The comparison of phonophoresis, iontophoresis and local steroid injection in carpal tunnel syndrome treatment

Dexamethasone Sodium Phosphate Penetration During Phonophoresis at 2 Ultrasound Frequencies

CONTEXT

The effect of ultrasound frequency on phonophoresis drug delivery in humans is unknown.

OBJECTIVE

To determine if a low (45-kHz) or high (1-MHz) frequency delivered a higher dexamethasone (Dex) concentration through the skin.

DESIGN

Controlled laboratory study.

SETTING

Laboratory.

PATIENTS OR OTHER PARTICIPANTS

A total of 40 healthy men between the ages of 18 and 45 years (age = 23.1 ± 2.6 years, height = 176.1 ± 7.2 cm, mass = 88.5 ± 19.4 kg, posterior calf subcutaneous thickness measured using musculoskeletal ultrasound imaging = 0.6 ± 0.2 cm).

INTERVENTION(S)

Participants were randomly assigned to 1 of 4 groups (ultrasound frequency at microdialysis probe depth): (1) 45-kHz frequency at 1 mm, (2) 45-kHz frequency at 4 mm, (3) 1-MHz frequency at 1 mm, or (4) 1-MHz frequency at 4 mm (n = 10 in each group). Three linear microdialysis probes were inserted at the desired tissue depth. We rubbed dexamethasone sodium phosphate (Dex-P) into the skin and then applied a 15-minute phonophoresis treatment.

MAIN OUTCOME MEASURE(S)

Dialysate was collected during the treatment and 60 minutes posttreatment and analyzed for Dex-P, Dex, and the metabolite form of Dex. The sum of the 3 analytes was calculated as total dexamethasone (Dex-total), and differences between the 45-kHz and 1-MHz treatment groups were determined by a repeated-measures analysis of variance.

RESULTS

At 1 mm, 3 (30%) participants in the 45-kHz and 4 (40%) participants in the 1-MHz group had measurable levels of Dex-P. Total dexamethasone increased after the treatment ceased, independent of ultrasound frequency (P < .001), with a trend of the 45-kHz treatment to produce a greater increase in drug concentration (P = .006). At 4 mm, 5 (50%) participants in the 45-kHz and 1 (10%) participant in the 1-MHz group had measurable levels of Dex-P. We observed no difference in Dex-total concentration between treatment groups at 4 mm (P = .72).

CONCLUSIONS

Phonophoresis provided a mechanism for Dex-total delivery at the 1- and 4-mm tissue depths. However, the effectiveness of the ultrasound frequencies varied between the 2 measured tissue depths.

Hand Pain and Sensory Deficits: Carpal Tunnel Syndrome

The Academy of Orthopaedic Physical Therapy and the Academy of Hand and Upper Extremity Physical Therapy have an ongoing effort to create evidence-based clinical practice guidelines (CPGs) for orthopaedic and sports physical therapy management and prevention of musculoskeletal impairments described in the World Health Organization's International Classification of Functioning, Disability and Health (ICF). This particular guideline focuses on hand pain and sensory deficits in carpal tunnel syndrome. J Orthop Sports Phys Ther 2019;49(5):CPG1-CPG85. doi:10.2519/jospt.2019.0301.

Cochrane corner: local corticosteroid injection for carpal tunnel syndrome

BACKGROUND

Carpal tunnel syndrome is a clinical syndrome manifested by signs and symptoms of irritation of the median nerve at the carpal tunnel in the wrist. Local corticosteroid injection for carpal tunnel syndrome has been studied but its effectiveness is unknown.

OBJECTIVES

To evaluate the effectiveness of local corticosteroid injection for carpal tunnel syndrome versus placebo injection or other non-surgical interventions.

SEARCH METHODS

We searched the Cochrane Neuromuscular Disease Group Trials register (searched May 2006), MEDLINE (searched January 1966 to May 2006), EMBASE (searched January 1980 to May 2006) and CINAHL (searched January 1982 to May 2006).

SELECTION CRITERIA

Randomized or quasi-randomized studies.

DATA COLLECTION AND ANALYSIS

Three authors independently selected the trials and rated their overall quality. Relative risks and 95% confidence intervals were calculated for each trial and summary relative risks and 95% confidence intervals were also calculated.

Effects of low-power LED and therapeutic ultrasound in the tissue healing and inflammation in a tendinitis experimental model in rats

This work evaluated the anti-inflammatory response of low-power light-emitting diode (LED) and ultrasound (US) therapies and the quality and rapidness of tendon repair in an experimental model of tendinitis, employing histomorphometry and Raman spectroscopy. Tendinitis was induced by collagenase into the right tendon of 35 male Wistar rats with an average weight of 230 g. The animals were randomly separated into seven groups of five animals each: tendinitis without treatment-control (TD7 and TD14, where 1 and 2 indicated sacrifice on the 7th and 14th day, respectively), tendinitis submitted to US therapy (US7 and US14) and tendinitis submitted to LED therapy (LED7 and LED14). Contralateral tendons of the TD group at the 14th day were used as the healthy group (H). US treatment was applied in pulsed mode at 10 %, 1 MHz frequency, 0.5 W/cm(2), 120 s. LED therapy parameters were 4 J/cm(2), 120 s, daily dose at the same time and same point. Sacrifice was performed on the 7th or 14th day. Histomorphometric analysis showed lower number of fibroblasts on the 14th day of therapy for the US-treated group, compared to the TD and LED, indicating lower tissue inflammation. Raman showed that the LED group had an increase in the amount of collagen I and III from the 7th to the 14th day, which would indicate more organized fibers and a better quality of the healing, and US showed lower collagen I synthesis in the 14th day compared to H, indicating a lower tissue reorganization.

Use of iontophoresis or phonophoresis for delivering onabotulinumtoxinA in the treatment of palmar hyperidrosis: a report on four cases

Idiopathic palmar hyperhidrosis is a common disease that exerts a considerable effect on patients' quality of life. The definitive treatment of this condition (sympathectomy) is associated with some adverse effects and surgical risks. Drugs such as onabotulinumtoxinA can be percutaneously delivered by phonophoresis or by iontophoresis and may be useful in the treatment of hyperhidrosis. In this paper, the authors describe four cases in which an objective and subjective improvement in sweating was seen following 10 daily sessions of phonophoresis or iontophoresis. No adverse effects were reported. The clinical results achieved with treatment were maintained over 16 weeks of follow-up after the end of treatment. Percutaneous drug delivery techniques should be perceived as an option for the treatment of dermatologic conditions.

Effects of steroid with repetitive procaine HCl injection in the management of carpal tunnel syndrome: an ultrasonographic study

BACKGROUND AND AIM

With the use of musculoskeletal ultrasonography (MSUS), morphological changes in the median nerve have been recently reported in patients with carpal tunnel syndrome (CTS). On the other hand, the literature still lacks the information whether those changes are further altered with steroid and local anesthetic injection which is a widely used treatment in this group of patients. Therefore, the aim of our study was to explore in-vivo the effects of steroid with repetitive procaine HCl injection on the median nerve of patients with CTS.

MATERIALS AND METHOD

This prospective clinical trial followed-up patients for 2 months. 22 patients (37 median nerves) with clinical and electrophysiological evidence of CTS were included in the study. All patients received both 40 mg of triamcinolone acetonide once and 4 ml of 1% procaine HCl twice a week for 2 weeks with the same technique. Clinical, functional, electrophysiological and ultrasonographic evaluations were performed at the study onset, and 2 months after the last injection.

RESULTS

Electrophysiological, ultrasonographic findings (median nerve anterior-posterior diameter, transverse diameter and cross sectional area in the proximal carpal tunnel and volar bulging,) VAS scores, Boston carpal tunnel symptom and function assessment scale improved significantly (P<0.05).

CONCLUSION

Steroid injection with repetitive procaine HCl injection effectively reduced the symptoms of CTS, improved the Boston carpal tunnel symptom and function assessment scale and also electrophysiological and ultrasonographic findings. Long term effects remain to be studied. Indisputably, the use of MSUS seems to be promising in this regard.

Assessment of phonophoresis and iontophoresis in the treatment of carpal tunnel syndrome: a randomized controlled trial

To define the role of phonophoresis and iontophoresis of corticosteroids in conjunction with wrist splint use in the treatment of carpal tunnel syndrome (CTS) compared to wrist splint use alone, 52 CTS subjects were analyzed based on clinical and electrophysiological criteria. A prospective, randomized controlled trial was carried out to assess symptom severity, motor skills, and hand function according to the Boston Symptom Severity Scale (BSSS), grip strength, and nine-hole peg test (NHPT), respectively, on the initial visit and in the 3rd month after treatment. The patients underwent conservative interventions randomly as follows: (1) 3 weeks of phonophoresis with betamethasone in conjunction with wrist splint use (group I, n: 18) or (2) 3 weeks of iontophoresis with betamethasone in conjunction with wrist splint use (group II, n: 16) or (3) wrist splint use alone (control, group III, n: 18). The mean age of the patients was 43.7 ± 8.4 (range 24-57) years. Groups I, II, and III showed a significant and further improvement in BSSS at the 3rd month evaluations compared with baseline (P < 0.001, P = 0.001, P < 0.001, respectively), but no significant change was observed in grip strength or NHPT (P > 0.05). There was a statistically significant difference between the phonophoresis and control groups after treatment only regarding BSSS, in favor of phonophoresis (P = 0.012). We recommend the use of wrist splints especially with phonophoresis for relief of symptoms in patients with CTS. Our results demonstrated no superiority among the treatment groups. Further, transdermal steroid treatments are not key determinants of efficacy with respect to motor skills and hand dexterity.

Comparative study of the topical application of Aloe vera gel, therapeutic ultrasound and phonophoresis on the tissue repair in collagenase-induced rat tendinitis

The aim of our study was to compare topical use of Aloe vera gel, pulsed mode ultrasound (US) and Aloe vera phonophoresis on rat paw with collagenase-induced tendinitis. Edema size, tensile tendon strength, tendon elasticity, number of inflammatory cells and tissue histology were studied at 7 and 14 days after tendinitis induction. Pulse mode US parameters were: 1 MHz frequency, 100 Hz repetition rate, 10% duty cycle, and 0.5 W/cm(2) intensity, applied for 2 min each session. A 0.5 mL of Aloe vera gel at 2% concentration was applied for 2 min per session, topically and by phonophoresis. Topical application of Aloe vera gel did not show any statistically significant improvement in the inflammatory process, whereas phonophoresis enhanced the gel action reducing edema and number of inflammatory cells, promoting the rearrangement of collagen fibers and promoting also the recovery of the tensile strength and elasticity of the inflamed tendon to recover their normal pre-injury status. Results seem to indicate that Aloe vera phonophoresis is a promising technique for tendinitis treatment, without the adverse effect provoked by systemic anti-inflammatory drugs.