Medicine Section - Trigger Point Therapy

IMPORTANT REMINDER

Regence Medical Policies are developed to provide guidance for members and providers regarding coverage in accordance with contract terms. Benefit determinations are based in all cases on the applicable contract language. To the extent there may be any conflict between the Medical Policy and contract language, the contract language takes precedence.

PLEASE NOTE: Contracts exclude from coverage, among other things, services or procedures that are considered investigational or cosmetic. Providers may bill members for services or procedures that are considered investigational or cosmetic. Providers are encouraged to inform members before rendering such services that the members are likely to be financially responsible for the cost of these services.

NOTE:  This policy has been revised.  The revised policy will be effective November 1, 2004.  To view the revised policy, click here.

Description
A trigger point is a discrete focal tenderness located in a palpable taut band of skeletal muscle, which produces a local twitch in response to stimulus to the band. Myofascial pain syndrome is a regional painful muscle condition with a direct relationship between a specific trigger point and its associated pain region. Modalities used in the treatment of myofascial pain syndrome include trigger point injection with local infiltration of a local anesthetic with or without a steroid, trigger point injection with saline or glucose, intramuscular dry needle stimulation, stretch and spray, massage, ultrasound and TENS.

The therapeutic effect of dry needle stimulation relies on mechanical disruption or direct stimulation of trigger points.

Policy/Criteria
Trigger point injections with a local anesthetic with or without steroid may be considered medically necessary for the treatment of myofascial pain syndrome.

Dry needle stimulation and trigger point injections with any substance (eg, saline or glucose) other than local anesthetic with or without steroid are considered investigational. Due to insufficient evidence to permit conclusions concerning the effect of dry needle stimulation and injection of any other substance(s) on the health outcomes of patients with myofascial pain syndrome.

Scientific Background
Medicare medical policy provides the following description of trigger points and trigger point therapy:

Trigger points or trigger zones are hyperirritative foci that may occur in any skeletal muscle on the body that are particularly sensitive to touch and when stimulated, become the site of a painful neuralgia. These trigger points produce a referred pain pattern characteristic for that individual muscle and sometimes remote from the point itself and not related to it by anatomically definable pathways. Usually, the involved muscle is felt as a tight palpable band. Frequently affected sites include the trapezius, supraspinatus, infraspinatus, teres major, lumbar paraspinals (2 sites), gluteus and pectoralis muscles.

There is no laboratory or imaging test for establishing the diagnosis of trigger points. It depends upon the detailed history and a thorough directed examination.

Injections of substances such as anesthetic and/or steroids are done to affect therapy for the pathological condition.

Esenyl et al, randomized 102 patients with chronic trigger point pain of the upper trapezius muscle to: ultrasound and neck stretching exercises (group 1); trigger point injections and neck stretching exercises (group 2); or neck stretching exercises alone (control group). Compared with the control group, patients in group 1 and 2 had a statistically significant reduction in pain intensity, an increase in pressure pain threshold, and an increase in range of motion. There were no statistically significant differences in outcomes between groups 1 and 2. (5)

An updated search of the literature for clinical studies through May 2003 reveals one new study of dry needle stimulation for tension headaches. Karakurum and colleagues randomized 15 patients to dry needle trigger point therapy at 6 trigger point sites or sham dry needle therapy. (6) Mean headache indices improved in both the experimental group and the sham therapy group, however the difference was not statistically significant. In the dry needle trigger point group neck tenderness and neck range-of-motion improved more than in the sham treated group. The number of patients treated was too small for the difference to reach statistical significance.

Due to insufficient scientific evidence that dry needling or injection of saline or glucose at trigger point sites affects pain of patients with myofascial pain syndromes or tension headaches, conclusions cannot be reached concerning their effect on health outcomes.

References

1. Cousins, Bridenbaugh. Neural blockade in Clinical Anesthesia and Management of Pain, Lippincott-Raven, Philadelphia, New York, 1998
2. Simons and Travell. Myofascial Pain & Dysfunction: The Trigger Point Manual, Lippincott-Williams & Wilkins
3. Han et al. Myofascial pain syndrome and trigger-point management. Regional Anesthesia, Jan-Feb 1998:30-6
4. Ferrante et al. Sphenopalatine Ganglion block for the treatment of myofascial pain of the head, neck, and shoulders. Regional Anesthesia Pain Medicine, Jan-Feb 1998;23:30-6
5. Esenyel et al. Treatment of Myofascial Pain. Am J Phy Med Rehabil Jan-Feb 2000;79:48-52
6. Karakurum B, Karaalin O, Coskun O et al. The 'dry-needle' technique: intramuscular stimulation in tension-type headache. Cephalgia 2001;21(8):813-7

Cross References

Prolotherapy, TRG Medical Policy Manual, Medicine, Policy No. 40

Medicine Section Table of Contents