Download a current overview of iontophoresis

A CURRENT OVERVIEW OF IONTOPHORESIS
USED IN THE TREATMENT OF T.M. JOINT
INFLAMMATION; MYO-FASCIAL PAIN
AND TRIGGER POINTS
INTRODUCTION
Early work by Dr. Louis Gangarosa and Dr. Arthur Jeske proved the validly of
using Iontophoresis intra-orally. Their research was primarily directed
toward dental related problems such as tooth hypersensitivity. However,
early use of Iontophoresis in extra-oral treatment of joint inflammation,
myo-fascial pain and trigger points proved to be unpredictable. It is now
felt that early equipment, protocols, techniques and procedures developed
primarily for the Physical Therapy marketplace were lacking and provided
inconsistent results.
The study "Degenerative Joint Disease Part 1: Management and Diagnosis
Considerations". Dr. Bates et al. states in the section dealing with the
management and therapy for the TMJ-DJD patient:
"The use of Iontophoresis drug application has proven to be a major advance
in the symptomatic care of those patients unable to take the various antiinflammatory medications. This mode of application of anti-inflammatory
agents to the painful joint is accomplished by the iontophoretic transport
of the agents through the skin surface, and has minimized the need for
intra-articular injections of corticosteroid. Although the direct injection
has been shown to give relief in the acute phase, studies have indicated
that multiple injections into the TMJ are not advisable due to the potential
increase of degenerative changes."
Iontophoresis has proven to have several advantages over the traditional
delivery of drugs (injection; oral medications).
These advantages are:
1) Concentration of therapeutic agents at the desired treatment site
2) Minimization of systemic side effects, especially when
a vasoconstrictor is used
3) Decrease in tissue trauma
4) Increase in patient acceptance and compliance
Current iontophoretic applications are proving to be very beneficial for the
Dental practice providing care for patients suffering from T.M.D. Beginning
with the study by Drs. Lark and Gangarosa in the April, 1990 issue of
CRANIO, the techniques and protocols for iontophoretic applications have
been refined to provide consistent, successful results.
Subsequent studies, articles and papers:
1) Pharmacological Management of Temporomandibular Joint Disorders and
Chronic Head and Neck Pain; Drs. Louis Gangarosa and Parker Mahan (October
1991; CRANIO)
2) Degenerative Joint Disease Part I: Management and Diagnosis
considerations; Drs. Robert Bates Jr.; Henry Gremillion; Carol Stewart
(October 1993; CRANIO)
3) Electrotherapeutics in the Clinical Management of Head, Neck, Facial Pain
and Temporomandibular Joint Disorders; Dr. Gerald Murphy (1992; ANTHOLOGY OF
CRANIOMANDIBULAR ORTHOPEDICS, Volume II) Presented by The International
College of CRANIOMANDIBULAR Orthopedics
4) Inflammation of the Temporomandibular Joint; Dr. C. Paschal Brooks
(October 1993; T.M. Diary); NEWS JOURNAL OF THE AMERICAN ACADEMY OF HEAD,
NECK, FACIAL PAIN & ORTHOPEDICS
In addition to the above researchers, it would be appropriate to thank the
many "Wet Finger Dentists" for their work and effort to refine and improve
the protocols and techniques used in today's iontophoretic applications.
PlEASE KEEP IN MIND, THE PROTOCOLS, DRUGS AND TECHNIQUES DISCUSSED ON THESE
PAGES, WERE DEVELOPED BY THE AUTHORS OF VARIOUS STUDIES AND IN THE FIELD.
LIFE/TECH AND LANDMARK MEDICAL CANNOT, BECAUSE OF FDA REGULATIONS, RECOMMEND
ANY MEDICATIONS, CHEMICALS OR SUBSTANCES.
PREVIEW
The practitioner must keep in mind that Iontophoresis combines the
technologies of electrical current, pharmacology and anatomy. Each of these
technologies contributes to the successful application of Iontophoresis. For
instance, "current follows the path of least resistance" this electrical law
works both for and against the practitioner. Consider, the lower resistance
in the soft tissue of the joint will "allow" the current and hence the drug
ion to flow into the joint space. The bony areas around a joint have a
higher electrical resistance. This higher resistance will create a soft
tissue electrical pathway. But if the treatment area has a skin irregularity
(lowered electrical resistance) most of the current would flow through the
skin irregularity, and without proper technique, the patient's tissue could
conceivably be traumatized.
The active or beneficial part of the drug compound must have the highest
electrical charge. The current flow has no way of discriminating between
"good"(beneficial drug) or "bad" (preservative or non-beneficial) ions. The
unit will predominantly push the ion which has the highest electrical
charge. For this reason, only certain drugs or brands of drugs are suggested
for use with Iontophoresis. The results become more predictable and
consistent when the compound of the drug is known.
The use of a vasoconstrictor has proven to be of particular
vasoconstrictor will temporarily restrict the blood flow in
area of treatment and allow for a higher cellular uptake of
With no vasoconstrictor the vascular blood flow will "wash"
percentage of the drug during treatment.
benefit. The
the immediate
the active drug.
away a large
The use of a large ground will reduce resistance. This will allow a high
current to flow comfortably into the patient's tissue. Comfortable treatment
levels (before the anesthesia effect) can often be used as a method to
determine the current level best suited to iontophoretic application.
PRACTICAL METHODS FOR IONTOPHORETIC APPLICATIONS
SECTION ONE
1) Treatment site selection for the TMJ
2) Meditrode(s) selection
3) Skin preparation
4) Meditrode(s) placement and filling
5) Wire and cable selection
6) Review
MEDITRODE(S)SITE SELECTION
Proper placement of the Meditrode(s) will insure maximum penetration of the
drug Ions. For instance, when working with a bony area remember bone is only
about 5% electrically conductive as compared to soft tissue being about 80%
electrically conductive. Palpate the treatment area not only for centering
the electrode over the pi-center of the treatment area but also consider
soft tissue pathways for maximum penetration of current and drug to the
deeper depths. For example, when treating the T.M.D., place the gauze
portion of the Meditrode(s) directly over the Coronoid notch. This will
"allow" the current/drug to be pushed into the joint with minimum
resistance. When treating patients with a deep recession or hollowed area
over the Coronoid notch, it may be necessary to place a small piece of
cotton in the recessed area. Press the gauze portion of the Meditrode(s)
against the cotton. By filling the hollow, a consistent skin contact is
maintained. This procedure will ensure the current/drug flows into the joint
space.
Remember to increase the amount of liquid in your drug "cocktail". This will
ensure there is enough liquid to moisten both the cotton and the
Meditrode(s).
DUAL MEDITRODE (S)
TREATMENT FOR
Many times it is very beneficial to drive both
JOINTS
TMJ joints simultaneously. Keep in mind, lack of conductivity
over bone and place Meditrodes over soft tissue pathways, which will deliver
the drug into both joint spaces. Remember that the current is not flowing
between the two "drug" delivery Meditrodes. During a dual application each
Meditrode creates a separate current flow or channel with the "return"
electrode. When treating larger joints, the operator should "bracket" the
joint by placing Meditrodes on both sides of the joint, allowing soft tissue
pathways to deliver the current/drug to deeper depths.
MEDITRODE (S) SITE
SELECTION FOR
Meditrode(s) placement over myo-fascial
SOFT TISSUE
treatment sites should be palpated to determine
AND TRIGGER
the epicenter of the painful treatment site. The
POINTS
Meditrode(s) should be centered over this area.
as Trigger points have a lowered electrical resistance most of the
current/drug will flow through the trigger point. Do not place Meditrode(s)
with the active drug pad of the Meditrode(s) over major blood vessels,
because in this placement, a greater portion of the drug ions will "wash" or
flow away from the treatment site. When treating sites such as trigger
points, keep in mind, using a large Meditrode(s) may be more beneficial than
a smaller Meditrode(s) because you will also be treating satellite trigger
points and overall myo-fascial soreness and spasm surrounding the selected
treatment site.
MEDITRODE(S) SIZE
SELECTION
The size, shape and location of the treatment
site should dictate the selection of the Meditrode(s). Also, you must
consider if you want to concentrate the drug ions in a small space such as
the insertion of a nerve ending or a joint, or are you treating a soft
tissue pain/spasm area and its surrounding tissue. Location will determine
if you need a Meditrode(s) which will contour to the treatment area.
Life/Tech has 6 different size and shape drug delivery Meditrodes. Select a
Meditrode(s) which will cover the treatment area and a small margin of
tissue surrounding that area. The last consideration is, will the
Meditrode(s) pad conform tightly to the treatment site? If not, small pieces
of clean cotton balls may be used, to complete skin contact (explained
earlier).
SKIN PREPARATION
OF TREATMENT SITE
The treatment site should be thoroughly cleansed
with an alcohol pad or warm soapy water. It is Imperative
that all makeup and oils are removed from the treatment area. Do not abrade
the skin with harsh scrubbing as this will create problems during the actual
treatment phase, but the skin must be clean. Oils and makeup add electrical
resistance and will decrease conductivity. Also keep in mind that cosmetics
may have active ions and would have the potential to be driven into the skin
during the treatment phase. Hairy areas can be difficult. Consider, current
normally will follow the hair follicle as the path of least resistance.
However, if you are dealing with thick hairy areas such as a beard or scalp,
there is no way to contour the Meditrode(s) tightly to tissue and skin burns
may occur. At the very least, the current sensation will be uncomfortable to
the patient because of electrical arcing.
VISUALLY INSPECT
the treatment site for skin defects such as scars,
TREATMENT
moles, freckles, enlarged pores or other
SITE
imperfections which could create a pathway of least
resistance, and as such, may create a uncomfortable sensation during
treatment. Also if the treatment period is lengthy a skin burn could result
from the concentration of current in the small area of the imperfection. An
easy method for insulating the skin defect area would be to use a very small
amount of Vaseline on the end of a "Q" tip. Lightly touch the skin area with
the "Q" tip and Vaseline. If there is a scar, trace the scar with the
Vaseline. DO NOT use a large amount of Vaseline or spread the jelly over a
large area, as this will prevent or limit the amount of ions passing through
this insulated area. REMEMBER as you press the Meditrode(s) in place you
will spread the jelly. So please "a little dab will do you".
MEDITRODE(S)
PLACEMENT
After cleaning and inspecting the treatment
site, select the proper Meditrode and slightly
stretch the Meditrode(s) over the skin. You must ensure
complete contact between the skin and the gauze treatment pad to prevent
arcing of the current through open air. this arcing could cause an
uncomfortable current sensation. Ensure the tape surrounding the medications
pad is flat and smooth against the skin, with no puckers or ridges.
CONNECTING THE
MEDITRODE(S)WIRES before filling the Meditrode(s) connect the wires to the
Meditrode(s) snaps. You do this to prevent squeezing the medication out of
the Meditrode(s) while connecting the wires after filling.
FILLING THE
MEDITRODE(S)
After mixing the medications and creating the "medication
cocktail" ALWAYS REMOVE THE NEEDLE PORTION OF THE SYRINGE before filling the
Meditrode(s). This will prevent the inadvertent "sticking" of the patient
through the Meditrode(s), thus preventing a problem during the treatment
phase. The hub of the syringe is inserted into the medicine port (holes).
The Meditrode(s) is filled SLOWLY by depressing the plunger. An eye dropper
can be substituted for the syringe. Starting at the uppermost port, fill
each of the medicine ports ensuring the Meditrode(s) is completely
saturated. The Meditrode(s) is filled when you see a small drop of
medication appear at the medicine ports during application. DO NOT OVER FILL
as this will cause the tape to lift away from the skin. If lifting does
occur, use a piece of tape to "stick" the Meditrode(s) back into complete
contact with the skin.
SELECTION OF
MEDITRODE(S)
If a dual treatment is being considered you must use the
WIRES
red wires connected with the grey grommet. This grommet has a
resistor in place which will allow the current to flow evenly to both
Meditrodes, regardless of resistance. Of course, if a single site is being
treated, then a single red wire is used. Do not attempt to use the dual
wire during a single site treatment, remember the unused snap portion of the
dual Meditrode(s) wire will still be passing current (if still plugged into
the treatment cable) and could burn the patient if the snap remains in
contact with the skin.
CONNECTING WIRES
AND CABLE TO UNIT
The treatment cable has two red female connectors
marked "drug". Connect either the dual or single Meditrode wire(s) into
these red connector(s). The cable also has a black female connector which is
marked "return", the black ground or reference wire is plugged into this
connector. The unit itself has a connector on the top marked "reference".
You may also plug the return wire into this connector. When using the large
5" X 8" ground, plug the attached wire into either or the "return" or "
"reference" connector. The circuit will be complete when the drug and return
electrodes are attached to the patient and filled with medication.
Remember the terms "reference"; "return"; "dispersive" and "ground" are
synonymous. However, we avoid the word "ground" because of any harmful
electrical connotations the patient may harbor.
The treatment cable snaps straight into the unit. Do not attempt to turn or
twist the connector into the unit as this will bend the connecting wires
within the unit.
REVIEW
1) Select either a single or dual treatment site keeping in mind the soft
tissue flow or channels into a joint area. Do not place Meditrode(s) over a
major blood vessel.
2) Select Meditrode(s) which will contour to the skin and create a slight
margin surrounding the treatment site.
3) Cleanse the skin and insulate any imperfections which may be present.
4) Place the Meditrode(s) to ensure complete contact between medication pad
and tissue.
5) Fill the Meditrode(s) before connecting the wires.
6) Remove the needle from the syringe before filling the Meditrode(s) to the
saturation point.
7) Always select the correct Meditrode wires for a single or dual treatment.
DO NOT twist the patient cable connector when connecting unit.
A two phase treatment IS NOT the same as a dual
treatment.
NOTE In a two phase treatment the operator is driving a positive charged
drug (lidocaine; vasoconstrictor) and then a negative charged drug (antiinflammatory) during the same treatment to a single application. In a dual
treatment, the unit is being used to drive two treatment sites
simultaneously with one or more medications. Of course, a two phase
treatment is most often used in either a single or dual treatment.
For More Information concerning Iontophoresis
Please contact
Landmark Medical, Inc. ~ 1-800-334-5618 ~ 770-785-7359
Fax 770-785-7495
www.landmarkmedical.com
E-mail [email protected]