C. Solución a la problemática presente en la CCSS con respecto a la gestión de la póliza
VIII. Alternativa de Solución
3. PROPUESTA DE ESTRATEGIA PARA IMPLEMENTACIÓN DE LA POLÍTICA DE
Problems that might potentially arise from treating a patient using iontophoresis techniques may be avoided for the most part if the athletic trainer (1) has a good understanding of the existing condi- tion to be treated; (2) uses the most appropriate ions to accomplish the treatment goal; and (3) uses ap- propriate treatment parameters and equipment setup. Poor treatment technique on the part of the athletic trainer is most often responsible for adverse reactions to iontophoresis. 97 A list of indications and contraindications appears in Table 6–3.
Treatment of Burns
Perhaps the single most common problem associated with iontophoresis is a chemical burn, which usually occurs as a result of the direct current itself and not as a result of the ion being used in treatment. 65 Passing a continuous direct electrical current through the tissues creates migration of ions, which alters the normal pH of the skin. The normal pH of the skin is between 3 and 4. In an acidic reaction the pH falls below 3, whereas in an alkaline reaction the pH is greater than 5. Although chemical burns may occur under either electrode, they most typically result from the accumulation of sodium hydroxide at the cath- ode. The alkaline reaction causes sclerolysis of local tissues. Initially, the burn lesion is pink and raised but within hours becomes a grayish, oozing wound. 58 Decreasing current density by increasing the size of the cathode relative to the anode can minimize the potential for chemical burn.
Heat burns may occur as a result of high resis- tance to current flow created by poor contact of the electrodes with the skin. Poor contact results when the electrodes are not moist enough; when there are wrinkles in the gauze or paper towels impregnated with the ionic solution; or when there is space between the skin and electrode around the perimeter of the electrode. The patient should not be treated with body weight resting on top of the electrode since this is likely to create some ischemia (reduced circulation) under the electrode. Instead, the electrode should be held firmly in place with adhesive tape, elastic bands, or lightweight sand bags. It is recommended that both chemical burns and heat burns should be treated with sterile dressings and antibiotics. 58
T A B L E 6 – 3 Indications and Contraindications for Iontophoresis INDICATIONS Inflammation Analgesia Muscle spasm Ischemia Edema Calcium deposits Scar tissue Hyperhidrosis Fungi
Open skin lesions Herpes
Allergic rhinitis Gout
Burns
Reflex sympathetic dystrophy
CONTRAINDICATIONS
Skin sensitivity reactions Sensitivity to aspirin (salicylates)
Gastritis or active stomach ulcer (hydrocortisone) Asthma (mecholyl)
Sensitivity to metals (zinc, copper, magnesium) Sensitivity to seafood (iodine)
Clinical Decision-Making Exercise 6–4
After having an iontophoresis treatment, a patient comes into the clinic the next day with an area of skin that is red and tender. It is apparent that the treatment has produced a mild burn. What can the athletic trainer do to minimize the likelihood of a reoccurrence?
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Sensitivity Reactions to Ions
Sensitivity reactions to ions rarely occur; however, they may potentially be very serious. The athletic trainer should routinely question the patient about known drug allergies prior to initiating iontophore- sis treatment. During the treatment the athletic trainer should closely monitor the patient, looking for either abnormal localized reactions of the skin or systemic reactions.
flow of ions that cannot be accomplished using a bidirectional or alternating current.
6. Electrodes may be either reusable or commer- cially produced, self-adhering prepared elec- trodes that must be securely attached to the skin.
7. It is critical that the athletic trainer be knowl- edgeable in the selection of the most appropri- ate ions for treating specific conditions. 8. Clinically, iontophoresis is used in the treat-
ment of inflammatory musculoskeletal condi- tions, for analgesic effects, scar modification, and wound healing, and in treating edema, calcium deposits, and hyperhidrosis.
9. Perhaps the single most common problem as- sociated with iontophoresis is a chemical burn, which usually occurs as a result of the direct current itself and not because of the ion being used in treatment.
Summary
Patients who have sensitivity to aspirin may have a reaction when using salicylates. Hydrocorti- sone may adversely affect individuals with gastritis or an active stomach ulcer. In cases of asthma, mecholyl should be avoided. Patients who are sensi- tive to metals should not be treated with copper, zinc, or magnesium. Iodine iontophoresis should not be used with individuals who have allergies to seafood or those who have had a bad reaction to intravenous pyelograms. 58
1. Iontophoresis is a therapeutic technique that involves the introduction of ions into the body tissues by means of a direct electrical current. 2. The manner in which ions move in solution
forms the basis for iontophoresis. Positively charged ions are driven into the tissues from the positive pole and negatively charged ions are introduced by the negative pole.
3. The force that acts to move ions through the tissues is determined by both the strength of the electrical field and the electrical impedance of tissues to current flow.
4. The quantity of ions transferred into the tissues through iontophoresis is determined by the intensity of the current or current density at the active electrode, the duration of the current flow, and the concentration of ions in solution. 5. Continuous direct current must be used for
iontophoresis, thus ensuring the unidirectional
Review Questions
1. What is iontophoresis and how may it be used?
2. What is the difference between iontophoresis and phonophoresis?
3. How do ions move in solution?
4. What determines the quantity of ions trans- ferred through the tissues during iontophoresis? 5. Why must continuous direct current be used
for iontophoresis?
6. What types of electrodes can be used with ion- tophoresis and how should they be applied? 7. What characteristics should be considered
when selecting the appropriate ion for an ion- tophoresis treatment?
8. What are the various clinical uses for iontopho- resis in athletic training?
9. What treatment precautions must be taken when using iontophoresis?
CHAPTER 6 Iontophoresis 179 Solutions to Clinical Decision-Making Exercises
6–3 The dexamethasone should be placed under the negative electrode since it is a nega- tively charged ion. Current intensity should be set between 3 and 5 IDA. Treatment time should be 15 minutes. The athletic trainer should check the skin every 3 to 5 minutes for a reaction.
6–4 By increasing the size of the cathode rela- tive to the anode, the current density can be decreased. Also, increasing the spacing between the electrodes will decrease current intensity, thus minimizing the chances of a chemical burn.
6–1 If the hydrocortisone comes in a eucerine- based cream preparation or in solution, the athletic trainer should use phonophoresis with the cream preparation to deliver whole mole- cules. Iontophoresis is more appropriate when ions are suspended in solution and can be car- ried into the tissues by an electrical current. 6–2 The safest choice is to reduce the intensity of
the treatment while increasing the duration. For example, a normal dosage may be delivered at 4 mA for 10 minutes. A setting of 2 mA with a treatment time of 20 minutes would deliver the same dosage at a safer intensity. Self-Test Questions
True or False
1. Ionization is the movement of ions in solution. 2. The dispersive electrode contains the ions. 3. pH reactions of greater than 5 are alkaline. Multiple Choice
4. Which type of current does iontophoresis produce?
a. biphasic
b. continuous monophasic c. polyphasic
d. pulsatile
5. What is the recommended range for iontopho- resis current amplitude?
a. 3–5 mA b. 5–10 mA c. 50–100 mA d. 100–150 mA
6. Chemical burn is often associated with ionto- phoresis and may be attributed to
a. allergic reaction b. poor electrode contact c. the medication
d. continuous direct current
7. Which of the following is NOT an ion used to treat inflammation?
a. hydrocortisone b. salicylate c. lidocaine d. dexamethasone
8. Skin impedance usually decreases during
treatment. should be de-
creased to avoid pain and burning. a. current intensity
b. electrode size c. treatment time d. ion dosage
9. What problem do areas of thick fat and skin present?
a. decreased ion absorption b. increased ion absorption c. decreased resistance d. increased resistance
10. Which of the following is a contraindication for iontophoresis?
a. inflammation b. analgesia c. asthma d. muscle spasm
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