Participatory action imaging in increasing clinician confidence of trigger point dry needling or trigger point injection of muscles requiring use of intercostal blocking: A case report

Abstract

Some clinicians privately report a lack of confidence of being able to safely perform trigger point dry needling (TrPDN) or trigger point injection (TrPI) on muscles that require intercostal blocking, presumably resulting in procedural underutilization. Participatory action imaging (PAI), combined with procedural training and literature review of adverse event incidence, can be a useful tool in enhancing clinician confidence. A 6’ 2”, 185 lbs, 53-year-old male clinician subject with a latissimus dorsi trigger point (TrP) and privately reported high anxiety of performing TrPDN using the intercostal blocking technique, was examined to determine how clinician subject confidence could be improved through PAI and education regarding the degree of coverage of the intercostal space and rib during intercostal blocking. The clinician subject was placed in a left lateral decubitus position and rib imaged with a Siemens Acuson S2000 Ultrasound system with an 18L6 16 Hz high definition linear probe without intercostal blocking, and subsequently with intercostal blocking during maximal exhalation and inhalation, respectively. During intercostal blocking with maximal exhalation, the pleural space and an additional 13% of each side of the rib’s superior and inferior borders were completely blocked by the examiner’s fingers. During intercostal blocking with maximal inhalation, the pleural space and an additional 3% of each side of the rib’s superior and inferior borders were completely blocked by the fingers of the clinician. On visual inspection and interpretation of the images (e.g., PAI), the clinician subject reported a “significant” decrease in self-reported anxiety in performing the intercostal blocking technique (STAI Y-1 score improvement to “low to no anxiety range”). While more study is needed to investigate how variation in patient anatomy (weight, height, and morphology), clinician anatomy (hand size), needle direction, and specific rib being used for influences patient safety, this case report presents PAI as a previously undescribed means for future research and clinician education regarding risk assessment of TrPDN or TrPI of muscles requiring intercostal blocking.