Treatment with IMS: Preparation Precautions Procedures
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- Roger Holt
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1 Treatment with IMS: Preparation Precautions Procedures John Kent, BSc, MD Specialist in Family Medicine Founder, Israeli Society for Musculoskeletal Medicine
2 Indications for IMS Myofascial component to the pain problem Must be combined with: Exercise Supervised (Physiotherapy) Unsupervised Postural education Work modifications Treat sleep disturbance Treat tension/anxiety/depression Treat metabolic disturbances Magnesium, Fe, Ca Vitamin D, B12, folate Thyroid 2
3 Red Flags Red Flag Cauda Equina Syndrome Severe unremitting worsening of pain (non-mechanical) Significant trauma Weight loss, fever, history of cancer/hiv Use of IV drugs or steroids Patient over 50 Widespread neurological signs Description sudden onset major bladder or bowel symptoms, perineal numbness (at night and pain when laying down) consider infection/tumor consider fractures consider infection/tumor consider infection/compression fracture (if first ever episode of serious back pain) refer SOON for prompt investigation consider infection/tumor/neurological disease 3
4 Yellow Flags o o o o o o o o o Belief that pain and activity are harmful Sickness behaviours (like extended rest) Low or negative moods, social withdrawal Treatment beliefs do not fit best practice Problems with claim and compensation History of back pain, time-off, other claims Problems at work, poor job satisfaction Heavy work, unsociable hours (shift work) Overprotective family or lack of support 4
5 Contraindications to IMS Not myofascial pain Early pregnancy Local infection Hemophilia Anticoagulants Tumors, moles, warts General Infection Hepatitis B, C, HIV Concurrent Acute Illness Abnormal behavior Pain Behavior Artificial joints Lymph node resection 5
6 Informed Consent You might die, be paralyzed, get a pneumothorax, hematuria, infection, syncope Risk Likelihood Precaution Death 0 Paralysis Pneumothorax Hematuria Almost 0 Position patient Direction of needle Infection 1-2:1,000,000 Wash your hands Syncope Possible Position patient Hematoma Possible Oops. I m sorry 6
7 Advisory to Patient Needle insertion is virtually painless Needling of a taut band or TrP: dull, deep pain +/- Post-needling soreness after treatment Chronic problem: 1 treatment not sufficient Treatment speaks to your body: may be repeated in 3-4 days The more chronic the problem, more treatment will be needed Return to usual activity within a day or two Analgesia as required, preferably not NSAIDs 7
8 8
9 The target of the needle: BONE (yours or the patient s) 9
10 Single use, disposable needle 10
11 Equipment 11
12 Equipment Single use, disposable needle 12
13 Equipment 13
14 Stop Look for it Pick it up Dispose of it 14
15 Work-related injuries Reporting to Workers Compensation Blood testing (Hep B, HIV, STD) Anxiety, Trauma Loss of work days Lawsuit 15
16 Skin Preparation (?) The Patient Injections s.c. or i.m. clean skin does not require antisepsis If cleansed EtOH wash 30 secs, dry 30 secs The Physician Must disinfect hands! Chlorhexidine/EtOH 70% Povidone/EtOH 70% 20 secs minimum Revised Injection Safety Assessment Tool (Tool C revised)
17 Handling the Needles 17
18 Needle Technique Insertion Deep insertion Stimulation Removal 18
19 Needle re-use not recommended 19
20 Response to Needling Potential undesired effects My personal catastrophes Vasovagal response Pneumothorax Bleeding Renal biopsy Bowel perforation Nerve injury 20
21 Cautions Vasovagal reaction It WILL happen Positioning Precautions Sterile Precautions Patient Yourself Equipment sterilization Mishaps Broken needle Bleeding Pneumothorax, hematuria Liability Coverage 21
22 Positioning the Patient Pillow Head Chest Arm Bolster Legs 22
23 Positioning the Therapist 23
24 Treatment Failure Inadequate medical evaluation Incorrect diagnosis of Myofascial Pain Incomplete treatment of myotome/satellites/multifidi Fibrosis & Postsurgical scarring Endocrine: Thyroid, Estrogen, Diabetes Metabolic: Fe ++, Mg ++, Vit.D, Vit.B12 Inappropriate expectation of time to reverse supersensitivity Unable to tolerate treatment Psychosocial Issues Failure to address ergonomic/vocational issues Current of Injury : Chronological Age Biological Age This is the second-last slide, so relax! 24
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