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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 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 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
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
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
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
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 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
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 needling
Supinator Needling
  • Have patient supinate forearm to identify muscle
  • .20 x 25mm needle
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
ecrl needling
ECRL Needling
  • .20 x 25mm needle
  • Muscle twitch is strong
ed needling
ED Needling
  • .20 x 25mm needle
  • Muscle twitch is strong
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 needling
Anconeus Needling
  • .20 x 25mm needle
  • Muscle twitch is vague to moderate
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 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 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 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
glute max needling
Glute Max Needling
  • Patient prone or on side
  • .30 x 50mm
  • Avoid sciatic nerve
  • Have pt extend hip to ID muscle
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 needling
Rectus Femoris Needling
  • Patient supine
  • 30ga x 1.5” or .30 x 50mm
  • Muscle twitch is usually strong
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
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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