1. Trigger Point Workshop Phillip Snider, RD, DO Bon Secours Medical Associates Virginia Beach, VA

2. Common Complaints Headaches Low Back Pain Tennis Elbow Post-surgical Neuropathic Pain Runners – Glutes – TFL – Hamstring – Gastroc / Soleus – FDB

3. Treatments OMT TPI (trigger point injections) Neural Therapy PT – Posture education – Watch for trigger point irritation Muscle relaxants

4. 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 (Ameritox) is a must – Drug monitoring system – eg pill counts HA Meds (BB, CCB, Antiepilectics)

5. Trigger Point Injections 0.25% Lidocaine – 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)www.lhasaoms.com – Name brands: Seirin Hwa-to

6. Trigger Point Injections.3030.2036.1442.1244 Needle Diameter Hypodermic Gauge

7. Trigger Point Injections Needle Sizes –.30 x 50 mm for most muscles –.30 x 60 for QL –.30 x 75 for psoas or obese pt –.20 x 25 mm for forearm –.14 x for face / head –.12 x for hands / feet

8. Headaches Migraines – IHS Criteria – Anyone can get one – Triggers often include MSK component Most Common Offenders –Traps –SCM –Levator Scapulae

9. 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

10. Trapezius

11. 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

12. Levator Scapulae

13. 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

14. Sternocleidomastoid

15. 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 lots of ENT-like symptoms

16. Low Back Pain Common muscle trouble makers: – QL – Iliopsoas – Multifidis – Iliocostalis & Longissimus – Glute medius

17. Quadratus Lumborum

18. QL Needling Patient on side May need pillow under opposite side ID muscle using midpoint of iliac crest and ½ way b/w there and rib 12 Insert.30 x 50mm or.30 x 60mm needle lateral to medial toward middle of spinous process

19. QL Stretch

20. Iliopsoas

21. 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

22. Iliopsoas

23. Iliopsoas Stretch

24. Multifidus

25. 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

26. Multifidus Origin – Posterior surface of the sacrum – Articular processes of the lumbar vertebrae – Transverse processes of the thoracic vertebrae – Articular processes of C3-7 Insertion – Each part of the muscle inserts into the spinous process 2-4 vertebrae higher than its origin Actions – Extension, lateral flexion and rotation of the spine

27. Iliocostalis & Longissimus

28. 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

29. Gluteus Medius

30. 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

31. 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

32. Supinator

33. Supinator Needling Have patient supinate forearm to identify muscle.20 x 25mm needle

34. Brachioradialis

35. 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 1 st MTP Mimics scaphoid pain

36. ECRL

37. ECRL Needling.20 x 25mm needle Muscle twitch is strong

38. Extensor Digitorum

39. ED Needling.20 x 25mm needle Muscle twitch is strong

40. Triceps

41. 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

42. Anconeus

43. Anconeus Needling.20 x 25mm needle Muscle twitch is vague to moderate

44. Supraspinatus

45. 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

46. Infraspinatus

47. 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

48. Serratus Posterior Superior

49. 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

50. Serratus Posterior Superior Needling You may get the best access with 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

51. 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

52. 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

53. Piriformis

54. 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

55. Gluteus Maximus

56. Glute Max Needling Patient prone or on side.30 x 50mm Avoid sciatic nerve Have pt extend hip to ID muscle

57. Gluteus Medius

58. Gluteus Minimus

59. Glute Minimus Patient side lying.30 x 50mm needle Muscle twitch ranges from barely noticeable to fairly strong Can mimic greater trochanteric bursitis

60. Rectus Femoris

61. Rectus Femoris Needling Patient supine 30ga x 1.5” or.30 x 50mm Muscle twitch is usually strong

62. Vastus Medialis, Intermedius & Lateralis

63. 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

64. Adductors aDDUCTORaDDUCTOR

65. 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

66. Hamstrings

67. 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

70. 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

71. Nutritional or Metabolic Considerations Vitamin D deficiency: 268.9 – Goal = 40+ – 50,000 IU/week – 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 27 mg BID

72. 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 1 st 24 hr and then heat Stretch affect muscles twice a day Manual treatment daily using – The Trigger Point Therapy Workbook by Claire Davies

73. 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

74. 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 or private insurance) – 20553: 3+ muscles (Private insurance only) x=5,6,7,8 or 9

75. CPT Codes - cont ’ d Tendon Injection: 20550 Joint/bursa Aspiration or Injection – Small (finger/toes): 20600 – Medium: 20605 – Large (shoulders/hips/SI/knee): 20610

76. ICD-9 Codes for TPI 729.1 – Myofascial pain, fibromyalgia – Medicare or private insurance 728.85 – Muscle spasm – Private insurance

77. 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 Circle 99213 (established patient office visit) Circle the 24 modifier, assigning it to the 99213 Write in 728.85 or 9892x Circle TPI or OMT CPT code

78. 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 Circle 99203 (new patient office visit) Circle the 25 modifier, assigning it to the 99203 Write in 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

79. 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 – Circle 99203, attach 25 modifier to it – Write in 726.19 – Circle 20550 and attach the 50 modifier to it

80. 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 circle 98926 for the OMT – You link the 59 modifier to the OMT* *Attach the 59 to the less expensive procedure (OMT - $80)

81. 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

82. Charges: Trigger Point Trigger Point Injection – 20552 or 20553$160

83. 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.

84. Online Resources http://www.proceduresconsult.com/medical -procedures http//emedicine.medscape.com www.aafp.org My email: Phillip_Snider@bshsi.org