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

Trigger Point Workshop

Phillip Snider, RD, DO

Amelia Medical Associates

Bon Secours Medical Group

Norfolk, VA


Common complaints

Common Complaints

  • Headaches

  • Low Back Pain

  • Tennis Elbow

  • Post-surgical Neuropathic Pain

  • Runners

    • Glutes

    • TFL

    • Hamstring

    • Gastroc / Soleus

    • FDB


Treatments

Treatments

  • OMT

  • TPI (trigger point injections)

  • Neural Therapy

  • PT

    • Posture education

    • Watch for trigger point irritation

  • Muscle relaxants


Treatments cont d

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

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 injections1

Trigger Point Injections

Needle

Diameter

Hypodermic

Gauge


Trigger point injections2

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

Headaches

  • Migraines

    • IHS Criteria

    • Anyone can get one

    • Triggers often include MSK component

      • Most Common Offenders

        • Traps

        • SCM

        • Levator Scapulae


Ihs migraine criteria

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


Trapezius needling

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


Levator scapulae needling

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

Sternocleidomastoid


Scm needling

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

Low Back Pain

  • Common muscle trouble makers:

    • QL

    • Iliopsoas

    • Multifidis

    • Iliocostalis & Longissimus

    • Glute medius


Quadratus lumborum

Quadratus Lumborum


Ql needling

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

QL Stretch


Iliopsoas

Iliopsoas


Iliopsoas needling

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


Iliopsoas1

Iliopsoas


Iliopsoas stretch

Iliopsoas Stretch


Multifidus

Multifidus


Multifidus needling

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


Iliocostalis longissimus needling

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

Gluteus Medius


Glute medius needling

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

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


Supinator needling

Supinator Needling

  • Have patient supinate forearm to identify muscle

  • .20 x 25mm needle


Brachioradialis

Brachioradialis


Brachioradialis needling

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


Trigger point workshop

ECRL


Ecrl needling

ECRL Needling

  • .20 x 25mm needle

  • Muscle twitch is strong


Extensor digitorum

Extensor Digitorum


Ed needling

ED Needling

  • .20 x 25mm needle

  • Muscle twitch is strong


Triceps

Triceps


Triceps needling

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


Anconeus needling

Anconeus Needling

  • .20 x 25mm needle

  • Muscle twitch is vague to moderate


Supraspinatus

Supraspinatus


Supraspinatus needling

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


Infraspinatus needling

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


Serratus posterior superior needling

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 needling1

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

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

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


Piriformis needling

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

Gluteus Maximus


Glute max needling

Glute Max Needling

  • Patient prone or on side

  • .30 x 50mm

  • Avoid sciatic nerve

  • Have pt extend hip to ID muscle


Gluteus medius1

Gluteus Medius


Gluteus minimus

Gluteus Minimus


Glute 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


Rectus femoris needling

Rectus Femoris Needling

  • Patient supine

  • 30ga x 1.5” or .30 x 50mm

  • Muscle twitch is usually strong


Vastus medialis intermedius lateralis

Vastus Medialis, Intermedius & Lateralis


Vastus muscles

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

Adductors

aDDUCTOR


Adductor needling

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

Hamstrings


Hamstring needling

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

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

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

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 treatment1

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

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

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

ICD-9 Codes for TPI

  • 729.1

    • Myofascial pain, fibromyalgia

    • Medicare/Medicaid

  • 728.85

    • Muscle spasm

    • Private insurance


Modifiers 25

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

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

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

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

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

Charges: Trigger Point

  • Trigger Point Injection

    • 20552 or 20553$160


Documentation

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

Online Resources

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

  • http//emedicine.medscape.com

  • www.aafp.org

  • My email: [email protected]


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