Dr. Alex Ginsburg is an emergency medicine resident physician in Rochester, MN.
Dr. Sasha Selby is an emergency medicine resident physician in Rochester, MN.
Dr. Jim Homme is an emergency medicine consultant physician in Rochester, MN.
Dr. Sara Hevesi is an emergency medicine consultant physician in Rochester, MN.
The fifth Mayo EM residency journal club was held on November 17th. This journal club was hosted by EM program director and consultant physician, Dr. Jim Homme. We discussed evidence behind the use of trigger point injections (TPIs) for back pain. We reviewed two standard journal articles and a FOAMed piece from EMRAP by Ruben Strayer about using TPIs. We also watched a brief video from EMRAP HD on how to do the procedure, found here at https://www.emrap.org/episode/triggerpoint/triggerpoint.
Dr. Alex Ginsburg presented on the American Journal of Emergency Medicine article on IV NSAIDS versus lidocaine trigger point injection for back pain1. This article suggests that TPI is effective when compared with NSAIDS, which are a mainstay of treatment. It also suggests that it is also a safe intervention. However, this was specifically focused on patients with myofascial pain syndrome which the authors itself identify as an uncommon cause of musculoskeletal pain (although it may be underdiagnosed). As such, it may have a limited impact on emergency medicine practice. Additionally, it is a randomized controlled trial, but it is not placebo controlled and there is potentially a placebo effect of performing the injection itself.
Dr. Jim Homme presented on the American Journal of Emergency Medicine article discussing normal saline versus lidocaine for trigger point injections2. This article discusses the concept of trigger point injections and the possibility that some elements of this practice may provide some low risk benefits to patients. This study has a low number of patients and a variety of different applications (ie. types of myofascial pain) where it was employed. They also don't describe in great detail the procedures utilized (could be lots of variability between practitioners and patients). They did randomize patients to two different treatment regiments and did a good job of trying to compare the groups to each other. There did not appear to be a bias in the study and the results at least seemed to support no difference in treatment groups (non-inferiority). Skeptics can dither about the mechanisms of benefit such as "laying on of hands", "doing something or SHOT effect", "magic show", or true physiologic reason for benefit - but the evidence based on patient ratings seems to imply benefit. A wise Homme-ism, he suggested we “hold loosely to the ‘why’ and focus more on the ‘what’ (i.e. patient do seem to benefit)”.
Dr. Sasha Selby presented on the EMRAP piece from November 2019, Strayerisms, entitled “Penetrating the Neck” (https://www.emrap.org/episode/penetratingthe/strayerisms). This podcast discussed how to do a trigger point injection step by step, why do a trigger point injection and reasons we shouldn't do a trigger point injection. Evidence provided was unfortunately mostly anecdotal, however this population is difficult to study and randomize given that placebo effect may be such a large part of the reason this works. This is a simple, yet effective procedure to combat probably one of the most common issues seen in the emergency department. Back pain is something that is poorly understood and poorly managed as a result. This session offered an approach that has shown some benefit and can certainly use resident trialing.
We also discussed that there should also be a clear understanding of how this fits into patient care outside of the ED. These conditions are typically chronic and/or recurrent. Acute response may not be the end of the story. Having mechanisms to plug patients into care systems where they can observe the demand for and response to these services over time would be important. This stuff really isn't new, but it is new to our discipline. Trigger point injections are a tool to put into the tool box for practitioners to consider - but for those who do not choose to adopt the practice, there is not a compelling reason (at this point) to say that they should reconsider their position.
Due to COVID, this journal club was entirely virtual (via Zoom). Each participant was invited to order their own food from Door Dash – some popular choices were mac n cheese from Noodles and Company. Special appearances were made by various pets, significant others and babies of those in attendance!
We will be taking a brief hiatus for the holiday season and to ring in the New Year. The next journal club will be January 12th, 2021 at 6pm. We will be discussing antibiotics for diverticulitis and GI cocktail efficacy. Dr. Homme has offered to host this session as well. Hope to see you there!
1. Kocak AO, Ahiskalioglu A, Sengun E, Gur STA, Akbas I. Comparison of intravenous NSAIDs and trigger point injection for low back pain in ED: A prospective randomized study. Am J Emerg Med. 2019 Oct;37(10):1927-1931. doi: 10.1016/j.ajem.2019.01.015. Epub 2019 Jan 15. PMID: 30660342.
2. Roldan CJ, Osuagwu U, Cardenas-Turanzas M, Huh BK. Normal Saline Trigger Point Injections vs Conventional Active Drug Mix for Myofascial Pain Syndromes. Am J Emerg Med. 2020 Feb;38(2):311-316. doi: 10.1016/j.ajem.2019.158410. Epub 2019 Aug 24. PMID: 31477359.