1. IONTOPHORESIS Reading: Cameron pgs 272-276 Use of Direct Current to facilitate delivery of ions into the skin for therapeutic purposes.Use of Direct Current to facilitate delivery of ions into the skin for therapeutic purposes. Mechanism of delivery:Mechanism of delivery: “LIKE CHARGES REPEL” Positive Electrode (anode) delivers (+) ions Negative Electrode (cathode) delivers - ions

2. Historical Highlights Concept first developed & researched over a century ago.Concept first developed & researched over a century ago. Therapeutic use for more than 70 years.Therapeutic use for more than 70 years. Popularity & usage was declining until Joseph Kahn PhD,PT had 9 publications from 1973 to 1983.Popularity & usage was declining until Joseph Kahn PhD,PT had 9 publications from 1973 to 1983. Most case studies & clinical commentaries Kahn, J. Case Report: Lithium lontophoresis for Gouty Arthritis. J Orthop Sports Phys Ther 1982;4(2):113-114.Most case studies & clinical commentaries Kahn, J. Case Report: Lithium lontophoresis for Gouty Arthritis. J Orthop Sports Phys Ther 1982;4(2):113-114.

3. Contemporary Use In PT: primarily for treating localized inflammatory conditions in superficial tissuesIn PT: primarily for treating localized inflammatory conditions in superficial tissues –Use corticosteroids, (usually dexamethasone) Multiple uses of other non-steroidal ions both within & outside PTMultiple uses of other non-steroidal ions both within & outside PT Ex: Dentistry, Dermatology, Emergency Dept, OphthalmologyEx: Dentistry, Dermatology, Emergency Dept, Ophthalmology

4. Ionto: Advantages over injection non-invasive; less risk of infectionnon-invasive; less risk of infection less pain & anxietyless pain & anxiety less drug into systemic circulation; decreased side effectsless drug into systemic circulation; decreased side effects Less risk of local collagen catabolism*Less risk of local collagen catabolism* * assuming use of corticosteroid

5. Ionto: Advantages over drug PO avoids “first-pass” elimination by liver.avoids “first-pass” elimination by liver. less drug into systemic circulation; decreased side effects.less drug into systemic circulation; decreased side effects. potentially greater concentration of drug in the target areapotentially greater concentration of drug in the target area supervised; maximizes compliance.supervised; maximizes compliance.

6. Ionto: Disadvantages risk skin irritation or burnrisk skin irritation or burn depth of penetration known to vary b/c of variation of current density, skin impedence, skin/fat thickness, and ionization/pHdepth of penetration known to vary b/c of variation of current density, skin impedence, skin/fat thickness, and ionization/pH greater risk of local collagen catabolism than oral administration*greater risk of local collagen catabolism than oral administration* Action of drug – localized immunosuppression*Action of drug – localized immunosuppression* * assuming use of corticosteroid

7. Treatment Parameters (when using a DC stimulator eg. “dose controller”) Current: DC; “high current, short duration”Current: DC; “high current, short duration” Amplitude: 0.5 to 4.0 mA is the rangeAmplitude: 0.5 to 4.0 mA is the range depends on pt. tolerance, polarity, electrode sizedepends on pt. tolerance, polarity, electrode size Dosage: 40 to 80 mA-minDosage: 40 to 80 mA-min Dosage Formula: amplitude X time = mA minDosage Formula: amplitude X time = mA min Time: calculated by the unit, you set the dosageTime: calculated by the unit, you set the dosage The dispersive pad should be put about 6 inches away from the active pad on the same side of the body.The dispersive pad should be put about 6 inches away from the active pad on the same side of the body.

8. Parameters cont... Polarity – use the same polarity as the drug ionPolarity – use the same polarity as the drug ion Rx frequency: every other day at the mostRx frequency: every other day at the most steroid effects can be delayed & last several dayssteroid effects can be delayed & last several days allows time for skin to recoverallows time for skin to recover minimize risk of side effectsminimize risk of side effects cost effectivecost effective Rx number: 4 - 7 maxRx number: 4 - 7 max More than 7 treatments in a short period of time can produce detrimental effects such as skin and connective tissue break-down.More than 7 treatments in a short period of time can produce detrimental effects such as skin and connective tissue break-down.

9. Parameters cont... Due to continuous stim using DC, no need for dealing with:Due to continuous stim using DC, no need for dealing with: –Waveform –Ramp-surge –Frequency –Width –Amplitude, Time, & Polarity abide

10. Treatment Guidelines (Skin Safety) Amplitude: the patient feels a slight tingling, itching or mild stinging. Check the skin under both electrodes after ~ 5 minutes.Amplitude: the patient feels a slight tingling, itching or mild stinging. Check the skin under both electrodes after ~ 5 minutes. Mildly red skin under the electrodes is a normal reaction due to vasodilation & heat buildup.Mildly red skin under the electrodes is a normal reaction due to vasodilation & heat buildup. DC can cause mast cells to release histamine = small bumps/vesicles and maybe petechiae. These reactions are normal and resolve within hours.DC can cause mast cells to release histamine = small bumps/vesicles and maybe petechiae. These reactions are normal and resolve within hours. If the skin is bright red or if many small vesicles are forming, should decrease the amplitude and check skin again after a few minutes. In some cases, may terminateIf the skin is bright red or if many small vesicles are forming, should decrease the amplitude and check skin again after a few minutes. In some cases, may terminate

11. Many factors affect skin reaction The patient's skin type & sensitivity to DC currentThe patient's skin type & sensitivity to DC current Current density: not > 0.5 mA/cm 2Current density: not > 0.5 mA/cm 2 Heat build-up; Chemical build-upHeat build-up; Chemical build-up Skin pigmentation: skin response harder to judge.Skin pigmentation: skin response harder to judge.

12. Skin safety cont.. Caution you about increasing the amplitude after accommodation occurs.Caution you about increasing the amplitude after accommodation occurs. –Counterbalance with repeated skin checks Some clinicians end the treatment by application of a skin lotion containing lanolin or aloe vera.Some clinicians end the treatment by application of a skin lotion containing lanolin or aloe vera.

13. Contraindications & Precautions E-stim standard contraindications & precautions applyE-stim standard contraindications & precautions apply Pt. allergic to ions/drugsPt. allergic to ions/drugs Impaired skin sensation is a precautionImpaired skin sensation is a precaution No thermal modalities immediately before or after. Why??No thermal modalities immediately before or after. Why?? No conductive gel before Ionto. Why??No conductive gel before Ionto. Why?? Diabetes is a precaution due to decreased peripheral sensation and secondary to localized immunosuppression caused by corticosteroid.Diabetes is a precaution due to decreased peripheral sensation and secondary to localized immunosuppression caused by corticosteroid.

14. Most Common Ion in PT Dexamethasone Sodium PhosphateDexamethasone Sodium Phosphate 0.4% aqueous solution0.4% aqueous solution 0.4% = 0.004 g/ml = 4 mg/ml0.4% = 0.004 g/ml = 4 mg/ml corticosteroid for anti-inflammatorycorticosteroid for anti-inflammatory effects; polarity is (-)effects; polarity is (-)

15. Additional Ions (know name, polarity, usage) Acetic Acid (-) dissolve Ca depositsAcetic Acid (-) dissolve Ca deposits Calcium Chloride (+) ms. relaxantCalcium Chloride (+) ms. relaxant Hyaluronidase (+) disperse edema; not acuteHyaluronidase (+) disperse edema; not acute Iodine (-) softens adhesions & scar tissueIodine (-) softens adhesions & scar tissue Magnesium Sulfate (+) ms. relaxantMagnesium Sulfate (+) ms. relaxant Sodium Salicylate (-) ms. & joint painSodium Salicylate (-) ms. & joint pain Lidocaine (+) local anestheticLidocaine (+) local anesthetic Example pharmacy servicesExample pharmacy servicespharmacy servicespharmacy services

16. Equipment & Supplies Drug ion dissolved in aqueous solution or suspended in ointmentDrug ion dissolved in aqueous solution or suspended in ointment Absorbent & buffered electrodeAbsorbent & buffered electrode Iontophoresis devicesIontophoresis devices Dupel DC stimulator by EMPI is what we will useDupel DC stimulator by EMPI is what we will use –Numerous other brands of DC stimulators exist Patch products: Iontopatch, ActionPatchPatch products: Iontopatch, ActionPatch Newest – Hybresis by EMPINewest – Hybresis by EMPI

17. Dupel by EMPI

18. Phoresor II and look-a-likes

19. Current: DC, “low current, long duration”Current: DC, “low current, long duration” Amplitude: ~0.2 mA and less (if constant voltage)Amplitude: ~0.2 mA and less (if constant voltage) Dosage: 40 to 80 mA-minDosage: 40 to 80 mA-min –more convenient for clinicians and perhaps patients because in-clinic wear time is greatly decreased. Efficacy?? Patch (Integrated) Systems

20. Iontopatch by Birch Medical

21. Action Patch by EMPI

22. HYBRESIS by EMPI

23. Effectiveness Factors Dosage: mA-minDosage: mA-min Little evidence exists that different combinations of amplitude & duration provide equivalent amounts of ion transfer; some evidence that 4mA X 10 min is best. 40 mAmin is a commonly accepted standard.Little evidence exists that different combinations of amplitude & duration provide equivalent amounts of ion transfer; some evidence that 4mA X 10 min is best. 40 mAmin is a commonly accepted standard. Preparation of skinPreparation of skin must be clean; no competing ions.must be clean; no competing ions. Depth of target tissueDepth of target tissue skin thickness, fat layer, overlying tissuesskin thickness, fat layer, overlying tissues Electrode ContactElectrode Contact

24. Depth of ion penetration Believed to occur primarily thru pores (sweat & oil) & hair folliclesBelieved to occur primarily thru pores (sweat & oil) & hair follicles Passsive diffusion and local circulation are required to shuttle the drug deeper, to the cells of the target tissuePasssive diffusion and local circulation are required to shuttle the drug deeper, to the cells of the target tissue Research – effect is often inferred based on clinical effectiveness (pain, ROM, MMT, function)Research – effect is often inferred based on clinical effectiveness (pain, ROM, MMT, function) max depth of ion penetration is largely unknown in humans (8-10mm in mammals)max depth of ion penetration is largely unknown in humans (8-10mm in mammals)