Trigger point workshop
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Trigger Point Workshop. Phillip Snider, RD, DO Amelia Medical Associates Bon Secours Medical Group Norfolk, VA. Common Complaints. Headaches Low Back Pain Tennis Elbow Post-surgical Neuropathic Pain Runners Glutes TFL Hamstring Gastroc / Soleus FDB. Treatments. OMT

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Trigger Point Workshop

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Trigger Point Workshop

Phillip Snider, RD, DO

Amelia Medical Associates

Bon Secours Medical Group

Norfolk, VA


Common Complaints

  • Headaches

  • Low Back Pain

  • Tennis Elbow

  • Post-surgical Neuropathic Pain

  • Runners

    • Glutes

    • TFL

    • Hamstring

    • Gastroc / Soleus

    • FDB


Treatments

  • OMT

  • TPI (trigger point injections)

  • Neural Therapy

  • PT

    • Posture education

    • Watch for trigger point irritation

  • Muscle relaxants


Treatments cont’d

  • NSAIDs – po, gel, drops, patch

  • Lidoderm patch

  • Tylenol

  • Narcotics

    • Short term use is best

    • Narcotic contract is a must

    • Urine drug testing

    • Drug monitoring system – pill counts, PMP

  • HA Meds (BB, CCB, Antiepilectics)


Trigger Point Injections

  • 0.25% Lidocaine w/ NaHCO3

    • 1cc into each muscle

    • 30ga 1.5 inch needle

    • Avoid use in face and forearm

  • Dry Needling (Acupuncture needle)

    • My favorite: Lhasa OMS (www.lhasaoms.com)

    • Name brands:

      • Seirin

      • Hwa-to


Trigger Point Injections

Needle

Diameter

Hypodermic

Gauge


Trigger Point Injections

  • Needle Sizes

    • .30 x 50 mm for most muscles

    • .30 x 60 for QL

    • .30 x 75 for psoas or glutes in obese pt

    • .20 x 25 mm for forearm

    • .14 x for face / head

    • .12 x for hands / feet


Headaches

  • Migraines

    • IHS Criteria

    • Anyone can get one

    • Triggers often include MSK component

      • Most Common Offenders

        • Traps

        • SCM

        • Levator Scapulae


IHS Migraine Criteria

  • 4+ HA lasting 4 - 72 hr, 2 of the 4 with:

    • Unilateral location

    • Pulsating quality

    • Moderate or severe intensity (affecting ADLs)

    • Aggravated by walking stairs or similar routine physical activity

  • During headache at least 1 of the 2 following symptoms occur:

    • Phonophobia, photophobia or osmophobia

    • Nausea and/or vomiting


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 50mm or 30ga x 1”

  • DO NOT insert needle posterior to anterior

  • Muscle twitch is moderate


Sternocleidomastoid


SCM Needling

  • Patient supine

  • Pincer grasp of muscle

  • 30ga 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 many ENT-like symptoms


Low Back Pain

  • Common muscle trouble makers:

    • QL

    • Iliopsoas

    • Multifidis

    • Iliocostalis & Longissimus

    • Glute medius


Quadratus Lumborum


QL Needling

  • Patient on side, affected side up

  • May need pillow under unaffected side

  • 1 – 2” posterior of iliac crest apex, approx ½ way b/w there and rib 12

  • Insert .30 x 50mm or .30 x 60mm needle lateral to medial toward midshaft of spinous process


QL Stretch


Iliopsoas


Iliopsoas Needling

  • Patient prone

    • Insert .30 x 75mm needle posterior lateral to anterior medial through QL

  • Patient on side

    • Insert a .30 x 75mm needle posterior lateral to anterior medial lateral through QL; aim for base of transverse process


Iliopsoas


Iliopsoas Stretch


Multifidus


Multifidus Needling

  • Patient supine

  • Safety zone is 1 finger width lateral to spinous process

  • Insert .30 x 50mm needle from posterior lateral to anterior medial; aim for base of transverse process and lamina


Iliocostalis & Longissimus


Iliocostalis & Longissimus 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


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


Tennis Elbow

  • Don’t Forget - Joint Above and Below

    • Shoulder

    • Radial head

    • Wrist

  • Myofascial Pain Referral Patterns

  • Trigger Point Injection/needling

    • Don’t use Lidocaine near the radial nerve


Supinator


Supinator Needling

  • Have patient supinate forearm to identify muscle

  • .20 x 25mm needle


Brachioradialis


Brachioradialis Needling

  • Pincer grasp of muscle

  • .20 x 25mm needle

  • Insert needle only through portion of muscle you’re holding

  • Mimics OA pain in the 1st MTP

  • Mimics scaphoid pain


ECRL


ECRL Needling

  • .20 x 25mm needle

  • Muscle twitch is strong


Extensor Digitorum


ED Needling

  • .20 x 25mm needle

  • Muscle twitch is strong


Triceps


Triceps Needling

  • Pincer grasp of muscle

  • .30 x 50mm 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

  • 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


Post-Surgical Neuropathic Pain (729.2)

  • Occurs due to surgical scar

  • Pain is burning and usually local

  • Neural therapy

    • Injection of 0.25% Lidocaine along scar

    • 30ga needle


Runners

  • Injuries result from

    • Overuse (volume, intensity)

    • Biomechanical imbalance

  • Treatment includes

    • PRINCE

    • Identify and address the imbalances

    • Calm down the injured muscles & joints

    • Structured return to running


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

aDDUCTOR


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


Nutritional or Metabolic Considerations

  • Vitamin D deficiency: 268.9

    • Goal = 40+

    • 50,000 IU/week x 16 weeks, recheck

    • 5,000 IU/day

  • Hypothyroid: 244.9

    • Goal = TSH < 3.5

    • Some may need optimization of T3

  • Fe-def anemia 280.9

    • Goal = Ferritin > 40

    • Ferrous Gluconate 327 mg BID


Post Treatment

  • Instruct patient to go to get CXR if any SOB, chest pain or cough developing within 24 hours

  • 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

    • Billed by number of regions treated

    • 1-2, 3-4, 5-6, 7-8, 9-10

  • Trigger Point Injection

    • 20552: 1-2 muscles (Medicare/Medicaid)

    • 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/Medicaid

  • 728.85

    • Muscle spasm

    • Private insurance


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

      • Enter 99203 (new patient office visit)

      • Enter the 25 modifier, attaching it to the 99203

      • Enter dx of muscle spasm 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 - 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

      • Code 99213 (established patient office visit)

      • Enter a 24 modifier, attached to the 99213

      • Enter a 25 modifier as the 2nd modifier, attached to the 99213

      • Write in 728.85 or 9892x

      • Enter the appropriate TPI or OMT CPT code


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

    • Enter 99203, attach 25 modifier to it

    • Enter 726.19

    • Enter 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 enter 98926 for the OMT

    • You link the 59 modifier to the OMT*

      *Attach the 59 to the less expensive procedure (OMT - $80)


Typical charges: OMT

  • 98925 (1 – 2 regions)$59

  • 98926 (3 – 4 regions)$80

  • 98927 (5 – 6 regions)$103

  • 98928 (7 – 8 regions)$122

  • 98929 (9 - 10 regions)$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.


Online Resources

  • http://www.proceduresconsult.com/medical-procedures

  • http//emedicine.medscape.com

  • www.aafp.org

  • My email: [email protected]


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