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Robert P. Nirschl, MD Dennis
M. Rodin, MD
Derek H. Ochiai, MD Craig
Maartmann-Moe MPT ABSTRACT Medial and lateral epicondylitis is
a common disorder affecting 4-7 per 1000 general practice patients seen.
The duration averages 6 months to 2 years, affects men more than
women, affects the dominant arm more, and usually occurs when persons with
compromised fitness begin an activity that requires repetitive motion.
Inflammation and eventually tissue degeneration, scarring and
tendinosis occur, requiring common treatments of NSAID’s, ultrasound,
phonophoresis, electrical stimulation, heat, and cold.
Injections may be used, but have adverse affects including tendon
rupture, nerve injury, joint degeneration, skin atrophy, pigment changes,
and chemical neuritis. Iontophoresis
is a treatment that permits transmission of the drug dexamethasone sodium
phosphate (dex) into the tissues. This study used two groups of
randomly chosen individuals with less than 3 months duration of either
medial or lateral epicondylitis. The
patients did not have any recent injections, were not on any NSAID
therapy, not auto or worker’s compensation claims, were not receiving
any other form of treatment, and were divided into two groups.
One group, N+99 received a total of 6 iontophoresis treatments with
4mg/ml dexamethasone sodium phosphate with a dosage of 40 mA-min. The
second group, N=100, received only a placebo treatment, with the same
IOMED electrodes and stimulator. After 6 treatments, patients had a
2-day follow up for examination, and at 30 days had a phone call
follow-up. Results show that
there was a significant reduction in VAS pain scores for the dex group
compared to the placebo group. In
addition, the dex group had significant improvement for investigators
evaluation of global improvement, patient’s self-assessed global
improvement, overall symptom improvement, and patient improvement for all
3 primary efficacy variables tested.
In addition, the data showed that those patients who received all 6
treatments within 10 days had improved outcomes compared to those who took
more than 10 days. There
were no significant differences between the groups when phone tested at
the one-month point. Adverse affects included some
blistering, complaints of pain, atopic dermatitis, pruritis, and skin
irritation. The placebo group
also had a list of soft tissue and skin side effects.
The authors believe that the use of dexamethasone iontophoresis is
a valid method to reduce pain, perhaps improving the likelihood of the
patient undergoing a therapy program that would incorporate exercise and
other treatments. COMMENTS It is nice to see another article
dealing with a treatment modality that I use quite often.
There have been numerous times that a patient begins reporting
improvement when we began the iontophoresis.
Placebo or psychosomatic? Perhaps.
There were still some hefty numbers of patients in this study
receiving only a placebo who still reported improvement in their pain and
improvement in their global function.
There may also be the chance, which was not discussed in this
article that the electrical current itself is assisting in the process.
The authors feel that the month time between the 2 day follow-up
and the one month follow-up may have given some the chance to use other
treatments or medications, which could have adversely affected the longer
term results. I am not sure why so many PT’s do
not use this treatment. It is
easy, relatively inexpensive, and has shown such promise. As I have mentioned before, I have even had luck at reducing
the size of heterotropic ossification via acetic acid iontophoresis, and
have always had good luck with the steroid version as well.
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