for whether adding ultrasound to exercise beats exercise alone was very low.
Three independent bodies, reading the same literature, arriving in the same place. That is about as clear as this kind of evidence gets.
Why the machines are still everywhere
Because they are profitable and pleasant. Ultrasound is warm, it feels like treatment, it takes no effort from the patient, and it is billable. A clinic can run three of them simultaneously. Nothing about that requires anybody to be acting in bad faith — a modality that patients enjoy and that pays for the lights is a very easy habit to keep.
There is also a real placebo effect, and it is not nothing. A person who believes they have been treated frequently feels better for a while, and if the alternative were nothing at all we would think harder about it. The alternative is not nothing. It is the hour of loaded exercise the machine displaced.
Where these things are genuinely useful
We are not going to tell you no machine has a place. Electrical stimulation has a real role in re-educating a muscle that will not switch on after surgery — a quadriceps in the fortnight after a knee replacement is the standard case, and we use it for exactly that. It is a bridge to loading, used for a defined reason over a defined period.
TENS for symptom relief at home is a reasonable thing for some people with persistent pain, and we will show you how to use one. What it is not is a treatment we should be billing you to sit through in our building.
Heat and ice are comfort measures. They are cheap, they help some people, and you can do both at home. We are not going to charge you for a hot pack.
What we do with the hour instead
Assessment at the start of every visit, hands-on work where it buys range or comfort, and then loaded exercise supervised properly — which means somebody watching the quality, adding weight when you have earned it, and catching the compensation you have started doing without noticing.
That is a harder sell than a warm ultrasound head, and it is genuinely more uncomfortable for the first fortnight of most conditions. It is also the thing that changes tissue, and it is what the hour is for.
In order
How this works in practice
We assess what changed since last time
Every visit starts here. If nothing has changed, that is information about the plan.
Hands-on work, where it earns its place
Soft tissue and joint work to buy range and reduce guarding — a means to the loading, not the treatment.
Loaded exercise, supervised
The bulk of the hour. Progressed on what you achieved rather than on the calendar.
The home programme, revised
Three or four things, written down, with sets and load. This is where most of the change actually happens.
Electrical stimulation, occasionally and for a reason
A quadriceps that will not activate after surgery. Named purpose, defined period, then it stops.
Questions we are actually asked
What the evidence says about the machines — frequently asked
Do you use ultrasound?
Almost never, and not as part of a routine plan. The WHO's 2023 guideline recommends against it for chronic low back pain, NICE says not to offer it for back pain with or without sciatica, and the Cochrane review found an effect too small to be clinically important. We would rather spend the hour on something that changes tissue.
My last clinic used ultrasound on me every visit. Was that wrong?
It was very common, and the evidence does not support it as a routine treatment. We are not going to call a colleague dishonest for a habit half the profession shares. What we will say is that the time it occupied was time not spent on loaded exercise, and that is the part with the durable evidence behind it.
Is TENS useless then?
No. TENS can genuinely help some people manage symptoms, particularly in persistent pain, and we will show you how to use a home unit. The question is whether it should be something you are billed to sit through in a clinic, and our answer to that is no.
Do you ever use electrical stimulation?
Yes, for one specific job: re-educating a muscle that will not switch on after surgery, most often a quadriceps in the first fortnight after a knee replacement. It is a bridge to loading, used for a stated reason over a defined period, and then it stops.
What about traction for a disc problem?
The evidence for mechanical traction in low back pain and sciatica is weak, and the major guidelines do not recommend it as routine care. Some people report short-term relief during a session; what the literature does not show is durable change. We would rather use the hour on the things that produce it.
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