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Iontophoresis Protocol:

Carpel Tunnel Sydrome 2


The carpal tunnel lies deep to the palmaris longus muscle A. Subjective:
and is bordered: anteriorly by the transverse carpal liga- Patient complaint
ment; medially by the pisiform and hook of hamate; later- Location
ally by the tubercle of scaphoid and the tubercle of trape- Onset and duration of symptoms (usually early,
zium; and posteriorly by the carpals. The median nerve mild to moderate CTS responds better to treat-
and finger flexor tendons pass through this tunnel. ment; late, severe CTS tends not to respond well
Overuse of the finger flexors, repeated trauma, sprains, or due to tissue damage)
swelling can cause compression of the median nerve, Description of symptoms (i.e. numbness, pain
resulting in decreased median nerve sensation in the hand, [constant, dull, sharp] hypersensitivity, stiffness);
restriction or possible prevention of finger flexion. use pain scale
Pattern of when symptoms occur (AM, PM, after
Diagnosis and confirmation of CTS is based on: activity, etc.)
Self-help or other formal treatment
1) Numbness, pain or paresthesia of hand and wrist along Other medical problems
median nerve distribution, nocturnal awakening from Concurrent medications and allergies
hand pain and aggravation of symptoms with repetitive
hand/wrist motion. Weakness may occur in the abductor B. Objective (also compare with uninvolved wrist):
pollicis brevis muscle with thenar atrophy. 1. Inspection:
2) Positive Tinel's sign (tapping over the volar tunnel lig- Atrophy
ament and reproducing pain along the median nerve dis-
tribution) and/or positive Phalen's test (passively flexing 2. Palpation:
the wrist to its maximum degree for one minute causing Carpal bones
tingling along the median nerve distribution). Soft tissue: muscles and tendons (anteriorly,
medially, posteriorly, laterally), palmaris
3) Electrodiagnostic studies showing abnormal motor or longus
sensory median nerve distal latencies.
3. Mobility (Active and Passive)
Wrist ROM (flexion, extension, radial devia-
tion, ulnar deviation, supination, pronation)
Finger ROM (flexion, extension, abduction,
Drug Thumb ROM (flexion, extension, palmar
Electrode abduction, palmar adduction, opposition)
Site 4. Muscle Tests:
Wrist (flexors, extensors, ulnar deviators,
radial deviators)
Finger (flexors, extensors)
Thumb (abduction, adduction, flexion,
extension, opposition)

5. Provocation Tests:
Reproducing pain or paresthesia along median
nerve distribution into the hand:
- Tinel sign: tap volar carpal ligament with
palm open, fingers extended.
Transverse - Phalen's test: passively flex both wrists in
Finger maximum flexion for one (1) minute.
Flexor 6. Neurological Tests:
Tendons Sensory and conduction tests of the median

7. Other Joints: IMPORTANT: See iontophoresis system and electrode

Assess elbow and shoulder for concurrent instruction guides for indications, contraindications, warnings,
precautions and directions for use.
1. Clean skin is absolutely necessary to minimize or elim-
8. Review x-rays and physician's report; rule out: inate skin irritation. Clean both electrode sites vigor-
Colles fracture and anterior dislocation of the ously with an alcohol wipe prior to applying electrodes
lunate to remove dry skin, salts and oils. Excess hair may be
Systemic disease trimmed with scissors or electric clippers. Do not
shave skin. Doing so may result in excessive irritation
or burns.
C. Assessment:
1. Problem list 2. Prepare electrodes according to package instructions.
2. Goals
3. Recommended Treatment: 3. Place the drug electrode longitudinally, centered over
Iontophoresis ( medications, dosages, the involved carpal tunnel, with wrist crease "divid-
electrode size) ing" electrode approximately in half.
Rest and wrist splint in neutral position
4. The dispersive pad Dispersive pad may be placed
Oral or injectable medications administered by proximal to drug electrode, over a major muscle on the
physician (e.g. NSAIDs, corticosteroids) forearm. Never tape, bind or compress either electrode
Patient education on work activities or sports in any way. Properly prepared drug electrodes and dis-
for prevention of re-injury, etc.) persive pads do not require added fixation on properly
prepared skin.
D. Plan:
1. Frequency and duration of treatment 5. Do not allow patient to extend or flex the wrist or to
press on or lean against electrodes during treatment.
2. Date(s) for assessment of progress This prevents circuit breaks and minimizes the possi-
bility of excessive skin irritation or burns.
APPROPRIATE THERAPY 6. Initially, treat at 2.0mA for 20 minutes to deliver a
Iontophoretic drug delivery for the condition of mild to total dosage of 40 milliampere-minutes according to
package instructions. Increase current for subsequent
moderate carpal tunnel syndrome provides an alternative treatments if patient tolerates higher current levels
to hypodermic injection of corticosteroids, with increased comfortably.
comfort and decreased systemic side effects. It allows
short term administration and avoids the associated dis- 7. Treat every other day. Usually, no more than three
comfort of needle insertion at an already tender area of tis- treatments are required, but there is no contraindica-
sue. Avoiding the use of a hypodermic needle prevents tion for additional treatments.
further tissue trauma, eliminates the risk of infection at the REFERENCES
injection site and eliminates the risk of potential necrosis
1. Cyriax, J. 1983. Illustrated Manual of Orthopedic
and/or tendon weakening associated with bolus injections Medicine. Butterworths. London.
of corticosteroids. Carpal tunnel syndrome is usually a
very well localized condition, appropriate for electrode 2. Hartley, A. 1990. Practical Joint Assessment. Mosby Year
placement over the affected area. Book. St. Louis.

3. Hoppenfeld, S. 1976. Physical Examination of the Spine

RE-EVALUATION and Extremities. Appleton-Century-Crofts. New York.
In addition to the patient's subjective reports, check for
4. Saunders, H.D. 1985. Evaluation, Treatment & Prevention
decreased pain, decreased paresthesia, increased strength of Musculoskeletal Disorders. W.B. Saunders. Minneapolis.
of the abductor pollicis brevis muscle, negative Tinel sign
and negative Phalen's test. Neurological tests may be used 5. Warwick, R. and Williams, P. 1983. Gray's Anatomy, 35th
to check for improved sensation and conduction of the British Ed. W.B. Saunders. Philadelphia
median nerve. Edited By: For:
Distributed By:
Balego & Associates, Inc. Rebecca Stephenson, PT IOMED, Inc.
1-800-322-2781 Stephenson Physical Therapy 2441 South 3850 West, Suite A
Fax: 651-633-0024 335 Main Street Salt Lake City, Utah 84120 USA Medfield, MA 02052 Ph. 800.621.3347 Fax 800.318.7793

IOMED, Inc., 1993. Printed in USA. 3/03. All rights reserved.