I recently started my Family Medicine rotation and almost daily, every provider in the group has 1 patient that is there for trigger point injections. After the first patient, I asked about the evidence etc… The physicians response was among the lines of “I know its controversial, but I believe the evidence supports it”, I replied “I have to look into it more but I remember reading that TrPs may not even exist and no one knows what they are, yet how to treat them”… his response “that would be a good learning issue” (although no matter what I present, he/she won’t change his approach to this issue)
Every physician in the group does trigger point injections, they all feel around the back, poking needles of lidocaine randomly in muscle spots that the patient says hurt, injecting anywhere from 0.2cc to 1cc. When I bring up some evidence their response is always something like “I understand the evidence is weak, but my patients benefit from it placebo or not” and then they say something like “If they report relief from previous injections, should we stop doing them? They are pretty low risk when done correctly” And at that point I don’t know how to respond, and also don’t want to argue about the topic anymore as they are deciding my clinical grade…
I guess my question is how do I respond to the question of “Placebo or not, they report relief so should we not give them the injections?”
Thanks BBM, y’all are awesome and have helped shape the physician I want to be in the future.
I think you could start by asking them if they have considered how very often patients become over reliant on “treatments”. They may not understand how damaging it may be for a patient to rely on an intervention to relieve their pain which leads to things like lack of internal locus of control. These doctors are only thinking about the acute pain relief and see nothing but benefit but it seems as though they are missing the long term effects their interventions may have.
Now the bigger issue here is the acknowledgement of weak or no research supporting their trigger points = pain theory. They know that their treatment is unsubstantiated yet they still provide it and they say it’s okay because of the acute pain relief. I suppose here you could supply them with the quality research showing how most anything we do can work due to therapeutic alliance and because of this we should instead worry less about using a fancy intervention and start promoting self efficacy and autonomy.
Best of luck to you and your career!!
I have experienced this also. It does require some tact, as these physicians will decide your clinical grade. The discussions I’ve had typically conclude with the agreement that the evidence to support the trigger point construct is weak, although some providers will point to thermography, MRE and fMRI studies to argue its potential legitimacy.
Ultimately, I’m not certain that these providers will change the way they practice. I’ve brought up the talking point that I am not totally opposed to this treatment provided it is offered as an adjunct to facilitate engagement in exercise and physical activity. But as we all know, patients are free to use their time as they please and we can’t force anyone to adopt healthy lifestyle modifications.
On this view, clinicians are left with the options of a) offering education and recommending exercise therapy without administering these injections, b) administering the injections as an adjunct and recommending exercise as the cornerstone of care, or c) continuing as usual and ignoring the exercise discussion altogether.