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iontophoresis and phonophoresis

Iontophoresis and Phonophoresis: Basics for OT

Iontophoresis and phonophoresis are intervention options therapists use to treat several different physical conditions.

Physical agent modalities (PAMs) include superficial modalities such as thermotherapy and cryotherapy, and deep modalities such as ultrasound, electrical stimulation, and the application of topical medications. The two forms of topical medication application include iontophoresis and phonophoresis. Unfortunately, in educational settings and in practice, iontophoresis and phonophoresis are under-discussed and underutilized.

This might be due to the lack of ability to provide hands-on training in educational settings, as students are unable to practice applying medication to each other in labs. It may also be due to lack of understanding of the purpose and proper use of topical medication applications in therapy practice.

Common Practice Areas for Iontophoresis and Phonophoresis Use:

The purpose of this article is to discuss topical medication application, appropriate diagnoses for topical medication, typical protocols, and contraindications for iontophoresis and phonophoresis within occupational therapy practice to better help practitioners in their understanding, confidence, and use of the underutilized topical medication modalities.

Iontophoresis

If you recall from your training and curriculum, iontophoresis is the application of ionized topical medication through the skin to tissues of the body by the continuous and direct electrical current. Research indicates iontophoresis is experimental/investigational in the treatment of physical conditions. Literature exemplifies the use of iontophoresis in clinical applications to assist in treating conditions including, but not limited to (Baskurt, Ozcan, & Algun, 2003; Starsky, 2015):

  • Lateral epicondylalgia
  • Adhesive capsulitis
  • Plantar fasciitis
  • Patellofemoral pain syndrome
  • Carpal tunnel syndrome

Iontophoresis uses two electrodes to deliver medication. Many protocols exist, varying in dosage and intensity. However, the following principles are consistent in all iontophoresis applications: the skin should be properly cleaned prior to treatment, positively charged medication should be placed in the positive electrode, and negative medication in the negative electrode. Common medications include (Watson, 2015):

  • Acetic acid
  • Calcium chloride
  • Dexamethasone
  • Hydrocortisone
  • Iodine
  • Lidocaine
  • Magnesium sulphate
  • Hyaluronidase
  • Salicylates
  • Tolazoline hydrochloride
  • Zinc oxide

Check with referring doctors and your facility to determine the medication available at your practice. Dosage is expressed in milliamp per minute.

To determine the effectiveness of iontophoresis, remember that a patient receiving iontophoresis should report positive results within one to three treatment sessions. If no signs of improvement are reported, iontophoresis should be discontinued. Contraindications for iontophoresis are pacemakers, pregnancy, cancer, decreased sensation, and over broken/bleeding skin (Hecox, Mehreteab, Welsberg, & Sanko, 2006).

Instructions for How to use an Iontophoresis Patch to treat Lateral Epicondylalgia:

1. Prepare application site

Ensure there are no open wounds or damaged skin on the elbow at the application site. Trim excess hair at application site if necessary. Do not shave the hair at the site. Clean the site with soap and water. Alcohol may be used, but is typically not preferred. Pat the elbow dry with a towel.

2. Position the joint

Position the elbow joint at ~45 degrees so the patient will have the full range of motion of their arm once the patch is applied.

3. Fill the electrodes

Locate the positive and negative electrodes on the patch. (These are often clearly labeled). Add negative medication to the negative pad and positive medication to the positive pad. We use Dexamethasone in our clinic, which is a negative medication, added to the negative pad. Saline solution is added to the opposite pad.

4. Place patch

Place the medication pad over the patient’s lateral elbow joint at the place they indicate the most pain. Secure the patch by pressing on the adhesive seal surrounding the pad. The battery is already in the patch and is activated with wear. A patient may feel a slight tingling or “pins and needles” at the start of iontophoresis patch treatment.

5. Wear time

Discuss wear time for the iontophoresis patch. This may vary between patch type. In my clinic, we use the “Ionto STAT” patch with an average wear time of 4 to 6 hours.

6. Removal of Patch

To remove the patch, advise the patient to use soap and water. Removing the patch dry may impair the integrity of the skin or be painful to the patient. Treat the elbow with moisturizing lotion between patch use. A patient must wait 48 hours before a new patch can be placed.

Visual Learners: Watch this video to help with your next iontophoresis application!

Phonophoresis

Alternatively, phonophoresis is the application of topical medication by skin absorption and deep tissue distribution facilitated by ultrasound waves. Literature suggests phonophoresis is experimental/investigational in use but may be effective in the treatment of several conditions including:

  • Adhesive capsulitis
  • Carpal tunnel syndrome
  • Epicondylalgia
  • Iliotibial band syndrome
  • Arthritis
  • Medial tibial stress syndrome
  • Patellofemoral pain
  • Rotator cuff issues
  • Myofascial pain
  • Shoulder impingement

(Ay, Doğan, Evcik, & Başer, 2010; Garcia, Lobo, Lopez, Servan, & Tenias, 2016; Jain et al., 2010; Lake & Wofford, 2011, Starsky, 2013).

Protocols for phonophoresis vary in frequency, duration, time of treatment, and medication being used. The current literature recommends an intensity of 1.5 W/cm2 (Starsky, 2013). Remember that the ultrasound head should be held perpendicular to the treatment area. Medication gels for phonophoresis include local anesthetics and anti-inflammatory drugs (Loyd, 2011):

  • Hydrocortisone
  • Dexamethasone
  • Lidocaine
  • Carbopol
  • Methylcellulose
  • Ketoprofen
  • Zinc oxide
  • Methylparaben

Once, again, check with referring physicians and your facility to see what medication you may have available to use.

Treatments should be discounted if no signs of improvement are reported after six to eight therapy sessions. Contraindications for phonophoresis are pacemakers, pregnancy, application over the eyes or testes, deep vein thrombosis (DVT), tumor/malignancy, infection, active bleeding, and over epiphyseal growth plates (Loyd, 2011).

Visual learners: Watch this video to help you with phonophoresis application!

Helpful hint: Remember, multiple states have additional licensure requirements for therapists prior to the use of physical agent modalities, including iontophoresis and phonophoresis, in various settings. The requirements may include additional continuing education as well as proctored practice administering the superficial and deep modalities. Check with your state licensing board prior to using iontophoresis and phonophoresis in your practice.

For example, I practice in Montana where the state mandates occupational therapist have superficial and deep modality endorsements in order to use PAMS:

To earn certification in superficial modalities, an OT/OTA must have 16 hours of instruction/training in thermo and cryotherapy. They must also pay a $20 certification fee.

To earn certification in deep modalities, an OT/OTA must have 20 hours of ultrasound instruction and five proctored treatment sessions, 20 hours of instruction in electrical and five proctored treatment sessions, and five hours of instruction/training in topical drug interaction, adverse reactions, and techniques that drugs are administered, as wells as four proctored topical medication applications and iontophoresis and phonophoresis applications. 

Prior to application of iontophoresis or phonophoresis, remember the following key points: PAMs are best used as preparatory methods, assess if the patient has any contraindications for treatment, check for topical drug interactions, and be aware of potential adverse reactions to treatment such as rashes or burns.

Following application, document all parameters, procedures, and the patient’s response to treatment. For billing, iontophoresis and phonophoresis are timed codes. Iontophoresis is billed under the code 97033. Phonophoresis is billed under the ultrasound code of 97035. To bill 1 unit of these codes, treatment must be at least 8 minutes in duration per session.

Looking to get certified?

  1. First check with your state requirements for certification
  2. Use continue education resources including MedBridge and get $175 off a yearly subscription using the coupon code NEWgradOT
  3. Check for weekend PAMs courses in your area, such as: http://www.pampca.org/index.php
  4. Ask a certified mentor to help you with proctored treatments
  5. Submit the following to your state board for review: Copies of your course syllabus, copies of course certificates of completion, modality application, a copy of your proctor’s license, and appropriate fees
Be sure to register and subscribe to NewGradOccupationalTherapy.com to follow future articles covering advanced interventions tailored for new grads!

References

References

Ay, S., Doğan, Ş. K., Evcik, D., & Başer, Ö. Ç. (2010). Comparison the efficacy of phonophoresis and ultrasound therapy in myofascial pain syndrome. Rheumatology International, 31(9), 1203-1208. doi:10.1007/s00296-010-1419-0

Baskurt, F., Ozcan, A., & Algun, C. (2003). Comparison of effects of phonophoresis and iontophoresis of naproxen in the treatment of lateral epicondylitis. Clinical rehabilitation, 17(1), 96-100.

Garcia, I., Lobo, C., Lopez, E., Servan, J. L., & Tenias, J. M. (2016). Comparative effectiveness of ultrasonophoresis and iontophoresis in impingement syndrome: a double-blind, randomized, placebo controlled trial. Clinical rehabilitation, 30(4), 347-358. doi:10.1177/0269215515578293

Hecox, B., Mehreteab, T., Welsberg. J., & Sanko, J. (2006). Integrating physical agents in rehabilitation. Upper Saddle River, NJ: Pearson Prentice Hall.

Jain R, Jain E, Dass AG, et al. (2010). Evaluation of transdermal steroids for trapeziometacarpal arthritis. J Hand Surg Am., 35(6), 921-927.

Lake, D. A., & Wofford, N. H. (2011). Effect of therapeutic modalities on patients with patellofemeral pain syndrome: A systematic review. Sports Health, 3(2), 182-189.

Loyd, A. (2011). Compounding for phonophoresis. Secundum artem, 11(2). Starsky, A. (2013, April 15). Ultrasound as a therapeutic intervention [PDF document]. Retrieved from http://www.occupationaltherapy.com/ot-ceus/course/ultrasound-as-a-therapeutic-intervention-1410

Starsky, A. (2015, February 15). Advanced applications in electrotherapy [PDF document]. Retrieved from http://www.occupationaltherapy.com/ot-ceus/course/advanced-applications-in-electrotherapy-2289 Watson, T. (2015). Electrotherapy on the Web. Retrieved from http://www.electrotherapy.org

About Kyla Salisbury

Kyla Salisbury
Outpatient and Home Health OT working with a variety of diagnoses and patient populations ranging from pediatric to geriatric. UMary OT Grad, 2016; MSU Architecture Grad, 2011.

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2 comments

  1. Dominic Lloyd-Randolfi

    Hi Kyla! Question for you. When you do this as a treatment, how do you write your goals? Is it something like “Client will complete X activity with 0 pain after 3 treatment sessions”? Thanks!

    • Kyla Salisbury

      Yes! Great question.
      Remember, all physical agent modalities are considered preparatory activities. This means you must do them in preparation to and for increasing function in occupation-based activities. Although you may write a goal to with the intervention strategy in mind to use ionto or phonophoresis, goals should address occupations. Examples of generic goals may include:

      Patient will demonstrate increased engagement in ADLs in 2/3 sessions following the use of PAMs to improve independence and quality of life by discharge.

      Patient will report a 2/10 pain or less during functional activities on 4/5 sessions following the use of PAMs and pain management strategies to increase participation in occupations by discharge.

      Remember to validate and document why you think ionto/phonophoreis will be effective in the treatment of your specific individual prior to treatment. Following treatment, critically determine if the PAMs are helping or not. Discontinue if ineffective.

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