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General Principles
Although injections may be helpful in confirming a diagnosis,
they should be used primarily after a specific presumptive diagnosis has been
established. Injections should not be used in isolation, but rather in conjunction
with a program stressing muscle flexibility, strengthening, and functional restoration.
Proper follow-up after injections to assess the patient's treatment response
and ability to progress in the rehabilitation program is essential. A limited
number of injections can be tried to reduce pain, but careful monitoring of
the response is required prior to a second or third injection. These injections
are an adjunct treatment, which facilitates participation in an active exercise
program and may assist in avoiding the need for surgical intervention. All physiatrists
who perform injections should be aware of the indications, contraindications,
and complications of therapeutic injections, and fully inform patients of the
potential risks. Trigger Point Injections
Myofascial trigger points are felt
to be hyperirritable foci in muscles and fascia associated with taut muscle
bands. Trigger points are diagnosed by palpation and produce a local twitch
response and a referred pain pattern distal to the site of muscle irritability.
Trigger points cannot be properly diagnosed in the acute stages of low back
pain when muscle spasm and inflammation are present. Initially, trigger points
generally respond to a program of stretching and correction of poor postural
mechanics with or without other modalities, such as superficial heat or cold.
Trigger point injections should be reserved for patients who have not responded
in the first four to six weeks to a properly directed program and appropriate
pharmacologic intervention. The trigger point injection should be carried out
under antiseptic technique informing the patient of potential adverse effects.
There is little evidence to support any beneficial effect of adding corticosteroid
to the injection. In fact, a saline injection can as effective as a local anesthetic.
However, for patient comfort and to assist in deciding upon therapeutic efficacy,
injecting a local anesthetic such as lidocaine and/or mepivacaine is acceptable.
Injection of multiple trigger points should be avoided. Some trigger points
may require more than one injection, but generally more than three injection
of the same trigger point is not indicated. Repeated trigger point injections
may cause local muscle damage and scarring, which may potentially lead to a
poor functional outcome. They should not be performed in isolation, but rather,
in conjunction with a directed exercise program. Proper follow-up after injections
is necessary in order to assess the patient's response to the injection and
to progress the rehabilitation program.
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