Short-wave Diathermy in the treatment of Knee Osteoarthritis

Submitted by:

Malak Ayache, Megan Brow, Eldon Graham, and Joe Mitrzyk

 In the Western world, the most common form of arthritis is knee osteoarthritis (OA). In

adults over 60 years old the prevalence is 10-15%. Some of the primary symptoms of knee OA

include joint stiffness, morning pain, joint swelling, muscle weakness, and joint instability.

These indications decrease the quality of life in patients and reduce the ability to do ADLs, such

as house work, occupation duties, walking, and stair-climbing. Since OA cannot be treated, the

main goal is to alleviate signs and symptoms along with slowing down the progression of the

disease. There are various research studies that explore the benefits of usage of modalities with

patients that have knee OA.1

Short-wave diathermy (SWD) is one of the oldest electrotherapeutic modalities

conventionally used by physical therapists to treat symptoms of knee OA. SWD is typically

utilized in a continuous (CSWD) or a pulsed (PSWD) mode. PSWD is used for athermal effects

and results in increased blood flow, decreased joint pain and stiffness, reduced inflammation, and

faster resolution of edema.1 CSWD produces thermal effects that result in: reducing

inflammation, muscle spasms, and chronic inflammation, while it increases laxity in joints, pain

threshold, blood flow, and soft tissue and collagen extensibility. The goal of any treatment of

knee OA is to relieve pain, to improve function, and to alleviate joint destruction by changing the

inflammatory process.2 The following paper will be reviewing and analyzing the usage of SWD

and its effect on knee OA.

Jan and Chai conducted research on the Effects of Repetitive Shortwave Diathermy for

Reducing Synovitis in Patients with Knee Osteoarthritis. Jan and Chai realized that decreased

synovial inflammation in patients with knee OA had not been investigated previously. SWD is

known to improve circulation, decrease inflammation and pain for patients with OA. The
purpose of this study was to investigate whether repetitive SWD, could reduce synovitis in

patients with knee OA.2

The study Jan and Chai produced had 6 men and 24 women for a total of 30 participants.

Participants were split randomly into three groups: 14 participants received SWD, 13 received

SWD and NSAIDS, and a control group of 9 participants received no treatment. Measurements

were assessed by using a pain index scale and evaluating synovial sac thickness of the knee

joints. By sitting the subject in a relaxed recumbent position with the knee at 30 degrees of

flexion, this position allows overstretching of the synovial sac to be avoided. To measure the

thickness, researchers used a technique of applying some pressure on the examined area

(superior patellar recess) to expel the joint fluid apart from the synovial sac. Two treatment

groups used 20 minute of induction coil SWD, 3-5 times a week, for a total of 30 sessions.2

The results of the study that Jan and Chai conducted were in favor of SWD successfully

decreasing synovial sac thickness and pain index. The researchers concluded that SWD can

control synovial inflammation, and the possible physiological mechanisms underlying significant

changes may be associated with improvement in circulation of vascular network in the synovial

membrane.2 This study’s results are in agreement with another study conducted by Anand et al

who also found that SWD is an effective modality that decreases synovial inflammation, which

can be an objective measure to assess pain relief in patients with knee OA.3

In some instances the effects of SWD on knee OA have not been significantly different

than other deep heating modalities. In 2012, a study examined the effects of pain, stiffness,

functional status, and results from a general evaluation were compared between groups receiving

treatment using ketoprofen phonophoresis (PH), ultrasound (US), and SWD. The 101 female

participants included in the study were between the ages of 40-65 and had experienced knee pain
for at least 6 months. They were all diagnosed with bilateral knee OA and had a Kellgren &

Lawrence radiological grade of 2-3 (definite osteophytes, definite narrowing of joint space, and

deformity of bone contour). There were 33 participants each in the PH and US group and 35

participants in the SWD group. All participants consented to participate in the study and were

then randomly divided among treatment groups. Each treatment began with a hot pack for 20

minutes and was followed by the treatment which was provided 5 times a week for 2 weeks. In

the week leading up to the study and throughout the study, participants did not ingest any

NSAIDs or any analgesic medications. Outcomes of treatment and initial evaluation was

measured using the Visual Analogue Scale, a 15 meter walking timed test, and the Western

Ontario and McMaster Universities Arthritis Index (WOMAC).4

The parameters for the SWD treatment group were that 12 cm diameter electrodes were

placed on the knees parallel to each other while the knees were flexed to 90°. Frequency was set

to 27.12 MHz to provide a continuous thermal dose, which was provided for 20 minutes each

session. The Curapulse 970 machine was calibrated annually along with the ultrasound machine.

The settings of the ultrasound machine were frequency of 1 MHz, power of 1.5 W/cm2, with a 5

cm diameter transducer. An 8 minute ultrasound was given to both knees every session. The

phonophoresis parameters included 4 grams of 2.5% cream with ketoprofen gel applied to each

knee. Again, a 5 cm diameter transducer was used in the mediolateral direction on both knees.

Similarly, the frequency was 1 MHz and the power was 1.5 W/cm2 and the treatment was

provided for 8 minutes on each knee every session.4

Results of this study found that all 3 of the treatment therapies were effective at

alleviating symptoms of knee OA, however, no significant difference was found between the

treatments. In other words, this means that no significant difference was found in the VAS, 15
meter walking time, WOMAC scores, or the physician and patient evaluations. Although

significant differences were not found when data was analyzed, the post treatment values for

SWD were between PH and US for the following clinical characteristics: VAS, 15-m walk time,

and WOMAC pain. While the SWD post treatment values were lower than PH and US groups

for WOMAC stiffness, WOMAC function, and WOMAC total. For the physician post treatment

evaluation, only one individual was noted as having excellent improvement and they were from

the SWD treatment group. 19 individuals were also noted as having moderate improvements,

which was higher than the 11 and 16 noted in the PH and US groups respectively. Also, there

were more individuals who stated that they felt a moderate improvement during the patient

evaluation in the SWD treatment group than the other groups. Overall, there was no significant

improvement found between these 3 different deep heating treatment modalities, but there were

some slight differences between them. It is important to mention that all 3 of the treatment

groups had an improvement in their bilateral knee OA symptoms.4

In other cases it has been found that SWD has no significant effects on patients with knee

OA. Laufer et al conducted a study that compared the effects of high-intensity PSWD (H-

PSWD), low- intensity PSWD (L-PSWD), and a sham SWD (SSWD). This study screened

participants between November 2002 to May 2003 who were referred to outpatient

physiotherapy in the local community. Inclusion criteria included participants that were 65 and

older, had primary OA in one or both knee joints of grades 2-3 on the Kellgren and Lawrence

classification scale, knee pain for at least 3 months, independent ambulation with or without an

assistive device, no PT treatment or change in medication in the last month, no previous knee

surgery in the last 3 months, normal warm sensation, and no contraindication to SWD.5

Participants were randomly split into either H-PSWD, L-PSWD, or SSWD groups and
received 3 20-minute long treatments per week for 3 weeks. To ensure blindness and eliminate

bias, participants weren’t told which treatment they would be receiving, and the evaluator was

blind to which group the participants were allocated. Participants split into the H-PSWD group

received treatment with pulse duration at 300 μsec, a pulse frequency of 300 Hz, peak power of

200 W, and mean power of 18 W. Participants spilt into the L-PSWD group received treatment

with pulse duration at 82 μsec, pulse frequency of 100 Hz, peak power of 200 W, and mean

power of 1.8 W. The SSWD group consisted of turning on the SWD machine but not raising the

power. All SWD treatments were administered with a Curapuls 670 machine and participants sat

comfortably with a single Circuplode inductive electrode applied at a 3-cm distance from the

anterior aspect of the knee during the treatment.5

Patients were assessed before initial treatment, at the end of the last treatment, and 12

weeks following the last treatment. Each assessment included a disease related health status

questionnaire and 4 tests examining functional mobility including the WOMAC Osteoarthritis

Index, TGUG test, Timed stair-climbing, timed stair-descending, and the three-minute walk test.5

Results of this study were found using repeated measure ANOVA, which showed no

statistical differences between the effects of PSWD and a SWD placebo treatment on the self-

reported measures of pain, stiffness, and functional activity, or on objective measures of

functional performance. This remained true whether the PSWD was H-PSWD at a thermal level,

or L-PSWD at an athermal level. Results also showed a decrease in reported joint stiffness and

pain which did not differ among groups. No significant changes in functional performance over

time were observed in any group. While this study showed that PSWD was found to be

ineffective in the treatment of knee OA, it would be interesting to see studies conducted with a

continuous delivery method to compare the effectiveness of these interventions.5

 On the other hand, some studies conclude that SWD is an effective modality for treating

knee OA. Teslim et al conducted a study that compared the effectiveness of CSWD and PSWD

on patients with knee OA. This study consisted of 24 participants with current knee OA who

were currently receiving treatment at a physiotherapy outpatient clinic at the Obafemi Awolowo

University Teaching Hospital Complex in Nigeria. The participant’s knee OA had to have a

duration of onset of more than 3 months and a radiological report confirming knee OA. Patients

with thermal sensitivity or metallic implants were excluded from the study. A SWD unit

(Curaplus 967), a 10-point semantic pain differential scale to rate intensity of pain, and a

goniometer (E-Z Read) were the instruments used in this study. Patients were divided into

Group 1 who were treated with CSWD or Group 2 who received pulsed PSWD. Both groups

were treated for 20 minutes twice a week for 4 weeks. Both groups had 15-minute cycle

ergometry and stimulation massage baseline treatment programs. Both active and passive knee

flexion ROM was assessed using the goniometer with the patient lying in prone.6

Participants were maintained in a high sitting position during application of SWD. Two

13 cm diameter electrodes were placed parallel to the skin on the lateral and medial side of the

affected knee joint, they were slightly larger than the surface area of the knee, and they were

placed at an optimal electrode distance of 3 cm from one another. After each treatment, the pain

intensities and joint ranges of motion (active and passive knee flexion) were assessed and

recorded. Skin temperature was measured immediately before and after each treatment with a

mercury thermometer at the armpit to report the skin temperature distal from the SWD

application site.6

Results showed a significant reduction in pain experienced during ROM and an increase

in knee flexion among the CSWD group than compared to the PSWD group. This study also
found an increase of a range of 0.61 to 0.63℃ in the skin temperature of participants following

application of CSWD, while a range of 0.31 to 0.35℃ was observed for the PSWD group. This

study concluded that CSWD was more effective than PSWD in alleviating pain and increasing

knee flexion ROM among participants with chronic knee OA. Also, the recorded increase in

skin temperature for both CSWD and PSWD were enough to cause physiologic and therapeutic

effects for management of chronic knee OA.6

The goal of treatment for knee OA is to relieve pain, improve function, and to alleviate

joint destruction by altering the inflammatory process. SWD is a management approach that

involves the application of deep heat, which has been shown to have a measurable effect for

patients with knee OA. The effects of SWD involve increasing tissue temperature and

circulation, and reducing pain in patients with degenerative OA. Two studies found that SWD

can help control synovial inflammation and cause significant improvements in circulation of the

synovial membrane.2,3 Another study found that SWD, US, and PH all provided significant

improvement in knee OA, but no treatment had a significant effect over the others.4 When

PSWD, whether administered for thermal or athermal effects, was compared to a placebo

treatment no statistical differences were found.5 Another study that compared the effects of

CSWD and PSWD found that CSWD is more effective in reducing joint pain and increasing

joint ROM when compared to PSWD.6 A meta-analysis also found that SWD produced small

statistically significant changes on muscle performance and pain when a thermal sensation was

produced.1 We believe SWD is an effective modality for treating patients with knee OA;

however, it is not “a one size fits all modality,” meaning that not all patients may respond

positively to SWD and other modalities may treat other patients just as effectively. Clinical use
of SWD should be case dependent and treatment should be contingent on how well each patient

responds to the modality.

 References

1) Laufer Y, Dar G. Effectiveness of thermal and athermal short-wave diathermy for the

management of knee osteoarthritis: a systematic review and meta-analysis. Osteoarthritis

and Cartilage. 2012;20(9):957-966.

2) Jan M-H, Chai H-M, Wang C-L, Lin Y-F, Tsai L-Y. Effects of repetitive shortwave

diathermy for reducing synovitis in patients with knee osteoarthritis: an ultrasonographic

study. Physical Therapy. 2006;86(2):236-244.

3) Anand B, Kharat A, Singh A, Franklin J, Naware S, Thind S. High resolution ultrasound

evaluation of synovial thickness as a marker to assess response to deep tissue heating for

pain relief in knee osteoarthritis. Medical Journal of Dr DY Patil Vidyapeeth.

2012;5(2):120-136.

4) Boyaci A, Tutoglu A, Boyaci N, Aridici R, Koca I. Comparison of the efficacy of

ketoprofen phonophoresis, ultrasound, and short-wave diathermy in knee osteoarthritis.

Rheumatology International. 2013;33(11):2811-2818.

5) Teslim OA, Adebowale AC, Ojoawo AO, Sunday OA, Bosede A. Comparative effects of

pulsed and continuous short wave diathermy on pain and selected physiological

parameters among subjects with chronic knee osteoarthritis. Technology & Health Care.

2013;21(5):433-440.

6) 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.