Why We Don't Use Ultrasound, TENS, or Laser

Patients sometimes notice on their first visit that we don't have an ultrasound machine, a TENS unit, or a laser device anywhere in the treatment room. Once or twice a year someone asks why — usually because a previous clinic used those tools heavily, and the absence is conspicuous. The answer is the same in each case: the current evidence doesn't support those modalities as primary treatments for the conditions we see, and replacing the time they'd take with active care produces better outcomes.

This is a position post, not a takedown. There are clinical scenarios where any of these tools have a defensible role. We've simply concluded that those scenarios are narrow enough that other interventions are a better default.

Therapeutic ultrasound

Therapeutic ultrasound has been a fixture in physiotherapy and chiropractic clinics for half a century. Its proposed mechanisms include thermal effects in deep tissues and non-thermal effects on cellular activity. The clinical evidence has not aged well. A series of Cochrane reviews and systematic reviews across low back pain, shoulder pain, lateral epicondylitis, knee osteoarthritis, and Achilles tendinopathy have repeatedly concluded that the evidence for therapeutic ultrasound, where it exists at all, is generally low quality and shows small or no clinical effect compared to sham^1,2.

That doesn't mean the patient doesn't feel better after a session. It means the feeling-better is largely attributable to the contact, the time spent, and the expectations the patient brings — none of which are unique to ultrasound. We can produce the same expectation effects, and produce more durable change, by spending that ten minutes on graded loading, mobility work, or education.

TENS

Transcutaneous Electrical Nerve Stimulation has a more mixed evidence base. There are clinical scenarios — neuropathic pain, certain post-surgical settings, some chronic pain populations — where short-term pain modulation with TENS produces meaningful patient-reported benefit³. As a primary treatment for the musculoskeletal conditions we see most — mechanical low back pain, neck pain, knee osteoarthritis, tendinopathies — the evidence for TENS as a stand-alone or central intervention is unconvincing⁴.

The bigger concern is what TENS displaces. A patient who attributes their improvement to the TENS pads becomes dependent on a passive intervention rather than building confidence in active care. That's a long-term outcome problem, even when the short-term comfort is real.

For a patient who finds genuine relief from a home TENS unit between sessions, we don't object to that as part of the plan. We just don't make it part of the in-clinic treatment.

Low-level laser therapy

Low-level laser therapy (LLLT) has the most genuinely contested evidence base of the three. There are reasonable systematic reviews showing modest effects in tendinopathies and chronic neck pain at specific dose-response parameters; there are equally reasonable reviews showing no clinically meaningful effect once methodological quality is adjusted for⁵. Clinical effects, where they exist, tend to be small and short-lived.

The clinical case for LLLT, even at its strongest, is that it's a low-cost, low-risk adjunct. The case against is that the time and visit slot it takes up could be doing something with more durable evidence behind it. We've made that trade in favor of active care.

What we use instead

Our treatment time goes to four things: assessment-driven manual therapy (when indicated), neuromuscular re-education, graded loading, and patient education. The evidence for those four pillars in the conditions we see is far stronger than for any of the modalities listed above⁶. They also share a feature that passive modalities don't: they produce changes that the patient can replicate outside the treatment room.

That's the same logic we apply to shoulder pain and load management — what happens between sessions does most of the work. There are no bad treatment tools, only ones that displace better ones, and our default is to spend the visit on the active side.

Where this leaves the patient

If you've been getting ultrasound, TENS, or laser at another clinic and you've felt better afterward, that's worth taking seriously. Your experience isn't wrong. The question worth asking is whether the gains have lasted, whether the underlying problem is improving, and whether the plan is making you less dependent on the clinic over time, not more.

The plans we build at Boreal Spine & Sport are aimed at making patients independent, not regular. That's part of why our toolset looks the way it does.

References

1. Ebadi S, Henschke N, Forogh B, et al. Therapeutic ultrasound for chronic low back pain. Cochrane Database Syst Rev. 2020;7(7):CD009169.
2. Page MJ, Green S, Mrocki MA, et al. Electrotherapy modalities for rotator cuff disease. Cochrane Database Syst Rev. 2016;(6):CD012225.
3. Vance CG, Dailey DL, Rakel BA, Sluka KA. Using TENS for pain control: the state of the evidence. Pain Manag. 2014;4(3):197–209.
4. Khadilkar A, Odebiyi DO, Brosseau L, Wells GA. Transcutaneous electrical nerve stimulation (TENS) versus placebo for chronic low-back pain. Cochrane Database Syst Rev. 2008;(4):CD003008.
5. Chow RT, Johnson MI, Lopes-Martins RA, Bjordal JM. Efficacy of low-level laser therapy in the management of neck pain: a systematic review and meta-analysis of randomised placebo or active-treatment controlled trials. Lancet. 2009;374(9705):1897–1908.
6. Lin I, Wiles L, Waller R, et al. What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high-quality clinical practice guidelines: systematic review. Br J Sports Med. 2020;54(2):79–86.

Author: Dr. Michael Minenna D.C., B.Sc., SFMA, FMS — Boreal Spine & Sport, Winnipeg, Manitoba.