Trigger point injections for chronic non-malignant musculoskeletal pain

Scott A, Guo B
Record ID 32005000070
Authors' objectives: This report aims to assess the efficacy and safety of using trigger point injection (TPI) to treat patients with chronic non-malignant musculoskeletal pain, based on a systematic review of the current published evidence, and to determine the current status of the procedure, the feasibility of delivering it to patients in regional communities, and the clinical accreditation and training required to perform it.
Authors' results and conclusions: Ten randomised controlled trials met the inclusion criteria. However, deficiencies in reporting, small sample sizes, and marked inter-study heterogeneity with respect to patient population, treatment regimen, injection site, and experimental protocol precluded a definitive synthesis of the data. TPI is a safe procedure when used by clinicians with appropriate expertise and training. However, the evidence for its effectiveness when used as the sole treatment for patients with chronic head, neck, and shoulder pain and whiplash syndrome was inconclusive. The combined use of dry needling and trigger point injection with procaine offers no obvious clinical benefit in the treatment of chronic craniofacial pain, while the effectiveness of trigger point injection for the treatment of cervicogenic headache is unknown. In contrast, trigger point injection with lidocaine may be a useful adjunct to intra-articular injection in the treatment of joint pain caused by osteoarthritis, compared to intra-articular injection alone. There was no proof that trigger point injection is more effective than other less invasive treatments, such as physical therapy and ultrasound, in achieving pain relief, and there is some suggestion that the only advantage of injecting anaesthetic into trigger points is that it reduces the pain of the needling process.
Authors' recommendations: The efficacy of trigger point injection is no more certain than it was a decade ago since, overall, there is no clear evidence of either benefit or ineffectiveness. Trigger point injection was generally analysed as a stand-alone treatment, so it is possible that the effectiveness of trigger point injection was underestimated by analysing it in isolation rather than in the adjunct capacity in which it is routinely used in clinical practice. The advantage of TPI therapy may lie in enabling patients to undergo remedial exercise therapy sooner than other less invasive techniques, such as ultrasound, which may require more treatment sessions to obtain the same result. However, this benefit may be counteracted by the greater skill required to correctly administer TPI, particularly in regional areas where such expertise may be scarce. The extent of use of trigger point injection in Alberta is unclear, but it is important that physicians understand the importance of not relying on trigger point injection as a sole treatment for chronic non-malignant musculoskeletal pain. Professional bodies, such as The Royal College of Physicians and Surgeons of Canada, should consider providing a training and accreditation program for practitioners wishing to use trigger point injection in Canada. It may also be prudent to tie the successful completion of such training to the ability to apply for reimbursement from the Alberta Health Care Insurance Plan, as this would curb the potential overuse and misuse of trigger point injection therapy. Since equipoise exists among many of the potential treatments for chronic non-malignant musculoskeletal pain, and the treatments have similar safety profiles, further research should centre on good quality RCTs rather than non-randomised controlled trials. Given the purported popularity of trigger point injection, this research is essential for establishing more realistic expectations of what the treatment can achieve in clinical practice.
Authors' methods: Systematic review
Project Status: Completed
Year Published: 2005
English language abstract: An English language summary is available
Publication Type: Not Assigned
Country: Canada
MeSH Terms
  • Analgesics
  • Chronic Disease
  • Injections
  • Myofascial Pain Syndromes
  • Pain
Organisation Name: Institute of Health Economics
Contact Address: 1200, 10405 Jasper Avenue, Edmonton, Alberta, Canada, T5J 3N4. Tel: +1 780 448 4881; Fax: +1 780 448 0018;
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Copyright: <p>Alberta Heritage Foundation for Medical Research (AHFMR)</p>
This is a bibliographic record of a published health technology assessment from a member of INAHTA or other HTA producer. No evaluation of the quality of this assessment has been made for the HTA database.