A Review of the Literature on
Shortwave Diathermy as
Applied to Osteo-arthritis of
the Knee
Summary This review specifically examined the efficacy of
shortwave diathermy (SWD) for alleviating the main symptoms of
osteo-arthritis (OA) of the knee. To this end, the available
databases were searched, and then the outcomes of the 1 1
relevant non-randomised comparative and randomised controlled
clinical studies detailing the application of SWD for treating knee
OA were critically evaluated using specified criteria, and their
outcomes categorised in terms of their favourable, non-favourable
and questionable effects on pain and mobility.
Given the equivocal findings and poor methodological quality
of most studies reviewed, we conclude further controlled studies
are essential t o establish whether either continuous or pulsed
SWD is efficacious for treating patients with knee OA.
Introduction
Osteo-arthritis (OA), the most prevalent of
the rhcurnatic diseases, affects more than
60% ofwestern World adults over the age of
65 years (Lawrence et al, 1986), with the
knee being one o f the most corrinionly
afflicted .joints (Davis, 1988). Knee OA,
marked by pain, deformity, inflammation,
stiffness, muscle atrophy and damage, and
progressive loss of independence (Threlkeld
and Currier, 1988) is also considered a
leading cause of functional disability in the
elderly (Hochberg, 1984).
No curative treatment has yet been found
for knee OR (Puet.t and Grif'ien, 1994).
Treatment is therefore directed towards
symptom relicf arid the prevention of
further functiorial deterioration (Dekker et
al, 1992; Munice, 1986) and often includes a
number of' e lec tro th erapeu tic modalities
(Marks and Cantin, 1997).As yet, however, it
is relatively unclear whether any o f these
modalities is efficacious, over and above the
placebo effect.
In view of this, we initially set o u t to
Marks, R, Ghassemi, M,
examine and document all the research
Duarte, R and Van
findings concerning the unique value of
Nguyen, J P (1999).
'A 1.c.vic.w of thr lit.eratiirc those e 1e c t r o t h e r a p e u t i c inter ve n t.io n s
o i l shortwave diathermy as commonly described in the English
iq)pl i cd 10 o s teo-arthrit i s literature for treating O A of the knee.
()f' t l 1 c It11r r ' , z%y.sioth/r/gly, Particular attention was paid riot only to the
85, (i,304-3 16. study results, but to analysing the quality of
the research designs used by the various
investigators in support of these. However,
given that many of the investigations
reviewed at that time were found to have
used a combination of electrotherapeutic
modalities, a n d that these were poorly
controlled, with very low methodological
scores (Ghassemi and Marks, 1995), we were
not able to determine their separate effects
with any clarity.
In the present paper, we thus attempted
to remedy this situation by specifically
describing the results of those studies which
employed shortwave diathermy (SWD), one
form of electrotherapy widely applied to
alleviate the symptoms associated with OA
joint disease (Vanharanta, 1982), separately
from studies describing o t h e r forms of
electrotherapy. We have also attempted to
classify the published trials according to
their implied findings and to examine each
published trial with respect to method-
ological issues, using a standardised format
and three separate reviewers who were
essentially blind to the a u t h o r s a n d
ins ti tu ti o n s . Notwithstanding the poor
quality of most of these studies, the
discussion then attempts to summarise the
present findings s o that future work may be
directed towards clarifying and overcoming
the present limitations in this important
area.
T h e data were retrieved from a com-
puterised Medicine, Cumulative Index to
Nursing and Allied Health, and Excerpta
Medica database search plus a manual
search o i bibliographies of original and
review articles and appropriate Internet
resources. Studies on both continuous SWD
which has been used in the treatment of
many conditions for a considerable time by
physiotherapists and those on pulsed SWD,
often referred to as pulsed electroniagnetic
field (PEMF) treatments, first introduced in
the early 1950s (Kitchen and Partridge,
1992) were evaluated. Overall, the time
period 1955-97 was considered and the key
words used were osteo-arthritis, arthritis, knee
joint, shortwave diathermy, electromagnetic
fields, physical therapy, physiotherapy,
diathermy, diapulse, shortwave therapy, pain,
articular cartilage, .joints, and electrotherapy.
The articles had to be published in English or
have an English abstract.
This literature search revealed 11 relevant
treatment studies, and in addition several
basic studies, relevant reviews concerning
the thermal a n d non-thermal effects of
SWD, and the application of SWD and PEMF
applications in several animal models of
arthritis and related soft tissue abnormalities
(see tables 1 and 2 ) .
T h e retrieved clinical studies were
reviewed qualitatively and in narrative form
t o highlight their distinctive protocols
a n d varied outcomes (see table l ) , and
quantitatively according to the criteria
of Beckerman et al (1992) and Gam and
Johannsen (1995), to assess their method-
ological deficiencies (see tables 3 and 4).
Osteo-arthritis
Osteo-arthritis, a progressive degenerative
disease affecting synovial joints such as the
knee, is characterised by the focal loss ofthe
articular cartilage lining of the joint, by
sclerosis of the underlying subchondral
bone, and by osteophyte formation at the
joint margins (Doherty and Jones, 1994;
Souhami and Moxham, 1990). A number of
processes that may be involved in the
development of OA include a failure of
c arti 1age re m o d e 11in g , in flarnm a tio n ,
ligamentous damage, altered neurological
and muscle function, muscle damage, and
pathological changes in the surrounding
soft tissues which can increase articular
compression and promote further j o i n t
damage (Marks, 1993).
As a consequence of these pathological
changes, people diagnosed as having O A
may present clinically with considerable
pain, stiffness, .joint swelling, and secondary
muscle wasting in and around the affected
joirits (Doherty and Jones, 1994). Function
may also be significantly impaired over time
a n d considerable disability may result
(Munice, 1986).
Owing to the limits of medical treatments
for reducing these disease symptoms, and
claims that SWD may have beneficial effects
in this respect, this form of physiotherapy
is often recommended for the treatment
of OA.
Shortwave Diathermv Authors
Shortwave diathermy, a form of Ray Marks PT is director
electromagnetic therapy, produces a n of clinical rcsearch in the
oscillating electromagnetic field i n the Osteo-arthritis Research
Centre in Toronto, and a
frequency range of 27.12 M H z . These rcsearch fellow a n d
oscillations, applied in either the continuous lecturer at Columbia
o r pulsed modes, a r e thought to cause Univcrsitys Tkachers
movement of ions, distortion of molecules (hllegc Department of
and creation of eddy currents within the Mcalth a n d Beliaviour.
field (Goats, 1989a, b ) . T h e therapeutic Masoumeh Ghassemi BSc
PT and Richard Duarte
effects of these oscillations lies in their
BSc PT are physical
ability to decrease tissue viscosity and with therapists in Toronto,
this muscular (Thom, 1966) and tendinous Ontario.
contractures ( L e h m a n n et al, 1970). John P Van Nyugen BSc
Additionally, the deep heating effect of PT is a physical therapist
continuous SWD may induce a n anti- in Peel, Ontario.
inflammatory response (Kitchen a n d This article was rcceived
Partridge, 1992; Nadasdi, 1960); reduce o n J u l y 29, 1997, a n d
joint stiffness (Wright, 1973); stimulate accepted on.July 27, 1998.
connective tissue repair (Aaron a n d
Ciomber, 1993); reduce muscle spasm and Address for
pain, restore the action potential of Correspondence
traumatised muscle a n d aid healing of li Marks, PO Box 1153
muscle tissue (Bansal et al, 1990) and of Adelaide Postal Smtiori,
bone (Aaron et al, 1989). It may also alleviate Toronto M5C 2K5,
Ontxio, Canada.
tendinitis (Andrew a n d Bassett, 1993)
and/or render a joint more amenable to
physical exercise (Vanharanta et al, 1982).
Additionally, at the cellular/biochemical
level, SWD has been shown to increase the
uptake of 35s-sulphate by capsular tissues
of rabbit knees, the glycosaminoglycan
concentration of treated cartilage (Liu et al,
1996; Threlkeld, 1984), and the galacto-
samine and glucosamine concentrations
of ligamentous tissue (Vanharanta et al,
1982) which could be highly beneficial in
mediating repair in damaged OAjoints.
In the pulsed mode, which is usually of
the same frequency as continuous shortwave
but in pulse trains varying from 25-400
microseconds delivered at a rate of between
15 a n d 800 p e r second (Kitchen a n d
Partridge, 1992), the thermal effect of SWD
is said to be reduced, although not entirely
lost. However, pulsed m o d e SWD
therapeutic effects which may include the
induction of osteogenesis ( Binderman et al,
1985), and cytodifferentiation of cartilage
(Grigorieva et al, 1980; Liu et al, 1996;
Sanseverino, 1980), are generally attributed
to a non-thermal effect (Chapman, 1991). In
addition, the use of low frequency PEMF
may produce a potentiated anti-inflammat-
ory effect (Fabbri a n d Lucchese, 1980;
Nadasdi, 1960) and reduce pain (Wdrnke,
1983) without the unfavourable effects of
excessive heat production (Nadasdi, 1960).
Due to the potential benefits of either
Physiotherapy,June1999/vol85/no 6
 306

Table 1: Published studies of shortwave diathermy for treatment of knee OA

Authors Sample Design Controls Outcome measures Results

Basil and Joshi 60 OA knee Prospective No Pain, discomfort, deqree of 1, Subjectively SWD was slightly
(1975) patients randomised mixed relief, ROM, ability 6 more effective than US in cases of
(40 F, 20 M; 20 factor experiment squat, cross-leg sitting, acute pain
uniMO bilateral, comparing coplanar walking, stair climbing,
ages 40-85 years) SWD for 20 min and US presence of swelling, 2. Objectively, US seemed
for 3-7 min crepitus and deformity marginally superior
30 SWD
30 US

Chambet . i n 42 OA knee Prospective equivalent No Pain, function (walking, 1. SWD + Ex versus Ex alone
e t a / (1982) patients groups randomised stairs, kneeling, use of were equally effective in
(10 M, 32 F) mixed factor cane), ROM, endurance decreasing pain and increasing
experiment function a t 4 weeks
24 SWD 18 Ex comparing SWD and
ex vs ex alone 2. Effect was maintained at
12 weeks only in those who
continued Ex

Clarke e t a / 48 OA knee Prospective equivalent Yes Pain (0-4 scale), stiffness 1. Group receiving ice showed
(1974) patients groups randomised (0-3 scale), ten%erness best improvement at 3 weeks
(15 M, 33 F, mixed factor design and swelling (0-3 scale),
mean age 61 yr) of SWD versus ice knee girth, walk time, 2. Equal improvement in all
doctor's assessment groups at 3 months
13 placebo SWD
17 SWD
15 Ice

Hamilton e t a / 100 patients Repeated treatment Yes Girth, ROM, strength, 1. Improvements in outcome with
(1959) design with cross-over walk time, stairs SWD, IR, Faradism, and cold SWD
18 RA knee of SWD versus IR
26 OA knee versus Faradism vs wax 2. No significant difference
33 RA hand between the outcomes measured
for any electrotherapeutic
modality and cold SWD

Jan and Lai 61 female OA Prospective equivalent No Functional incapacity, 1. All groups had similar decreases
(1991) knee patients groups randomised knee torque in pain and functional
(28 uni133 mixed factor design of improvements
bilateral, ages SWD versus US versus
40-74 years) SWD and Ex versus US 2. Ex in addition t o SWD
and Ex promoted treatment effect

21 knees US
28 SWD
20 US + Ex
25 SWD + Ex

Klaber Moffett 92 patients Prospective placebo Yes Pain, general health, 1, No difference between active
e t a / (1996) (34 M, 58 F, controlled double blind activities of daily living or placebo treatment in effect on
35-80 years) trial of the comparative pain
efficacy of active pulsed
46 OA hip SWD, placebo SWD, and 2. Patients in placebo group
46 OA knee no treatment reported more benefit from
treatment than those receiving
30 active pulsed active treatment
SWD

30 placebo SWD

30 no treatment

Lankhorst e t a / 24 OA knee Prospective randomised No Maximal knee extensor 1. Marked improvement in knee
(1982) patients controlled trial using torque, walking speed, torque and function for both
independent observer number of steps, stair groups (p < 0.001)
12 SWD +Ex climbing
12 SWD 2. No group difference in any
outcome measure

PhysiotherapyJune IYl)l)/vol85/no 6
ProfessionaI a r t ides 307

Table 1 continued
Authors Sample Design Controls Outcome measures Results

Quirk e t a / 38 OA knee Pilot study of SWD No ROM, Ex tolerance, 1. Post-treatment improvement in

(1985) patients versus IFC versus Ex knee girth, rest pain mean pain score for all 3 groups.
(9 M, 29 F; mean using a randomised (verbal and VAS)
age approx mixed factor design 2. No significant outcome
60 years) difference between regimes
was found
21 IFC + Ex
12 SWD + Ex
14 Ex only

Svarcova e t a / 180 OA hip and Mixed factor design Yes Pain relief using VAS, 1. No difference between
(1988) knee patients comparing pulsed SWD therapeutic effect as therapies or combined effect
(mean age + medication, US, evaluated by patient of physiotherapy and drugs
63 years) galvanic current and physician and physiotherapy alone,
after 5 treatments
60 US
50 galvanic 2. After 10 treatments pain
current intensity (VAS) decreased and the
60 SWD combined effect of physio and
drug therapy was significant
(p < 0.05). No outcome difference
between SWD, US or galvanism
was found

Valtonen and 132 OA knee Randomised trial No Subjective distress level 1.One-fifth patients markedly
Alaranta (1971) patients comparing the effects improved
(15 M, 117 F; of SWD versus LWD
mean age 3 x week with average 2. Three-fifths slightly improved
62 years) course of 13-14
treatments 3. One-fifth no benefit at all
70 SWD
62 LWD 4 SWD provided similar results to
that of LWD

Wright (1964) 38 OA knee Randomised trial Yes Walk time, tenderness, 1. Significantly greater benefits
patients comparing the effects pain, number of analgesic derived from SWD than from
(3 M, 35 F; mean of placebo tablets tablets taken daily placebo
age 62 years) 2 x day, fortnightly
placebo injections, and 2. More patients improved after
13 placebo SWD 3 x week SWD than after injections, and
tablets for 6 weeks this was more noticeable in long-
term improvement, but
12 placebo differences did not achieve
intra-articular significance
injections

13 SWD

Abbreviations: Ex = exercise; F = females; IR = infra-red; IFC = interferential current; LWD = longwave diathermy; M = males;
ROM = range of motion; SWD = shortwave diathermy; US = ultrasound; VAS = visual analogue scale

Table 2: Animal studies of shortwave diathermy applied to knees in experimental arthritis

Authors Sample Methods Controls Outcome measures Results

Nadasdi 30 rats Athermal pulsed SWD Yes Rate o f inflammation SWD significantly inhibited
(1960) applied at 400 pulses inflammation during
per sec and Volume o f paw experimental joint damage
penetration rate o f 4
for 10 min at a time

Vanharanta 9 rabbits SWD 55 times for Yes Range o f motion 1. SWD increased development
(1982) 5 min at 50 watts for (goniometer) of extension deficiency at knee
11 weeks t o one knee o f the treated group
X-rays
2. Small decreases in flexion
mobility

PhysiotherapyJune IY99/vol85/no 6
 Table 3: Results of methods assessment of clinical trials of shortwave diathermy for knee OA and their criterion
scores (adapted from Beckerman et a/ (1992) and from criteria described by authors of reported studies)
Criteria Points awarded
Possible Banshi Chamber- Clarke Hamilton Jan and Klaber Lakhorst Quirk Svarcova Valtonen Wright
points and Joshi lain e t a / eta/ eta/ l a ; (1991) Moffett eta/ eta/ eta/ and Alaranta (1964)
(1975) (1982) (1974) (1959) (1996) (1985) (1985) (1988) (1971)

Randomisation correct 1 1 1 1 1 0 1 1 1 0 1 1

No of patients in smallest
group after randomisation 3* 1 0 0 1 1 1 0 0 2 2 0
I I
Percentage lost t o follow-up 2+ 2 1 2 0 2 2 2 2 2 2 2

No selective loss t o follow-up 1 1 0 1 1 1 1 1 1 1 1 1

Restriction t o homogeneous
group 1 1 1 1 1 1 0 1 1 0 0 1

Relevant baseline
characteristics described 1 1 0 1 1 1 1 1 1 1 0 0

Co-interventions similar in
all groups 1 0 0 0 1 0 0 1 0 0 0 0

Com para bi Iity of prognoses

groups 1 1 1 1 1 1 0 1 0 0 1 1

Correction for imbalance at

baseline 1 0 1 1 0 0 0 0 0 0 0 0

Patients blinded 1 0 0 1 0 0 1 0 0 0 0 0

Therapists blinded 1 0 0 0 0 1 1 0 0 0 0 0

Evaluator blinded 1 0 1 1 0 0 0 1 1 0 0 0

Outcome measured relevant

and well described 2* 1 1 1 1 2 1 1 0 1 1 1

Outcome measures a t
relevant points in trial 1 1 1 1 1 0 1 0 0 0 1 1

Outcome measured after

treatment period (follow-up) 1 0 1 1 1 0 1 1 1 0 1 1

Analysis blinded 1 0 0 0 0 0 0 0 1 0 0 0

Adverse effects investigated 1 0 1 1 1 0 0 0 1 0 0 0

Intention-to-treat analysis 1 0 0 0 1 0 0 0 1 0 0 0

Frequencies o f most important

outcomes presented for each
group 1 1 1 1 0 1 1 0 1 1 1 1

Therapy standardised and

explicitly described 1 0 0 0 0 0 1 1 1 1 0 0

Other interventions
standardised and described 1 0 1 1 1 1 0 1 0 1 1 1

Statistical analysis n o t correct -1 0 0 -1 0 -1 0 0 - 0 0 0

Power calculations n o t
performed -1 -1 -1 -1 -1 -1 -1 -1 -1 -1 -1 -1

Total 25 10 11 14 12 10 12 12 11 9 8 10

L
* 2 25 = 1 point, t 50 = 2 points, t 75 = 3 points 5 20% = 1 point, 5 10% = 2 points
* Valid and reliable according t o reviewer = 1 point, valid and reliable according t o relevant publications = 2 points
Note: One point was awarded if criterion was attained, with a maximum score o f 25 points, unless otherwise stated. Where reviewers
were uncertain about whether a criterion was implemented or criteria were clearly not met, no points were awarded.

- ~~ . ... -
PhysiotherapyJunc l'.N9/vol 85/no 6
Professiona I a rt ides
Table 4: Information abstracted from 11 clinical
trials examining shortwave diathermy applications
in knee OA with available data expressed as a
percentage of the 11 reviewed studies (adapted
f r o m Gam and Johannsen, 1995)
Percentage
Sample size
Sex
Age
Selection criteria
inclusion criteria
Exclusion criteria
Description o f drop-outs
Description of randomisation method
Comparison group
Placebo SWD
Control group and placebo SWD
Co-interventions
Description of apparatus
Name of apparatus
Description of placebo-SWD apparatus
Frequency (MHz)
Intensity (W)
Mode of delivery
Treatments
Number
Treated area
Dosehime per treatment
Total treatment period
Assessments
Subjective measures - pain*, patientlphysician
assessments
Objective measures -function, knee range,
knee strength
Subjective and objective measures
*Pain instruments included unsegmented visual
analogue scale, verbal scoring of rest, post-exercise,
nocturnal pain; pain a t rest, level walking, ascending
a n d descending stairs a n d squatting o n a three-
p o i n t scale; pain relief on a four-point scale; pain
and subjective reports o n pain intensity and pain
related distress using a 0-100 numerical scale; crude
scoring of diurnalhocturnal pain with weighting
score according t o severity and duration.
continuous or pulsed electromagnetic fields
for reducing the symptoms and signs of OA
i n c 1u d i n g pa i n , in fl am m a ti o n , caps u 1a r
thickening and contracture, muscular and
t c n d i n o u s contractures, a n d cartilage
proteoglycan a n d ligamentous collagen
losses, plus the high incidence of functional
disability associated with this disease at the
knee j o i n t , we specifically elected to
establish whether SWD, i n any form
(continuous or pulsed), is efficacious for
treating knee OA. To this e n d , the 11
published studies we retrieved and analysed
in depth, with respect to their conclusions,
experimental methodologies
limitations, are shown in tables 1, 3 and 4.
These trials and their outcomes are also
described in detail, in the following section.
Clinical Trials with SWD .. . . ..
ReasonablyFavourable Results
T h e earliest evidence of a reasonably
favourable outcome for the application of
SWD for treating knee OA was that reported
by Wright (1964). In that seminal study,
100 Wright compared the outcome of six weeks
73 of placebo tablet treatment, fortnightly
82 in,jections of normal saline, a n d SWD
90
45 treatments applied for 20 minutes three
64 times per week to 38 cohorts diagnosed as
45 having unilateral or bilateral knee OA. The
55 treatments were randomly allocated and the
90 four efficacy measures documented were
27 pain, tenderness, analgesic intake levels, and
9 walking time.
63
T h e assessments were conducted im-
55 mediately before the start of the trial and at
45 fortnightly intervals for 26 weeks. At each
9 assessment a patient was considered
27
18 improved if two of the four efficacy para-
55 meters showed improvement. The results
showed that more knees improved after
100
a course of SWD than after a course of
100
18 placebo tablets. Although t h e r e was
81 n o significant difference between the
100 improvements observed after SWD a n d
those after placebo injections, more patients
showed long-term improvement after SWD
31 than after placebo injections, even though
this difference did not reach the level of
81
54 significance (p < 0.1). However, the sample
size was small and a power analysis was not
forthcoming. Unfortunately, too, it was
difficult to establish whether optimal SWD
parameters were used in the trial, as the
type, frequency and intensity of SWD used
were not recorded. The SWD group also
seemed to be more disabled than the other
groups.
Another early study suggesting a positive
effect of SWD applications for treating knee
OA was that of Valtonen and Alaranta
(1971). A strength of that study was the
large sample of 160 patients, of whom 132
had radiologically verified knee OA. After
being treated with a self-tuning SWD
machine with a frequency of 27.33
megacycles for 15-20 minutes three times
weekly for an average of 13-14 treatments
with a n intensity that did n o t exceed
a comfortable sensation of warmth,
approximately one-fifth of these patients
improved markedly (ie a complete or almost
complete disappearance of the patients
and main symptom a n d the disturbances
associated with it) ; three-fifths were slightly
improved ( i e a clear decrease of the
patients subjective distress) ; and only one-
-
PhysiotherapyJune1999/vol %/no 6
 310
fifth showed no beneficial treatment effects.
T h e results were comparable to those
obtained with long-wave diathermy, said to
be much more cumbersome to apply. The
main study limitations were the concurrent
application of exercise therapy; and the lack
of'a control group.
In a study by Lankhorst et a1 (1982), 24
patients with OA of one or both knees who
were able to walk were randomly divided
i n t o two equally sized a n d comparable
groups with no baseline clinical, radiological
or age differences.
Patients in the first g r o u p received a
combination of SWD treatments applied
with condensator electrodes, 11 m wavesbat
2'7.12 MHz and 150 watts, two to three times
a week for 15 minutes for six weeks, and
individually tailored mobilising,
strengthening and stabilising exercises, co-
ordination training and functional walking
training for 30 minutes immediately after
diathermy during the last four weeks.
The second group was treated according
to the same time schedule, but received
diathermy only.
Knee extension torque, endurance and
walking speed measures on level ground and
stairs were made by a n i n d e p e n d e n t
observer, under standardised conditions, one
week before treatment and two weeks after
cessation of treatment.
Although maximal knee extensor torque
a n d t h e functional measures improved
significantly after therapy for both groups,
analysis of variance showed no significant
differences between the time courses of the
variables of either group.
While it is possible the marked functional
improvements in both groups were d u e
simply to a learning and/or a Hawthorne
effect, since SWD treatment was given to
both groups, it is possible the application of
SWD alone contributed to these very
favourable results.
Questionable Results
O n e widely cited controlled trial of
physiotherapy which examined the effects of
several forms of electrotherapy, including
SWD, for treating degenerative knee joints
has been that ol' Hamilton et al (1959). In
that repeated trial 26 patients were treated
with o n e of f o u r randomly assigned
treatment modalities as follows: SWD for 20
minutes three times per week; infra-red
radiation for 20 minutes three times per
week; faradism to the knee for the same
duration; and 'cold SWD' (control treatment
PhysiotherapyJuncIW9/vol 85/no ti
which a p p e a r e d to apply SWD b u t the
current was not switched on).
Although knee strength a n d walking
time up and down four stairs and on level
ground generally showed post-treatment
improvements for the SWD applications, all
treatments as well as 'cold SWD' yielded
similar results. The overall improvement
irrespective of' t r e a t m e n t o r dummy
exposure may have been confounded by
the fact that patients were on a basic exer-
cise regimen, analgesics, a n d splintage
throughout the study.
B a n d and Joshi (1975) compared the
effectiveness of three to seven minutes of
ultrasound (US) and 20 minutes contra-
planar SWD for the treatment of' knee OA
using a randomised mixed factor research
design, That is, 60 patients aged 40 to 85
years with knee OA of one to ten years'
duration were randomly allocated to one of
two comparable treatment groups. After a
single treatment session, analysis suggested
that SWD using the contraplanar method for
20 minutes was subjectively more effective in
decreasing acute OA pain than US delivered
for three to seven minutes with an intensity
ranging from 2-3 watts/cmL and a frequency
of' 1 MHz. However, although no statistical
evidence was forthcoming in that study, the
converse result was said to occur when the
investigators used objective outcome
measures such as swelling.
A single-blinded study by Chamberlain et a1
(1982) determined whether treatment for
knee OA involving SWD by inductotherm
coil a n d exercise t h r e e times a week
administered by trained personnel, plus
instructions regarding addition a1 home
exercises, was better than home exercise
instruction alone. The results indicated that
after four weeks t h e r e were significant
improvements in function, maximum weight
lifted and endurance (p < 0.01) irrespective
of treatment group. The dropout rate was
higher for the exercise group, however, and
these data were not included in the analysis.
The SWD group was also significantly weaker
than the exercise-only group at baseline
which suggests some benefit was achieved
from the SWD applications. It is also possible
that pain relief attributable to the SWD
applications was masked by permitting the
patients to use unlimited analgesic
medication, o r by a suboptimal m o d e ,
frequency, d u r a t i o n , a n d intensity of
application as these characteristics were not
documented.
In a study of 180 hip or knee OA patients,
Professional articles
Svarcova et aZ(1988) cornpared the analgesic
effects of t h r e e different types of
physiotherapy: US; galvanic current; or
pulsed SWD, frequency 46 M H z a n d
iriaxirnum peak intensity 700 W. The groups
were further sub-divided: with half of the
patio n t s receiving a n ti -inflarnm ato ry
rri c dic a ti o n , a n d half p lac e h o tab1e ts .
Patients from all groups received ten
treatments at two-day intervals for three
weeks. Results on a visual analogue pain
scale showed n o main effect for any
treatment. However, physiotherapy and drug
therapy were found significantly better than
physiotherapy a n d placebo treatments
alone. Further, it was concluded that
plvanic current alone was as effective as any
individual treatment when combined with
d r u g therapy, although the unclear
doc 11men ta ti o n m e tho d , grea te r disc as e
duration of the SWD group compared to the
galvanic g r o u p , a n d the higher than
standard SWD frequency and two-minute
treatment duration used made it difficult to
justify this conclusion.
In 1991, Jan and Lai examined the effects
of U S and SWD with and without exercise
with respect to OA knees. Sixty-one women
(with 94 OA knees) were allocated to one of
four groups: SWD for 20 minutes in the
traditional way; ten minutes continuous
U S alone; SWD plus exercise and US plus
a t lcast 200 straight leg raise exercises
per day. Treatment was terminated when
a patients p r e d o m i n a n t symptom was
significantly relieved for one to two weeks.
Following an average of 41.2 (range 24-69)
treatments, a11 patients improved their
fiinctioiial scores significantly, but the SWD
treatment alone was not as cffective as the
excrciscs and SWD or the exercises and US.
Patients in thc latter groups may, however,
h avc: 1) e e r i th o s e w h o r c c e ive d bi 1 ate r a1
LJS o r SWD treatments a n d therefore
expcrienced an additive treatment dosage
and greater attention as a whole.
Negative Results
I 11 a p r o s p e c ti ve rand o m i s e d c o n t r o 11e d
(rial contliicted by Clarke et aZ (1974), the
investigators cornpared t h e outcome of
applying ice, continuous SWD administered
according to standard practice, and placebo
SWD to 48 osteo-arthritic knees. All treat-
ments were administered three times a
week lbr three weeks and patients were re-
assessed then, and after a further three
months. D e p e n d e n t variables assessed
included pain, stiffness, knee circumference,
311
range of motion, walking time, radiographic
grading, physician assessment and self-
assessment. After three weeks, the ice group
showed significant within-group improve-
ments in pain and stiffness (p < 0.05). It was
also shown at three months that ice, SWD
and untuned SWD all had a similar effect
on improving the subjects pain.
Comparable findings were those of Quirk
et aZ(l985) who compared the effects on the
O A knees of continuous SWD using the
condenser field m e t h o d a n d exercise,
interferential stimulation and exercise, and
exercise alone. Patients in the first two
groups were treated for 20 minutes three
times per week and patients in the exercise-
only group were treated twice a week for two
weeks, and then once a week for two weeks.
Results showed all three groups had similar
decreases in pain intensity and an improved
clinical conditions suggesting n o benefit
of either the SWD, the interferential
treatments, or the extra attention given
to patients in these groups. Yet, as in the
study by Clarke et al (1974), history was
not controlled for.
Similarly, in a more recent randomised
controlled trial evaluating the efficacy of
pulsed SWD for alleviating OA hip and knee
pain, Klaber Moffett et a1 (1996) found no
significant differences between groups
receiving active, placebo and no treatment
protocols after nine SWD treatment sessions
of 15 minutes duration using a pulse
frequency of 8 2 pulses/sec x 7. Some
patients given placebo SWD treatments were
said to have had more benefit from these
than those receiving active treatment, as did
pre-surgical patients. Reported outcome
measures were average sensory and affective
pain diary r e p o r t scores, self-reported
benefit scores, a n d a general health
questionnaire, indicative of minor psy-
c h i a tr i c disturb a n c e s . T h e t r e a t m e n t
dosage, based o n the non-significant
outcome oi the pain responses of a sample
of 45 hip O A patients t.o pulsed SWD may
not have been optimal for treating patients
with knee OA, especially those requiring
surgery. Further, all groups received
instruction in exercise, and walking aids as
required, and the placebo group may, due to
their lengthier disease duration (ie 103.07
versus 62.00 months), along with those
awaiting surgery, have had a higher exercise
and/or medication compliance rate, or a
preferential response to the advice and
attention afforded by the treatment
situation.
Physiotherapy,Jirne1999/vol 85/rio 6
 312
Overview of Study Methods
The 11 papers reporting on the application
of SWD-for treating the symptoms of knee
OA were found lacking in most cases when
assessed according to criteria used for
similar purposes in the recent literature.
Table 3 and data in appendix 1 highlight
some of these deficiencies. They include
inadequate information concerning group
assignment, the n u m b e r of subjective
outcome variables used, the number of
different variables used to assess pain and
function, possible bias due to the lack of
adequate blinding procedures, the study of
non-homogeneous groups, failure to include
results of failures or drop-outs into the
analyses, use of co-interventions which were
not necessarily standardised, failure
to c o n d u c t power analyses to estimate
t h e impact of small sample size a n d
measurement variability o n insignificant
results, failure to report the rationale for the
SWD parameters used, and failure to specify
in detail the SWD parameters used. Also,
although we found nine studies which stated
that randomisation had been used, only
Iaaber Moffett el al (1996) described their
precise method of randomisation, so we
cannot evaluate the randomisation quality
of the remaining studies.
Due to their failure in general to use a
control g r o u p a n d their insufficient
reporting of the outcome parameters, we
were unable to apply techniques of meta-
analysis to the present data. As a result, the
outcomes reported above must be seen only
as suggestive, irrespective of the reported
effect. The papers we studied also give no
information about dose-responsiveness or
mechanisms of action.
Discussion
In the present review, 11 English-language
articles were retrieved a n d analysed to
answer the question: Is SWD efficacious for
treating knee OA? However, given their
generally low methodological quality, their
incomparable co-interventions, protocols,
o u t c o m e measures, a n d outcomes, n o
definite conclusions could bc reached.
Indeed, even if we overlooked some SWD
trials in our literature search, the scrutinised
results varied from extremely positive (eg
Lankhorst P t al, 1982), to extremely negative
(eg Klaber Moffett P t al, 1996). The same
variability was observed with respect to the
outcomes of the few animal models used to
test the effects of SWD on joint inflamm-
ation and motion limitation (eg Nadasdi,
Physiotherapy,Jimel9W/vol 85/no ti
1960; Vanharanta, 1982) and muscle injury
(Bansal et al, 1990; Brown and Baker, 1987).
Factors that could influence the extent of
the benefit of SWD treatments applied to
OA knees, even if a consistent treatment
mode such as continuous SWD is used,
might be the size of the treatment area;
degree of inflammation; treatment method;
frequency, duration and intensity; unreliable
outcome measures; other co-interventions
such as exercise which were not controlled
for; and the stage of OA studied. Neither a
reasonably positive nor a negative study
result could be attributed to any single study
parameter.
The widespread use of subjective outcome
measures may suggest, however, that some of
the results we reviewed were subject to
reporting, recall or rater error. As indicated
in table 3 , in most cases the reliability and
validity of the outcome measures employed
must remain in question. Table 3 also shows
that neither the evaluators nor the therapists
a n d patients were necessarily blinded,
and the quality of blinding when it did take
place was unclear. Along with inadequate
reporting of the data and selection criteria,
it was therefore impossible to pool these
results a n d h e n c e e i t h e r to justify the
common usage of SWD by physiotherapists
for treating knee OA, o r t o refute the
commonly held view that SWD is efficacious
for reducing OA knee stiffness and pain.
Indeed, potential clinically beneficial effects
which might accrue from either thermal or
non-thermal SWD applications to an OA
knee might have been overlooked in the
currently r e p o r t e d studies d u e to sub-
optimal treatments, inadequate power,
switch-overs, sample heterogeneity, carry-
over effects, inappropriate effect measures
a n d / o r lack of adequate follow-up pro-
cedures.
Clearly, to improve practice, a n d to
rationalise and optimise physiotherapeutic
strategies for knee OA, research results
based o n s o u n d methodologies, using
comparable samples and protocols which
provide support for postulated mechanisms,
must be emphasised.
Outline of Future Efficacy Trial Design
To determine more precisely whether SWD
is efficacious for treating the OA knees, and
under what conditions, we propose that the
following experimental a p p r o a c h be
adopted to examine this issue selectively
with respect to patients with varying degrees
of disease severity and chronicity using both
Professiona I a rt ides
pulsed arid continuous SWD without any
extraneous interventions.
IjeJign: T h e design advocated is double-
a n d / o r t r i p 1e-b 1i n d e d a n d p 1ace b o-
controlled, with an adequately blinded and
valid randomisation procedure.
Sample: The prospective study sample should
be homogeneous with respect to disease
duralion, activity and stage, past treatments,
age, and knee involvement, arid constituted
by persons conforming to the American
R h c 11matol ogy Asso cia ti o n cli ni cal an d
radiographic criteria for a single diagnosis
01 knee OA (Altman et al, 1986) with pain
of at least one years duration.
Size: The sample should be large enough to
account for potential drop-outs and loss to
follow-up, stratification of patients according
to sex, age arid disease severity, and normal
day-today variations in disease presentation,
as these impact o n measurement e r r o r
magnitudes.
Main exclusion criteria: Evidence of current or
recent participation in SWD or other forms
of physiotherapy, r e c e n t knee j o i n t
in.jections o r surgery, a n d patients n o t
stabilised for at least t h r e e months o n
nnchanged medication.
15.f .f i ca cy criteria: O u tc o m e s i n c 1u d i n g
measnres of daily activities a n d work
capacity; stair climbing and walking ability;
weighlbearing pain; knee strength, stability,
joint stiffness, range ofmotion, and swelling;
kntx: joint synovial fluid keratin sulphate
composition, and fernorotibial bone corn-
position must be assessed with reliable and
validated indices or instruments.
E:valutntor~s:Assessors should be well-trained,
consistent and blinded to the study hypo-
theses and group assignment.
lhv-ation: Treatments should be applied
three times per week Ibr a maximum of six
weeks or on the basis of a pilot study of a
Gniilar sample.
l h w g p : Treatment dosages should be those
suggested by previous research, for example
11 ni waves at 27.12 MH7 and 150 watts for
15 minutes with condcnsater electrodes
(Lankhorst rt al, 1982); or indicated by pilot
work on a similar sample; or specified by the
dcvice manufacturer.
313
StatiJtical procedures: Appropriate analyses,
inclnding power analyses where results are
non-conclusive, should be carried out by
blinded analysts using a sufficiently
discriminating significance level. Group
comparability, prior to a n d during the
experimental schedule, should also be
validated and calculations should be made
according to the intention-to-treat
principle. That is drop-outs and losses are
assumed to represent treatment failures.
Measurementx Pretreatment measurements
should be implemented at least twice over a
one-week period and comparable mid-point
and post-experiment follow-up measures
should be implemented by the same blinded
evaluators at bi-monthly intervals for at least
one year.
firording: Finally, a complete description of
the apparatus and placebo-apparatus, mode
of delivery, dosage parameters, randomi-
sation method, specification of the joint
selected for symptom evaluation in bilateral
cases, and other methodological variables
used by any future investigators of this
question must be clearly documented to
permit study replication a n d facilitate
interpretation of findings.
l u r t h e r studies: If shown t.o be efficacious,
dose-effects, the effects of SWD o n the
pathology of knee OA and the numerous
explanations suggested as to why SWD is
effective in treating knee OA should be
investigated, preferably through collabor-
ation with researchers in biomechanical,
radiological and biochemical laboratory
settings.
Summary and Conclusions
Although strong theoretical arguments can
be made for the potential benefits of SWD
on the underlying pathological processes
found in OA (see Andrew and Bassett, 1993;
Harris, 1963; Weinberger, 1988), the
prevailing clinical studies concerning the
application of SWD for treating painful knee
OA are essentially non-conclusive, given
their poor overall methodological quality as
highlighted in table 3. In particular, several
had inadequately \ized Famples and n o
non-treatment control group, and used
c om p e tin g i n t e rve n ti o n 9. Fur t h e r, few
d o c u m e n t e d their p r e c i 5 e therapeutic
paradigms, and the reliability and validity of
their treatments and outcome measures
remain in question. Table 4 also highlights
Physiotherapy,lurle lSOS/vol 85/no 6
314
their lack of stringent inclusion criteria,
u n k n o w ri treat m e n t par am e t e rs , a n d
possible failure to exclude patients with
acute ixiflarnmatory OA from some studies.
Consequently, we conclude additional study
is essential to determine whether SWI) is
indeed efficacious for knee OA in either its
continuous or pulsed mode or both, and if
s o , f o r which osteo-arthritic symptoms
Favourable treatment effects are likely to
occur. Additionally, if a specific form of SWD
is found beneficial for treating knee OA
patients, the mechanism (s) underlying this
should be explored with a view to exploiting
appropriate cell-specific field intensities.
Also, if short-term treatment efficacy can be
demoristrated, long-term follow-up stud
SWD for treatment of knee OA woii
indicated.
Kising health care costs as our population
ages and the substantial contribution to
this cost d u e to the growing number of
individuals with disabling knee OA, plus
the need to satisfji clients' treatment object-
ives, have placed a strong dcniand o n
physiotherapy providers to ensure optimal
treatments for their patients. In this regard,
i t is the present authors' view that to
increase productivity and con t air1 disease
costs, while alleviating the symptoms of knee
Oh, the value of' using SWD as cit.hcr a
primary or an adjunctive physiotherapeulic
measure ii)r the treatment of knee OR, if
any, should not he overlooked due to the
lack of' rigorously controlled trials with large
homogenous samples arid clinically reliable
and valid endpoints.
Shortwave diathermy, unlike several other
elcctrical modalities, requires very little
t1ic:rapist time beyond its initial set-up.
Evidence from several basic scicncc exper-
iments also indicates that improving our
ability t o apply selectively modes of SWL)
and parameters of' application would have a
beneficial elftct on the ccllirlar pa
O A knee joints including thcir
muscle pathology (eg I3;rrisal el al, 1990).
lridcetl, the very positive hidings of a post-
(reatment. gain in knee ext,ensor torque and
walking ability as described by Lankhorst
et al (1982) in a small group of patients
who received n o t r e a t m e n t o t h e r than
continuous SWD warrant further study to
rule out placebo attention, learning or other
effects.
O n the o t h e r h a n d , although Klaber
Moffett et a1 (1996) have shown that pulsed
SWD may have no more than a placebo
ef'fect on OA knee pain when applied for
three weeks, positive effects with respect to
treatments of longer duration and different
dosages cannot be ruled out.
Further, while not necessarily considered
as a form of SWD, very positive benefits
might yet be attained for these patients by
stepwise application of extremely l o w
li-equency PEMF as indicated by Trock el nl
(1993, 1994) in two recent multi-centre
double blind trials and by Nadasdi (1960).
In view of this possibility, plus the urgent
need fbr physiotherapists to validate their
practice and provide optimal treatments to
their clients, we would like to stress o u r
belief in the importance of future efforts to
establish unequivocally the true efficacy of
continuous and pulsed electromagnetic field
treatment applications used by physiothera-
pists for treating knee OA. In particular,
i n ad di t i o r i to d o 11b 1e b 1in d , rand o rn is e d
cont.rolled trials o f large homogencous
samples using reliable arid validaled
indices, we would encourage preliminary
ex p c ri me n tal stu di e s to tie te rni i ne pos-
sible positive a n d negative dose-effect
relationships a n d optimal s e t t i n g s I'or
SWD machint: parameters. Sex arid age
effects that could influence dose-resporis-
iveriess to SWD of patients with knee OA
also need investigation.
Implications for Practice
(kneralisable conclusions which lead to
effective control by physiotherapists of OA
symptoms will not only help to reduce the
personal disability associated with this
disease, but should help t o control health
care costs arid could ensure our future role
i n the market place.
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