Effects of Iontophoresis in the Treatment of Pain

Summer Demeuse

Darie Kirschling

Tellie Kumar

Kayla Rolling

PTH 645

November 16, 2018

 EFFECTS OF IONTOPHORESIS ON THE TREATMENT OF PAIN

INTRODUCTION

Iontophoresis is a modality used in physical therapy to deliver drugs through a

transdermal route with the use of elecroportation, electrorepulsion, and electroosmosis. A 1

direct current is used to have a more efficient, and direct delivery than if the drug were

taken orally or applied topically. These effects include altering the permeability of the

skin, repelling like charges in the drug away from the electrode, and pulling the

medication deeper to the location of interest. A specific current amplitude and duration
1

of treatment are determined to calculate a current dosage being delivered to the patient. A

low current amplitude is applied which varies from about 1.0 mA to 5.0 mA. Amplitude

is carefully chosen based on patient comfort, size of the area being treated, and duration

of the treatment. Amplitude that is lower will be better tolerated by the patient but can be
1

an issue if time restrictions are a factor.

           Iontophoresis is used primarily for its anti-inflammatory effects, but it can also be

used for analgesic effects. This literature review focuses on studies that used

iontophoresis with dexamethasone in order to treat a variety of inflammatory diseases and

measured the effect it has on pain. Dexamethasone is a corticosteroid that alters immune

response in order to relieve several symptoms associated with inflammation, such as

swelling and redness. Upon relieving these symptoms, it is anticipated that it will lead to

a decrease in pain in the area being treated. Several articles were found in support of and

against the use of iontophoresis with dexamethasone in the clinic for treating

inflammation and pain. After conducting a thorough review of the articles, meanwhile

considering their validity and reliability, a recommendation is suggested for the use of
this modality as an effective use of time and money to treat pain for inflammatory

conditions.

EVIDENCE ADVOCATING FOR THE USE OF IONTOPHORESIS

    The first study supports the modality and compares the use of iontophoresis with

dexamethasone and the use of iontophoresis with saline in the treatment of patients with

acute Achilles tendon pain. This was a randomized, double-blinded, placebo-controlled

study looking at the difference in range of motion, muscular endurance, pain and

symptoms before and after treatment. The subject pool was a total of 25 people, both

women and men with an average age of 38. There were 14 subjects in the experimental
2

group and 11 in the control group. The inclusion criteria for this study included: acute
2

pain from the Achilles tendon with an onset of less than three months and the pain had to

be located between two and six centimeters proximal to the calcaneal insertion. The 2

exclusion criteria included: surgery or previous injury to the involved foot, history of

rheumatoid arthritis, diabetes, and any other illnesses affecting this limb. 2

           All 25 patients were evaluated at five different times; after two weeks, six weeks,

three months, six months, and one year. During the evaluation before treatment, each

patient was tested for their range of motion, tenderness (by palpation), strength (toe-raise

test), and pain via a questionnaire to explain their pain levels during certain activities (i.e.

walking up and down stairs, in the morning, before or after physical activity, etc.).

Treatment included four administrations of three milliliters of dexamethasone

(experimental group) or three milliliters of saline (control group) with three to four days

in between administrations. Each treatment session lasted 20 minutes. After treatment,

2  2
each group followed a similar rehab program for ten weeks, consisting mainly of range of

motion and strengthening exercises.

           The results stated, “Several significant improvements were seen in the experiment

group but not in the control group, in the range of motion test, pain during and after

physical activity, pain during walking and walking up and down stairs, morning stiffness

and tendon swelling” . The results also showed that at the one-year follow-up there were
2

significantly fewer patients in the experimental group that reported pain during or after

physical activity than the control group. It is important to note that there were no
2

measurements where the control group had significant improvement over the

experimental group. It should, however, be noted that this study had a small subject pool

and wide age range, encompassed both men and women, and included both the left and

right foot. All of these components make this study difficult to generalize to the entire

population.

           The second study we found supporting the use of iontophoresis with

dexamethasone was done because the experimenters believed that a better modality was

needed to treat medial and lateral epicondylitis. A common way to treat this condition is
3

with steroid injections because topical application of medicine does not typically diffuse

efficiently enough through the skin. The problem with injections is that it contains a lot of

adverse effects including: tendon rupture, nerve injury, destruction of the joint, etc. Since

iontophoresis delivers drugs through a transdermal route, it is able to deliver drugs

locally, in high concentrations, and with less severe side effects than steroid injections.

           This was also a randomized, double-blinded, placebo-controlled study assessing

pain control in patients with lateral or medial humeral epicondylitis. The subjects were
3
recruited from 11 locations around the United States and were between the ages of 18 and

75. Each patient was evaluated and rated as having either moderate or severe intensity of
3

medial or lateral humeral epicondylitis for three months or less during their most recent

episode. Patients who had recurrent injury to the area, had multiple affected areas, or a
3

history of steroid injections/surgery were deemed ineligible for this study. Once subjects

were obtained, they were separated into the experimental group receiving iontophoresis

with dexamethasone or the control group receiving iontophoresis with saline. There were3

99 subjects in the experimental group and 100 subjects in the control group. 3

    All of the subjects were treated with iontophoresis that was administered via IOMED

Phoresor Iontophoretic Drug Delivery System. The electrode pad was consistently placed
3

over the most tender site around the medial or lateral epicondyle, and each patient

received 40 mA-minutes of either the dexamethasone or placebo on six occasions. Each 3

treatment was spaced one to three days apart and completed within a 15 day period. The 3

patients’ final evaluation was done two days after the final treatment. 3

    The results of this study showed that the treatment was relatively well-tolerated. There

was a significant difference within one month after treatment showing that the

experimental group had decreased pain when compared to the control group. This early,
3

non-invasive pain relief may allow patients to proceed with physical therapy exercise

programs. This study had a greater subject pool with a wider variety of subjects as

compared to our first study supporting the use of iontophoresis. Those two components

make this study more generalizable to the population, and therefore provides better

support for the use of iontophoresis and dexamethasone in the treatment of pain.

EVIDENCE ADVOCATING AGAINST THE USE OF IONTOPHORESIS

 In a randomized-controlled clinical trial that examined the differences between

two types of iontophoresis drug-delivery systems, three patellar tendinopathy participant

groups were analyzed: one group treated with a wireless patch, one treated with a wired

dose controller, and one group treated with a placebo. After measuring pain levels post-

treatment using a numeric knee pain scale, the results showed that general improvement

was noted in all groups regardless of treatment type, including the sham treatment. This 4

demonstrated that the actual treatment was no more effective than the placebo in treating

patellar tendinopathy. This research study, with only 31 participants, had relatively low
4

external validity due to the fact that the sample size was small and therefore not

representative of the entire patellar tendinopathy population. However, its results were
4

valuable; many studies have shown that iontophoresis is effective in reducing pain, but

the value in this article is that it suggests the effectiveness of iontophoresis may be due,

in part, to the patient believing that it works. The results of this study call for greater

investigation in differences between actual treatments and sham treatments in order to

show iontophoresis truly relieves pain.  

Further, a number of studies that compared the effectiveness of iontophoresis and

phonophoresis showed that iontophoresis was no more effective than phonophoresis for

pain reduction of various musculoskeletal conditions. Research conducted at the Dokuz

Eylül University School of Physical Therapy and Rehabilitation found no statistical

differences between groups receiving iontophoresis or phonophoresis for the treatment of

lateral epicondylitis before or after treatment, suggesting that “iontophoresis and

phonophoresis are equally effective electrotherapy methods in the treatment of lateral

epicondylitis. 6
 In another article, researchers compared the two treatments with the same dose of

Dexamethasone Sodium Phosphate and measured pain as an outcome using the Visual

Analog Scale at the first session, end of therapy, and after a four week follow-up. The
5

researchers concluded that pain in patients with carpal tunnel syndrome was significantly

reduced in groups treated with phonophoresis compared with groups treated with

iontophoresis. This evidence suggests that phonophoresis may be an even more effective
5

method of reducing pain. The results of this study yield high reliability since all of the
5

subjects were similar in baseline values and duration of current symptoms prior to

receiving the treatment. 5

CONCLUSION

Iontophoresis may be an effective treatment for the reduction of pain in some

cases, but there may be other treatment modalities that are equally effective or even

moreso. Current research has demonstrated that the delivery of dexamethasone using

iontophoresis may alleviate some forms of musculoskeletal pain, but not necessarily that

is the best pain-reducing treatment modality for the short term. When comparing the use

of iontophoresis to more invasive procedures like steroid injections, it may be a more

efficient, safer way to administer medication locally and transdermally in order to reduce

pain.

Depending on confounding factors such as access to dexamethasone and an

iontophoresis machine, as well as the etiology, intensity, and region of the patient’s pain,

iontophoresis may or may not be the most effective treatment. Further more generalizable

research needs to be conducted comparing iontophoresis with other pain reducing

treatment modalities. Based on the literature review completed, iontophoresis is not the

best non-invasive way to reduce pain.

 REFERENCE LIST

1. Zipple, T, 2018, Week 7: Electrotherapy - Iontophoresis. Central Michigan

University, delivered October 31, 2018.

2. Neeter C, Thomee R, Silbernagel KG, Thomee P, Karlsson J. Iontophoresis with

or without dexamethazone in the treatment of acute Achilles tendon pain.

Scandinavian Journal of Medicine and Science in Sports. 2003;13(6):376-382.

3. Nirschl RP, Rodin DM, Ochiai DH, Maartmann-Moe C. Iontophoretic

Administration of Dexamethasone Sodium Phosphate for Acute Epicondylitis: A

Randomized, Double-Blinded, Placebo-Controlled Study. The American Journal

of Sports Medicine. 2003;31(2):189-195.

4. Rigby JH, Mortensen BB, Draper DO. Wireless Versus Wired Iontophoresis for

Treating Patellar Tendinopathy: A Randomized Clinical Trial. Journal of Athletic

Training. 2015;50(11):1165-1173.

5. Bakhtiary AH, Fatemi E, Emami M, Malek M. Phonophoresis of Dexamethasone

Sodium Phosphate May Manage Pain and Symptoms of Patients With Carpal

Tunnel Syndrome. The Clinical Journal of Pain. 2013;29(4):348-353.

6. Baskurt, F. Comparison of effects of phonophoresis and iontophoresis of

naproxen in the treatment of lateral epicondylitis. US National Library of

Medicine. 2003;17(1):96-100.