IONTOPHORESIS

1. IONTOPHORESIS Use of Direct Current to facilitate delivery of ions into the skin for therapeutic purposes. Mechanism of delivery: �LIKE CHARGES REPEL�

4. Historical Highlights Concept first developed & researched over a century ago. Therapeutic use for more than 50 years. Popularity & usage was declining until Joseph Kahn PhD,PT had 9 publications from 1973 to 1983. All case studies & clinical commentaries

5. Contemporary Use In PT: primarily for treating localized inflammatory conditions in superficial tissues Use corticosteroids such as dexamethasone Multiple uses of other non-steroidal ions both within & outside PT Ex: Dentistry, Dermatology, Emergency Dept, Ophthalmology

6. Side Note: Sweat Test for CF Iontophoresis of pilocarpine has been the preferred method of testing infants for cystic fibrosis since 1978. The major component of this test is collection of sweat, which is accomplished by iontophoretic delivery of safe and optimal quantities of pilocarpine for sweat stimulation.

7. Advantages over injection non-invasive; less risk of infection less pain & anxiety less drug into systemic circulation; decreased side effects Less risk of local collagen catabolism

8. Advantages over PO avoids �first-pass� elimination by liver. less drug into systemic circulation; decreased side effects. potentially greater concentration of drug in the target area supervised; maximizes compliance.

9. Disadvantages risk skin irritation or burn depth of penetration known to vary greater risk of local collagen catabolism than oral administration Action of drug � localized immunosuppression

10. Treatment Parameters(when using a DC stimulator, �dose controller�) Current: DC; �high current, short duration� Amplitude: 0.5 to 4.0 mA is the range depends on pt. tolerance, polarity, electrode size Dosage: 40 to 80 mA-min Dosage Formula: amplitude X time = mA min Time: 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.�

11. Treatment Parameters(when using a patch device) Current: DC, �low current, long duration� Amplitude: 0.1 mA and less (automated, constant voltage) Dosage: 40 to 80 mA-min

12. Parameters cont. . . Polarity � use the same polarity as the drug ion Rx frequency: every other day at the most steroid effects can be delayed & last several days allows time for skin to recover minimize risk of side effects cost effective Rx 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.

13. Parameters cont. . . Due to use of DC, no need for dealing with: Waveform Duty cycle or Ramp time Frequency Phase duration

14. Treatment Guidelines (Safety) The intensity should be set to where 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.� DC can cause mast cells to release histamine. Can result in small bumps/vesicles and petechiae. These reactions are normal and generally resolve within hours to days. 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.�

15. Do not increase the amplitude of the stimulus after 5 minutes of treatment. Some clinicians end the treatment by application of a skin lotion containing lanolin, aloe vera or a similar substance. Some will even leave the drug electrode on the skin for several hours following the treatment.

16. Factors that affect skin reactions The patient's skin type: Fair or sensitive skinned patients will usually exhibit more skin irritation or sensation. The patient's sensitivity to DC current increased redness small bumps/vesicles or small hives (a reaction to the DC, not to the drug) Skin pigmentation: In darker skinned patients, the normal reddening is usually less visible than with lighter skinned patients.

17. Precautions E-stim contraindications apply Be aware of pt. allergies to ions/drugs Skin sensation is a factor Do not apply over freshly shaven skin or open tissue (even minor blemish) No thermal modalities immediately before or after. Why Not?? No conductive gel before Ionto Rx. Diabetes Mellitus is a relative contraindication due to decreased peripheral sensation and secondary to metabolic alterations caused by glucocorticoid administration.

18. Equipment & Supplies Drug ion dissolved in aqueous solution or suspended in ointment Absorbent & buffered electrode Iontophoresis device Dupel by EMPI Phoresor by IOMED Iontophor by Dynatronics Patch products: Iontopatch, ActionPatch, Companion 80 New � Hybresis by EMPI

21. Patch (Integrated) Systems Avoid need for dose controllers and wires (DC unit) and are more convenient for clinicians and perhaps patients because in-clinic wear time is decreased or eliminated. Allow patients to be ambulatory during treatment, which in some cases must be as long as 24 hours. Major disadvantage current output will depend strongly on the skin resistance of the treatment site of each individual patient. No feedback to the clinician or patient of the exact wear time required or the iontophoretic dose received within the prescribed wear time.

23. Action Patch & Companion 80

24. HYBRESIS by EMPI

26. Common Ions in PT Dexamethasone Sodium Phosphate 0.4% aqueous solution corticosteroid for anti-inflammatory effects; polarity is (-)

27. Common Ions in PT Lidocaine HCl; 4.0% aqueous solution; short-term local anesthetic; polarity + useful for a few minutes of pain control, particularly in painful local procedures. more useful in dentistry & ophthalmology. could use as test-run for Iontophoresis

28. Additional Ions(know name, polarity, usage) Acetic Acid (-) dissolve Ca deposits Calcium Chloride (+) ms. relaxant Hyaluronidase (+) disperse edema; not acute Iodine (-) softens adhesions & scar tissue Magnesium Sulfate (+) ms. relaxant Sodium Salicylate (-) ms. & joint pain http://www.vannhealthcare.com/

30. Preparing Aqueous Solution(using distilled water & soluble solid) 2.0% = 0.02 g/ml = 20 mg/ml = 20 g/L 4.0% = 0.04 g/ml = 40 mg/ml = 40 g/L 0.4% = 0.004 g/ml = 4 mg/ml = 4 g/L or contact your local pharmacist or chemist.

31. Effectiveness Factors Dosage: 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. Preparation of skin must be clean; no competing ions. Depth of target tissue skin thickness, fat layer, overlying tissues Electrode Contact

32. Factors cont. . . Depth of penetration thought to occur primarily thru pores (sweat & oil) & hair follicles Depth is inferred based on clinical effectiveness max depth of penetration is largely unknown in humans Some animal studies exist

33. Iontophoresis enhances the transdermal delivery of ionized drugs through the skin's outermost layer (stratum corneum) which is the main barrier to drug transport. The absorption rate of the drug is increased, however, once the drug passes through the skin barrier. Natural diffusion and circulation are required to shuttle the drug to its proper location. Ion Penetration

34. Ion Penetration cont. . Issues Does local microcirculation help or hinder? What is the effect of DC stimulation without a drug (DC only) over Iontophoresis (DC with a drug)? DC with tap water revealed a 200% increase in local microcirculation at the cathode. Microvas Res, July 1997