Positive Health Online

Neuromuscular Therapy (NMT) is a comprehensive approach to the treatment of musculoskeletal pain and postural dysfunction. It is part of a naturopathic approach to physical medicine. It combines orthopaedic assessment, clinical kinesiology, joint mobilization, postural re-education and soft tissue manipulation (STM) - including myofascial release (MFR), passive positional release (PPR), trigger point therapy (TPT) and muscle energy techniques (MET). It can be combined most effectively with thorough investigation into postural compensation patterns as well as health education, nutrition and effective neuromuscular rehabilitation programs.

Client Age: 34
Gender: Male
Background: Patient is an Elite Triathlete. Moderate Weekly Training Volume: 15-20 hours. 3 swim sessions, 3 bike sessions, 3 run sessions and core stability/flexibility/strength sessions.

Information and TX History: Pain in right(R) Shoulder started prior to race while abroad. Continued training up to race with lighter load in swimming pool. Raced at weekend, the R arm and shoulder increased with pain during duration of open water swim. Motion of front crawl difficult to maintain. R Glenohumeral (GH) Joint operation to repair cartilage previously. Pain R shoulder continued for 3 weeks before consultation with osteopath was first arranged. Tx consisted of thoracic, cervical and lumbar HVLA adjustments to facets. Pain in mid back appeared after these adjustments. Moderate decrease in pain on left arm and shoulder following manipulations. Athlete sought help with problem after pain had not subsided. 

Diagnosis: Thorough examination of shoulder joint was required due to the possible involvement of the cervical spine. Examination showed Protracted R Scapula. Med Rotation R GH joint. Pain with Flexion. Humerus: Drop can test - Supraspinatus Hyper-tonic (HT) with severe (S-) muscle (ms) weakness. Trigger Points (TPs) on lateral border scapula at teres minor and major origins. S+ Weak Serratus Anterior. TPs R sub scapula. Examination of the Glenohumeral joint capsule showed difficulty with performing Apleys scratch test. Also with completion of the painful arc there was tenderness in the abduction of the shoulder. R brachialis HT at insertion. This can indicate a number of possible pathologies including subacromial bursitis or calcium deposits. Coracoid Pressure Syndrome - compression of brachial plexus below Coracoid process of scapula, was also present. Common Compensatory Pattern Left, Right, Left, Right (L, R, L, R) at Occipital-Atlantal (OA), b) Cervico-Thoracic (CT), c) Thoraco-Lumbar (TL), Lumbo-Sacral (LS) was observed.

Treatment Protocol Including Objectives

Tx1: The aim of the first treatment was to address any underlying inflammation in the affected area, decrease the pain and assess the injury comprehensively. A full orthopaedic assessment was conducted examining movement in all planes. There were muscle tests whole shoulders girdle as well those around the C-Spine and T-Spine (as above). Checked junctions for compensation patterns with OA, CT, TL and LS showing L, R, L, R. Manual Lymphatic Drainage performed alongside Passive Range of Motion, Light MFR Ant. Chest, Chest Cavity, Ribs, intercostals. Release Sub Occiput with gentle traction and PPM.

We also identified other triggers in the injury/inflammatory process, including regular coffee consumption, red meat and increased laptop use. The guidelines below for nutrition and lifestyle practice for reduction in pain and inflammation were given:

• Cut out coffee, tea and all caffeinated drinks;
• Decrease red meat consumption. Avoid if possible;
• Avoid processed sugars. Biscuits, Milk chocolate etc;
• Turmeric, ginger and garlic all aid anti-inflammatory response;
• Eat Omega-3 oils at every meal. Focus on Mackerel, Salmon and Herring;
• Decrease intake of saturated fats and Omega-6 oils (sunflower & corn etc);
• Eat all whole grains;
• Water intake should be at least 8-10 glasses a day;
• Increase seed consumption;
• Increase vegetable and fruit intake. At least 8-10 portions per day;
• Cut out alcohol and smoking;
• Get 8 - 9 Hours sleep per night.

Tx2: The second treatment was 5 days after the initial consultation. Pain had decreased and range of motion increased in the initial 48 hours after treatment. Sleep quality had improved, but the arm shoulder was still painful to sleep on if lying on right side. Continued MFR work down lateral torso on R side. Worked to restore balance into the pelvic girdle, addressing a lateral pelvic tilt (right side high) with a HT R quadratus lumborum. Anterior and Posterior MFR of torso alongside release of Anterior and Mid Scalenes. Mobilization of R ribs 5-10. TPT Serratus Anterior. After this session we had managed to get Serratus Anterior firing properly again and also more stabilization through the whole shoulder girdle.

At end of 2nd session we performed some Rehabilitation exercises which were to be continued in the following week: Specific focus on shoulder stability and proprioceptive neuromuscular facilitation (PNF) Working with all 3 planes of movement. This involved spiral shoulder METs, functional exercise utilizing theraband with special attention paid to the strengthening of the serratus anterior.

Tx3: This session was given 1 week after the 2nd treatment. The focus of the session was to restore any remaining tissue in torso and Transverse Friction Massage on right upper and lower rhomboids. This was aimed at reducing the fibrous adhesions in the stretch weakened tissue. Prior to the commencement of friction massage, an application of ice was used over the area to induce an anti-inflammatory response in the tissue and vasoconstrict the blood vessels. This application was repeated after the friction work to create vasodilation and a vascular pump of the tissue. More vigorous STM was performed of the upper torso, TPT sub scapula, TPT R sub occiput and mobilization of C-spine OA through to CT. STM R brachialis on Humerus in distal portion.

Treatment strategy used: The strategy of Neuromuscular Therapy is to objectively identify both local and global factors in the appearance of pain and inflammation in the body. In most cases, I can identify a pre-disposition to specific postural adaptations acquired from emotional, physical, bio-chemical or environmental stresses. These patterns that are already in the body determine the outcome from accidents, injury or trauma. In the above case, an increased workload on a laptop computer, coupled with an increase in swimming workload had meant that the scapula had become protracted and compromised.

Treatment outcome: After three treatments the patient had returned to between 75-85% mobility in the shoulder. An increased focus on postural and scapula stabilization work was indicated to ensure that the load on the shoulder could be reduced. An increased awareness of the importance of managing injury with nutritional, lifestyle and conservative treatment was highlighted. Also focus on decrease of postural load on R shoulder in future and continuation of performance and remedial related NMT.