Effective, noninvasive, and quick, iontophoresis provides PTs with a virtually painless method of delivering medications to patients suffering from inflammatory conditions.

The process works because a low-level electrical current is applied to a similarly charged drug solution on a transdermal skin patch. Iontophoresis repels the drug ions, pushing them through the skin and into the desired area without the disadvantages of injections—such as infection and tissue trauma—or oral administration.

"The skin can be a little bit reddened and you occasionally get some superficial bubbles or bumps on the skin, but those typically subside within an hour or so," says Lonnie Dorcey, PT for The Orthopedic Center, Trussville, Ala, who notes that while adverse reactions are minimal, PTs need to use caution to avoid other negative responses. "One of the side effects of iontophoresis is that you could potentially burn the patient; that's uncommon to the technology but does occasionally occur."

To lessen the risk of burning a patient, Dorcey recommends using only a reputable iontophoresis delivery system. "In particular, use only high-quality electrodes or pads," he adds.

Dorcey uses the ActivaTek Trivarion Drug Delivery System, which features large dispersive pads, he says. They are also uniquely shaped.

"It has something of a clover leaf shape and it is very flexible, so it works great for adhering it to the bony prominences such as the Achilles tendon," he says. "The shape also makes it ideal for working on fingers and hands, which are areas that are usually difficult to adhere to."

ON TARGET

The primary benefit of iontophoresis is the ability to deliver anti-inflammatory medication directly to the affected area.

"Because it's transdermal, it generally is a very good way to put medicine directly into tissue in a specific location and it's often very effective at reducing inflammation for acute injuries or overuse injuries," says Anne Mackin, DPT, at Merrimack Valley Physical Therapy, Bedford, NH. "There is also typically less steroid in the body as a result of this treatment, as compared to injections, because you're treating a small area so it's not going to the bloodstream."

Though it must be ordered by a physician, the iontophoresis treatment itself can be administered by an orthopedic specialist or other trained personnel in a physical therapy office, often making it much faster than waiting for someone qualified to give an injection.

The most common application of iontophoresis is for the delivery of anti-inflammatory medications, both steroidal and nonsteroidal.

"For musculoskeletal inflammation or any type of tendinitis, bursitis, or inflammation, we use ketoprofen for a nonsteroidal anti-inflammatory and dexamethasone, a corticosteroid," Dorcey says.

Mackin uses iontophoresis across the board. "It's often very effective with lateral epicondylitis, greater trochanteric bursitis, shoulder bursitis, patellar tendinitis," she says. "Think of any of the ‘itis's. Anything where you have got a specific area that you would want to get anti-inflammatory medication into."

An iontophoresis system has other therapeutic uses as well. PTs can deliver a saline solution to break down scar tissue or use acetic acid to break up calcium deposits.

Regardless of how it's utilized most, getting the right system is a key component to successfully delivering the treatment, according to Dorcey.

"In the past few years, there have been a lot of knockoff products that have come out, and they have really lessened the quality as compared to traditional iontophoresis systems," he says. "I've found they are a lot more painful for people, so to me, it is not worth the risk of using a lesser-quality system on my patient."

PAD PARTICULARS

The primary component of any iontophoresis system is its pad, through which medication is delivered.

"Having larger pads really helps," he says. "Because you are dispersing the treatment over a larger surface area; it is generally much more comfortable for the patients."

He adds that ActivaTek's new pads also removed some frustrations he experienced on other machines.

"They effectively addressed a lot of the shortcomings of the other pads on the market," Dorcey says. "On other systems, I've had trouble with some pads sticking, I've had other pads burning people or pads that were painful for patients."

He gives the example of pads using a gel that he said often seeps out from underneath the adhesive area, with more gel ending up on the floor than the patient.

"It ends up falling off, and you have to start over using a second pad," he adds. "Another problem for me are pads that use a powder as the buffering agent. You can end up with ‘hot spots' on it, depending on how unevenly it's hydrated, which may end up burning the patient."

He also notes that it's counterintuitive to use a dry material to conduct electric current.

Another important feature for an iontophoresis pad is that it be able to maintain a precise pH regulation with Carbon Ag/Agcl. The pads Dorcey prefers also allow for the delivery of a maximum dosage, when appropriate.

"To me, it's important to have a unit that can deliver 80-milliamps-per-minute treatments, because that's something that I regularly do for patients, especially early on in the treatment plan," he says. "I don't think a lot of clinicians are aware that you can do that—and it's one of the benefits with this type of pad."

The pads are approved for 80-milliamps-per-minute (mA-minute) treatments—as well as the 40 mA-minute option—so PTs can be more aggressive in trying to get the inflammation under control.

"It allows you to deliver more medication to the patient in less time," he says.

That rapid response is part of what appeals to clinicians about the treatment. Both Mackin and Dorcey use the process in addition to manual therapies.

"Iontophoresis is very specific for reducing inflammation, especially if there is an acute injury," Mackin says. "Often, patients are feeling improvement within the first one to three treatments."

PART OF THE BIG PICTURE

Just like any therapy system, the iontophoresis process isn't a one-size-fits-all application. Special consideration must be made for patients with specific conditions, such as diabetics.

"For our diabetic patients, I still use the technique, but I will use it with ketoprofen instead of dexamethasone, so it doesn't affect their sugar levels," Dorcey says.

Mackin adds that occasionally, she will choose to give injections to individuals with very sensitive skin or those who are uncomfortable about the use of a transdermal process.

"If someone doesn't want something going across their skin, I won't force them to do it. As with any treatment we provide, we always want to make sure that the patient is comfortable," she says. "However, in general, most patients are willing to try it at least once and then if they see the benefits, they are happy with the results."

THE NEXT BEST THING

While the technology has been around for years, the companies that manufacture iontophoresis systems continue to improve the product.

Earlier this year, Iomed Inc, released its new Hybresis™ System. Referred to as Hybresis by Empi, the manufacturer's latest product added an integrated mini-controller and patch system that uses no lead wires and can deliver in-clinic treatment in as little as 3 minutes.

The Hybresis System consists of a wireless, miniaturized, rechargeable controller that connects directly to an iontophoresis patch and a charging station with four controller bays.

According to the company, the dose controller powers the patch in just about 3 minutes, at which point the controller is removed and the patient can proceed through his or her day, receiving treatment without limiting any physical activities.

A range of patch options is also available, many also made by Empi, the system Mackin uses in her practice.

"One of the greatest things is the Ionto to-go patches. A lot of patients really like those, because it allows someone to put a patch on and keep it on for up to 24 hours, with the medication working the whole time," Mackin says.

This form of the application is typically giving patients the option of shorter visits at the physical therapy clinic.

"It's the same type of medication used through the system in our office, and we still apply it for them," Mackin adds. "It's very convenient for patients; we can just put it on for them, and they are good to go."

Because the therapeutic benefits are similar, exactly who gets the patch and who sits with the machine is usually based on convenience.

"It all depends on if someone has time to stay for a treatment or if someone needs to leave," Mackin says. "It provides us with options so they don't have to sit for a 15-minute treatment.

Patches made by Iomed are capable of delivering an 80-mA per-minute dose, spread over a 24-hour period. They are designed to stay in place, even if the patient showers, and include reserve battery capacity to compensate for patients with higher skin resistance.

For Dorcey, it's that type of flexibility and effectiveness of iontophoresis that is the most appealing.

"I'm always looking for a better, more effective way to treat patients," he says. "It's part of a comprehensive rehab or treatment program in which we'll address every problem the patient has. If pain and inflammation is part of the problem, I want to have a specific way to address it—and iontophoresis provides it."

Dana Hinesly is a contributing writer for Physical Therapy Products. For more information, contact .