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Br. J. Sp. Med; Vol 24, No. 4

Physiotherapy Treatment Modalities
Microwave diathermy
G.C. Goats, PhD, MCSP
Department of Physiotherapy, The Queen's College, Glasgow, UK

Introduction antennae and reflectors are rarely capable of radiating

Microwave and shortwave radio frequency radiation safely more than 25 W and protective circuitry within
is used clinically to heat tissue situated deep in the the generator prevents this limit being exceeded8.
body and minimize the coincidental rise in skin Domestic microwave ovens often deliver 600-1000 W.
temperature seen with other forms of therapeutic Microwave energy is generated by an electronic
heating. Microwave radiation is defined as that with a device known as a magnetron. The magnetron was
frequency of 300 MHz-300 GHz, which lies on the invented in 1938, but did not find civilian application
electromagnetic spectrum between radio frequency until 1945 when the classified military role in airborne
and infrared radiation. radar became less important. Some apparatus is
Microwave diathermy units operate at a frequency designed to emit a pulsed output that causes less
higher than that used for shortwave diathermy and heating and should promote non-thermal interac-
this confers significant operational advantages. tions between electromagnetic energy and the tis-
Microwave radiation is radiated as a beam from an sues .
antenna and absorbed by water-rich tissues 7000
times more effectively than shortwave radio frequen-
cy energy'. The latter must be coupled to the patient
by a capacitor or an inductor2, whilst microwave
energy is radiated as a beam from an antenna. A
microwave beam can be narrowed to allow small
areas to be treated accurately, is highly directional,
and can be aligned rapidly.
A microwave diathermy unit with antenna (Figure
1) is easy to use and robust, although not found as
frequently in clinics as shortwave therapy units. The
common indications for microwave therapy include
soft tissue lesions of traumatic origin, degenerative or
chronic arthropathy and some localized infections3.

Equipment
Microwave diathermy units and domestic microwave
ovens usually operate at the internationally agreed
frequency of 2450 MHz (2.45 GHz). Some clinical
devices, particularly in the United States, emit
radiation with a frequency of 915MHz. Although
these are less common in Europe, energy at this
lower frequency is absorbed more efficiently and
uniformly within the tissues4 and lies close to
750 MHz, the optimum frequency for therapeutic
heating7.
The power output of therapeutic microwave units
can approach 250W although the maximum in
practice is limited by the design of the antenna. Small

Address for correspondence: Dr G.C. Goats, Department of

Occupational Therapy and Physiotherapy, University of East
Anglia, Norwich NR4 7TS
© 1990 Butterworth-Heinemann Ltd
0306-3674/90/040212-07 Figure 1. A microwave diathermy unit with antenna

212 Br. J. Sports Med., Vol 24, No. 4

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Microwave diathermy: G.C. Goats

Thermal mechanisms
Microwave energy is absorbed in the tissues princip-
ally by the movement within the electromagnetic
field of dipolar water molecules and of ions in
aqueous solution. This vibrational energy is heat.
Furthermore, the dielectric nature of the tissues
allows heat production by the relaxation of polar
macromolecules, and closely associated water mole-
cules, from the distortions caused by a strong
electromagnetic field. Relaxation energy is also
released as heat. Hence the tissue warms by the
conversion of energy at one frequency to that at
another'4. The rate of energy absorption by tissue can
be calculated from the conductivity and dielectric
constant.
Figure 2. Non-contact microwave applicators. Note that The distribution of heat within the tissues caused
one applicator (far left) is disassembled to reveal the by the passage of microwaves depends upon the
antenna and reflector
properties of propagation and absorption possessed
by the irradiated tissue and is, of course, superim-
posed upon pre-existing temperature gradients with-
in the body17. Tissues of high water content
The applicators consist of an antenna element characteristically absorb microwaves strongly, and
backed by a reflector and endosed within a plastic musde'8, fluid filled organs such as the eye, joint
case, one face of which is transparent to microwave effusions and surface water are heated preferential-
energy. Non-contact applicators (Figure 2) are com- ly.
mon in the UK and continental Europe but not The depths to which microwave energy penetrates
considered as safe or effective as the direct contact (expressed as the distance in which the field strength
applicators preferred in North America7. Direct has fallen to 37% of the incident value) varies
contact applicators release less stray radiation and according to tissue and frequency. Microwaves with a
produce a more uniform pattern of heating deep in frequency of 2450MHz penetrate 1.7cm in muscle
the tissues10, especially when cooled by a flow of and skin, and 11.2cm in fat and bone, whilst at
liquid or air that limits any increase in skin 915MHz these values increase to 3.04 cm and 17.7cm
temperature"1 12 respectively8. Experiments with dead pig tissue
Statutory regulations exist that detail the specifica- demonstrate that at 2450 MHz, subcutaneous tissue
tions controlling the manufacture or importation of with a depth greater than 2 cm warms excessively and
microwave diathermy units within the UK13. will reduce the heating of muscle, although at
900 MHz, much less energy is deposited in the
superficial layers. Subcutaneous tissue 4cm deep
reduces the heating of muscie at both microwave
Interactions between microwaves and frequencies'9. Clinical studies have confirmed these
tissue findings, although frequency-dependent differences
Microwaves are electromagnetic radiation and as in temperature distribution are much reduced by the
such will be reflected, refracted or transmitted at forced convection of the circulation5 and this may
boundaries. The most serious hazard arising from explain the apparent therapeutic effectiveness of
reflection is the development of a standing wave in 2450 MHz radiation20.
which a static field pattern is produced within the The final temperature distribution is affected
tissues due to interference between the incident and greatly by blood flow, which can in turn be modified
reflected beams. Excellent reflectors of microwave by microwave diathermy20 21. Superficial tissues
energy indude interfaces between fat and muscle, moderately heated, achieve a maximum temperature
bone and muscle, and between tissue and the metal within five to ten minutes, after which local
used in orthopaedic surgery. Intense and highly vasodilation prevents further warminge. Contact
undesirable heating can occur in these regions' 14,15, applicators incorporating a system of circulating
resulting in an unpredictable and non-uniform coolant restrict this rise in skin temperature to
pattern of heating'6. acceptable levels and permit more vigorous heating
Reflection at the air-skin interface occurs frequently of the deep tissues23.
when non-contact applicators are used, occasionally
generating unacceptably intense stray radiation. The Non-thermal effects
efficacy of reflection of microwaves at such interfaces
is determined by the relative conductivity and Pulsed microwave diathermy operates by delivering a
dielectric constant of the tissues, whilst the pattern of train of short pulses of high intensity microwave
reflection depends upon the geometry and size of the radiation. Whilst this causes the temperature of the
structures affected. Those which are large compared tissues to rise momentarily, between pulses cooling
to the wavelength (approximately 1 mm) act as good occurs by the action of the forced convection of the
reflectors. circulation. This treatment is said to promote the true

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Microwave diathermy: G.C. Goats

non-thermal effects of electromagnetic irradiation, effects and elicits a spectrum of physiological
although some effects might be explained by the brief responses common to both. Differences will tend to
temperature rise generated with each pulse9. This be qualitative and dependent upon the pattern of
argument also applies to the action of pulsed heating induced within the tissue.
shortwave therapy24. When applied at similar mean The thermal effects of diathermy upon biological
output, no difference was found between the tissue reflect closely the more general effects of
therapeutic effects of pulsed or continuous micro- heating. These include increased plasticity of connec-
wave treatments. tive tissue and a potential for correcting contractures,
Some authors remain sceptical of a non-thermal decreased viscosity of body fluids and improved joint
effect of microwave radiation on biological systems8, mobility, changes in nerve conduction velocity,
although evidence is accumulating to refute this modified output from muscle spindles and decrease
view25. Summaries of Soviet and Eastern European in muscle spasm. Pain is reduced by enhanced
studies, not readily available in the West, report removal of nocigenic compounds and relief of
many biological effects at levels of exposure less than pressure of interstitial fluid together with facilitation
10 mW.cm , with a significant influence seen at of the 'pain gate' mechanism. Increased metabolic
150 ILW.cm2 or less26 rate and accelerated growth, together with vasodila-
The animal subjects studied in this latter group tion in certain tissues, will assist the resolution of
would experience little heating but responded with inflammation. These therapeutic effects are discussed
changes in body weight and fertility; altered endoc- at length elsewhere` 35.
rine activity, electrolyte balance and EEG; inhibition One should also remember that microwave di-
of phagocytosis by neutrophils27; and an affect upon athermy is used to induce hyperthermia in the
neurone membrane function2. Many of these obser- treatment of skin conditions such as psoriasis6 and
vations are verified in the West and have informed to slow the growth of malignant neoplasia. The
the discussion setting current safe exposure guide- highly directional nature of the beam facilitates
lines. The frequency-dependent nature of these accurate treatment of the latter with minimal side
effects tends to obscure their relevance to electrother- effects37 38.
apy practice'
Any non-thermal effect must be caused by an
interaction between the imposed electromagnetic Vascular responses
field and specific types, or assemblages, of receptor A local rise in temperature usually produces vasodila-
molecules. Weak inter- and intramolecular bonds, tion and an increase in blood flow. Elevated
reversibly disrupted by the field, will allow these temperature appears to affect the calibre of small
structures to change shape and exhibit altered blood vessels by mechanisms as diverse as the
biological activity9. Other events such as the reduced activity of sympathetic nerves, a direct action
homogeneous orientation of large molecules in the upon vascular smooth muscle, release of vasoactive
field (including the much reported, and of doubtful compounds from tissue suffering thermal stress,
significance, 'pearl-chain formation'9' 3 and induc- increased concentration of metabolites and decreased
tion of transmembrane potentials sufficient to alter oxygen tension in the tissues as a result of accelerated
ion flow, are highly unlikely except at very high field metabolic rate, and stimulation of a cutaneous axon
strengths31. Recent research indicates that exposure reflex"39' .
,

to microwaves may isomerise amino acids, an event Studies investigating the effects of microwave
with serious implications for protein metabolism32. diathermy have generally concentrated upon rate of
Evidence for a direct effect of the electromagnetic blood flow in muscle. Significant increases in flow,
field upon the shape of biologically active molecules, measured indirectly using mechanical sensors, were
often referred to as the 'electroconformational cou- observed after treatment at 60-80W mean output for
pling model', is drawn in part from work with periods of one to 30 minutes. The rate of increase was
Na+/K+ ATP-ases. These molecules occur within the greatest early in the treatment period18. Rate of blood
cell membrane and appear to receive energy directly flow in human muscle has also been estimated by
from an applied oscillating electric field. The energy monitoring the rate of washout of radioactive tracers
appears subsequently as an enhanced rate of Na' such as Xe' . Microwave irradiation of an unnamed
and K+ pumping across the cell membrane. This muscle at 2.45 GHz, to the maximum tolerable
mechanism is fundamental to many cellular activities, temperature, was calculated to cause blood flow to
is both frequency and field intensity dependent, and rise, after a 12 minute delay, to 11.4ml.100g.miw'
requires that the energy of the weak electric field is compared to 2.9ml.100g.min-' before treatment4.
amplified at the cell membrane to exert an effect3. Similar experiments using the anterior musculature
Clearly, if this enzyme system can be affected directly of the thigh in healthy subjects showed that
by an electromagnetic field, then so might others pre-treatment flow was 2.6ml.100g.mi'-1, rising to
having many and various biological effects. approximately 32ml.100g.mir-1 after irradiation at
915 MHz with coincidental skin cooling for 20
Physiological effects and therapeutic minutes at 40W absorbed power21. Subsequent
applications studies concluded that flow in heated muscle
approaches 48ml.100g.mi'n-1 once the threshold
Diathermy, whether achieved using shortwave radio temperature of 420C is achieved'.
frequency or microwave energy, exerts physical More complex vascular reflexes appear responsible

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Microwave diathermy: G.C. Goats

for the reduction in blood flow occuring in rested and elements of the muscle spindle active in maintaining
non-heated muscle underlying heated skin43, spasm
although exercised and heated muscle shows maxim- Pain is also reduced by thermal activation of the
al vasodilation44. Cutaneous warming in one limb 'pain gate' mechanism, in which cutaneous sensory
produces vasodilation in the contralateral extremity information entering the spinal cord through the
as well as a local response45. Some suggest that this substantia gelatinosa takes precedence in transmis-
phenomenon be employed to increase blood flow in sion to the higher centres over activity in fibres
vessels partially occluded by peripheral vascular conveying pain information. Thus analgesia is in-
disease and for which direct heating is contraindi- duced'55 .
cated46. A descending pain control mechanism, mediated
by endogenous opiate compounds, may make a
lesser contribution to heat induced analgesia. This
Joints and soft tissues mechanism is explained fully elsewhere,' ', but
Limitation of range of movement at a joint often would rely for activation upon a degree of heating too
follows contracture of the periarticular connective vigorous and uncomfortable for routine use ther-
tissue and shortening of other soft tissues crossing apeutically.
the joint line. Heat alters the viscoelastic properties of
collagen and, at temperatures within the therapeutic
range 41-45°C, exhibits viscous, rather than elastic Resolution of inflammation
behaviour. When stretched passively whilst hot, Many authors consider that diathermy, judiciously
collagen remains elongated as it cools47 and is less applied, will assist the resolution of inflammation
prone to rupture than tissue stretched without and promote healing1' 3 44 The principal mechan-
.

heating. ism producing these effects is likely to be vasodila-

Microwave diathermy is reported to correct con- tion, which facilitates the influx of material required
tractures of rectus femoris when combined with for the healing process, efflux of metabolites and
stretching49, and by heating effectively structures toxins, and improved drainage of the inflamed site
that lie superficially, such as the interphalangeal and with subsequent reduction in oedema. These effects
metacarpophalangeal joints69, is likely to improve of diathermy are described fully elsewhere' 2' 3 59
function in the hands. Deep structures such as the and the common indications for microwave diather-
hip do not achieve therapeutically effective tempera- my are based largely upon experimental evidence
tures because microwave energy is dissipated in the gained using shortwave diathermy, modified with
thick subcutaneous tissues-;. This reduction in force, intelligent regard for the pattern of heating generated
needed to deform the soft tissues permanently, is by each modality. The non-thermal effects of diather-
accompanied by a decrease in the viscosity of my at various frequencies may indeed differ,
synovial fluid and subsequent frictional stiffness51. although research has not advanced sufficiently in
Heat is often used in the treatment of the this area to allow definitive comment.
arthritides although it can activate the enzymes Few reports comment specifically upon the action
responsible for the destruction of articular cartilage in of microwave therapy upon the resolution of inflam-
rheumatoid disease. This effect is most marked mation. The rate of healing of radiolabelled haemato-
during mild heating between 39-41oC'2, whilst at mata, induced artificially in the muscles of pigs, was
temperatures approaching 45°C proteins are dena- claimed to increase when exposed to 915 MHz
tured and collagenase activity is diminished'. Ex- microwave treatments twice daily at an output of
perimental inhibition of the metabolic activity of 40 W. This caused the washout rate of radioisotope to
animal synovial tissue by heat was achieved by accelerate as blood flow increased in response to a
microwave diathermy at 915 MHz. The microwave rise in tissue temperature to 42-45oC6°.
applicator was water-cooled and highly directional,
allowing very localized irradiation. The coincidental
vasodilation improved the penetration of anti- Patient safety
inflammatory drugs into the joint cavity54. The contra-indications to microwave therapy include
impaired cutaneous thermal sensitivity, ischaemia,
local thrombosis or malignancy, metallic implants
Relief of pain and muscle spasm including pacemakers or other indwelling electrodes,
Microwave diathermy can be used to reduce pregnancy and recent radiotherapy. Tissues showing
pain 3 34, although the narrow focus of many acute inflammation, infection or haemorrhage should
commercial applicators may render the treatment of not be treated, hearing aids should be switched off
diffuse lesions more difficult than with other and, together with jewellery, removed from the
methods of diathermy2. Clinical investigations of field3 34. Structures poorly vascularized are unable to
pain relief using microwave therapy are reported dissipate heat effectively and should not be treated.
rarely although the mechanisms of heat-induced pain Such sites include the eyes and testes, which must be
control are well understood. Vasodilation transports adequately screened using wire mesh goggles or
nocigenic compounds such as bradykinin and hista- shields respectively when treatment of adjacent
mine from the tissues. Ischaemia resulting from tissues is planned. The ovaries lie too deep for
muscle spasm is relieved55 by the direct and microwave diathermy to cause undesirable heating
predominantly inhibitory effect of heat upon those but, in the absence of detailed knowledge of the

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Microwave diathermy: G.C. Goats

effects of such radiation, prudence directs that these power output. The contra-indications and safety
organs are not irradiated . procedures attending the use of this equipment
The patient should be positioned to allow full requires that it is operated only by trained personnel.
relaxation in an environment in which adjacent metal The indications and therapeutic effects are similar
fittings do not contribute to the formation of standing to those for shortwave RF diathermy, although
waves or stray radiation from incident or transmitted modified to take account of the different pattern of
beams. The patient must understand the warning of heating produced in the tissue. These differences are
the risk of burning which should be included with an a function of the frequency-dependent nature of
explanation of the procedure. The skin must be propagation and absorption behaviour within the
exposed, dry and free from liniments or creams61'62. tissue. Non-thermal effects have not been elucidated
dearly but may contribute to the total therapeutic
effect.
Occupational safety The principal physiological effects of microwave
The adverse effects of exposure to microwaves, such induced heating upon tissues that preferentially
as cataract formation, appear to result primarily from absorb this energy, such as muscle and fluid filled
altered thermal gradients within the body, and the cavities induding joints, are vasodilation, altered
case for a carcinogenic or teratogenic effect remains mechanical properties of connective tissue, increased
not proven63 65. metabolic rate and an effect upon nerve function.
The Medical Research Council considers that Therapeutically these changes accelerate the resolu-
continuous exposure to microwave radiation at an tion of inflammation, decrease pain and restore
intensity not exceeding 10 mW.cm72 is safe6l. This normal function to contracted fibrous tissue.
recommendation is based upon previous studies Microwave therapy can contribute usefully to the
made in the clinical environment by the UK National management of many pathologies seen in sports
Radiological Protection Board and is derived from the medicine, and when used intelligently performs a
Specific Absorption Rate (SAR) of microwave energy function not readily replaced by other treatments.
by the body. Therapists adhering to the simple safety
guidelines set out below are unlikely to receive a dose
of microwave radiation exceeding this limit6, which
is low when compared to the intensity of References
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The guidelines informing the safe use of therapeu- Therapeutic Heat and Cold Chapter 10, 404-562, (Ed) Lehmann,
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