What you should read First

What you should read Second.

Start with "Fibromyalgia Definition"and and then move on to the rest of the posts of dated April 24th

Thursday, January 27, 2011

Fibromylagia and Social Security Disability Insurance

Fibromyalgia is now a recognized medically determinable impairment by Social Security. I will talk about the symptoms of fibromyalgia and how these symptoms relate to a Social Security Disability or SSI claim. I will also discuss the type of treatment that Social Security recognizes for this condition. You will also read about how the limitations from fibromyalgia can help show you are disabled.

Fibromyalgia is pain in several areas or all over body with no functional or structural disease to explain the pain. It is much more common in women than in men. In fact women account for about 80% of fibromyalgia cases. The American College of Rheumatology defines fibromyalgia as a history of widespread pain lasting longer than 3 months, with pain in at least 11 of 18 tender points, and the pain can not be attributed to another illness mimicking fibromyalgia. Social Security will accept a diagnosis of fibromyalgia if a physical and neurological exam is taken by a reumatologist. Symptoms include but are not limited to headaches, muscle weakness, muscle stiffness, multiple trigger points (tender), fatigue, numbness, depression, difficulty with memory or concentration, sleep disturbance, and vestibular dysfunction. The disease is usually caused by some trauma such as sexual or physical abuse, or illness.

Social Security Ruling SSR99-2p addresses fibromyalgia and chronic fatigue syndrome. This ruling clearly shows Social Security now considers fibromyalgia to be a medically determinable impairment. To see this ruling go to Social Security's web site by clicking on the ruling SSR99-2p.

There is not a listing for fibromyalgia so unless your doctor with help from your lawyer can show you equal one of the other listings you will have to use your limitations from your fibromyalgia to show you are disabled. You should read the section on this site called "are you disabled" to understand how Social Security will determine if you are disabled. If fibromyalgia is one of your medical conditions there is a few things you should know. First, you should be diagnosed and seen regularly by a rheumatologist the diagnosis should include a physical and neurological exam including trigger points. It is important that you are being treated by a Rhemotologist because SSA gives these doctors opinion more weight when it comes to this condition. Make sure all the rheumotologist's records are submitted and that you have a fibromyalgia RFC completed by him or her in your file. The RFC specifically for fibromyalgia is extremely important because fibromyalgia has many possible limitations that cover both physical and mental limitations. Your testimony in these cases can be extremely important because so many of the symptoms are subjective. It is very important that your testimony come across to the ALJ as credible. You may even want to have someone who sees you on a regular basis testify as to what you go through dealing with your condition on a daily basis.

It is very common for a person to have fibromyalgia and other medical conditions at the same time. So keep in mind that Social Security will look at all of your medical conditions together and how they limit you.

One difficulty often seen in these cases is that many times a person suffering from this condition will have gone through many doctors trying to find out what is wrong with them. A diagnosis is often times not made for months or years. This can create problems with onset date and sometimes DLI issues (being found disabled while still covered). It is a good idea to have records that show you complaining of you symptoms to other doctors even if a diagnosis was not made yet. This way the evidence can show you actually were suffering from the condition well before you got a diagnosis and this can possibly lead to an earlier onset date.

Here is an explanation of Social Security's five-step process to determine if a fibromyalgia patient qualifies for SSDI:

1. Determine if an individual is "working (engaging in substantial gainful activity)" according to the SSA definition. Earning more than $1,000 a month as an employee is enough to be disqualified from receiving Social Security disability benefits.

2. Conclude the fibromyalgia disability must be severe enough to significantly limit one’s ability to perform basic work activities needed to do most jobs. For example:

Walking, standing, sitting, lifting, pushing, pulling, reaching, carrying or handling
Seeing, hearing and speaking
Understanding/carrying out and remembering simple instructions
Responding appropriately to supervision, co-workers and usual work situations
Dealing with changes in a routine work setting
3. Fibromyalgia has no medical listing, so at this level of consideration, the adjudicator is required to consider “equating” a medical listing. To establish fibromyalgia as a medically determinable severe impairment, there must be evidence of widespread pain present for at least three months. There must be pain present on palpation in at least 11 of the 18 tender point sites as identified by the American College of Rheumatology and the Centers for Disease Control. There must be evidence of morning stiffness and/or stiffness after sitting for a short period of time. Fatigue is to be present. To equate a medical listing, the signs, symptoms and laboratory findings must be equivalent to an established listing. In most claims with a diagnosis of fibromyalgia, finding of disabled is usually at Step 5, i.e., functional limitations so significantly erode the occupational base for sedentary work that a finding of disabled is warranted.

4. Explore the ability of an individual to perform work they have done in the past despite their fibromyalgia. If the SSA finds that a person can do his past work, benefits are denied. If the person cannot, then the process proceeds to the fifth and final step.

5. Review age, education, work experience and physical/mental condition to determine what other work, if any, the person can perform. To determine fibromyalgia disability, the SSA enlists medical-vocational rules, which vary according to age.

For example, if a person is:

Under age 50 and, as a result of the symptoms of fibromyalgia, unable to perform what the SSA calls sedentary work, then the SSA will reach a determination of disabled. Sedentary work requires the ability to lift a maximum of 10 pounds at a time, sit six hours and occasionally walk and stand two hours per eight-hour day.

Age 50 or older and, due to the disability, limited to performing sedentary work, but has no work-related skills that allow him to do so, the SSA will reach a determination of disabled.

Age 55 or older and, due to the disability, limited to performing light work, but has no work-related skills that allow him to do so, the SSA will reach a determination of disabled.

Over age 60 and, due to the disability unable to perform any of the jobs he performed in the last 15 years, the SSA will likely reach a determination of disabled.

Any age and, because of fibromyalgia, has a psychological impairment that prevents even simple, unskilled work, the SSA will reach a determination of fibromyalgia disabled.

Finding a Lawyer for your Fibromyalgia Social Security Disability Claim.

If you are looking for a lawyer for your fibromyalgia SSDI claim you should look for one who has handled many of these claims. These cases require an understanding of the disease and how to deal with the all too common skeptical eye some of those at SSA view these cases with. Many of you who have this condition have probably heard things like "it's in your head", or you have gone to numerous doctors to get a diagnosis. Attorneys who represent many disability cases know it is a medical condition and that those who have it suffer on a daily basis with little relief. Many lawyers won't even take these cases because they can be difficult to prove to an often times skeptical SSA

Synthetic Vs. Natural Thyroid Medication

There is a lot of debate about which thyroid medicine you should take. There are those who say that synthetic medications, like Synthroid are superior. You also have those who say that natural medications like Armour are always better. Both sides go to extremes in claiming the superiority of their medication and the inferiority of the competitor. Being a thyroid patient myself that has tried both, I believe it varies for each person. What may work wonderfully for one person, may make another person feel worse.

What is the difference between synthetic and natural thyroid medications? The main difference is what they are made from. Synthetic thyroid medications are made from levothyroxine sodium while natural thyroid medications are made from dessicated pig thyroid. The other major difference is what thyroid hormones they contain. Most synthetic thyroid medicines, like Synthroid, contain only T4. The natural medications, like Armour contain both T4 and T3. There is a synthetic T3 medication available called Cytomel. Some people take both a synthetic T4 and a synthetic T3 medication to get both thyroid hormones. There is also one synthetic thyroid medication that contains both T4 and T3 called Thyrolar.

Both the synthetic and the natural thyroid medications are made in a lab with consistent amounts of thyroid hormones in them. They both have to meet federal regulations and guidelines. They are also both available in several different strengths.

You can find varying opinions from doctors, books, online forums and thyroid patients about which one you should take. I believe the opinion varies so much because what works for each person varies just as much. I have met people who take every variety of thyroid medications. I've come across a multitude of combinations and doses. Some take synthetic T4 only. Some take synthetic T4 and T3. Some only take synthetic T3. Some take natural T4/T3 medication. Some take synthetic T4 and natural T4/T3 medication. The more I've heard from people about what works for them, the more I realize how individual the needs of each person are. The general consensus among thyroid patients seems to be what works for one person, may not work for another and that what does work varies from person to person.

I personally have tried generic Levothyroxine, Synthroid, Levoxyl (all synthetic) and Armour (natural dessicated pig thyroid). I felt worse on all the synthetics. I actually became deathly ill and even had emotional and personality changes on Synthroid. I do better on Armour, but still have some problems on it. I personally am still looking for what works best for me, but I now know some thyroid medications that I absolutely can't take.

A lot of the doctors I've seen think Synthroid is the best and don't understand why I have problems with the synthetic medications. Some have even acted like I couldn't possibly know what I'm talking about. I have come to trust myself and my body more than a doctor who doesn't believe me when I say I'm worse on a medication than I was before I took it. I currently have a good doctor that is working with me on my thyroid problem. I am very hopeful that we will find what is best for me.

From experience, all I've read and all those I have talked to, I believe thyroid treatment is very individual. I don't believe there is a "one-size-fits-all" thyroid medication that makes every person who takes it feel better. I do believe some people do well on the first thyroid medication they take and never have problems with it. But if you are one of the people that seems to be doing worse on your thyroid medication than you were before you starting taking it, then it is very possible that you are not on the thyroid medication that works best for you.

If you take this concern to your doctor and you get treated like you don't know what you're talking about, then it's time to find a different doctor. I have personally been through seven doctors and four endocrinologists to finally find the doctor I am currently happy with. Getting off of the thyroid medication that was making me so incredibly sick has given me my life back and I will never make myself take a medication again that I think is making me sick because a doctor told me to.

So the question isn't really whether you should take synthetic or natural thyroid medication, but what works best for you. Remember that it is your body and you most likely know it better than anyone. If you are not doing well on the thyroid medication you are currently on, there are other options. It may take a while to find what works best for you, but even finding something better can make a huge difference.

About Armour Thyroid
Armour Thyroid is a type of hormone replacement therapy.

It differs from other therapies in two important ways:

•It is a natural product—not a synthetic compound
•It provides both of the key thyroid hormones levothyroxine (T4) and L-triiodothyronine (T3).

Your doctor may prescribe Armour Thyroid if you have had problems with a synthetic therapy or, if you or your doctor prefer natural products.

About Synthroid

Synthroid is a prescription medication that treats hypothyroidism and may help manage your hypothyroid symptoms. The active ingredient in Synthroid is called levothyroxine sodium. It is a synthetic hormone identical to thyroxine – the hormone that the thyroid gland naturally makes.

Wednesday, January 26, 2011

Trigger Points: Diagnosis and Management

Trigger points are discrete, focal, hyperirritable spots located in a taut band of skeletal muscle. They produce pain locally and in a referred pattern and often accompany chronic musculoskeletal disorders. Acute trauma or repetitive microtrauma may lead to the development of stress on muscle fibers and the formation of trigger points. Patients may have regional, persistent pain resulting in a decreased range of motion in the affected muscles. These include muscles used to maintain body posture, such as those in the neck, shoulders, and pelvic girdle. Trigger points may also manifest as tension headache, tinnitus, temporomandibular joint pain, decreased range of motion in the legs, and low back pain. Palpation of a hypersensitive bundle or nodule of muscle fiber of harder than normal consistency is the physical finding typically associated with a trigger point. Palpation of the trigger point will elicit pain directly over the affected area and/or cause radiation of pain toward a zone of reference and a local twitch response. Various modalities, such as the Spray and Stretch technique, ultrasonography, manipulative therapy and injection, are used to inactivate trigger points. Trigger-point injection has been shown to be one of the most effective treatment modalities to inactivate trigger points and provide prompt relief of symptoms.

About 23 million persons, or 10 percent of the U.S. population, have one or more chronic disorders of the musculoskeletal system.1 Musculoskeletal disorders are the main cause of disability in the working-age population and are among the leading causes of disability in other age groups.2 Myofascial pain syndrome is a common painful muscle disorder caused by myofascial trigger points.3 This must be differentiated from fibromyalgia syndrome, which involves multiple tender spots or tender points.3 These pain syndromes are often concomitant and may interact with one another.

Trigger points are discrete, focal, hyperirritable spots located in a taut band of skeletal muscle. The spots are painful on compression and can produce referred pain, referred tenderness, motor dysfunction, and autonomic phenomena.4

Trigger points are classified as being active or latent, depending on their clinical characteristics.5 An active trigger point causes pain at rest. It is tender to palpation with a referred pain pattern that is similar to the patient's pain complaint.3,5,6 This referred pain is felt not at the site of the trigger-point origin, but remote from it. The pain is often described as spreading or radiating.7 Referred pain is an important characteristic of a trigger point. It differentiates a trigger point from a tender point, which is associated with pain at the site of palpation only (Table 1

Trigger Points vs. Tender Points
Trigger points Tender points
Local tenderness, taut band, local twitch response, jump sign
Local tenderness

Singular or multiple

May occur in any skeletal muscle
Occur in specific locations that aresymmetrically located

May cause a specific referred pain pattern
Do not cause referred pain, but often cause a total body increase in pain sensitivity

A latent trigger point does not cause spontaneous pain, but may restrict movement or cause muscle weakness.6 The patient presenting with muscle restrictions or weakness may become aware of pain originating from a latent trigger point only when pressure is applied directly over the point.9

Moreover, when firm pressure is applied over the trigger point in a snapping fashion perpendicular to the muscle, a “local twitch response” is often elicited.10 A local twitch response is defined as a transient visible or palpable contraction or dimpling of the muscle and skin as the tense muscle fibers (taut band) of the trigger point contract when pressure is applied. This response is elicited by a sudden change of pressure on the trigger point by needle penetration into the trigger point or by transverse snapping palpation of the trigger point across the direction of the taut band of muscle fibers. Thus, a classic trigger point is defined as the presence of discrete focal tenderness located in a palpable taut band of skeletal muscle, which produces both referred regional pain (zone of reference) and a local twitch response. Trigger points help define myofascial pain syndromes.

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.8 Patients with fibromyalgia have tender points by definition. Concomitantly, patients may also have trigger points with myofascial pain syndrome. Thus, these two pain syndromes may overlap in symptoms and be difficult to differentiate without a thorough examination by a skilled physician.


There are several proposed histopathologic mechanisms to account for the development of trigger points and subsequent pain patterns, but scientific evidence is lacking. Many researchers agree that acute trauma or repetitive microtrauma may lead to the development of a trigger point. Lack of exercise, prolonged poor posture, vitamin deficiencies, sleep disturbances, and joint problems may all predispose to the development of micro-trauma.5 Occupational or recreational activities that produce repetitive stress on a specific muscle or muscle group commonly cause chronic stress in muscle fibers, leading to trigger points. Examples of predisposing activities include holding a telephone receiver between the ear and shoulder to free arms; prolonged bending over a table; sitting in chairs with poor back support, improper height of arm rests or none at all; and moving boxes using improper body mechanics.11

Acute sports injuries caused by acute sprain or repetitive stress (e.g., pitcher's or tennis elbow, golf shoulder), surgical scars, and tissues under tension frequently found after spinal surgery and hip replacement may also predispose a patient to the development of trigger points.12

Clinical Presentation

Patients who have trigger points often report regional, persistent pain that usually results in a decreased range of motion of the muscle in question. Often, 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.13 Although the pain is usually related to muscle activity, it may be constant. It is reproducible and does not follow a dermatomal or nerve root distribution. Patients report few systemic symptoms, and associated signs such as joint swelling and neurologic deficits are generally absent on physical examination.14

In the head and neck region, myofascial pain syndrome with trigger points can manifest as tension headache, tinnitus, temporomandibular joint pain, eye symptoms, and torticollis.15 Upper limb pain is often referred and pain in the shoulders may resemble visceral pain or mimic tendonitis and bursitis.5,16 In the lower extremities, trigger points may involve pain in the quadriceps and calf muscles and may lead to a limited range of motion in the knee and ankle. Trigger-point hypersensitivity in the gluteus maximus and gluteus medius often produces intense pain in the low back region.15 Examples of trigger-point locations are illustrated in Figure 1.16



Palpation of a hypersensitive bundle or nodule of muscle fiber of harder than normal consistency is the physical finding most often associated with a trigger point.10 Localization of a trigger point is based on the physician's sense of feel, assisted by patient expressions of pain and by visual and palpable observations of local twitch response.10 This palpation will elicit pain over the palpated muscle and/or cause radiation of pain toward the zone of reference in addition to a twitch response. The commonly encountered locations of trigger points and their pain reference zones are consistent.8 Many of these sites and zones of referred pain have been illustrated in

No laboratory test or imaging technique has been established for diagnosing trigger points.9 However, the use of ultrasonography, electromyography, thermography, and muscle biopsy has been studied.


Predisposing and perpetuating factors in chronic overuse or stress injury on muscles must be eliminated, if possible. Pharmacologic treatment of patients with chronic musculoskeletal pain includes analgesics and medications to induce sleep and relax muscles. Antidepressants, neuroleptics, or nonsteroidal anti-inflammatory drugs are often prescribed for these patients.1

Nonpharmacologic treatment modalities include acupuncture, osteopathic manual medicine techniques, massage, acupressure, ultrasonography, application of heat or ice, diathermy, transcutaneous electrical nerve stimulation, ethyl chloride Spray and Stretch technique, dry needling, and trigger-point injections with local anesthetic, saline, or steroid. The long-term clinical efficacy of various therapies is not clear, because data that incorporate pre- and post-treatment assessments with control groups are not available.

The Spray and Stretch technique involves passively stretching the target muscle while simultaneously applying dichlorodifluoromethane-trichloromonofluoromethane (Fluori-Methane) or ethyl chloride spray topically.5 The sudden drop in skin temperature is thought to produce temporary anesthesia by blocking the spinal stretch reflex and the sensation of pain at a higher center.5,10 The decreased pain sensation allows the muscle to be passively stretched toward normal length, which then helps to inactivate trigger points, relieve muscle spasm, and reduce referred pain.5

Dichlorodifluoromethane-trichloromono-fluoromethane is a nontoxic, nonflammable vapor coolant spray that does not irritate the skin but is no longer commercially available for other purposes because of its effect in reducing the ozone layer. However, its use is safer for both patient and physician than the original volatile vapor coolant, ethyl chloride. Ethyl chloride is a rapid-acting general anesthetic that becomes flammable and explosive when 4 to 15 percent of the vapor is mixed with air.10 Nevertheless, ethyl chloride remains a popular agent because of its local anesthetic action and its greater cooling effect than that of dichlorodifluoromethane-trichloromonofluoromethane.5

The decision to treat trigger points by manual methods or by injection depends strongly on the training and skill of the physician as well as the nature of the trigger point itself.10 For trigger points in the acute stage of formation (before additional pathologic changes develop), effective treatment may be delivered through physical therapy. Furthermore, manual methods are indicated for patients who have an extreme fear of needles or when the trigger point is in the middle of a muscle belly not easily accessible by injection (i.e., psoas and iliacus muscles).10 The goal of manual therapy is to train the patient to effectively self-manage the pain and dysfunction. However, manual methods are more likely to require several treatments and the benefits may not be as fully apparent for a day or two when compared with injection.10

While relatively few controlled studies on trigger-point injection have been conducted, trigger-point injection and dry needling of trigger points have become widely accepted. This therapeutic approach is one of the most effective treatment options available and is cited repeatedly as a way to achieve the best results.5

Trigger-point injection is indicated for patients who have symptomatic active trigger points that produce a twitch response to pressure and create a pattern of referred pain. In comparative studies,17 dry needling was found to be as effective as injecting an anesthetic solution such as procaine (Novocain) or lidocaine (Xylocaine).10 However, post-injection soreness resulting from dry needling was found to be more intense and of longer duration than the soreness experienced by patients injected with lidocaine.10

One noncontrolled study17 comparing the use of dry needling versus injection of lidocaine to treat trigger points showed that 58 percent of patients reported complete relief of pain immediately after trigger-point injection and the remaining 42 percent of patients claimed that their pain was minimal (1–2/10) on the pain scale. Both dry needling and injection with 0.5 percent lidocaine were equally successful in reducing myofascial pain. Postinjection soreness, a different entity than myofascial pain, often developed, especially after use of the dry needling technique.17 These results support the opinion of most researchers that the critical therapeutic factor in both dry needling and injection is mechanical disruption by the needle.1,10


Trigger-point injection can effectively inactivate trigger points and provide prompt, symptomatic relief. Table 210,18 outlines the necessary equipment for trigger-point injection. Contraindications to trigger-point injection are listed in Table 310,18 and possible complications are outlined in Table 4.

Equipment Needed for Trigger-Point Injection
Rubber gloves

Gauze pads

Alcohol pads for cleansing skin

3- or 5-mL syringe

Lidocaine (Xylocaine, 1 percent, without epinephrine) or procaine (Novocain, 1 percent)

22-, 25-, or 27-gauge needles of varying lengths, depending on the site to be injected

Adhesive bandage


Information from references10 and18.

Contraindications to Trigger-Point Injection
Anticoagulation or bleeding disorders

Aspirin ingestion within three days of injection

The presence of local or systemic infection

Allergy to anesthetic agents

Acute muscle trauma

Extreme fear of needles


Information from references10 and18.

Complications of Trigger-Point Injections
Vasovagal syncope

Skin infection

Pneumothorax; avoid pneumothorax complications by never aiming a needle at an intercostal space.

Needle breakage; avoid by never inserting the needle to its hub.

Hematoma formation; avoid by applying direct pressure for at least two minutes after injection.


Increased bleeding tendencies should be explored before injection. Capillary hemorrhage augments postinjection soreness and leads to unsightly ecchymosis.10 Patients should refrain from daily aspirin dosing for at least three days before injection to avoid increased bleeding.

The patient should be placed in a comfortable or recumbent position to produce muscle relaxation. This is best achieved by positioning the patient in the prone or supine position. This positioning may also help the patient to avoid injury if he or she has a vasovagal reaction.18

Needle Selection

The choice of needle size depends on the location of the muscle being injected. The needle must be long enough to reach the contraction knots in the trigger point to disrupt them. A 22-gauge, 1.5-inch needle is usually adequate to reach most superficial muscles. For thick subcutaneous muscles such as the gluteus maximus or paraspinal muscles in persons who are not obese, a 21-gauge, 2.0-inch needle is usually necessary.10 A 21-gauge, 2.5-inch needle is required to reach the deepest muscles, such as the gluteus minimus and quadratus lumborum, and is available as a hypodermic needle. Using a needle with a smaller diameter may cause less discomfort; however, it may provide neither the required mechanical disruption of the trigger point nor adequate sensitivity to the physician when penetrating the overlying skin and subcutaneous tissue. A needle with a smaller gauge may also be deflected away from a very taut muscular band, thus preventing penetration of the trigger point. The needle should be long enough so that it never has to be inserted all the way to its hub, because the hub is the weakest part of the needle and breakage beneath the skin could occur.6

Injection Solutions

An injectable solution of 1 percent lidocaine or 1 percent procaine is usually used. Several other substances, including diclofenac (Voltaren), botulinum toxin type A (Botox), and corticosteroids, have been used in trigger-point injections. However, these substances have been associated with significant myotoxicity.10,19 Procaine has the distinction of being the least myotoxic of all local injectable anesthetics.10

Injection Technique

Once a trigger point has been located and the overlying skin has been cleansed with alcohol, the clinician isolates that point with a pinch between the thumb and index finger or between the index and middle finger, whichever is most comfortable (Figures 3a and 3b). Using sterile technique, the needle is then inserted 1 to 2 cm away from the trigger point so that the needle may be advanced into the trigger point at an acute angle of 30 degrees to the skin. The stabilizing fingers apply pressure on either side of the injection site, ensuring adequate tension of the muscle fibers to allow penetration of the trigger point but preventing it from rolling away from the advancing needle.10 The application of pressure also helps to prevent bleeding within the subcutaneous tissues and the subsequent irritation to the muscle that the bleeding may produce. The serious complication of pneumothorax can be avoided by refraining from aiming the needle at an intercostal space.

Before advancing the needle into the trigger point, the physician should warn the patient of the possibility of sharp pain, muscle twitching, or an unpleasant sensation as the needle contacts the taut muscular band.17 To ensure that the needle is not within a blood vessel, the plunger should be withdrawn before injection. A small amount (0.2 mL) of anesthetic should be injected once the needle is inside the trigger point. The needle is then withdrawn to the level of the subcutaneous tissue, then redirected superiorly, inferiorly, laterally and medially, repeating the needling and injection process in each direction until the local twitch response is no longer elicited or resisting muscle tautness is no longer perceived (Figure 3c).10


Cross-sectional schematic drawing of flat palpation to localize and hold the trigger point (dark red spot) for injection. (A, B) Use of alternating pressure between two fingers to confirm the location of the palpable nodule of the trigger point. (C) Positioning of the trigger point halfway between the fingers to keep it from sliding to one side during the injection. Injection is away from fingers, which have pinned down the trigger point so that it cannot slide away from the needle. Dotted outline indicates additional probing to explore for additional adjacent trigger points. The fingers are pressing downward and apart to maintain pressure for hemostasis.

Post-injection Management

After injection, the area should be palpated to ensure that no other tender points exist. If additional tender points are palpable, they should be isolated, needled and injected. Pressure is then applied to the injected area for two minutes to promote hemostasis.10 A simple adhesive bandage is usually adequate for skin coverage.

One study20 emphasizes that stretching the affected muscle group immediately after injection further increases the efficacy of trigger point therapy. Travell recommends that this is best performed by immediately having the patient actively move each injected muscle through its full range of motion three times, reaching its fully shortened and its fully lengthened position during each cycle.10

Postinjection soreness is to be expected in most cases, and the patient's stated relief of the referred pain pattern notes the success of the injection. Re-evaluation of the injected areas may be necessary, but reinjection of the trigger points is not recommended until the postinjection soreness resolves, usually after three to four days. Repeated injections in a particular muscle are not recommended if two or three previous attempts have been unsuccessful. Patients are encouraged to remain active, putting muscles through their full range of motion in the week following trigger-point injections, but are advised to avoid strenuous activity, especially in the first three to four days after injection.10

Link to the web page

What are Fibromyalgia Tender Points?

Tender points are specific places on the body (18 specific points at 9 bilateral locations) that are exceptionally sensitive to the touch in people with fibromyalgia upon examination by a doctor.

•The 18 Tender Points of Fibromyalgia

Tender points of fibromyalgia exist at these nine bilateral muscle locations:

•Low Cervical Region: (front neck area) at anterior aspect of the interspaces between the transverse processes of C5-C7.
•Second Rib: (front chest area) at second costochondral junctions.
•Occiput: (back of the neck) at suboccipital muscle insertions.
•Trapezius Muscle: (back shoulder area) at midpoint of the upper border.
•Supraspinatus Muscle: (shoulder blade area) above the medial border of the scapular spine.
•Lateral Epicondyle: (elbow area) 2 cm distal to the lateral epicondyle.
•Gluteal: (rear end) at upper outer quadrant of the buttocks.
•Greater Trochanter: (rear hip) posterior to the greater trochanteric prominence.
•Knee: (knee area) at the medial fat pad proximal to the joint line.


This is a link to the picture of where tender points are on the body.

Saturday, January 8, 2011

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