Tandem Point Tandem Point(SM) Therapy:
An integrated acupressure approach for myofascial pain

by Rena K. Margulis
Presented to Rehabilitation Medicine Grand Rounds
Institutes of Health
March 17, 2000

Conclusion and questions

That concludes my formal presentation. I hope that you have come to share my excitement in the possibilities of integrating eastern and western approaches to myofascial pain.

I'll be glad to answer any questions. Thank you.

[Question: During the demonstrations, you had to urge both models to breathe. Do you find that patients who are trained in tai chi breathing do better with this work? Answer: Yes. While all patients need to be reminded to breathe, patients experienced at tai chi or yoga will do better at breathing and therefore get a faster result.

Question: Are your results just as effective with old injuries? Answer: If the original injury was an abrupt-onset injury, then I am optimistic about the patient's chances, even if the injury is very old. If the patient has a pain pattern not associated with an abrupt-onset injury, then the patient will probably have to incorporate stretching in his or her life on a daily basis, because some aspect of the individual's behavior is resulting in the activation of trigger points. I am certainly in favor of physical therapy to teach a patient how to move, sit, stand, and so forth to prevent re-activation of trigger points.

Question: What about focus on yourself, your own issues, intention, being present for the patient? Answer: Certainly the clinician has to stay present, because the clinician always has to be feeling for what points are working for the patient.

Question: Can a patient be educated to take points, or could perhaps a spouse be taught to do an approach? Answer: Yes. Especially with TMJ pain, I teach patients the points to take. The entire protocol for TMJ is on the anterior side of the body, and it is relatively easy for the patient to perform. As you know, TMJ is usually not a root problem, that is, something else is causing the TMJ, sometimes stress, sometimes bite problems, sometimes neck problems. Therefore TMJ can recur, and patients need to know how to treat it themselves.

Question: How can you justify this as rehabilitation? It seems like chiropractic, except that it focuses on the muscles. Repeated treatments are necessary. Rehabilitation is about relearning, so continuing treatment is unnecessary. Answer: I had been referring to TMJ, where frequently the trigger points in the muscles are secondary rather than primary, so addressing the TMJ pattern does not address the root problem. Where it is possible to address the root problem, further treatment can be unnecessary. For example, one patient presented with recurring numbness in her arms. While she was driving, while she was sleeping, while she was holding a baby, her arms would go numb. She had seen one doctor who told her that the problem was degenerative discs in her neck. She had seen another doctor, a physiatrist, who told her the problem was in her carpal tunnels, and she needed surgery on both wrists. She declined surgery and came to see me. Having seen this pattern before, I wondered if the root cause could be trigger points in pectoralis minor. Indeed, I found her pectoralis minor muscles to be harder than any others I had ever palpated. As an experiment, I released the trigger points in the right pectoralis minor only and discussed stretching with the patient. For three weeks, until the next treatment, she had no numbness in her right arm, but continued to have recurring numbness in her left arm. At the next session, therefore, I released the trigger points in the left pectoralis minor, and her numbness disappeared in her left arm. Now hers was not an abrupt-onset injury: she needs to stretch on a daily basis. When she did not stretch, the problem did recur. But now she stretches every day, and she does not need further treatment for this problem. She is better. She has no numbness in her arms. This is a big difference in her life.

Question: Would you recommend this therapy as a first line of action or would your recommend it only after traditional treatment? Answer: When you think that muscle contracture is a problem, I would choose this approach early on. What happens is that I usually see patients when they have already been through the mill.

Question: That makes a problem longer and harder to treat? Answer: Yes, it does. You'll see this is in the iliopsoas cases that I wrote up for you. When I have worked on an iliopsoas case in the first day or two following injury, only the iliopsoas is involved, and generally one treatment to just the iliopsoas is enough. As the iliopsoas muscle remains in contracture, other muscles in the functional unit also develop contractures, just for the patient to remain vertical and for his or her joints to function properly. So as cases get older, more and more muscles get involved, and of course treatment takes longer.

Comment from a physician: Part of the problem is that muscles are not palpated. In today's world of HMO care, you have a 15-minute visit. A doctor comes in to ask you how you are doing and may check your range of motion. But what we must do is palpate the muscles. See if trigger points are there. If they are present, we have many techniques to try, whether it is acupuncture or all the techniques that Rena described, craniosacral therapy, myotherapy. You asked about how this is pertinent to rehabilitation. This is the essence. What we do in rehabilitation is try to address impairment, disability, and handicap. If you can get rid of the impairment, it is no longer an issue. We are not treating people to live with their pain, we are getting rid of their pain.]



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