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 102.2F.13 For optimal results, Kottke recommended that a vaginal temperature of 106 to 110F be maintained during SWD.12 No consensus currently exists among clinicians regarding the effective temperature level for the treatment of pelvic infections. 1541

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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 mod2,5 ulatepain.1, 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 1542

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 (40C) and cold (5C) 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.

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. 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.

TABLE Treatment Protocol and Duration

Treatment Session Method cross-firea cross-fire cross-fire cross-fire cross-fire cross-fire cross-fire monopolarb monopolar Total Treatment Duration (min)

1 2 3 4 5 6 7 8 9
a

40 50 50 50 60 60 60 25 25

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 1543

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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, 1544
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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.
REFERENCES
1. Santiesteban AJ: Physical agents and musculoskeletal pain. In Gould JA, Davies GJ (eds): Orthopaedic and Sports Physical Therapy. St. Louis, MO, C V Mosby Co, 1985, vol 2, pp 199-211 2. Scott PM: Clayton's Electrotherapy and Actinotherapy, ed 7. Baltimore, MD, Williams & Wilkins, 1975, pp 230-265 3. Shriber WJ: A Manual of Electrotherapy, ed 4. Philadelphia, PA, Lea & Febiger, 1975, pp 212-233 4. Hayes KW: Manual for Physical Agents, ed 2. Chicago, IL, Northwestern University Press, 1979, pp 41-46

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PRACTICE APPENDIX
Ten-Point Ratio Scale for Rating Pain" 9. ory and Technique 26:93-97,1978 Rogoff JB: High frequency instrumentation. In Licht S (ed): Therapeutic Heat and Cold, ed 2. Baltimore, MD, Waverly Press, Inc. 1972, pp 266-278 Licht S: History of therapeutic heat. In Licht S (ed): Therapeutic Heat and Cold, ed 2. Baltimore, MD, Waverly Press, Inc, 1972, pp 217-219 Lehmann JF: Diathermy. In Krusen FH, et al (eds): Handbook of Physical Medicine and Rehabilitation, ed 2. Philadelphia, PA, W B Saunders Co, 1971, pp 273-297 Kottke FJ: Heat in pelvic diseases. In Licht S (ed): Therapeutic Heat and Cold, ed 2. Baltimore, MD, Waverly Press, Inc, 1972, pp 474-490 Scott BO: Short wave diathermy. In Licht S (ed): Therapeutic Heat and Cold, ed 2. Baltimore, MD, Waverly Press, Inc, 1972, pp 279-309 Wale JO: Tidy's Massage and Remedial Exercises, ed 15. Bristol, England, John Wright & Sons Ltd, 1976, pp 455-456 Gaya H, Hawkins DF: Pelvic infection. In Hawkins DF (ed): Gynecological Therapeutics. London, England, Bailliere Tindall, 1981, pp 142210 Rodnan GP, Schumacher RH, Zvaifler NJ: Primer on the Rheumatic Diseases, ed 8. Atlanta, GA, Arthritis Foundation Press, 1983, pp 188-192 De Alvarez RR, Figge DC: Influence of antibiotics on pelvic inflammatory disease. Obstet Gynecol 5:765-769,1955 Saunders HA: Evaluation of musculoskeletal disorders. In Gould JA, Davies GJ (eds): Orthopaedic and Sports Physical Therapy. St. Louis, MO, C V Mosby Co, 1985, vol 2, pp 169-180 Balogun JA: Pain complaint and muscle soreness associated with high-frequency electrical stimulation. Percept Mot Skills 62:799-810, 1986 Letter to the editor. Progress Report of the American Physical Therapy Association, September 1984, p 2 Wolf SL: Perspectives on central nervous system responsiveness to transcutaneous electrical nerve stimulation. Phys Ther 58:14431449,1978 Hughes GS Jr, Lichstein PR, Whitlock D, et al: Response of plasma beta-endorphins to transcutaneous electrical nerve stimulation in healthy subjects. Phys Ther 64:1062-1066, 1984 Ignelz RH, Nyquist JK: Excitability changes in peripheral nerve fibers after repetitive electrical stimulation. J Neurosurg 51:824-833,1979 Santiesteban AJ: Selected physiological properties of pulsed short-wave diathermy. Abstract. Phys Ther 61:738,1981 Brown M, Baker RD: Effect of pulsed short wave diathermy on skeletal muscle injury in rabbits. Phys Ther 67:208-214,1987 Dawood MF, Khan-Dawood FS, Wilson L: Peritoneal fluid prostaglandins and prostanoids in women with endometriosis, chronic pelvic inflammatory disease and pelvic pain. Am J Obstet Gynecol 148:391,1984 Currier DP: Elements of Research in Physical Therapy, ed 2. Baltimore, MD, Williams & Wilkins, 1984

0no pain at all 1very, very mild pain 2 3very mild pain 4 5moderate pain 6 7very uncomfortable pain 8 9unbearable pain 10most intense pain ever felt
a

19.

10.

20.

11.

21.

12.

22.

Adapted from Balogun. 19

13.

23.

14. 5. Griffin JE, Karselis TC: Physical Agents for Physical Therapists. Springfield, IL, Charles C Thomas, Publisher, 1978 6. Bassett CA, Mitchell S, Gaston S: Pulsing electromagnetic field treatment in ununited fractures and failed arthrodeses. JAMA 5:247252,1982 7. Nwuga VCB: Relative therapeutic efficacy of vertebral manipulation and conventional treatment in back pain management. Am J Phys Med 61:273-278,1982 8. Overgaard J: Biological effects of 27.12-MHz shortwave diathermic heating in experimental tumors. IEEE Transactions on Microwave The-

24.

15.

25. 26.

16.

17. 18.

27.

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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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