Musculoskeletal Injection Skills.

Kesson M, Atkins E, Davies I. Philadelphia, PA 19106, Butterworth-Heinemann Inc, 2003, paperback, 206 pp, illus, ISBN: 0-7506-4372-2, $37.95.

In England in 1995, the Chartered Society of Physiotherapy (CSP) extended the scope of practice of physiotherapy to include injections and developed new guidelines for practice, which reinforced the need for postgraduate training in the administration of injections. In accordance with the Medicines Act, physicians would be responsible for prescribing the drug, and physical therapists would be responsible for administering the injections. In 1999, the Crown Review of Prescribing, Supply and Administration of Medicines recommended that prescribing rights should be extended to physical therapists who are appropriately qualified and who have made a diagnosis and devised a plan of care.

In that same year, the CSP endorsed "A Clinical Guideline for the Use of Injection Therapy by Physiotherapists," which had been prepared by the Association of Chartered Physiotherapists in Orthopaedic Medicine, a clinical interest group of the CSP. According to the guideline, "Injection therapy courses sit comfortably within master's degree programs, since they conform to the achievement of level 4 (master's level) learning outcomes in allowing the demonstration of mastery in the application of a clinical skill with post-graduate education programs."

With this in mind, this book was written to support British injection therapy courses by addressing its underlying theory and the specific techniques used to treat each region. The authors offer information on how practitioners and patients should be positioned for all common musculoskeletal injections (see note at the end of this review). This book is a pearl for clinicians who provide musculoskeletal injections, because the clarity and apparent accuracy of its presentation as well as its readability are exceptional.

The book is divided into 2 sections. Section 1 describes principles of musculoskeletal injections, including basic pharmacology, essential equipment, safety precautions, emergency situations (eg, fainting and anaphylactic shock), record keeping, injectable drugs for musculoskeletal lesions (eg, corticosteroids and local anesthetics), and general injection principles. A flow chart provides a background for the clinical decision-making process. Section 2 outlines detailed regional injection techniques for the shoulder, elbow, wrist and hand, hip, knee, and ankle and foot. The effectiveness of these procedures are not discussed; however, there is an extensive list of references to the literature at the end of the book.

This book's excellent anatomical illustrations include photographs (with matching drawings and close-ups) that identify key landmarks where needles must be placed. Needle size and dosage of injectable drugs are highlighted for each region, and the book provides extremely useful clinical tips that identify the position of critical landmarks (eg, nerves and vessels) so that harmful placements can be avoided. Advice to patients to rest the affected area for a couple of weeks is also outlined with each intervention. Many of these injection techniques, which are credited to the work of Cyriax, are considered to be in common practice in sports and orthopedic medicine in the United Kingdom.

Perhaps therapists in the United States should someday consider expanding their academic training and revising their practice acts to include musculoskeletal injection techniques. The British system, as described in this book, would certainly serve as a model for how physical therapists in the United States could incorporate this intervention into an expanded scope of autonomous practice.

Jean-Pierre L Viel, PT, OCS 

Mt Eden Physical Therapy Center

Castro Valley, Calif

Mr Viel is a private practice owner and full-time clinician specializing in neuro-orthopedics. He is a member of the clinical faculty for the University of California San Francisco/San Francisco State University Graduate Program in Physical Therapy.

[Note: According to APTA's Government Affairs Department, no state practice act permits physical therapists to offer musculoskeletal injections.]