Iontophoresis Protocol:
Carpel Tunnel Sydrome
ETIOLOGY
The carpal tunnel lies deep to the palmaris longus muscle
and is bordered: anteriorly by the transverse carpal liga-
ment; medially by the pisiform and hook of hamate; later-
ally by the tubercle of scaphoid and the tubercle of trape-
zium; and posteriorly by the carpals. The median nerve
and finger flexor tendons pass through this tunnel.
Overuse of the finger flexors, repeated trauma, sprains, or
swelling can cause compression of the median nerve,
resulting in decreased median nerve sensation in the hand,
restriction or possible prevention of finger flexion.
Diagnosis and confirmation of CTS is based on:
1) Numbness, pain or paresthesia of hand and wrist along
median nerve distribution, nocturnal awakening from
hand pain and aggravation of symptoms with repetitive
hand/wrist motion. Weakness may occur in the abductor
pollicis brevis muscle with thenar atrophy.
2) Positive Tinel's sign (tapping over the volar tunnel lig-
ament and reproducing pain along the median nerve dis-
tribution) and/or positive Phalen's test (passively flexing
the wrist to its maximum degree for one minute causing
tingling along the median nerve distribution).
3) Electrodiagnostic studies showing abnormal motor or
sensory median nerve distal latencies.
Drug
Electrode
Site
Transverse
Finger
Carpal
Flexor
Ligament
Tendons
2
PATIENT EVALUATION
A. Subjective:
Patient complaint
Location
Onset and duration of symptoms (usually early,
mild to moderate CTS responds better to treat-
ment; late, severe CTS tends not to respond well
due to tissue damage)
Description of symptoms (i.e. numbness, pain
[constant, dull, sharp] hypersensitivity, stiffness);
use pain scale
Pattern of when symptoms occur (AM, PM, after
activity, etc.)
Self-help or other formal treatment
Other medical problems
Concurrent medications and allergies
B. Objective (also compare with uninvolved wrist):
1. Inspection:
Posturing
Atrophy
2. Palpation:
Carpal bones
Soft tissue: muscles and tendons (anteriorly,
medially, posteriorly, laterally), palmaris
longus
3. Mobility (Active and Passive)
Wrist ROM (flexion, extension, radial devia-
tion, ulnar deviation, supination, pronation)
Finger ROM (flexion, extension, abduction,
adduction)
Thumb ROM (flexion, extension, palmar
abduction, palmar adduction, opposition)
4. Muscle Tests:
Wrist (flexors, extensors, ulnar deviators,
radial deviators)
Finger (flexors, extensors)
Thumb (abduction, adduction, flexion,
extension, opposition)
5. Provocation Tests:
Reproducing pain or paresthesia along median
nerve distribution into the hand:
- Tinel sign: tap volar carpal ligament with
palm open, fingers extended.
- Phalen's test: passively flex both wrists in
maximum flexion for one (1) minute.
6. Neurological Tests:
Sensory and conduction tests of the median
nerve.
(Objective continued)
7. Other Joints:
Assess elbow and shoulder for concurrent
disorders
8. Review x-rays and physician's report; rule out:
Colles fracture and anterior dislocation of the
lunate
Systemic disease
C. Assessment:
1. Problem list
2. Goals
3. Recommended Treatment:
Iontophoresis ( medications, dosages,
electrode size)
Rest and wrist splint in neutral position
Oral or injectable medications administered by
physician (e.g. NSAIDs, corticosteroids)
Patient education on work activities or sports
for prevention of re-injury, etc.)
D. Plan:
1. Frequency and duration of treatment
2. Date(s) for assessment of progress
WHY IONTOPHORESIS IS
APPROPRIATE THERAPY
Iontophoretic drug delivery for the condition of mild to
moderate carpal tunnel syndrome provides an alternative
to hypodermic injection of corticosteroids, with increased
comfort and decreased systemic side effects. It allows
short term administration and avoids the associated dis-
comfort of needle insertion at an already tender area of tis-
sue. Avoiding the use of a hypodermic needle prevents
further tissue trauma, eliminates the risk of infection at the
injection site and eliminates the risk of potential necrosis
and/or tendon weakening associated with bolus injections
of corticosteroids. Carpal tunnel syndrome is usually a
very well localized condition, appropriate for electrode
placement over the affected area.
RE-EVALUATION
In addition to the patient's subjective reports, check for
decreased pain, decreased paresthesia, increased strength
of the abductor pollicis brevis muscle, negative Tinel sign
and negative Phalen's test. Neurological tests may be used
to check for improved sensation and conduction of the
median nerve.
Distributed By:
Balego & Associates, Inc.
1-800-322-2781
Fax: 651-633-0024
www.BalegoOnline.com
IOMED, Inc., 1993. Printed in USA. 3/03. All rights reserved.
IONTOPHORESIS PROCEDURE
IMPORTANT: See iontophoresis system and electrode
instruction guides for indications, contraindications, warnings,
precautions and directions for use.
1. Clean skin is absolutely necessary to minimize or elim-
inate skin irritation. Clean both electrode sites vigor-
ously with an alcohol wipe prior to applying electrodes
to remove dry skin, salts and oils. Excess hair may be
trimmed with scissors or electric clippers. Do not
shave skin. Doing so may result in excessive irritation
or burns.
2. Prepare electrodes according to package instructions.
3. Place the drug electrode longitudinally, centered over
the involved carpal tunnel, with wrist crease "divid-
ing" electrode approximately in half.
4. The dispersive pad Dispersive pad may be placed
proximal to drug electrode, over a major muscle on the
forearm. Never tape, bind or compress either electrode
in any way. Properly prepared drug electrodes and dis-
persive pads do not require added fixation on properly
prepared skin.
5. Do not allow patient to extend or flex the wrist or to
press on or lean against electrodes during treatment.
This prevents circuit breaks and minimizes the possi-
bility of excessive skin irritation or burns.
6. Initially, treat at 2.0mA for 20 minutes to deliver a
total dosage of 40 milliampere-minutes according to
package instructions. Increase current for subsequent
treatments if patient tolerates higher current levels
comfortably.
7. Treat every other day. Usually, no more than three
treatments are required, but there is no contraindica-
tion for additional treatments.
REFERENCES
1. Cyriax, J. 1983. Illustrated Manual of Orthopedic
Medicine. Butterworths. London.
2. Hartley, A. 1990. Practical Joint Assessment. Mosby Year
Book. St. Louis.
3. Hoppenfeld, S. 1976. Physical Examination of the Spine
and Extremities. Appleton-Century-Crofts. New York.
4. Saunders, H.D. 1985. Evaluation, Treatment & Prevention
of Musculoskeletal Disorders. W.B. Saunders. Minneapolis.
5. Warwick, R. and Williams, P. 1983. Gray's Anatomy, 35th
British Ed. W.B. Saunders. Philadelphia
Edited By: For:
Rebecca Stephenson, PT IOMED, Inc.
Stephenson Physical Therapy 2441 South 3850 West, Suite A
335 Main Street Salt Lake City, Utah 84120 USA
Medfield, MA 02052 Ph. 800.621.3347 Fax 800.318.7793