533 - Trigger Points, Behavioral Economics and Low Value Care, A Waken

From the Literature and Personal Experience

1)  Diagnosis and Management of Trigger Points

Myofascial trigger points are hypersensitive, hyperirritable  nodules that can occur in tight bands of skele­tal muscle.  They may cause motor, sensory, and autonomic pain symptoms locally and in a referred pattern, decreased range of motion, and musculoskeletal dysfunction.  They often accompany chronic musculoskeletal disorders and can arise from muscle overuse, injury, or stress.  These can be located anywhere skeletal muscle is found but are most often found in the muscles used to maintain body posture are affected, namely the muscles in the neck, shoulders, and pelvic girdle, including the upper trapezius, scalene, sternocleidomastoid, levator scapulae, and quadratus lumborum.

The first step in managing trigger points is their accurate identification. Diagnosis is primarily clinical, based on patient history and physical examination. Patients typically present with localized reproducible pain, tenderness, and sometimes referral pain patterns that mimic other conditions. Palpation of the affected muscle can reveal a taut band or nodule, and applying pressure can elicit a characteristic twitch response or referred pain locally or directed proximally or distally, but not in a dermatomal or nerve root distribution.  Tender points, by comparison, are associated with pain at the site of palpation only, are not associated with referred pain, and occur in the insertion zone of muscles, not in taut bands in the muscle belly.  Patients with fibromyalgia have tender points by definition. 

Treatment of myofascial trigger points aims to alleviate pain, restore function, and address any underlying causes.  Management strategies include both non-pharmacological and pharmacological approaches, tailored to the patient's specific needs and clinical presentation.  There is no accepted standardized treatment protocol for treatment due to lack of comprehensive comparative trials.  Presently accepted pharmacologic treatments include massage, osteopathic manual medicine, physical therapy, and the spray and stretch technique.  Oral nonsteroidal anti-inflammatory drugs, acetaminophen, and muscle relaxants can be used in conjunction with or instead of these.  More invasive  strategies include acupuncture, dry needling, and trigger point injections using pharmacologic agents.

A common modality used by primary care clinicians is trigger point injections.  These are distinguished from dry needling, which involves inserting needles into trigger points to elicit a local twitch response and can help relieve muscle tension and pain.  Trigger point injections involve injections of local anesthetics (sometimes combined with corticosteroids), into trigger points and can provide immediate relief of pain and muscle tension.  Some also use normal saline or sterile water as the injection agent.  No single pharmacologic agent or mixture of active drugs has been proven superior to another in the treatment of trigger points, nor has any agent been proven superior to placebo.

Complications of trigger point injection and dry needling are rare; however, injuries can occur, including pneumothorax, a vasovagal response, needle breakage and localized fat atrophy from the corticosteroid.  Because of the potential for patient harm and lack of evidence for superiority, less invasive meth­ods are recommended as first-line treatments.  If a trigger point injection is performed, a 1.5 inch 25- or 27-gauge needle is recommended with a volume of liquid typically ranging from 0.5 mL to 2 mL per trigger point.  The goal is to use the minimum effective volume that provides symptomatic relief.  If lidocaine is used it should be without epinephrine.  It is essential to be well-versed in the anatomy of the area being treated and the technique for injection to ensure efficacy and minimize complications.

Educating patients about trigger points and their management as well as is crucial.  Advising on ergonomic adjustments, stress management techniques, and regular physical activity can help prevent the development or exacerbation of trigger points.

Mark’s Comments:

The original impetus for this Pointer was a peer review case I was asked to review regarding a complication from a trigger point injection.  However, since that time, I have unfortunately had personal experience of the incredible pain these can cause and the vast array of neurological symptoms that can manifest.  I’ve also experienced the power of PT, osteopathic manipulation, massage, and dry needling to help them resolve.  This experience has left me wondering how many of these I’ve missed over the years by not doing a careful enough musculoskeletal exam. 

Note:  The 2^nd reference, which is available without membership, provides much better details of the actual trigger point injection procedure.

References:

• Shipton B, Sunkesula S, Mall J.  Trigger Point Injections.  Am Fam Phys February 2023;107 (2): 159-164.  Link
• Alvarez D and Rockwell P,  Trigger Points: Diagnosis and Management.  Am Fam Phys February 15, 2002;65(4):653-661. Link

From the Literature

2)  Using “Behavioral Economics” to Reduce Low Value Care

The term “low value care” refers to healthcare provided to patients that is of no benefit or causes harm. Low value care (LVC) was the target of the Choosing Wisely Campaign from the American Board of Internal Medicine but is a worldwide problem. Reducing LVC has been trickier to accomplish than encouraging high-value care, and we need better interventions to change practice.

Researchers from Michigan developed a practice-based study to reduce three low-value care measures based on the American Geriatric Society Choosing Wisely Recommendations: 1) in adults >65 years with diabetes and hemoglobin A1c<7.0%, avoid using medications other than metformin, 2) avoid using benzodiazepines or sedative-hypnotics as first line treatment for insomnia or anxiety in adults older than 65 years, and 3) avoid screening for prostate cancer in men > 75 years. Clinicians were enrolled in the study after watching a presentation about these recommendations. Four different interventions were applied: a) the clinicians signed a written commitment to these recommendations, b) photos of the committed clinicians were placed in waiting rooms and exam rooms with information about the recommendations they committed to, c) patients for whom these recommendations applied were mailed an information sheet about the recommendations prior to appointments with the committed clinicians, and d) the committed clinicians received weekly emails reminding them about the recommendations and describing strategies for implementing them in practice.

The researchers measured patient-months of LVC as the primary outcome since they wanted to evaluate whether ongoing LVC was discontinued or “de-intensified” (i.e., dose reductions in the diabetes and insomnia/anxiety patients) as well as whether new LVC was avoided. There were 81 clinicians from two health systems that participated. LVC was present in 20.5% of the control patient-months and 16.0% of intervention patient-months and the odds of LVC were 0.79 (95% confidence interval (CI) 0.65 to 0.97) in the intervention group compared to control. None of the cohorts (diabetes, insomnia/anxiety, or prostate cancer screening) showed statistically significant reduction independently. The reduction lessened over the time of the trial (mostly due to the insomnia/anxiety cohort) but remained significant in adjusted multivariable analysis. There was also more de-intensification during the intervention patient-months with the diabetes cohort (OR 1.85, 95% CI 1.06 to 3.24) than with the insomnia/anxiety cohort (OR 0.84, 95% CI 0.53 to 1.33).

John’s Comments:

Changing LVC practice in this study required not educating patients or physicians, but leveraging written commitments, social norms, and deliberative thinking. These techniques worked best with diabetes and screening for prostate cancer but didn’t work as well for the challenging clinical problems of insomnia and anxiety. Our education and best intentions frequently give way to patient pressure and lack of good alternatives. With opioid prescribing, we needed state laws and registries to change our behavior to make a meaningful difference, so I’m not clear how we make substantial progress in this area without the pressure of a public health problem. In the meantime, it is important to think creatively about achieving even small reductions in LVC.

References:

• Kullgren JT, Kim HM, Slowey M, et al. Using Behavioral Economics to Reduce Low-Value Care Among Older Adults: A Cluster Randomized Clinical Trial. JAMA Intern Med. Published online January 29, 2024. Link

From PeerRxMed ( www.PeerRxMed.org )

3)  A Waken:  Happy 4^th Anniversary PeerRxMed!

“Courage starts with showing up and letting ourselves be seen …. Because true belonging only happens when we present our authentic, imperfect selves to the world.”  Brene Brown (The Gifts of Imperfection). 

This week marks the 4^th Anniversary of the launch of the PeerRxMed process and 14 years since the vision for PeerRx was first planted in me.   For each of the over 200 times I’ve shared a blog since then, I still feel that same vulnerability I felt when I first hit the “make public” button on the PeerRxMed website and the program was officially “out there.”

In that first blog, I wrote the following, “Those of you who know me well will likely be surprised as to how hard it was for me to do this.  The vulnerability I have been feeling at the prospect of sharing this dream more widely has at times been stifling … as I was allowing my fears that it wouldn’t be ‘perfect’ or some might think it was ‘soft’ or ‘trite’ and the potential criticism that may arise to prevent me from moving ahead.  It’s the same reason that in the past I have shared the poetry I write with so few people, even though I consider it to be a vital expression of who I am.” 

I went on to write; “It is my suspicion that many of us don’t allow wonderful, deeply important parts of ourselves to be “seen” due to our fear as to how those parts will be received.   And in the process, we don’t really bring our “authentic selves” to the world.  If that is true for you, what are some of those parts of you and what prevents you from sharing more?”

As I reflected this week on the incredible journey that the PeerRx process has taken since that time, I had a realization regarding that first blog.  Though I have shared the works of other poets on the blog, I have never shared any of my own poetry that I consider to be “a vital expression of who I am.”

So on the “4^th Anniversary” of PeerRxMed, I share with you (click below) a poem that in many ways has come to serve as an expression of my “essence.”  It is my hope that it might speak to you something “essential” in you as well.