Neuromyofascial Trigger Point Infiltration

Description and Preamble for

Neuromyofascial Trigger Point Infiltration Protocols

Sandro Strix S. Toledo, M.D.

Neuromyofascial Trigger Points are small, discrete, hyper-irritable, hyperalgesic muscular foci within spastic or turgid muscles.

Frequent loci include the trapezius, the supraspinatus, the infraspinatus, the teres major, the rhomboids, the erector spinae group, and gluteal muscles. 


The upper body foci of these Trigger Points appear to be reflective of a Sympathetic predominance pattern for the ANS, and may be reflective of Dural Irritation or Inflammation.

The typical "Myofascial Pain Syndrome" is a regional clumping of Trigger Points.

Both dry needling and local infiltration with an anesthetic or steroid (or both) is an established clinical intervention.

Criterion for the justification or the medical necessity for intervention with needling for Trigger Points include:

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  A regional pain complaint
  
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  A proper neuro-orthopedic evaluation
  
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  The complete subjective record of pain
  

HMOs (Medical Insurance Services) often require proof that: 

(1) conservative therapy has failed or is not an option, and that 

(2) a return to previous levels of function and ADLs is possible. TP needling may also be justified as needed prior to more aggressive mobilization or manipulation.

Trigger Points are very often associated with exquisite point tenderness, with or without a referral pattern. Regional ROMs are usually compromised when TPs are present.

A "reproducible sign" or "exactly like that" or "duplication sign" pertains to the duplication of pain on palpation of a TP. 

A Local Twitch Response may be elicited with "snapping palpation" over a TP. Needling may evoke the same response.

The American College of Rheumatology diagnostic criteria for Fibromyalgia, when met, justify needling intervention for TPs. The Fibromyalgia Critera include:

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  Documented widespread pain for at least 3 months.  This means that manifestations are bilateral, with a cranial and caudad extent, plus axial skeletal pain
  
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  Tenderness must be present in at least 11 of the following 18 sites:
  
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    Occiput: Bilateral, at the suboccipital muscle insertions;
    
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    Low cervical: Bilateral, at the anterior aspects of the inter-transverse spaces at C5-C7;
    
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    Trapezius: Bilateral, at the midpoint of the upper border;
    
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    Supraspinatus: Bilateral, at origins, above the scapula spine near the medial border;
    
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    Second rib: Bilateral, at the second costochondral junctions, just lateral to the junctions on upper surfaces;
    
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    Lateral epicondyle: bilateral, 2 cm distal to the epicondyles;
    
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    Gluteal: bilateral, in upper outer quadrants of buttocks in anterior fold of muscle;
    
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    Greater trochanter: bilateral, posterior to the trochanteric prominence;
    
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    Knee: bilateral, at the medial fat pad proximal to the joint line.
    

Medically justified schedules of intervention via needling for TPs include:


Diagnostic or stabilization phase: Two weeks apart, with a maximum of four times a year. The minimum period between interventions is often set at one week. 


TP needling is deemed useful when pain is reduced by at least 50%, with this therapeutic effect carrying over at least a six week period. This is the Therapeutic Phase or Treatment Phase. 


Persistence or recurrence of TP pain or MPS may warrant a repeat intervention.


Please note that most insurance carriers will not deem Dry Needling or Acupuncture as medically necessary. These then become an out-of-pocket expense for patients for whom this intervention is deemed useful.


ICD9 CM Diagnoses include:

723.1	Cervicalgia
725-728.9	Rheumatism, excluding the back
729.1	Myalgia and myositis, unspecified (fibromyalgia) Secondary Diagnoses: 338.0    Central pain syndrome 338.19    Other acute pain 338.29    Other chronic pain    724.00-724.9  Other and unspecified disorders of back The American Current Procedural Terminology Coding for TPs and MPSs includes:
20552	Injection(s); single or multiple trigger point(s), one or two muscle(s)
20553	Injection(s); single or multiple trigger point(s), three or more muscle(s)
	No specific code exists for dry needling
	TRICARE has drastically reduced the amount it will pay for Infiltration techniques in 2010.

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Suggested Reading:

Alvarez DJ, Rockwell PG. Trigger points: diagnosis and management. Am Fam Physician. 2002; 15;65(4):653-660.

Cummings TM, White AR. Needling therapies in the management of myofascial trigger point pain: a systematic review. Arch Phys Med Rehabil. 2001; 82(7):986-992.

Huguenin L. Myofascial trigger points: the current evidence. Physical Therapy in Sport 5. 2004; 2-12.

Irnich D, Behrens N, Gleditsch JM, et al. Immediate effects of dry needling and acupuncture at distant points in chronic neck pain: results of a randomized, double-blind, sham-controlled crossover trial.  Pain. 2002; 99 (1-2):83-89

Kamanli A, Kaya A, Ardicoglu O, et al. Comparison of lidocaine injection, botulinum toxin injection, and dry needling to trigger points in myofascial pain syndrome. Rheumatol Int. 2005; 25(8):604-611.