ORIGINAL RESEARCH ARTICLE

Effectiveness of Shortwave Diathermy for Subacromial

Impingement Syndrome and Value of
Night Pain for Patient Selection
A Double-Blinded, Randomized, Placebo-Controlled Trial
Meryem Yilmaz Kaysin, MD, Pinar Akpinar, MD, Ilknur Aktas, MD, Feyza Unlü Ozkan, MD,
Duygu Silte Karamanlioglu, MD, Hulya Cagliyan Hartevioglu, PT, and Nazan Vural, PT

Objective: The aim of this study was to investigate the effectiveness of short wave diathermy (SWD) in patients with subacromial impingement
syndrome.
Design: In this double-blinded, randomized, placebo-controlled trial, 57 patients (aged 35–65 yrs) were classified into night pain positive (NP[+])
(n = 28) and night pain negative (NP[−]) (n = 29) groups. Both groups were randomly assigned to SWD (NP[+], n = 14; NP[−], n = 14) and
sham (NP[+], n = 15; NP[−], n = 14) subgroups. Visual analog scale, Constant-Murley Scale (CS), and Shoulder Disability Questionnaire
(SDQ) scores were used for evaluation.
Results: There was only a significant difference in pain with activity at 1-mo (mean difference [MD], −1.65; 95% confidence interval, −3.01 to
−0.28]) and 2-mo evaluations (MD, −2.1; 95% confidence interval, −3.51 to −0.69) between SWD versus sham groups. In the NP(+) SWD
group, the CS pain score was significantly higher than in the NP(+) sham group at all evaluations after treatment. At 1 mo, the NP(−)
SWD group showed significantly better pain, strength, total CS, and SDQ scores than the NP(−) sham group. At 2 mos, the pain, range of
motion, strength, and total CS and SDQ scores were better in the NP(−) SWD group than in the NP(−) sham group (P < 0.05).
Conclusions: Short wave diathermy is more effective in subacromial impingement syndrome without NP.
Key Words: Shoulder Impingement Syndrome, Short Wave Diathermy, Night Pain
(Am J Phys Med Rehabil 2017;00:00–00)

houlder pain is highly prevalent within general population,
S and shoulder impingement syndrome (SIS) is a common
1
cause of shoulder pain. The underlying mechanism of SIS is
compression of the rotator cuff tendons, subacromial bursa,
and other soft tissues (e.g., long biceps tendon) between the
humeral head and the undersurface of the acromion, acromio-
clavicular joint, or the coracoacromial arch.2,3 Although non-
operative and operative treatment strategies are available for
From the Department of Physical Medicine and Rehabilitation, University of Health
Sciences, Fatih Sultan Mehmet Education and Training Hospital, Istanbul,
Turkey.
All correspondence and requests for reprints should be addressed to: Meryem
Yilmaz Kaysin, MD, Department of Physical Medicine and Rehabilitation,
University of Health Sciences, Fatih Sultan Mehmet Training and Research
Hospital, Istanbul/Sağlık bilimleri Üniversitesi, Fatih Sultan Mehmet Egitim ve
Arastırma Hastanesi, Fiziksel Tıp ve Rehabilitasyon Klinigi H blok, Atasehir,
Istanbul, Turkiye.
Informed consent was obtained from the participants, and all procedures were
conducted in accordance with the Helsinki Declaration of 1975 and approved by
the local institutional clinical research ethical committee (Fatih Sultan Mehmet
Training and Research Hospital).
There is no financial benefit to the authors. This manuscript was not
presented previously.
Financial disclosure statements have been obtained, and no conflicts of interest have
been reported by the authors or by any individuals in control of the content of
this article.
Supplemental digital content is available for this article. Direct URL citations appear
in the printed text and are provided in the HTML and PDF versions of this article
on the journal’s Web site (www.ajpmr.com).
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0894-9115
DOI: 10.1097/PHM.0000000000000819
SIS, many patients recover with nonsteroidal anti-inflammatory
drugs, physical therapy, activity modification, and corticoste-
roid injections.4,5
Short wave diathermy (SWD) is one of the deep heating
modalities used in the treatment of musculoskeletal disorders.6
In our clinical practice, we have observed that night pain (NP)
is an important musculoskeletal symptom and might be related
to local inflammation.7–9 Previous reports have demonstrated
that proinflammatory cytokines, including tumor necrosis fac-
tor, interleukin (IL) 1α, IL-1β, IL-6, IL-8, transforming growth
factor-β, and basic fibroblast growth factor are present at high
levels in the subacromial bursa of patients with rotator cuff
disease.10–12 Okamura et al. suggested that intra-articular cyto-
kines in the shoulder joint might be associated with resting
shoulder pain in patients with rotator cuff disease.12 Many
studies have reported the use of deep heat for the treatment
of SIS and adhesive capsulitis.13–15 Detailed review of these
studies revealed that deep heat was used for these pathologies
without consideration of NP. We have observed that patients
without NP seemed to benefit greatly from deep heating mo-
dalities; therefore, we hypothesized that NP could be a factor
in the choice of treatment. The latest Cochrane reviews also
showed conflicting results with regard to the use of deep heating
modalities for adhesive shoulder capsulitis.16 No randomized
controlled study has examined the effect of NP in treatment
of SIS. Therefore, we aimed to evaluate the effectiveness of
SWD in patients with SIS and to determine the effect of NP
on treatment.

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Yilmaz Kaysin et al.
MATERIALS AND METHODS
A randomized, prospective, double-blinded, placebo-
controlled trial was conducted. The study evaluated 98 patients
aged 35–65 yrs, with SIS diagnosed according to history and
clinical evaluation using Neer, Hawkins-Kennedy, and painful
arc shoulder impingement tests. A careful examination of the
neck and upper limbs, conventional shoulder radiography
and magnetic resonance imaging of neck and shoulder were
performed to rule out abnormalities of the cervical spine and
other shoulder pathologies. Detailed routine laboratory tests
(complete blood count, blood glucose level, serum thyroid-
stimulating hormone level, erythrocyte sedimentation rate,
and C-reactive protein level) were performed. Data included
patient age, sex, occupation, body mass index, hand dominance,
duration of pain, and presence of NP and medication history.
A subacromial injection test was performed in 72 patients for
differential diagnosis. The subacromial space just under the
acromion was injected with 5 mL of 2% lidocaine using a
21-G needle via an anterior approach. All patients were injected
by the same specialist. A positive subacromial injection test was
indicated by 80% relief of pain and almost total improvement
in passive and/or active range of motion (ROM), 30 mins after
the injection.17,18 Patients who had (1) concomitant shoulder
pathologies such as adhesive capsulitis, calcific tendinitis, full-
thickness tears of the rotator cuff tendons, osteoarthritis of
the acromioclavicular joint, dislocations, acute traumatic con-
ditions, etc.; (2) previous applications of physiotherapy and
injection of hyaluronic acid and/or corticosteroid during the
preceding 6 mos; (3) cervical pain or other conditions such
as fibromyalgia confusing the clinical picture; (4) malignancy;
(5) neurologic, motor, and/or sensory deficit in the upper ex-
tremity; (6) pregnancy; (7) an open wound near the shoulder;
(8) presence of an implanted cardiac pace maker; (9) and local
anesthetic allergy were excluded from the study. One patient
with uncontrolled diabetes mellitus, three with calcific tendini-
tis, four with cervical discopathy, one with a risk of pregnancy,
five who underwent subacromial corticosteroid injection during
the preceding 6 mos, two with a history of shoulder trauma, and
ten who refused the subacromial injection test were excluded.
Written informed consent was obtained from all patients,
and all procedures were conducted in accordance with the
Helsinki Declaration of 1975, and approved by the local in-
stitutional clinical research ethical committee (2012/15).
Treatment Protocol
The study had a randomized, placebo-controlled, double-
blinded design. A sample size of 27 subjects was determined
for NP positive (NP[+]) and NP negative (NP[−]) groups,
and follow-up loss of 10% was assumed. Sixty patients were
separated into NP(+) and NP(−) groups, with 30 patients per
group. Each group was also randomly separated into SWD
and sham subgroups, with 15 patients per group. Patients in
the NP(+) SWD (n = 14) and NP(−) SWD (n = 14) subgroups
received 27.12 MHz of continuous SWD, as a 20-min daily
session, 5 days per week for 2 wks, for a total of ten sessions.
The physiotherapist applied SWD ITO SW-180 device. The af-
fected shoulder was positioned between 2 condenser electrodes,
with 20 cm between the anterior and posterior electrodes with
the patient seated on a wooden chair. Patients in the NP(+) sham
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Volume 00, Number 00, Month 2017
(n = 15) and NP(−) sham groups (n = 14) underwent treatment
with the same protocol. The physiotherapist applied sham
SWD by starting the device but without applying heat. The
same physiotherapist applied all SWD or sham treatments.
All groups were instructed in a conservative treatment program,
Codman pendulum exercises (five sets daily, 5 mins each set),
cold pack application (cold pack gel, three times daily, 20 mins
per session) on the affected shoulder, restriction of daily activ-
ities requiring the overhead use of hands, and sleeping on the
affected shoulder, and oral meloxicam 15 mg daily was admin-
istered for 2 wks. The same physiotherapist supervised the ex-
ercise program and cold pack application. Patients were requested
to continue the Codman pendulum exercises and cold pack ap-
plication for 2 wks after SWD or sham treatment.
Randomization
Randomization was performed with a computer-generated
list of numbers, and group allocation was concealed. A phys-
iatrist not involved with data collection performed random
number generation using Microsoft Excel for Windows. The
assignment of subjects into groups (NP[+] SWD, NP[−]
SWD, NP[+] sham, NP[−] sham) was performed randomly
using opaque sealed envelopes. One physiotherapist who was
blinded to the randomization process provided all SWD or
sham treatments. A second blinded physiotherapist supervised
the exercise protocols. Finally, all assessments were made by
another physiatrist who was blinded to the group assignments
and interventions.
Outcome Evaluation
Patient evaluation was performed at treatment initiation
and at 2 wks and 1 and 2 mos after treatment initiation. All pa-
tients were evaluated by the same physiatrist who was blinded
to the randomization process and treatment protocols. All
groups were evaluated for shoulder pain with visual analogue
scale (VAS) for rest, activity, and sleep-disturbing NP.19 Pa-
tients were instructed to indicate the severity of pain on a 10-
point scale, on which 0 meant no pain, 5 meant moderate pain,
and 10 meant intolerable pain. Functional shoulder status in all
groups was evaluated with the total Constant-Murley Scale
(CS).20 The CS evaluates overall shoulder function on a 100-
point scale. The higher the CS score, the better the functional
status of the shoulder. Subsections of this analysis score up
to 15 points for shoulder pain, 20 points for activities of daily
living, 40 points for active ROM, and 25 points for strength.
Activities of daily living were evaluated with the Shoulder Dis-
ability Questionnaire (SDQ), which was translated into Turkish
and validated by Ozsahin et al.21 The SDQ is a pain-based dis-
ability questionnaire and contains 16 items describing com-
mon situations that may induce symptoms in patients with
shoulder disorders. All items refer to the preceding 24 hrs. A
final score is calculated by dividing the number of positively
scored items by the total number of applicable items and sub-
sequently multiplying the score by 100, resulting in a final
score between 0 (no disability) and 100 (severe disability).22
STATISTICAL ANALYSIS
Calculations of the estimated sample size were based on a
previous study by Galace de Freitas et al.23 assuming that α is
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Volume 00, Number 00, Month 2017
0.05 and power is 0.80. Sample sizes of 27 subjects were de-
termined for both the NP(+) and NP(−) groups, and follow-up
loss of 10% was assumed. With allowance for dropouts,
60 subjects were recruited for this study. G*Power was used
for this calculation. Number Cruncher Statistical System
2007 and Power analysis and Sample Size 2008 (Statistical
Software, Kaysville, UT) were used for data analysis. Student t test
was used to compare the study data for average, standard de-
viation, median, frequency, and ratio for quantitative data and
parameters that showed a normal distribution. The Mann-
Whitney U test was used to compare groups that did not show
a normal distribution. The Fisher-Freeman-Halton test, Fisher
exact test, and the Yates Continuity correction test were used
FIGURE 1. Flow diagram of patient selection process.
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Diathermy Treatment in Subacromial Impingement
in the comparison of qualitative data. A P < 0.05 was consid-
ered significant.
RESULTS
Sixty-four patients with a positive subacromial injection
test were asked to participate in the study. Four patients de-
clined to participate. Two patients disagreed with the treatment
program, and one patient was unwilling to continue treatment
because of increased pain. Seven were excluded, leaving a final
sample of 57 participants. A flow diagram of the patient alloca-
tion is presented in Figure 1 (Supplemental Checklist, CONSORT
2012 Checklist, http://links.lww.com/PHM/A492).
www.ajpmr.com 3
Yilmaz Kaysin et al. Volume 00, Number 00, Month 2017

0.788
0.242
0.036
0.073
No significant difference was found between the NP(+)

p
and NP(−) groups or subgroups for age, sex, body mass index,

(95% Confidence
work status, and education. Other than sex and work status, no

−2.2 (−4.35 to 0.04)

SWD (n = 14), Sham (n = 14), Mean Difference

−0.23 (−1.6 to 1.13)

−2.64 (−4.98 to 0.3)

−1.28 (−3.76 to 1.2)
significant difference was found between NP(+) SWD and

Intervals)
sham groups for disease-related variables of pain duration,
dominant hand, affected shoulder, etiology of pain, and chronic
disease. There were more women and homemakers in the sham

Night Pain VAS

group (see Table, Supplemental Digital Content 1, http://links.
lww.com/PHM/A477, which demonstrates the comparison of

7.73 ± 1.75 (8)

6.13 ± 3.11 (8)
6.07 ± 3.39 (8)
6.27 ± 2.99 (8)
Med ± SD
SWD and sham groups according to demographic parameters

(Median)

0.033
0.024
0.024
and disease-related variables).
There was no significant difference between pain scores
measured by the VAS, total and subsection parameters of CS,
and SDQ at baseline evaluation of all groups (P > 0.05).

7.5 ± 1.83 (7)

4.86 ± 3.39 (5)
3.43 ± 2.68 (3)
4.07 ± 2.64 (4)
Med ± SD
(Median)
Primary Outcomes

0.006
0.002
0.003
TABLE 1. Comparison of SWD and sham treatment groups according to VAS scores for rest, activity, and night pain in NP(+) group
When we compared SWD versus sham treatment groups
according to VAS scores, there was only a significant differ-
ence in pain with activity at the 1- and 2-mo evaluations

0.630
0.389
0.074
0.080
p
(P < 0.05). In the SWD group, VAS scores with activity were
lower than those in the sham group (see Table, Supplemental

(95% Confidence

−0.4 (−1.33 to 0.54)

−0.69 (−2.84 to 1.46)

−1.57 (−3.34 to 0.21)

SWD (n = 14), Sham (n = 14), Mean Difference

−1.57 (−3.3 to 0.16)

Digital Content 2, http://links.lww.com/PHM/A478, which

Intervals)
demonstrates the comparison of SWD and sham treatment
groups according to VAS scores for rest, activity, and NP).
The CS pain scores after 2 wks, and at 1- and 2-mo evaluations,
total CS scores at 1- and 2-mo evaluations, and CS activities of Night Pain (+)
daily living scores at the 2-mo evaluation were higher in the Activity VAS
SWD group than in the sham group (P < 0.05) (see Table, Sup-

6.33 ± 2.97 (7)

7.07 ± 2.34 (8)

7.0 ± 2.33 (7)
8.47 ± 0.83 (9)
Med ± SD
(Median)
plemental Digital Content 3, http://links.lww.com/PHM/A479,

0.012
0.018
0.018
which demonstrates the comparison of SWD and sham treat-
ment groups according to the total CS and subsection parame-
ters scores). The SDQ scores showed a significant difference
between SWD and sham groups at 1-mo and 2-mo evaluations 5.64 ± 2.65 (5.5)

5.5 ± 2.31 (5)

8.07 ± 1.54 (8)

5.43 ± 2.21 (5)

Med ± SD
(Median)

with lower SDQ scores in the SWD group (P < 0.05) (see Table,
0.012
0.005
0.007
Supplemental Digital Content 4, http://links.lww.com/PHM/
A480, which demonstrates the comparison of SWD and sham
treatment groups according to SDQ scores).
0.740

0.597
0.519
0.424
p

Secondary Outcomes
(95% Confidence

−0.76 (−3.44 to 1.93)

−1 (−3.31 to 1.31)
−0.78 (−3.01 to 1.45)
SWD (n = 14), Sham (n = 15), Mean Difference

In the NP(+) group, there were no significant differences

−0.15 (−2.5 to 2.21)

AT, after treatment; BT, before treatment; SD, standard deviation.

between SWD and sham groups according to VAS scores with

Intervals)

rest and activity pain at 2 wks and at 1- and 2-mo after treat-
A P < 0.05 was considered significant and written in bold.

ment initiation and VAS scores with NP at 2 wks and at

2 mos after treatment initiation (P > 0.05). There was a statisti-
Resting VAS

cally significant decrease in VAS for NP scores at 1 mo in a

comparison of SWD and sham treatment (P < 0.05) (Table 1).
5.93 ± 2.58 (6)
4.4 ± 3.31 (4)
4.07 ± 3.39 (5)
4.07 ± 3.39 (5)
Med ± SD
(Median)

In the NP(−) group, there was no statistically significant differ-

0.031
0.021
0.020

ence between SWD and sham treatment according to VAS

scores with rest and activity at 2 wks and 1 mo after treatment
initiation. Short wave diathermy was superior to sham treatment
at 2 mos with both rest and activity pain (P < 0.05) (Table 2) (see
5.79 ± 3.56 (7)
3.64 ± 3.73 (3)
3.07 ± 2.59 (3)

Figures, Supplemental Digital Content 5, 6, 7, 8, 9, and 10,

Med ± SD

3.29 ± 2.4 (3)

(Median)

http://links.lww.com/PHM/A481, http://links.lww.com/PHM/
0.011
0.09
0.07

A482, http://links.lww.com/PHM/A483, http://links.lww.com/

PHM/A484, http://links.lww.com/PHM/A485, http://links.lww.
com/PHM/A486, which demonstrate the VAS scores for rest,
BT, 2 mos p
BT, 1 mo p
AT (2 wks)

activity, and night pain in patients with or without NP).

BT-AT p

In the NP(+) group, there were no statistically significant

2 mos
1 mo
BT

differences between SWD and sham treatment groups according

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Volume 00, Number 00, Month 2017 Diathermy Treatment in Subacromial Impingement

0.911
0.130
0.055
0.096
to the total CS and subsection parameters at all evaluations

p
(P > 0.05); however, CS pain scores showed statistically signif-
icant improvements with SWD compared with that in the sham

(95% Confidence
SWD (n = 14), Sham (n = 14), Mean Difference

−0.57 (−1.31 to 0.17)

−0.64 (−1.61 to 0.32)

0.07 (−0.86 to 1)

−0.93 (−1.85 to 0)
treatment group (P < 0.05) (Table 3) (see Figure, Supplemental

Intervals)
Digital Content 11, http://links.lww.com/PHM/A487, which
demonstrates the total CS scores in patients with NP). In the
NP(−) group, the total CS scores at all evaluations, the CS pain

Night Pain VAS

and strength scores at 1 mo and 2 mos, and the CS ROM scores
after 2 wks showed significant improvements with SWD com-

0.71 ± 0.99 (0)

1.07 ± 1.54 (0)

0.93 ± 1.38 (0)
Med ± SD
pared with those with sham treatment (P < 0.05) (Table 3) (see

0.71 ± 1.2 (0)

(Median)

1.000
0.339
0.414
Figure, Supplemental Digital Content 12, http://links.lww.com/
PHM/A488, which demonstrates the total CS scores in patients
without NP).
Based on the SDQ, in the NP(−) groups, there was a statis-

0.79 ± 1.37 (0)

0.14 ± 0.53 (0)

0.29 ± 1.07 (0)
0.14 ± 0.53 (0)
tically significant difference between SWD and sham treatment

Med ± SD
(Median)
groups (P < 0.05) (Table 4; Fig. 2). The SDQ scores decreased

0.109
0.109
0.102
in the SWD group at all posttreatment evaluations. There were

TABLE 2. Comparison of SWD and sham treatment groups according to VAS scores for rest, activity, and night pain in NP(−) group
no significant differences between SWD and sham treatment
in NP(+) groups at all evaluations (P > 0.05) (Table 4; Fig. 3).

0.167

0.073
0.225

0.015
Comparison of NP(+) SWD and NP(−) SWD groups

p
showed that VAS scores for resting, night, and activity pain

(95% Confidence
SWD (n = 14), Sham (n = 14), Mean Difference

0.86 (−0.34 to 2.06)

−1.21 (−2.97 to 0.54)
were lower in NP(−) SWD groups at all evaluations except

−1.64 (−3.5 to 0.21)

−2.57 (−4.5 to 0.65)
Intervals)
for resting pain after 2 wks of treatment, and activity pain be-
fore treatment (see Table, Supplemental Digital Content 13,
http://links.lww.com/PHM/A489, which demonstrates the com-
parison of NP(−) SWD and NP(+) SWD treatment groups Night Pain (−)
according to VAS scores for rest, activity, and NP). The CS Activity VAS
showed a significant difference between NP(−) SWD and

4.86 ± 2.44 (4.5)

Med ± SD

6.64 ± 1.86 (6)

(Median)
NP(+) SWD groups after 2 wks of treatment, and at 1- and

4.71 ± 2.70
5.21 ± 2.97
0.011
0.011
0.024
2-mo evaluations (P < 0.05), except for the CS pain scores
at the 1-mo evaluation (P > 0.05) (see Table, Supplemental
Digital Content 14, http://links.lww.com/PHM/A490, which
demonstrates the comparison of NP(−) SWD and NP(+) 3.64 ± 2.06 (3.5)
Med ± SD

7.5 ± 1.09 (8)

SWD treatment groups according to the total CS and subsec-

(Median)

3.07 ± 2.02
2.64 ± 1.86
0.002
0.001
0.001
tion parameter scores). There was a significant difference be-
tween NP(−) SWD and NP(+) SWD groups at all evaluations
(P < 0.05), with SDQ scores lower in the NP(−) group (see Table,
Supplementary Digital Content 15, http://links.lww.com/PHM/
0.072
0.957
0.423
0.014
p

A491, which demonstrates the comparison of NP(−) SWD and

NP(+) SWD treatment groups according to SDQ scores).
−1.64 (−3.01 to −0.28)
(95% Confidence
SWD (n = 14), Sham (n = 14), Mean Difference

−0.14 (−1.72 to 1.43)

−0.57 (−1.83 to 0.69)

AT, after treatment; BT, before treatment; SD, standard deviation.

1.29 (−0.22 to 2.8)
Intervals)

DISCUSSION
A P < 0.05 was considered significant and written in bold.

Shoulder impingement syndrome is a common cause of

shoulder pain and loss of function.1 Physical therapy modali-
Resting VAS

ties aim to increase blood flow and cellular metabolism and

stimulate healing in tendons.5,23,24 Short wave diathermy is
1.5 ± 1.79 (0.5)
2.07 ± 1.94 (2)
1.29 ± 2.16 (0)

2.07 ± 2.23 (2)

Med ± SD
(Median)

one of the most preferred deep-heating modalities and typically

0.043
0.230
1.000

uses electromagnetic radiation at 27.17 MHz in either continu-

ous or pulsed mode. Short wave diathermy has thermal and
nonthermal effects on tissues. Increased tissue temperature
causes arteriolar and capillary dilatation followed by increased
3.36 ± 1.95 (3.5)

blood flow to the tissue. This leads to an increase in cellular

1.14 ± 1.88 (0)
0.93 ± 1.44 (0)
0.43 ± 0.94 (0)
Med ± SD
(Median)

metabolism and increased tendon and muscle flexibility.24 In

0.005
0.005
0.002

this way, it reduces muscle spasm and raises the pain threshold.6,25
Short wave diathermy is frequently used in the manage-
ment of shoulder pathologies, particularly frozen shoulder and
BT, 2 mos p
BT, 1 mo p
AT (2 wks)

SIS. However, there is no randomized controlled study on the

BT-AT p

therapeutic effects on SIS in the literature.15,26 Leung and

2 mos
1 mo

Cheing15 compared the effects of SWD and superficial heating

BT

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 6
Yilmaz Kaysin et al.

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TABLE 3. Comparison of SWD and sham treatments according to the total CS and subsection parameters in NP(+) and NP(−) groups

Constant Pain Constant ADL Constant ROM

SWD (n = 14), Sham (n = 15), Mean Difference SWD (n = 14), Sham (n = 15), Mean Difference SWD (n = 14), Sham (n = 15), Mean Difference
Med ± SD Med ± SD (95% Confidence Med ± SD Med ± SD (95% Confidence Med ± SD Med ± SD (95% Confidence
(Median) (Median) Intervals) p (Median) (Median) Intervals) p (Median) (Median) Intervals) p
NP(+)
BT 1.07 ± 2.13 (0) 0.67 ± 1.76 (0) 0.4 (−1.08 to 1.89) 0.571 11.14 ± 3.21 (11) 9.6 ± 4.15 (10) 1.54 (−1.3 to 4.39) 0.277 29.86 ± 9.62 (33) 30.53 ± 7.87 (32) −0.68 (−7.35 to 6) 0.807
AT (2 wks) 4.64 ± 3.65 (5) 2.0 ± 2.54 (0) 2.64 (0.26 to 5.02) 0.043 12.57 ± 4.73 (12) 11.33 ± 4.88 (12) 1.24 (−2.43 to 4.91) 0.551 33.57 ± 4.09 (33) 32.67 ± 8.27 (34) 0.9 (−4.12 to 5.93) 0.579
1 mo 6.43 ± 3.63 (5) 2.33 ± 3.72 (0) 4.1 (1.29 to 6.9) 0.007 14.0 ± 4.44 (15) 12.0 ± 4.96 (12) 2 (−1.59 to 5.59) 0.279 34.86 ± 3.21 (34) 33.87 ± 7.5 (36) 0.99 (−3.46 to 5.44) 0.690
2 mos 6.07 ± 3.5 (5) 1.67 ± 2.44 (0) 4.4 (2.12 to 6.69) 0.001 14.86 ± 3.82 (16) 12.13 ± 4.87 (12) 2.72 (−0.63 to 6.07) 0.116 35.43 ± 3.18 (36) 33.47 ± 7.8 (36) 1.96 (−2.62 to 6.54) 0.947
BT-AT p 0.015 0.046 0.047 0.012 0.056 0.004
BT, 1 mo p 0.004 0.059 0.007 0.024 0.095 0.005
BT, 2 mos p 0.006 0.083 0.003 0.019 0.065 0.018

SWD (n = 14), Sham (n = 14), Mean Difference SWD (n = 14), Sham (n = 14), Mean Difference SWD (n = 14), Sham (n = 14), Mean Difference
Med ± SD Med ± SD (95% Confidence Med ± SD Med ± SD (95% Confidence Med ± SD Med ± SD (95% Confidence
(Median) (Median) Intervals) p (Median) (Median) Intervals) p (Median) (Median) Intervals) p
NP(−)
BT 2.5 ± 2.59 (2.5) 2.5 ± 2.59 (2.5) 0 (−2.02 to 2.02) 1.000 13.43 ± 4.26 (12) 16.0 ± 4.96 (18) −2.57 (−6.16 to 1.02) 0.135 33.14 ± 5.91 (33) 33.14 ± 9.11 (35) 0 (−5.96 to 5.96) 0.500
AT (2 wks) 8.21 ± 4.21 (10) 5.0 ± 3.92 (5) 3.21 (0.05 to 6.38) 0.057 17.0 ± 3.66 (18) 16.0 ± 4.77 (18) 1 (−2.3 to 4.3) 0.683 38.57 ± 2.28 (40) 34.43 ± 9.42 (38) 4.14 (−1.39 to 9.68) 0.145
1 mo 9.29 ± 3.85 (10) 4.64 ± 3.65 (5) 4.64 (1.73 to 7.56) 0.006 17.86 ± 2.88 (19) 16.14 ± 4.47 (18) 1.71 (−1.23 to 4.66) 0.382 39 ± 1.71 (40) 34.43 ± 9.45 (38) 4.57 (−0.94 to 10.08) 0.108
2 mos 10.0 ± 3.4 (10) 4.64 ± 3.65 (5) 5.36 (2.62 to 8.1) 0.001 18.86 ± 1.51 (20) 15.43 ± 5.35 (18) 3.43 (0.27 to 6.59) 0.138 39.29 ± 1.68 (40) 33.86 ± 9.59 (38) 5.43 (−0.16 to 11.02) 0.032
BT-AT p 0.003 0.020 0.007 1.000 0.005 0.288
BT, 1 mo p 0.001 0.014 0.003 0.705 0.009 0.269
BT, 2 mos p 0.001 0.014 0.002 0.157 0.009 0.497

A P < 0.05 was considered significant and written in bold.

AT, after treatment; BT, before treatment; SD, standard deviation.

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Constant Strength Constant Total

Mean Difference Mean Difference
SWD (n = 14), Sham (n = 15), (95% Confidence SWD (n = 14), Sham (n = 15), (95% Confidence
Med ± SD Med ± SD Intervals) p Med ± SD Med ± SD Intervals) p

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13.64 ± 7.91 13.73 ± 2.74 −0.09 (−4.54 to 4.36) 0.967 55.71 ± 12.99 54.53 ± 12.51 1.18 (−8.54 to 10.9) 0.805
13.5 ± 4.2 14.93 ± 3.59 −1.43 (−4.41 to 1.54) 0.331 64.29 ± 12.42 60.93 ± 16.01 3.35 (−7.62 to 14.33) 0.536
14 ± 3.94 15.4 ± 4.63 −1.4 (−4.69 to 1.89) 0.390 69.29 ± 11.64 63.6 ± 16.84 5.69 (−5.42 to 16.8) 0.303
14.57 ± 3.96 15.2 ± 4.59 −0.63 (−3.9 to 2.65) 0.697 70.93 ± 11.12 62.47 ± 16.24 8.46 (−2.22 to 19.15) 0.116
0.936 0.031 0.011 0.002
0.867 0.046 0.003 0.003
0.647 0.079 0.001 0.006

Mean Difference Mean Difference

SWD (n = 14), Sham (n = 14), (95% Confidence SWD (n = 14), Sham (n = 14), (95% Confidence
Med ± SD Med ± SD Intervals) p Med ± SD Med ± SD Intervals) p

15.86 ± 3.94 15.07 ± 2.73 0.79 (−1.85 to 3.42) 0.545 64.93 ± 10.59 66.71 ± 16.48 −1.79 (−12.54 to 8.97) 0.736
17.43 ± 5.14 14.5 ± 2.85 2.93 (−0.34 to 6.2) 0.077 81.21 ± 9.52 69.93 ± 17.35 11.29 (0.41–22.16) 0.042
18.86 ± 4.99 14.71 ± 2.79 4.14 (0.96 to 7.33) 0.013 85.0 ± 8.16 69.93 ± 17.61 15.07 (4.19–25.95) 0.009
19.93 ± 4.38 14.5 ± 2.85 5.43 (2.54 to 8.32) 0.001 88.07 ± 6.81 68.43 ± 18.88 19.64 (8.29–31) 0.002
0.030 0.293 0.001 0.174
0.005 0.615 0.001 0.163
0.001 0.466 0.001 0.493

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7
Diathermy Treatment in Subacromial Impingement
Yilmaz Kaysin et al. Volume 00, Number 00, Month 2017

TABLE 4. Comparison of SWD and sham treatment groups according to SDQ in NP(+) and NP(−) groups

Night Pain (+) Night Pain (−)

SWD (n = 14), Sham (n = 15), Mean Difference SWD (n = 14), Sham (n = 14), Mean Difference
SDQ Med ± SD Med ± SD (95% Confidence Intervals) p Med ± SD Med ± SD (95% Confidence Intervals) p
BT 86.45 ± 8.24 66.85 ± 17.64 −7.06 (−14.08 to 0.05) 0.048 76.99 ± 13.81 93.51 ± 10.0 10.14 (−2.17 to 22.44) 0.102
AT (2 wks) 66.97 ± 23.24 52.53 ± 24.52 0.94 (−19.75 to 21.64) 0.926 30.94 ± 23.71 66.03 ± 30.32 −21.59 (−40.33 to 2.85) 0.026
1 mo 56.1 ± 27.25 54.48 ± 28.66 −7.13 (−29.99 to 15.72) 0.527 21.72 ± 22.57 63.23 ± 32.3 −32.76 (−52.8 to 12.71) 0.002
2 mos 52.81 ± 29.18 55.75 ± 28.35 −13.82 (−36.56 to 8.92) 0.223 15.07 ± 18.98 66.63 ± 30.42 −40.68 (−59.77 to −21.59) 0.001
BT-AT p 0.006 0.002 0.001 0.007
BT, 1 mo p 0.001 0.002 0.001 0.047
BT, 2 mos p 0.001 0.004 0.001 0.054
A P < 0.05 was considered significant and written in bold.
AT, after treatment; BT, before treatment; SD, standard deviation.

in patients with frozen shoulder. They found greater improve-
ment in pain relief, activities of daily living, and ROM with ad-
dition of SWD to stretching exercises. Pajareya et al.27 studied
patients with frozen shoulder, and found that SWD enhanced
the therapeutic effects of nonsteroidal anti-inflammatory drugs
and exercise after 3 wks, but there was no significant additional
effect at 12 wks.
Many clinical trials have evaluated the effects of therapeu-
tic ultrasound (US) for deep-heat therapy in patients with SIS;
however, studies investigating the effects of SWD in SIS are
lacking, despite its common clinical use. Yazmalar et al.13 con-
ducted a randomized controlled study to evaluate the efficacy
of therapeutic US on pain, disability, anxiety, depression, sleep
quality, and quality of life in patients with SIS. They randomly
divided the patients with SIS into two groups, which are con-
tinuous US and sham US groups. Transcutaneous electrical
nerve stimulation and an exercise program were also added
for both groups. They found that US does not offer any bene-
fits for SIS. Desmeules et al.14 conducted a systematic review
on the efficacy of therapeutic US in adults with rotator cuff
tendinopathy. They stated that therapeutic US was not superior
to placebo intervention in terms of pain reduction and func-
tional improvement. When provided in conjunction with exer-
cise, US therapy was not superior to exercise alone in terms
of pain reduction and functional improvement. In another
study, which compared the short-term effectiveness of high-
intensity laser therapy and US therapy in the treatment of
SIS, there was greater reduction in pain and improvement in
functionality and muscle strength in the affected shoulder after
high-intensity laser therapy therapy.28 Calis et al29 compared
US, laser, and exercise therapies in the treatment of SIS. They
found that US and laser treatments were not superior to each
other in the treatment of SIS. The results of a recent Cochrane
review of electrotherapy modalities for rotator cuff disease sup-
port these contradictory results.30 The conflicting results in
these trials with deep heat might be due to methodological def-
icits. In particular, the NP symptoms in SIS may increase with
the severity of the bursitis or tendinitis. Therefore, application
of deep-heat therapy may not be effective. Based on this hy-
pothesis, the patients were separated according to groups with
and without NP, to determine the effect of NP on the treatment
response. The aim was to identify patients with SIS who were
most likely to benefit from deep-heating modalities.
In this study, NP(+) groups showed statistically significant
improvement over baseline values in VAS scores for rest, night,
and activity pain, in the total CS and subsection parameters,
and in the SDQ. However, there was no significant difference
between the SWD and sham treatment groups in the aforemen-
tioned parameters other than for the CS pain score, the SWD
group was superior to the sham treatment group. The results
of VAS and CS pain scores may have differed from each other
for two reasons. First, the CS pain score evaluates shoulder
pain in one dimension. Activity pain, NP, and rest pain are re-
corded, and the most severe pain is used for scoring. Second,
the CS pain score uses a narrow scale (15 indicates no pain;
10, mild pain; 5, moderate pain; and 0, severe pain) in compar-
ison with VAS scores (scores range from 0, with no pain, to 10,
with severe pain).20

FIGURE 2. Shoulder Disability Questionnaire scores in patients without NP. This figure shows the SDQ scores in patients without NP before treatment,
at 2 wks and at 1 mo, and 2 mos after treatment initiation. The vertical axis shows the SDQ scores.

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Volume 00, Number 00, Month 2017
FIGURE 3. Shoulder Disability Questionnaire scores in patients with NP. This figure shows the SDQ scores in patients with NP before treatment, at
2 wks and at 1 mo, and 2 mos after treatment initiation. The vertical axis shows the SDQ scores.
In the NP(−) groups, statistically significant improve-
ments over the baseline values were also obtained for all eval-
uation parameters. In comparison with the sham group, the
SWD group showed superior results for all parameters except
for the CS activities of daily living scores at the 2-mo evalua-
tion. The SWD group also showed superior results for param-
eters of CS pain, CS strength, CS total score, and SDQ at 1-mo
evaluation. These results suggest that baseline cold pack appli-
cation, Codman pendulum exercises, and oral nonsteroidal
anti-inflammatory drugs are the main reasons for an early de-
crease in pain scores and improvements of shoulder functions.
Short wave diathermy may provide long-term benefit in NP(−)
patients whose pain does not have an inflammatory character.
These outcomes emphasize the importance of identifying the
NP symptoms in SIS. This basic history may provide evidence
for the inflammatory status of the disease and guide the choice
of a better treatment modality.
There are limitations in this study. The results with the
small sample size require replication with larger samples and
longer follow-up periods. It could be better to analyze the mag-
netic resonance imaging findings to support the effect of NP
symptoms on treatment of SIS. We did not investigate acromion
morphology in these patients. The use of acromion morphology
might have yielded different results.
In conclusion, addition of 27.12 MHz of continuous SWD
(as a 20-min daily session, 5 days per week for 2 wks, for a total
of 10 sessions) to conventional therapies provides long-term
benefits when compared with sham treatment, in terms of
VAS scores for rest and activity pain, and CS and SDQ scores
in SIS patients without NP. However, there was no convincing
evidence that SWD treatment is of additional benefit in NP(+)
SIS. Therefore, in the case of SIS, NP symptoms should be
evaluated to use deep heat more effectively in clinical practice.
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