Topic: Electrical Stimulation (EMS)

Question: An orthopedic surgeon/IME recommended a denial for all electrical stimulation (EMS) by stating that "according ODG electrical stimulation is experimental therefore not medically necessary or eligible for reimbursement." Is that true?

Answer: NO. ODG DOES NOT prevent reimbursement for electrical stimulation. As so often happens, the IME who stated that EMS is experimental misquoted ODG content and cherry picked a specific sentence, out of context, in order to support his intent to deny care. ODG does state the following: "Not recommended as an isolated intervention."

But who used EMS as an isolated treatment option? Most physicians or therapists who utilize EMS do so as just one component of an overall treatment plan that also may include a combination of other passive and active therapies.

ODG further states, "There is no quality evidence of effectiveness except in conjunction with recommended treatments, including return to work, exercise and medications, and limited evidence of improvement on those recommended treatments alone."

In other words, it is perfectly acceptable to use EMS in combination with exercises. Treatment plans utilized by physicians and physical therapists typically include a combination of passive and active therapies used concurrently, not in isolation. Treatment plans can justifiably include treatments like spinal manipulation, electrical stimulation and exercise, all therapies supported by ODG and other treatment guidelines.

Furthermore, while the literature is limited for use of electric stim and other passive therapies there are a few studies which do support treatment. ODG states, "Two recent randomized double-blind controlled trials suggested that ICS and horizontal therapy (HT) were effective in alleviating pain and disability in patients with chronic low back pain compared to placebo at 14 weeks, but not at 2 weeks."

Additionally, ODG suggests that payors consider the information contained in two papers published by The Council on Chiropractic Guidelines and Practice Parameters (CCGPP).

CHIROPRACTIC MANAGEMENT OF LOW BACK DISORDERS: REPORT FROM A CONSENSUS PROCESS. Globe et al. JMPT . November/December 2008. Volume 31, Number 9. Pages 651-658.

MANAGEMENT OF CHRONIC SPINE-RELATED CONDITIONS: CONSENSUS RECOMMENDATIONS OF A MULTIDISCIPLINARY PANEL. Farabaugh et al. JMPT. Sept 2010. Volume 33, Number 7. Pages 484-492.

The 2008 paper pertains to acute pain and the 2010 paper pertains to chronic pain. Both papers suggest that electrical stimulation is a treatment option in the acute and chronic phases of treatment. Neither paper suggests the use of any passive therapy in isolation, but both papers are supportive of passive therapies in combination with active care recommendations, especially during the initial acute phases of care, but also after the first few weeks of care.

Lastly, a word of caution is warranted regarding research. Sackett, the father of evidence-based medicine, warns about being tyrannized by the evidence. He states, "Evidence-based medicine (EBM) means integrating individual clinical expertise with the best available external clinical evidence from systematic research."

He further states that, "Good doctors use both individual clinical expertise and the best available external evidence, and neither alone is enough. Without clinical expertise,
practice risks becoming [sic] tyrannized by external evidence, for even excellent external evidence may be inapplicable to or inappropriate for an individual patient. Without current best external evidence, practice risks becoming [sic] rapidly out of date, to the detriment of patients."

In summary:

1. ODG DOES NOT exclude the use of EMS if used in combination with other therapies. It only warns about using it as the sole means of treatment.
2. ODG does provide other statements that DO include the use of EMS in both the acute and chronic phases of care.
3. ODG supports CCGPP recommendations which do include the use of EMS as part of a multi-modal treatment plan in both the acute and chronic phases.
4. Research alone is not a basis to exclude EMS and/or any other therapy. One must also consider clinical expertise, patient values, the uniqueness of the patient, and response to care when evaluating the medical necessity of care.