SHORTWAVE DIATHERMY GENERATORS The shortwave diathermy unit consists of a power supply that provides power to a radio frequency

oscillator (Fig. 10-1). This radio frequency oscillator provides stable, drift-free oscillations at the required frequency. The power amplifier generates the power required to drive the different types of electrodes. The output resonant tank tunes in the patient as part of the circuit and allows maximum power to be transferred to the patient. Figure 10-2 shows the control panel of a shortwave diathermy unit. The output intensity knob controls the percentage of maximum power transferred to the patient circuit. This is similar to the volume control on a radio. The tuning control adjusts the output circuit for maximum energy transfer from the radio frequency oscillator, which is similar to tuning in a station on a radio. The power output meter monitors only the current that is drawn from the power supply and not the energy being delivered to the patient. Thus, it is only an indirect measure of the energy reaching the patient. The power output of a shortwave diathermy unit should produce sufficient energy to raise the tissue temperature into a therapeutic range. The specific absorption rate (SAR) represents the rate of energy absorbed per unit area of tissue mass. Most shortwave units have a power output of between 80 and 120 W. Some units are not capable of this, making them safe but ineffective. It is important to remember that the tissue temperature rise with diathermy units can be offset dramatically by an increase in blood flow, which has a cooling effect in the tissue being energized. Therefore, units should be able to generate enough power to provide for an excess of the SAR. Patient sensation provides the basis for recommendations of continuous shortwave diathermy dosage and thus varies considerably with different patients.29,44 The following dosage guidelines have been recommended. Dose I (lowest): No sensation of heat Dose II (low): Mild heating sensation Dose III (medium): Moderate (pleasant) heating sensation Dose IV (heavy): Vigorous heating that is tolerable below the pain threshold Some older shortwave diathermy generators have manual tuning although the majority of new models do have automatic tuning devices. If the machine is not an automatically tuning type, it is necessary to tune the patient's circuit to resonance with the oscillating circuit of the unit. This is accomplished by placing the electrodes over the area to be treated and then setting the output intensity at 30-40 percent. Then, the variable capacitor in the generator's circuitry can be adjusted by using the meter on the generator to determine the peak tuning readings. These readings should not be confused as an indication of the power received by the patient. The tuning control should be adjusted until the output power meter moves to the maximum and then it should be adjusted down to patient tolerance, which is usually about 50 percent of maximum output. If more than 50 percent of the available power on the meter is used, then the patient's setup is out of tune or out of resonance. Shortwave diathermy units with automatic tuning turn off the power when the patient circuit is out of tune. A shortwave diathermy unit that generates a high-frequency electrical current will produce both an electrical field and a magnetic field in the tissues.14 The ratio of the electrical field to the magnetic field depends on the characteristics of the different units as well as on the characteristics of electrodes or applicators. Shortwave units with a frequency of 13.56 MHz

tend to produce a stronger magnetic field than do units with the frequency of 27.12 MHz, which produces a stronger electric field. The majority of the new pulsed shortwave diathermy units use a drum electrode and produce a stronger magnetic field. SHORTWAVE DIATHERMY ELECTRODES Shortwave diathermy may be delivered to the patient via either capacitance or induction techniques. Each of these techniques can affect different biologic tissues, and selection of the appropriate electrodes is essential for effective treatment. The shortwave diathermy uses several types of applicators or electrodes, including air space plates, pad electrodes, cable electrodes, or drum electrodes. Capacitor Electrodes The capacitance technique, using capacitor electrodes, creates a stronger electrical field than a magnetic field. As discussed in Chapter 7, within the body there are many free ions that are positively or negatively charged. A positively charged electrode or plate will repel positively charged ions and attract negatively charged ions. Conversely, the negative electrode will repel negative ions and attract positive ions (Fig. 10-3). Capacitor Electrodes Air space plates Pad electrodes An electrical field is essentially the lines of force exerted on these charged ions by the electrodes that cause charged particles to move from one pole to the other (Fig. 10-4). The intensity of the electrical field is determined by the spacing of the electrodes and is greatest when they are close together. The center of this electrical field has a higher current density than regions at the periphery. When using capacitance electrodes, the patient is placed between two electrodes or plates and becomes part of the circuit. Thus, the tissue between the two electrodes is in a series circuit arrangement (see Chapter 5). As the electrical field is created in the biologic tissues, the tissue that offers the greatest resistance to current flow tends to develop the most heat. Tissues that have a high fat content tend to insulate and resist the passage of an electrical field. These tissues, particularly subcutaneous fat, tend to overheat when an electrical field is used, which is characteristic of a capacitance type of electrode application. Capacitor electrodes = strong electrical field Air Space Plates Air space plates are an example of a capacitance (strong electrical field) technique or a capacitor electrode. This type of electrode consists of two metal plates with a diameter of 7.517.5 cm surrounded by a glass or plastic plate guard. The metal plates may be adjusted approximately 3 cm within the plate guard, thus changing the distance from the skin (Fig. 10-

5).24 Air space plates produce high-frequency oscillating current that is passed through each plate millions of times per second. When one plate is overloaded, it discharges to the other plate of the lower potential, and this is reversed millions of times per second.16 When air space plates are used, the area to be treated is placed between the electrodes and becomes part of the external circuit (Fig. 10-6). The sensation of heat tends to be in direct proportion to the distance of the plate from the skin. The closer the plate is to the skin, the better the energy transmission because there is less reflection of the energy. However, it should be remembered that the closer plate will also generate more surface heat in the skin and the subcutaneous fat in that area (Fig. 10-7). The greatest surface heat will be under the electrodes. Parts of the body that are low in subcutaneous fat content (e.g., hands, feet, wrists, and ankles) are best treated by this method. Patients who have a very low subcutaneous fat content can be effectively treated in other body areas.15 This technique is also very effective for treating the spine and the ribs. Pad Electrodes Pad electrodes are seldom used in the clinical setting; however, they may be available for some units. They are true capacitor electrodes, and they must have uniform contact pressure on the body part if they are to be effective in producing deep heat, as well as in avoiding skin burns (Fig. 10-8). The patient is part of the external circuit. Several layers of toweling are necessary to make sure that there is sufficient space between the skin and the pads. The pads should be separated such that they are at least as far apart as the cross-sectional diameter of the pads. In other words, if the pads are 15 cm across, then there should be at least 15 cm between the pads. The closer the spacing of the pads, the higher the current density in the superficial tissues. Increasing the space between the pads will increase the depth of penetration in the tissues (Fig. 10-9). The part of the body to be treated should be centered between the pads.14,16,19,27 Induction Electrodes The inductance technique, using induction electrodes, creates a stronger magnetic field than an electrical field. When the induction technique is used in shortwave diathermy, a cable or coil is either wrapped circumferentially around an extremity or it is coiled within an electrode. In either case, when current is passed through a coiled cable a magnetic field is generated that can affect surrounding tissues by inducing localized secondary currents, called eddy currents, within the tissues (Fig. 10-10).24 Eddy currents are small circular electrical fields, and the intermolecular oscillation (vibration) of tissue contents causes heat generation. In the induction technique, the patient is in a magnetic field and is not part of the circuit. The tissues are in a parallel circuit, thus the greatest current flow is through the tissues with least resistance (see Chapter 5). When a magnetic field is used with an induction-type setup, the fat does not provide nearly as much resistance to the flow of the energy. Therefore, tissues that are high in electrolytic content (i.e., muscle and blood) respond best to the magnetic field by producing heat. It is important to remember that if the energy is owing primarily to generation of a magnetic field, heating may not be as obvious to the patient because the magnetic field will not provide nearly as much sensation of warmth in the skin as an electrical field. Cable Electrodes

The cable electrode is an induction electrode, which produces a magnetic field (Fig. 10-11). There are two basic types of arrangements: the pancake coil and the wraparound coil. If a pancake coil is used, the size of the smaller circle should be greater than 6 inches in diameter. In either arrangement, there should be at least 1 cm of toweling between the cable and the skin. Stiff spacers should be used to keep the coils or the turns of the pancake or the wraparound coil between 5 and 10 cm between turns of the cable, thus providing spacing consistency. Both the pancake coils and the wraparound coils often provide more even heating because they are able to follow the contours of the skin than are the drum or the air space plates. It is important that the cables not touch each other because they will short out and cause excessive heat buildup. Diathermy units that operate on a frequency of 13.56 MHz are probably best suited to cable electrode-type applications. This is primarily because the lower frequency provides better production of a magnetic field.15 Drum Electrodes The drum electrode also produces a magnetic field. The drum electrode is made up of one or more monoplanar coils that are rigidly fixed inside some kind of housing (Fig. 10-12). If a small area is to be treated, particularly a small flat area, then a one-drum setup is fine. However, if the area is contoured, then two or more drums, which may be on a hinged apparatus or hinged arm, may be more suitable. Penetration into the tissues tends to be on the order of 2-3 cm if the skin is no more than 1-2 cm away from the drum.5 The magnetic field may be significant up to 5 cm away from the drum. A light towel must be kept in contact with the skin and between the drum and the skin. The towel is used to absorb moisture because an accumulation of water droplets would tend to overheat and cause hot spots on the surface. If there is more than 2 cm of fat, there probably will be no great tissue temperature rise under the fat with a drum setup. The maximum penetration of shortwave diathermy with a drum electrode is 3 cm, provided there is no more than 2 cm of fat beneath the skin. For best absorption of energy, the housing of the drum should be in contact with the towel that is covering the skin.15 Figure 10-1. The component parts of a shortwave diathermy unit.

Figure 10-2. A. Shortwave diathermy unit. B. Control panel of a shortwave diathermy unit: A, Power switch; B, timer; C, output power meter (monitors current drawn from power supply only and not in patient circuit); D, output intensity (controls the percentage of maximum power transferred to the patient); and E, tuning control (tunes the output circuit for maximum energy transfer from radio frequency oscillator). Figure 10-3. A positively charged electrode or plate will repel positively charged ions and attract negatively charged ions. Conversely, the negative electrode will repel negative ions and attract positive ions.

Figure 10-4. An electrical field is essentially the lines of force exerted on these charged ions by the electrodes that cause charged particles to move from one pole to the other. (Modified from Michlovitz, S.: Thermal agents in rehabilitation, Philadelphia, PA, 1990, F.A. Davis.) Figure 10-5. Air space plate electrodes consist of a metal plate enclosed in a glass or plastic plate guard. The metal plate may be adjusted approximately 3 cm within the plate guard, thus changing the distance from the skin. Figure 10-6. Treatment of the low back with air space plates. The patient is in a series setup.

Figure 10-7. As the plate moves closer to the surface of the skin the electrical field shifts, generating more surface heat in the skin and the subcutaneous fat. Figure 10-8. Pad electrodes showing correct placement and spacing.

Figure 10-9. Pad electrodes should be separated by at least the diameter of the electrodes. A. Electrodes placed close together produce more superficial heating. B. As spacing increases, the current density increases in the deeper tissues. Figure 10-10. When current is passed through a coiled cable, a magnetic field is generated that can affect surrounding tissues by inducing localized secondary currents, called eddy currents, within the tissues. (Modified from Michlovitz, S.: Thermal agents in rehabilitation, Philadelphia, PA, 1990, F.A. Davis.) Figure 10-11. Pancake cable electrode.

Figure 10-12. Drum electrode.

CASE STUDY 10-1: SHORTWAVE DIATHERMY Background: A 22-year-old graduate student developed the gradual onset of lumbar paravertebral muscle spasm following a self-made move of his apartment contents. The symptoms were noted the day after the move upon arising and were described as a tightness and restriction of mobility in the low back. He reported no radiation of his symptoms into the buttocks or legs and no difficulty with bowel or bladder function. Physical examination revealed restriction in forward flexion and side rotation of the trunk with tenderness to

palpation in the lumbar paravertebral musculature 1 week after the episode of extensive bending and lifting. Impression: Lumbar paravertebral muscle strain, subacute. Treatment Plan: The patient was initiated on a course of inductive shortwave diathermy to the lumbar paravertebral musculature, followed by active and active-assisted lumbar region range of motion exercise. Treatment was provided on an every-other-day basis for 2 weeks with increasing emphasis on mobilizing and strengthening the lumbar paravertebral musculature. Response: The patient experience immediate, but short duration relief of his low back pain following the initial treatment and enthusiastically pursued his exercise sequence. With each subsequent session, the duration of relief and improved trunk mobility increased. At the 2week point in the treatment regimen, the patient was independent in the performance of his lumbar exercise regimen and scheduled to attend a back education class prior to discharge. Discussion Questions What tissues were injured/affected? What symptoms were present? What phase of the injury-healing continuum did the patient present for care in? What are the physical agent modality's biophysical effects (direct/indirect/depth/tissue affinity)? What are the physical agent modality's indications/contraindications? What are the parameters of the physical agent modality's application/dosage/duration/frequency in this case study? What other physical agent modalities could be utilized to treat this injury or condition? Why? How? The rehabilitation professional employs physical agent modalities to create an optimum environment for tissue healing while minimizing the symptoms associated with the trauma or condition. PULSED SHORTWAVE DIATHERMY Pulsed shortwave diathermy, also referred to in the literature as pulsed electromagnetic energy (PEME), pulsed electromagnetic field (PEMF), or pulsed electromagnetic energy treatment (PEMET), is a relatively new form of diathermy.20 Pulsed diathermy is created by simply interrupting the output of continuous shortwave diathermy at consistent intervals (Fig. 10-13). Energy is delivered to the patient in a series of high-frequency bursts or pulse trains. Pulse duration is short, ranging from 20 to 400 sec with an intensity of up to 1000 W per pulse. The interpulse interval or off time depends on the pulse repetition rate, which ranges between 1 and 7000 Hz. The pulse repetition rate may be selected using the pulse-frequency control on the generator control panel.24 Generally the off time is considerably longer than the on time. Therefore, even though the power output during the on time is sufficient to produce tissue heating, the long off time interval allows the heat to dissipate. This reduces the likelihood of any significant tissue temperature increase and reduces the patient's perception of heat.

Pulsed diathermy is claimed to have therapeutic value and to produce nonthermal effects with minimal thermal physiologic effects, depending on the intensity of the application. But pulsed shortwave diathermy can also have thermal effects.40 When pulsed diathermy is used in intensities that create an increase in tissue temperature, its effects are no different from those of continuous shortwave diathermy. Successful treatments have largely resulted from the application of higher intensities and longer treatment times. Studies that use pulsed shortwave diathermy do not normally compare it with continuous shortwave diathermy but rather with a control group that has received no heat treatment.28 Treatment Tip Pulsed shortwave diathermy is capable of heating a much larger area than ultrasound; the applicator is stationary so the heat applied to the area is more constant; the rate of temperature decay is slower following diathermy application allowing more time for stretching; using diathermy doesn't require constantmonitoring. With pulsed shortwave diathermy, mean power provides a measure of heat production. Mean power may be calculated by dividing peak pulse power by the pulse repetition frequency to determine the pulse period (on time plus off time).

The percentage on time is calculated by dividing the pulse duration by pulse period.

Pulsed Shortwave Diathermy uses drum electrodes. The mean power is then determined by dividing the peak pulse power by the percentage on time.

With pulsed shortwave diathermy, the highest mean power output is usually lower than the power delivered with continuous shortwave diathermy. Generators that deliver pulsed shortwave diathermy typically use a drum type of electrode (Fig. 10-14). As with continuous shortwave diathermy, the drum electrode is made of a coil wrapped in a flat circular spiral pattern and housed within a plastic case. The energy is induced in the treatment area via the production of a magnetic field. TREATMENT TIME

Treatments lasting only 15 minutes have produced vigorous heating of the triceps surae muscle of humans.9 A 20- to 30-minute treatment for one body area is probably all that is necessary to reach maximum physiologic effects.15 The physiologic effects, particularly circulatory, seem to last about 30 minutes. Treatments in excess of 30 minutes may create a circulatory rebound phenomenon in which the digital temperature may drop after the treatment because of reflex vasoconstriction. If a therapist finds that a diathermy unit has been left on in excess of 30 minutes, it would be wise to check the temperature of the toes or fingers, depending on which extremity has been treated. It was observed that pulsed shortwave diathermy administered to the triceps surae resulted in peak heating at only 15 minutes into the treatment, and the temperature actually dropped 0.3C from the 15- to 20-minute mark.9 Perhaps this can be explained by the increase in blood flow created by the thermal effects of diathermy. The increase in temperature and blood flow engages the body's natural cooling mechanism. Therefore, it may be more difficult to heat muscle tissue than the less vascular tendinous tissue. Perhaps tissue temperatures as high as 45C, as postulated by other researchers, are too high for the body to tolerate.9 Figure 10-13. Pulsed diathermy is created by simply interrupting the output of continuous shortwave diathermy at consistent intervals.

Figure 10-14. A. The Magnatherm. B. The Megapulse. Both are examples of generators capable of producing pulsed shortwave diathermy. Energy is delivered to the patient through a drum electrode. (courtesy of International Medical Electronics) (courtesy of Physiotechnology) CASE STUDY 10-2: SHORTWAVE DIATHERMY Background: A 79-year-old male with a documented history of right knee osteoarthritis, comes to your clinic with a history of increasing pain and swelling over the past 2 months. Gait endurance is beginning to decline. The referral was to initiate quadriceps strengthening, joint protection activities, and gait training as indicated. Impression: Degenerative joint disease with concurrent muscle inhibition and atrophy. Treatment Plan: The patient received 15 minutes of capacitive shortwave diathermy prior to initiating quadriceps exercise. He reported short-term relief, which allowed for the performance of his exercise program. Treatment was provided on a twice per week outpatient basis with the patient given specific instructions in the performance of home lower extremity closed-chain exercises two other times per week. At the tenth visit the patient was discharged as he was adequately self-managing his condition. Response Discussion Questions What tissues were injured/affected? What symptoms were present?

 What phase of the injury-healing continuum did the patient present for care in? What are the physical agent modality's biophysical effects (direct/indirect/depth/tissue affinity)? What are the physical agent modality's indications/contraindications? What are the parameters of the physical agent modality's application/dosage/duration/frequency in this case study? What other physical agent modalities could be used to treat this injury or condition? Why? How? Further Discussion Questions Was the choice of SWD optimal for this patient's suspected injury? What other things would you counsel this patient to be aware of while undergoing diathermy treatment? The rehabilitation professional employs physical agent modalities to create an optimum environment for tissue healing while minimizing the symptoms associated with the trauma or condition. It is important to remember that as skin temperature goes up, impedance goes down. Therefore, the unit may need to be returned after 5-10 minutes of treatment.