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2.1 Constant repetition of uniform movements
  1. Trigger Points & Myofascial Pain Syndrome
  2. Why does just a little rubbing seem to help so much?
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  4. What are the characteristics of trigger points in cervical myofascial pain?

The choice of needle size depends on the location of the muscle being injected. The needle must be long enough to reach the contraction knots in the trigger point to disrupt them. A gauge, 1. For thick subcutaneous muscles such as the gluteus maximus or paraspinal muscles in persons who are not obese, a gauge, 2. Using a needle with a smaller diameter may cause less discomfort; however, it may provide neither the required mechanical disruption of the trigger point nor adequate sensitivity to the physician when penetrating the overlying skin and subcutaneous tissue.

A needle with a smaller gauge may also be deflected away from a very taut muscular band, thus preventing penetration of the trigger point. The needle should be long enough so that it never has to be inserted all the way to its hub, because the hub is the weakest part of the needle and breakage beneath the skin could occur.

An injectable solution of 1 percent lidocaine or 1 percent procaine is usually used.

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Several other substances, including diclofenac Voltaren , botulinum toxin type A Botox , and corticosteroids, have been used in trigger-point injections. However, these substances have been associated with significant myotoxicity. Once a trigger point has been located and the overlying skin has been cleansed with alcohol, the clinician isolates that point with a pinch between the thumb and index finger or between the index and middle finger, whichever is most comfortable Figures 3a and 3b. Using sterile technique, the needle is then inserted 1 to 2 cm away from the trigger point so that the needle may be advanced into the trigger point at an acute angle of 30 degrees to the skin.

The stabilizing fingers apply pressure on either side of the injection site, ensuring adequate tension of the muscle fibers to allow penetration of the trigger point but preventing it from rolling away from the advancing needle. The serious complication of pneumothorax can be avoided by refraining from aiming the needle at an intercostal space. Before advancing the needle into the trigger point, the physician should warn the patient of the possibility of sharp pain, muscle twitching, or an unpleasant sensation as the needle contacts the taut muscular band.

A small amount 0. The needle is then withdrawn to the level of the subcutaneous tissue, then redirected superiorly, inferiorly, laterally and medially, repeating the needling and injection process in each direction until the local twitch response is no longer elicited or resisting muscle tautness is no longer perceived Figure 3c.

Trigger Points & Myofascial Pain Syndrome

Cross-sectional schematic drawing of flat palpation to localize and hold the trigger point dark red spot for injection. A, B Use of alternating pressure between two fingers to confirm the location of the palpable nodule of the trigger point. C Positioning of the trigger point halfway between the fingers to keep it from sliding to one side during the injection. Injection is away from fingers, which have pinned down the trigger point so that it cannot slide away from the needle. Dotted outline indicates additional probing to explore for additional adjacent trigger points.

Why does just a little rubbing seem to help so much?

The fingers are pressing downward and apart to maintain pressure for hemostasis. After injection, the area should be palpated to ensure that no other tender points exist. If additional tender points are palpable, they should be isolated, needled and injected. Pressure is then applied to the injected area for two minutes to promote hemostasis. One study 20 emphasizes that stretching the affected muscle group immediately after injection further increases the efficacy of trigger point therapy.

Travell recommends that this is best performed by immediately having the patient actively move each injected muscle through its full range of motion three times, reaching its fully shortened and its fully lengthened position during each cycle. Postinjection soreness is to be expected in most cases, and the patient's stated relief of the referred pain pattern notes the success of the injection. Re-evaluation of the injected areas may be necessary, but reinjection of the trigger points is not recommended until the postinjection soreness resolves, usually after three to four days.

Repeated injections in a particular muscle are not recommended if two or three previous attempts have been unsuccessful. Patients are encouraged to remain active, putting muscles through their full range of motion in the week following trigger-point injections, but are advised to avoid strenuous activity, especially in the first three to four days after injection. Already a member or subscriber?

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Log in. Address correspondence to David J. Alvarez, D. Reprints are not available from the authors. The authors indicate that they do not have any conflicts of interest. Sources of funding: none reported.

Pain management using myofascial approach when other treatment failed. Musculoskeletal disorders. Bethesda: National Institutes of Health, — Difference in pain relief after trigger point injections in myofascial pain patients with and without fibromyalgia. Arch Phys Med Rehabil.

2.2 Inactivity: Prolonged holding of a muscle in a contracted or elongated position

Han SC, Harrison P. Myofascial pain syndrome and trigger-point management.

Reg Anesth. Use of trigger point injections in chronic pelvic pain. Obstet Gynecol Clin North Am. Mense S, Schmit RF. Muscle pain: which receptors are responsible for the transmission of noxious stimuli? In: Rose FC, ed. Physiological aspects of clinical neurology. Oxford: Blackwell Scientific Publications, — Factors associated with failure of trigger point injections. Clin J Pain. Myofascial pain syndrome of the head and neck: a review of clinical characteristics of patients. Rachlin ES. Trigger points. In: Rachlin ES, ed.

Myofascial pain and fibromyalgia: trigger point management. Louis: Mosby, — Fischer AA. Injection techniques in the management of local pain. Chronic work-related myalgia: neuromuscular mechanisms behind work-related chronic muscle pain syndromes. Henneman, E. Excitability and inhibitibility of motoneurons of different sizes.

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De Luca, C. Some properties of motor unit action potential trains recorded during constant force isometric contractions in man. Behaviour of human motor units in different muscles during linearly varying contractions. Flodgren, G. Glutamate and prostaglandin E2 in the trapezius muscle of female subjects with chronic muscle pain and controls determined by microdialysis.

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What are the characteristics of trigger points in cervical myofascial pain?

Person, R. Discharge frequency and discharge pattern of human motor units during voluntary contraction of muscle. Restricted Blood Flow. Wisnes, A. Regional distribution of blood flow in calf muscles of rat during passive stretch and sustained contraction. Degens, H. Intramuscular pressure, force and blood flow in rabbit tibialis anterior muscles during single and repetitive contractions. Physiological response in the forearm during and after isometric intermittent handgrip. Muscle blood flow during isometric activity and its relation to muscle fatigue.

Cagnie, B. Changes in microcirculation of the trapezius muscle during a prolonged computer task. Continuously Active Motor Units. Lexell, J. Stimulation-induced damage in rabbit fast-twitch skeletal muscles: a quantitative morphological study of the influence of pattern and frequency.