Biofeedback

Biofeedback

                Electromyographic biofeedback is a modality that seems to be gaining increased popularity in clinical settings.  It is a therapeutic procedure that uses electronic or electromechanical instruments to accurately measure, process, and feedback reinforcing information via auditory or visual signals.  In clinical practice, it is used to help the patient develop greater voluntary control in terms of either neuromuscular relaxation or muscle reeducation following injury. (Prentice,  Therapeutic Modalities in Rehabilitation)

IN FAVOR

The article “Management of Stress Urinary Incontinence With Surface Electromyography-Assisted Biofeedback in Women of Reproductive Age” by Rett et al. was a case study of twenty-six women of reproductive age.  The purpose of the study was to test the ability of a biofeedback-assisted pelvic floor muscle exercise (PFME) program as a viable conservative alternative to surgery.  The twenty-six women were treated for twelve therapy sessions using a surface electromyography assisted biofeedback unit. All women were of reproductive age.  Results were determined from a seven day voiding diary, a one hour pad test, pelvic-floor muscle strength measurements, sEMG amplitudes, a leakage index, and a quality of life questionnaire.  All variables were taken before and after intervention.  Results that were found were that the frequency of urine loss, the occurrence of nocturia, and the number of pads required decreased significantly after intervention.  What they defined as an “objective cure” was found in 61.5% of the women.  There was also a significant improvement in the quality of life, in pelvic-floor muscle strength, and in the sEMG amplitudes of all contractions during the intervention. They concluded that a short-term intervention of PFME with sEMG-assisted biofeedback could be helpful in treating symptoms of SUI in women of reproductive age and that this may be a reasonable conservative management option.

Rett, M. et al. (2007).  Management of Stress Urinary Incontinence With Surface Electromyography—  

             Assisted Biofeedback in Women of Reproductive Age.  Journal of the American Physical           

             Therapy Association. 87: 136-142.

The goal of this randomized-controlled, double-blind investigation of patients with chronic low back pain was to determine the effectiveness and efficacy of respiratory feedback in comparison to a strict placebo group. Participants were randomized either to a respiratory feedback (RFB) or a non-contingent respiratory feedback group. RFB is considered to be a valuable tool to train individuals to calm their breathing in order to become more relaxed. Those in the non-contingent group received a constant signal corresponding to a breathing rate of roughly 8 breaths/min which was independent of the participants breathing (i.e. not prompted by the participant). This is a type of pseudo-feedback, in which biofeedback signals mask actual body processes. The participants performed a HEP 30 min per day for 15 days. A respiratory associated relaxation index (RI) was utilized to quantify the level of relaxation through calmed breathing. Compared to placebo (non-contingent) RFB, real RFB induced a higher RI, higher reductions in pain at rest and during activity, and in psychopathological symptoms. Results did not, however, display significant difference between-groups, although symptom reductions were more evident in the RFB group from pre-posttest.

Kapitza,K. P., Passie, T., Bernateck, M., & Karst, M. (2010). First non-contingent respiratory 

               biofeedback     placebo versus contingent biofeedback in patients with chronic low back pain: a 

               randomized, controlled, double-blind trial. Applied psychophysiology and biofeedback, 35(3), 

               207-17. doi:10.1007/s10484-010-9130-1.

               

             The article “A randomized controlled trial of anorectal biofeedback for constipation” by Hart et. al. was a study to examine the efficacy of anorectal biofeedback v. a biofeedback control for treating constipation.  Twenty-one subjects with pelvic floor dyssynergia were placed in either the biofeedback treatment group or the biofeedback control group.  The treatment group received pelvic floor and external sphincter training using a rectal biofeedback probe.  The control group was administered upper trapezius relaxation training using biofeedback.  The study showed that overall constipation severity scores of the treatment group improved by 35.5% and obstructive defacation scores decreased by 37%.  Irritable Bowel Syndrome Quality of Life scores for the treatment group improved by 28% while the control group decreased 13%.  Although the study shows benefits to biofeedback, it was greatly underpowered because there were only 21 subjects.  Further research should be conducted.

Hart, Stacy L., Janet Waimin Lee, Julia Berian, Taryn R. Patterson,  Amanda del Rosario, Madhulika G.

Varma.  A randomized controlled trial of anorectal biofeedback for constipation.  Int J.

Colorectal Dis, 8 Nov., 2011.  DOI 10.1007/s00384-011-1355-9. 

ARTICLES AGAINST

The article by Moreland and Thomson was a literature review and meta-analysis conducted to examine the efficacy of EMG biofeedback compared with conventional physical therapy for improving upper-extremity function in patients who suffered a stroke.  A literature search was conducted from the years 1976-1992 of single-blinded randomized control trials.  Six studies were selected that met nine different criteria.  Because all of the analyses were statistically non-significant, the studies to date did not conclusively demonstrate that EMG biofeedback was superior to conventional therapy.  The estimated size of the effect was small therefore it was recommended that therapists consider factors such as cost, ease of application, and patient preference when deciding between the two forms of treatment.

Moreland, J, Thompson, M.  Efficacy of Electromyographic Biofeedback Compared With Conventional                   Physical Therapy for Upper-Extremity Function in Patients Following Stroke:  A Research                   Overview and Meta-analysis.  Physical Ther. 1994. Jun ;(74)6: 534-543.

The objective of this literature review and meta-analysis was to find a complementary and alternative medicine (CAM) for Raynaud’s Syndrome. Although the study was inconclusive as to what  type of CAM was most effective in treating Raynaud’s the only conclusion is came to was that biofeedback was actually not only not significant in a change of frequency, duration and severity of Raynaud attacks, it actually favored the control. Many trials had to be excluded, however, due to their lack of quality of statistics. Only one study that was included which demonstrated more significance towards the control versus biofeedback. Therefore, still, this is not conclusive in determining that biofeedback in not a useful tool.

Malenfant,D., Catton, M., & Pope, J. E. (2009). The efficacy of complementary and alternative medicine                    in the treatment of Raynaud’s phenomenon: a literature review and meta-analysis.             

                  Rheumatology (Oxford, England), 48(7),791-5. doi:10.1093/rheumatology/kep039

             The article “Behavioral and Physical Treatments for Migraine Headache” by Goslin et. al. is a meta-analysis of comparative clinical trials of behavioral and physical treatments of migraine headaches.  The studies in this review were prospective, controlled trials of behavioral or physical treatments whose purpose was to prevent attacks of migraine headaches or relieve symptoms.  Biofeedback treatments were not described in detail, but simply as thermal biofeedback combined with relaxation training and EMG biofeedback.  The biofeedback techniques did not prove to be statistically significant for treating migraine headaches when compared to a control.

 

Goslin RE, Gray RN, McCrory DC, et al. Behavioral and Physical Treatments for Migraine Headache.                           Rockville (MD): Agency for Health Care Policy and Research (US); 1999 Feb. (Technical 

                 Reviews,   No. 2.2.) Summary

               

Mallory Mahoney, Adam Mathers, Brandon Smith

IFC for Pain Management

IFC, or interferential current, is a type of electrical stimulation that uses two different channels at the same time. When setting it up, the electrodes for the respective channels should be set up in a crossing pattern so that the electrical currents cross. When two waves combine at the same point, they have a summative result. Setting each channel at a different frequency results in a varied summation at each time point and makes a beat frequency. This type of electrical stimulation is used for pain, edema, and muscle rehab depending on the beat frequency that is produced.

Articles in Favor of IFC:

Goats, G.C. article explained the basics of how IFC works while incorporating older studies that supported the effectiveness. Some of the studies were aimed at determining dosage; therefore, already assuming IFC works. Goats explained that interferential therapy is theoretically effective for stimulating muscle, increasing blood flow, and accelerating bone healing. Case studies and observational evidence support edema reduction, incontinence control, and pain reduction from IFC. Take into consideration that this article was published many years ago so new studies may be more pertinent to today. Nonetheless, this article drew upon numerous studies that specifically identified IFC as an effective method of therapy. It’s obvious that IFC has great potential as a therapeutic intervention but further research is needed to fully understand how it fits in the clinic.

Goats, G. C. (1990). Interferential current therapy. British journal of sports medicine, 24(2), 87-92. Retrieved from http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1478878&tool=pmcentrez&rendertype=abstract

The article by Jorge, Parada, Ferreira, and Tambeli analyzed the effect of interferential current therapy on inflammatory pain and edema in rats.  They used formalin injections, which evoked a local release of histamine and serotonin which activated nociceptors, and carrageenan injections, which produced a mechanical hyperalgesia.  Both injection types resulted in edema.  They rats were divided into groups, based on which injection they received and when the interferential current treatment was given, before or after.  Edema was monitored in separate groups.  For each group, there was one control group, which had the interferential current off, and one in which there were no electrodes at all. 

In the groups with the formalin injection, a significant effect was found only in the nociceptive behavior in the group receiving the interferential current for the hour after the injection.  In the groups with Carrageenan injections, the interferential current showed significant effects while on, but once discontinued, those effects disappeared.  There was not a significant change in the amount of edema with any of the groups.  Both formalin and carrageenan mimic the human inflammatory pain state brought on by traumatic pain.  This information would be most appropriate for pain relief post-surgical or after other trauma induced pain.

Jorge S, Parada C, Ferreira S, Tambeli C. Interferential therapy produces antinociception during application in various models of inflammatory pain. Physical Therapy [serial online]. June 2006;86(6):800-808. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed February 27, 2012.

This article by Jarit, Mohr, Waller, and Glousman looked at the effect of IFC versus placebo effect on post-op knee surgery patients. The results looked at edema (girth measurement), range of motion, pain rating, and amount of pain medication taken. All subjects using IFC had significantly less pain than the placebo group. In general, the IFC group also took less pain medication, had greater range of motion and had less edema. The theory behind the greater ROM is that the patients that had IFC had less pain and were therefore able to tolerate more physical therapy. This article shows that IFC is a significantly effective way to decrease the amount of pain a patient is experiencing. However, there were some limitations to this study and more research needs to be done to have a greater picture of the benefits of IFC.

Jarit, G.J., Mohr, K.J., Waller, G., Glousman, R.E. The Effects of Home Interferential Therapy on Post-Operative Pain, Edema, and Range of Motion of the Knee. Clinical Journal of Sports Medicine. Jan 2003: 13(1): 16-20.

Articles Against IFC:

IFC is widely used in clinical practice to treat pain and there is a great deal of anecdotal support for its efficacy.  Unfortunately, there aren’t any high quality studies with sound methodological design that have substantiated its use. This can partly be attributed to the difficulty in adhering to strict methodological protocols (such as blinding subjects and therapists) when using therapeutic interventions like IFC.  But, more importantly, the absence of such high quality studies is more readily attributable to the lack of understanding concerning IFC’s mechanism of action and the attendant lack of standardization with regard to its application – such as electrode placement, stimulation frequency and intensity, or length of treatment time.  Beatti et al began a systematic review in 2008 of RCTs conducted since 1980 which had examined the efficacy of IFC. Of the 59 studies they found, only nine met their inclusion criteria. The studies used the outcome measures of pain intensity, pain threshold, and ROM, but, unfortunately, were of average methodological quality, and had findings that were either contradictory, inconclusive, or unpersuasive.  Beattie et al concluded that IFC may have an effect in reducing pain, but more rigorous, high quality research is needed to substantiate its efficacy.

Beatti, A.  et al. (2010). The analgesic effect of interferential therapy on clinical and experimentally induced pain. Physical Therapy Reviews, 15(4), 243-252.

This systematic review included randomized controlled trials that aimed to determine IFC’s effectiveness in treating musculoskeletal pain. The results were inconclusive, indicating that IFC alone was not shown to have significantly better results than other therapies. Keep in mind that the studies that used IFC as the ONLY intervention were very small. IFC as an adjunct to other interventions was found to be more effective for reducing pain than the control or placebo treatments. Optimal dosage for IFC is not clear. The results also imply that there are potential long-term benefits from IFC like in chronic conditions; currently IFC is mostly used for short-term pain. Heterogenity in the population was the main limit to this meta-analysis. Overall the evidence is weak to proclaim that IFC is truly effective.

Fuentes, J. P., Armijo Olivo, S., Magee, D. J., & Gross, D. P. (2010). Effectiveness of interferential current therapy in the management of musculoskeletal pain: a systematic review and meta-analysis. Physical therapy, 90(9), 1219-38. doi:10.2522/ptj.20090335

Furlan reviewed 154 eligible studies relating to interferential current, either independently or as a cointervention, for subjects clinically diagnosed with a painful musculoskeletal condition.  Twenty studies were included in a qualitative synthesis and fourteen studies were included in a meta-analysis.  A lack of consensus was found within the articles.  Some of the articles indicated that interferential current was not significantly different from the placebo or from a cointervention of interferential current and manual therapy.  There was also conflict between studies over the same condition, some showing a significance, others not.  The meta-analysis results indicated that interferential current may be beneficial for pain management when combined with other therapies, however independently it did not show a significant improvement.

Furlan, A. D. (2011). Evidence for Interferential Current to Treat Musculoskeletal Pain Remains Weak. Clinical Journal of Sport Medicine, 21(3), 278-279. Retrieved February 27, 2012, from http://ovidsp.tx.ovid.com.proxy.kumc.edu:2048/sp-3.5.1a/ovidweb.cgi?QS2=434f4e1a73d37e8c6a

Kylie Palermo, Rick Hill, Kate Wiens, Sarah Jarvis

High Voltage Pulsed Current

High Voltage Pulsed Current (HVPC) can be used for treatment of dermal wounds, edema managment, muscle weakness, and pain management depending on the parameters the machine is set to. HVPC is a twin-peaked, pulsed, direct current. We found it difficult to stick to one specific injury and the effects HVPC has. Therefore, a summary of articles that both support and refute the use of HVPC for some of the reasons listed are presented below.

Articles that Support

Among the uses of HVPC can be edema management. Mendel et al. demonstrates this in Influence of High Voltage Pulsed Current on Edema Formation following Impact Injury in Rats.

This study used four 30-minute treatment sessions of HVPC at 120 pps on rats in order to determine the effect on reducing edema. HVPC was performed on one leg of each rat after both legs were put under trauma. After two treatments, leg measurement was significantly decreased in the treated leg as compared to the untreated leg (p=0.0057). Thus, this article shows that HVPC can be used to decrease edema.  

HVPC is the "gold standard" stimulation modality for wound healing.  A study in Cairo, Egypt by Ahmed studied the effect of HVPC on chronic pressure ulcers and the optimal duration for enhancing healing.  This study included sixty participants suffering from chronic pressure ulcers, monitored for a treatment period of five weeks.  Participants were divided into four equal groups.  Each group received HVPC seven days a week for a different amount of time, and one group served as the control, receiving sham HVPC.  The wound surface area was measured at initial treatment, three weeks, and five weeks, and served as the dependent variable.  The independent variable was varied HVPC treatment times.  Wound surface area decreased in the 60 minute and 120 minute groups, seven days a week.  These two groups proved to be the optimal duration for enhancing healing of chronic pressure ulcers.

Again, HVPC is recognized as a "gold standard" stimulation modality for wound healing.  A study published in the Journal of the American Physical Therapy Association looked at the effectiveness and efficiency of HVPC for treating and healing pressure ulcers in patients with spinal cord injury.  Seventeen patients were included in the study.  They were divided into a placebo HVPC group or a group that received HVPC.  The treatment lasted 20 days for one hour each day.  This study as well as the one above, measured wound surface area to see if the treatment of HVPC was helping with pressure ulcers.  Pressure ulcers on the spinal cord patients were measured at initial treatment, 5, 10, 15, and 20 days after the start of treatment.  There was a reduction in the size of the pressure ulcers after treatment from the HVPC group compared to the placebo, meaning HVPC is a good choice as a modality treatment among patients with pressure ulcers that suffer from spinal cord injury.  

Articles that Refute

High voltage pulsed current can be used for several purposes, but Butterfield et al. found that it does not provide a significant effect for helping delayed-onset muscle soreness (DOMS). This article examined the effects HVPC has on pain, ROM loss, and strength loss due to the DOMS. The randomized control trial tested 28 college students in which there was a control group that received sham treatments where they believed they were being given a nonsensory treatment and an experimental group that received 3 30-minute treatments of HVPC at 125 pps over 48 hours. The DOMS was induced by having the subjects perform concentric and eccentric knee extension exercises with their right leg. Subjects were not allowed to use any other form of treatment such as ice, massage, or pain medications. Pain was less during the HVPC treatment but did not have a significant affect 24 to 72 hours post-exercise (p=0.67). There was also no significant decrease in loss of ROM as compared to the control group (p=0.38) or decrease in loss of strength (p=0.25).

In the article by Michlovitz, Smith, and Watkins, the researchers wanted to compare ice versus ice and high voltage pulsed stimulation (HVPS) for the treatment of ankle sprains (Michlovitz, Smith, & Watkins, 1988).  There were 30 subjects used in this study all of which had either grade I or grade II ankle sprains.  All 30 subjects were given treatment within 30 hours of their injury and were treated once daily for 3 days.  The subjects were randomly assigned and separated into 3 groups of 10, group 1’s treatment only consisted of 30 minutes of ice, group 2’s treatment consisted of ice and HVPS (28 pps, negative polarity, current to comfort without contraction,) and group 3’s treatment consisted of ice and HVPS (80 pps, negative polarity, 30 minutes.)  The results of this experiment found that there was no significant difference between the duration of injury between the groups and that there were no significant differences between the groups in volumetric or ROM measures.  Overall this study concluded that there were no significant differences between treatment effects among groups sprains (Michlovitz, Smith, & Watkins, 1988).

In the study by Mendel, Dolan, Fish, Marzo, and Wilding, the researchers investigated whether the use of subsensory High-Voltage Pulsed Current (HVPC) applied almost continuously for 3 days immediately after a lateral ankle sprain decreased the time lost to the injury (Mendel, Dolan, Fish, Marzo, & Wilding, 2010).  This study was a multicenter, randomized, double-blind, placebo-controlled trial that collected data from 9 colleges and 1 professional training site.  There were 50 subjects in this study and they were randomly given HVPC or the placebo in addition to traditional acute/subacute care.  This study found that there was no difference between the 2 groups in regards to the time lost to injury and it was actually found that in the subjects that had grade I ankle sprains the treatment group that was being administered the live HVPC actually lost more time to injury than did the placebo group.  The conclusion of the study was that the use of subsensory HVPC does not decrease the time lost to injury in regards to lateral ankle sprain injuries (Mendel, Dolan, Fish, Marzo, & Wilding, 2010).

Sources

Ahmad, E.T., "High Voltage Pulsed Galvanic Stimulation: Effect of Treatment Duration on Healing of Chronic Pressure."  Faculty of Physical Therapy, Cairo University, Cairo, Egypt. (2008): Vol. XXI-n.3. <http://www.ncbi.nlm.gov/pmc/articles/PMC3188162/pdf/Ann-Burns-and-Fire-Disasters-21-124.pdf> 

Butterfield, David L., David O. Draper, Mark D. Ricard, J. W. Myrer, Earlene Durrant, and Shane S. Schulthies. "The Effects of High-Volt Pulsed Current Electrical Stimulation on Delayed-Onset Muscle Soreness." Journal of Athletic Training 32.1 (1997): 15-20. PubMed. NCBI. Web. 04 Mar. 2012. <http://www.ncbi.nlm.nih.gov.proxy.kumc.edu:2048/pubmed/16558426>.

Griffin, Judy W., Tooms, R., Mendius, R., Clifft, J., Zwaag, V., El-Zeky, F.  "Efficacy of High Voltage Pulsed Current for Healing of Pressure Ulcers in Patients with Spinal Cord Injury."  Journal of the American Physical Therapy Association (1991): 71:433-422.   <http://ptjournal.apta.org/content/71/6/433.long>   

Mendel, Frank C., Juli A. Wylegala, and Dale R. Fish. "Influence of High Voltage Pulsed Current on Edema Formation following Impact Injury in Rats." Physical Therapy 72 (1992): 668-73. PubMed. Web. 4 Mar. 2012. <http://www.ncbi.nlm.nih.gov.proxy.kumc.edu:2048/pubmed/1508974>.

Mendel, F. C., Dolan, M. G., Fish, D. R., Marzo, J., & Wilding, G. E. (2010). Effect of high-voltage pulsed current on recovery after grades I and II lateral ankle sprains. Journal of sport rehabilitation, 19(4), 399-410. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/21116009

Michlovitz, S. L., Smith, W., & Watkins, M. (1988). Ice and high voltage pulsed stimulation in treatment of acute lateral ankle sprains*. The Journal of orthopaedic and sports physical therapy, 9(9), 301-4. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/18796993

-Brittany Brown, Lauren Mulsow, Zac Snow, Andrew Towell

Iontophoresis

Iontophoresis is commonly used in physical therapy practice as an alternative to oral or injection methods of drug delivery. Electrostatic repulsion is the driving force behind this modality. Common indications for iontophoresis are pain, inflammation, edema, calcium deposits, and hyperhidrosis. Generally, results should be achieved within 4-5 treatments and there must be at least 24-48 hour separation between each treatment.

Article for Ionophorsis

The study by Melson.,et al. (2011) examined the effectiveness of dexamethasone iontophoresis for temporomandibular joint involvement in juvenile idiopathic arthritis. There were twenty-eight patients used in this study between the ages of two and twenty-one years old. They received dexamethasone iontophoresis for the temporomandibular joint an average of eight sessions. This type of iontophoresis used low-grade electric currents to deliver dexamethasone into the temporomandibular joint. One TMJ measurement (in mm) examined was the maximal interincisal opening (MIO) which is the distance between the upper and lower incisor during full mouth opening with head in neutral. The other measurement (in mm) was the maximum lateral excursion (MLE) which is the horizontal distance measured between the upper and lower central incisors with movement of the mandible to the left or right side. Both measurements used the TheraBite range of motion scale and were measured before and after treatment.

 After accessing the patient’s records, 28 of the patients had serial MIO measures and only 16 of the 28 had serial MLE measurements. The median increase in MIO measurement was 4.5 mm and 2.25 mm for the MLE measurement. There were 19 of the 28 patients (68%) that saw an increase in their MIO measurement, and there were 11 of the 16 patients (69%) that saw in increase in their MLE measurement. Also, 15 of the 28 patients reported that they had pain in their TMJ joint when they were chewing or they were at rest, which was resolved in 11 of the patients with the use of dexamethasone iontophoresis. There were 1/3 of the 28 patients that saw no improvements. Overall, the article shows that dexamethasone iontophoresis is effective for treating temporomandibular joint limitations in juvenile arthritis patients.

In the study Physical Therapist Management of an Adult with Osteochondritis Dissecans of the Knee by Michael P Johnson, interventions for OCD were evaluated and followed up nine months after the treatment. The patient was a twenty-four year old female who was diagnosed using MRI. During therapy, she was educated on minimizing loading across the knee, performed strengthening exercises, and received iontophoresis. Iontophoresis was applied to anteromedial condyle of the femur using 4mg/mL solution of DEX-P. After five treatment sessions, the patient reported 0/10 knee pain and only reported slight pain with palpation. At the nine month follow-up, the patient reportedly had 95% of prior knee function and no pain during daily activities or palpation.

In a study by Sreerekha et al, the use of dexamethasone to suppress the histamine-induced wheal was examined. They compared dexamethasone delivered by iontophoresis and without iontophoresis (topical).  Twenty volunteers were used. Each volunteer had a dexamethasone soaked gauze piece placed on each forearm, one connected to the iontophoretic machine and one not. Electric current was delivered for 15 minutes with amperage according to patient tolerance. Prick testing was done with histamine solution at the end of 30 minutes, 1 hour, and 2 hours. The wheal diameter on the arm that used iontophoresis was lower and statistically different than the other at the end of 30 minutes. At the end of 1 and 2 hours there was no statistically significant difference in wheal suppression. This study found iontophoresis to be more effective in suppressing the histamine wheal at the end of 30 minutes, but the effect decreases at the end of 1 hour. It was also concluded that dexamethasone administered using iontophoresis is more effective than dexamethasone without iontophoresis.
 

Article Against Iontophoresis

 In a study by Cleland., et al. (2009) the effectiveness of manual therapy and exercise was compared to the effectiveness of electrophysical agents and exercise for the management of plantar heel pain. There were 54 subjects in this study between the ages of 18 and 60 that had a primary complaint of plantar heel pain. There were six therapists involved in this study that received standardized training by one of the investigators. Each patient was seen a total of 6 times over a period of 4 weeks. The patients were divided into two groups (27 people in each): manual physical therapy and exercise (MTEX) and electrophysical agents and exercise (EPAX). The MTEX group received 5 minutes of aggressive soft tissue mobilizations that were directed at the triceps surae, insertion of plantar fascia, and rearfoot eversion. They also received impairment based physical therapy for hip, knee, ankle, and foot. They also were given a home exercise program that included gastroc and soleus stretches. The EPAX group received ultrasound for five minutes followed by iontophoresis with dexamethasone. They then were given stretches for the gastroc, plantar fascia, and soleus along with intrinsic foot strengthening exercises. 

The results were measured using the LEFS (lower extremity functional scale), the FAAM (the foot and ankle ability measure), and the NPRS (the numeric pain rating scale). The patients were examined at baseline, 4 weeks, and 6 months. For the LEFS and FAAM tests the MTEX group had better measures than the EPAX group at both the 4 week and 6 month follow up appointments. Also The MTEX groups had a much larger NPRS improvement than the EPAX group at the 4 week follow up appointment, but by 6 weeks there as not a significant difference between the groups. The results show that MTEX is a better choice than EPAX for the management of plantar heel pain. This means that ultrasound and dexamethasone iontophoresis with exercise are not the most effective choice when compared to manual therapy and exercise.

Amirjani et al conducted a study evaluating the effectiveness of dexamethasone iontophoresis as a noninvasive method of treating carpal tunnel syndrome. Subjects in the treatment group received 0.4% dexamethasone sodium phosphate dissolved in distilled water, whereas the placebo group received distilled water. The delivery electrode was placed directly over the carpal tunnel, and each patient received 6 treatments (on alternate days over a 2-week period) of a dose of 80 mA/min at a rate of 2 mA/min. Baseline measures were repeated at monthly intervals after treatment for a total of 6 months. Most of the outcome measures were not shown to have any significant change after treatment. This study found that although iontophoresis of 0.4% dexamethasone is well-tolerated by patients, it was not effective in the treatment of moderate carpal tunnel syndrome.

In a study A systematic review and meta-analysis of clinical trials on physical interventions for lateral epicondylalgia by Bisset L, Paungmali A, Vicenzino B, and Beller E, the effectiveness of treatment for lateral epicondylagia was evaluated. Twenty eight randomized controlled trials met the minimum criteria for meta-analysis. Iontophoresis was evaluated using a control group receiving saline and the experimental group receiving a corticosteroid solution. After one to three months of treatment, significant results were not found in the experimental group.

Chelsea K., Kelci M., Shannon L.

References

Mina, R., Melson, P., Powell, S., Rao, M., Hinze, C., Passo, M., et al. (2011). Effectiveness of Dexamethasone Iontophoresis for Temporomandibular Joint Involvement in Juvenile Idiopathic Arthritis. Arthritis Care & Research, 63(11), 1511-1516. doi:10.1002/acr.20600 

Cleland, J., Abbot, J., Kidd, M., Stockwell, S., Cheney, S., Gerrard, D., et all. (2009) Manual Physical Therapy and Exercise Versus Electrophysical Agents and Exercise in the Management of Plantar Heel Pain: A Multicenter Randomized Clinical Trial. Physical Therapy, 39(8), 573-585. doi:10.2519/jospt.2009.3036

Amirjani, N., Ashworth, N. L., Watt, M. J., Gordon, T., & Chan, K. M. (2009). Corticosteroid iontophoresis to treat carpal tunnel syndrome: a double-blind randomized controlled trial. Muscle & nerve, 39(5), 627-33. doi:10.1002/mus.21300 

Sreerekha, Rai R, Shanmuga SV, Karthick, Prabhu S, Srinivas CR, Mathew AC. Study of histamine wheal suppression by dexamethasone with and without iontophoresis. Indian J Dermatol Venereol Leprol 2006;72:283-5 

Johnson, Michael P. "Physical Therapist Management of an Adult With Osteochondritis Dissecans of the Knee." Journal of the American Physical Therapy Association 85.7 (2005): 665-75. Physical Therapy. Web. 05 Mar. 2012. <http://ptjournal.apta.org/content/85/7/665.long>.

Bisset, L., Paungmali, A., Vicenzino, B., & Beller, E. (2005). A systematic review and meta-analysis of clinical trials on physical interventions for lateral epicondylalgia. British Journal of Sports Medicine, 39(7), 411-422. doi: 10.1136/bjsm.2004.016170