Trigger Point Workshop: A Practical OMT Approach Only the Stuff that s Useful

Trigger Point Workshop: A Practical OMT Approach Only the Stuff that s Useful Sam Detwiler, DO Butler Health System FastERcare Clinical Associate Professor of Family Medicine, OUCOM

Why Care About a Trigger Point? 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. Hypertension Diabetes Well check URI Pregnancy Back and Neck Pain***** Well Child Extremity pain***** Asthma Depression Sinusitis OM Hyperlipidemia GERD Acute Pharyngitis Headache***** Pneumonia/Bronchitis Arthritis conditions/pain***** 19. Obesity 20. Allergic Rhinitis 21. CV- not chest pain 22. Abdominal pain/ N,V, D, C 23. Menstrual Disorder 24. Vaginitis 25. UTI 26. Rash 27. Thyroid disease 28. COPD 29. Chest Pain 30. Injury (laceration, wound, etc.) 31. Anxiety/stress 32. Contraception 33. Eye complaint 34. Dementia 35. STD

Common Complaints Associated with TPs Headaches Muscle Tension/Migraine Low Back Pain Chronic and Acute Myofascial Pain Syndrome Muscle Strains Extremity Pain Arthritis

What is a Trigger Point? Trigger points are discrete, focal, hyperirritable spots located in a taut band of skeletal muscle. They produce pain locally and in a referred pattern and often accompany chronic musculoskeletal disorders. Acute trauma or repetitive microtrauma may lead to the development of stress on muscle fibers and the formation of trigger points. Patients may have regional, persistent pain resulting in a decreased range of motion in the affected muscles.

The Trigger Point

Where do TPs manifest? These include muscles used to maintain body posture, such as those in the neck, shoulders, and pelvic girdle. Trigger points may also manifest as tension headache, tinnitus, temporomandibular joint pain, decreased range of motion in the legs, and low back pain.

Physical exam of Trigger Points Palpation of a hypersensitive bundle or nodule of muscle fiber of harder than normal consistency is the physical finding typically associated with a trigger point. Palpation of the trigger point will elicit pain directly over the affected area and/or cause radiation of pain toward a zone of reference and a local twitch response.

Treatments to Consider for TPs OMT Soft Tissue: Ischemic Compression Strain/CS MFR FPR Still Spray and Stretch TPI (trigger point injections) Neural Therapy PT Posture education Watch for trigger point irritation Muscle relaxants

Treatments cont d NSAIDs Lidoderm patch Tylenol Narcotics Short term use is best Narcotic contract is a must Urine drug testing is a must Drug monitoring system eg pill counts HA Meds (BB, CCB, Antiepilectics, Triptans)

OMT Techniques to Treat TPs

OMT of the Trigger Point Soft Tissue Techniques Ischemic compression Hold pressure on the TP for 30 to 60 seconds Home teaching Home devices Massotherapy

OMT of the Trigger Point Strain/Counterstrain Locate the tender point. Place in a position of relief by wrapping the point Hold for 90 seconds Slowly return to neutral position

OMT of the Trigger Point Myofascial Release Locate Tender Point Take tissues surrounding the point to a position of ease Hold for 30 to 60 seconds or until you feel tissues release Return to neutral

OMT of the Trigger Point Facilitated Positional Release MFR + Vector compressive force Locate tender point. Take to a position of ease Add a vector compressive force through the TP for 5 seconds Return to neutral

OMT of the Trigger Point A.T. Still Technique FPR + a ROM around the compressive force. Locate Tender Point Take tissues surrounding the point to a position of ease Add a vector compressive force through the TP for 5 seconds Take the Tissue/Limb in a ROM around the point Demonstrate with C-spine

OMT of the Trigger Point Spray and Stretch Spray skin coolant in the direction of pain pattern and passively stretch in between sprays Ethyl Chloride

Adjunct to OMT: TP Injections

Equipment Needed for Trigger-Point Injection Rubber gloves Gauze pads Alcohol pads for cleansing skin 3- or 5-mL syringe Lidocaine (Xylocaine, 1 percent, without epinephrine) or procaine (Novocain, 1 percent) 22-, 25-, or 27-gauge needles of varying lengths, depending on the site to be injected Adhesive bandage

Contraindications to Trigger-Point Injection Anticoagulation or bleeding disorders Aspirin ingestion within three days of injection The presence of local or systemic infection Allergy to anesthetic agents Acute muscle trauma Extreme fear of needles

Complications of Trigger-Point Injections Vasovagal syncope Skin infection Pneumothorax; avoid pneumothorax complications by never aiming a needle at an intercostal space. Needle breakage; avoid by never inserting the needle to its hub. Hematoma formation; avoid by applying direct pressure for at least two minutes after injection

Needle Selection The choice of needle size depends on the location of the muscle being injected. The needle must be long enough to reach the contraction knots in the trigger point to disrupt them. A 22-gauge, 1.5-inch needle is usually adequate to reach most superficial muscles. For thick subcutaneous muscles such as the gluteus maximus or paraspinal muscles in persons who are not obese, a 21-gauge, 2.0-inch needle is usually necessary. A 21-gauge, 2.5-inch needle is required to reach the deepest muscles, such as the gluteus minimus and quadratus lumborum, and is available as a hypodermic needle.

Trigger Point Injections: Hypodermic Needles

Needle Selection Using a needle with a smaller diameter may cause less discomfort; however, it may provide neither the required mechanical disruption of the trigger point nor adequate sensitivity to the physician when penetrating the overlying skin and subcutaneous tissue. A needle with a smaller gauge may also be deflected away from a very taut muscular band, thus preventing penetration of the trigger point. The needle should be long enough so that it never has to be inserted all the way to its hub, because the hub is the weakest part of the needle and breakage beneath the skin could occur.

Trigger Point Injections Dry Needling (Acupuncture needle) My favorite: Lhasa OMS (www.lhasaoms.com) Name brands: Seirin Hwa-to

Accupuncture Needles

Trigger Point Injections Needle Diameter Hypodermic Gauge.30 30.20 36.14 42.12 44

Injection Solutions An injectable solution of 0.5 to 1 % lidocaine or 1 % procaine is usually used. Several other substances, including diclofenac (Voltaren), botulinum toxin type A (Botox), and corticosteroids, have been used in trigger-point injections. However, these substances have been associated with significant myotoxicity. Procaine has the distinction of being the least myotoxic of all local injectable anesthetics.

Trigger Point Injections 0.5% Lidocaine 0.2-0.5 cc into each muscle 30ga 1.5 inch needle Avoid use in face Inject 4-10 sites per session, in same region 1% Lidocaine 27 G needle, 1.25"long 3 cc syringe Inject 0.2-0.5 cc per site Avoid use in face Inject 4-10 sites per session, in same region

Injection Technique Once a trigger point has been located and the overlying skin has been cleansed with alcohol, the clinician isolates that point with a pinch between the thumb and index finger or between the index and middle finger, whichever is most comfortable.

Injection Technique Using sterile technique, the needle is then inserted 1 to 2 cm away from the trigger point so that the needle may be advanced into the trigger point at an acute angle of 30 degrees to the skin. The stabilizing fingers apply pressure on either side of the injection site, ensuring adequate tension of the muscle fibers to allow penetration of the trigger point but preventing it from rolling away from the advancing needle.

Injection Technique Before advancing the needle into the trigger point, the physician should warn the patient of the possibility of sharp pain, muscle twitching, or an unpleasant sensation as the needle contacts the taut muscular band. To ensure that the needle is not within a blood vessel, the plunger should be withdrawn before injection. A small amount (0.2 ml) of anesthetic should be injected once the needle is inside the trigger point. The needle is then withdrawn to the level of the subcutaneous tissue, then redirected superiorly, inferiorly, laterally and medially, repeating the needling and injection process in each direction until the local twitch response is no longer elicited or resisting muscle tautness is no longer perceived.

Post-injection Management After injection, the area should be palpated to ensure that no other tender points exist. If additional tender points are palpable, they should be isolated, needled and injected. Pressure is then applied to the injected area for two minutes to promote hemostasis. A simple adhesive bandage is usually adequate for skin coverage. One study emphasizes that stretching the affected muscle group immediately after injection further increases the efficacy of trigger point therapy. Travell recommends that this is best performed by immediately having the patient actively move each injected muscle through its full range of motion three times, reaching its fully shortened and its fully lengthened position during each cycle.

Post Injection Management Postinjection soreness is to be expected in most cases, and the patient's stated relief of the referred pain pattern notes the success of the injection. Re-evaluation of the injected areas may be necessary, but reinjection of the trigger points is not recommended until the postinjection soreness resolves, usually after three to four days. Repeated injections in a particular muscle are not recommended if two or three previous attempts have been unsuccessful. Patients are encouraged to remain active, putting muscles through their full range of motion in the week following trigger-point injections, but are advised to avoid strenuous activity, especially in the first three to four days after injection

Myofascial Pain Syndrome (MPS) Characterized by the development of Myofascial trigger points that are locally tender when active Refer pain through specific patterns to other areas of the body. Due to many causes like trauma, arthritis, deconditioning. Trigger points are usually associated with a taut band, a ropey thickening of the muscle tissue. PREVALENCE (since 1980 s) Primary care: 30% present with pain & 30% of these pts. have MPS Pain clinics: 50-85% of pts. present with MPS

Headaches Migraines IHS Criteria Anyone can get one Triggers often include MSK component Most Common Offenders Traps SCM Levator Scapulae

Trapezius

Trapezius Needling Patient supine Pincer grasp of muscle Insert needle anterior to posterior 30ga x 1.5 or.30 x 50mm Muscle twitches can be significant

Levator Scapulae

Levator Scapulae Needling Patient prone Insert needle at shallow angle toward superior angle of scapula.30 x 50 mm or 30 ga x 1 DO NOT insert needle posterior to anterior Muscle twitch is moderate

Sternocleidomastoid

SCM Needling Patient supine Pincer grasp of muscle 30 ga x 1 or.30 x 50mm Avoid external jugular (bruising) Insert needle only through portion of muscle you re holding Muscle twitch is moderate Responsible for lots of ENT-like symptoms

Low Back Pain Common muscle trouble makers: QL Iliopsoas Multifidis Iliocostalis & Longissimus Glute medius

Quadratus Lumborum

QL Needling Patient on side May need pillow under opposite side ID muscle using midpoint of iliac crest and ½ way b/w there and rib 12 Insert.30 x 50 mm or.30 x 60 mm needle lateral to medial toward middle of spinous process

QL Stretch

Iliopsoas

Iliopsoas Needling Patient prone Insert.30 x 75 mm needle posterior lateral to anterior medial through QL Patient on side Insert a.30 x 75 mm needle posterior lateral to anterior medial lateral through QL; aim for base of transverse process

Iliopsoas Stretch

Multifidus

Multifidus Needling Patient supine Safety zone is 1 finger width lateral to spinous process Insert.30 x 50 mm needle from posterior lateral to anterior medial; aim for base of transverse process and lamina

Multifidus Origin Insertion Posterior surface of the sacrum Articular processes of the lumbar vertebrae Transverse processes of the thoracic vertebrae Articular processes of C3-7 Each part of the muscle inserts into the spinous process 2-4 vertebrae higher than its origin Actions Extension, lateral flexion and rotation of the spine

Iliocostalis & Longissimus

Iliocostalis & Longissimus Needling Patient prone.30 x 50 mm needle Identify trigger point Use index and middle fingers to block the adjacent intercostal spaces Insert needle using shallow angle

Gluteus Medius

Glute Medius Needling Patient on side.30 x 50mm needle into trigger point Muscle twitch ranges from barely noticeable to fairly strong Can mimic greater trochanteric bursitis

Triceps

Triceps Needling Pincer grasp of muscle.30 x 50 mm needle Insert needle only through portion of muscle you re holding Review anatomy to avoid median nerve and radial nerve Muscle twitch is strong

Anconeus

Anconeus Needling.20 x 25mm needle Muscle twitch is vague to moderate

Supraspinatus

Supraspinatus Needling Pt seated or prone 30ga x 1.5 or.30 x 50mm needle You must identify the spine of scapula Insert needle anterior to posterior and medial to lateral Muscle twitch is vague Very common trigger point in shoulder pain

Infraspinatus

Infraspinatus Needling Pt seated or prone 30ga x 1.5 or.30 x 50mm needle You must identify the medial border and inferior angle of scapula Muscle twitch is moderate Very common trigger point in shoulder pain

Serratus Posterior Superior

Serratus Posterior Superior Needling Patient prone.30 x 50mm needle Identify trigger point Use index and middle fingers to block the adjacent intercostal spaces Insert needle using shallow angle Muscle twitch vague to moderate

Serratus Posterior Superior Needling You may get the best access with patient side-lying Affected side down Arm internally rotated with hand behind back Pull scapula away from ribs Insert.30 x 50mm needle parallel to rib cage and scapula Also treats: Rhomboid, Subscapularis, Serratus anterior

Piriformis

Piriformis Needling Patient prone.30 x 50mm needle Avoid middle portion of piriformis to avoid sciatic nerve Have pt ext rotate leg to ID muscle

Gluteus Maximus

Glute Max Needling Patient prone or on side.30 x 50mm Avoid sciatic nerve Have pt extend hip to ID muscle

Gluteus Medius

Gluteus Minimus

Glute Minimus Patient side lying.30 x 50mm needle Muscle twitch ranges from barely noticeable to fairly strong Can mimic greater trochanteric bursitis

Rectus Femoris

Rectus Femoris Needling Patient supine 30ga x 1.5 or.30 x 50mm Muscle twitch is usually strong

Vastus Medialis, Intermedius & Lateralis

Vastus Muscles Patient supine 27ga x 1.5 or.30 x 50mm (I prefer the hypodermic needle) Muscle twitch can be very strong Have pt extend knee and slightly lift leg to ID muscle

Adductors a D D U C T O

Adductor Needling Patient supine or side lying Pincer grasp of muscle 30ga x 1.5 or.30 x 50mm needle Muscle is twitch fairly strong

Hamstrings

Hamstring Needling Patient prone.30 x 50mm needle Angle away from midline to avoid sciatic nerve Muscle is twitch fairly strong and trigger point feels particularly crampy

Soleus and Gastroc Needling Patient prone 30ga x 1.5 or.30 x 50mm needle Muscle is twitch strong Only do one side per treatment session

Post Treatment Ice several times a day for 1st 24 hr and then heat Stretch affect muscles twice a day Manual treatment daily using The Trigger Point Therapy Workbook by Claire Davies

Post Treatment Warn patient that pain may temporarily increase after the treatment. Treat with: Ice NSAID Rest If no better after 4 or 5 treatments, verify that patient is doing their part, keep looking for other reasons including Vit D, Thyroid or Iron status Botox may be another treatment option

Common Musculoskeletal CPT Codes OMT: 9892x Trigger Point Injection Billed by number of regions treated 1-2, 3-4, 5-6, 7-8, 9-10 20552: 1-2 muscles (Medicare or private insurance) 20553: 3+ muscles (Private insurance only) x=5,6,7,8 or 9

CPT Codes - cont d Tendon Injection: 20550 Joint/bursa Aspiration or Injection Small (finger/toes): 20600 Medium: 20605 Large (shoulders/hips/si/knee): 20610

ICD-9 Codes for TPI 729.1 Myofascial pain, fibromyalgia Medicare or private insurance 728.85 Muscle spasm Private insurance

Modifiers - 24 Used on E/M code only Appends office visit if occurring during the global time period of a surgery and the visit is unrelated to that surgery Example Pt had TPI or OMT and returns 1 week later for reassessment of the symptoms that prompted the treatment and possible retreatment Your billing sheet Circle 99213 (established patient office visit) Circle the 24 modifier, assigning it to the 99213 Write in 728.85 or 9892x Circle TPI or OMT CPT code

Modifiers - 25 Used on E/M code only Separate and distinct procedure Example: New non-medicare Pt seen for LBP and you diagnose them with QL and multifidus trigger points Your billing sheet Circle 99203 (new patient office visit) Circle the 25 modifier, assigning it to the 99203 Write in 728.85 Circle 20552 (1-2 muscle TPI) You ve just added $160 to your billing Used for anything else you do other than lab & x-ray EKG, nebulizer, TPI, OMT, etc

Modifiers - 50 Used on the procedure code Bilateral procedure (joint/tendon injection) Example: New patient presents c/o bilateral shoulder pain You diagnose bilateral subacromial bursitis (726.19) You inject each subacromial bursa (20610) Your billing sheet Circle 99203, attach 25 modifier to it Write in 726.19 Circle 20550 and attach the 50 modifier to it

Modifiers - 59 Used on the procedure code Prevents bundling of multiple procedures Based on the National Correct Coding Initiative In above example, the patient also had a SD of the C-spine, T-spine and First ribs: You add 739.1, 739.2 & 739.8 to the dx list You also circle 98926 for the OMT You link the 59 modifier to the OMT* *Attach the 59 to the less expensive procedure (OMT - $80)

Charges: OMT 98925 (1 2 regions) 98926 (3 4 regions) 98927 (5 6 regions) 98928 (7 8 regions) 98929 (9-10 regions) $59 $80 $103 $122 $140

Charges: Trigger Point Trigger Point Injection 20552 or 20553 $160

Documentation Because injections are considered surgical procedures, they require a procedure note. The procedure note should include a signed consent, documentation of the anatomic location, preparation of the site, local anesthetic administration, name and dosage of drug administered, and patient reaction to procedure. Documentation should also include all postoperative instructions related to the procedure.

References & Resources 1. Imamura ST, Fischer AA, Imamura M, Teixeira MJ, Tchia Yeng Lin, Kaziyama HS, et al. Pain management using myofascial approach when other treatment failed. Phys Med Rehabil Clin North Am. 1997;8:179 96. 2. Cole TM, Edgerton VR. Musculoskeletal disorders. In: Cole TM, Edgerton VR, eds. Report of the Task Force on Medical Rehabilitation Research: June 28 29, 1990, Hunt Valley Inn, Hunt Valley, Md. Bethesda: National Institutes of Health, 1990:61 70. 3. Hong CZ, Hsueh TC. Difference in pain relief after trigger point injections in myofascial pain patients with and without fibromyalgia. Arch Phys Med Rehabil. 1996;77:1161 6. 4. Simons DG, Travell JG, Simons LS. Travell & Simons' Myofascial pain and dysfunction: the trigger point manual. 2d ed. Baltimore: Williams & Wilkins, 1999:5. 5. Han SC, Harrison P. Myofascial pain syndrome and trigger-point management. Reg Anesth. 1997;22:89 101. 6. Ling FW, Slocumb JC. Use of trigger point injections in chronic pelvic pain. Obstet Gynecol Clin North Am. 1993;20:809 15. 7. Mense S, Schmit RF. Muscle pain: which receptors are responsible for the transmission of noxious stimuli? In: Rose FC, ed. Physiological aspects of clinical neurology. Oxford: Blackwell Scientific Publications, 1977:265 78. 8. Hopwood MB, Abram SE. Factors associated with failure of trigger point injections. Clin J Pain. 1994;10:227 34. 9. Fricton JR, Kroening R, Haley D, Siegert R. Myofascial pain syndrome of the head and neck: a review of clinical characteristics of 164 patients. Oral Surg Oral Med Oral Pathol. 1985;60:615 23. 10. Simons DG, Travell JG, Simons LS. Travell & Simons' Myofascial pain and dysfunction: the trigger point manual. 2d ed. Baltimore: Williams & Wilkins, 1999:94 173. 11. Rachlin ES. Trigger points. In: Rachlin ES, ed. Myofascial pain and fibromyalgia: trigger point management. St. Louis: Mosby, 1994:145 57. 12. Fischer AA. Injection techniques in the management of local pain. J Back Musculoskeletal Rehabil. 1996;7:107 17. 13. Simons DG, Travell JG, Simons LS. Travell & Simons' Myofascial pain and dysfunction: the trigger point manual. 2d ed. Baltimore: Williams & Wilkins, 1999:11 93. 14. Yunus MB. Fibromyalgia syndrome and myofascial pain syndrome: clinical features, laboratory tests, diagnosis, and pathophysiologic mechanisms. In: Rachlin ES, ed. Myofascial pain and fibromyalgia: trigger point management. St. Louis: Mosby, 1994:3 29. 15. Sola AE, Bonica JJ. Myofascial pain syndromes. In: Bonica JJ, ed. The management of pain. 2d ed. Philadelphia: Lea & Febiger, 1990: 352 67. 16. Rachlin ES. History and physical examination for regional myofascial pain syndrome. In: Rachlin ES, ed. Myofascial pain and fibromyalgia: trigger point management. St. Louis: Mosby, 1994:159 72. 17. Hong CZ. Lidocaine injection versus dry needling to myofascial trigger point. The importance of the local twitch response. Am J Phys Med Rehabil. 1994;73:256 63.

Online Resources http://www.proceduresconsult.com/medicalprocedures http//emedicine.medscape.com www.aafp.org DrSamuelDetwiler@gmail.com