in Luhačovice Spa - 1st INTERNATIONAL...

3 years with

in

Luhačovice Spa

Jiří Staňa, MD

MUDr. Jiří Staňa,

Lázně Luhačovice,a.s.

Luhačovice Spa is Word known Czech Spa Resort with more than 200 years

tradition and 12 springs of powerful mineral water, originally based on healing

patients with asthma and COPD.

This time we meet more and more oncologic patients and patients with

musculoskeletal disorders.



Team work: Head of Spa Policlinic, second graduated

anaesthesiologist with graduation in internal and

emergency medicine.

Working team consists of rehabilitation doctor, ORL

and orthopedist. We prefer individual and holistic

approach to the patient and try to get him involved in

the healing process.

Patient Profile

About 30.000 patients/year

• 1/4 asthma + COPD

• 1/4 onkologic

• 1/4 musculoskeletal disorders

• 1/4 metabolic, digestive and circulatorydisorders



Patient Prototype

• Woman 55+ with back pain and mobility disorder

• Obesity, Hypertension, Thyreopathy, Osteoporosis, Hyperlipoproteinemia.

• Stp.CHCE, HYE

• More than 5 medicaments

• More than 3 doctors



History of Applications



• Till 2013: Lidocain + Steroid

• GUNA MD from 2013

• Total No.of MD from 1.1.2016: 602 = cca 10%• Knee: 356

• Back pain: 108

• Shoulder: 57

• Piriformis: 32

• Carpal tunel: 28

• Others: 21

Comparsion of Trigger Points

Clinical criteria Skin TgP Muscle TgP Periosteum TgP

Character of pain burning deep, aching sharp

Pattern of the pain permanent increase with activity increase with activity

Location no special site in affected muscle around joint

Radiating pattern no along the muscle to the joint

Depending frommovements

no yes yes

Satellite Trigger points no yes yes

Other symptomsparaesthesie, hyperalgesia

muscular weeknesspain of the joint,

muscular weekness



WOMAC Questionniare

• The Western Ontario and McMaster Universities Arthritis Index (WOMAC) is a

widely used, proprietary set of standardized questionnair used by health

professionals to evaluate the condition of patients with osteoarthritis of the knee and

hip, including pain, stiffness, and physical functioning of the joints. The WOMAC has

also been used to assess back pain.

• The WOMAC measures five items for pain (score range 0–20), two for stiffness

(score range 0–8), and 17 for functional limitation (score range 0 –

68/068).

Physical functioning questions cover everyday activities such as stair use, standing

up from a sitting or lying position, standing, bending, walking, getting in and out of a

car, shopping, putting on or taking off socks, lying in bed, getting in or out of a bath,

sitting, and heavy and light household duties.[

• A WOMAC test takes about 12 minutes, but is also available in a short form

( Wikipedia)



WOMAC scoring system



Piriformis syndrome

• What is that?

• When orthopedist says: this is not hip

• and neurologist says: this is not discus…



Piriformis syndrome - etiologyPS remains usually hidden in such diagnosis as:Low back pain, ischias (sciatica), FBSS, L5/S1 nerve roots irritation, SI syndrome etc.Dg. often supported by X- ray, CT or MRI scan showingspondylosis and osteochondrosis of LS spine or discushernia. Structural changes found on X-ray,CT or MRI photoesare often not able to explain patient´s complains.More than 50% of healthy PTS have „positive“ scan.



Piriformis syndrome• Anatomy: intimate relationship between m.piriformis and n.ischiadicu.

Tunnel: walls created by os ischii + os ilium and bottom by lig.sacrospinale

In fact: Compartment (tunnel) syndrome with compression of the sciatisnerve caused by oedema, haematoma or myositis ossificans of the piriformismuscle. The cause could be multiple: sedentary job, overloading or trauma ofrotators of the hip duering sports or another physical activities...

Piriformis syndrome

Piriformis syndrome

• Clinical picture: patient suffering from unilaterál back and gluteal painirradiating down by lower extremity. Pain and paresthesia come fromaffected branches of ischiadicus: n.pudendus, n.gluteus. Some authors say that PS is even responsible for male impotence and female dyspareunia...

Piriformis syndrome - diagnostics• Anamnesis data – sedentary job, trauma, sport activities

• Painful gluteal muscle TgP in 100% patients

• Positive Beatty´s manoeuvre

• Positive Lassegue in > 50% patients

Treatment:Of course, you cannot palpate your legs!

That´s because you have amputated your hands…

Noninvasive• Physiotherapy: exercises, joga, stretching, massages etc.• Electrotherapy: magnet, laser, ultrasound etc.• Watertherapy, peloids etc.

Invasive• Akupunkture• Infiltration• Operation

Piriformis syndrome



Piriformis syndrome

Infiltration agents till 2013:

• Lidocain (Marcaine)

• Steroids

• Combination of both above

• Botulotoxin – USA, under CT control

• From 2013 MD GUNA injections



Tips and Tricks

• MD Matrix, Muscle, Neural or combination

• The needle long enough (20G 0,9x70-90mm)

• Gentle leading of the needle – os sacrumidentification

• Aspiration – haematoma of m.piriformis

• Risk: ???? N. ischiadicus damage, bleeding, allergic reaction



Tips and Tricks

• Muscular TgP

TargetNavigation

Piriformis TgPts

Know how:

TERUMO, B Braun

20G 0,9x70-90mm

Piriformis syndrome

Results: 28 pacients ( 3x surgery indicated)

MD Matrix, Muscle

• 21 patients „One shot“ therapy

• 7 pacients both 2 TgP

• 2 pacients more than 3 applications

• 2x identified haematoma m.piriformis

• No one worsened

• No one operatedMUDr. Jiří Staňa,


WOMAC scoring system



the best 57….17 the worst 50….30

Maximum 96 pts

Possible Pitfals and Mistakes

• Needle too short…

• Wrong navigation

• Severe pain caused by nerve touch

• Bleeding – never treat PTS with haemophiliaand PTS taking anticoagulants !!!



Literature

Thank You !


Lázně Luhačovice,a.s

www.spaluhacovice.cz

[email protected]

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