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Comparative effects of pulsed and continuous short wave diathermy on pain

and selected physiological parameters among subjects with chronic knee
osteoarthritis

Article  in  Technology and health care: official journal of the European Society for Engineering and Medicine · September 2013
DOI: 10.3233/THC-130744 · Source: PubMed

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Technology and Health Care 21 (2013) 433–440 433
DOI 10.3233/THC-130744
IOS Press

Comparative effects of pulsed and

continuous short wave diathermy on pain and
selected physiological parameters among
subjects with chronic knee osteoarthritis

Onigbinde Ayodele Teslima,∗, Adenle Charles Adebowalea , Adesola Ojo Ojoawoa,

Odejide Akinwole Sundayb and Arilewola Bosedeb
a Medical Rehabilitation Department, Faculty of Basic Medical Sciences, Obafemi Awolowo University,
Ile-ife, Osun State, Nigeria
b Department of Medical Rehabilitation, Obafemi Awolowo University Teaching Hospital Complex,

Ile-ife, Osun State, Nigeria

Received 22 June 2013

Accepted 24 July 2013

Abstract.
PURPOSE: The purposes of this study were to compare the effects of pulsed and continuous short wave diathermy on pain,
range of motion, pulse rate and skin temperature in subjects with chronic knee osteoarthritis.
METHODS: 24 Participants with grade 111 OA of the knee were randomly selected into CSWD and PSWD groups. Pre and
post treatment parameters were recorded at onset and the end of 4th week. ANO VA, independent, paired t-test and chi-square
were used to analyze the data.
RESULTS: The pain experienced by participants in the CSWD group was significantly lower than that of the PSWD groups
(P < 0.03) after 4 weeks. Also, both active and passive knee range of motions significantly increased in the CSWD group
compared to that of PSWD group (p < 0.01 and 0.002). Across the groups, there was no significant difference in the initial
pulse rate at onset of treatments and at the end of 4 weeks. There was an increase in skin temperature within a range of 0.61
to 0.63◦ C and 0.31 to 0.35◦ C of participants within both the CSWD and PSWD group respectively. The skin temperature of
participants who had continuous SWD was significantly higher after 4 weeks (F = 8.38, p < 0.001) but the difference was
insignificant within the pulse group. However, there was no significant difference in body temperatures of the 2 groups.
CONCLUSION: This study concluded that CSWD was more effective than PSWD in alleviating pain and in increasing knee
flexion range of motion among subjects with chronic knee OA. Also, a mild elevation of skin temperature was able to elicit
physiological effects that could exert therapeutic effects.

Keywords: Short wave diathermy, pain, skin temperature, osteoarthritis

∗
Corresponding author: Onigbinde Ayodele Teslim, Medical Rehabilitation Department, Faculty of Basic Medical Sciences,
Obafemi Awolowo University, Ile-ife, Osun State, Nigeria. Tel.: +234 806 258 7784; E-mail: ayotesonigbinde@yahoo.co.uk.

0928-7329/13/$27.50 
c 2013 – IOS Press and the authors. All rights reserved
434 O.A. Teslim et al. / Comparative effects of pulsed and continuous short wave diathermy on pain

1. Introduction

The clinical signs and symptoms of Osteoarthritis (OA) are pain, poor flexibility and restricted joint
range of motion [19]. The etiology of OA is frequently associated with excessive loading of joints,
occupational tasks, as well as hereditary, metabolic and endocrinological factors [3]. The primary goals
of managing knee osteoarthritis are to alleviate pain, improve functions, prevent and correct deformities
and retard disease progression [4]. There are several methods of thermotherapy being utilized and this
includes the use of electromagnetic radiation such as short wave diathermy (SWD). There are two modes
of SWD applications, namely continuous and pulsed forms [22].
Pulsed Shortwave Therapy (PSWT) dissipates electromagnetic energy in short burst, hence, the tissues
are subjected to a lower thermal load; and it is widely used in the UK [2]. The ‘non thermal’ effects
of the modality are generally thought to be of greater significance [25]. Continuous SWD increases
temperature from 37 to 45◦ C in deep tissues. Several studies had investigated the possible effect of
pulsed and continuous short wave on the rate of healing in patient with osteoarthritis; however there is
conflicting evidence [21]. Also, Continuous short wave (SWD) is poorly researched but pulsed SWD
have been found to produce a significant relief of pain associated with acute injuries, however, its value
in the treatment of chronic conditions remains to be adequately proven [7]. The efficacy of PSWD
and CSWD for the treatment of osteoarthritis of the knee is still inconclusive and there is an envelope
of doubt over which one is superior to the other especially in chronic knee osteoarthritis. Short wave
applied to tissue gives rise to conduction current and displacement current [13]. The rise in temperature
during the application of SWD depends on a factor known as the specific absorption rate. The specific
absorption rate is the rate by which energy is absorbed by a known mass of tissue; it is a function of
tissue conductivity and electrical field magnitude in tissue [13].
In Nigeria, there is dearth of data on skin thermal response following either application of CSWD or
PSWD. There are only a few published studies on the influence of various physical therapy approaches
on the skin temperature and other physiological changes. Aside these, most available literature describ-
ing the physiological and therapeutic effects of SWD are very old and are mostly reported in Europe [9,
20]. Furthermore, considering variations in skin structures and racial differences between blacks and
white, there is need for a local study which will monitor physiological responses following applications
of CSWD and PSWD. The primary aims of this study are to compare the therapeutic and physiological
effects of pulsed and continuous short wave diathermy in the management of chronic knee osteoarthri-
tis. It was hypothesized that there would be no significant difference in pre and post pain intensity levels
and active knee flexion between the knee OA patients that received pulsed and continuous short wave
diathermy. It was also hypothesized that there would be no significant difference in the pre and post
treatment skin temperature and pulse rate changes between the 2 groups of subjects with knee OA.

2. Materials and methods

2.1. Subjects

The participants comprised of 24 subjects with knee OA who were receiving treatment at the out-
patient physiotherapy clinic of Obafemi Awolowo University Teaching Hospital Complex (OAUTHC),
Ile-Ife, Osun staten Nigeria.
 O.A. Teslim et al. / Comparative effects of pulsed and continuous short wave diathermy on pain 435

2.2. Inclusion criteria

The Subjects were diagnosed of having knee osteoarthritis with duration of onset more than 3 months
and they had radiological report confirming knee OA with grade 111 using Kellgren and Lawrence clas-
sification [11]. Subjects with impaired thermal sensitivity, metallic implants and other contra-indications
for the use of Short wave diathermy were excluded from the study.

2.3. Instruments

The instruments used are SWD (Curaplus 967) and a 10 point semantic pain differential scale to rate
pain intensity while Goniometer (E-Z Read) was used to assess the active and passive range of motions
(ROMs).

2.4. Research design

The pretest and the posttest experimental design were used in this study.

2.5. Sampling technique

Subjects were purposively selected while random sampling through balloting was used to assign them
into 2 groups with 12 participants in each group. The participants were blinded to the group allocation.

2.6. Procedures

The Ethic and research committee of Obafemi Awolowo University Teaching Hospital Complex
(OAUTHC) granted approval for the study. The purposes and procedure of the research were explained to
each of the subjects prior to the commencement of data collection. All participants signed and informed
consent.
The participants maintained high sitting position on a wooden chair during application of SWD. They
were propped with pillow at the back for Comfort. The electrodes which are equal in size (13 cm in
diameter) were applied parallel to the skin surface using contra-planar technique (one on the medial side
of the knee joint and other on the lateral side); and they were slightly larger than the surface area of the
knee, with optimal electrode distance of 3 cm, equidistant from skin and electrodes [20].
Group 1 participants were treated with Continuous SWD mode while Group 2 had Pulsed SWD. Both
groups were treated for 20 minutes. The electrodes were aligned on the medial and lateral aspect of the
affected knee. Both groups had the pain intensity rated on a 10 point semantic differential pain rating
scale while the joint range of motions (active and passive knee flexion) were measured using goniometer
on weekly basis for 4 weeks (pre and post interventions).
The frequency of application (intervention) was twice a week for 4 weeks. After each treatment,
the pain intensities and joint ranges of motion were assessed and recorded. Both group had baseline
treatment programmes in the form of cycle ergometry for 15 minutes and stimulation massage using
diclofenac cream. The active and passive knee flexion ROM was assessed using the goniometer with the
patient lying in prone on the treatment couch. The reference point for the proximal arm of goniometer
was the greater tubercle of the hip joint while the distal reference point was the lateral malleolus of the
ankle joint.
436 O.A. Teslim et al. / Comparative effects of pulsed and continuous short wave diathermy on pain

Table 1 Table 2
Comparison of physical characteristics of the partici- Comparison of pain intensities, active and passive knee flexion range
pants of motions for participants in the continuous group
Variables Groups Mean SD t-cal p-value Variables Intervention periods Mean SD t-cal p-value
Age (yrs) CT 58.77 9.48 1.00 0.33 PI Pre intervention 4.85 0.80
PD 55.00 8.82 1.01 0.33 Post intervention 2.46 0.88 11.20 0.001
Height (m) CT 1.65 0.11 0.59 0.56 AKF Pre intervention 83.38 10.99
PD 1.63 0.06 0.62 0.54 Post intervention 101.92 8.91 −11.12 0.001
Weight (kg) CT 73.38 10.76 0.49 0.63 PKF Pre intervention 90.69 11.67
PD 71.45 8.21 0.50 0.62 Post intervention 106.92 8.32 −9.17 0.001
Key: CT = Continuous; PD = Pulsed; m = meters; Keys: PI = Pain Intensity; AKF = Active Knee Flexion; PKF =
yrs = years; kg = kilogram. Passive Knee Flexion.

The skin temperature was measured at the armpit of each participant using a mercury thermometer.
This was based on the report of Klein and Mba, that the primary effect of local application of heat
produces higher temperature at a site distant from the heating modality [12]. The skin temperature of
all the participants was taken at the same time of the day, same place and under the same condition.
They were all instructed not to apply an excessive force on the thermometer but only a mild pressure
that will firmly hold the thermometer in place. The thermometer was kept in place until the expansion
of the mercury stopped and it was cleansed after each use. The temperature was measured before and
immediately after application of SWD.
Pulse rate was assessed by placing 2 fingers on the radial artery at the wrist of the participants and the
number of pulse was counted for 15 seconds. The value obtained was multiplied by 4 and this gave the
number of pulses per minute.

2.7. Data analysis

The data were analyzed using descriptive statistics and parametric inferential statistics (Analysis of
variance, independent t-test and paired t-test). Analysis of variance (ANOVA) was used to compare the
pain intensities, ROMs, pulse rate and skin temperature (pre and post interventions on day 1; and pre
and post interventions on at the end of the 4th week) while paired t-test was used to compare pre and
post intervention values within each group on the first treatment day. The independent t-test was used
to compare age and anthropometric parameters of the 2 groups. Chi square test of analysis was used
to compare the pain intensity of the participants in the pulsed group when the paired t-test could not be
computed because the standard error of the difference was zero. The level of significance was set at 0.05.

3. Results

Table 1 shows the result of the Independent t-test comparing the physical characteristics of the
2 groups. There were no significant differences in the age, height and weights of the 2 groups.
Table 2 shows the result of the paired t-test comparing pain intensity, active and passive knee flexion
of participants in the continuous group at the end of the first treatment session. There are significant dif-
ferences in pain intensity, active and passive knee flexion on the first day and at the end of the 4th week.
There was no significant difference in the pulse rates measured prior to intervention and post interven-
tion, However there are significant differences in the skin temperature at different periods of intervention
(Table 3). The results of the post hoc analysis showed that the skin temperature was significantly higher
post intervention (p < 0.001) when compared to the skin temperature prior to intervention at the first
treatment session. Similarly, at the end of the 4th week, the skin temperature was significantly higher
 O.A. Teslim et al. / Comparative effects of pulsed and continuous short wave diathermy on pain 437

Table 3
Comparison of pulse rate and skin temperature of participants in the continuous group
Variable Interventions Mean SD F P -value
PR (beat/min) Pre intervention 69.31 7.13
Post intervention 73.92 8.65
Pre intervention (4th week) 68.62 6.50
Final intervention (4th week) 72.31 6.82 1.45 0.24
◦
STP ( C) Pre intervention 36.13 0.43
Post intervention 36.76 0.43
Pre intervention (4th week) 36.20 0.44
Final intervention (4th week) 36.81 0.39 8.38 0.001
Keys: PR = Pulse Rate; STP = Skin Temperature.

Table 4
Comparison of pulse rate and skin temperature of participants in the pulsed group
Variables Interventions Mean SD F P -value
PR (beat/min) Pre intervention 70.18 6.78
Post intervention 70.18 6.78
Pre intervention (4th week) 75.64 5.78
Final intervention (4th week) 75.64 5.78 2.78 0.05
STP (◦ C) Pre intervention 36.20 0.58
Post intervention 36.55 0.65
Pre intervention (4th week) 36.25 0.63
Final intervention (4th week) 36.56 0.58 1.21 0.32
Keys: PR = Pulse Rate; STP = Skin Temperature.

Table 5
Comparison of pre and post interventions pain intensities in the pulsed SWD group
Variables Interventions Mean SD χ2 P -value
PI Pre intervention 4.16 1.03
Post intervention 3.37 1.03 3.32 0.001
Key: PI = Pain Intensity.

than the initial temperature prior to intervention at the first treatment session (p < 0.001) and the pre
intervention temperature at the 4th week.
Table 4 presents the result of the ANOVA and comparing the pulse rate and skin temperature for
participant in the pulsed group. The result showed that there was a significant difference in the pulse
rates measured prior to intervention and post intervention (F = 2.78, p = 0.05). The results of the post
hoc analysis showed that the pulse rate was significantly higher post intervention (p < 0.001) than the
initial PR.
The result of chi square comparing pain intensity of participants in the pulsed SWD group is presented
in Table 5. The result showed that there was a significant difference in the pain intensity pre and post
intervention of participants in the pulse group. (χ2 = 3.32, p < 0.001).
The result of the paired t-test showed that there were significant differences in the pre and post inter-
ventions active and passive knee flexions on the first day of treatment among participants in the pulsed
group (Table 6). However, there was no significant difference in the pain intensity of the participants in
both groups at the first treatment session. There was also significant difference in the pain intensity of the
participants on a 10 point pain rating scale between the groups after 4 weeks of intervention (Table 7).
438 O.A. Teslim et al. / Comparative effects of pulsed and continuous short wave diathermy on pain

Table 6 Table 7
Comparison of active and passive knee flexion ROMS for Result of the independent t-test comparing the pain intensity
participants in the pulsed group of the continuous and pulsed group
Variables Interventions Mean SD t-cal p-value Variables Groups Mean SD t-cal p-value
AKF Pre intervention 79.60 10.92 Baseline pain CT 4.84 0.80 1.29
Post intervention 89.27 7.98 −8.62 0.001 intensity PD 4.36 1.03 1.27 0.22
PKF Pre intervention 84.91 10.86 Final pain CT 2.46 0.88 −2.32
post intervention 95.64 7.54 −8.53 0.001 intensity PD 3.36 1.03 −2.29 0.03
Keys: AKF = Active Knee Flexion; PKF = Passive Knee Keys: CT = Continuous; PD = Pulsed.
Flexion.

Table 8 Table 9
Result of the independent t-test comparing the active and Comparison of pulse rate and skin temperature of the continu-
passive knee flexion ROM of the continuous and pulsed ous and pulsed group
group
Variables Groups Mean SD t-cal p-value
Variables Groups Mean SD t-cal P -value Pulse rate (1st week) CT 69.31 7.13 −0.31
IKF AROM CT 83.38 10.99 0.98 PD 70.18 6.78 −0.31 0.76
PD 79.00 10.92 0.98 0.34
Pulse rate (4th week) CT 72.31 6.82 −1.20
FKF AROM CT 101.92 8.91 3.63 PD 75.64 5.78 −1.29 0.21
PD 89.27 7.98 3.67 0.01
ST◦ C (1st day) CT 36.13 0.43 −0.34
IKF PROM CT 90.69 11.67 1.25 PD 36.20 0.58 −6.33 0.75
PD 84.91 0.86 1.26 0.22
ST◦ C (4th week) CT 36.81 0.39 1.22
FKF PROM CT 106.92 8.32 3.45 PD 36.56 0.58 1.19 0.25
PD 95.64 7.54 3.50 0.02
Keys: CT = Continuous, PD = Pulsed, ST = Skin Temperature.
Keys: IKF = Initial Knee Flexion; FKF = Final Knee Flex-
ion; AROM = Active Range Of Motion; PROM = Passive
Range Of Motion: CT = Continuous: PD = Pulsed.

There was no significant difference in the baseline active knee flexion ROM of the participants in
both groups at the first treatment session. However there were significant differences in the final active
and passive knee flexion ROM across the groups after 4 weeks of intervention (Table 8). There was no
significant difference in the pulse rate and skin temperature between the groups (Table 9). There was an
increase of a range of 0.61 to 0.63◦C in the skin temperature of participants in the CSWD while a range
of 0.31 to 0.35◦ C was found in those in PSWD group (pre and post-interventions skin temperature).

4. Discussion

Short wave diathermy because of its deep heating effect is more effective than superficial heating
modalities in clinical practice [8]. Therapeutic application of heat results into vasodilatation with in-
crease in the release of inflammatory chemical mediators and nitrous oxide [18]. The vasodilatation
increases the rate of enzymatic biological reactions, the nerve conduction velocity, and soft tissue ex-
tensibility with resultant physiologic effects of promoting tissue healing, reducing pain and increasing
range of motion [17].
Our current findings showed that there was significant reduction in pain experienced; and an increase
knee flexion among participants who had CSWD compared to those who had PSWD. This is consistent
with the findings of Cetin who reported that pain experienced was remarkably reduced with improved
function following application of continuous wave diathermy [6]. Application of SWD in a single treat-
ment session at the first treatment session, decreased pain intensities and it also improved knee range
 O.A. Teslim et al. / Comparative effects of pulsed and continuous short wave diathermy on pain 439

of motion. The current findings are also consistent with that of Thiago et al. [24] and Laufer et al. [14]
on the usage of pulsed shortwave diathermy to facilitate pain relief and improved functions and qual-
ity of life for short term in subjects with knee osteoarthritis. Although, it is noteworthy that diclofenac
was applied topically but the effects became insignificant as both groups had it as baseline treatment
programme. The differences observed could only be attributed to the physiological effects of SWD.
Similarly, Steven et al. reported that pulse shortwave diathermy before stretching is an effective pro-
tocol for increasing tissue extensibility and range of motion [23]. Denegar et al. reported that at certain
range of therapeutic temperatures (103–104F), the collagen becomes more plastic [10]. Candi et al. also
reported the effectiveness of pulsed short-wave diathermy in heating large muscle mass which facilitated
muscles retaining heat [5].
There was no difference in the pulse rate and skin temperature of participants in the CSWD and
PSWD groups at the end of the 4th week. However, there was significant elevation of only the skin
temperature post intervention amongst the subjects who had CSWD at the first and the end of the 4th
week, while amongst participants in the pulsed group; there was significant increase in only the pulse
rate post intervention at the first treatment session and at the end of the 4th week. This implied that
pulsed SWD had effect in eliciting physiological changes which could affect the pulse rate.
This study found an increase of a range of 0.61 to 0.63◦C in the skin temperature of participants
following application of CSWD while a range of 0.31 to 0.35◦ C was observed for PSWD. These values
were low when compared to the values reported by Lehmann [15,16] and Oosterveld et al. who reported
an increase of 2.4◦C [20]. Although, Lehmann [16] reported values for tissue temperature and not skin
temperature. Lehmann reported that temperature increase of 1◦ C can reduce mild inflammation and
increase metabolism and that moderate heating, an increase of 2 to 3◦ C, will decrease pain and muscle
spasm while an increase of more than 3 to 4◦ C above baseline will increase tissue extensibility [16]. The
range of values observed in our study was still low compared to an increased value of 1.3◦ C obtained in
an old study by Abramson et al. [1]. The lower value of skin temperature may be attributed to the armpit
where the mercury thermometer was inserted for measurement, although, the superficial temperature
is low at the skin surface but it is higher in the tissue under point of application [12]. The values of
increment and efficacy within the groups in our study implied that the raised in skin temperature was
enough to exact therapeutic and physiologic effects because of pain reduction and increment in knee
range of motion. Klein and Mba reported that physiologic effects of temperature usually occur at the site
of the application and in distant tissues [12]. This study measured axillary (armpit) skin temperature but
it had been noted that it correlated relatively poorly with core body temperature. Also, skin temperatures
are also influenced by factors such as pressure contact and atmospheric temperature [26]. These might
limit the interpretation of the findings on skin temperature.
We concluded that continuous SWD was more effective than pulse SWD in alleviating pain among
participants with knee joint OA of more than 3 months duration of onset. Also, continuous SWD was
more effective than pulse SWD in increasing knee flexion range of motion. A mild elevation of skin
temperature from baseline to 0.31◦ C and 0.61◦ C for CSWD and PSWD respectively were enough to
elicit physiologic and therapeutic effects for the management of chronic knee osteoarthritis.
We recommend larger sample size and a control group in future studies. Also, tissue temperature
within the joint should be considered as an outcome measure in future studies.

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