How To Order Dexamethasone For Iontophoresis

Am Fam Medico. 2007;76(eleven):1661-1666

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Numerous guidelines recommend concrete therapy for the management of musculoskeletal conditions. However, specific recommendations are defective apropos which exercises and offshoot modalities to use. Physical therapists use various techniques to reduce pain and improve mobility and flexibility. There is some evidence that specific exercises performed with the education of physical therapists improve outcomes in patients with low back hurting. For almost modalities, evidence of effectiveness is variable and controlled trials are lacking. Multiple modalities may be used to treat one clinical condition; decisions for the treatment of an individual patient depend on the expertise of the therapist, the equipment available, and the desire of the attending doc. A concrete therapy prescription should include the diagnosis; type, frequency, and duration of the prescribed therapy; goals of therapy; and safety precautions.

Concrete therapists are an integral office of inpatient and outpatient treatment of neurologic and musculoskeletal injuries and disabilities. They likewise can assist with and broaden the care of patients with cardiac, pulmonary, and developmental disorders. Family physicians should have some understanding of the various treatments and modalities used by physical therapists.

Physical Therapy

Modalities are adjunctive treatments to do and manual therapy; the use of modalities alone is not considered physical therapy. The American Physical Therapy Association states: "Without documentation which justifies the necessity of the sectional use of physical agents/modalities, the use of concrete agents/modalities in the absence of other skilled therapeutic or educational interventions should not be considered physical therapy."¹ The ultimate goal of any physical therapy intervention is to improve the long-term office of the patient, which is best accomplished with the use of practice, manual therapy, and modalities.

Research conducted during the development of several physical therapy modalities focused on how they bear on inflammation. Many of the conditions that were thought to be inflammatory (e.yard., patellar tendonitis) are in fact not histologically inflammatory. However, these tendinopathies (a more accurate nomenclature) continue to be treated with modalities designed to decrease inflammation. There is some show that these modalities may be beneficial, only this may non exist related to a truthful anti-inflammatory outcome.

Do and Adjunct Modalities

A working knowledge of the uses and limitations of unlike modalities will assist family physicians in prescribing physical therapy. Table 1 summarizes some of the concrete therapy modalities that are available. The practicality of individual modalities may vary, and physicians are encouraged to discuss the options with qualified physical therapists.

THERAPEUTIC Do

Exercises that target muscle deficiencies or that aid rehabilitate patients after surgery or injury are a mainstay of many concrete therapy protocols. Therapeutic exercise is used to improve strength, mobility, and part and to subtract pain and swelling.

Family unit physicians often prescribe simple habitation-based rehabilitation exercises by providing patients with brief educational activity and handouts. Supervised therapeutic exercise has been shown to be more than benign than home-based do in patients with depression back injury,² osteoarthritis of the human knee,³ or intermittent claudication.⁴ Other studies, however, have found that home-based exercise is as beneficial as supervised physical therapy for postoperative recovery after anterior cruciate ligament reconstruction.^v,6 Table 2 includes common therapeutic exercises.

ULTRASOUND

Therapeutic ultrasound is another unremarkably employed technique. Modifying the awarding parameters (i.e., intensity, wavelength, duty cycle, and frequency) provides a variety of local effects on tissues.

Ultrasound provides therapeutic benefit via thermal (continuous ultrasound) and nonthermal (pulsed ultrasound) effects.^7,8 Continuous ultrasound heats the tissue. Pulsed ultrasound is thought to accelerate tissue healing at the cellular level, primarily through alteration of membrane permeability, ionic concentration gradients, and cellular biochemical activeness.^7,8 College-frequency ultrasound waves treat superficial tissues such as patellar tendons. Lower frequencies penetrate deeper (up to two in [5 cm]) to treat deep muscle bruising, spasms, and strains.⁷ Selection of ultrasound application parameters is based on the desired effect and the location and density of the tissue to be treated. These decisions are best made past a therapist experienced in performing therapeutic ultrasound.

Common indications for ultrasound therapy include treatment of tendon injuries and brusque-term pain relief.^7,9–11 Ultrasound has also been shown to promote healing of some acute bone fractures, venous and pressure ulcers, and surgical incisions.^7,8,12,13 Therapeutic ultrasound tin can cause burns or endothelial harm if applied incorrectly.^7,8,14

Despite the widespread use of therapeutic ultrasound in the physical therapy setting, testify of its clinical effectiveness is defective. Although in that location is limited evidence that ultrasound benefits musculoskeletal hurting and soft tissue injury, more well-designed studies of its clinical furnishings are needed.^9,15–17 In the absence of more definitive prove, family physicians should prescribe therapeutic ultrasound only equally symptomatic treatment.

PHONOPHORESIS

Phonophoresis uses loftier-frequency sound waves (i.e., ultrasound) to evangelize therapeutic medications, usually topical analgesics or steroids, through the skin to deeper tissues. It is used for the treatment of conditions that may also be treated with local anesthetic or steroid injections. In that location is a risk of thermal injury, which increases with the amount and intensity of the free energy practical.¹⁸

A corticosteroid or nonsteroidal anti-inflammatory drug usually is mixed with an appropriate aqueous base in a 10 percent concentration and is practical with ultrasound at 1 to 2 watts per cm^2.18 Ane written report showed an increased level of ketoprofen in tissues post-obit phonophoresis compared with topical application lonely.¹⁹ Studies of the systemic effects of phonophoresis with steroids have had contradictory results. I study demonstrated a possible systemic subtract in collagen deposition subsequently phonophoresis with dexamethasone, but another study showed no effect on adrenal function.^xx,21

IONTOPHORESIS

This modality uses an electric current to deliver an ionically charged substance through the pare to deeper tissues. Iontophoresis is often used to treat arthritis, bursitis, and tendinopathy. Information technology tin can also be used to treat edema, hyperhidrosis, and certain dermatophytoses.¹⁸ Hypersensitivity to direct current may cause a feature galvanic pare response.

Dexamethasone 0.4% solution is the virtually commonly prescribed medication used to care for tendinopathies and possible inflammatory weather. Cathodes are used for negatively charged substances, and anodes are used for positively charged substances. The amperage used depends on the natural resistance provided by the peel.

Iontophoresis in conjunction with traditional modalities tin can shorten treatment time for plantar fasciitis.²² Ane small case study showed that acetic acid iontophoresis in conjunction with ultrasound was benign in the handling of myositis ossificans.²³ However, a pocket-sized randomized controlled trial showed no difference in the clinical outcome of patients with calcific tendinopathy in the shoulder.²⁴

Electrical STIMULATION

There are several electrical stimulation methods used in physical therapy. Family physicians usually are most familiar with electrical musculus stimulation and transcutaneous electrical nerve stimulation. The theoretical goal of electric stimulation is to generate an action potential in nerve tissue, causing a muscle wrinkle or altering sensory input.⁷

Muscle wrinkle allows for isometric activation, making electric stimulation useful for the handling of muscle spasm or atrophy and for strengthening muscles.^vii,8,25 In addition, electric currents are thought to impact ionic tissue and change vascular membrane permeability, which promotes tissue healing, decreases edema, and improves drug penetration.^vii,8 Pain reduction is idea to be achieved by altering the gate mechanism and through endogenous opioid and cortisol release.^vii,8

Electrical stimulation may as well help reduce inflammation and edema and facilitate chronic wound healing.^7,8,26–28 Basic transcutaneous electric nerve stimulation uses multiple electrodes that are impregnated with a conduction medium and applied over muscle groups. The location and spacing of the electrodes varies depending on treatment surface area and desired outcome. Specific electrode placements are needed to create pain control, isometric muscle wrinkle, wound healing, and edema reduction.^{seven,25–27}

Although there are few risks with electrical therapy, potential adverse effects primarily include burns from improper parameter settings, allergic reaction to electrodes or the conduction medium, and pain during handling.^seven,8,28 Adept opinion and anecdotal reports support the use of this modality; withal, studies are lacking, express, or alien. More evidence is needed on the long-term benefits, platonic parameters, and overall effectiveness of electrical stimulation methods.^16,25,28,29

LOW-LEVEL LASER THERAPY

The mechanism of depression-level laser therapy is non well understood, simply it appears to be related to a photochemical reaction at the cellular level rather than a thermal effect. According to one theory, cytochrome oxidase acts equally an acceptor of photon radiations in the 600 to 900 nm range. This stimulation increases adenosine triphosphate production and cellular oxidative metabolism. A contempo study showed a pregnant subtract in prostaglandin E2 concentration in peritendinous fluid in patients treated with depression-level laser therapy compared with those treated with sham therapy.^xxx Larger studies are needed to confirm this mechanism.

Low-level laser therapy is used to treat musculoskeletal disorders, including muscle strains, epicondylitis, rheumatoid arthritis, osteoarthritis, and carpal tunnel syndrome. This therapy is approved past the U.S. Food and Drug Administration for the treatment of paw and wrist pain associated with carpal tunnel syndrome and for pocket-size musculoskeletal pain. Although nausea has been reported with prolonged use, there are no other known agin effects.

Differences in studies of low-level laser therapy (due east.g., device used, end points, command group) make it difficult to determine the effectiveness of this modality. A Cochrane review of low-level laser therapy in patients with osteoarthritis showed minimal improvement in pain and joint movement, only written report results were alien.³¹ A similar Cochrane review of the therapy in patients with rheumatoid arthritis showed limited do good only stated that it could be considered for curt-term relief of pain and morning time stiffness.³² In general, low-level laser therapy has not been shown to crusade adverse effects, but a benefit has not been conspicuously established.

Concrete Therapy Prescription

Table 3 lists the components of a concrete therapy prescription. Proper coding should exist used to ensure correct insurance reimbursement (online Table A). Physical therapy clinics often provide standard forms that facilitate prescribing of therapy. These forms can improve teamwork and communication between the physician and the therapist. Usually, there is an "evaluate and care for" option that allows the therapist to use discretion in the application of therapeutic interventions.

The frequency and elapsing of physical therapy treatments will vary based on the patient's status. Astute musculus strains often benefit from daily treatment over a curt menses, whereas chronic injuries are usually addressed less frequently over an extended menses. Figure ane is a general algorithm for prescribing physical therapy interventions to treat musculoskeletal injury; yet, private prescriptions are based on the patient'south specific condition and comorbidities and on the availability of modalities.

It is important for the concrete therapist to document the patient'south progress and so that the doctor can modify the care plan, if needed. This documentation is typically given to the physician every 30 days or before the patient sees the physician for a follow-up visit.

Source: https://www.aafp.org/pubs/afp/issues/2007/1201/p1661.html

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