https://doi.org/10.4082/kjfm.18.

0065 • Korean J Fam Med 2019;40:344-347

Original Article

The Effect of Trigger Point Injections on

eISSN: 2092-6715

Pain in Patients with Advanced Cancer

Chang Yub Lee*, Eeun Jung Kim, Dae Geun Hwang, Moon Yong Jung, Hyun Geun Cho

Department of Family Medicine, Busan Bohun Veterans, Busan, Korea

Background: It has been reported that in 62.5% of cases of incurable cancer pain, the complaint is due to myofas-
cial pain syndrome. Trigger point injections using dibucaine hydrochloride help patients with such cancer pain.
This study evaluated the efficacy of trigger point injections for alleviating pain in patients with advanced cancer.
Methods: Twenty patients with advanced cancer who had a life expectancy of 6 months or less and had been diag-
nosed with myofascial pain syndrome were treated with trigger point injections. Prior to treatment, a Visual Analog
Scale (VAS) was used to measure the resting pain level and discomfort upon application of pressure on the site of
pain. These values were compared with last treatment measurements.
Results: The mean pre-treatment VAS scores for pain at rest and upon application of pressure on the pain site were
7.3 and 9.0, respectively. These scores decreased significantly to 1.95 and 3.2, respectively, after the treatment
(P<0.05).
Conclusion: Trigger point injection is an alternative and effective pain control modality for advanced cancer pa-
tients with myofascial pain syndrome.

Keywords: Advanced Cancer; Cancer Pain; Myofascial Pain Syndromes; Trigger Points

Received: May 16, 2018, Revised: June 10, 2018, Accepted: June 22, 2018
*Corresponding Author: Chang Yub Lee https://orcid.org/0000-0003-0848-3433
Tel: +82-51-601-6000, Fax: +82-51-601-6339, E-mail: yub5115@naver.com

Copyright © 2019 The Korean Academy of Family Medicine

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0)
which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Chang Yub Lee, et al. • TPI Effect on Terminal Cancer www.kjfm.or.kr  345

INTRODUCTION and suspected areas were injected with 1 to 4 mL of lidocaine depend-

Myofascial pain syndrome is a condition characterized by an area of
muscle with hypersensitive response, called a trigger point, which can
cause pain, muscle weakness, limited range of motion, symptoms of
autonomic nervous system mismatch, depression, and insomnia
among other symptoms. Trigger points are regions of tender muscle
1,2)
fibers (taut bands) in skeletal muscle that can evoke major pain.
The pain caused by cancer is extensive, and some forms are resis-
tant to even opioid medication. Among incurable cancer pain, one in-
vestigation reports that 12%–17% of cancer patients complain of pain
and of those 62.5% are experiencing myofascial pain syndrome. Every-
one has experienced functional muscle pain in their daily lives, but
cancer patients can experience sustained episodes of such pain.3)
Myofascial pain syndrome was observed in one out of nine patients
treated for cancer in the head and neck, and a decreased quality of life
was observed among these patients.4) In a previous study, 84.9% of
cancer patients reported their response to trigger point therapy using
Neovitacain injection for myofascial pain as ‘good’ or ‘better’ and Vi-
5)
sual Analog Scale (VAS) scores also improved.
This study aimed to evaluate the effect of trigger point injections on
the advanced cancer patient with cancer pain.
METHODS
ing on the size of the muscle.6,7) Based on another study, the average
number of injections was 2.4 and 3.7 at the time of evaluation, so we
estimated the efficacy after the fourth injection.5) In our study, the
treatment was limited to one or two injections per week. And maxi-
mum injections of times were limited of four injections, if initial two
injections were effective. When the administration was terminated be-
fore the final injection, the evaluation was performed at that time point
or the next treatment day. Pain levels were compared between before
and after injections using a 100-mm VAS scale for pain at rest and pain
upon application of pressure to the trigger point.
The collected data was analyzed by IBM SPSS statistics ver. 20.0 pro-
gram (IBM Corp., Armonk, NY, USA). The VAS of the pain before and
after trigger point injections was considered to be statistically signifi-
cant when the P-value was less than 0.05 using the Wilcoxon signed-
rank test, a nonparametric test of two related samples.
This study was reviewed and waived by the Institutional Review
Board, and it complied with the Declaration of Helsinki. And written
informed consents were obtained from patients.
RESULTS
Within the study group, there were 16 males (80%) and four females
(20%). The participants included two patients in their 60s (10%), 15 in

The study enrolled a total of 20 advanced cancer patients in hospice Table 2. Patient background
care. They were able to verbally express their pain levels and their pre- Variable No. (%)
sumed life expectancy was approximately 6 months or less. Proce-
No. of cases 20 (100)
dures were conducted only on those patients who agreed to receive Sex
trigger point injections after receiving sufficient explanation regarding Male 16 (80)
the treatment. Trigger points were determined using the diagnosis cri- Female 4 (20)
teria of Simons (Table 1).6) Patients prone to bleeding or infection were Age (y)
60s 2 (10)
excluded. Details of previous or current medications and remedies in-
70s 15 (75)
tended for pain control were recorded during the assessment period. 80s 3 (15)
A physical examination was conducted to check for trigger points, Pain
0: None 0
1: Tenderness or pain on exercise 0
Table 1. Diagnostic criteria 2: Mild pain in daily life 1 (5)
Diagnostic criteria 3: Moderate pain 6 (30)
4: Severe pain 10 (50)
Major criteria 1. A patients’ regional pain complaint
2. ‌Palpation of a trigger point elicits a stereotypic zone of 5: No activity at all 3 (15)
referred pain specific to that muscle Primary disease
3. Identification of a palpable taut band Pulmonary cancer 5 (25)
4. ‌Location of an exquisitely tender spot along the length of that Gastrointestinal cancer 6 (30)
taut band Hepatobiliary cancer 3 (15)
5. ‌Some degree of restricted range of motion of the involved Urogenital cancer 1 (5)
muscle Gynecologic cancer 3 (15)
Minor criteria 1. ‌Palpation of a trigger point should reproduce the clinical pain Hematologic cancer 1 (5)
complaint
Miscellaneous 1 (5)
2. ‌A local twitch response may be elicited by transverse
snapping or needling of the trigger point Pain site (no. of overlap=36)
3. The alleviation of pain by trigger point inactivation Head and neck 12 (33.3)
Shoulder 5 (12.8)
Suggested diagnostic features have been divided into major and minor criteria, of
Thoracolumbal area 15 (41.6)
which all five major criteria and at least one minor criterion must be fulfilled to
establish the diagnosis of myofascial pain syndrome. Miscellaneous 4 (11.1)

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Table 3. Combined medications
Variable No. (%)
No. of cases 20 (100)
Combination drugs that may affect myofascial pain syndrome
(no. of overlap=54)
None 0 signed-rank test.
Nonsteroidal anti-inflammatory drugs 3 (15)
Acetaminophen 3 (15)
Opioids 18 (90)
Muscle relaxant 5 (25)
Gabapentin 3 (15)
Steroid 9 (45)
Benzodiazepine 13 (65)
their 70s (75%), and three in their 80s (15%); the mean age was 74.2
years. The most common primary diseases were cancer of the gastro-
intestinal tract (30%) followed by pulmonary cancer (25%). The most
common pain complaints were ‘severe pain’ (50%) followed by ‘mod-
erate pain’ (30%). The areas of pain to be evaluated included: the ‘tho-
racolumbar area’ (41.6%) and the ‘neck and shoulder area’ (33.3%)
(Table 2). In regards to medication combinations used for myofascial
pain syndromes, 90% of patients had used opioids, followed by benzo-
diazepines (65%) and steroids (45%) (Table 3).
The VAS at rest before and after injections decreased from 7.3 to 1.95
(P-value <0.001). The VAS with pressure applied to trigger points be-
fore and after injections decreased from 9.0 to 3.2 (P-value <0.001) (Ta-
ble 4). Thirteen patients (65%) improved immediately after injections,
while five patients (25%) improved within 3 days, and two patients
(10%) had no improvement after injections. None of the patients expe-
rienced increased or worsened pain. Pain improvement was only as-
sessed at the injection site and the affected area of the injected muscle,
though many patients had decreased pain in other areas. For example,
after injections in the cervical area, pain in forearm also improved.
These results were excluded from the analysis because causality is dif-
ficult to prove. If there was no response after the first and second injec-
tions, no additional treatments were performed. There were five pa-
tients whose symptoms such as nausea, vomiting, depression, and in-
somnia, unrelated to pain after injection, improved at the same time.
Three patients (15%) complained of pain at the injection site for 1 to 2
days after the injections, but no other side effects were noted. Pain and
swelling at the site of injection were self-limiting.
DISCUSSION
Myofascial pain syndrome is a pain syndrome caused by muscle and
fascial lesions. It causes a trigger point, or hypersensitive region in the
skeletal muscle. Pain is consistently reproduced at a specific site when
the trigger point is stimulated.8) Common sites of pain include the
head, neck, and lower back. It is usually managed with conservative
treatment such as physical therapy and medication. In severe cases,
the pain needs to be alleviated by inactivating the trigger point and re-
storing muscle function.1,7,9) Various studies have reported that pain
https://doi.org/10.4082/kjfm.18.0065
Chang Yub Lee, et al. • TPI Effect on Terminal Cancer
Table 4. Changes of VAS for pain before and after TPI
Variable Before TPI After TPI
Resting VAS 7.3±0.8 1.0±2.3*
Pressing on pain site VAS 9.2±0.9 2.8±2.5†
Values are presented as mean±standard error. Obtained by analysis of Wilcoxon
VAS, Visual Analog Scale; TPI, trigger point injection.
*Z=-3.742, P-value <0.001. †Z=-3.842, P-value <0.001.
due to cancer can create trigger points, that trigger points can coexist
with cancer pain, and that pain may be exacerbated by cancer.5,10) Es-
pecially in advanced cancer patients, opioids alone may not adequate-
ly control pain or the side effects of the opioids may prevent a satisfac-
tory dosage from being attained.11-13) In those cases, although cancer
pain is difficult to control, total pain can be improved by managing
other types of pain such as myofascial pain syndrome.
Most tender points are caused by myofascial pain syndrome, while
some cancer pains can also create tender points. Therefore, it is diffi-
cult to differentiate cancer pain from myofascial pain syndrome before
injection. Two patients with non-responsive pain were thought to have
pain secondary to the cancer itself.
In this study, the accompanied symptoms such as nausea, vomiting,
depression, and sleeping disorders were improved in a few patients.
Because the pain itself is highly stressful, it affects the autonomic ner-
vous system and can cause concomitant symptoms. Therefore, proper
treatment of pain can improve the patient’s overall quality of life.
During the course of this study, some patients who did not benefit
from the first injection were later satisfied with the final injections. This
may be due to insufficient dosages or inappropriate site of injection
initially. For that reason, we recommended at least two treatments be-
fore considering the injections ineffective.
There are several limitations of this study. First, the efficacy of treat-
ment was dependent on the skill of the practitioner. Secondly, it was
difficult to control the combined medicines that could interfere with
pain control by injection. Lastly, the study group was small, and the
study lacked a control group.
This study suggests that trigger point injection is an effective and
safe supplemental treatment for controlling pain in cancer patients.
However, the primary regimen for cancer pain remains to be the basic
principles of the World Health Organization guidelines and attempt-
ing to control all cancer pain by trigger point injection alone is not ad-
vised.
CONFLICT OF INTEREST
No potential conflict of interest relevant to this article was reported.
ORCID
Chang Yub Lee: https://orcid.org/0000-0003-0848-3433
Eeun Jung Kim: https://orcid.org/0000-0002-1427-3101
Chang Yub Lee, et al. • TPI Effect on Terminal Cancer
REFERENCES
1. Kim CH, Park JW. Trigger point injection for myofascial pain syn-
drome. J Korean Orthop Ultrasound Soc 2014;7 Suppl 2:127-31.
2. Scott NA, Guo B, Barton PM, Gerwin RD. Trigger point injections for
chronic non-malignant musculoskeletal pain: a systematic review.
Pain Med 2009;10:54-69.
3. Twycross RG, Fairfield S. Pain in far-advanced cancer. Pain
1982;14:303-10.
4. Cardoso LR, Rizzo CC, de Oliveira CZ, dos Santos CR, Carvalho AL.
Myofascial pain syndrome after head and neck cancer treatment:
Prevalence, risk factors, and influence on quality of life. Head Neck
2015;37:1733-7.
5. Yamaguchi A, Ogino Y, Iwakoshi C, Karasawa K, Ohki M. Trigger point
therapy for myofascial pain in cancer patients (first report): analysis
results of special use-results surveillance by Neovitacain injection.
Gan To Kagaku Ryoho 2011;38:1659-65.
6. Simons DG, Travell JG, Simons LS. General overview. In: Simons DG,
Travell JG, Simons LS, editors. Myofascial pain and dysfunction: the
trigger point manual. 2nd ed. Baltimore (MD): Lippincott Williams
www.kjfm.or.kr  347
and Wilkins; 1999. p. 31-5.
7. Seong JW. Principle and insights into pain. Paju: Koonja Press; 2015.
8. Simons DG. Muscle pain syndromes. J Man Med 1991;6:3-23.
9. Lang AM. Botulinum toxin therapy for myofascial pain disorders. Curr
Pain Headache Rep 2002;6:355-60.
10. Hasuo H, Ishihara T, Kanbara K, Fukunaga M. Myofacial trigger points
in advanced cancer patients. Indian J Palliat Care 2016;22:80-4.
11. Ministry of Health and Welfare. Cancer pain management guideline
[Internet]. Sejong: Ministry of Health and Welfare; c2010 [cited 2016
Apr 10]. Available from: http://www.cancer.go.kr/2010/05/27/Can-
cer_Pain_management_guideline(Dr).PDF.
12. Hubbard DR. Chronic and recurrent muscle pain: pathophysiology
and treatment, and review of pharmacologic studies. J Musculoskelet
Pain 1996;4:123-44.
13. Gordon DB, Dahl J, Phillips P, Frandsen J, Cowley C, Foster RL, et al.
The use of “as-needed” range orders for opioid analgesics in the man-
agement of acute pain: a consensus statement of the American Society
for Pain Management Nursing and the American Pain Society. Pain
Manag Nurs 2004;5:53-8.
https://doi.org/10.4082/kjfm.18.0065