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Phonophoresis and Ice
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Phonophoresis and Ice - March 24, 2002 6:23:00 PM
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ptace
Posts: 85
Joined: January 20, 2001
From: Illinois
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Hi,
I am a student athletic trainer and I am trying to find research concerning the use of phonophoresis and ice together. Recently during a clinical experiance a PT told me that he prefers to use an ice massage/ice pack immediatly following a phonophoresis treatment in order to allow the medication to stay in the tissues longer.
Is there any scientific basis for this claim? I would appreciate any relevant research in this subject.
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Re: Phonophoresis and Ice - March 24, 2002 7:20:00 PM
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PTstud
Posts: 86
Joined: March 8, 2002
From: Texas
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Im not a Pt yet, but from what I know, it seems to make sense. Cooling the area slows down circulation in the area so the medicine will not be carried away from the area as quick. It seems like common sense, but I might be wrong...
PTStud
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Re: Phonophoresis and Ice - March 25, 2002 4:46:00 AM
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ptace
Posts: 85
Joined: January 20, 2001
From: Illinois
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I know that cooling the area would help keep the medication in the tissues, I had someone else tell me that most phonophoresis medications are designed to work at body temperature. The cold will slow down the metabolism of the drugs so they would be less effective.
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Re: Phonophoresis and Ice - March 25, 2002 6:05:00 AM
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Andrew M. Ball MS MBA PT
Posts: 271
Joined: September 30, 2001
From: Chapel Hill
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Good question.
Dr. Charles Ciccone at Ithaca College would be a great person to tap for additional information on the subject.
My evidence-based solution is as follows:
There isn't any research on Ice and Phonophoresis combination treatments, so I'd suggest that if your PT is doing this, it is incumbent upon him to begin collecting data (even qualitative data) to support as yet unsubstantiated claims. It may be every bit as effective as he suggests. His rationale sounds good, and I'll buy that it slows metabolism of the drug, but I'd also buy that that the cryotherapy affects the pharmadokinetics and pharmacodynamics of the drug so as to make it LESS effective in the intended tissue (assuming it ever gets there in the first place). Clinical opinion just isn't good enough anymore.
Lack of evidence, however, is NOT the same thing as lack of effect, but if there isn't any evidence (and there isn't), it is incumbent upon the PT to collect information, publish results, and support clinical decision making with something more than physiologic philosophy based opinion. I'm not saying that it's unethical to provide and charge for treatments or treatment combinations that have no evidence-based foundation, but there IS an increased responsibility for PT's who choose to practice that way.
The little that has been done and can be applied to your clinical question, stacks the few evidence-based facts we have against what sounds like the experience-based opinions of your mentor PT.
A good initial read would be the Fedorczyk article. In it, you will see that questions exist regarding the efficacy of most physical agents. In order for your PT's statements to be evidence-based, the efficacy of ice and phonophoresis must be demonstrated in isolation BEFORE the jump can be made to evidence-based combination therapy.
Depending upon the PT's goals for the combination treatment, he may need to contend with the possibility that the cold slows metabolism and healing down to the point that the phonophoretic treatment may be completely ineffective and counterproductive to the PT's healing goals. Carr, et al. speak to this point. An additional point was raised in the Carr study, suggesting that innervation and proper flow of peripheral neurologic information is critical for optimally efficient healing to occur. Does cooling a region restrict peripheral neurologic functioning? The Morrissey study, suggests that it might.
Furthermore, the jury is still out as to whether or not phonophoresis actually does what is said to do, and what is typically taught in physical therapy education programs. The Klaiman study illustrates that patients do just as well with Ultrasound as they do with Phonophoresis, begging the questions, "Why bother with the drug?" and "Are the effects nothing more than placebo?" Considering the results of the Bare study (which suggests that phonophoretic drugs don't pass the epidermis), the Klaiman results are not surprising.
REFERENCES:
Bare AC, McAnaw MB, Pritchard AE, Struebing JG, Smutok MA, Christie DS, Domenech MA, Bare MA, Bloodworth ML, Seal LA. Phonophoretic delivery of 10% hydrocortisone through the epidermis of humans as determined by serum cortisol concentrations. Phys Ther. 1996 Jul;76(7):738-45; discussion 746-9.
Carr RW, Delaney CA, Westerman RA, Roberts RG. Denervation impairs cutaneous microvascular function and blister healing in the rat hindlimb. Neuroreport. 1993 May;4(5):467-70.
Fedorczyk J. The role of physical agents in modulating pain. J Hand Ther. 1997 Apr-Jun;10(2):110-21. Review.
Klaiman MD, Shrader JA, Danoff JV, Hicks JE, Pesce WJ, Ferland J. Phonophoresis versus ultrasound in the treatment of common musculoskeletal conditions. Med Sci Sports Exerc. 1998 Sep;30(9):1349-55.
Morrissey MC. Reflex inhibition of thigh muscles in knee injury. Causes and treatment. Sports Med 1989 Apr;7(4):263-76.
[This message has been edited by Andrew M. Ball MS MBA PT (edited March 25, 2002).]
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Re: Phonophoresis and Ice - March 25, 2002 6:36:00 AM
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PTupdate.com
Posts: 1478
Joined: October 8, 2001
From: Pittsburgh, PA USA
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Mr Ball is quite correct in his response. There is no evidence yet to indicate the benefits of cryotherapy with either phono or iontophoresis. As I am not a believer in phono anyway (nothing has been published to convince me to change my mind), my treatments focus more heavily on iontophoresis. There has always been the trend in orthopaedic medicine that with a corticosteroid injection, application of ice and decreased movement are recommended, to decrease the liklihood of "flushing" the product out of the tissue or joint space and into the general circulation. There may be more evidence for that in general medicine or pharmacology literature, I don't know. If and when I perform ionto on a patient, I usually apply at the end of treatment, while they are icing
John Duffy, PT OCS [URL=http://www.PTupdate.com]www.PTupdate.com[/URL]
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Re: Phonophoresis and Ice - July 4, 2002 6:27:00 AM
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gilbertthomson
Posts: 33
Joined: July 1, 2002
From: Elka Park, NY USA
Status: offline
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Using cold to decrease circulation and therefore decrease flushing the medication out of the area certainly makes sense IF any medication is in the target tissues. Unfortunately, there is no conclusive evidence that the medication "delivered" with phonophoresis actually gets deeper than the skin, so positive effects may be due to other factors (the effects of ultrasound? placebo?) Clinicians should think about the depth of the structures they are attempting to treat before deciding if phonophoresis is appropriate.
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