Trigger Point Workshop NPO Conference 2015 Mary Derlacki, FNP Drs. Cassell and Braun 132 E. Broadway #830 Eugene, OR 97401 541-687-0816 mderlacki@comcast.net Background Skeletal muscle is 40% of ideal body weight Fascia exerts 2000 lbs of pressure per square inch Dull, aching, deep persistent pain Low grade discomfort to severe and incapacitating pain Cost of chronic neck and back pain is in the billions of dollars each year 1983 Drs. Janet Travell and David Simons publish Myofascial Pain and Dysfunction: The Trigger Point Manual 20 years in the making Muscular Rheumatism, idiopathic myalgia, nodular fibromyositis, myodysneuria, fibrositis, rheumatic myalgia and finally myofascial pain. Diagnosed entirely by history and physical exam Low Tech Medicine at it's best! 1
Trigger Points and Referred Pain Trigger Points create specific patterns of myofascial pain depending on the source muscle Referred pain is elicited by pressing on the TrP The more hyperactive the TrP, the more intense the pain pattern Rarely symmetrical Does not follow familiar dermatome patterns Indications and Contraindications INDICATIONS: PAIN CONTRAINDICATIONS: INFECTION, PSORIASIS, INABILITY TO FOLLOW AFTER CARE INSTRUCTIONS Active TrP causes pain and dysfunction Latent TrP causes restriction and weakness and may last for YEARS after the injury CASE STUDIES CY 36 y/o female with 10 yr hx of headaches. Unresponsive to all meds. All imaging negative or normal. Referral to OHSU didn't alter her headaches. TrP injected: Splenus Capitus, Trapezius, Sternocleidomastoid and Levator Scapulae. SH 32 y/o female with 12 yr hx of back pain. 2 previous lumbar surgeries, spinal stimulator placed then removed. Using wheelchair 75% of time. Pain medication limited benefits. TrP injected: Glutes min medius, and maximus. Piriformis and Quadratis Lumborum. 2
Choice of Medication Total Lidocaine dose = 10cc of 1% OR 20 cc of 0.5%, 10 cc of 1%, 5 cc of 2% Preservative Free Procaine Sterile Water Methylprednisolone or Triamcinalone Dry Needle Technique Supplies 27g 1 1/4 needle 3-10 cc of Lidocaine Isopropyl Alcohol and cotton balls EXAMINE AND INJECT TrP feel like a taut, palpable band OR as a tender depression in the muscle Lightly palpate the area around the TrP Find the most tender point of the muscle Enter the TrP perpendicularly...90 degrees Twitch Response? Inject 0.2-0.3 cc Lidocaine Always inject R and L side of body 3
POSITIONING Headache and Neck Pain Seated on table 45* angle away from affected side Always inject both sides of the body Low Back Pain Lay on side, knees slightly bent Reposition on opposite side AFTERCARE INSTRUCTIONS Heat, Hydration and Gentle Stretching for 48 hours Heat: Moist Heat Q 2 hrs is best, flax seed bag also good Hydration: 48 ounces of good fluids in the next 24 hours Gentle Stretching: Full ROM for the affected muscle Gently stretch every 2 hours, breathe, go slow Charting O:Patient has tight, tender, reactive Trigger Points in the Right and Left... Occiput, Trapezius, Levator Scapulae and SCM. A: Persistent Headache unresponsive to medication P: PARQ/prep/inject above mentioned Trigger Points with 0.5% Lidocaine. Discussed aftercare including heat, hydration, and gentle stretching. 4
Links to videos https://www.youtube.com/watch?v=klez2h1qeom Home Trigger Point Therapy for Tinnitus Dr. Jay Hobbs https://www.youtube.com/watch?v=krdimryatlw Watch Dr. Sugar Do Trigger Point Injections- Part 3 https://www.youtube.com/watch?v=sltgyjvbvww Trigger Point Explained with Animation by Michiel Akkerman RESOURCES TriggerPoints.net An excellent site with maps of every muscle and associated referred pain pattern. App for iphone and Android! Grouped by muscle, symptom or general location in the body. Myofascial Pain and Dysfunction: The Trigger Point Manual A classic text in 2 volumes by Drs. Travell and Simons GOOD LUCK! mderlacki@comcast.net 541.687.0816 5