Saturday, July 31, 2010

Triggerpoint Injections

A question that has been asked on several occasions is which medications to use while performing a triggerpoint injection? The combination of medications clinicians use for triggerpoint and joint injections can be quite a complex mixture at times but it boils down to the individual clinicians judgement based on previous experiences from which combinations of short/long acting corticosteroid along with whichever "flavor" of short and/or long acting anesthetic works for them.

As far as my previous experience, I see no difference in sustained analgesic effect using corticosteroids in triggerpoint injections vs. using anesthetic alone. Now, I'm not saying NEVER use corticosteroids along with an anesthetic but one needs to remember why triggerpoints are being performed: 1. to provide relief of pain in the specific muscle and 2. to promote circulation of the triggerpoint area by active needling during the procedure. I know some clinicians that perform triggerpoint with a dry needle (no medications at all) with good results- however, I'm concerned about patients pain level while performing the procedure- especially in those with chronic myofascial pain (Fibro) that would require additional injections in the future.

Including corticosteroids in triggerpoint injections does pose a chance of hypopigmentation of the skin as well as atrophy of surrounding tissues that could cause scarring in that area. If you choose to perform triggerpoint injections with corticosteroids- Please discuss with the patient in rare occasions patients do experience these complications and have this on your consent form.

I'd love to hear from others who perform these procedures and what medication combinations work best for your patients?

All the best,
Andy Austin FNP-C, FAAPM

Wednesday, July 28, 2010

Joint Injections for Arthritic Pain in the Elderly

As I currently work in an interventional pain management- many of my Nurse Practitioner colleagues in Rural Family Practice ask "I have this old patient that has severe arthritic pain, the patient does not want to have replacement surgery, they have been on NSAIDS for a while but now it just not helping their pain as much as it did before. I don't want to start them on opioids right now either due to: NP wanting to avoid treating chronic pain- as in our state NPs cannot prescribe narcotics for chronic pain, potential side effects of opioids (constipation), poly pharmacy or future dependency issues. But, the patient can't drive to another city for a specialist to treat their arthritis pain."

When conservative treatment of arthritic joint pain fails (i.e. weight loss, exercise/PT, NSAIDS, etc.) the nurse practitioner should consider performing corticosteroid joint injection for symptomatic relief, usually in conjunction with previously mentioned treatments. Joint injections have longed been consider an appropriate treatment for arthritic joint pain. My personal experience with joint injections is that these simple in office procedures decrease patients' joint pain and improves their functionality and mobility.

Down and Dirty on Joint Injections:
A patient with less arthritic knee pain as a result of an injection is more likely to increase their activity of daily living- thereby, maintaining or improving lower extremity strength. Improved lower extremity means better stability and hopefully less likely to fall- we all know what happens when they fall.

As the current number of aging patients with mild to moderate OA is staggering with the number only increasing- Learning joint injections is an important skill necessary for the Nurse Practitioner treating our aging population.

Andy Austin FNP-C, FAAPM