PHYS THER
Vol. 87, No. 11, November 2007, pp. 1558-1559
DOI: 10.2522/ptj.2007.87.11.1558.2
On "A survey of therapeutic ultrasound..." Wong et al. Phys Ther. 2007;87:986–994.
There seemed to be a disagreement between Wong and associates2 and the invited commentator on the effectiveness of ultrasound. Although Robertson1 in her commentary referred to ultrasound therapy as being ineffective, the evidence provided by Wong et al that 11 of 15 reviews could not come to a conclusion about the effectiveness of ultrasound therapy shows that there might still be some uncertainty.1,2 Based on the definition of an established effective treatment (EET), ultrasound therapy is certainly not an EET.3 However, because most systematic reviews could not draw a definite conclusion on the effectiveness of ultrasound therapy and because there is evidence of emerging potential for clinical use of ultrasound in physical therapy,1 I would think that there is a state of "equipoise" on this issue.4 Equipoise is the situation where honest ambivalence, uncertainty, or indifference exists. Until the uncertainty is disturbed somehow and conclusive evidence is provided, there will continue to be a disconnect between the clinical and the scientific (research) physical therapy communities on the issue of ultrasound therapy. What if clinicians using ultrasound have anecdotal evidence that patients are benefiting?
The fact that some randomized trials do not have adequate sample sizes and hence do not have adequate power has been pointed out. Altman and Bland5 contended that describing the intervention under investigation as "ineffective" may be wrong. Similar danger of misinterpretation was shown to exist in meta-analyses of published trials, too.5 The inconclusive reviews certainly raised methodological concern as one of the issues in ultrasound studies.6,7 On the issue of how long ultrasound should be applied, are we also "out to lunch" on this too? The animal studies discussed by Robertson used far more time on small animals than clinicians used on humans. Overall, we have so many questions in need of answers, which certainly might have contributed to the difficulty in the integration of current evidence into practice. Absence of "proof of effectiveness" may not be proof of "absence of effectiveness."5
Nurudeen T Amusat
NT Amusat is a Physical Therapist at Two Hills Health Centre, Two Hills, Alberta, Canada
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This letter was posted as a Rapid Response on September 5, 2007, at www.ptjournal.org.
References
- Robertson VJ. Invited commentary. [RE: A survey of therapeutic ultrasound use by physical therapists who are orthopaedic certified specialists.]
Phys Ther. 2007;87:995–999.[Free Full Text]
- Wong RA, Schumann B, Townsend R, Phelps CA. A survey of therapeutic ultrasound use by physical therapists who are orthopaedic certified specialists.
Phys Ther. 2007;87:986–994.[Abstract/Free Full Text]
- National Placebo Initiative. Final report of the National Placebo Working Committee. 2004. Available at http://www.cihr-irsc.gc.ca.login.ezproxy.library.ualberta.ca/e/25139.html. Accessed on August 31, 2007.
- Freedman B. Equipoise and the ethics of clinical research.
N Engl J Med. 1987;317:141-145.[Abstract]
- Altman DG, Bland JM. Absence of evidence is not evidence of absence.
BMJ. 1995;311:485.[Free Full Text]
- Brosseau L, Casimiro L, Robinson V, et al. Therapeutic ultrasound for treating patellofemoral pain syndrome.
Cochrane Database Syst Rev. 2001;(4):CD003375.
- Welch V, Brosseau L, Peterson J, et al. Therapeutic ultrasound for osteoarthritis of the knee.
Cochrane Database Syst Rev. 2001;(3):CD003132.
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Copyright © 2007 by the American Physical Therapy Association.
