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    1988; 68:1541-1545.PHYS THER.Joseph A Balogun and Friday E Okonofuawith Shortwave Diathermy : A Case ReportManagement of Chronic Pelvic Inflammatory Disease

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    M a n a g e m e n t o f C h r o n ic P e lv i c In f lam m a to r y D i s e a s ew i th S h o r t w a v e D iat h er m yA C a s e R e p o rtJOSEPH A. BALOGUNand FRIDAY E. OKONOFUA

    P a t i e n t s w i t h p e l v i c i n f l a m m a t o r y d i s e a s e ( P I D ) a r e n o t r o u t i n e l y r e f e r r e d f o rp h y s i c a l t h e r a p y u n t il t h e c o n d i ti o n i s f o u n d t o b e r e s i s t a n t t o a n t i bi o t ic t h e r a p y .A 3 9 - y e a r - o l d b l a c k w o m a n w i t h a n e i g h t - y e a r h i s t o r y o f P I D w a s t r e a t e d w i t hs h o r t w a v e d i a th e r m y (S W D ) u s in g a m o d i fi ed " c r o s s -f i re " t e c h n i qu e . A t h e r m a ld o s a g e t r e at m e n t l a s t in g b e t w e e n 2 0 a n d 3 0 m i n ut es ( fo r e a c h h a lf o f t h e c r o s s f i re t e c h n i q ue t r e a t m e n t ) w a s a d m i n i s t e re d . A t t h e b eg i n n i n g o f e v e r y t r e at m e n ts e s s i o n , t h e p a t i e n t r a t e d h e r p a i n p e r c e p t i o n o n a 1 0 - p o i n t r a t i o s c a l e . T h ep a t ie n t r e c e i v e d a t o t a l o f n i n e tr e a t m e n t s , a f te r w h i c h s h e w a s c o m p l e te l y p a i nf r e e . T h e r e s u l t s o f t h i s c a s e s t u d y s u g g e s t t h a t S W D m a y b e e f f e c t i v e i n t h em a n a g e m e n t o f p e l v ic i n f e c t io n s t h a t a r e u n r e s p o n s i v e t o c h e m o t h e r a p y . Fu rt h e rs t u d i e s u s i n g l a r g e r s a m p l e s i z e s a n d a c o n t r o l g r o u p , h o w e v e r , a r e n e e d e db e f o r e c o n c l u s iv e s t a t e m e n t s c a n b e m a d e o n t h e r e l at iv e e f f ic a c y o f S W D i n t h em a n a g e m e n t o f c h r o n ic P ID .K e y W o r d s : Electrotherapy, general; Obstetrics an d gynecology; Pain; Short-wave

    therapy.

    The application of physical modalitiesin clinical practice is becoming increasingly popular.1 Many physical agenttextbookshaverecommended the use ofshortwave diathermy (SWD) in themanagement of deeply placed lesionsthat cannot be easily affected by otherphysical modalities.2"5 More recently,SWD has been used as an adjunct in thetreatment of patients with nonunionfractures,6 low back pain,7 and cancer.8In a review of current literature on physical modalities, Santiesteban highlightedthe usefulness of SWD in the management of musculoskeletal lesions andconcluded that the "future holds greatpromise for shortwave therapy."1 Currently, a dearth of information exists onthe efficacy of SWD in the treatment ofgynecological conditions.

    Shortwave diathermy generators produce high frequency (27.12 M Hz) alternating current with a wavelength of 11m.1-5 International standards exist concerning the frequency bandwidth of

    SWD units; however, in some countriesnational requirements dictate the rangeof 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, whereasin Great Britain, frequency-modulated(FM ) bandwidths are allocated fordiathermy equipment. Frequency-modulated radio operates between 88and 108 MHz, which includes the fourthharmonic of the 27.12-M Hz diathermybandwidth.9The use of SWD in physical therapyis not new. A historical review of thedevelopment and methods of application of the modality in different pathological conditions is provided in majorphysical agent textbooks.2" 51011 According to K ottke, the most effective methodof increasing the temperature of the pelvic viscera is the use of a bare metalvaginal electrode and a dispersive electrode over the anterior abdominalwall.12 Other authors recommend theuse of externally applied electrodes withthe patient positioned so that the axialline of the electric field passes throughthe pelvic viscera.21314 An example ofthis method is the "cross-fire" techniquerecommended in the treatment of extensive lesions of the hip joint, pelvic organs, and walls of body cavities containingair (eg, the frontal, maxillary sinusesor the lungs).214

    Externally applied diathermy requiresa treatment duration of between 20 and30 minutes,2 whereas the intrapelvicdiathermy technique requires a treatment duration of 30 minutes to 3hours.12 The externally applied methodiseasier to set up and is more acceptableto 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 cervicaltemperature during the procedure; however, extra caution is needed because ofthe increased risk of burns.13 In addition, patients occasionally experiencesoreness after the initial twotreatments.12The physical effects of SWD are theproduction of heat in the tissues and aconcomitant rise in the tissue temperature.1"5 It has been observed that externally applied diathermy does not increase the intrapelvic temperature asadequately as intrapelvic diathermy.12Scott reported that the externally applied diathermy method may raise thepelvic temperature as high as 102.2F.13For optimal results, K ottke recommended that a vaginal temperature of106 to 110F be maintained duringSWD.12 No consensus currently existsamong clinicians regarding the effectivetemperature level for the treatment ofpelvic infections.

    J . Balogun, PhD , L PT , is L ecturer 1, Departmentof M edical R ehabilitation, Faculty of Health Sciences, Obafemi A wolowo University, Ile-Ife, OyoState, Nigeria, W est A fri ca.F. O konofua, FM CO G, is Senior L ecturer, Department of Obstetrics and Gynecology, Faculty ofHealth Sciences, Obafemi A wolowo University.Address correspondence to Dr. Balogun.This article was submitted December 10, 1987;was with the authors for revision nine weeks; andwas accepted M ay 4, 1988. Potential Conflict ofInterest: 4.

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    Gaya and Hawkins recently suggestedthat a course of SWD (ie, 20 treatmentsover three to four weeks) may bringabout symptomatic pain relief in patients with chronic pelvic inflammatorydisease (PID).15 Chronic PID is the residual debilitating illness that follows anacute episode of pelvic infection and ischaracterizedbyvarious symptoms suchas persistent or recurrent lower abdominal pains, vaginal discharge, dyspareu-nia, and menstrual disorders. The mostserious clinical consequences of chronicPID include infertility, chronic pelvicpain, and ectopic pregnancy. Of these,chronic pelvic pain is potentially amenable to treatment with physical modalities. Alternative treatment options suchasanalgesics, antibiotics, and surgery areunsatisfactory because microorganismsoften are not present, and the patientmay not accept surgery or the side effects of conventional analgesics. Theprolonged administration of antiinflammatory analgesics is associatedwith maculopapular rash, agranulocytosis, aplastic anemia, tinnitus anddeafness, peptic ulceration, and nephrotoxicity.16 Similarly, repeated or prolongedantibiotic therapy can result in development of resistant strains of organismsand predispose the patient to candidiasis.17 Furthermore, pelvic surgeries (including hysterectomy) have not beenknown to consistently relieve symptoms in patients with chronic PID. Insome instances, the situationwasactually made worse by the operativeprocedure.15In clinical practice, physical therapistscommonly use infrared radiation, transcutaneous electrical nerve stimulation,electroacupuncture, and SWD to modulatepain.1,25 No significant rise in tissue temperature is expected with the useof TENS and electroacupuncture.5 Inthe management of pain attributable tochronic PID, SWD is preferred to otherphysical agents because of its greaterdepth of penetration.2 It is capable ofintroducing heat 3 to 5 cm below theepidermis.4 To our knowledge, no recent reportexistson the use of externallyapplied diathermy in the managementof chronic PID. In this case report, wediscuss the efficacy of SWD, using surface electrodes, in alleviating the pain ofa patient with chronic PID.M E T H O D A N D M A T E R I A L SP a t i e n t ' s M e d i c a l H i s t o r y

    On January 7, 1987, a 39-year-oldblack woman with secondary infertility

    and amenorrhea of eight years' durationconsulted a gynecologist (F.E.O.). Following her only delivery in October1979, for which she required manualremoval of the placenta, she failed tomenstruate but experienced intermittent, throbbing lower abdominal pain.On three occasions between 1984 and1986, she had dilatation and curettagein various clinics to cure her amenorrhea, but these procedures failed toinduce her menses. She reported nodysuria, diuresis, or appreciable vaginaldischarge.Examination by the gynecologist revealed mild bilateral lower abdominaltenderness without rebound, scanty en-docervical discharge, moderate bilateraladnexal tenderness with minimal thickening on the right, and moderate cervical tenderness on movement. The uteruswas normal in size and was nontender.Laboratory examination revealed ahematocrit of 43%, peripheral white cellcount of 7,500with polymorphonuclearleukocytes of 45%, an erythrocyte sedimentation rate of 43 mm/hr, a nonreac-tive VDRL test result, a normal urinalysis result and culture, and a negativeurine pregnancy test result. The endo-cervical and high vaginal swabs revealedno significant growth. Serum FSH andLH were 5.6 and 6.3 IU /L , respectively,indicating no ovarian failure. The patient was treated with 100 mg of Vibra-mycin* (doxycycline) twice a day for 10days. The pain persisted, however, andon March 19, 1987, a hysterosalpingog-raphy was performed. The test revealeda poorly outlined endometrial cavityand the presence of multiple filling defects (synechiae) in the endometrium.The right fallopian tube was outlinedand demonstrated dye spillage. The leftfallopian tube showed terminal hydrosalpinx but no dye spillage. A laparos-copy performed on March 27, 1987, tofurther evaluate the pelvic pain showeda normal patent right fallopian tube anda normal right ovary. The left fallopiantube was thick and occluded with terminal hydrosalpinx, and itwasadherentto the left ovary. Flimsy adhesions wereevident in the pouch of Douglas.On March 31, 1987, uterine adhesi-olysis was administered to the patientwith the aid of a uterine sound followed by insertion of an inert intrauterine contraceptive device for 10days under broad-spectrum antibiotic cover.She initially received two weekly injec

    tions of estradiol valerate followed laterby the daily administration of a highlyestrogenic oral contraceptive pill (Nori-day) for three months. She experienced regular painful menstrual bleeding upon withdrawal of the contraceptive pills. On J uly 23,1987, she reportedto the clinic with complaints of bilateralabdominal and back pain, and she wasthen referred for physical therapy.P h y s i c a l E xa m i n a t io n

    The patient complained of a constantand diffuse abdominal pain radiating tothe lumbar region. A detailed medicalhistory was taken to eliminate conditions that are contraindicated toSWD.2,3 Specifically, we solicited fromthe patient information about her 1)menstrual cycle to rule out pregnancyand hemorrhage; 2) contraceptive habitsto rule out use of intrauterine device;and 3) past medical history to rule outvenous (thrombosis) phlebitis, arterialdisease, and malignant tumors.Spinal motions (flexion, extension,side bending, and rotation) did not relieve or aggravate her pains. To rule outmusculoskeletal problems of spinal origin, we conducted a full evaluation ofthe patient's vertebrae and sacroiliacjoints, as advocated by Saunders.18 Thelower-quarter screening (LQS) examination was undertaken. The LQS examination entails a series of mobilityand 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 painwas not of spinal origin or referred fromthe lower extremities.18We also tested the patient's ability todiscriminate between hot and cold. Theskin sensation test was undertaken withtwo test tubes containing hot (40C) andcold (5C) water, placed alternately overthe abdomen and lumbar region. Thepatientwasable to consistently discriminate between the two extreme temperatures, suggesting that she had normalsensation over the areas to be irradiated.We tested for skin sensation because thetreatment dosage is dependent on thepatient's ability to perceive the intensityof heat.2Based on the results of the laboratory,spinal mobility, and L QS tests, we concluded that the lumbar region pain wasreferred from the pelvic organs. The pa-

    * Ranbaxy M ontari (Nigeria), Ltd, Sango-Otta,Niger ia, West Afr ica. Syntex L aboratories, Inc, 3401 Hi llview Ave,PO Box 10850, Palo Alto, CA 94304.

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    PRACTICEtient was not particularly concernedabout her infertility, and she did notwant to have major abdominal surgery.As such, SWD therapy was recommended as an alternative method to relieve her of thepains.T RE AT M E NT

    A Megatherm Junior Mark FiveSWDgenerator* with 2-FMHz frequency outputwasused.To reduce hazard of burnsand electrical shock, we removed fromthe immediate treatment area all metallic objects (including chairs and bed)and electrical devices.1 We used themodified version of the cross-fire technique because the metallic chairs in ourclinic made it impossible to administertreatment in the sitting position as advocated by Wale.14 The cross-fire technique is a method of surface electrodearrangement that enables the therapistto irradiate the four walls of the pelvicorgans (ie, uterus and fallopiantubes).214The SWD treatment was administered on a plinth with the patient in alying position. The protocol was dividedinto two parts. During the first part, thepatient was positioned prone over amalleable electrode (26 x 27.5 cm) withthe long axis placed at the abdominallevel. A second electrode (26 x 27.5 cm)was placed over the lumbar region andwas held in place by a 0.5-kg sandbag.The electrodes were padded with 5-cmthick perforated felt and towel insulation to prevent burns. Duringthesecondpart, the patient was positioned supinewith the padded electrodes positionedon the small axis and parallel to the iliaccrest. The two malleable electrodes wereheld in place with a VELCRO brandtouch fastened strap tied around theabdomen.A thermal dosage treatment wasadministered2 after the patient was informed that she should feel a mild, comfortable sensation of warmth over theabdominal wall and lumbar region during the treatment and that a danger ofburns exists if the heat becomes excessive. A thermal dosage, as perceived bythe patient, corresponds to an ammeterreading of 3 on the SWD unit when itis in tune. This power output is 60% ofthe maximum power of the SWD generator. At the first treatment session, thethermal dosage was applied for 20 min-

    T A B L ET r e at m e n t P r o t o c o l a n d D u r a t io nT r e a t m e n t

    S e s s i o n123456789

    M e t h o dc r o s s - f i r e ac r o s s - f i r ec r o s s - f i r ec r o s s - f i r ec r o s s - f i r ec r o s s - f i r ec r o s s - f i r em o n o p o l a r bm o n o p o l a r

    T o t a l T r e a t m e n tD u r a t i o n ( m i n )

    405050506060602525

    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 andno untoward symptoms occurred duringthe first treatment session.13 At the fifthtreatment session, we progressed thetreatment duration to 30 minutes in linewith Scott's recommendation.2We adopted the monopolar electrodearrangement2 at the eighth treatmentsession because the patient's pain waslocalized to the left anterior abdominalwall. During the treatment, the activemalleable electrode was placed over thepainful left abdominal wall, and the inactive malleable electrode was tied tothe left quadriceps femoris muscle. Thetreatment duration was reduced to 25minutes. The procedurewasrepeated onthe ninth treatment session. A summaryof the treatment protocol and durationsis presented in the Table. The patientduring the course of the SWD therapydid not receive any other form of treatment (eg, exercise or drugs).T r e a t m e n t E v a lu a t io n

    Before the initial treatment session,we introduced the patient to a 10-pointratio pain scale. The pain scale is amodified version of an earlier scale described by Balogun,19 who found it tobe reliable (r = .82). The range of numbers on the scale (A ppendix) representsa range of perceived sensations from nopain at all (ie, 0) to the most intensepain ever experienced since the problemstarted (ie, 10).At the beginning of every treatmentsession, the patient was instructed torate her pain perception as accurately aspossible, rounding up to the nearestwhole 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 abdominalpain (AP).RESULTS

    The patient's responses to SWD treatment are summarized in the Figure. Thepatient received a total of nine treatments. On the first day of treatment(July 23, 1987), the patient's BP and APratings on the 10-point ratio scale wereboth 8. The patient's pain perceptionremained unchanged after two treatment sessions. The AP rating remainedunchanged until the sixth treatment session; however, by the third treatmentsession, an improvement was noted inthe BP rating. On the seventh treatmentsession, the patient reported that her BPwas completely relieved (ie, 0 rating),and her AP had decreased considerably(ie, a rating of 3). She also reported herfirst "good night's sleep in many years."After the seventh treatment session,the SWD treatment was suspended because the patient was menstruating. Hermenstrual period lasted for four days,and the treatment was resumed on August 16, 1987. As compared with herprevious menses, the patient reported"mild pain" during the menstruation.She also described the menstrual flow as"normal" as compared with the "mildspotting" experienced in previousmonths.On the eighth treatment session, nopain was felt on the right abdominalwall, and the pain was limited to the leftabdominal region. On August 19, 1987,the patientwascompletely pain free andwas discharged. She was instructed toreturn to the clinic for treatment in theevent of relapse. At the time of writing

    a For the cross-fire technique, the patient received 20 minutes of treatment in the proneposition 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.

    M odel 78/12, ElectroMedical Supplies Gr een-ham, L td, Wantage, Oxfordshire, England. VE L CR O U SA , Inc, PO B ox 5218, 406 BrownA ve, M anchester, N H 03108.

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    this report (six months after discharge),the patient was still pain free.DISCUSSION

    The use of SWD in the clinical settinghas systematically decreased in the lastdecade because of the discovery ofnewer electroanalgesia such as theTENS, electroacupuncture, and lasers.Recently, Nickel20 suggested the elimination of SWD from physical therapy'srepertoire of treatment modalities because of the dearth of evidence supporting its therapeutic effectiveness in thedifferent clinical conditions for which itisrecommended.1"5 Our findings suggestthat SWD still has a place in the armamentarium of the physical therapist andis indicated in gynecological practice.The relative efficacy of the variousphysical modalities used in the management of chronic pain has not been compared objectively. Various theories currently exist on the mechanism of actionof the different modalities. Well-accepted theories include the "gatecontrol" theory of pain, the role ofendogenous opiates, and changes innerve ibers'excitability after repetitivestimulation.21" 23 The exact mechanismwhereby SWD exerts its salutary effectis currently not wellknown.24,25 Following SWD therapy, there is a generaldilatation of the arterioles and capillaries.1"5 The improved blood circulationenhances 1) the presence of oxygen, tissue nutrients, and phagocytic cells and2) the removal of metabolic waste products. These physiological effects aid inthe resolution of theinflammatory process and may account for the pain reliefnoted in this case report.Recent reports indicate that the concentration of certainprostanoids are elevated in the peritoneal fluid of patientswith chronic PID.26 These prostanoidspossibly mediate pelvic pain by causingvasoconstriction and reduction in bloodflow to the pelvic organs. Theoretically,SWD can reverse these effects by producing a definite increase in local bloodflow to pelvic organs.Patients with P ID are not routinelyreferred for physical therapy until thecondition is found to be resistant toantibiotic therapy. The results of thiscase report reveal that SWD may beeffective in the management of chronicPID that is unresponsive to chemotherapy. Shortwave diathermy may also beuseful in the treatment of other inflammatory pelvic conditions such as salpingitis, parametritis, urethritis, prostatitis,

    F i g u r e . P atient pain perception at beginning of eac h treatmen t sess ion.

    and osteitis pubis.12 This patient's painrelief may be attributable to the placeboeffect.27 It isimportanttonote, however,that the patient had undergone variousmedical treatmentsduring thepast eightyears without success. Following acourse of SWD therapy, the patient wasrelieved of her pains, and six monthsposttreatment, she is still pain free. We,however, are currently undertaking alarger prospective controlled study thatwould conclusively determine the efficacy of SWD in the management ofchronic PID.Although it has been suggested thatSWD may initially cause a flare-up ofinfection,15 this complication did notoccur during the treatment of this patient, despite the avoidance of prophylactic antibiotics. Thisresult may bedueto the pretreatment use of doxycyclineand the absence of microorganismsin the patient's vaginal and cervicalcultures.Burns are a major hazard inherent inthe use of SWDtherapy. The therapist,however, must be alert to certain precautions and contraindications. Pregnant patients and those with sensorydeficit, phlebitis, arterial disease, andmalignant tumors should be identifiedand excluded from SWD therapy. Itshould not be applied to areas recentlyexposed to radiotherapy.2 Patients withpacemakers and superficial metallic implants (ie, intrauterine devices) shouldbe excluded. Patients with deeper me

    tallic implants, however, may be treatedat nonthermal dosages.1 Based on itssimplicity, relative safety, and shortertreatment duration required duringtreatment, we recommend the use ofsurface-electrodeSWD for wider clinicaluse in the treatment of chronicPID.S U M M A R Y

    A case report of a39-year-old patientwith an eight-year history of chronicPI D was presented. After nine SWDtreatments using a modified cross-firetechnique, she was completely relievedof her abdominal and back pains. Basedon our indings,we recommend the useof surface-electrode SWD in the management of chronic PID that is unresponsive to antibiotic therapy. Furtherstudies with a control group and largersample sizes are needed before conclusive statements can be made on the relative efficacy of SWD in the treatmentof chronic PI D.REFERENCES

    1. Santiesteban A J : Physical agents and musculoskeletal pain. In Gould J A, Davies G J (eds):Orthopaedic and S ports Physical Therapy. S t.Louis, MO, C V Mosby Co, 1985, vol 2, pp199-2112. Scott P M: Clayton's Electrotherapy and Acti-notherapy, ed 7. Baltimore, MD, Williams &Wilkins, 1975, pp 230-2653. Shriber WJ : A Manual of Electrotherapy, ed 4.Philadelphia, PA, Lea & Febiger, 1975, pp212-2334. Hayes KW: Manual for P hysical Agents, ed 2.Chicago, IL, Northwestern University P ress,1979, pp 41-46

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    PRACTICE

    APPENDIXT e n - P o i n t R a t i o S c a l e fo r R a t i n g P a i n "

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    10

    n o p a in at all v e r y , v e r y m i ld p a in v e r y m i l d p a i n m o d e r a t e p a in v e r y u n c o m f o r ta b le p a inunbearab le pa in m o s t i n t e n s e p a in e v e r f e lt

    5. Griffin J E, Karselis TC: Physical Agents forPhysical Therapists. Springfield, IL,Charles CThomas, Publisher, 19786. Bassett CA, M itchell S, Gaston S: Pulsing electromagnetic field treatment in ununited fractures and failed arthrodeses. JAMA 5:247-252,19827. Nwuga VCB: Relative therapeutic efficacy ofvertebral manipulation and conventional treatment inback pain management. Am J PhysMed 61:273-278,19828. Overgaard J : Biological effects of 27.12-MHzshortwave diathermic heating in experimentaltumors. IEE E T ransactions on M icrowave The

    ory and Technique 26:93-97,19789. Rogoff J B: High frequency instrumentation. InLicht S (ed): Therapeutic Heat and Cold, ed 2.Baltimore, MD , Waverly Press , Inc. 1972, pp266-27810. Licht S: History of therapeutic heat. InLicht S(ed): Therapeutic Heat andCold, ed 2. Baltimore, MD, Waverly P ress, Inc, 1972, pp217-21911. Lehmann J F: Diathermy. InKrusen FH, et al(eds): Handbook ofPhysical Medicine and Rehabilitation, ed 2.Philadelphia, PA, W B Saunders C o, 1971, pp 273-29712. Kottke F J : Heat inpelvic diseases. InLicht S(ed): Therapeutic Heat andCold, ed 2. Baltimore, MD, Waverly P ress, Inc, 1972, pp474-49013. Scott BO: Short wave diathermy. In Licht S(ed): Therapeutic Heat andCold, ed 2. Baltimore, MD, Waverly P ress, Inc, 1972, pp279-30914. Wale J O: Tidy's M assage and Remedial Exercises, ed 15.Bristol, England, J ohn Wright &Sons Ltd, 1976, pp 455-45615. Gaya H,Hawkins DF: Pelvic infection. In Hawkins DF (ed): Gynecological Therapeutics. London, England, Bailliere Tindall, 1981, pp 142-21016. Rodnan GP, Schumacher RH, Zvaifler NJ:Primer on theRheumatic Diseases, ed 8. Atlanta, GA, Arthritis Foundation Press, 1983, pp188-19217. De Alvarez RR, Figge DC: Influence ofantibiotics onpelvic inflammatory disease. ObstetGynecol 5:765-769,195518. Saunders HA:Evaluation of musculoskeletal

    disorders. In Gould J A, Davies GJ (eds): Orthopaedic and S ports Physical Therapy. S t. Louis,MO , C V Mosby C o, 1985, vol 2, pp169-18019. Balogun J A: Pain complaint and muscle soreness associated with high-frequency electricalstimulation. Percept Mot Skills 62:799-810,198620. Letter to the editor. Progress Report of theAmerican P hysical Therapy Association, S eptember 1984, p 221. Wolf S L: P erspectives on central nervous system responsiveness totranscutaneous electrical nerve stimulation. Phys Ther 58:1443-1449,197822. Hughes GS J r, Lichstein PR , Whitlock D, et al:Response ofplasma beta-endorphins to transcutaneous electrical nerve stimulation inhealthy subjects. Phys Ther 64:1062-1066,198423. Ignelz RH, Nyquist J K: E xcitability changes inperipheral nerve fibers after repetitive electricalstimulation. J Neurosurg 51:824-833,197924. Santiesteban AJ : Selected physiological properties of pulsed short-wave diathermy. Abstract. Phys Ther 61:738,198125. Brown M, Baker RD: Effect of pulsed shortwave diathermy on skeletal muscle injury inrabbits. Phys Ther 67:208-214,198726. Dawood MF, Khan-Dawood FS, Wilson L:Peritoneal fluid prostaglandins and prostanoidsin women with endometriosis, chronic pelvicinflammatory disease and pelvic pain. Am JObstet Gynecol 148:391,198427. Currier DP: Elements ofResearch inPhysicalTherapy, ed 2. Baltimore, MD, Williams &Wil-kins, 1984

    a Adapted from Balogun.19

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    1988; 68:1541-1545.PHYS THER.Joseph A Balogun and Friday E Okonofuawith Shortwave Diathermy : A Case ReportManagement of Chronic Pelvic Inflammatory Disease

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