Do trigger point injections effectively treat fibromyalgia?

Article Type
Changed
Mon, 01/14/2019 - 13:59
Display Headline
Do trigger point injections effectively treat fibromyalgia?
EVIDENCE-BASED ANSWER:

Possibly. Trigger point injections appear effective in reducing pain and increasing pressure thresholds in patients with fibromyalgia and myofascial trigger points (strength of recommendation [SOR]: B, small randomized controlled trials [RCTs]).

Consensus guidelines suggest that trigger point injections may have a role in the treatment of fibromyalgia (SOR: C, expert opinion).

 

Active injections produce sustained improvement

A 2011 double-blind RCT randomized 68 female patients with both fibromyalgia and myofascial trigger points to either active trigger point injections with 1 mL 0.5% bupivacaine or placebo-like needle penetration with no medication to an area near the trigger point.1 Patients were evaluated for both local and generalized fibromyalgia symptoms at 4 and 8 days (trial period) and after 30 days (follow-up). Injections occurred on Days 1 and 4, with an option of additional injections on Days 8 and 11.

Compared to baseline (7 days before the injection), patients receiving active trigger point injections had decreased myofascial pain episodes 7 days after the injection (5.6 vs 0.97 episodes; P<.001), decreased pain intensity (62 vs 19/100 mm Visual Analog Scale score; P<.001), and increased pressure threshold at the trigger point (1.5 vs 2.9 kg/cm2; P<.0001), whereas the control group showed no differences.

During Days 1 to 8, patients receiving active trigger point injections required less acetaminophen (0.2 vs 2.7 tablets/d; P<.0001). At Day 8, no patients in the active trigger point injection group requested additional injections, whereas all the patients in the control group requested an injection (P<.0001).

At Day 8, patients also had significantly decreased intensity of fibromyalgia pain, fewer tender points, and higher tender point pressure thresholds; none of these differences were statistically significant in the placebo injection group (data presented graphically). The improvements persisted at 30 days of follow-up (data presented graphically).

 

 

Small study shows improvement with injections after 2 weeks

An uncontrolled prospective before-after study in 1996 evaluated the effectiveness of 0.5% lidocaine trigger point injections in 9 patients with myofascial trigger points plus fibromyalgia compared with 9 patients with myofascial trigger points alone.2

Immediately after injection, patients with fibromyalgia had a nonsignificant worsening in pain intensity (pain scale 8.1 to 8.4/10; P>.1), but there was a significant improvement at 2 weeks (5.9; P<.01). The pressure threshold also decreased initially (1.7 to 1.4 kg/cm2; P>.1), but significantly increased at 2 weeks (2.4 kg/cm2; P<.01). In comparison, patients without fibromyalgia showed immediate improvement in all domains, which persisted at 2 weeks (P<.01).

What the guidelines say

Recent Canadian Fibromyalgia Guidelines discuss trigger point injections in the section on “off-label” medications, stating that they “may have some place in treatment of fibromyalgia.”3

References

1. Affaitati G, Costantini R, Fabrizio A, et al. Effects of treatment of peripheral pain generators in fibromyalgia patients. Eur J Pain. 2011;15:61-69.

2. Hong CZ, Hsueh TC. Difference in pain relief after trigger point injections in myofascial pain patients with and without fibromyalgia. Arch Phys Med Rehabil. 1996;77:1161-1166.

3. Fitzcharles MA, Ste-Marie PA, Goldenberg DL, et al. 2012. Canadian Guidelines for the diagnosis and management of fibromyalgia syndrome: executive summary. Pain Res Manag. 2013;18:119-126.

Article PDF
Author and Disclosure Information

Daniel White, MD
Thomas Staff, MD

University of Colorado Family Medicine Residency, Denver

EDITOR
Corey Lyon, DO
University of Colorado Family Medicine Residency, Denver

Issue
The Journal of Family Practice - 64(7)
Publications
Topics
Page Number
427,435
Legacy Keywords
Daniel White, MD; Thomas Staff, MD; pain; fibromyalgia; musculoskeletal; trigger point injection
Sections
Author and Disclosure Information

Daniel White, MD
Thomas Staff, MD

University of Colorado Family Medicine Residency, Denver

EDITOR
Corey Lyon, DO
University of Colorado Family Medicine Residency, Denver

Author and Disclosure Information

Daniel White, MD
Thomas Staff, MD

University of Colorado Family Medicine Residency, Denver

EDITOR
Corey Lyon, DO
University of Colorado Family Medicine Residency, Denver

Article PDF
Article PDF
EVIDENCE-BASED ANSWER:

Possibly. Trigger point injections appear effective in reducing pain and increasing pressure thresholds in patients with fibromyalgia and myofascial trigger points (strength of recommendation [SOR]: B, small randomized controlled trials [RCTs]).

Consensus guidelines suggest that trigger point injections may have a role in the treatment of fibromyalgia (SOR: C, expert opinion).

 

Active injections produce sustained improvement

A 2011 double-blind RCT randomized 68 female patients with both fibromyalgia and myofascial trigger points to either active trigger point injections with 1 mL 0.5% bupivacaine or placebo-like needle penetration with no medication to an area near the trigger point.1 Patients were evaluated for both local and generalized fibromyalgia symptoms at 4 and 8 days (trial period) and after 30 days (follow-up). Injections occurred on Days 1 and 4, with an option of additional injections on Days 8 and 11.

Compared to baseline (7 days before the injection), patients receiving active trigger point injections had decreased myofascial pain episodes 7 days after the injection (5.6 vs 0.97 episodes; P<.001), decreased pain intensity (62 vs 19/100 mm Visual Analog Scale score; P<.001), and increased pressure threshold at the trigger point (1.5 vs 2.9 kg/cm2; P<.0001), whereas the control group showed no differences.

During Days 1 to 8, patients receiving active trigger point injections required less acetaminophen (0.2 vs 2.7 tablets/d; P<.0001). At Day 8, no patients in the active trigger point injection group requested additional injections, whereas all the patients in the control group requested an injection (P<.0001).

At Day 8, patients also had significantly decreased intensity of fibromyalgia pain, fewer tender points, and higher tender point pressure thresholds; none of these differences were statistically significant in the placebo injection group (data presented graphically). The improvements persisted at 30 days of follow-up (data presented graphically).

 

 

Small study shows improvement with injections after 2 weeks

An uncontrolled prospective before-after study in 1996 evaluated the effectiveness of 0.5% lidocaine trigger point injections in 9 patients with myofascial trigger points plus fibromyalgia compared with 9 patients with myofascial trigger points alone.2

Immediately after injection, patients with fibromyalgia had a nonsignificant worsening in pain intensity (pain scale 8.1 to 8.4/10; P>.1), but there was a significant improvement at 2 weeks (5.9; P<.01). The pressure threshold also decreased initially (1.7 to 1.4 kg/cm2; P>.1), but significantly increased at 2 weeks (2.4 kg/cm2; P<.01). In comparison, patients without fibromyalgia showed immediate improvement in all domains, which persisted at 2 weeks (P<.01).

What the guidelines say

Recent Canadian Fibromyalgia Guidelines discuss trigger point injections in the section on “off-label” medications, stating that they “may have some place in treatment of fibromyalgia.”3

EVIDENCE-BASED ANSWER:

Possibly. Trigger point injections appear effective in reducing pain and increasing pressure thresholds in patients with fibromyalgia and myofascial trigger points (strength of recommendation [SOR]: B, small randomized controlled trials [RCTs]).

Consensus guidelines suggest that trigger point injections may have a role in the treatment of fibromyalgia (SOR: C, expert opinion).

 

Active injections produce sustained improvement

A 2011 double-blind RCT randomized 68 female patients with both fibromyalgia and myofascial trigger points to either active trigger point injections with 1 mL 0.5% bupivacaine or placebo-like needle penetration with no medication to an area near the trigger point.1 Patients were evaluated for both local and generalized fibromyalgia symptoms at 4 and 8 days (trial period) and after 30 days (follow-up). Injections occurred on Days 1 and 4, with an option of additional injections on Days 8 and 11.

Compared to baseline (7 days before the injection), patients receiving active trigger point injections had decreased myofascial pain episodes 7 days after the injection (5.6 vs 0.97 episodes; P<.001), decreased pain intensity (62 vs 19/100 mm Visual Analog Scale score; P<.001), and increased pressure threshold at the trigger point (1.5 vs 2.9 kg/cm2; P<.0001), whereas the control group showed no differences.

During Days 1 to 8, patients receiving active trigger point injections required less acetaminophen (0.2 vs 2.7 tablets/d; P<.0001). At Day 8, no patients in the active trigger point injection group requested additional injections, whereas all the patients in the control group requested an injection (P<.0001).

At Day 8, patients also had significantly decreased intensity of fibromyalgia pain, fewer tender points, and higher tender point pressure thresholds; none of these differences were statistically significant in the placebo injection group (data presented graphically). The improvements persisted at 30 days of follow-up (data presented graphically).

 

 

Small study shows improvement with injections after 2 weeks

An uncontrolled prospective before-after study in 1996 evaluated the effectiveness of 0.5% lidocaine trigger point injections in 9 patients with myofascial trigger points plus fibromyalgia compared with 9 patients with myofascial trigger points alone.2

Immediately after injection, patients with fibromyalgia had a nonsignificant worsening in pain intensity (pain scale 8.1 to 8.4/10; P>.1), but there was a significant improvement at 2 weeks (5.9; P<.01). The pressure threshold also decreased initially (1.7 to 1.4 kg/cm2; P>.1), but significantly increased at 2 weeks (2.4 kg/cm2; P<.01). In comparison, patients without fibromyalgia showed immediate improvement in all domains, which persisted at 2 weeks (P<.01).

What the guidelines say

Recent Canadian Fibromyalgia Guidelines discuss trigger point injections in the section on “off-label” medications, stating that they “may have some place in treatment of fibromyalgia.”3

References

1. Affaitati G, Costantini R, Fabrizio A, et al. Effects of treatment of peripheral pain generators in fibromyalgia patients. Eur J Pain. 2011;15:61-69.

2. Hong CZ, Hsueh TC. Difference in pain relief after trigger point injections in myofascial pain patients with and without fibromyalgia. Arch Phys Med Rehabil. 1996;77:1161-1166.

3. Fitzcharles MA, Ste-Marie PA, Goldenberg DL, et al. 2012. Canadian Guidelines for the diagnosis and management of fibromyalgia syndrome: executive summary. Pain Res Manag. 2013;18:119-126.

References

1. Affaitati G, Costantini R, Fabrizio A, et al. Effects of treatment of peripheral pain generators in fibromyalgia patients. Eur J Pain. 2011;15:61-69.

2. Hong CZ, Hsueh TC. Difference in pain relief after trigger point injections in myofascial pain patients with and without fibromyalgia. Arch Phys Med Rehabil. 1996;77:1161-1166.

3. Fitzcharles MA, Ste-Marie PA, Goldenberg DL, et al. 2012. Canadian Guidelines for the diagnosis and management of fibromyalgia syndrome: executive summary. Pain Res Manag. 2013;18:119-126.

Issue
The Journal of Family Practice - 64(7)
Issue
The Journal of Family Practice - 64(7)
Page Number
427,435
Page Number
427,435
Publications
Publications
Topics
Article Type
Display Headline
Do trigger point injections effectively treat fibromyalgia?
Display Headline
Do trigger point injections effectively treat fibromyalgia?
Legacy Keywords
Daniel White, MD; Thomas Staff, MD; pain; fibromyalgia; musculoskeletal; trigger point injection
Legacy Keywords
Daniel White, MD; Thomas Staff, MD; pain; fibromyalgia; musculoskeletal; trigger point injection
Sections
PURLs Copyright

Evidence-based answers from the Family Physicians Inquiries Network

Disallow All Ads
Article PDF Media