Management Methods

Management Methods (81)

Children categories

Injection Procedures

Injection Procedures (81)

The injection procedures outlined in this chapter are appropriately used in conjunction with other aspects of rehabilitation to reduce pain and increase function. Sterile technique and knowledge of anatomic relationships are required. Aspiration is performed before injecting and is repeated as necessary throughout administration of medication to prevent intravascular injection. For optimal results and safety with injection techniques, the practitioner needs the necessary skill, training, and education to perform the procedures. Haste and failure to observe the necessary precautions by the practitioner increase the risks for any procedure. Knowledge of the anatomy pertaining to each injection procedure is a requirement for safe and successful outcomes in even the simplest injection. 

 

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Indications

Hip adductor muscle injection is a useful diagnostic and therapeutic procedure for myofascial pain.

Techniques

After informed consent is obtained, the patient is placed in the supine position and the affected limb flexed, adducted, and externally rotated. The adductor longus, adductor brevis, and adductor magnus are palpated along the medial aspect of the humerus and thigh. The injection sites are identified as points of maximal tenderness to deep palpation, reproducing the patient’s pain complaint. This may or may not result in referred pain. The patient is prepared in a standard aseptic fashion over an area large enough to allow palpation of landmarks, and sterile technique is used throughout the procedure. A 1½-in. (4-cm), 21- to 25-gauge needle is inserted at the point of maximal tenderness and advanced to the area of the trigger point. After negative aspiration, the trigger point area is injected with 4 mL of local anesthetic (Fig. 67-32).

FIGURE 67-32. Hip adductor trigger points and referred pain patterns.

Comment

The referred pain pattern for the adductor muscles of the hip often involves the proximal hip, medial thigh, anterior thigh, and knee. The patient should be fully familiar with the stretching program for the adductor muscle and be instructed in a home program. Failure to include a home stretching program usually results in short-term relief.

Complications

Significant complications are uncommon with hip adductor trigger point injections.

Refferences

Source: Physical Medicine and Rehabilitation - Principles and Practice

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Indications

Piriformis muscle injection is a useful diagnostic and therapeutic procedure for myofascial pain.

Techniques

After informed consent is obtained, the patient is placed in the lateral Sims’ position. The piriformis muscle is palpated from the sacrum toward the hip. The injection sites are identified as points of maximal tenderness to deep palpation, reproducing the patient’s pain complaint. This may or may not result in referred pain. The patient is prepared in a standard aseptic fashion over an area large enough to allow palpation of landmarks, and sterile technique is used throughout the procedure. A 1½-in. (4-cm), 21- to 25-gauge needle is inserted at the point of maximal tenderness and advanced to the area of the trigger point. After negative aspiration, the trigger point area is injected with 4 mL of local anesthetic (Fig. 67-31).

FIGURE 67-31. Piriformis trigger points and referred pain patterns.

Comments

The referred pain pattern for the piriformis muscle often involves the buttocks, iliosacral region, and posterior hip. The patient should be familiar with the stretching program for the piriformis muscle and be instructed in a home program. Failure to include a home stretching program usually results in short-term relief.

Complications

Attention to the anatomy of the sciatic nerve in this region will prevent intraneural injection; otherwise, significant complications are uncommon with trigger point injections. Severe pain on injection suggests the possibility of an intraneural injection, and the needle should be repositioned immediately. Temporary lower extremity weakness is possible from regional spread of the local anesthetic.

Refferences

Source: Physical Medicine and Rehabilitation - Principles and Practice
Thứ hai, 10 Tháng 3 2014 11:29

Gluteal Trigger Point Injection

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Indications

Gluteal muscle injection is a useful diagnostic and therapeutic procedure for myofascial pain.

Techniques

After informed consent is obtained, the patient is placed in the lateral position with the unaffected side down, or in the prone position. The gluteus maximus, minimus, and medius muscles are palpated. The injection sites are identified as points of maximal tenderness to deep palpation, reproducing the patient’s pain complaint. This may or may not result in referred pain. The patient is prepared in a standard aseptic fashion over an area large enough to allow palpation of landmarks, and sterile technique is used throughout the procedure. A 1½-in. (4-cm), 21- to 25-gauge needle is inserted at the point of maximal tenderness and advanced to the area of the trigger point. After negative aspiration, the trigger point area is injected with 4 mL of local anesthetic (Fig. 67-30).

FIGURE 67-30. Gluteal trigger points and referred pain patterns.

Comment

The referred pain pattern for the gluteus maximus usually involves the sacroiliac joint, hip, and buttock. The referred pain pattern for the gluteus medius often involves the iliac crest, sacroiliac joint, and buttock. The referred pain pattern for the gluteus minimus muscle usually involves the buttock and lateral aspect of the lower extremity. The patient should be fully familiar with the stretching program for the gluteal muscle and be instructed in a home program. Failure to include a home stretching program usually results in short-term relief.

Complications

Significant complications are uncommon with gluteal trigger point injections; however, the anatomy of the region, including the sciatic nerve, must be carefully considered with these injections. Intraneural injection may result in nerve damage. Severe pain on injection suggests the possibility of an intraneural injection, and the needle should be immediately repositioned. Temporary lower extremity weakness is possible from regional spread of the local anesthetic.

Refferences

Source: Physical Medicine and Rehabilitation - Principles and Practice

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Indications

The paraspinal muscle injection is a useful diagnostic and therapeutic procedure for myofascial pain.

Techniques

After informed consent is obtained, the patient is placed in the prone position. The appropriate thoracic and lumbar regions are palpated. The injection sites are identified as points of maximal tenderness to deep palpation, reproducing the patient’s pain complaint. This may or may not result in referred pain. The patient is prepared in a standard aseptic fashion over an area large enough to allow palpation of landmarks, and sterile technique is used throughout the procedure. A 1½-in. (4-cm), 21- to 25-gauge needle is inserted at the point of maximal tenderness and advanced to the area of the trigger point. After negative aspiration, the trigger point area is injected with 4 mL of local anesthetic (Fig. 67-29).

FIGURE 67-29. Paraspinal musculature. Trigger points and referred pain patterns.

Comment

The referred pain pattern for the thoracic paraspinal muscles often involves the scapular and chest wall region, as well as the lower thoracic paraspinal muscles and abdomen region. The referred pain pattern for the lumbar paraspinal muscles often involves the buttock, iliac crest, and sacroiliac joint region. These muscles involve the erector spinae, semispinalis cervicis, longissimus capitis, longissimus cervicis, longissimus iliocostalis thoracis, iliocostalis lumborum, and semispinalis multifidus. The patient should be fully familiar with the stretching program for the affected paraspinal muscle and be instructed in a home program. Failure to include a home stretching program usually results in short-term relief.

Complications

Significant complications are uncommon with paraspinal trigger point injections.

Refferences

Source: Physical Medicine and Rehabilitation - Principles and Practice

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Indications

Quadratus lumborum injection is a useful diagnostic and therapeutic procedure for myofascial pain.

Techniques

After informed consent is obtained, the patient is placed in a prone position. The quadratus lumborum muscle is palpated from the 12th rib to the iliac crest and from vertebral attachments L1 to L4 to its lateral border. The injection sites are identified as points of maximal tenderness to deep palpation, reproducing the patient’s pain complaint. This may or may not result in referred pain. The patient is prepared in a standard aseptic fashion over an area large enough to allow palpation of landmarks, and sterile technique is used throughout the procedure. A 1½-in. (4-cm), 21- to 25-gauge needle is inserted at the point of maximal tenderness and advanced to the area of the trigger point. After negative aspiration, the trigger point area is injected with 4 mL of local anesthetic (Fig. 67-28).

FIGURE 67-28. Quadratus lumborum. Trigger points and referred pain patterns.

Comment

The referred pain pattern for the quadratus lumborum muscle usually involves the iliac crest, hip, and buttock. The patient should be fully familiar with the stretching program for the quadratus lumborum muscle and be instructed in a home program. Failure to include a home stretching program usually results in short-term relief.

Complications

Significant complications are uncommon with quadratus lumborum trigger point injections.

Refferences

Source: Physical Medicine and Rehabilitation - Principles and Practice
Chủ nhật, 09 Tháng 3 2014 14:26

Deltoid Trigger Point Injection

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Indications

Deltoid muscle injection is a useful diagnostic and therapeutic procedure for myofascial pain.

Techniques

After informed consent is obtained, the patient is placed in the sitting position. The anterior, middle, and posterior components of the deltoid muscle are palpated. The injection sites are identified as points of maximal tenderness to deep palpation, reproducing the patient’s pain complaint. This may or may not result in referred pain. The patient is prepared in a standard aseptic fashion over an area large enough to allow palpation of landmarks, and sterile technique is used throughout the procedure. A 1½-in. (4-cm), 21- to 25-gauge needle is inserted at the point of maximal tenderness and advanced to the area of the trigger point. After negative aspiration, the trigger point area is injected with 4 mL of local anesthetic (Fig. 67-27).

FIGURE 67-27. Deltoid. Trigger points and referred pain patterns.

Comment

The referred pain pattern for the deltoid muscle usually involves the shoulder and proximal upper extremity. The patient should be fully familiar with the stretching program for the deltoid muscle and be instructed in a home program. Failure to include a home stretching program usually results in short-term relief.

Complications

Significant complications are uncommon with deltoid trigger point injections.

Refferences

Source: Physical Medicine and Rehabilitation - Principles and Practice
Chủ nhật, 09 Tháng 3 2014 04:24

Pectoralis Trigger Point Injection

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Indications

Pectoralis muscle injection is a useful diagnostic and therapeutic procedure for myofascial pain.

Techniques

After informed consent is obtained, the patient is placed in the supine position. The pectoralis muscles are palpated. The injection sites are identified as points of maximal tenderness to deep palpation, reproducing the patient’s pain complaints. This may or may not result in referred pain. The patient is prepared in a standard aseptic fashion over an area large enough to allow palpation of landmarks, and sterile technique is used throughout the procedure. A 1½-in. (4-cm), 21- to 25-gauge needle is inserted at the point of maximal tenderness and advanced to the area of the trigger point. After negative aspiration, the trigger point area is injected with 4 mL of local anesthetic (Fig. 67-26).

FIGURE 67-26. Pectoralis. Trigger points and referred pain patterns.

Comment

The referred pain pattern for the pectoralis muscles usually involves the anterior chest wall and breast regions. The patient should be fully familiar with the stretching program for the pectoralis muscle and be instructed in the home program. Failure to include a home stretching program usually results in short-term relief.

Complications

Significant complications are uncommon with pectoralis trigger point injections; however, the anatomy of the region, including the close proximity of the thoracic cavity, must be carefully considered. The risk for pneumothorax is reduced by approaching the trigger point with the needle tangential to the thoracic wall.

Refferences

Source: Physical Medicine and Rehabilitation - Principles and Practice

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Indications

Infraspinatus injection is a useful diagnostic and therapeutic procedure for myofascial pain.

Techniques

After informed consent is obtained, the patient is placed in the sitting or prone position. The infraspinatus muscle is palpated from the infraspinous fossa of the scapula to the humerus. Trigger points are most often located below the spine of the scapulae. The injection sites are identified as points of maximal tenderness to deep palpation, reproducing the patient’s pain complaint. This may or may not result in referred pain. The patient is prepared in a standard aseptic fashion over an area large enough to allow palpation of landmarks, and sterile technique is used throughout the procedure. A 1½-in. (4-cm), 21- to 25-gauge needle is inserted at the point of maximal tenderness and advanced to the area of the trigger point. After negative aspiration, the trigger point area is injected with 4 mL of local anesthetic (Fig. 67-25).

FIGURE 67-25. Infraspinatus. Trigger points and referred pain patterns.

Comment

The referred pain pattern for the infraspinatus often involves the deltoid muscle, as well as the area over the lateral shoulder and proximal upper extremity. Pain also may be referred in the infrascapular region. The patient should be fully familiar with the stretching program for the infraspinatus muscle and be instructed in a home program. Failure to include a home stretching program usually results in short-term relief.

Complications

Significant complications are uncommon with infraspinatus trigger point injections.

Refferences

Source: Physical Medicine and Rehabilitation - Principles and Practice

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Indications

Supraspinatus injection is a useful diagnostic and therapeutic procedure for myofascial pain.

Techniques

After informed consent is obtained, the patient is placed in a sitting or prone position. The supraspinatus muscle is palpated for trigger points from the supraspinous fossa to the humerus. The injection sites are identified as points of maximal tenderness to deep palpation reproducing the patient’s pain complaint. This may or may not result in referred pain. The patient is prepared in a standard aseptic fashion over an area large enough to allow palpation of landmarks, and sterile technique is used throughout the procedure. A 1½-in. (4-cm), 21- to 25-gauge needle is inserted at the point of maximal tenderness and advanced to the area of the trigger point. After negative aspiration, the trigger point area is injected with 4 mL of local anesthetic (Fig. 67-24).

FIGURE 67-24. Supraspinatus. Trigger points and referred pain patterns.

Comment

The referred pain pattern for the supraspinatus muscle often involves the posterior lateral aspect of the shoulder and upper extremity. The patient should be fully familiar with the stretching program for the supraspinatus muscle and be instructed in a home program. Failure to include a home stretching program usually results in short-term relief.

Complications

Significant complications are uncommon with supraspinatus trigger point injections.

Refferences

Source: Physical Medicine and Rehabilitation - Principles and Practice

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Indications

Levator scapulae trigger point injection is a useful diagnostic and therapeutic procedure for myofascial pain.

Techniques

After informed consent is obtained, the patient is placed in a sitting or prone position. The levator scapulae muscle is palpated along the attachment at the C1 to C4 vertebrae and the superior angle of the scapulae. The injection sites are identified as points of maximal tenderness to deep palpation reproducing the patient’s pain complaint. This may or may not result in referred pain. The patient is prepared in a standard aseptic fashion over an area large enough to allow palpation of landmarks, and sterile technique is used throughout the procedure. A 1½-in. (4-cm), 21- to 25-gauge needle is inserted at the point of maximal tenderness and advanced to the area of the trigger point. After negative aspiration, the trigger point area is injected with 4 mL of local anesthetic (Fig. 67-23).

FIGURE 67-23. Levator scapulae. Trigger points and referred pain patterns.

Comment

The entire body of the levator scapulae muscle should be palpated from origin to insertion and all trigger points injected.

Total injection should not exceed maximum safe dosage. The referred pain pattern for the levator scapular muscle often includes a posterior lateral neck and occipital and temporal regions. The patient should be fully familiar with the stretching program for the levator scapulae muscle and be instructed in a home program. Failure to include a home stretching program usually results in short-term relief.

Complications

Nerve root blockade may result from improper needle placement or injection of large quantities of local anesthetic in the vertebral region. Intraneural injection may result in nerve damage. Severe pain on injection suggests the possibility of an intraneural injection, and the needle should be repositioned immediately.

Refferences

Source: Physical Medicine and Rehabilitation - Principles and Practice
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