Feeling Better and Getting Better Are Not the Same Thing

The most dangerous outcome in physical therapy is when a patient feels significantly better after treatment, but nothing has changed in the way their body moves, loads and functions.

This is the consistent finding in the research on electro modalities: laser therapy, therapeutic ultrasound, TENS, electrical stimulation, and shockwave therapy all produce some short-term reductions in pain. But, none of them produce lasting improvements in nerve or muscle function. And when the pain comes back, which it does, the patient returns for another round of the same treatment that didn’t fix it the first time, and won’t fix it the second, forth or tenth time.

What the Research Shows

In 2020, NICE (the UK’s National Institute for Health and Care Excellence) updated its clinical guidelines for chronic pain and explicitly advised clinicians not to offer TENS, ultrasound, or interferential therapy, stating that the evidence does not support their use. Their 2020 guidelines for low back pain and sciatica reinforced this position, listing these modalities among passive interventions that should not be offered.

📚 NICE 2020/2021 Guidelines: Do not offer TENS, ultrasound, or interferential therapy for chronic primary pain or low back pain.

Electrical Stimulation & TENS

The largest analysis of TENS ever conducted — pooling 381 randomized controlled trials involving over 24,000 participants — found moderate-certainty evidence that TENS reduces pain intensity during or immediately after treatment. It did not produce lasting change. A 2024 systematic review on TENS for neuropathic pain concluded that TENS provides a slight but not clinically significant reduction in pain compared to placebo, with high heterogeneity preventing firm conclusions.

📚 BMJ Open 2022 Meta-TENS: 381 RCTs, 24,000+ participants — pain reduction during/immediately after only; no lasting effect.

📚 PMC 2024 Systematic Review: TENS vs. placebo for neuropathic pain — not clinically significant (SMD -0.35, p=0.13).

Therapeutic Ultrasound

A 2020 Cochrane review on therapeutic ultrasound for chronic low back pain concluded there was little to no difference between therapeutic ultrasound and placebo for improving pain or back-specific function. Cochrane reviews represent the highest tier of evidence synthesis, and this one is unambiguous.

📚 Cochrane 2020: Therapeutic ultrasound vs. placebo for chronic low back pain — little to no difference in pain or function.

Shockwave Therapy

Shockwave therapy applies acoustic waves to tissue, typically for conditions like plantar fasciitis, shoulder tendinitis, and knee pain. While some studies show short-term pain reduction, the mechanism is primarily sensory nerve overload, not structural repair. The pain relief is short. The underlying mechanical dysfunction that caused the tendon symptoms are left unaddressed.

Laser Therapy

Low-level laser therapy (LLLT) is promoted for its ability to stimulate cellular activity and reduce inflammation. The evidence base is inconsistent, with studies showing variable results depending on wavelength, dosage, and condition. Like the other modalities in this category, the best outcomes are short-term pain and inflammation reduction — not restoration of function on any level.

The Modality Trap

Clinics that rely heavily on modalities have a built-in incentive to keep patients coming back. A patient who feels better after a session using the latest “cool technology” will return for another, because of the short term relief, even if the cause remains unchanged. This is an unfortunate feature of a healthcare model that measures success by pain reduction rather than by functional restoration.

At One80, we do not own a single passive modality machine. Our investment is in our patented assessment and neuromuscular rehabilitation techniques that produce functional change at the cellular level, not just pain relief. Patients don’t come back because the problem came back. They come back because they want to send their family.

FAQs

What about shockwave for plantar fasciitis? My doctor recommended it.

Shockwave can reduce pain in plantar fasciitis, that’s documented. What it doesn’t do is address why the plantar fascia is overloaded in the first place. We’d rather reverse the root cause of function and eliminate the problem there rather than manage the pain it creates. Also, the likelihood of your doctor ever experiencing shock wave first hand and reading the lack of research outcomes behind it is extremely low.

If these are gimmicks, why do insurance companies cover them?

Coverage doesn’t equal efficacy. Insurance coding and clinical evidence move on very different timelines. Many of these modalities became reimbursable before rigorous placebo-controlled trials existed, and removal from coverage lists faces enormous institutional resistance. NICE and Cochrane have been clear. Practice hasn’t always followed.