---
title: Which PT Treatments Have Evidence? | HWY PT
description: "Ultrasound, TENS, traction and dry needling: an honest look at what the research really shows, and which physical therapy treatments hold up after 50."
image: https://hwypt.clinic/hubfs/HWY/hwy-modality-evidence-hero.jpg
---

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Common Physical Therapy Techniques

# Ultrasound, TENS, Traction, Dry Needling: Which Physical Therapy Treatments Actually Have Evidence?

Ultrasound, TENS, traction and dry needling: an honest look at what the research really shows, and which physical therapy treatments hold up after 50.

[Dr. Raj Pusuluri, PT, DPT](https://hwypt.clinic/blog/author/raj-pusuluri)

 Oct 16, 2026

---

You lay face down on a padded table. Someone put warm gel on your back. A machine hummed against your skin for eight minutes. Then it stopped, you got dressed, and you drove home.

Maybe that helped. Maybe it did not. You have probably wondered about it ever since, and never quite known who to ask.

This article is our attempt to answer that honestly. We are a physical therapy clinic, and we are about to tell you that several treatments our own profession uses every day do not have strong research behind them.

That is an uncomfortable thing for us to publish. We think you deserve it anyway.

## How to read this article

Before the answers, a short guide. It will make everything below make sense.

### What we mean by "the evidence"

We are not quoting single studies. One study can point any direction by chance, by design, or by who paid for it.

Instead we use two stronger things. The first is a **systematic review**, where researchers gather every decent trial on a question and pool the results. The second is a **clinical guideline**, where an expert panel reads all of that and writes down what clinicians should do.

Reviewers also rate how much you should trust their own answer. You will see the words high, moderate, low and very low certainty throughout this article. Low certainty does not mean the researchers were careless. It means the underlying trials were small, or poorly blinded, or disagreed with each other.

### Evidence is specific to a condition

This is the part people miss most often, so we will say it plainly. A guideline about knee arthritis does not settle a question about heel pain.

You will see that exact situation twice below. One guideline says do not use dry needling for arthritis. A different guideline says dry needling helps plantar fasciitis. Both are correct, because they are answering different questions.

So whenever we quote a rule, we will tell you which condition it covers. If your condition is not the one named, the rule does not automatically apply to you.

### "We do not know" is a real answer

There is a difference between these two sentences, and it matters:

- "This treatment has little or no effect."
- "The research cannot tell us whether this treatment works."

The first is a finding. The second is a gap. A gap is not proof of failure, and it is not permission to promise results either. It simply means nobody has done the studies well enough yet.

You will meet both kinds of answer below. We have labeled which is which every time.

## The short answers, in one table

Here is the summary, strongest evidence at the top. Details, conditions and caveats follow underneath.

| Treatment | What the best evidence says | Condition studied | Certainty |
| --- | --- | --- | --- |
| Exercise | Helps pain and function, but newer reviews call the size of the benefit uncertain | Knee arthritis; chronic low back pain | Low to moderate |
| Dry needling | Helps pain in the short term, up to about 12 weeks; long-term benefit not shown | Muscle and joint pain; plantar fasciitis | Very low to moderate |
| Manual therapy | Small benefit, and guidelines say only alongside exercise | Hip and knee arthritis; chronic low back pain | Low to very low |
| TENS | Two strong reviews disagree. See the section below | Chronic pain; acute and chronic pain | Very low, and separately moderate |
| Braces and insoles | Not recommended routinely, with named exceptions | Osteoarthritis | Guideline position |
| Traction, low back | Little or no effect on pain, function or return to work | Low back pain, with or without sciatica | Low to moderate |
| Traction, neck | Research can neither support nor refute it | Chronic neck disorders | Very limited |
| Therapeutic ultrasound | Evidence does not support its use | Chronic low back pain | Very low to low |

## Therapeutic ultrasound

This is the humming machine from the opening paragraph. A therapist puts gel on your skin and moves a small round head over the area. It uses sound waves you cannot hear, and it usually feels like nothing at all, or mildly warm.

### Does ultrasound therapy work?

For long-standing low back pain, the honest answer is that it has not been shown to. A Cochrane review published in 2020 pooled 10 trials with 1,025 people and reached this conclusion:

> The current evidence does not support the use of therapeutic ultrasound in the management of chronic LBP.

In plain words: the studies we have do not give a reason to use it for ongoing back pain.

The same reviewers rated their certainty as very low for pain relief. They found small gains in function at low certainty, and said those gains were not large enough to matter clinically. They also noted the trials were small and often poorly blinded.

Ultrasound also appears on a separate list. The UK guideline body NICE publishes a guideline on **osteoarthritis**, which is the wear and tear kind of arthritis. That guideline names ultrasound therapy among treatments clinicians should not offer:

> Do not offer any of the following electrotherapy treatments to people with osteoarthritis because there is insufficient evidence of benefit: transcutaneous electrical nerve stimulation (TENS), ultrasound therapy, interferential therapy, laser therapy, pulsed short-wave therapy, neuromuscular electrical stimulation (NMES).

That instruction covers osteoarthritis only. It is not a ruling about every condition on earth.

**Where it may still be reasonable.** Neither source says ultrasound harms anyone. Neither covers every diagnosis. A therapist who uses it briefly to make you comfortable enough to move is not doing something outrageous. What we would question is a plan built mainly around it, week after week, with nothing measured.

## TENS

TENS stands for transcutaneous electrical nerve stimulation. We will just call it TENS from here. Sticky pads go on your skin, a small unit sends a mild current through them, and you feel a buzzing or tingling. Many people find it pleasant.

TENS is the one treatment here where two serious research teams looked at the evidence and came to different conclusions. Both are worth your attention.

### The cautious answer

In 2019 a Cochrane team reviewed the existing Cochrane reviews on TENS for long-standing pain. That covered 9 reviews, 51 trials and 2,895 people. Their conclusion:

> We were therefore unable to conclude with any confidence that, in people with chronic pain, TENS is harmful, or beneficial for pain control, disability, health-related quality of life, use of pain relieving medicines, or global impression of change.

Read that carefully. It does not say TENS fails. It says the research was not good enough to tell, in either direction.

### The more positive answer

In 2022 a different team published a much larger analysis in BMJ Open, covering 381 trials and 24,532 people. For the comparison against a dummy treatment, which drew on 91 trials and 4,841 people, they concluded:

> There was moderate-certainty evidence that pain intensity is lower during or immediately after TENS compared with placebo and without serious adverse events.

In plain words: pain tends to be lower while the machine is on, and it appears to be safe.

### Why two good reviews disagree

This is genuinely useful to understand, because it happens across medicine.

They asked different questions. The 2019 team looked only at long-standing pain. The 2022 team included short-term pain too, and short-term pain may simply respond better.

They used different nets. The 2019 team reviewed only existing Cochrane reviews, which are strict about which trials they admit. The 2022 team went straight to the trials themselves and found 381 of them.

They measured at different moments. "Pain intensity during or immediately after" is not the same outcome as lasting pain control, disability or quality of life. TENS may well do the first without doing the second.

And there is a problem neither team could solve. You cannot properly blind a treatment the patient can feel. If the machine buzzes, you know you got the real one, and expectation becomes part of the result. That single fact drags down the certainty rating of almost every trial in this article.

**Where it may still be reasonable.** A safe, drug-free thing that makes you comfortable enough to do your exercises is not nothing. Just know what you are signing up for: comfort now, with real uncertainty about lasting change. And note that TENS sits on the NICE do-not-offer list for **osteoarthritis** specifically, quoted in full above.

## Traction

Traction means pulling. A machine, a harness or a therapist's hands apply a gentle stretch along the spine, usually for a set number of minutes. It is often used for back or neck pain, especially when pain travels down a limb.

For the low back, the answer is one of the clearest in this article. A Cochrane review from 2013 pooled 32 trials and 2,762 people:

> These findings indicate that traction, either alone or in combination with other treatments, has little or no impact on pain intensity, functional status, global improvement and return to work among people with LBP.

That is a finding, not a gap. The reviewers rated the evidence low to moderate quality.

The neck is a different story, and it is the perfect example of the distinction we drew earlier. A Cochrane review of mechanical traction for neck pain looked at 7 trials covering 958 people, of which only one had a low risk of bias:

> The current literature does not support or refute the efficacy or effectiveness of continuous or intermittent traction for pain reduction, improved function or global perceived effect when compared to placebo traction, tablet or heat or other conservative treatments in patients with chronic neck disorders.

In plain words: for necks, nobody has done the studies well enough to say either way.

**Where it may still be reasonable.** Some people report that traction eases leg or arm symptoms while it is happening. That is a real experience and we do not dismiss it. It is just not a foundation for a long plan of care.

## Dry needling

A therapist inserts a very thin needle into a tight band of muscle. There is no medicine in the needle. You may feel a brief twitch, an ache, or a deep cramp-like sensation.

Here the research is more encouraging, with an important limit on the clock. A 2017 review in the Journal of Orthopaedic and Sports Physical Therapy pooled 13 trials and found:

> Very low-quality to moderate-quality evidence suggests that dry needling performed by physical therapists is more effective than no treatment, sham dry needling, and other treatments for reducing pain and improving pressure pain threshold in patients presenting with musculoskeletal pain in the immediate to 12-week follow-up period.

In plain words: it appears to help with pain for up to about three months. The same authors add that evidence of long-term benefit is currently lacking.

Now watch what happens when we change the condition. The NICE osteoarthritis guideline is blunt:

> Do not offer acupuncture or dry needling to manage osteoarthritis.

But a 2025 summary in American Family Physician, reporting the American Physical Therapy Association guideline for plantar fasciitis, says this:

> Dry needling of the gastrocnemius, soles, and plantar muscles improves pain and reduces disability for up to 6 months.

Two respected bodies, opposite instructions, no contradiction. One is talking about worn joints. The other is talking about an irritated band of tissue under the heel. This is the single clearest proof in this article that the right question is never "does this treatment work", but "does this treatment work for what I have".

So if someone offers you dry needling, the useful question is not whether it works in general. It is which of those two categories your own problem sits in.

## Manual therapy

This is hands-on work: joint movement, pressure through stiff segments, soft tissue techniques. Most people find it the most pleasant part of a session, which is worth naming honestly, because pleasant and effective are not the same thing.

The NICE osteoarthritis guideline permits it, but with two conditions attached:

> Only consider manual therapy (such as manipulation, mobilisation or soft tissue techniques): for people with hip or knee osteoarthritis and alongside therapeutic exercise.

In plain words, for **osteoarthritis**: hips and knees only, and never as the whole treatment.

For long-standing low back pain, a 2026 Cochrane review of spinal manipulative therapy pooled 76 trials and 11,866 people. Against a dummy treatment at one month, average pain fell by about 7 points on a 100-point scale, with a range that ran from about 12 points down to about 1.5. Compared against other conservative treatments, the authors describe little to no difference in pain, with a small improvement in function. Every comparison was rated low or very low certainty.

**Where it is reasonable.** Hands-on work can reduce pain and stiffness enough to let you move better today, and moving better today is how exercise becomes possible. That is a sound use of it. A course of hands-on treatment with no exercise attached is a different proposition, and the guidelines do not support it.

## Braces, insoles, tape and supports

People often expect us to hand them a support. Sometimes we do. More often we explain why we are not going to, and readers are frequently surprised by how firm the guideline wording is.

For **osteoarthritis**, NICE says:

> Do not routinely offer insoles, braces, tape, splints or supports to people with osteoarthritis unless: there is joint instability or abnormal biomechanical loading and therapeutic exercise is ineffective or unsuitable without the addition of an aid or device and the addition of an aid or device is likely to improve movement and function.

Note the word "and" between those three conditions. All three have to be true, not just one.

In plain words: a support is a considered exception for a joint that is genuinely unstable or loading badly, not a default. And again, that recommendation covers osteoarthritis. Other conditions, including several foot problems, have their own separate guidelines that read differently.

## Exercise, and its own limits

![Older man performing a guided resistance band exercise while a physical therapist watches his form in a Salem clinic](https://hwypt.clinic/hubfs/HWY/hwy-modality-exercise-therapy-1.jpg)

Here is the positive answer. Exercise has the best evidence of anything in this article. It also has real limits, and we are going to publish those too, because an article that audits everyone else's tools and protects its own would be worthless.

The NICE osteoarthritis guideline makes exercise the core recommendation:

> For all people with osteoarthritis, offer therapeutic exercise tailored to their needs (for example, local muscle strengthening, general aerobic fitness).

That is an "offer to everyone" instruction. It is the strongest wording in the whole guideline.

### Where the picture gets more honest

Now the part most clinics leave out. In 2015, a Cochrane review of exercise for knee arthritis pooled 54 trials and reported high-quality evidence of about a 12-point pain reduction on a 100-point scale.

In 2024 that review was updated. The new version was far larger, covering 139 trials and 12,468 people, and it was noticeably more cautious. Pain improved by roughly 9 to 13 points depending on the comparison, and function by roughly 10 to 13 points. The authors concluded:

> Exercise probably results in an improvement in pain, physical function, and quality of life in the short-term. However, based on the thresholds for minimal important differences that we used, these benefits were of uncertain clinical importance.

In plain words: exercise helps, and the newer, bigger review was not confident the average benefit is large enough for a person to clearly notice.

Chronic low back pain shows a similar split. A 2021 Cochrane review of 249 trials found moderate-certainty evidence that exercise reduced pain by about 15 points on a 100-point scale. For physical function the improvement was about 7 points, and the authors state plainly that it did not meet their threshold for a difference that matters clinically. Worth noting for our readers: the average participant in those trials was about 44 years old, younger than most people reading this.

### So why do we still build care around exercise?

Four reasons, and we think they are good ones.

It is the only item in this article that a major guideline tells clinicians to offer to everyone with the condition. It is the only one where the debate is about the size of the benefit, rather than whether there is one. It produces changes you can measure yourself, like standing from a chair or climbing stairs. And it keeps working after your course of care ends, which nothing passive on this list can claim.

Honest version: exercise is not magic, and the averages are more modest than the fitness industry implies. It is still the best thing we have.

## Our own device, held to the same standard

We use a device called the Neubie in our clinic. It would be easy to write this whole article and quietly skip that. We are not going to.

The Neubie is FDA-cleared as a Class 2 device. It uses direct current, and its maker states plainly that it is not a TENS unit, since TENS uses alternating current.

Its cleared uses are:

- neuromuscular re-education
- maintaining or increasing range of motion
- increasing local blood circulation
- preventing atrophy
- reducing spasms
- preventing venous thrombosis after surgery
- management or relief of chronic pain
- management of pain after surgery or injury

That is the whole list. It names no disease, and we will never tell you otherwise.

Now the uncomfortable part. The NICE list we quoted twice above tells clinicians not to offer electrical treatments for **osteoarthritis**, and it names both TENS and neuromuscular electrical stimulation. The Neubie is not on that list by name and uses a different current. We are not going to lean on that distinction to excuse ourselves.

So here is our position, stated plainly. We do not use the Neubie as a primary treatment for osteoarthritis. It is not a substitute for exercise, and we do not present it as one. It is a tool we use alongside a program, mostly where nerve and muscle recruitment is the problem.

The strongest study on it is a 2025 trial in the Journal of Diabetes Research, with 150 people across 13 affiliated sites, comparing it against TENS for diabetic peripheral neuropathy. The device group improved on several measures where the TENS group did not.

Now the same scrutiny we applied to everything else. That was one trial, not a systematic review, which makes it a weaker form of evidence than almost every source above. It was open-label, meaning nobody was blinded, which is exactly the flaw we described in the TENS section. And the sites belonged to one affiliated network.

It is promising. It is not settled. We would like to see it repeated by people with nothing riding on the answer.

## What this means for you as a patient

![Older man asking his physical therapist a question about his treatment plan in a Salem clinic](https://hwypt.clinic/hubfs/HWY/hwy-modality-questions-to-ask.jpg)

None of this means you should walk into your next visit ready for an argument. Most therapists are thoughtful people who want you to get better, and guidelines change faster than anyone's training does.

It does mean you are allowed to ask questions. Here are four that work, asked in a normal tone:

1. **What is this treatment for?** You are asking about the goal, not challenging the choice.
2. **What does the evidence say for my condition?** The condition part matters, for every reason above.
3. **What are we going to measure?** Steps, stairs, a pain score, minutes standing. Something countable.
4. **When will we review whether it is working?** A date, not a feeling.

A good therapist will welcome all four. If a plan cannot survive those questions, that is useful information for you.

We have written more about [how to tell whether your therapy is actually working](https://hwypt.clinic/blog/is-my-physical-therapy-working-over-50-salem), including what a fair review point looks like. And if you are trying to work out whether therapy or a surgical opinion is your next step, [that decision has its own guide](https://hwypt.clinic/blog/do-i-need-surgery-or-physical-therapy-over-50-salem).

## What we do, and why

Our approach follows from everything above.

Care is exercise-led. Hands-on work and comfort measures exist to make the exercise possible, not to replace it. We set something countable at the start, so progress is not a matter of opinion. We agree a review date, and we keep it.

If something is not working by that date, we say so and change the plan. That is the whole method. It is less exciting than a machine, and it is what the research supports.

Soreness after a session can be normal, and it can also be a signal. We have written about [how to tell those two apart](https://hwypt.clinic/blog/is-it-normal-to-hurt-after-physical-therapy-over-50-salem).

## Frequently asked questions

**My last therapist used ultrasound on me. Was I wasting my time?**

Almost certainly not, and we would not want you to walk away thinking that. A course of care is rarely just one machine. You were also seen, examined, reassured, given exercises and asked to come back, and those things carry real value.

Pain also fluctuates, and improvement during a course of treatment is common whatever was used. What the research questions is whether the ultrasound itself was the active part. That is a narrow claim, and it is not a judgment of your therapist or of you.

**Should I throw away my TENS unit?**

No. Two strong reviews disagree about it, the larger one found lower pain intensity during and right after use, and serious side effects were not reported. If it makes you comfortable enough to move, keep using it. Just do not expect it to change the underlying problem on its own.

**Is dry needling safe, and should I ask for it?**

The 2017 review found it more effective than no treatment and than sham needling for short-term pain. Whether it fits you depends on your condition. Remember the contrast above: a guideline recommends against it for osteoarthritis, while a plantar fasciitis guideline reports benefit for up to six months. Ask which category your problem falls into.

**Why do clinics still use treatments with weak evidence?**

Several ordinary reasons, none of them sinister. Guidelines have changed a lot in the past decade, and continuing education takes time to catch up. Some patients genuinely feel better with these treatments. And a clinic that has owned a machine for fifteen years has an understandable habit built around it. Habit is not fraud. It is just worth examining.

**Does this mean physical therapy does not work?**

No, and that would be the wrong lesson entirely. It means the active ingredient is usually the part where you move, load and progress, not the part where a machine is applied to you. Exercise carries the strongest recommendation in every guideline quoted here. The honest caveat is that the size of the average benefit is more modest than most advertising suggests.

**How do I bring this up without offending my therapist?**

Ask about goals rather than credentials. "What are we hoping this does, and how will we know?" is a question any good clinician is glad to answer. If you would rather start fresh, [here is what a first visit involves](https://hwypt.clinic/blog/first-physical-therapy-visit-after-50-salem).

## Talk it through with us

If you have been through a course of treatment and are not sure it did anything, that is a reasonable thing to want a second opinion on. Dr. Raj Pusuluri, PT, DPT, works with adults over 50, and the conversation starts with what you want to be able to do again.

Book a **Wellness Video Call** and talk it through from home before you decide anything: [schedule a time here](https://meetings.hubspot.com/raj-pusuluri/virtual-pt-visit?uuid=29177845-1ade-43b0-87d2-1cba35e0a730), or call **(971) 202-1979**.

Direct-pay, no insurance required.

---

**HWY Physical Therapy**

**North Salem:** 2615 Portland Rd NE, Salem, OR 97301 (at Center 50+). Walk-ins welcome.

**South Salem:** HWY Physical Therapy Clinic South Salem, 180 Ramsgate Square S, Salem, OR 97302. By appointment only.

**Phone (both locations):** (971) 202-1979

**Hours:** Monday to Friday, 8:00 AM to 5:00 PM

---

## Sources

1. National Institute for Health and Care Excellence. *Osteoarthritis in over 16s: diagnosis and management* (NG226), recommendations 1.3.1, 1.3.6, 1.3.8, 1.3.9 and 1.3.11. [Full text via NCBI Bookshelf](https://www.ncbi.nlm.nih.gov/books/NBK588843/)
2. Ebadi S, et al. Therapeutic ultrasound for chronic low back pain. *Cochrane Database of Systematic Reviews*, 2020. [PMID 32623724](https://pubmed.ncbi.nlm.nih.gov/32623724/)
3. Wegner I, et al. Traction for low-back pain with or without sciatica. *Cochrane Database of Systematic Reviews*, 2013. [PMID 23959683](https://pubmed.ncbi.nlm.nih.gov/23959683/)
4. Graham N, et al. Mechanical traction for neck pain with or without radiculopathy. *Cochrane Database of Systematic Reviews*, 2008. [PMID 18646151](https://pubmed.ncbi.nlm.nih.gov/18646151/)
5. Gibson W, Wand BM, Meads C, Catley MJ, O'Connell NE. Transcutaneous electrical nerve stimulation (TENS) for chronic pain: an overview of Cochrane Reviews. *Cochrane Database of Systematic Reviews*, 2019. [PMID 30941745](https://pubmed.ncbi.nlm.nih.gov/30941745/)
6. Johnson MI, Paley CA, Jones G, Mulvey MR, Wittkopf PG. Efficacy and safety of transcutaneous electrical nerve stimulation (TENS) for acute and chronic pain in adults: a systematic review and meta-analysis of 381 studies. *BMJ Open*, 2022. [PMID 35144946](https://pubmed.ncbi.nlm.nih.gov/35144946/)
7. Gattie E, Cleland JA, Snodgrass S. The effectiveness of trigger point dry needling for musculoskeletal conditions by physical therapists: a systematic review and meta-analysis. *Journal of Orthopaedic and Sports Physical Therapy*, 2017. [PMID 28158962](https://pubmed.ncbi.nlm.nih.gov/28158962/)
8. American Academy of Family Physicians. Practice guidelines: plantar fasciitis (American Physical Therapy Association), 2025. [Read the summary](https://www.aafp.org/pubs/afp/issues/2025/0200/practice-guidelines-plantar-fasciitis.html)
9. Lawford BJ, et al. Exercise for osteoarthritis of the knee. *Cochrane Database of Systematic Reviews*, 2024. [PMID 39625083](https://pubmed.ncbi.nlm.nih.gov/39625083/)
10. Fransen M, et al. Exercise for osteoarthritis of the knee. *Cochrane Database of Systematic Reviews*, 2015. [PMID 25569281](https://pubmed.ncbi.nlm.nih.gov/25569281/)
11. Hayden JA, et al. Exercise therapy for chronic low back pain. *Cochrane Database of Systematic Reviews*, 2021. [PMID 34580864](https://pubmed.ncbi.nlm.nih.gov/34580864/)
12. de Zoete A, et al. Spinal manipulative therapy for adults with chronic low back pain. *Cochrane Database of Systematic Reviews*, 2026. [PMID 41494147](https://pubmed.ncbi.nlm.nih.gov/41494147/)
13. NeuFit. The Neubie: frequently asked questions. [neu.fit/faq](https://www.neu.fit/faq)
14. Kostopoulos D, et al. An open-label comparative study of two types of electrical stimulation on physical therapy treatment of diabetic peripheral neuropathy. *Journal of Diabetes Research*, 2025. [PMID 39949402](https://pubmed.ncbi.nlm.nih.gov/39949402/)

*This article is general information, not medical advice. It does not tell you to stop or refuse any treatment. If you have questions about your own care, talk to the clinician who knows your case.*

[Common Physical Therapy Techniques](https://hwypt.clinic/blog/tag/common-physical-therapy-techniques) [Salem Oregon](https://hwypt.clinic/blog/tag/salem-oregon) [Seniors 50+](https://hwypt.clinic/blog/tag/seniors-50) [Healthy Aging](https://hwypt.clinic/blog/tag/healthy-aging)

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