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Physical Agents 
Panel findings and recommendations: 
 -   The use of physical agents and modalities in the treatment of low back problems is of insufficiently proven benefit to justify their cost.  As an option, patients may be taught self-application of heat or cold to the back at home. (Strength of Evidence = C.)  
  Physical agents and modalities include ice, heat (including diathermy), massage, ultrasound, cutaneous laser treatment, and electrical stimulation (not transcutaneous electrical nerve stimulation or TENS).  The therapeutic objective of physical agents and modalities is to provide symptomatic relief and, for some modalities, to reduce inflammation, "muscular symptoms," or joint stiffness. 
Physical Agents and Modalities 
Literature Reviewed     Evidence on Efficacy    Potential Harms and Costs      Summary of Findings     Author's Example 
Physical Agents and Modalities 
  Literature Reviewed.  Of 25 articles screened for this topic, 10 reporting on 8 RCTs met criteria for review. 
85, 133, 140, 150, 151, 152, 153, 154, 155, 156 
  Evidence on Efficacy.    Many studies compared different combinations of physical agents and modalities, making it difficult to evaluate effectiveness of specific modalities.  Only two studies evaluated physical agents and modalities in patients with low back pain. 85, 140  Neither found significant differences in self-rated pain relief or other outcome measures between patient groups receiving physical agents and modalities (including diathermy, ultrasound, flexion/extension exercises, massage, and electrotherapy) and groups receiving a placebo.  The other studies reported on groups of either chronic or a mix of acute and chronic low back pain patients.  Three studies found no significant differences in patient-reported outcome measures between treatments (including cutaneous laser, diathermy, electrotherapy, exercise, heat, massage, and ultrasound) and a placebo. 133, 150, 151, 152, 153  Manniche, Hesselsoe, Bentzen, et al.155 found intensive back-strengthening exercises superior to physical agents and modalities on patient-rated outcome measures, but the group receiving physical agents/modality treatment was not compared with a control group receiving no intervention.  Melzack, Vetere, and Finch156 found that a group receiving TENS therapy had greater pain relief than a group receiving massage therapy.  Again, treatments were not compared with a no-intervention control.  Linton, Bradley, Jensen, et al.154 found that a group given a combination of physical agents and modalities, ergonomic education, and behavioral therapy had significantly better outcomes than a control group receiving no intervention, but the effect of physical agents and modalities could not be determined. 
  Potential Harms and Costs.  Risks from potential complications of physical agents and modalities are believed to be small.  A possible exception is in pregnant patients, for whom ultrasound and diathermy are not recommended because of theoretical risks to the fetus. 
  The costs of individual treatment sessions using physical agents and modalities are variable, determined by the number of modalities used, the length of treatment, and the number of treatment visits.  
  Summary of Findings.  No well-designed controlled trials support the use of physical agents and modalities as treatments for low back problems.  However, some patients with low back problems appear to have temporary symptomatic relief with physical agents and modalities.  Therefore, self-administered home programs for modalities involving heat or cold are considered a treatment option. The support is still limited as noted by French`06
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