acetic acid iontophoresis protocol

The transdermal iontophoresis with 4% acetic acid on the negative electrode is placed on the skin over the insertion of the Achilles tendon. He had pain with isometric knee extension, but no pain with resisted hip flexion. Marcos Edgar Fernandez-Cuadros During the second week postinjury, pain was increasingly present on descending stairs. Perron To the best of authors` knowledge, there is no report on the effectiveness of acetic acid iontophoresis and ultrasound on bilateral calcifying tendonitis of Achilles tendons. Rebecca Barbosa de Decco Monteiro Marinho, Introducao: A tendinite calcaria do ombro e uma calcificacao caracterizada pela deposicao de sais de calcio nos tendoes do manguito rotador, provocando dor no ombro e perda de amplitude de movimento, View 4 excerpts, references background and results, By clicking accept or continuing to use the site, you agree to the terms outlined in our. Luz Otilia Casique-Bocanegra After the translation and cultural adaptation, it was obtained a reliable version of SPADI-Brazil and to assess its reliability. Before treatment: pain measured by VAS 5/10, calcification 6.6 mm evaluated by sonography (A) and radiography (C). Therapeutic ultrasound. Rather than impairing our professional growth or denying advancements in care, use of evidence as described in this article represents an objective and mature way to practice. Orthop Rheumatol. D dorsiflexion splints provide relief from the symptoms of recalcitrant plantar fasciitis in the majority of patients, and response to splinting did not correlate with foot type, degree of obesity, or the presence of heel spur on radiographs. CALCIUM DEPOSITS Gulick 2000 35 Acetic acid . . He acknowledges that this study failed to provide evidence of treatment efficacy but fell short of providing evidence of treatment ineffectiveness. doi: 10.19080/oroaj.2016.03.555611. It is the type of judgment call that sets the clinician apart from the technician. If the acetic acid iontophoresis treatment were merely 20% more effective than no treatment or treatment with ultrasound alone, it could take a cohort of as many as 200 patients with the same exact diagnosis to demonstrate that effectiveness. [10] Antao NA. [6] The clinical use of acetic acid iontophoresis in the treatment of patients with calcium deposits was first described in 1955 by Psaki and Carroll [7], and again in 1977 by Kahn. Lidocaine (+): Iontophoresis. I thank Mr Tygiel for his thoughtful comments. Calcific tendinitis within the rotator cuff tendon is a common shoulder disorder that should be differentiated from dystrophic calcification as the pathogenesis and natural history of both is totally. Intervention: Iontophoresis with 5% acetic acid at 4,7mA x 10 minutes and continuous Ultrasound 1W/cm2 /1MHz x 5 minutes over calcification. She was treated with acetic acid iontophoresis and a combination of rehabilitation protocols, ultrasound, athletic taping, custom orthotics and soft tissue therapies with symptom resolution and return to full activities within a period of 6 weeks. Mr Tygiel also overlooked an important finding from that study that I used to guide my clinical decision. Specialty Drugs. As traumatic myositis ossificans is an uncommon pathology, little research has been completed in this area of treatment. 1984;9:460-462. Traumatic myositis ossificans is a reactive osseous lesion occurring in soft tissues and at times close to bone and periosteum. We have always assumed that the size of the calcium deposit must be reduced, and acetic acid iontophoresis offered a chemical (albeit theoretical) method that might accelerate resorption. A hierarchy such as the one proposed by Mr Tygiel is very useful, but only if we have the confidence to accept evidence from higher levels that might contradict the opinions of clinical experts. Fernandez Cuadros M, Perez Moro O, Diez Ramos F, Albaladejo Florin MJ. International Journal of Preventive, Curative & Community Medicine. DL This scant evidence, the only available evidence on which to make a clinical decision, suggests that acetic acid iontophoresis treatment might be helpful. CD 1940;22:315--323. After treatment pain measured by VAS 4/10, calcification 4.3 mm evaluated by sonography (B) and radiography (D). This perpetuates practice decisions made on non-evidence and does so in the name of evidence-based practice. Early in his letter he claims to have heard from several respected colleagues that acetic acid iontophoresis had good results in accelerating the resorption of recalcitrant calcific tendinitis, and he later makes a vague reference to opinions from other (unnamed) authorities. Philadelphia, Pa: FA Davis Co; 1986:160. Drug Metabolism. Described initially by Le Duc in 1908, iontophoresis is based on the principle that an electrical charge will repel a similarly charged ion. Treatment Protocols: Iontophoresis 1. Perron and Malouin, however, suggest that changes in the size of the lesion are not associated closely with functional improvement. Certainly, when the effectiveness of an intervention is demonstrated by a good RCT or even a higher study on the hier-archy, we should do our best to use that intervention. From his search Dr Ciccone was only able to find 2 articles that he felt might provide evidence on the question. Fernandez Cuadros M, Perez Moro O. I cannot understand why these opinions should supercede the findings from Perron and Malouin (a randomized controlled trial that corresponds to level 4 of his hierarchy). What caused the reabsorption of the calcifying myositis ossificans in this patient is unknown. Iontophoresis in conjunction with traditional modalities can shorten treatment time for plantar fasciitis. It should be noted that this is a conclusion based on speculation rather than on evidence. Consider, for example, what would happen if a new medication was developed, but this medication was no more effective in resolving a medical condition than no treatment. She reported no significant return of symptoms post follow-up at 2 months. Principles and Practice of Electrotherapy. Mr Tygiel mentions the small cohort size of the Perron and Malouin study, and I applaud his awareness of issues related to sample size and statistical power. Mr Tygiel also suggests that my clinical decision was not evidence based. Please check for further notifications by email. This was not a case study. 2018;5(2):e62397. The iontophoresis theory states that the negatively charged electrode will repel negatively charged ions through tissue. The purpose of this study was to compare the reduction in cutaneous sensation following two iontophoresis protocols with the same 40 mA*min dosage to a sham treatment. Calcifying tendonitis of the shoulder, risk factors and effectiveness of physical therapy. J Hand Ther. . Case description: A 19 year old male sustained a soft tissue injury to his upper arm while playing hockey. These results represent a 98.9% decrease in the size of the mass. Manual Therapy, Posturology & Rehabilitation Journal, Background: The calcific tendinitis of the shoulder is a dysfunction conservatively treated by shock waves, iontophoresis, and phonophoresis, associated or not with the use of acetic acid. , Malouin F. Rioja Toro Ultrasound guided Injection in Bexleyheath. 1973;55:95--104. If I knowingly provided an ineffective treatment, I would be violating APTA's Code of Ethics and wasting health care resources. , Romo Monje M, Cantalapiedra Puentes E, et al. She was a right-handed housewife, with no important antecedents. After 15 sessions of 5% acetic acid iontophoresis (2 mL, 4.7 mA 10 minutes) and continuous ultrasound (1 W/cm2,1 MHz 5 minutes) over the calcification area, pain decreased from 9/10 to 4/10 (left tendon) and from 5/10 to 0/10 (right tendon) on visual analogical scale (VAS). doi: 10.5812/mejrh.62397. [2] Huss CD. Creative Commons Attribution Non Commercial 4.0 International License. Authors Roger Lee Kilfoil Jr 1 , Garry Shtofmakher 1 , Gregory Taylor 2 , Jessica Botvinick 2 Affiliations 1 New York College of Podiatric . It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide, This PDF is available to Subscribers Only. 1966;6:724--738. Khan WS, et al. Perron and Malouin reported a reduction in size and density of calcium deposits in both the untreated control group and the group treated with a regimen of acetic acid iontophoresis and ultrasound. Moreover, Mr Tygiel maintains that there is a big difference between those studies that fail to provide evidence of efficacy and those that provide evidence of ineffectiveness. The patient regained full knee ROM of 149 degrees and was able to resume playing soccer pain-free. He had no pain with any activities of daily living including running and descending stairs. Regards,Ultrasound guided Injection in Bexleyheath, I am reading your post from the beginning, it was so interesting to read & I feel thanks to you for posting such a good blog, keep updates regularly.Regards,Frozen Shoulder Injection in Bexleyheath. It looked at 34 patients who were treated with acetic acid iontophoresis and ultrasound and found that, in all those patients, the calcification size was modified and pain was reduced. Crossref. He suggests the use of such a hierarchy based on some common study designs. Ruben Algarra-Lopez However, there are controversial results on CT, and limited case reports on effectiveness in other tendons such as gluteus medium and minimum and Achilles tendons (5). Middle East J Rehabil Health. Bilateral Calcification of Achilles Tendons, and Acetic Acid Iontophoresis Marcos Edgar Fernandez-Cuadros: [13] Ziskin MC, Michlovitz SL. HiDoes anyone know where in LA I can get Iontophoresis with acetic acid treatment for myositis ossificans? Summary and Conclusions For full access to this pdf, sign in to an existing account, or purchase an annual subscription. 1997 73. We must continually reexamine long-held beliefs and opinions when higher levels of evidence suggest that these beliefs might not be true. Iontophoresis is the introduction of topically applied, physiologically active ions through the epidermis using continuous direct current. 1984;9:460--462. The physician hypothesized that the small anterior superior iliac spine contusion may have bled into the lateral thigh musculature, therefore contributing to the formation of the myositis ossificans. Additional research, including single-subject designs, should be implemented to document the efficacy of this procedure. Based on the Perron and Malouin study, he decided not to include acetic acid iontophoresis in the plan of care for his patient. Evidence-based practice does not mean that clinicians can use only those treatment procedures that have been proven effective in RCTs or higher rated studies. Case Report Additional treatment consisted of mild treatment consisted of mild passive-range-of-motion (PROM) movements within pain-free limits for 5 minutes three times a week. Essentially, the study on which Dr Ciccone based his clinical decision provided no evidence. The integration of acetic acid iontophoresis orthotic therapy. O S, Albaladejo-Florin Both electrode sites were thoroughly cleansed with an isopropyl alcohol wipe, and the active (negative) drug electrode was placed over the site of ossification. Vitamins and Minerals Medicines. Objective: To check the effects of phonophoresis with acetic acid in the treatment of calcific tendinitis of the shoulder in resorption stage. This article describes a physical therapy intervention that I have not used yet; but I have heard, from several colleagues whom I respect, that this intervention had good results when other interventions had failed. Protocol for Neurophysiological Studies of the Superior and Recurrent Laryngeal Nerves and of the Cricothyroid and Thyroarytenoid Muscles . Thermal Agents in Rehabilitation. Myositis ossificans seems to be a self-limiting disease. Tygiel Physical Therapy 6606 E Carondelet Dr Tucson, AZ 85710. The patient was then referred back to his physician with a suggestion that the physician investigate the possibility of myositis ossificans. I disagree. Acetic acid iontophoresis for the treatment of insertional Achilles tendonitis BMJ Case Rep. 2014 Jul 23;2014:bcr2014206232. [6] Cummings J. Iontophoresis. If the patient didn't get better, however, the patient might have been denied a beneficial intervention because of Dr Ciccone's failure to recognize and properly use what little evidence there was. Calcifying tendonitis (CT) is defined as the deposition of hydroxyapatite within tendons. , * I recognize that this is difficult because of the paucity of good studies, particularly in orthopedics and physical medicine. Radiographs, repeated 1 week post treatment and 9 weeks since his initial. It follows for acetic acid: acetic acid [g/L] 6300 x 1.0 x 0.10 acetic acid [g/L] If the sample has been diluted during preparation, the result must be multiplied by the dilution factor, F. When analysing solid and semi-solid samples which are weighed out for sample preparation, the content (g/100 g) is calculated from the amount weighed as . The patient was instructed to avoid any painful activity including stair climbing. 1 In addition, an anti-inflammatory agent may be prescribed. Password. Occup Med Health Aff. M J, Casique-Bocanegra J Urol. GR DL [8] Middle East J Rehabil Health Stud. It is true that I did not retrieve any of these types of studies, presumably because they do not yet exist. A program of non-weight-bearing stretching exercises specific to the plantar fascia is superior to the standard program of weight-bearing Achilles tendon-stretching exercises for the treatment of symptoms of proximal plantar fasciitis. [12,13] Properly controlled studies are necessary to determine the efficacy of the individual entities of the treatment program chosen. Synthetic steroidal anti-inflammatory agent. I cannot understand, however, how Mr Tygiel can state categorically that as many as 200 subjects would be needed to find a specific effect (a 20% improvement) without also taking into account all the factors that influence the statistical power of these results. NSAIDs did not alleviate pain. Calcifying tendonitis of the shoulder, risk factors and effectiveness of acetic acid iontophoresis and ultrasound. Myositis of the hip in a professional soccer player. With no control group, it was of course difficult to definitely attribute the outcome to the treatment. There is a big difference between the two. Fluid, Electrolyte, and Acid-base Balance. Further studies are needed to support the use of acetic acid iontophoresis for both treatment and possible use as prevention once initial trauma has occurred. New York, NY: Churchill Livingstone Inc; 1987;165. Due to failure, she also went through bilateral shock wave therapy, but no alleviation was observed on pain or the calcification. chronic plantar fasciitis. At the shoulder, Supraspinatus tendon was the most affected (91.5%; n = 65) followed by Subscapularis (8.5%; n = 9). Finally, Mr Tygiel expressed his disappointment that the Journal would publish this Evidence in Practice article as an example of evidence-based practice. Advanced treatment includes shock-waves, eco-guided aspiration, and arthroscopy (1-3). I agree with Mr Tygiel that evidence-based practice should be based on a hierarchy of evidence. I really appreciate it! [. The outcome measures were found to be suitable for subjects with plantar fasciitis and the methodology appropriate for the research design chosen and the feasibility of a clinical trial comparing the effects of transverse friction massage and a home exercise programme and a HEP alone was demonstrated. Because using no treatment was just as effective as using the intervention, I must interpret these results as providing evidence that the treatment did not work and was therefore ineffective. Your comment will be reviewed and published at the journal's discretion. This article reviews plantar fasciitis, presents the most effective treatment options currently available, and proposes nutritional considerations that may be beneficial in the management of this condition. Subsequently, continuous Ultrasound with an intensity of 1 W/cm2 and 1 MHz frequency was applied for 5 minutes at the insertion of the Achilles tendon on the affected ankle. There was no history of prior injury or illness. [4,5] Physicial therapy protocols for this pathology have been argued in the literature. Philip Paul Tygiel, PT, MTC, On Does acetic acid iontophoresis accelerate the resorption of calcium deposits in calcific tendinitis of the shoulder?, Physical Therapy, Volume 83, Issue 7, 1 July 2003, Pages 667670, https://doi.org/10.1093/ptj/83.7.667, I looked forward to reading the Evidence in Practice article by Charles D Ciccone, which asked the question Does acetic acid iontophoresis accelerate the resorption of calcium deposits in calcific tendinitis of the shoulder?1. This review provides a detailed account of mechanisms, current status and future prospects of ultrasonic cavitation in drug and gene delivery applications. Drug Metabolism. Female 70% (n = 64). For the best clinical results at 4 weeks, taping combined with acetic acid is the preferred treatment option compared with taping combined with DEX or saline iontophoresis. CT could affect different tendons, as the rotator cuff, Achilles, patella, forearm extensors, biceps brachi, and tibialis posterior tendons. As we have indicated many times in the past, these articles are intended to illustrate the search process rather than establish best practice or serve as clinical guidelines. Because recurrent injury resulting in additional bleeding often is a precursor to the myositis ossificans formation, [10] additional damage to tissues and resultant bleeding may occur from invasive injection by a syringe and needle. 12 June 2013. I found one RCT that provided evidence that this intervention has the same effect as no treatment. Immobilization is usually continued until all pain has disappeared, at which time range-of-motion maneuvers and strenthening exercises are slowly initiated. We really don't know. Results: Mean age 55.0811.62 years (n = 91). The physician ordered anterior-posterior and lateral radiographs of the right femur, which revealed a maturing myositis ossificans located in the region of the vastus lateralis musculature (Fig. In the situation described in my article, however, we do not have absence of evidence. Clinical orthopaedics and related research. No signs of redness or streaking around the mass were found, and the patient had a normal body temperature. Calcific tendinitis of the shoulder is a self-limiting calcification of the rotator cuff that is most common among people between 30 and 60 years of age and women are slightly more likely to be affected than men, and workers in sedentary jobs appear to be at higher risk than those in manual work. I chose to exclude acetic acid iontophoresis because there is no evidence to suggest that adding this intervention would provide additional benefits for my patient. He was treated with iontophoresis for 3 visits per week for 5 weeks. I havent any word to appreciate this post..Really i am impressed from this post.the person who create this post it was a great human..thanks for shared this with us.Go to brand website, Your story is really hurtful, anyway it's a good help for others about Frozen Shoulder Injection side effects and bad experience.RegardsRegardsFrozen Shoulder Injection, Thanks for the post. Iontophoresis , Erdogmus CB, Resch KL, et al. The problem is how to prepare 5% acetic acid solution. Bone Joint Surg [Am]. 1). Diagnostic Agents. The information of acetic acid iontophoresis protocol is constantly complemented and updated on echemi.com. The positive electrode is placed on the lateral leg. She reported no significant return of symptoms post follow-up at 2 months. The current case report confirmed that 5% acetic acid iontophoresis plus ultrasound was safe and effective to treat bilateral calcifying tendonitis of Achilles tendons. [12] Cline PD. }, author={Ivano A Costa and A Dyson . Treatment should initially be aimed at decreasing pain and inflammation through rest, modification of activity, medication, orthotics, and physical therapy, with emphasis on etiologic factors and current conservative management. Perron and Malouin clearly provided evidence that the intervention did not work in the 21 subjects in their study. 2016;3(3). Calcifying Tendonitis @article{Costa2007TheIO, title={The integration of acetic acid iontophoresis, orthotic therapy and physical rehabilitation for chronic plantar fasciitis: a case study. Hence, my decision was evidence based because I weighed my options according to the preponderance of the evidence that I had at hand. This comment has been removed by the author. Although it is true that their study failed to provide evidence of efficacy for this treatment, it is not true that it also proved the null hypothesis (ie, that evidence was found that the treatment was not effective). In this case, Dr Ciccone's careful literature searches produced no meta-analyses, no systematic reviews, and no clinical practice guidelines. R. Bilateral Calcification of Achilles Tendons, and Acetic Acid Iontophoresis Plus Ultrasound Effectivenness. The patient's 3-week physical therapy program consisted of a 2% acetic acid iontophoresis treatment followed by pulsed ultrasound and mild PROM movements. For transdermal patch therapy you can rely on, choose . Rest, ice, elevation, compression dressings, and immobilization are initiated with moderate to severe contusions. Calcifying tendonitis, effect of physical therapy and iontophoresis. This does more to set back our professional growth and deny advancements in care for our patients than it does to advance us. In physical therapy, the use of dexamethasone for inflammation and acetic acid for calcific deposits has been used for many years in numerous clinical settings. Dexamethasone (-): Iontophoresis. The study did not, in any way, provide evidence that this intervention is not effective. The study failed to provide any conclusive evidence of anything. In: Michlovitz SL, ed. Clinical Electrotherapy. The potential for a therapeutic program of acetic acid iontophoresis and ultrasound in eliminating myositis ossificans is demonstrated and the patient regained full range of motion and was able to return to pain-free activity. One week later, the patient noticed increased swelling and pain in his right lateral anterior thigh. Theoretically, acetic acid replaces carbonate in calcium carbonate to become calcium acetate, which is blood soluble, thereby leaching the calcium away from the site of bony spur and inflammation. Phoresor Forum. In the 1950s, Psaki and Carroll were the first to use acetic acid iontophoresis as an effective treatment for shoulder CT (4). Acetic Acid Iontophoroesis (AAI) treatment with that of Ultrasound therapy along with high heel usage (USHH) on heel pain and functional outcomes is compared. Without considering other factors such as the variance of their data, Mr Tygiel is incorrect in assuming that Perron and Malouin were not capable of making the correct conclusion (ie, that there really was no difference between the groups). Iontophoresis is a conservative, non-surgical technique that favors the penetration of transdermal substances/drugs through the skin with the help of electric current, based on physical-chemical properties of attraction and repulsion of charges. The iontophoresis, ultrasound, and passive stretching treatment was administered on alternate days three times per week for 3 weeks. She already went through physical therapies (laser and physiotherapy) without any success. [1] Tyler JL, Derbekyan V, Lisbona R. Early diagnosis of myositis ossificans with To99m diphosphonate imaging. After treatment: pain measured by VAS 0/10, calcification 0 mm evaluated by sonography (B) and radiography (D). He could remember no other traumatic incident since the diving accident. Iontophoresis (c) Tim Watson (2014) Page 1 Iontophoresis Iontophoresis is a technique which uses an electric current to deliver a medicine or other chemical through the skin. It was very interesting and meaningful. doi: 10.17795/mejrh-41112. By clicking accept or continuing to use the site, you agree to the terms outlined in our. Alternative medicine review : a journal of clinical therapeutic. Sackett Protocol applied at the Department of Rehabilitation at Santa Cristina's University Hospital (Madrid-Spain), and at Santsima Trinidad's Foundation Hospital (Salamanca-Spain). . An ultrasonic coupling gel was used as the transfer medium. [9] Kahn J. Wieder, Deborah L. "Treatment of traumatic myositis ossificans with acetic acid iontophoresis." CT . . The athlete complained of pain rated a 2-3 out of 10. Figure 2 Acetic acid iontophoresis applied to the heel with buffered Dupel pads. [CaCO.sub.2] + [2H(C.sub.2H.sub.3O.sub.2]) =Ca([C.sub.2H.sub.3O.sub.2. 2 Radiographic measurements revealed the mass to be 7.1 cm in length, 4.2 cm in width, and 2.1 cm in thickness. In popular (lay) terms it is sometimes called "an injection without the needle". The study focuses on the integrative use of acetic acid iontophoresis in combination with active rehabilitation for her treatment. I have 100% acetic acid but as far as I know the solution should be based not on volumetric measures (e.g mililiters), but on mols. Regrettably, Perron and Malouin do not provide measures of effect size or statistical power directly in their paper. If that were the case, our patients would have never benefited when their physical therapists used the works and ideas of other innovative clinicians, from Bobath and Brunnstrom to McKenzie and McConnell. 1. how to cite: Still, my clinical decision in this case was based on the evidence that is currently available and relevant to this particular patient.

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