Physiotherapy Theory and Practice

An International Journal of Physical Therapy

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Ultra-shortwave diathermy - a new purported

treatment for management of patients with
COVID-19

Homer Peng-Ming Yu, Alice YM Jones, E Dean & E- Liisa Laakso

To cite this article: Homer Peng-Ming Yu, Alice YM Jones, E Dean & E- Liisa Laakso (2020) Ultra-
shortwave diathermy - a new purported treatment for management of patients with COVID-19,
Physiotherapy Theory and Practice, 36:5, 559-563, DOI: 10.1080/09593985.2020.1757264

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PHYSIOTHERAPY THEORY AND PRACTICE
2020, VOL. 36, NO. 5, 559–563
https://doi.org/10.1080/09593985.2020.1757264

Ultra-shortwave diathermy - a new purported treatment for management of

patients with COVID-19
Homer Peng-Ming Yu, MPTa, Alice YM Jones, PT, PhD, FACPb,c, E Dean, PT, PhDd, and E- Liisa Laakso, PT, PhDe,f
a
Department of Rehabilitation, West China Hospital, Sichuan University, Sichuan, China; bSchool of Health and Rehabilitation Sciences,
University of Queensland, Brisbane, Australia; cSydney School of Health Sciences, University of Sydney, Sydney, Australia; dDepartment of
Physical Therapy, University of British Columbia, Vancouver, Canada; eMater Research, Brisbane, Australia; fMenzies Health Institute
Queensland, Griffith University, Gold Coast, Australia

ABSTRACT ARTICLE HISTORY

The pandemic spread of coronavirus disease 2019 (COVID-19) has driven efforts to address the Received 10 April 2020
global threat to public health and there is increasing pressure to exploit interventions to manage Revised 13 April 2020
the pneumonic inflammation manifested in this disease. Ultra-shortwave diathermy (USWD) is Accepted 15 April 2020
proposed by some rehabilitation professions in China, purportedly to minimise pneumonic KEYWORDS
inflammation. However, treatment of any symptomatic pneumonia should be evidence-based. Ultra-shortwave diathermy;
There is no valid evidence, published in English, which establishes any benefit of USWD in COVID-19; evidence-based
pulmonary conditions, let alone COVID-19. The need for rigorous research and evidence-based practice
practice is discussed in this article. Novel interventions require a solid physiological basis and must
undergo rigorous testing prior to clinical adoption even during a pandemic. We are of the view
that deployment of USWD in patients with COVID-19 must be prudent and supported by a logical
scientific basis.

Background
Coronavirus disease 2019 (COVID-19) has become
a pandemic. The death rate of confirmed cases was
highest in China but has now been overtaken by other
countries. China is doing its best to advocate relevant
protective strategies via public education and striving to
find the best way to combat the disease. Infections
resulting from COVID-19 are still being understood
but we now know the primary target organ is the
lungs (Yi et al., 2020). The resulting inflammatory
cytokine storm results in ICU admission for supportive
care in approximately 5% of cases (Guan et al., 2020).
Based on clinical presentation, patients with COVID-19
in China are classified into four categories (China
Medical Administration Hospital Authority, 2020)
(Table 1).
In response to the urgent need for clinical guidance
worldwide, an international guideline describing the
role of physiotherapy management for COVID-19 in
the acute hospital setting has been recently published
(Thomas et al., 2020). In China physiotherapy is still
a developing profession, and consequently, recom-
mendations for “rehabilitation” interventions for
patients with COVID-19 in China were propagated
by rehabilitation physicians (China Association of
Rehabilitation Medicine, 2020a). Severe cases mana-
ged in intensive care follow western medical proto-
cols, and general mobility and breathing exercises are
encouraged in the management of mild cases. At the
height of the outbreak, alternative therapy including
Chinese herbal medicine (Yi et al., 2020) and ultra-
shortwave diathermy (USWD), both of which have
a purported role in suppressing inflammation and
enhancing the immune response, were proposed by
Chinese medical practitioners through social media,
particularly health professional ‘WeChat’ social media
groups. To assist China in combating COVID-19,
three Curapulse 970TM short wave diathermy
machines and two Radarmed 950+ TM microwave
machines were donated to three hospitals in Wuhan
(the center of the disease outbreak) (China
Association of Rehabilitation Medicine, 2020b).
Following this donation, a “recommended protocol”
was shared extensively in advocating USWD therapy
for patients with COVID-19. The protocol recom-
mends “USWD be applied with electrodes to be placed
across the front and back of the torso, daily for
15 minutes, until the patient is discharged”. The

CONTACT Alice YM Jones, PT, PhD, FACP a.jones15@uq.edu.au School of Health and Rehabilitation Sciences, University of Queensland, Brisbane,
Australia
© 2020 The Author(s). Published with license by Taylor & Francis Group, LLC.
This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License (http://creativecommons.org/licenses/by-nc-nd/4.0/),
which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered, transformed, or built upon in any way.
560 H. P.-M. YU ET AL.
Table 1. Classification of patients with COVID-19 in China.
Mild: mild symptoms, pneumonia not evident in radiological reports.
General: fever, and respiratory symptoms and positive pneumonia
radiological signs.
Severe: one of the following:
1) respiratory rate ≥30 bpm
2) resting SpO2 ≤ 93%
3) PaO2/FiO2 ≤ 300 mmHg
4) worsening of radiological signs by >50% in 24–48 hrs.
Critical: one of the following:
1) sign of respiratory failure requiring mechanical ventilation
2) shock
3) co-existing with other organ failure requiring ICU care.
Source: China Medical Administration Hospital Authority. Protocol for treat-
ment of Novel Coroavrius Pneumonia (Trial Version 7).
evidence for the inclusion of USWD as part of the
management of COVID-19 is highly debatable, thus,
a discussion of USWD and reasons for its recommen-
dation is warranted.
Thermotherapy using electromagnetic fields (e.g.
short wave diathermy [SWD]) and microwave dia-
thermy were modalities commonly used in the physical
therapy profession in the management of painful mus-
culoskeletal conditions during the 1900s. The lack of
rigorous scientific evidence to support effectiveness in
comparison to exercise or placebo groups (Akyol et al.,
2010; Haik et al., 2016; Kroeling et al., 2013; Page et al.,
2014, 2016), the dated nature of clinical evidence, and
concerns regarding safety, have led to such modalities
being excluded from many physical therapy entry-level
curricula in some countries. Physical therapy is not yet
a profession recognized by the Chinese government;
and rehabilitation work in China is led by rehabilitation
medicine practitioners, assisted by rehabilitation thera-
pists. Rehabilitation therapists are graduates from
either a 3-year diploma or 4-year bachelor program
with a curriculum focusing on techniques used by
occupational therapists, speech therapists, and physical
therapists (but limited mainly to electrotherapy and
passive exercise). Physical therapy programs with cur-
ricula following international guidelines were intro-
duced in China in 2004. Currently, there are six such
programs recognized by the World Confederation for
Physical Therapy (2020). In China, there are no evi-
dence-based clinical guidelines regulating the use of
electrotherapies. Physical therapy graduates from
recognized programs would not select an electrotherapy
modality as a preferred patient management option, yet
electrophysical agents are widely applied to patients in
China by rehabilitation therapists, nurses, and rehabi-
litation practitioners. Many rehabilitation departments
have multiple rooms dedicated to the administration of
shortwave and microwave diathermy, magnetic fields,
high-, and low-voltage electrical stimulation, and light
therapy.
During the COVID-19 outbreak, some hospitals
recommended that USWD be used for patients in the
severe and critical categories as a means of reducing
inflammatory changes in the lungs. Given that COVID-
19 is novel, the use of USWD for such patients without
an evidence-base or safety guidelines could cause harm.
Clinicians in China should be alerted to the current
best evidence for USWD applications to the chest/
thorax of a patient. Furthermore, physiotherapists
need to exploit existing practice guidelines for the
care of critically ill patients (Gosselink et al., 2008).
These guidelines remain as the standard despite its
2008 publication date. Unproven interventions may
detract from focusing on those practices known to be
effective in patients in respiratory failure.
Is ultra-shortwave diathermy an appropriate
treatment for patients with COVID-19?
A wide search of the internet for USWD directs the
readership to an article published in 1938 (Rajewsky,
1938). The nomenclature used at that time was confus-
ing and differentiation between shortwave, ultra-short-
wave wave, and diathermy was incomplete (Krusen,
1938). The Great Soviet Encyclopedia states that ultra-
shortwave therapy is the ‘use of an alternating electro-
magnetic field with a frequency ranging from 30 to
300 MHz.’ It was claimed that USWD had “anti-
inflammatory, resorptive antispastic and analgesic”
benefits, however, no research evidence of these effects
is provided. Contraindications to the therapy included
“malignant neoplasms, active phase of tuberculosis,
systemic blood diseases, cardiac insufficiency, hypoten-
sion and tendency to bleed.”
To provide context, a recent review of the effects of
shortwave radiation reported that exposure to electro-
magnetic radiation (frequency range, 3–30 MHz) may
have benefits in certain clinical situations but can
cause headache, dizziness, insomnia and induce
abnormal ECG changes (Yu and Peng, 2017). Rats
exposed to pulsed SWD at 27.12 MHz for 10 min
per day for 15 days demonstrated structural and ultra-
structural changes in the adrenal glands (Gabriel and
Constantin, 2015).
A key word PubMed and PEDro (Pedro.org.au)
search using (ultra-shortwave diathermy OR shortwave
diathermy) AND (lung OR chest infection, lung OR
chest OR respiratory) produced two relevant titles in
English and only one describing SWD for small spon-
taneous pneumothorax (Ma, Li, and Liu, 1997) was
available for perusal. A similar search strategy in
Google Scholar produced four Chinese articles with
English abstracts (He, Ruan, Chang, and Zhu, 2006;
 PHYSIOTHERAPY THEORY AND PRACTICE 561

Wang et al., 2003; Zhang et al., 2007, 2003). These Evidence-based practice and clinical
articles reported the use of USWD in patients with: implications
severe acute respiratory syndrome (Zhang et al.,
Evidence-based practice is about the questioning of
2003); chronic obstructive pulmonary disease (Wang
practice and the application of best available evidence
et al., 2003; Zhang et al., 2007); and in children with
in clinical practice. Ethically, clinicians should “first do
bronchopneumonia (He, Ruan, Chang, and Zhu, 2006).
no harm”, hence it is important for clinicians to under-
The purported benefits were anti-inflammatory effects
stand that good quality research demonstrating that an
based on animal studies (Chen, Jin, and Li, 2000; Zhou
intervention is ineffective or potentially unsafe, is as
et al., 2002). Although all articles claimed to be rando-
valuable to the clinician as evidence showing positive
mized controlled trials (RCT), none described the
results of an intervention. The urgency of seeking man-
method of randomization, concealment, nor blinding
agement options during a pandemic must not outweigh
of subjects or therapists. Only two articles described
patient safety. In the absence of high-level evidence,
machine parameters (i.e. 40.6 MHz). The site of infec-
clinician judgment and patient preferences contribute
tion was not described and a description of electrode
to clinical decision-making, but these factors need to be
placement over the chest was not provided. There was
balanced against known or realistic hypothetical risks
no report of safety procedures adopted nor follow-up
and the uncertainty generated by those risks. Presently,
assessment of lung function. These articles reported
the absence of high-quality evidence to support the safe
that the treatments were prescribed daily with treat-
use of USWD in lung disease is lacking. The potential
ment times ranging from 15 to 30 min per day for
risks to patients receiving pulmonary USWD, such as
days or weeks. The rationale for use appeared to be
potential cardiac irregularity associated with passing
aimed at reducing inflammation; and presumably, the
a diathermy current close to the heart, have not been
same rationale has been applied in recommending the
established, thus its use in new diseases cannot be
use of USWD in patients with COVID-19 infections.
justified. Further, the application of USWD requires
COVID-19 is a new viral disease. The clinical man-
placement of the device and electrodes in close proxi-
ifestations of COVID-19 are being updated daily. What
mity to the infected patient, imposing an extra medium
is apparent so far is that COVID-19 can be associated
of potential viral contact for patients as well as health-
with myocardial damage producing ECG changes,
care professionals.
including ST-elevation in the absence of obstructive
Many patients with COVID-19 have cardiovascular,
coronary artery disease, elevated B-type natriuretic pep-
respiratory, renal, and neurological comorbidities, which
tide (BNP) (Arentz et al., 2020; Huang et al., 2020), and
have an impact on their functional capacity. Rehabilitation
that some current medications deployed to treat
disciplines should focus on evidence-based exercise pro-
COVID-19 (e.g. chloroquine, hydroxychloroquine, azi-
grams to optimize respiratory and peripheral muscle
thromycin, and ritonavir) can cause cardiac toxicity
strength. Long-term respiratory and functional outcomes
(Gautret et al., 2020). A recent report claims 71% of
for survivors of COVID-19 are still being investigated. The
patients who died with severe COVID-19 met criteria
impact of COVID-19 on the pulmonary and functional
for disseminated intravascular coagulation (DIC) and
capacity of COVID-19 survivors may be similar to that
pulmonary congestion associated with microvascular
reported in SARS survivors (Chan, 2005). If this is so,
thrombosis (Wang et al., 2020). The effects of passing
rehabilitation programs in China should be based on simi-
ultra-shortwave current through the heart and lungs of
lar evidence (Gosselink et al., 2008; Lau et al., 2005) and
severe COVID-19 patients must, therefore, be vigilantly
focus on improving the aerobic and exercise capacity of
considered. Patients with severe COVID-19 invariably
COVID-19 survivors.
require high inspired oxygen concentrations. If, as pro-
posed, USWD induces fibroblastic activity (Hill, Lewis,
Mills, and Kielty, 2002), an enriched oxygen environ-
Future research of pulmonary USWD
ment could hypothetically increase the risk of long-
term pulmonary complications, such as pulmonary Several research questions arise including whether
fibrosis. This hypothesis is speculative but underlines USWD is a safe and effective management option for
why it is essential that rigorous research on the effects lung disease; and what dosing and application regimen
of USWD on pulmonary physiology should be con- would be most efficacious. As there is currently no data
ducted before this modality is widely applied to on the use of USWD on patients with COVID-19 or
a large population of COVID-19 patients in China. other coronaviruses, we recommend that the first step
562 H. P.-M. YU ET AL.

Table 2. Essential points to consider in the preparation of a case study of USWD in patients with COVID-19.
Clear descriptions of:
1) criteria for patient selection
2) safety protocols, such as testing of machine output and patient’s skin sensation
3) placement of electrodes, and dose parameters (with a rationale for these)
4) relevant outcome measures (including change in: radiological presentations (via CT or spread of B-lines in lung ultrasound assessment), plasma IL-8 and
other inflammatory biomarkers, oxygenation status, respiratory signs, dose of anti-viral medication required, length of stay in hospital)
5) recording any adverse effects of the intervention such as an increase in chest pain, cardiac arrhythmia, and hypoxic events
6) procedures for long term follow-up for the exclusion of pulmonary fibrosis or signs of myocardial injury, and
7) any increase in patient or staff acquired infection by COVID-19
Other factors for consideration include:
8) ensuring that trial USWD devices are dedicated only for patients with COVID-19, and
9) application of appropriate and satisfactory cleaning procedures for all devices between uses with COVID-19 patients.

is well-constructed case study reports. Table 2 shows
the essential points for consideration in case studies.
A well-designed case series with consenting adults
using rigorous standardization of methods and outcome
measures would assist in establishing the safety, feasibility,
tolerability, and indicators of effectiveness of the inter-
vention. Case studies are necessary to identify risks and
potentially beneficial dosing parameters, prior to embark-
ing on pilot-randomized controlled trials. If case studies
and pilot studies suggest that USWD has some benefit,
a control group of patients matched for disease severity,
age, and gender must be included as part of an adequately
powered and rigorously controlled randomized clinical
trial to compare any purported outcome advantage, prior
to implementation in people with COVID-19. A data
monitoring committee should meet regularly to evaluate
safety data to determine suitability to continue with the
study, or the need to close the study. Before further reli-
able evidence is established, it is recommended that the
very recently published clinical practice guideline for the
management of COVID-19 by physiotherapists be
adopted as these recommendations are based on the best
available relevant evidence.
Conclusion
Due to the lack of evidence on beneficial effects of USWD
in patients with COVID-19, and the risk of cross-infection
between staff and patients using the devices, we recom-
mend that USWD not be deployed as a ‘recommended’
clinical treatment modality for patients with COVID-19.
Exploration of the possible anti-inflammatory effect of
USWD should be conducted initially in consistent, cali-
brated, and cautiously designed and reported case studies
with the primary objectives of understanding safety and
tolerability. A research escalator approach that includes
rigorously designed and controlled clinical trials, as well
as diligent reporting is necessary. Clinical practice should
be based on high quality-randomized controlled trials.
Until such efficacy can be firmly established, it is critical
that patients are not deprived of treatments deemed best
practice by cardiopulmonary experts.
Declaration of Interest
The authors declare no conflict of interest.
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