Andy Mancuso Therapeutic Modalities Literature Review 12-04-08

A Comparative Study of Iontophoresis vs. Phonophoresis:

I.

Introduction Have you ever been hurt or injured? Chances are that most individuals answer this

question with a yes. Health care is a growing profession that encompasses not only sports injuries but also injuries or pathologies suffered during activities of daily living. There are several different ways in which health care providers can choose to treat these various pathologies and conditions 1(p. 30). Some providers use methods of delivering drugs to patients via the skin. By nature, the skin gives a barrier to outside materials that limits the delivery of the drugs through the skin into deeper tissues. Regardless of this fact, the skin does have permeability, which enables the transfer of drugs to take place 2(p. 1). This facilitation of drugs through the skin is an important area of research specifically for pharmaceutical companies. If pharmaceutical companies can discover ways to create optimal penetration, they can achieve optimal results of their products 3(p.
129)

. Iontophoresis is a technique used to enhance drug delivery topically through the skin that

involves the application of an electric current 4(p. 1). Another technique commonly used to increase penetration of a substance through the skin is called phonophoresis. Phonophoresis involves the application of ultrasound to an area to achieve therapeutic gains 3(p. 129). Both of these techniques are used clinically and have had research conducted on each. The field of modern health care is moving in a new direction. Evidence-based research is providing information on what works and how it works best 5(p. 190). II. Iontophoresis

Iontophoresis is a technique used to penetrate the skin directly. This technique involves using an electrical current to transfer the substance. Iontophoresis has been used for a long period of time to treat inflammation in soft tissues 1(p.30). In addition to enhancing penetration of drugs, iontophoresis delivers the drugs in a high concentration to the area without having systemic side effects 6(p. 22-23). The science of what physiologically happens during iontophoresis is based on a simple quote likes attract, and opposites repel. Iontophoresis uses a low level electrical current to repel a drug through the skin 7(p. 18). Depending on the charge of the substance iontophoresis is set to the same charge. That is, a cathode, which is a negatively charged electrode, is used on negatively charged substances or drugs. Likewise, an anode, positively charged electrode, is used on positively charged substances 8(p. 1663). The electrodes charge and the substances charge create an electrical field, which breaks down the stratum corneum of the skin. The exact cause of this breakdown is still unknown according to a study printed in the International Journal of Pharmaceutics 4(p. 3). The substance is reported to penetrate the skin mainly via existing openings. These openings include hair follicles and sweat glands 9(p. 463). However, an early study also showed changes to the skin in which patterns developed. The patterns that occurred due to exposure to iontophoresis showed new pores, which could be, used as new pathways for the delivery of the drug 4(p. 4). Like with many things in medicine, various parameters, environments, and slightest change can have a significant effect on the results. Iontophoresis is no exception. A major adjustment would be the type of current delivered. A research study conducted at the Department of Medicine at the University of Texas Health Science Center reported that alternating current is a better current to use than a constant electrical current. The study showed

that the delivery of the drug increased with treatment time. A constant current puts the patient at a much higher risk of being burned then an alternating current does. In addition, the study reported that alternating current iontophoresis did in fact deliver the drug. Other factors that affect speed and productivity of delivery are molecular weight, electrode type, ion effect current intensity, pH of the system, and the amount of the drug being delivered 8(p.463), 10(p. 177). III. Phonophoresis Phonophoresis as a treatment dates all the way back to 1954. Since then is has become a common treatment used in the medical field 11(p. 46). Phonophoresis is based on ultrasonic energy being used to enhance delivery of drugs through the skin 10(p. 182). Primarily, phonophoresis is used in the treatment of inflammatory conditions 8(p. 1662). In an article published in Physical Therapy, more than fifty percent of physical therapists reported that they would use phonophoresis for soft tissue inflammation 12(p. 992). Like iontophoresis, studies have shown that phonophoresis also produces high concentrations of the drugs in localized areas while maintaining low or minimal systemic effects 13(p. 708-710). Phonophoresis achieves higher concentrations of substances in areas through ultrasound. Ultrasound is believed to allow penetration to tissue by heating, radiation pressure, cavitation and acoustic microstreaming. Each of these four potential mechanisms contributes in drug delivery in a specific way 3(p. 132). Heating causes increased fluidity, which increases permeability. Radiation pressure enlarges cellular space. Cavitation and microstreaming drive the drugs through the skin. The overall result of each mechanism is increased skin permeability
2(p. 7)

Similar to iontophoresis, the results of phonophoresis can be dramatically influenced by changes in parameters of treatment. Changing the type of wave being administered can cause significant differences in results. A research report conducted comparing phonophoresis verses topical application of ketoprofen, a medication used for various arthritis and musculoskeletal conditions, provided a great deal of information regarding phonophoresis. The study confirmed that phonophoresis through an alternating current could deliver a high concentration of a substance to a specific area without having systemic effects 13(p. 711). The study also revealed that continuous-wave ultrasound can be harmful and that pulsed-wave ultrasound is the more beneficial technique. Also, the sound head can be more stationary with pulsed-wave because there is low risk of burn. By not moving the sound head, one can achieve more concentrated delivery 13(p. 711). Other parameters including duration of treatment, intensity and frequency all have affects on the delivery of the drug 10(p. 182).
IV. Specific Studies Comparing Phonophoresis and Iontophoresis

A. Effects of naproxen in the treatment of lateral epicondylitis. Clinical Rehabilitation published an article about a study carried out in Turkey in which the objective was to compare the effectiveness of phonophoresis and iontophoresis in the delivery of a drug, naproxen, for the treatment of lateral epicondylitis. Lateral epicondylitis is an inflammatory condition associated with the origin of the wrist extensor muscles, the lateral epicondyle. Naproxen is a non-steroidal anti-inflammatory drug. This study chose a practical condition to compare phonophoresis and iontophoresis, in that they both are mostly used for delivery of anti-inflammatory conditions 14(p.96-100).

This study was conducted on sixty-one patients. The patients were divided randomly into two groups. One group received naproxen phonophoresis (10%) and the other group received naproxen iontophoresis (10%). After they received their treatments, the study conducted methods consistent with a standard physiotherapy program 14(p.96-100). The results of the study were clear. Both application of naproxen gel by phonophoresis and iontophoresis proved to cause improvements. The improvements included lowered pain levels, stronger grip, and higher functional levels. Unfortunately, this study did not show any difference when comparing phonophoresis and iontophoresis to each other. The results simply showed improvement in both but did not show which is more effective for lateral epicondylitis
14(p.96-100)

. B. Effects on pain in cases with shoulder periarthritis

In 2001, The Pain Clinic published a study about the Effects of iontophoresis and phonophoresis methods on pain in cases with shoulder periarthritis. Periarthritis is a chronic inflammatory condition of the shoulder. The study chose to use iodex as the medication to be delivered by both iontophoresis and phonophoresis. Iodex is an anti-inflammatory ointment used to rub externally over an inflamed area 15(p. 1). The study included forty-five patients all of whom were suffering with periarthritis. All of the patients were randomly separated into three groups. The first group received iodex iontophoresis. The second group received iodex phonophoresis. Last, the third group was used as a control group and received the placebo treatment 15(p. 1). Unfortunately, this study focused on whether or not iontophoresis or phonophoresis was effective when being compared to placebo group rather than to being compared to each other.

The results of the study showed that those patients in the iodex iontophoresis and iodex phonophoresis groups reported lower pain assessment when compared to the placebo, control group. Although the study failed to compare iontophoresis to phonophoresis it demonstrated that both are suitable for pain relief as well as reducing inflammation through the application, delivery and enhancement of topical medication 15(p. 1). C. Effects on the treatment of medial tibial stress syndrome Another study was conducted in which the objective was to compare the efficiency of iontophoresis and phonophoresis with diclefenac sodium in medial tibial stress syndrome. Medial tibial stress syndrome is basically a classification of symptoms. Symptoms include muscle pain due to inflammation or possibly a stress fracture among other things. Diclefenac sodium is a non-steroidal anti-inflammatory drug 16(p.17). Twenty-five patients were used in the study. All of the patients were suffering with pain within their anteromedial lower leg. They were randomly divided into two groups. The first group received iontophoresis treatment and the second received phonophoresis treatment. The treatment was given five times a week for two weeks 16 (p.17). The study resulted in similar results to previously conducted studies comparing iontophoresis and phonophoresis. Iontophoresis and phonophoresis both proved to lower pain and decrease inflammation. However, the study revealed slightly better results from iontophoresis compared to phonophoresis. These results were not considered significant in the study. It should also be noted that according to the study iontophoresis seemed to be more effective initially compared to phonophoresis 16(p.17-18). This gives some insight into which modality is better during a particular phase of the healing process.

V. Conclusions A. Generalized comparisons between iontophoresis and phonophoresis Results from the three studies focusing on comparing iontophoresis and phonophoresis in specific cases seemed to be consistent throughout. All three of the studies found both techniques to be beneficial. None of the studies found one to be far more effective than the other. Due to the findings reported from these studies and other research conducted, it can be concluded that both iontophoresis and phonophoresis have an effect in enhancing delivery of medication through the skin 14(p. 96), 15(p. 1), 16(p. 17-18). Although each method is effective, each has advantages and disadvantages associated with them. Iontophoresis has several advantages associated with it. First it allows for localized concentrations of a substance and eliminates systemic effects created when the substance is injected or orally administered 6(p. 22-23). With iontophoresis, the drug is delivered in proportion to the current. This means the amount of the drug delivered can be controlled and regulated by the clinician 4(p. 2). One disadvantage noted with iontophoresis is the risk of being burnt. Many health care providers find the risk of bun with iontophoresis is minimal and is outweighed by the advantages 6(p. 23). Furthermore, to eliminate the risk of burn, alternating current iontophoresis has been shown to decrease the chances of burning a patient. Phonophoresis also has some advantages and disadvantages. Literature supports the claims that phonophoresis does have some effect in increasing penetration of substances through the skin. Studies also show that phonophoresis achieves higher local concentrations without causing systemic effects 11(p. 46). Similar to iontophoresis, phonophoresis can cause burns if the sound wave is continuous rather than pulsed. In addition, phonophoresis has a dose-response

relationship. This means that increasing the intensity increases the amount of the substance transported through the skin 2(p. 13). Literature shows that phonophoresis does in fact deliver substances through the skin to soft tissues. Research also shows that it is unclear exactly how much or how deep the penetration occurs. Phonophoresis is still under question whether or not it is beneficial clinically at the present parameters being used 11(p. 47). A study printed in the International Journal of Pharmaceutics states that these current parameters used for phonophoresis demonstrated absence or mild effects 2(p. 1-2). Research currently suggests that iontophoresis is a more efficient modality than phonophoresis. Research shows mild effects from phonophoresis. Studies also show more efficient initial results from iontophoresis. These statements can be justified by specific studies and by generalized studies that report results from tests and experiments conducted on each modality. B. Future Studies It is clear that more research is needed on iontophoresis and phonophoresis. Medical professionals want to treat their patients in the most effective, practical, and safest ways possible. Due to the lack of research and knowledge in regards to this topic, medical professionals question what they are told about iontophoresis and phonophoresis 5(p. 191). Research should be done to optimize the parameters for phonophoresis specifically due to the fact that it is reported to have moderate increases in permeability 3(p. 146). Although iontophoresis has been clinically used for quiet some time now, more research is still necessary to further our knowledge and understanding of iontophoresis and measuring its effects 5(p. 193).

One article suggested that medical physicists and pharmaceutical scientists particularly work together on research in order to discover the most gains for clinical application of antiinflammatory medication by use of iontophoresis and phonophoresis 3(p. 146). Perhaps more studies need to be done in which iontophoresis and phonophoresis are directly measured in comparison to one and other. If enough of these studies are researched, then it will eliminate questioning which modality should be used and what parameters should the modality be set. By carrying out more studies about iontophoresis and phonophoresis, health care as a field, will have a better knowledge and understanding, leading to better treatment. Health care has moved to evidence-based information and more evidence will only result in more information and better treatment provided for us all 5(p. 190).

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