Shortwave Diathermy and Knee Osteoarthritis

Submitted by: Victoria Cushard, Allison Wierda, McKenna Mathis, Abby Flaminio
 Shortwave diathermy (SWD) is the use of electromagnetic waves to provide a therapeutic

effect. There are two settings in which these waves can be delivered. These include a constant

mode, causing a thermal effect in the target tissue. The other possible mode, pulsed shortwave

diathermy (PSWD), delivers waves with a brief interruption between waves, which limits

thermal effects and allows for an athermal treatment.1

Within these two settings, there are two types: capacitive (electric field) and inductive

(magnetic field). With use of the capacitive plates, the patient’s tissue becomes part of the

electric circuit, inducing a flow through the body. With resistance to the current flow (fat tissue

has a greater resistance than muscle), the soft tissues heat up. Placement of the plates is

important in determining whether the heat is deep heat or if the desired effect is more superficial.

The further the distance apart the plates are from one another, the deeper the heating effect will

go, which results in less sensation of heat that the patient perceives. With the use of inductive

plates, the individual is subjected to an oscillating magnetic field which creates currents in the

body. This form provides a greater heating effect to the deeper muscles.1

SWD applied in a constant form, causes thermal effects. Heating of the tissues leads to a

decrease in pain and stiffness as well as increases blood flow to the area, resulting in an

increased nutrition delivery. Another common use of any heating agent is the general relaxation

effect that occurs. PSWD results in an athermal effect. Generally, this form results in an increase

in cellular activity in the area, reducing inflammatory activity.2

Osteoarthritis (OA) is a disease that is generally characterized by joint degeneration

secondary to chronic inflammation. According to Fukuda et al., OA is one of the most prevalent

diseases in the world and most commonly present in the knee joint. The most common symptoms

for OA generally include joint pain, stiffness and deficiencies in activities of daily living. To
limit these symptoms, Physical Therapy treatment plans generally include interventions to

provide relief of pain and improvement of function.2

Given the effects of SWD, this modality has potential to be used for treatment of OA to

limit pain and stiffness, increase range of motion and reduce inflammatory activity within the

joint. SWD is still controversial in its effectiveness for treatment of OA. Because of this

controversy, this literature review seeks to compare previous studies to help determine if SWD is

an effective treatment method for the symptoms that occur with OA in the knee.

Fukuda et al. conducted a study to explore the effect of PSWD treatment in varying

doses. The study was set up as a randomized, multi-clinic, placebo-controlled study. 121 women

were randomly distributed into four different groups including control, placebo, low dose

PSWD, and high dose PSWD. In the low dose PSWD group, participants received at 19

minute treatment with a power of 14.5 W. In the high dose PSWD group, subjects received at 38

minute treatment with a power of 14.5 W. With the difference of treatment times the low dose

group totaled 17 kJ of energy, whereas the high dose group totaled 33 kJ of energy. Each group

was given 3 treatments a week for 3 weeks. Numerical pain scale and Outcome scores (KOOS)

were used to determine effectiveness of treatment with measurements before, immediately after

and 12 months after treatment. Within the KOOS questionnaires there are 5 subscales including

symptoms, daily activities, pain, recreational function, and quality of life. It was found that both

treatment groups displayed a decrease in pain and improvement of function when compared to

non-treatment groups. In this study, there was not a significant difference between the dosage

groups, however a low dose appeared to be more effective in the long term.2

In a study done by Cetin et al., a single-blind, randomized, controlled trial was used to

compare hot pack, SWD, ultrasound and TENS on isokinetic strength, pain and functional status
of women with OA knees. One hundred patients were randomly assigned to five groups, 20

patients in each group. Patients were evaluated at baseline and after treatment sessions by a

physician who was blinded with regard to the type of treatment the patients were receiving.

Patients received treatment 3 times per week for 8 weeks. Groups 1-3 received hot pack,

isokinetic exercises, and either SWD, TENS, or ultrasound. Group 4 received just hot pack and

isokinetic exercises. Group 5 was the control and received only isokinetic exercises. Pain,

disability, ambulation and muscle strength were used to measure therapeutic effects of the

different programs. Pain was measured using a visual analog scale (VAS) after a 50-m walk,

disability was evaluated using the index of severity for knee osteoarthritis (ISK), ambulation was

evaluated by recording the time (secs) it took to walk 50-m as comfortably and as quickly as

possible, and muscle strength was measured using a computerized isokinetic dynamometer. The

treatment protocol, specifically for group 1 (SWD), utilized a frequency of 27.12 MHz. The

condenser field technique was used for 15 minutes as each patient sat in a chair and placed her

legs on a table with both knees fully extended during treatment. The isokinetic muscle-

strengthening exercise protocol was used after the physical agents and warming up. The study

found that VAS scores decreased significantly in all groups after treatment. Group 1 (SWD) and

group 4 had the greatest reduction in pain. Walking time, ISK scores, and muscle strength also

significantly decreased in all groups after treatment. It was concluded that significant

improvements were found in patients in all groups with regard to pain, walking time,

functioning, and isokinetic performance. Treatment groups 1-4 demonstrated greater

improvements compared with patients in group 5 (control group).3

In a study done by Jan et al., they investigated whether repetitive SWD could reduce

synovitis in patients with knee OA and examined the relationship between synovial sac thickness
and pain index. There were 36 patients who participated, and they were divided into 3 study

groups, as determined by the participants’ own decision rather than random assignment. There

were 2 treatment groups and 1 control group. The first treatment group consisted of 14 patients

who received SWD and the second treatment group consisted of 13 patients who received SWD

and nonsteroidal anti-inflammatory drugs (NSAIDs). The control group had 9 patients who did

not receive any treatment. Diagnostic ultrasound imaging was performed on the OA knees at the

initial evaluation and 3 follow-up sessions to assess synovial sac thickness of the knee joint

throughout the total therapy. A visual analog scale (VAS) was used for the assessment of knee

pain. Patients were asked their level of knee joint pain before and after treatment. The 2

treatment groups attended 30 session of 20 minutes induction-coil SWD therapy, 3-5 times/week.

The intensity of the current was set based on each participant’s sensation of warmth (a mild but

pleasant sensation of heat.) After 10 sessions of SWD the synovial sac thickness in both

treatment groups decreased to approximately 81% - 84% of the initial thickness. After 30

treatment sessions it was approximately 67% - 72% of the initial thickness. The synovial

thickness in the control group did not change during the follow ups. However, the pain index

showed that it was lower in the control group than either of the treatment groups. Therefore, the

results suggest that a decreased in synovial sack thickness and knee pain is induced with used of

a series of SWD treatments in patients with knee OA. The results also demonstrated that with

more treatment sessions, there was a greater reduction in synovial sac thickness and knee pain. 4

In the article constructed by Y. Luafer et al., a double blind, placebo-controlled

experiment was formed. The study compared three different treatments of subjects with knee

OA. One group received high intensity (thermal) pulsed shortwave diathermy (H-PSWD), the

second group received low intensity (athermal) pulsed shortwave diathermy (L-PSWD), and the
last group in the study received a sham treatment. Each subject received three 20-minute

treatment sessions, three times a week for three weeks. The subjects were assessed three times

during the duration of the experiment: prior to treatments, after the ninth (final) treatment, and

12 weeks following the ninth (final) treatment. The assessments included five different measures.

The first measure was the WOMAC Osteoarthritis Index, which measures pain, stiffness, and

functional ability of each of the subjects on a 10cm rule. The next four measures were aimed

at quantify the functional mobility of the subjects, the measures included the Timed Up and Go

test, Timed stair-climb test, Timed stair-descending test, and Three-minute walk test. The study

found that there was no significant difference between groups in any of the five measurement

tools over the three assessment periods. A significant difference was found in the reduction of

pain and stiffness (p=0.033 and p=0.008, respectively) over time amongst subjects as a whole,

but not between treatments groups in the WOMAC Osteoarthritis Index. Thus, the experiment

concludes that H-PSWD and L-PSWD have no effect in the treatment of OA of the knee. 5

From January to June of 2004, Rattanachaiyanont and Kuptniratsaikul conducted a

randomized, double-blind placebo-controlled trial to determine whether SWD in conjunction

with an exercise program improved OA outcomes in peri- and post-menopausal women. The

individuals in question ranged in age from 50-85 years and had been diagnosed with primary

knee OA. These women were separated into 2 groups. One group, consisting of 53 individuals,

received SWD for 20 minutes at 27.12 MHz with a condenser plate wrapped around the OA

knee. The other group, which served as the control group of 60 individuals, were set up the same

way as the test group, but the SWD machine was not turned on. For the exercise regimen, each

patient performed isometric quadriceps contractions and isotonic resistive contractions. The

physical therapist was aware whether the patient was in the treatment or control group, but the
physician testing outcomes was blinded. The primary outcome was measured based on a

modified version of the WOMAC index. This version evaluated pain, stiffness, and function of

those with knee OA. Other outcomes measures included walking speed, stair ascent and descent

times, and patient satisfaction. The participants were evaluated at a baseline of week 0, after the

3-week treatment, and then again 3 weeks post-treatment. The results of this study showed that

there was no significant difference between those treated with SWD and exercise versus exercise

alone regarding pain, stiffness, function, walking speed, stair ascent and descent time, and patient

satisfaction. Therefore, this study concluded that treating patients with knee OA with SWD do

not benefit more than those treated with exercise only. 6

In the study conducted by Moffett et al., patients with knee and hip OA were placed into

double blind, randomized control trial. The purpose of this study was to evaluate the

effectiveness of pulsed SWD in patients with OA. Of the 92 participants in the study, 46 of them

had bilateral knee OA and there was shown to be no significant differences in response to

treatment between those with hip or knee OA. The study constructed three groups: active group,

placebo group, control (no treatment) group. The active group received 23 Watts (82Pulse/sec X

7) and the placebo group experienced the same process without the machine being turned on.

The control group received no treatment. The outcomes were measured by pain diaries that had

each subject rate their level of pain on a 1-100 analog scale for sensory pain and affect pain, at

four set times a day. The subjects were also required to complete a General Health Questionnaire

(GHQ-30) at 3 separate set times during the study. The data collected four times a day and at the

three set assessment points were averaged among each group. The study found slight significant

differences over time of the sensory and affect pain ratings of P< .0001 for both active and

placebo groups, yet not a difference between those two groups. The active and placebo group’s
data showed an improvement in pain during treatment, but then returned to baseline after and

between treatments. The study stated that there was no overall significance between the three

treatment groups over time. It was also noted that the placebo group rated an improvement in

pain greater than that of the active treatment groups after each treatment, and those waiting for

surgery rated their pain higher (regardless of active, placebo, or control group) than those who

were not awaiting surgical intervention. Thus, the study concludes that there is no evidence for

the effectiveness of SWD and that most of the results were “placebo-mediated.” 7

After thoroughly analyzing the aforementioned six articles, it was noted that there was

some discrepancy among the study design, protocol, and date of publication. In regards to the

study design, some studies were randomized whereas others were not, some blinded the

participants and clinicians, and others went as far as to allow the participants to choose whether

they took part in the treatment or control group. This may have led to biased or inaccurate

results. Each study followed a different protocol, as well. In some studies, individuals received

SWD in conjunction with other treatments, such as exercise and modalities. Conversely, others

received just SWD. Therefore, the effects may have been attributable to the other factors and not

just SWD itself. In addition, none of these studies were conducted before 2011. This lack of

recent research may lead one to be skeptical of the efficacy of SWD treatment.

Although this literature review only focused on studies that treated knee OA with SWD,

the discrepancies between the study design, protocol, and date of publication resulted in no

definitive conclusion. Despite the evidence in support of SWD, the factors previously mentioned

overshadow the potential benefits of the modality. Therefore, one would conclude that there is

not sufficient evidence for SWD as a treatment modality within physical therapy for knee OA.
Reference List

1. Bellew JW, Michlovitz SL, Nolan T. Modalities for Therapeutic Intervention. Philadelphia
(PA): F.A. Davis Company; 2016.

2. Fukuda TY, Cunha RAD, Fukuda VO, et al. Pulsed Shortwave Treatment in Women With
Knee Osteoarthritis: A Multicenter, Randomized, Placebo-Controlled Clinical Trial. Physical
Therapy. 2011; 91(7):1009-1017.

3. Cetin N., Aytar A., Atalay A. & Akman M. N. Comparing hot pack, short-wave diathermy,
ultrasound, and TENS on isokinetic strength, pain, and functional status of women with
osteoarthritic knees: a single-blind, randomized, controlled trial. Am J Phys Med Rehabil.
2008; 87:443–451.

4. Jan MH, Chai HM, Wang CL, Lin YF, Tsai LY. Effects of repetitive shortwave diathermy for
reducing synovitis in patients with knee osteoarthritis: an ultrasonographic study. Phys Ther.
2006; 86(2):236–244.

5. Laufer Y, Zilberman R, Porat R, Nahir AM. Effect of pulsed short-wave diathermy on pain
and function of subjects with osteoarthritis of the knee: a placebo-controlled double-blind
clinical trial. Clinical Rehabilitation. 2005; 19(3):255-263.

6. Rattanachaiyanont M, Kuptniratsaikul V. No additional benefit of shortwave diathermy over

exercise program for knee osteoarthritis in peri-/post-menopausal women: an equivalence
trial. Osteoarthritis and Cartilage. 2008; 16(7).
7. Moffett JAK, Richardson PH, Frost H, Osborn A. A placebo controlled double blind trial to
evaluate the effectiveness of pulsed short wave therapy for osteoarthritic hip and knee pain.
Pain. 1996; 67(1):121-127.