Trigger point paralysis

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"He had no family or personal history of periodic paralysis, muscle defects, or kidney disease. He was treated with trigger-point injection (TPI) consisting of methylprednisolone, bupivacaine, and epinephrine. A previous TIP had been effective in relieving his pain and he had experienced no adverse effects. The TPI was delivered to his left iliopsoas tendon and was administered under ultrasound guidancee

- not a TPI, but a peritendinous injection
- previous TPI, without side effects
- why epi?

Most of all, how does TPI induce hypokalemia? don't see any explanation on the mechanism of action.
 
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i read the following then figured it was either the epi or the steroid or stress or coincidence
Periodic paralysis - Wikipedia
//Periodic paralysis (also known as Myoplegia paroxysmalis familiaris) is a group of rare genetic diseases that lead to weakness or paralysis [1] from common triggers such as cold, heat, high carbohydrate meals, not eating, stress or excitement and physical activity of any kind. The underlying mechanism of these diseases are malfunctions in the ion channels in skeletal muscle cell membranes that allow electrically charged ions to leak in or out of the muscle cell, causing the cell to depolarize and become unable to move.[citation needed]//
 
i have had a patient with familial periodic paralysis who has said he had an episode after an ESI.

i did one on him anyway after consent, and he was fine.
 
putting steroid in TPI is standard practice.

epi is another story. not sure why

of course, you can do dry needling, and see what happens.
 
drpainfree said:
putting steroid in TPI is standard practice.

epi is another story. not sure why

of course, you can do dry needling, and see what happens.
Click to expand...

putting steroid in TPI is standard practice.......by idiots.

Great way to cause focal muscle atrophy, but more importantly a great way to give provide countless unnecessary exposures to corticosteroids with all the resultant systemic adverse effects.
They also hide the result of your treatment as you could just do a single gluteal injection with steroid and get similar results. TPI with steroid are a crutch for incompetent docs who can't do a proper trigger point injection.

If you want to step up from dry needling, then doing selective injections of actual trigger points with saline or lido is reasonable. For tougher myofasical points in patients without contraindications, adding a modest amount of ketorolac can be useful.
 
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1% lido only for TPIs.

btw, i agree, they are mostly for overweight women of house cleaners with anxiety. they sometimes work. if you are doing a lot of TPIs, you dont really know what you are doing.
 
bedrock said:
putting steroid in TPI is standard practice.......by idiots.

Great way to cause focal muscle atrophy, but more importantly a great way to give provide countless unnecessary exposures to corticosteroids with all the resultant systemic adverse effects.
They also hide the result of your treatment as you could just do a single gluteal injection with steroid and get similar results. TPI with steroid are a crutch for incompetent docs who can't do a proper trigger point injection.

If you want to step up from dry needling, then doing selective injections of actual trigger points with saline or lido is reasonable. For tougher myofasical points in patients without contraindications, adding a modest amount of ketorolac can be useful.
Click to expand...

agree.

I meant putting steroid in a peritendinous injection is standard as the technique described in the article is clearly a peritendinous injection.
 
SSdoc33 said:
btw, i agree, they are mostly for overweight women of house cleaners with anxiety. they sometimes work. if you are doing a lot of TPIs, you dont really know what you are doing.
Click to expand...

Agree. I learned how to do a proper TPI during my PMR residency, but then learned during my pain fellowship how to really treat the primary underlying pain generators, which now makes most TPI unnecessary.

However, I still find a few patients can benefit from them, if performed well.
 
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sounds like it was just the emotional stress of the procedure that likely triggered the paralytic episode
 
bedrock said:
Agree. I learned how to do a proper TPI during my PMR residency, but then learned during my pain fellowship how to really treat the primary underlying pain generators, which now makes most TPI unnecessary.

However, I still find a few patients can benefit from them, if performed well.
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What's a "proper tpi"? I think u could teach a premed student the proper tpi technique ??
 
painfree23 said:
What's a "proper tpi"? I think u could teach a premed student the proper tpi technique ??
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Palpate around the area of maximal tenderness moving from the outside in until you find the notable taut band. Ensure that palpation of taut band reproduces pain and referral pattern if present. Firmly place two fingers on either side of band to prevent movement. Prep and then advance a 25g needle in and out of the band in a fan like manner while injecting 1% lidocaine in fractionated doses. A twitch response confirms entry into the trigger point. After injection, massage to disperse medication and ensure hemostasis.

It's very technical 😉 In all honesty I think there is more of an art to it than people realize especially when injecting deeper points in the QL and lower paraspinal musculature. First locating the points can be difficult and proper depth is not always straightforward. With that being said, I do these only once in a blue moon
 
for QL/Psoas Major, Raj does it with fluoro. I'd recommend at least u/s.
 
bedrock said:
putting steroid in TPI is standard practice.......by idiots.

Great way to cause focal muscle atrophy, but more importantly a great way to give provide countless unnecessary exposures to corticosteroids with all the resultant systemic adverse effects.
They also hide the result of your treatment as you could just do a single gluteal injection with steroid and get similar results. TPI with steroid are a crutch for incompetent docs who can't do a proper trigger point injection.

If you want to step up from dry needling, then doing selective injections of actual trigger points with saline or lido is reasonable. For tougher myofasical points in patients without contraindications, adding a modest amount of ketorolac can be useful.
Click to expand...

Seems a bit hyperbolic. There are a lot of no nos in medicine. A tpi with a litttle steroid is not one of them.
 
painfree23 said:
Its this bs that makes the media and then even TPIs are scrutinized. Studies have shown it doesn't matter what u put in these trigger points, why is someone putting epi?? And using ultrasound??? Are u kidding me??? That procedure is as much bs as the complication itself.
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I'm very very confused by your statement.

You are questing the use of an ultrasound to direct exact placement of the medication around the deep psoas tendon structure? Please explain.
 
lobelsteve said:
Hocus pocus. Im not sure trigger points are real. Subjective pain, subjective exam, subjective treatment.
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Probably.

I have been doing all my thoracic TPI's under ultrasound and make sure the medication is placed into the fascial plane above (and sometimes below) the rhomboid. I dry needle the muscle, and deposit a little lidocaine - but I am starting to get the impression that the issue may be fascial based.

What is interesting is MOST times, the patient has reproduction of symptoms with injection of the painful lidocaine in the fascial plane, much more than in the muscle. Maybe there is something to that.
 
epidural man said:
I'm very very confused by your statement.

You are questing the use of an ultrasound to direct exact placement of the medication around the deep psoas tendon structure? Please explain.
Click to expand...
I thought OP was using ultrasound for TPIs. For sure for tendon injections, ultrasound is important.
 
painfree23 said:
I thought OP was using ultrasound for TPIs. For sure for tendon injections, ultrasound is important.
Click to expand...

I limit TPIs. The patient population who benefit from TPIs are generally a PITA.

Blind TPIs for cervical paraspinals and upper trap okay. But US a must when injecting Rhomboids or QL.
 
lobelsteve said:
Hocus pocus. Im not sure trigger points are real. Subjective pain, subjective exam, subjective treatment.
Click to expand...
Keep an open mind: Get/give a deep tissue/trigger point massage...feel/observe the twitch response as muscle knots release from tight band back to to smooth soft muscle. Palpate before and after and feels so good! "Trigger point therapy for myofacial pain" by finado and finado excellent resource also.
 
soggywaffle! said:
Keep an open mind: Get/give a deep tissue/trigger point massage...feel/observe the twitch response as muscle knots release from tight band back to to smooth soft muscle. Palpate before and after and feels so good! "Trigger point therapy for myofacial pain" by finado and finado excellent resource also.
Click to expand...

if you are going to be a myofascist, at least reference travell and simons....
 
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