Joseph A Balogun and Friday E Okonofua 1988; 68:1541-1545. PHYS THER.

Management of Chronic Pelvic Inflammatory Disease
with Shortwave Diathermy: A Case Report
Joseph A Balogun and Friday E Okonofua
PHYS THER. 1988; 68:1541-1545.
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Management of Chronic Pelvic Inflammatory Disease
with Shortwave Diathermy
A Case Report
JOSEPH A. BALOGUN
and FRIDAY E. OKONOFUA
Patients with pelvic inflammatory disease (PID) are not routinely referred for
physical therapy until the condition is found to be resistant to antibiotic therapy.
A 39-year-old black woman with an eight-year history of PID was treated with
shortwave diathermy (SWD) using a modified "cross-fire" technique. A thermal
dosage treatment lasting between 20 and 30 minutes (for each half of the crossfire technique treatment) was administered. At the beginning of every treatment
session, the patient rated her pain perception on a 10-point ratio scale. The
patient received a total of nine treatments, after which she was completely pain
free. The results of this case study suggest that SWD may be effective in the
management of pelvic infections that are unresponsive to chemotherapy. Further
studies using larger sample sizes and a control group, however, are needed
before conclusive statements can be made on the relative efficacy of SWD in the
management of chronic PID.
Key Words: Electrotherapy, general; Obstetrics and gynecology; Pain; Short-wave
therapy.
The application of physical modalities
in clinical practice is becoming increasingly popular.1 Many physical agent
textbooks have recommended the use of
shortwave diathermy (SWD) in the
management of deeply placed lesions
that cannot be easily affected by other
physical modalities.2"5 More recently,
SWD has been used as an adjunct in the
treatment of patients with nonunion
fractures,6 low back pain,7 and cancer.8
In a review of current literature on physical modalities, Santiesteban highlighted
the usefulness of SWD in the management of musculoskeletal lesions and
concluded that the "future holds great
promise for shortwave therapy."1 Currently, a dearth of information exists on
the efficacy of SWD in the treatment of
gynecological conditions.
Shortwave diathermy generators produce high frequency (27.12 MHz) alternating current with a wavelength of 11
m.1-5 International standards exist concerning the frequency bandwidth of
J. Balogun, PhD, LPT, is Lecturer 1, Department
of Medical Rehabilitation, Faculty of Health Sciences, Obafemi Awolowo University, Ile-Ife, Oyo
State, Nigeria, West Africa.
F. Okonofua, FMCOG, is Senior Lecturer, Department of Obstetrics and Gynecology, Faculty of
Health Sciences, Obafemi Awolowo University.
Address correspondence to Dr. Balogun.
This article was submitted December 10, 1987;
was with the authors for revision nine weeks; and
was accepted May 4, 1988. Potential Conflict of
Interest: 4.
SWD units; however, in some countries
national requirements dictate the range
of frequency allocated for medical purposes. For example, the assigned frequencies in the United States are 13.56,
27.12, 40.68, and 2,450 MHz, whereas
in Great Britain, frequency-modulated
(FM) bandwidths are allocated for
diathermy equipment. Frequencymodulated radio operates between 88
and 108 MHz, which includes the fourth
harmonic of the 27.12-MHz diathermy
bandwidth.9
The use of SWD in physical therapy
is not new. A historical review of the
development and methods of application of the modality in different pathological conditions is provided in major
physical agent textbooks.2"51011 According to Kottke, the most effective method
of increasing the temperature of the pelvic viscera is the use of a bare metal
vaginal electrode and a dispersive electrode over the anterior abdominal
wall.12 Other authors recommend the
use of externally applied electrodes with
the patient positioned so that the axial
line of the electric field passes through
the pelvic viscera.21314 An example of
this method is the "cross-fire" technique
recommended in the treatment of extensive lesions of the hip joint, pelvic organs, and walls of body cavities containing air (eg, the frontal, maxillary sinuses
or the lungs).214
Externally applied diathermy requires
a treatment duration of between 20 and
30 minutes,2 whereas the intrapelvic
diathermy technique requires a treatment duration of 30 minutes to 3
hours.12 The externally applied method
is easier to set up and is more acceptable
to the patients than the intrapelvic diathermy method. The intrapelvic diathermy technique is advantageous because it is possible to monitor the patient's internal vaginal and cervical
temperature during the procedure; however, extra caution is needed because of
the increased risk of burns.13 In addition, patients occasionally experience
soreness after the initial two
treatments.12
The physical effects of SWD are the
production of heat in the tissues and a
concomitant rise in the tissue temperature.1"5 It has been observed that externally applied diathermy does not increase the intrapelvic temperature as
adequately as intrapelvic diathermy.12
Scott reported that the externally applied diathermy method may raise the
pelvic temperature as high as 102.2°F.13
For optimal results, Kottke recommended that a vaginal temperature of
106° to 110°F be maintained during
SWD.12 No consensus currently exists
among clinicians regarding the effective
temperature level for the treatment of
pelvic infections.
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1541
Gaya and Hawkins recently suggested
that a course of SWD (ie, 20 treatments
over three to four weeks) may bring
about symptomatic pain relief in patients with chronic pelvic inflammatory
disease (PID).15 Chronic PID is the residual debilitating illness that follows an
acute episode of pelvic infection and is
characterized by various symptoms such
as persistent or recurrent lower abdominal pains, vaginal discharge, dyspareunia, and menstrual disorders. The most
serious clinical consequences of chronic
PID include infertility, chronic pelvic
pain, and ectopic pregnancy. Of these,
chronic pelvic pain is potentially amenable to treatment with physical modalities. Alternative treatment options such
as analgesics, antibiotics, and surgery are
unsatisfactory because microorganisms
often are not present, and the patient
may not accept surgery or the side effects of conventional analgesics. The
prolonged administration of antiinflammatory analgesics is associated
with maculopapular rash, agranulocytosis, aplastic anemia, tinnitus and deafness, peptic ulceration, and nephrotoxicity.16 Similarly, repeated or prolonged
antibiotic therapy can result in development of resistant strains of organisms
and predispose the patient to candidiasis.17 Furthermore, pelvic surgeries (including hysterectomy) have not been
known to consistently relieve symptoms in patients with chronic PID. In
some instances, the situation was actually made worse by the operative
procedure.15
In clinical practice, physical therapists
commonly use infrared radiation, transcutaneous electrical nerve stimulation,
electroacupuncture, and SWD to modulatepain.1,2,5 No significant rise in tissue temperature is expected with the use
of TENS and electroacupuncture.5 In
the management of pain attributable to
chronic PID, SWD is preferred to other
physical agents because of its greater
depth of penetration.2 It is capable of
introducing heat 3 to 5 cm below the
epidermis.4 To our knowledge, no recent report exists on the use of externally
applied diathermy in the management
of chronic PID. In this case report, we
discuss the efficacy of SWD, using surface electrodes, in alleviating the pain of
a patient with chronic PID.
METHOD AND MATERIALS
Patient's Medical History
On January 7, 1987, a 39-year-old
black woman with secondary infertility
and amenorrhea of eight years' duration
consulted a gynecologist (F.E.O.). Following her only delivery in October
1979, for which she required manual
removal of the placenta, she failed to
menstruate but experienced intermittent, throbbing lower abdominal pain.
On three occasions between 1984 and
1986, she had dilatation and curettage
in various clinics to cure her amenorrhea, but these procedures failed to
induce her menses. She reported no
dysuria, diuresis, or appreciable vaginal
discharge.
Examination by the gynecologist revealed mild bilateral lower abdominal
tenderness without rebound, scanty endocervical discharge, moderate bilateral
adnexal tenderness with minimal thickening on the right, and moderate cervical tenderness on movement. The uterus
was normal in size and was nontender.
Laboratory examination revealed a
hematocrit of 43%, peripheral white cell
count of 7,500 with polymorphonuclear
leukocytes of 45%, an erythrocyte sedimentation rate of 43 mm/hr, a nonreactive VDRL test result, a normal urinalysis result and culture, and a negative
urine pregnancy test result. The endocervical and high vaginal swabs revealed
no significant growth. Serum FSH and
LH were 5.6 and 6.3 IU/L, respectively,
indicating no ovarian failure. The patient was treated with 100 mg of Vibramycin®* (doxycycline) twice a day for 10
days. The pain persisted, however, and
on March 19, 1987, a hysterosalpingography was performed. The test revealed
a poorly outlined endometrial cavity
and the presence of multiple filling defects (synechiae) in the endometrium.
The right fallopian tube was outlined
and demonstrated dye spillage. The left
fallopian tube showed terminal hydrosalpinx but no dye spillage. A laparoscopy performed on March 27, 1987, to
further evaluate the pelvic pain showed
a normal patent right fallopian tube and
a normal right ovary. The left fallopian
tube was thick and occluded with terminal hydrosalpinx, and it was adherent
to the left ovary. Flimsy adhesions were
evident in the pouch of Douglas.
On March 31, 1987, uterine adhesiolysis was administered to the patient
with the aid of a uterine sound followed by insertion of an inert intrauterine contraceptive device for 10 days under broad-spectrum antibiotic cover.
She initially received two weekly injec* Ranbaxy Montari (Nigeria), Ltd, Sango-Otta,
Nigeria, West Africa.
tions of estradiol valerate followed later
by the daily administration of a highly
estrogenic oral contraceptive pill (Noriday®†) for three months. She experienced regular painful menstrual bleeding upon withdrawal of the contraceptive pills. On July 23,1987, she reported
to the clinic with complaints of bilateral
abdominal and back pain, and she was
then referred for physical therapy.
Physical Examination
The patient complained of a constant
and diffuse abdominal pain radiating to
the lumbar region. A detailed medical
history was taken to eliminate conditions that are contraindicated to
SWD.2,3 Specifically, we solicited from
the patient information about her 1)
menstrual cycle to rule out pregnancy
and hemorrhage; 2) contraceptive habits
to rule out use of intrauterine device;
and 3) past medical history to rule out
venous (thrombosis) phlebitis, arterial
disease, and malignant tumors.
Spinal motions (flexion, extension,
side bending, and rotation) did not relieve or aggravate her pains. To rule out
musculoskeletal problems of spinal origin, we conducted a full evaluation of
the patient's vertebrae and sacroiliac
joints, as advocated by Saunders.18 The
lower-quarter screening (LQS) examination was undertaken. The LQS examination entails a series of mobility
and neurological tests to identify problems emanating from the lumbar spine,
sacroiliac, hip, knee, ankle, and foot.
None of the LQS tests were positive,
indicating that the patient's back pain
was not of spinal origin or referred from
the lower extremities.18
We also tested the patient's ability to
discriminate between hot and cold. The
skin sensation test was undertaken with
two test tubes containing hot (40°C) and
cold (5°C) water, placed alternately over
the abdomen and lumbar region. The
patient was able to consistently discriminate between the two extreme temperatures, suggesting that she had normal
sensation over the areas to be irradiated.
We tested for skin sensation because the
treatment dosage is dependent on the
patient's ability to perceive the intensity
of heat.2
Based on the results of the laboratory,
spinal mobility, and LQS tests, we concluded that the lumbar region pain was
referred from the pelvic organs. The pa† Syntex Laboratories, Inc, 3401 Hillview Ave,
PO Box 10850, Palo Alto, CA 94304.
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PHYSICAL THERAPY
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PRACTICE
tient was not particularly concerned
about her infertility, and she did not
want to have major abdominal surgery.
As such, SWD therapy was recommended as an alternative method to relieve her of the pains.
TABLE
Treatment Protocol and Duration
TREATMENT
A Megatherm Junior Mark Five SWD
generator* with 2-FMHz frequency output was used. To reduce hazard of burns
and electrical shock, we removed from
the immediate treatment area all metallic objects (including chairs and bed)
and electrical devices.1 We used the
modified version of the cross-fire technique because the metallic chairs in our
clinic made it impossible to administer
treatment in the sitting position as advocated by Wale.14 The cross-fire technique is a method of surface electrode
arrangement that enables the therapist
to irradiate the four walls of the pelvic
organs (ie, uterus and fallopian
tubes).214
The SWD treatment was administered on a plinth with the patient in a
lying position. The protocol was divided
into two parts. During the first part, the
patient was positioned prone over a
malleable electrode (26 x 27.5 cm) with
the long axis placed at the abdominal
level. A second electrode (26 x 27.5 cm)
was placed over the lumbar region and
was held in place by a 0.5-kg sandbag.
The electrodes were padded with 5-cm
thick perforated felt and towel insulation to prevent burns. During the second
part, the patient was positioned supine
with the padded electrodes positioned
on the small axis and parallel to the iliac
crest. The two malleable electrodes were
held in place with a VELCRO® brand
touch fastened strap tied around the
abdomen.
A thermal dosage treatment was
administered2 after the patient was informed that she should feel a mild, comfortable sensation of warmth over the
abdominal wall and lumbar region during the treatment and that a danger of
burns exists if the heat becomes excessive. A thermal dosage, as perceived by
the patient, corresponds to an ammeter
reading of 3 on the SWD unit when it
is in tune. This power output is 60% of
the maximum power of the SWD generator. At the first treatment session, the
thermal dosage was applied for 20 min‡ Model 78/12, ElectroMedical Supplies Greenham, Ltd, Wantage, Oxfordshire, England.
§ VELCRO USA, Inc, PO Box 5218, 406 Brown
Ave, Manchester, NH 03108.
Treatment
Session
Method
Total Treatment
Duration (min)
1
2
3
4
5
6
7
8
9
cross-firea
cross-fire
cross-fire
cross-fire
cross-fire
cross-fire
cross-fire
monopolarb
monopolar
40
50
50
50
60
60
60
25
25
a
For the cross-fire technique, the patient received 20 minutes of treatment in the prone
position and the remaining 20 minutes of treatment in the supine position.
b
The monopolar technique was administered with the patient in the supine position only.
utes (for each half of the treatment session). By the second treatment session,
we increased the duration of the treatment to 25 minutes, because no appreciable decrease in pain was noted and
no untoward symptoms occurred during
the first treatment session.13 At the fifth
treatment session, we progressed the
treatment duration to 30 minutes in line
with Scott's recommendation.2
We adopted the monopolar electrode
arrangement2 at the eighth treatment
session because the patient's pain was
localized to the left anterior abdominal
wall. During the treatment, the active
malleable electrode was placed over the
painful left abdominal wall, and the inactive malleable electrode was tied to
the left quadriceps femoris muscle. The
treatment duration was reduced to 25
minutes. The procedure was repeated on
the ninth treatment session. A summary
of the treatment protocol and durations
is presented in the Table. The patient
during the course of the SWD therapy
did not receive any other form of treatment (eg, exercise or drugs).
Treatment Evaluation
Before the initial treatment session,
we introduced the patient to a 10-point
ratio pain scale. The pain scale is a
modified version of an earlier scale described by Balogun,19 who found it to
be reliable (r = .82). The range of numbers on the scale (Appendix) represents
a range of perceived sensations from no
pain at all (ie, 0) to the most intense
pain ever experienced since the problem
started (ie, 10).
At the beginning of every treatment
session, the patient was instructed to
rate her pain perception as accurately as
possible, rounding up to the nearest
whole number. She was specifically in-
structed not to underestimate or overestimate her pain perception. We requested her to rate the level of back pain
(BP) separately from the abdominal
pain (AP).
RESULTS
The patient's responses to SWD treatment are summarized in the Figure. The
patient received a total of nine treatments. On the first day of treatment
(July 23, 1987), the patient's BP and AP
ratings on the 10-point ratio scale were
both 8. The patient's pain perception
remained unchanged after two treatment sessions. The AP rating remained
unchanged until the sixth treatment session; however, by the third treatment
session, an improvement was noted in
the BP rating. On the seventh treatment
session, the patient reported that her BP
was completely relieved (ie, 0 rating),
and her AP had decreased considerably
(ie, a rating of 3). She also reported her
first "good night's sleep in many years."
After the seventh treatment session,
the SWD treatment was suspended because the patient was menstruating. Her
menstrual period lasted for four days,
and the treatment was resumed on August 16, 1987. As compared with her
previous menses, the patient reported
"mild pain" during the menstruation.
She also described the menstrual flow as
"normal" as compared with the "mild
spotting" experienced in previous
months.
On the eighth treatment session, no
pain was felt on the right abdominal
wall, and the pain was limited to the left
abdominal region. On August 19, 1987,
the patient was completely pain free and
was discharged. She was instructed to
return to the clinic for treatment in the
event of relapse. At the time of writing
Volume 68 / Number 10, October 1988
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1543
this report (six months after discharge),
the patient was still pain free.
DISCUSSION
The use of SWD in the clinical setting
has systematically decreased in the last
decade because of the discovery of
newer electroanalgesia such as the
TENS, electroacupuncture, and lasers.
Recently, Nickel20 suggested the elimination of SWD from physical therapy's
repertoire of treatment modalities because of the dearth of evidence supporting its therapeutic effectiveness in the
different clinical conditions for which it
is recommended.1"5 Our findings suggest
that SWD still has a place in the armamentarium of the physical therapist and
is indicated in gynecological practice.
The relative efficacy of the various
physical modalities used in the management of chronic pain has not been compared objectively. Various theories currently exist on the mechanism of action
of the different modalities. Wellaccepted theories include the "gate
control" theory of pain, the role of
endogenous opiates, and changes in
nervefibers'excitability after repetitive
stimulation.21"23 The exact mechanism
whereby SWD exerts its salutary effect
is currently not wellknown.24,25 Following SWD therapy, there is a general
dilatation of the arterioles and capillaries.1"5 The improved blood circulation
enhances 1) the presence of oxygen, tissue nutrients, and phagocytic cells and
2) the removal of metabolic waste products. These physiological effects aid in
the resolution of the inflammatory process and may account for the pain relief
noted in this case report.
Recent reports indicate that the concentration of certain prostanoids are elevated in the peritoneal fluid of patients
with chronic PID.26 These prostanoids
possibly mediate pelvic pain by causing
vasoconstriction and reduction in blood
flow to the pelvic organs. Theoretically,
SWD can reverse these effects by producing a definite increase in local blood
flow to pelvic organs.
Patients with PID are not routinely
referred for physical therapy until the
condition is found to be resistant to
antibiotic therapy. The results of this
case report reveal that SWD may be
effective in the management of chronic
PID that is unresponsive to chemotherapy. Shortwave diathermy may also be
useful in the treatment of other inflammatory pelvic conditions such as salpingitis, parametritis, urethritis, prostatitis,
Figure. Patient pain perception at beginning of each treatment session.
and osteitis pubis.12 This patient's pain
relief may be attributable to the placebo
effect.27 It is important to note, however,
that the patient had undergone various
medical treatments during the past eight
years without success. Following a
course of SWD therapy, the patient was
relieved of her pains, and six months
posttreatment, she is still pain free. We,
however, are currently undertaking a
larger prospective controlled study that
would conclusively determine the efficacy of SWD in the management of
chronic PID.
Although it has been suggested that
SWD may initially cause a flare-up of
infection,15 this complication did not
occur during the treatment of this patient, despite the avoidance of prophylactic antibiotics. This result may be due
to the pretreatment use of doxycycline
and the absence of microorganisms
in the patient's vaginal and cervical
cultures.
Burns are a major hazard inherent in
the use of SWD therapy. The therapist,
however, must be alert to certain precautions and contraindications. Pregnant patients and those with sensory
deficit, phlebitis, arterial disease, and
malignant tumors should be identified
and excluded from SWD therapy. It
should not be applied to areas recently
exposed to radiotherapy.2 Patients with
pacemakers and superficial metallic implants (ie, intrauterine devices) should
be excluded. Patients with deeper me-
tallic implants, however, may be treated
at nonthermal dosages.1 Based on its
simplicity, relative safety, and shorter
treatment duration required during
treatment, we recommend the use of
surface-electrode SWD for wider clinical
use in the treatment of chronic PID.
SUMMARY
A case report of a 39-year-old patient
with an eight-year history of chronic
PID was presented. After nine SWD
treatments using a modified cross-fire
technique, she was completely relieved
of her abdominal and back pains. Based
on ourfindings,we recommend the use
of surface-electrode SWD in the management of chronic PID that is unresponsive to antibiotic therapy. Further
studies with a control group and larger
sample sizes are needed before conclusive statements can be made on the relative efficacy of SWD in the treatment
of chronic PID.
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PRACTICE
APPENDIX
9.
Ten-Point Ratio Scale for Rating Pain"
0—no pain at all
1—very, very mild pain
2
3—very mild pain
4
5—moderate pain
6
7—very uncomfortable pain
8
9—unbearable pain
10—most intense pain ever felt
a
Adapted from Balogun. 19
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1545
Management of Chronic Pelvic Inflammatory Disease
with Shortwave Diathermy: A Case Report
Joseph A Balogun and Friday E Okonofua
PHYS THER. 1988; 68:1541-1545.
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