Short Wave Diathermy in the Symptomatic

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RESEARCH ARTICLE Short Wave Diathermy in the Symptomatic Management of Chronic Pelvic Inﬂ ammatory Disease Pain: A Randomized Controlled Trial Sikiru Lamina1*, Shmaila Hanif2 & Yusuf Saidu Gagarawa3

1 Biomedical Technology Department, School of Health Technology, Federal University of Technology, Owerri, Nigeria 2 Department of Physiotherapy, Murtala Mohammad Specialist Hospital, Kano, Nigeria 3 Physiotherapy Unit, Jigawa State Ministry of Health, Dutse, Jigawa State, Nigeria

Abstract Background and Purpose. Chronic pelvic infl ammatory disease (PID) refers to both residue of acute and sub-acute recurrence of a previous infection or/and as a result of late detection of and intervention for upper tract pelvic infection. Owing to the chronic nature of the disease, which may require large doses of analgesics and/or antibiotics both of which may have side effects on the body, there is a need for a non-invasive therapeutic and symptomatic chronic pain management. The main purpose of this study was to determine the effi cacy of short wave diathermy (SWD) in the symptomatic management of chronic PID pain. Method. An independent group; double blind random assignment design was used in data collection. A total of 32 subjects diagnosed as chronic PID patients referred for physiotherapy were randomly assigned to three (SWD, control and analgesic) groups. The SWD group received antibiotics, placebo (sham analgesic) tablets and SWD using the crossfi re technique for an average of 15 exposures lasting for 20 minutes on alternate days of the week. Other groups; Analgesic group received antibiotics, Analgesics and sham SWD; while the control group received antibiotics, sham SWD and placebo tablets. The study lasted for a period of 30 days. Result. Findings of the study revealed signifi cant effect of SWD over analgesic and control in pain responses and resolution of infl ammation at p < 0.05. Conclusion. It was concluded that SWD may be an effective and non invasive therapy in the management of chronic PID pain. Copyright © 2010 John Wiley & Sons, Ltd.

Received 21 September 2009; Revised 23 March 2010; Accepted 1 April 2010

Keywords chronic PID; pain; physiotherapy; SWD

*Correspondence Sikiru Lamina, BSc (PT), MSc, Lecturer, Physiokinetics and Biomedical Technology Department, School of Health Technology, Federal University of Technology, PMB 1526, Owerri, Nigeria. Email: [email protected]

Published online 18 June 2010 in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/pri.473

Introduction combination: endometritis, salpingitis, tubo-ovarian abscess and peritonitis in the small pelvis and in most Pelvic inﬂ ammatory disease (PID) and upper genital cases the infection is ascending. The spectrum ranges tract infection describe inﬂ ammatory changes in the from sub-clinical, asymptomatic infection to severe, upper female genital tract of any of the following life-threatening illness (Haggerly and Ness, 2006;

Hoof, 2007; Smith et al., 2008). The symptoms of PID and a decrease in pain and swelling (Hecox, 1994; are recurrent and chronic abdominal and pelvic pain, Rennie and Michlovitz, 1996). Such vascular improve- dyspareunia, dysmenorrhoea, menorrhagia, rectal dis- ment also encourages resolution of the infl ammatory comfort and smelly vaginal discharge (Llewellyn-Jones, processes by increasing nutrition, oxygen supply and by 1998; Tzafettas, 2006; Hoof, 2007). Tubal sterility and removing metabolic and waste products (Tindall, 1987; ectopic pregnancy, tubo-ovarian abscess are the long Goats, 1989) and in turn promotes natural resistance term sequelae (Gray-Swan and Peipet, 2006; Smith to infection (Tindall, 1987; Jan et al., 2006). et al., 2008). Though, Chronic PID is no longer Owing to the chronic nature of the disease, large common in developed countries, but still poses a sig- doses of analgesics, antibiotics and their side effects on nifi cant problem with chronic pain in the Third World the body, there is a need for a non-invasive therapeutic (EAU, 2007). and symptomatic chronic pain management. However, Signifi cant alterations in arterial and venous circula- studies investigating the effi cacy of alternative to anal- tion, primarily in the vascular bed of the small pelvis, gesics such as SWD are very few and mostly cases were detected in patients with chronic salpingo- reports with few numbers of participants. Therefore, oophoritis (Evseeva et al., 2006). Chronic PID refers to the primary and secondary purposes of this study were both residue of acute and sub-acute recurrence of a to investigate the effi cacy of SWD in the symptomatic previous infection or/and as a result of late detection of management of pain and anti-infl ammatory role in and intervention for upper tract pelvic infection. chronic PID respectively. Chronic PID presents a diagnostic and management challenge to healthcare providers (Kottamann, 1995). Methodology The aim of PID management is to alleviate pain and systemic malaise associated with infection, to achieve Design microbiological cure, to prevent development of per- A double blind pretest–post-test, independent group manent tubal damage with associated sequelae, such as assignment design was used in data collection. chronic pelvic pain, ectopic pregnancy and infertility and to prevent the spread of infection to other parts. Subjects The management of pelvic infl ammatory disease should be broad spectrum antibiotics. Recent treatment trials A total of 40 subjects with diagnosis of chronic PID have focused on shorter duration regimens such as were referred for physiotherapy from the Obstetric and azithromycin and monotherapies including ofl oxacin Gynaecology Department of Murtala Muhammed Spe- (Ross, 2001; Haggerly and Ness, 2006). Conventional cialist Hospital, Kano, Nigeria and from private gynae- chronic pain treatments included nonsteroidal anti- cologists. Patients who had stop analgesic for at least infl ammatory drugs (NSAIDs), etaminophen, narcotics one week and those who met the inclusion criteria were and medicinal marijuana (Roy, 1983). selected for this study. Subjects’ age ranged between 24 It is widely claimed that shortwave diathermy (SWD) and 40 years. can be used to reduce pain and swelling, accelerates the anti-infl ammatory process and promotes healing in Inclusion criteria tissues with chronic infl ammation (Roy, 1983). The Clinical diagnoses of PID for more than six months SWD is high-frequency electromagnetic waves (current history, laboratory (microbiological) examination indi- is of high alternating frequency) that do not stimulate cating presence of pus cells. motor or sensory nerve; it is a form of radiofrequency radiation, operating at a frequency of 27.12 MHz, used Exclusion criteria therapeutically by physiotherapists (Shields et al., 2003). It is ideal for heating tissues as deeply placed in Acute PID and other acute genital infections, intra- the pelvis as the female reproductive organs (Tindall, uterine device/implants, cardiac pacemaker, active 1987). Application of SWD to the involved tissues may tuberculosis, tumour, pregnancy, skin sensation defect, increase vascular circulation any changes are likely as a obesity (BMI ≤ 30 kgm−2), history of electromagnetic result of increasing tissue temperatures, which directly therapy, severely ill patients, intolerance to oral anti- results in vascular dilatation, increase in pain threshold, biotics, analgesics and electromagnetic therapy.

Procedure treatment. In this way, half the treatment was given antero-posteriorly through the pelvis with the patients Pre-treatment procedure in supine lying position and second half with the Informed consent was sought from patients willing patients in the side lying positions with their legs curled to participate in accordance with the ethics of human up and the electrodes over the pelvic outlets and the participation by the management committee of Murtala lumbo-sacral area of the spine. Mohammad Specialist Hospital, Private Clinics and diagnostics’ centres where the study was conducted. Treatment intensity An intensity that generated Laboratory (endocervical swab) investigations indi- moderate pleasant sensation of warmth (dose III) in cated evidence of pus and blood cells in all subjects the Kloth (1986) deﬁ nitions of dosage for SWD, recruited. Pre-treatment pain index assessment was the present study mean ± SD treatment power was conducted by a neutral assessor (senior physioth- 8.27 ± 2.53 W. erapist) through the visual analogue scale (VAS) (Hendiani et al., 2003; Hoof, 2007; Smth et al., 2008). Treatment frequency Treatment was given every It is a scale, using a 10-cm line divided into 10 equal alternative days for a total of 15 exposures (treatment sections, with 0 representing ‘no pain’ and 10 repre- sessions). senting ‘unbearable pain’. Each participant was asked to indicate on the scale the level of pain in their lower Treatment duration The treatment duration was 20 abdominal and pelvic region. minutes (Pages, 1993); split into two sessions of Patients were randomly assigned to three groups: 10-minutes per session in the crossﬁ re positions. SWD, control and analgesic groups

Group X2 Group X (SWD group) antibiotics + SWD + placebo 1 Control group received sham SWD, antibiotics and tablets (number of subjects =13) placebo tablets as prescribed by their gynaecologists. Group X2 (control group) antibiotics + sham SWD + placebo tablets (number of subjects =13) Group X3 Group X3 (analgesic group) antibiotics + sham SWD + analgesics and (number of subjects =14). The analgesic group received sham SWD, antibiotics and analgesic (NSAID) prescribed by their Following random assignment, the gynaecologists pre- gynaecologists. scribed antibiotics, placebo tablets and analgesics For all the groups, the study lasted for about 30 days. accordingly. Placebo tablets were mainly lactose and inert sub- Patients for SWD group were screened for all the stances. Sham SWD was light hot pack wrapped with contra-indications to SWD through the past medical towel placed beneath the electrodes for light warmth and family social history. Thermal skin sensation and SWD machine was on at zero intensity. Positioning test was carried out with two test tubes with cold for sham SWD was as earlier described for the SWD and warm water. It was ascertained that sensitivity of group. Both sham SWD and SWD treatments were the skin surface area of electrodes placement were halted during menstrual bleeding and treatment intact. resumed immediately after bleeding.

Treatment procedure Medications

Group X1 Antibiotics: oral ofl oxacin 400 mg b.d. (twice A continuous shortwave diathermy current was gen- daily) and metronidazole 400 mg b.d. erated by the Shortwave diathermy machine (Ultrath- Analgesic: oral ibuprofen 400 mg b.d. erm 608, Made in Germany by Siemens) adopting the Post-treatment procedure modifi ed crossfi re technique as described by Balogun and Okonofua (1988) and Lamina and Hanif (2008). At the end of the 30 days treatment duration and This involved moving electrodes to a position at right following 5 days (1 week) of no treatment (after which angles to their previous position half way through they had exhausted their analgesics, placebo, sham

SWD and SWD treatments) all subjects were assessed Data analysis for the post-treatment pain score (VAS) using the same pre-treatment procedure by another neutral Mean, standard deviation and percentage were com- assessor who had no prior knowledge of the study, puted. Chi-square, Kruskal-Wallis and Analysis of subjects’ records or groups. Post-treatment lab- covariance (ANCOVA) was used to assess the treat- oratory (endocervical swab) investigation was also ment outcomes. In the ANCOVA, the post-treatment conducted. pain values (post-test values) were the outcome vari- At the end of the study only 32 subjects (SWD group ables and baseline (pre-test values) pain scores as = 11; control group = 10; analgesic group = 11) com- covariates. Scheffe post hoc analysis was performed to pleted the study. Eight subjects (SWD = 2; control 3; identify which means signiﬁ cantly differ from one analgesic = 3) had dropped out and had incomplete another. Statistical analysis was performed on micro- data. Therefore, the data of 32 subjects were used in the computer using Statistical Package for the Social statistical analysis (Figure 1). After the post treatment Sciences (SPSS) version 16 (Chicago, IL, USA). A data, all subjects were referred back to their gynaecolo- probability level of 0.05 or less was used to indicate gists for further consultation. statistical signiﬁ cance.

Subjects with PID assessed for eligibility (N= 50)

Patients excluded for not meeting the inclution inclusion criteria (n= 10)

Patients randomized (n= 40)

Allocated to analgesic group (n= 14) Allocated to SWD group (n= 13) Allocated to control group (n= 13)

Discontinued due to unfavorable Discontinued due to unfavorable Discontinued due to unfavorable response to treatment n=2; responses to treatment n=2 response to treatment n=3 Lost to follow up on proximity ground n=1

Analyzed (n= 11) Analyzed (n= 10) Analyzed (n= 11)

Figure 1 Study design ﬂ ow chat

Results control (X2) and analgesics (X3) groups as depicted in Table 4. A total of 32 patients ranging in age from 24 to 40 years participated. The mean ± SD age (29.41 ± 5.48 years), Discussion weight (56.38 ± 3.26 kg), height (1.48 ± 0.07 m) and BMI (25.60 ± 2.77 kg/m2). Groups mean ± SD for the The main purpose of this study was to determine the SWD (n = 11), control (n = 10) and analgesic (n = 11) therapeutic effi cacy of SWD in the management of groups were 28.55 ± 5.45, 30.40 ± 5.60 and 28.36 ± 5.75, chronic pain in PID; while the subsidiary aim was to respectively. There was no age difference in the groups investigate the anti-infl ammatory role of SWD. The (F = 0.351, p = 0.707) at p < 0.05. present study reported a signifi cant effect of SWD in All subjects 32 (100%) pretest laboratory result indi- pain reduction over analgesic and overall adjunct anti- cated the presence of pus cells. Post-test laboratory infl ammatory role. This fi nding supports the work of investigation indicated that nine (82%), three (30%) Balogun and Okonofua (1988) who reported an effec- and four (36%) subjects in the SWD, control and anal- tive use of SWD in the management of chronic PID. gesic groups respectively reported absence of pus cells. They studied the effect of shortwave diathermy (SWD) Chi-square test indicated signifi cant association on PID pain using the 10-point ratio pain scale. They between treatment and resolution of chronic PID at concluded that SWD may be effective in the manage- p < 0.05 (Table 1). Kruskal Wallis test indicated signifi - ment of pelvic infections that are unresponsive to che- cant deference (χ2 = 6.658, p = 0.036) in treatment motherapy. Lamina and Hanif (2008) also reported a modalities and resolution of PID at p < 0.05. similar fi nding in a case series report; they concluded Groups’ pre- and post-treatment pain index scores that SWD may be an effective alternative to analgesic. were compared to determine any signifi cant difference Another similar study that investigated an alternative in severity of pain perception. Groups base line (pretest) therapy to analgesic was conducted by Evseeva et al. pain scores differ signifi cantly (F = 4.962, p = 0.014) at (2006). Sixty-three females with chronic salpingo- p < 0.05. Table 2 showed the pre- and post-test mean ± oophoritis participated, 52 patients received intensive SD pain level in the three groups. Table 3 (ANCOVA) therapy with impulse low-frequency electrostatic fi eld showed that the difference in the severity of pain before (ILFEF) through abdomino-vaginal, while the remain- and after treatment was statistically signifi cant (p < ing 11 patients were on sham. They reported that ILFEF 0.05) amongst groups. There was a signifi cant reduc- produced marked and long-term positive effects (up to tion in the mean pain of the SWD group (X1) over the 18 months) on pain relief.

Table 1. Group posttest and resolution of inﬂ ammation in Table 3. ANCOVA summary for groups pain level (N = 32) pelvic inﬂ ammatory disease (Chi square [χ2]), N = 32

Source SS df1 MS F p Variables Pus cells No pus cells χ2 p Between group 42.83 2 21.414 20.626 0.000* n (%) n (%) value value Within group 29.07 28 1.038 Short wave diathermy 2 (18.2) 9 (81.8) 6.873 0.032* Total 219.00 32 Control 7 (70) 3 (30) * Signiﬁ cant at p < 0.05. Analgesic 7 (63.6) 4 (36.4)

* Signiﬁ cant at p < 0.05.

Table 2. Mean and standard deviation of pain level in the 3 groups (N = 32) Table 4. Scheffe’s (groups mean difference) value

Variables SWD group Control group Analgesic group Groups Mean difference (I–J) (n = 11) (n = 10) (n = 11) X –X 3.154* X ± SD X ± SD X ± SD 1 2 X1–X3 1.839*

Pretest pain level 5.09 ± 0.83 5.90 ± 0.74 6.00 ± 0.63 X2–X3 1.315* Posttest pain level 0.55 ± 0.52 3.60 ± 0.97 2.27 ± 1.35 * Signiﬁ cant at p < 0.05.

A case study was conducted by Vance et al. (1996) facilitated ‘washout’ of the prostaglandins, which also though not infectious condition but a similar painful have been implicated in promoting infl ammation and symptom. The study investigated the therapeutic effi - causing pain (Vance et al., 1996; EAU, 2007). However, cacy of non-invasive alternative to analgesics in female there is no better way of eliminating pain than by condition (dysmenorrhoea). The case report docu- removing its cause. With any symptomatic therapy, mented the use of microwave diathermy on a 31-year- however, effi cacy must be weighed with the risks old woman who had had primary dysmenorrhoeal involved. SWD has the advantages over analgesic in the since menarche began at age 13 years, for 18 years. sense that it is non-invasive, non-addictive and causes Microwave diathermy (45 W total power) was admin- no known major side effects provided the contra- istered for 20 minutes each month on the day symp- indications are avoided. toms began (usually the fi rst day of menstruation) over seven-month interval, diathermy was followed by Conclusion and almost-immediate and long-lasting relief of symptoms. practical application They concluded that microwave diathermy may be an The study revealed therapeutic effi cacy of SWD in the effective treatment for dysmenorrhoea. Wang et al. symptomatic management of chronic pain and as an (2006) in their own study investigated the effect of adjunct anti-infl ammatory therapy in chronic PID. ultra-laser therapy in the management of chronic PID. However, due to the small sample size, some improve- Sixty cases of chronic PID were divided into a treatment ments may have been seen anyway with antibiotics, group and a control group, 30 cases in each group. The although the SWD group appears to improve more. treatment group were treated with point injection of This factor warrants more attention in future studies. Yuxingcao Injectio combined with ultra-laser point Also, studies are needed to objectively investigate the radiation, and the control group with simple point anti-infl ammatory effect and quality of life with SWD injection of Yuxingcao Injectio, once each day, for four in the management of chronic PID. weeks. They reported that twenty-eight cases were effective with a total effective rate of 93.3% in the treat- REFERENCES ment group, and 23 cases were effective with a total effective rate of 76.7%; the weighty pain of lower Balogun JA, Okonofua FE. Management of chronic pelvic abdomen, abnormal leucorrhea and signs of gynaeco- infl ammatory disease with shortwave diathermy. A case logical examination in the treatment group signifi cantly report. Physical Therapy 1988; 68 (10): 1541–1545. European Association of Urology (EAU). Guidelines on improved as compared with the control group. They Chronic Pelvic Pain, 2007. (Available at: http://www. concluded that point injection combined with ultra- uroweb.org/fileadmin/user_upload/Guidelines/22_ laser radiation has defi nite therapeutic effect on chronic Chronic_Pelvic_Pain_2007.pdf) (Accessed 20 June, pelvic infl ammatory disease. 2009). The favourable symptomatic pain and adjunct anti- Evseeva CL, Serov VN, Tkachenko NM. Chronic salpingo- infl ammatory effect of SWD in the management of PID oophoritis: clinical and physiological rationale for as reported in the present study could be associated therapeutic application of pulse low frequency electro- with the effect of SWD in dilation of arterioles and static fi eld. Vopr Kurortol Lech Fiz Kuit 2006; 1: 21–24. capillaries that result in an increased fl ow of blood to Goats GC. Continuous short-wave (radio-frequency) dia- the pelvic region, the dilation of capillaries also increases thermy. British Journal of Sports Medicine 1989; 23 (2): the exudation of fl uid into the tissues followed by 123–127. increased absorption these assist in the removal of Gray-Swan MR, Peipet JF. Pelvic infl ammatory disease in adolescents. Current Opinion in Obstetrics and waste products. These effects also help to bring about Gynecology 2006; 18 (5): 503–510. the resolution of infl ammation (Goats, 1989; Rennie Haggerly CL, Ness RB. Epidemiology, pathogenesis and and Michlovitz, 1996; Haggerly and Ness, 2006; Jan treatment of pelvic infl ammatory disease. Expert Review et al., 2006). Chronic PID is associated with chronic of Anti-infective Therapy 2006; 4 (2): 235–247. pelvic pain as a result of infl ammatory processes in the Hecox B. Physiological response to local heat gain or loss. pelvis (EAU, 2007). Resolution of the infl ammation is In: Hecox B, Mehreteab TA, Weisberg J (eds), Physical accompanied by relief of pain. Furthermore, increased Agents: A Comprehensive Text for Physical Therapists blood fl ow caused by heating the uterus may have East. Norwalk, CT: Appleton & Lange, 1994; 91–114.

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