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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