Report on Hands from Doctors Demystify, November 2012
CONTENTS
Happenings at Doctors Demystify
Journal Article Review: Phonophoresis vs. iontophoresis of dexamethasone for CTS
A New Prosthetic Finger
Goniometers; Contributions to Report on Hands by Therapists
LEARNING OPPORTUNITIES from DOCTORS DEMYSTIFY for 2013
Watch your mailbox. In the next few days, you will receive a postcard
inviting you to join Doctors Demystify in 2013 for one or more learning
opportunities. These include:
DOCTORS DEMYSTIFY CURRENT SCIENCE FOR HAND THERAPISTS
Miami, FL February 17-19, 2013 (Presidents’ Day Weekend)
Santa Monica, CA August 9-11, 2013
See the topics, learning objectives, and methods
DOCTORS DEMYSTIFY THE WHYS AND HOWS OF HAND SURGERY
Los Angeles, CA Saturday, January 26, 2013
In 30+ major cities on Saturdays thereafter
Hear area hand surgeons grapple with your tough questions
See the topics, schedule, learning objectives
JOURNAL ARTICLE REVIEW Phonophoresis vs. Iontophoresis of
Dexamethasone for Carpal Tunnel Syndrome
In a recently published article in the Clinical Journal of Pain, investigators from Iran
carefully studied the effects of dexamethasone delivered by phonophoresis vs
iontophoresis to 52 wrists of 34 patients with mild to moderate carpal tunnel syndrome.
This was a well-constructed, randomized, prospective, evaluator-blinded trial involving
subjects with carpal tunnel symptoms for more than 1 month, positive Phalen and Tinel
tests, and changes on electrodiagnostic testing. Eighteen subjects had bilateral findings,
and both of their wrists received the same treatment, so 26 wrists received iontophoresis
and 26 wrists received phonophoresis. The groups were matched well for age, duration of
symptoms, pretreatment strengths, and electrodiagnostic testing.
Outcome measures included pain measured on a visual analog scale, grip and pinch
strengths, electrodiagnostic testing. The investigators performed all outcome
measurements before treatment, at the end of the 2 weeks of treatment, and then again 2
weeks later. Treatments each lasted 5 minutes and occurred 5 days weekly for 2 weeks.
Both groups improved at the end of 2 weeks and after 4 weeks, and the group receiving
phonophoresis improved significantly more than the group receiving iontophoresis in all
measured outcomes.
Here is the abstract. Sound good? Is there anything missing here? Should you
start/continue using phonophoresis of dexamethasone for CTS? Here is the letter I just
sent to the editor of the Clinical Journal of Pain.
“Regarding Bakhtiary et al’s recent publication of the effects of dexamethasone
delivered by phonophoresis vs iontophoresis for the treatment of carpal tunnel
syndrome(1), a conceptual flaw and a design flaw require discussion.
The conceptual flaw is that data are nonexistent for the widely held desire that
drugs delivered through intact skin actually achieve any tissue level locally greater
than what can be measured systemically. Intuitively, any drug driven through the
skin by either phonophoresis or iontophoresis is going to be picked up by the
dermal and subcutaneous capillaries and distributed systemically, but it is not going
to somehow bypass the capillary bed and enter the desired target, in this case
penetrate the transverse carpal ligament and enter the carpal canal. It is wishful
thinking without an iota of scientific basis to think otherwise.
The design flaw is that at least 3 control groups are missing from the study. One
control group should have had nothing done or perhaps had sham treatment by
passing delivery instrument head over the treatment area with the machine turned
off and no dexamethasone applied to the skin. The other 2 control groups should
have been phonophoresis or iontophoresis without dexamethasone in order to
ascertain the effects of ultrasound and transcutaneous electrical nerve stimulation
by themselves.
The study was nicely designed and executed to obtain level 1 evidence, and the
authors correctly limited their conclusion to saying that phonophoresis with
dexamethasone was more effective than iontophoresis with dexamethasone in
patients with mild to moderate carpal tunnel syndrome. The much larger issue,
however, remains unaddressed. They have not proven that either treatment
modality is better than no treatment at all nor better than the use of ultrasound or
transcutaneous electrical nerve stimulation without dexamethasone.
Reference:
1. Bakhtiari AH, Fatemi E, Emami M, Malek M: Phonophoresis of
dexamethasone sodium phosphate may manage pain and symptoms of patients
with carpal tunnel syndrome. Clin J Pain 2012; epub ahead of print.”
If the letter gets accepted, I will let you know the authors’ response.
VIDEOCLIP OF A COOL PROSTHETIC FINGER
http://rcmenterprise.com/wordpress/
GONIOMETERS; CONTRIBUTIONS TO REPORT ON HANDS FROM
THERAPISTS
Therapist and Report on Hands reader Pam Millar made a good suggestion: include
contributions from therapists, so here is hers. Where is yours?
I call my goniometer my measuring stick. A valuable tool, apparently it has been around
since 1780. One of the oldest scientific instruments known to man, it is related to the
octant, quadrant, astrolabe and sextant. If you cut your goniometer, remember to measure
the full length of the joint segment, for maximizing inherent repeatability (reliability).
Pam Millar
Best wishes,
Roy A. Meals, MD
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