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13 Articles in Volume 10, Issue #5
An Osteopathic Approach to Fibromyalgia
Co-Morbid Psychological Disorders in Interventional Pain Management
Compliance Monitoring and Effective Risk Mitigation Strategy
Cultural Differences and Pain Management
Electronic Prescription of Controlled Substances
Kinetic Chain from the Toes Influences the Craniofacial Region
Non-responsive Pain Patients with CYP-2D6 Defect
Platelet Rich Plasma for Hamstring Tears
The Iontophore
The Treatment of Achilles Tendonitis Using Therapeutic Laser
Thoracic Facet Injections
Urine Drug Testing as an Evaluation of Risk
Vitamin D Levels In Pain and Headache Patients

The Iontophore

High potency corticoid hormones that are iontophoretically delivered by modern electromagnetic instruments have great patient acceptance and therapeutic benefit.

Iontophoresis simply means the transport of ions through tissue.1 Practitioners have attempted to treat pain sites by this method for several years by the use of electric currents.2 However, these attempts have never been widely adopted primarily due to inadequate instruments that provided relatively poor penetration of medication into tissue and the use of medication that had marginal pharmacologic effects. Today, new electromagnetic instruments are capable of driving medication deep into tissue and, most critically, high potency corticoid hormones provide an effective immunologic and healing effect. This report describes the hormones and the electromagnetic devices used by the author. The use of electromagnetic techniques and high potency corticoid hormones are simple to implement and they can even be inexpensively used at home by patients.

What Happened to the Old Iontophoresis?

The deficiencies of yesterday’s iontophoretic techniques are instructive and should provide a message to today’s practitioner that “things are now different.” There are two fundamental reasons for the heretofore limited use of iontophoresis. First, the fundamental purpose of iontophoresis is to drive medication from the skin surface to a pain site that may rest two to five inches below the skin surface. A pain site contains a host of biologic elements including inflammatory markers, retained electrical charges, opioid receptors, and blood-lymph drainage (see Figure 1). Medication agents administered by iontophoresis in the past were usually weak metals, salicylates, or corticoid preparations that were simply not potent enough to have much effect. The second reason that iontophoresis has never been widely adopted is that the commercial instruments marketed for this purpose were inadequate to the task. They usually utilized low intensity, low frequency electric currents and attempted to administer medical agents under a very small skin contact pad that may not have been larger than one-half inch on a side. In summary, the iontophoresis attempts of yesteryear were a good start that has progressively evolved into a system of effective delivery and pharmacologic activity.

Figure 1. The inflammatory pain site.

High Potency Hormones

I have systematically attempted to iontophoretically administer a number of corticoid, androgenic, and anti-inflammatory agents and have settled on two high potency corticoids after noting excellent skin penetration and good clinical response when administered by various electromagnetic instruments. Here are my choices of iontophoretic agents:

  1. Prednisone: 40mg in 1 ounce of base cream
  2. Medroxyprogesterone: 40 mg in 1 ounce of base cream.

Today’s compounding pharmacies are creating a number of very innovative mixtures and concentrations of topical agents. Some will very likely have great merit when used as iontophoretic agents. It should be noted that any topical agent which shows therapeutic benefit will have that benefit enhanced if it is applied under any one of a number of electromagnetic instruments that are now commercially available.

What Base Should Be Used?

My criteria for a base cream is simple. Will it dissolve rapidly when rubbed on the skin? Although some base gels for topical compounds are popular with compounding pharmacies, base agents for iontophoresis require only that the base cream be able to dissolve hormones and will diffuse rapidly into the skin when applied under an electromagnetic instrument.

The New Electromagnetic Instruments

Many of the new electromagnetic instruments now available are ideally suited for iontophoretic treatments. Instruments that use electric currents have the ability to deliver currents of different intensities and frequencies. Of critical importance is that many of the new electromagnetic instruments deliver their current or photon wave in pulses. The pulse action of an electric current or electromagnetic wave appears to enhance the penetration of medication into deep pain sites.

An electric current creates a series of photon waves in the electromagnetic spectrum (see Figure 2). Pain practitioners should be aware of this spectrum and know that radio, ultrasound, infrared, and laser waves are all fundamentally related. Their basic unit of mass is the photon. The waves can clinically differ in their intensity and frequency and can be delivered in pulses.

Figure 2. The electromagnetic spectrum.

Benefits of these electromagnetic in-struments include cell growth, increased vascular perfusion, dispersion of sequest-ered electrical charges, and reduction of edema and inflammation.2,3 Simply put, when these instrument are used for iontophoresis as described here, not only does the patient get the benefit of the basic electromagnetic current or wave but the added benefit of a high potency corticoid hormone. It is important that the electromagnetic instruments on the commercial market carry a US Food and Drug Administration (FDA) clinical indication for various pain problems. When used for iontophoresis, the treatment is an off-label use and the patient should be so informed.

Pulsed Radio Frequency

A pulsed radiofrequency instrument (Provant®, Scottsdale, Arizona) has had considerable success in treating the pain of surface wounds such as those caused by diabetes, trauma, or vascular disease. It has a square skin contact plate about 8" on a side that lays nicely over a relatively flat anatomical area such as the lumbar spine, cheek, or chest wall (see Figure 3).

Figure 3. Pulsed radiofrequency used as iontophoretic instrument to drive hormones into a pain site.

Electric Currents

An instrument is available in a probe about the size of a pencil that delivers a microcurrent of electricity (Alpha-Stim®, Mineral Wells, TX). The topical hormone can be placed over a small skin surface area such as the thumb or cervical area and the this instrument can make skin contact in these areas while a plate or patch cannot do so (see Figure 4).

There are now pulsed electric current instruments (H-wave®, Huntington Beach, CA and Impulse TENS®, Vista, CA) whose intensity and frequency can be adjusted upward as needed. They also have contact pads which measure about two to three inches in diameter and are large enough to administer hormones beneath them (see Figure 5).

Figure 4. Microcurrent used in a small, non-flat anatomical area. Figure 5. Electric current device with large contact pads to administer high potency hormones.

Infrared and Ultrasound

These devices have long histories in pain treatment and are now available at low prices for at-home use. No serious side-effects are known. Consequently, these simple instruments are suitable patient self-administration. The waves in these instruments are not usually pulsed, so the penetration of hormones into the pain site may be limited (see Figure 6).

Figure 6. Topical hormones applied to the knee under an inexpensive at-home infrared device.

Treatment Procedures and Precautions

About one quarter to half an ounce of hormone cream is applied to the skin directly over the pain site. The topical hormone dosage, therefore, is only about 5 to 20mg of prednisone or medroxyprogesterone. The electromagnetic instrument is then applied for 10 to 30 minutes.

To date, no lasting side-effect of the use of these high potency hormones has been noted. This is likely because the active hormone does not enter the systemic circulation in a high enough concentration to cause even temporary, nuisance side effects such as nausea. A caution is raised, however, that too frequent administration of prednisone or medroxyprogesterone could cause symptoms and signs of hyperadrenalism (e.g., Cushings Syn-drome) such as hypertension, edema, and a buffalo hump. Given this theoretical possibility, high potency corticoid hormone iontophoresis is not recommended for daily use. Also, it should be used sparingly in pregnant women, infants, and severe insulin-dependent diabetics.

All electromagnetic devices can pro-duce unpleasant, temporary side effects of nausea, headache, dizziness, and even increased pain. For this reason, treatment should begin with low intensity and frequency of the instrument and then increased as the patient tolerates it. Treatment should cease in the event side effects occur. It is theorized that electromagnetic side effects occur because the instrument sends an electric current or electromagnetic wave into a pain site that contains sequestered electric charges. The retained electric charges disperse into the surrounding tissue and/or along nerves connected to the pain site (see Figure 1). Patients should be informed before a treatment that these minor, harmless side-effects can occur and that the treatment may be stopped or adjusted at any time.

Results and Outcomes of Treatment

Fundamentally, the results of iontophoresis with high potency corticoid hormones is similar to that seen with intralesional, injected corticoids. Immediately following the treatment, the vast majority of patients report symptomatic pain relief. In addition they also tend to report: (1) less stiffness, (2) more movement, and (3) warmth. Those patients who treat them-selves at home with ultrasound or infrared report the same positive attributes and also report less reliance on oral medications together with improved activities of daily living.

A single office-based treatment will usually provide some symptomatic bene-fits for time periods up to six weeks as illustrated in the case reports below. Iontophoresis with high potency hor-mones is an adjunct to other treatments and should not be viewed as “curative” or as a “singular” treatment.

Case Illustrations

Case 1. A 44-year-old female has severe neuropathic pain of her face and jaw resulting from being trampled by a horse. She was given a single 30-minute pulsed radiofrequency treatment with medroxy-progesterone. Following this treatment she had immediate pain relief and could fully open her mouth and blink her eye. Pain was reduced about 80% and relief lasted about six weeks.

Case 2. A 26-year-old woman had a caesarean section. Post-delivery she had severe upper lumbar back pain and partial paralysis of both legs. She walks bent over and uses a walker at times. Diagnoses of transverse myelitis and arachnoiditis have been given as there is no stenosis, bulging disc, or other surgical spine lesion. Epi-dural corticoid injections and lidocaine patch have not provided any relief. Other than oral opioids for symptomatic relief, her only relief has been with iontophoresis using a pulsating electric current (H-wave) with high potency medroxyprogesterone. After two treatments a week for four weeks she has had less pain and is able to walk standing upright.

Case 3. A 34-year-old female has severe cervical spine disease and has had a cervical spine fusion. Pain has been severe between her clavical and spine. High potency prednisone was applied to the skin over the area and penetration into the pain site was done with a microcurrent under a probe instrument (Alpha-Stim®). This instrument was selected because the anatomic area over the pain site is small and not flat. After her first treatment, she received considerable pain relief and had a better range of motion in her shoulder and arm. Relief lasted four to six weeks.

Attributes of Hormonal Iontophoresis

Corticoids have been the long-standing, hormonal choice for intralesional treatment. The hormone cortisone and other members of the steroidogenic family such as progesterone are potent anti-inflammatory agents. Medroxyprogesterone is a derivative of progesterone that is a pre-cursor of cortisol, androgens, and estrogens. Although less appreciated and less used than cortisone analogues, it has been very effective in our hands.

The administration of these hormones by iontophoresis has several positive attributes. Injections of hormones (i.e., “trigger point”, etc.) are not only painful but, by the very nature of an intralesional injection, the practitioner must hit a pain site which may be very small in size. Whereas topical placement and massage of a hormone may not cause enough diffusion of the hormone into a pain site to be effective, iontophoresis with modern electromagnetic instruments covers a much wider area than can be achieved by an injection. For example, the pulsed radiofrequency instrument (Provant®) has a square skin contact surface plate of about eight inches on a side. The lack of pain from injection and the safety of hormone iontophoresis has great acceptance by patients.

Summary

The iontophoresis techniques of decades past have never been widely accepted due to a lack of effective medications and instruments that can predictably deliver medication to a sub-surface pain site. High potency corticoid hormones that are now iontophoretically delivered by modern electromagnetic instruments have great patient acceptance and therapeutic benefit. Pain practitioners should strongly consider adding high-potency hormone iontophoretic capability to their current treatment modalities.

Last updated on: December 28, 2011
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