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Martinez 2009 catCRITICALLY APPRAISED TOPIC (CAT)
What is the effectiveness of the iontophoretic transmission of dexamethasone in increasing function in patients diagnosed with carpal tunnel syndrome?
Abe Martinez, OTS (firstname.lastname@example.org) Department of Occupational Therapy School of Pharmacy and Health Professions Creighton University 2500 California Plaza Omaha, NE 68178
Date Review Completed:
Clinical studies have found that the iontophoresis of dexamethasone does result in the deposition of medication into the underlying connective tissue (Gurney, Wascher 2008). In the treatment of musculoskeletal conditions involving inflammation, pain, edema, and a reduction in movement, this particular treatment may effectively treat this symptomology in preparation for functional engagement in those activities which the client finds meaningful. As a preparatory method, the iontophoresis of dexamethasone will impact those client factors associated with neuromusculoskeletal and movement-related functions which include those components and factors which allow an individual to physically move and engage in or manipulate his or her contextual environment. Few studies have addressed functional outcomes in the treatment of Carpal Tunnel Syndrome with the iontophoresis of dexamethasone. In order to support client participation, the occupational therapist may manipulate certain client factors which may be specifically hindering the progression of the client’s ability to engage in the environment.
Summary of Key Findings:
Summary of Levels I, II, and III
Only one study (Gokog, et al, 2005) examined the functional outcomes of participants suffering from Carpal Tunnel Syndrome following treatment consisting of the iontophoresis of dexamethasone were included. The researchers studied the effects of iontophoresis of dexamethasone on Carpal Tunnel Syndrome versus a steroid injection. Thirty participants were given either a one-time steroid injection, or received steroid iontophoresis every other day for one week. The Functional Status Scores of both groups showed significant improvement at 2 and 8 weeks post intervention, with significantly better mean scores found with the injection group. Though steroid injection resulted in significantly better functional outcomes, iontophoresis treatment may be a viable alternative given the positive outcomes, its less invasive nature, and more localized administration resulting in minimal systemic effects. Obviously, the functional improvement gained from the iontophoresis of dexamethasone needs significantly more direct analysis. Formatted according to the AOTA Evidence-Based Literature Review Project No studies considered levels IV and V were included
Contri butions of Qualitative Studies:
Bottom Line for Occupational Therapy Practice:
There is limited evidence that suggests improved functional status of patients suffering from Carpal Tunnel Syndrome who are treated with the Iontophoretic transmission of Dexamethasone. Though limited anecdotal and clinical case evidence is present to support its effectiveness, sparse clinical trials and randomized studies exist addressing iontophoresis in the treatment of nerve entrapment conditions. Carpal Tunnel Syndrome is well known as the most prevalent upper-extremity neuropathy, though limited evidence exits to support current treatment commonly being using in the clinical setting. The appraised article suggests Iontophoresis to be a good alternative treatment based on the minimal side-effects, painless, localized, non- invasive nature of the treatment, in addition to the positive outcomes gained from the study participants. In the United States, an approximate 10% lifetime risk to develop Carpal Tunnel Syndrome exists (Gokog et al, 2005). This signifies a considerable client population in need of treatment rightly supported with controlled trials and experimental data. Our population is continually aging, leaving a greater number of individuals susceptible to repetitive, over-use injury such as Carpal Tunnel Syndrome. Care of the geriatric population makes up a significant portion of occupational therapy practice. A recent study (Blumenthal, Herskovitz, & Verhhese, 2006) found that older adults, over the age of 65, were 3.2 times more likely to have clinical symptoms of Carpal Tunnel Syndrome, signifying that older adults may have worse hand function but are under reporting their symptoms. In other words, occupational therapy may be at the front line in order to recognize, clinically diagnose, and treat these older adults who may be suffering with significantly impaired hand function.
Procedures for the selection and appraisal of articles
• The study must utilize measures which determine functional outcomes of participants • Articles dated from 1950 to the present • Treatment intervention consisting of Iontophoresis of Dexamethasone • Use of medications other than dexamethasone • Treatment of inflammatory conditions unrelated to Carpal Tunnel Syndrome • Outcome measures which did not address functional outcomes
Key Search Terms
Iontophoresis, Electrophoresis, Dexamethasone, Treatment Formatted according to the AOTA Evidence-Based Literature Review Project Databases and Sites Searched
Pubmed Medline CINAHL Cochrane Collaboration website
Quality Control/Peer Review Process:
The author was the primary reviewer of the studies. Rene Padilla, the course instructor, reviewed the chosen articles to help determine their clinical significance and extent to which they answered the focused question.
Results of Search
Summary of Study Designs of Articles Selected for Appraisal
Study Design/Methodology of Selected Articles
Number of Articles
Systematic reviews, meta-analysis, randomized Two groups, nonrandomized studies (e.g., cohort, One group, nonrandomized (e.g., before and after, Descriptive studies that include analysis of outcomes Case reports and expert opinion, which include narrative literature reviews and consensus statements
Limitations of the Studies Appraised
Levels I, II, and III
No control used in the trial; participants were not blinded to their treatment received; samples of both groups were not representative of those effected by carpal tunnel; treatment parameters were inconsistent with known best practices; reliability of outcome measures was not reported and may be questionable. Articles Selected for Appraisal
Gokog L. F., Findikog, L. G., Yorganciog, L. Z. R., Okumus, M., Ceceli, E., & Kocaog, L. S. (2005). Evaluation of iontopho resis and local corticosteroid injection in the treatment of carpal tunnel syndrome. American Journal of Physical Medicine and Rehabilitation, 84(2), 92-96. Formatted according to the AOTA Evidence-Based Literature Review Project References:
Blumenthal, S., Herskovitz, S., & J.,Verhhese (2006). Carpal Tunnel Syndrome in Older Adults. Gurney, A. B., & Wascher, D. C. (2008). Absorption of dexamethasone sodium phosphate in human connective tissue using iontophoresis. The American Journal of Sports Medicine, 36(4), 753-759. Formatted according to the AOTA Evidence-Based Literature Review Project
CURRICULUM VITAE Ajay Sahai BHATNAGAR Personal History: Date of Birth: Citizenship: Switzerland Marital Status: Education and Degrees: 1963-1967 University of Basel, Switzerland, Ph.D. University of Cambridge, England, M.A. University of Cambridge, England B.A. (Hons.) Postdoctoral Training: 1968-1970 Council of Scientific and Industrial Research For more