Iontophoresis in lateral epicondylitis: a randomized, double-blind clinical trial

Intradermal Delivery of Naked mRNA Vaccines via Iontophoresis

Messenger RNA (mRNA) vaccines against infectious diseases and for anticancer immunotherapy have garnered considerable attention. Currently, mRNA vaccines encapsulated in lipid nanoparticles are administrated via intramuscular injection using a needle. However, such administration is associated with pain, needle phobia, and lack of patient compliance. Furthermore, side effects such as fever and anaphylaxis associated with the lipid nanoparticle components are also serious problems. Therefore, noninvasive, painless administration of mRNA vaccines that do not contain other problematic components is highly desirable. Antigen-presenting cells reside in the epidermis and dermis, making the skin an attractive vaccination site. Iontophoresis (ItP) uses weak electric current applied to the skin surface and offers a noninvasive permeation technology that enables intradermal delivery of hydrophilic and ionic substances. ItP-mediated intradermal delivery of biological macromolecules has also been studied. Herein, we review the literature on the use of ItP technology for intradermal delivery of naked mRNA vaccines which is expected to overcome the challenges associated with mRNA vaccination. In addition to the physical mechanism, we discuss novel biological mechanisms of iontophoresis, particularly ItP-mediated opening of the skin barriers and the intracellular uptake pathway, and how the combined mechanisms can allow for effective intradermal delivery of mRNA vaccines.

BESS patient care pathway: Tennis elbow

This article provides a guidance summary for the management of lateral elbow tendinopathy (LET) using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system of the rating quality of the literature and grading the strength of available evidence. The process began by assembling a guideline development group of volunteers including orthopaedic surgeons, trainees, physiotherapists, rheumatologists, radiologists and patients. Virtual meetings were organised to set out explicit PICO questions, including specification of all important outcomes (including patient reported tennis elbow evaluation (PRTEE) as an important primary outcome) to determine the clinical effectiveness of common treatment options for LET compared with no treatment or placebo. Clinical librarian searched (date 31 April 2022) for available systematic reviews and randomised controlled trials reviewing the management of the LET January 2011 onwards and evidence was collected and summarized using explicit GRADE criteria for rating the quality of evidence that include study design, risk of bias, imprecision, inconsistency, indirectness, and magnitude of effect. Recommendations were characterized as strong or weak (alternative terms conditional or discretionary) according to the quality of the supporting evidence and the balance between desirable and undesirable consequences of alternative management options. This informative summary provides the quality of available evidence for the management of LET.

Skin permeation of curcumin nanocrystals: Effect of particle size, delivery vehicles, and permeation enhancer

Nanocrystals are characterized by high drug loading, low carrier toxicity, and great structural stability. Therefore, they are a promising and versatile strategy for enhancing the local delivery of insoluble drugs. They achieve this by improving skin adhesion, concentration gradients, and hair follicle accumulation, as well as generating corona diffusion (which forms through the overlap of dissolved drug molecules around a nanocrystal). The development of suitable formulations for enhancing the passive diffusion and/or follicular targeting of nanocrystals is of great importance to clinical practice. We sought to elucidate the influence of particle size, a penetration enhancer, and delivery vehicles on the follicular accumulation and passive dermal permeation of nanocrystals. For this purpose, curcumin nanocrystals (particle size: 60, 120, and 480 nm) were incorporated into xanthan gum gels (delivery vehicles) with propylene glycol (penetration enhancer). This evaluation was performed in a porcine skin model. The results showed that xanthan gum reduced the follicular penetration and passive skin accumulation of curcumin nanocrystals. The propylene glycol enhanced the skin penetration and retention of curcumin nanocrystals in vitro for 24 h. The curcumin nanocrystals of smaller particle size (i.e., 60 and 120 nm) displayed higher passive skin penetration versus those with larger particle size (i.e., 480 nm); however, the latter type showed deeper follicular accumulation. In conclusion, the delivery vehicles, penetration enhancer, and particle sizes examined in this study affect the dermal penetration and accumulation of curcumin nanocrystals. Hence, their effects should be adequately considered when designing formulations of such nanocrystals.

Lateral Elbow Pain and Muscle Function Impairments

Although often described as a self-limiting condition and likely to resolve on its own, high recurrence rates and extended sick leave frame a need for effective non-surgical treatment for people with lateral elbow tendinopathy. The interrelationship of histological and structural changes to the tendon, the associated impairments in motor control, and potential changes in pain processing may all drive symptoms. This clinical practice guideline covers the epidemiology, functional anatomy and pathophysiology, risk factors, clinical course, prognosis, differential diagnosis, tests and measures, and interventions for managing lateral elbow tendinopathy in the physical therapy clinic. J Orthop Sports Phys Ther 2022;52(12):CPG1-CPG111. doi:10.2519/jospt.2022.0302.

Advances toward transformative therapies for tendon diseases

Approved therapies for tendon diseases have not yet changed the clinical practice of symptomatic pain treatment and physiotherapy. This review article summarizes advances in the development of novel drugs, biologic products, and biomaterial therapies for tendon diseases with perspectives for translation of integrated therapies. Shifting from targeting symptom relief toward disease modification and prevention of disease progression may open new avenues for therapies. Deep evidence-based clinical, cellular, and molecular characterization of the underlying pathology of tendon diseases, as well as therapeutic delivery optimization and establishment of multidiscipline interorganizational collaboration platforms, may accelerate the discovery and translation of transformative therapies for tendon diseases.

In vitro bacteriological effect of tri-beveled needle electrolysis against Staphylococcus aureus

Percutaneous needle electrolysis using tri-beveled needles with a specific protocol (5 mA applied for 25 s) has demonstrated to provoke a clinical reduction of recurrent bacterial infections in mammary fistulas. However, the bactericidal effect of needle electrolysis in this pathology remains theoretical. This in vitro study evaluated the bactericidal effect of this protocol and whether it changed when introducing small variations. Staphylococcus aureus were generated in saline solution (9 Log₁₀ CFU/mL) and treated in three different experiments including the main protocol and introducing variations in needle gauge, intensity, and total dosage, respectively. After 24 h, the viable cell count showed that the protocol had an average reduction of 5 log₁₀ CFU/ml compared to the control group. While variations in needle gauge did not modify this effect, variations in current intensity or dosage did. This study demonstrated that the bacterial effect was greater by increasing either current intensity or total dosage, and it decreased with substantial reductions of these parameters.

Evaluation of the effectiveness of dexamethasone iontophoresis in patients with subacromial impingement syndrome

BACKGROUND

Subacromial impingement syndrome is the most common shoulder disease in individuals. There is no study evaluating the effectiveness of steroid iontophoresis in subacromial impingement syndrome. We aimed to assess the effectiveness of dexamethasone iontophoresis as treatment for impingement syndrome with respect to pain and function.

METHODS

Forty-six patients with subacromial impingement syndrome were recruited to the study and divided randomly into two groups (21 patients in iontophoresis group and 25 patients in control group). Demographic, clinical features and MRI findings of patients were recorded. Detailed physical examination of all patients were performed and Numerical rating scale (NRS) during rest and exercise, The Disabilities of the Arm, Shoulder and Hand (DASH) scores were recorded at baseline, week 2 and week 6. Both group received physiotherapy program for ten days. Additionally the patients in iontophoresis group recieved dexamethasone iontophoresis (1 mg dexamethasone per 1 g administered under the active electrode) with an intensity of 0.1-0.2 mA/cm2 galvanic current for ten days.

RESULTS

No significant difference was observed between the groups in terms of gender, job status, MRI findings, painful shoulder and pain duration. Baseline range of motion, Neer, Hawkins, Yocum and painful arc tests, numerical rating scale (NRS) and DASH scores were similar between groups. A significant improvement was found in terms of the NRS (resting and exercise) and DASH scores at week 2 and week 6 in both group (p < 0.001). A significant difference was found in terms of improvement NRS (resting) and DASH scores between baseline and week 6 in iontophoresis group (p = 0.007, p = 0.011 respectively).

CONCLUSIONS

Adding dexamethasone iontophoresis to physiotherapy for patients with subacromial impingement syndrome seems to provide a better clinical and functional improvement.

Toward Understanding Movement-evoked Pain (MEP) and its Measurement: A Scoping Review

OBJECTIVE

Individuals with chronic pain conditions often report movement as exacerbating pain. An increasing number of researchers and clinicians have recognized the importance of measuring and distinguishing between movement-evoked pain (MEP) and pain at rest as an outcome. This scoping review maps the literature and describes MEP measurement techniques.

MATERIALS AND METHODS

The scoping review utilized 6 databases to identify original studies that targeted pain or movement-related outcomes. Our search returned 7322 articles that were screened by title and abstract by 2 reviewers. The inclusion criteria focused on the measurement of MEP before, during, and after movement tasks in adults with chronic pain. Studies of children below 18 years of age or with nonhuman animals, case studies, qualitative studies, book chapters, cancer-related pain, non-English language, and abstracts with no full publish text were excluded from the study.

RESULTS

Results from 38 studies revealed great variation in the measurement of MEP, while almost all of the studies did not provide an explicit conceptual or operational definition for MEP. In addition, studies collectively illuminated differences in MEP compared with rest pain, movement provocation methods, and pain intensity as the primary outcome.

DISCUSSION

These results have clinically significant and research implications. To advance the study of MEP, we offer that consistent terminology, standardized measurement (appropriate for pain type/population), and clear methodological processes be provided in research publications. On the basis of the findings, we have put forth a preliminary definition of MEP that may benefit from the continued scholarly dialog.

The use of dry needling vs. corticosteroid injection to treat lateral epicondylitis: a prospective, randomized, controlled study

BACKGROUND

Lateral epicondylitis (LE) is a common disease especially at middle age. Different types of treatments have been used to address LE. Corticosteroid (CS) injections and dry needling (DN) are utilized options in the treatment. However, the question of which one is better has not been entirely discussed in the literature. We hypothesized that the use of DN to treat LE would be at least as effective as using CS injections. We compared the pain relief afforded and improvements in functional disability after DN and CS injection.

METHODS

A total of 108 LE patients whose pain was not relieved by 3 weeks of first-line treatment were included in a randomized manner, using an online application into DN or CS groups (54 patients each). The minimum follow-up duration was 6 months. We recorded "Patient-Rated Tennis Elbow Evaluation" (PRTEE) scores before treatment and after 3 weeks and 6 months of treatment.

RESULTS

Seven patients were excluded for various reasons; thus, 101 patients were finally evaluated. Before treatment, the groups were similar in terms of age, symptom duration, and PRTEE score, but after treatment, DN-treated patients showed better improvement in the PRTEE score than CS-treated patients (P < .01). Both treatments were effective (both P < .01). From assessments at 3 weeks and 6 months post-treatment, PRTEE scores decreased over time. Four CS-treated patients (7.6%) developed skin atrophy and whitening. One DN-treated patient (2.04%) could not tolerate the pain of the intervention and withdrew from treatment.

CONCLUSION

DN and CS injection afforded significant improvements during the 6 months of follow-up. However, compared with CS injection, DN was more effective.