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Integrative NeuroMuscular Therapy (NMT) is a compre- hensive system of soft-tissue manipulation techniques that were developed in the 1930s in England by Dr Stanley Lief. Lief trained in the United States as a chiropractor and naturopathic physician. The integrative discipline that he developed, with additional insights from bodywork professionals Leon Chaitow, Raymond Nimmo, John Upledger, Janet Travell and others, balances the central nervous system with the structure and form of the musculoskeletal system.

Patient Mary Jane undergoes pelvic facilitation

NMT is based on neurological laws that explain how the central nervous system maintains homoeostatic balance, and in many cases, eliminates the cause of a person's acute to chronic myofascial pain and dysfunction. Through the application of modern-day integrative NMT procedures, which include cranio-sacral therapy, myofascial release, positional release and trigger point therapy, homoeostasis is restored between the nervous and musculoskeletal systems. Integrative NeuroMuscular Therapy enhances the function of joints, muscles, and the biomechanics of the body, and speeds healing by facilitating the release of the body's natural pain killers, endorphins.

Applications of NMT

Patients who suffer from acute to chronic pain resulting from occupational, sports and/or automobile injuries, benefit from receiving integrative NeuroMuscular Therapy. Specific types of dysfunctions and repetitive motion and accumulative traumas respond well to this treatment, including sciatica, rotator cuff dysfunction, carpal tunnel and thoracic outlet syndrome, temporomandibular joint dysfunction and migraines. Integrative NeuroMuscular Therapy is also utilised in certain types of physical and sexual abuse-related traumas.

Integrative NeuroMuscular Therapy approaches healing from a holistic perspective (mind/body) creating long-term results. One of the premises governing NeuroMuscular Therapy is that the procedures utilised should stimulate the body to heal on its own. Once this healing has begun, NeuroMuscular Therapy can be used to stimulate soft-tissue repair in specific areas, while simultaneously addressing some of the perpetuating factors causing the patient's pain. In this manner, a whole body approach to healing is achieved.

Assessment

A NeuroMuscular Therapist utilises many tools to achieve this holistic goal, some of which involve assessing a patient's conditions and some of which involve treatment.

The first step is to look at the perpetuating factors that are creating or prolonging a patient's pain. Age, stress, response to prior therapies, pre-existing conditions, family history, nutrition, diet and exercise all play a role in the patient's ability to work in partnership with the therapist. The therapist determines which specific tool or tools will be utilised by assessing postural distortion and biomechanical dysfunction, the presence of ischaemia and trigger points, and by determining the presence of nerve compression and or entrapment in the soft tissue(s).

Postural distortion can be recognised by a raised, and in many cases, anteriorly rotated ilium, arm and hand, accentuated by an anterior rotation of the shoulder, that creates an abduction of the arm. (see photos 1-3 below). In this case, the cervical spine rotates, thereby compensating for the rotation in the pelvis. This can cause lower back and neck pain. The condition would be treated by pelvic facilitation, which is a three-dimensional approach to the release of soft-tissue constrictions.

The NeuroMuscular Therapist must always work within the limitations of a patient's health. For example, if a patient is a 75-year-old female who has smoked for 35 years and has a calcium-poor diet accompanied by chronic lower back and hip pain, the NeuroMuscular Therapist must allow for the possibility of osteoporosis or a recent hip fracture or replacement. In this circumstance, the therapist must work with the patient's primary care physician to construct a therapy that complements the patient's condition. Pelvic facilitation, erector spinae, quadratus lumborum and passive stretching procedures would be altered to fit her situation.

Treatment

Specific tools that a NeuroMuscular Therapist uses are the thumbs, fingers, elbows and pressure bars. Pressure bars are effective instruments for the release of deeper constrictions along the erector spinae musculature and at tendonous attachment sites throughout the body. NeuroMuscular Therapy addresses the release of tissues in layers, superficial to deep, and is performed at a moderate speed with light lubrication. Treating origins and insertions, as well as the belly of a muscle is also of critical importance. It doesn't require a great deal of pressure to be effective, which is a benefit to the patient. In the proper application of NMT, a "dig it out" mentality is never appropriate.

The ability to palpate and effectively treat trigger points is an additional tool that is effective in treating myofascial pain and dysfunction. A trigger point is an area of elevated neurological activity located in fascia and the bellies of muscles that may refer pain in a localised or peripheral manner. When a trigger point is active, it can cause a substantial increase in a patient's myofascial pain locally or, in what seems to be a totally unrelated area of the body. If left untreated, a trigger point can prevent muscles from fully healing and ultimately have adverse long-term effects on other systems.

The proper and judicious use of pressure, which includes the ability to feel constrictions and trigger points and know at what angle your thumb, finger or pressure bar might be best used, is critical in the effectiveness of the therapy. When NeuroMuscular Therapy is applied in this manner, it is very effective in releasing trigger points and tracking down the cause of a patient's pain. In my NeuroMuscular Therapy training workshops, I tell my students that in order to become superb NeuroMuscular Therapists, they must also become excellent "muscle detectives" and to be able to "dance with the muscles."

Another means of increasing the effectiveness of NeuroMuscular Therapy is through the use of empowerment, in other words, getting the patient involved in his or her own wellness. In America, and particularly in the Southwestern United States, we say that "you can lead a horse to water, but you can't make it drink."

So it is with people who are in pain. A therapist can suggest ways to help a person heal, using a number of tools, but if the patient refuses to actually use the tools, the therapist can't force the patient to feel better. Consistent consumption of water, multivitamins, B-12, B-6, stretching and a balanced diet, combined with effective hands-on therapy, will greatly enhance healing and reduce the amount of time the patient needs to undergo actual therapy. When the patient feels that he or she is truly in control of wellness and understands the mechanisms of their condition, long-term healing can occur.

Laws of NeuroMuscular Therapy

The NeuroMuscular Therapist also operates under a system of laws known as Pfluger's Laws, which illustrate acute to chronic pain patterns and how pain is distributed throughout the body. The nervous system is designed to produce normal muscle tonus at 30 stimuli per second. If, due to trauma, the nervous system is suddenly innervating the damaged tissues at perhaps 75 stimuli per second, it must respond in a more creative homoeostatic way to distribute the pain.

The first step, according to the Law of Unilaterality, states that "if a mild irritation is applied to one or more sensory nerves, the movement will take place usually on one side only and that side which is irritated." As an illustration, if I were involved in a motor vehicle accident, injure my left shoulder and decline treatment of any kind, then my left shoulder would probably be very tender within a matter of minutes. Assuming that I continue without treatment and to ease the pain, drink substantial amounts of alcohol and take a very hot shower, the next day not only would the initial injury site be in pain, but so would the equal and opposite side. This illustrates the second law, the Law of Symmetry that says, "if the stimulation is sufficiently increased the motor reaction is manifested not only to the irritated side but also in similar muscles on the opposite side of the body." From a practical perspective if I can treat the unaffected side, the injured, painful area can be addressed without initial direct application of NMT.

Still by way of illustration, the following day, if I continue to resist proper treatment of my condition, the pain would now have travelled back and intensified at the original injury site with a lesser pain still present on the opposite shoulder. This describes the third law, the Law of Intensity that states "reflex movements are usually more intense on the side of irritation and at times the movements of the opposite side equal them in intensity but they are usually less pronounced."

The fourth law, the Law of Radiation, states that "if the excitation continues to increase it is propagated upwards and reactions take place through centrifugal nerves coming from the cord segments higher up." In other words, the pain will radiate upward from the site of the original injury toward the brain and then, failing alleviation, will radiate outward, creating a general contraction of all the muscles in the body.

This is a very profound and unsettling series of events. If left untreated, I would, in all likelihood, awaken one morning unable to move with intense headache pain, accompanied by a general contraction of all the muscles from head to toe. Not only would the nervous and musculoskeletal systems be adversely affected but so would all of the other systems in the body, such as the respiratory, cardiovascular, digestive and endocrine. This illustrates the fifth law, the Law of Generalisation that states "if the irritation becomes very intense it is propagated in the medulla oblongata, which becomes the focus from which the stimuli radiate to all parts of the cord causing a general contraction of all the muscles of the body."

Unfortunately, if a patient arrives at this stage, they are often irritated by the seemingly do-nothing advice of the therapist. At this point, the best advice is to seek evaluation and treatment from a primary care physician and to RICE the body. Other integrative treatments that prove effective are to increase water consumption and to increase intake of vitamins, such as 1200 mcg of B-12 and 200 mg of B-6 per day in tablet form. NeuroMuscular Therapy, using as little as 2 grams of pressure, would be enough to significantly increase pain and further perpetuate muscle constrictions and trigger point referrals. Generally, within 48 to 72 hours, the patient's condition will have improved enough for healing body work to begin.

Once NeuroMuscular Therapy has begun, treatment can literally "pull the plug" on pain by interrupting the source of abnormal stimulation. This decreases the electrical innervation to the muscles and viscera, therefore decreasing muscle spasms, ischemia and metabolic waste build-ups throughout the body. This has a cascading positive effect on the other systems in the body. It is critical to maintain consistent consumption of water (6-8 glasses/day), a good multivitamin and vitamins B-6 and B-12.

Case Histories

Mary Jane

Mary Jane entered my clinic in November 1997. She had been diagnosed by her physician and dentist with temporomandibular joint dysfunction, accompanied by chronic neck and back pain. After seven automobile accidents – none of which had been her fault – her physician and dentist were at a loss to effectively treat and reduce her pain, which was at a level 8 on a scale of 10.

When she arrived at the clinic, the first thing I did was to take a photograph of her postural alignment. From this photograph, I determined that she had a raised and anteriorly rotated left ilium, forward rotated right shoulder and cervical spine, accompanied by a TMJ that tracked severely to the left with extreme discomfort in the rotation and translation. Next followed an information gathering period in which it was discovered that she drank very little water, took multivitamins sporadically, was on prescription anti-inflammatory medication and Prozac. Due to her pain, she seldom exercised.

Upon palpation using two ounces of pressure, my touch produced significant pain to the point that she could not tolerate my therapy. With such an acute pain pattern, some therapists might hesitate to treat the patient at all. Instead, the first course of treatment for Mary Jane was RICE, or rest, ice, compression and elevation. After 48 hours, I asked her to telephone me with the results.

Two days later, after the RICE treatment, Mary Jane called to say that her pain level had decreased to a level 5. At this point, Mary Jane's true healing began.

The integrative NeuroMuscular Therapy techniques that were helpful in treating Mary Jane were pelvic facilitation, intraoral gloved procedures and anterior/posterior cervical spine restorative procedures. I also worked on her psoas, erector spinae, quadratus lumborum/iliolumbar ligament, gluteals and deep six lateral rotators. This treatment, in partnership with her dentist and doctor, significantly improved Mary Jane's condition over the next several months, to the point that she is now on a bimonthly maintenance schedule. In addition, she enthusiastically altered her lifestyle and attitudes, drinking more water and exercising regularly. She also changed her diet to include more healthful, low-fat foods in smaller portions. Her improved lifestyle has led to a happier outlook as well.

Gloria N.

Gloria N was referred to my clinic by her physician with the diagnosis of carpal tunnel syndrome. A court stenographer, Gloria had progressively lost the use of her hands in the courtroom and was perilously close to being put on permanent disability, with a reduction in her retirement benefits as well. Gloria described a burning sensation radiating down her arms bilaterally into her carpal-metacarpal joints that created a level 8 pain. The pain kept her awake most of the night.

She was referred to a surgeon who recommended immediate surgery, but she balked. She asked her primary care physician for an alternative treatment instead. He suggested NeuroMuscular Therapy. Through the application of integrative NeuroMuscular Therapy techniques, she is now on a PRN ('as needed') maintenance schedule and has resumed a full work schedule without the need of surgery.

In Gloria's situation the procedures that proved to be effective were ones that dealt with soft-tissue entrapment of the brachial plexus which began unilaterally and then became bilateral in its scope. Again, pelvic facilitation was used to gain symmetry in her pelvis, the centre of gravity in the body, followed by assessment and soft-tissue release superficial to deep of both the posterior and anterior cervical musculature. The primary goal was to gain long-term relief from entrapment of the brachial plexus, therefore helping to create balance in her cervical spine. This included the release of the scalenes working through the platysma, sterno- cleidomastoid and the supra and infrahyoids. From there, treatment of the posterior cervical, upper posterior thoracic musculature, arms, forearms and hands (from a dorsal and palmar perspective), was performed.

In the case of most repetitive motion conditions, the therapist should always look outside of the immediate area for soft-tissue factors that contribute to a patient's pain. In Gloria's case, the nature of her job led to a need to assess the musculature of her shoulders and the ergonomics of her immediate work environment. Upon further investigation, it was discovered that the trapezius, SITS (supraspinatus, infraspinatus, teres minor and subscapularis), rhomboids and pectoralis major/minor and even subclavius by way of its trigger point referral, had all contributed to her condition.

In conjunction with NMT procedures, her stenographer's station was altered to cushion and raise the level of her arms and wrists while she worked, therefore reducing strain on the muscles. Coupled with an increase in water consumption and vitamin B-12, along with some cervical, shoulder, arm and back stretches that she could do at work, Gloria has regained 90% of her strength in both arms and wrists with a 95% decrease in pain. The Judge Advocate General of the U.S. Air Force is very happy to have her back full-time in the courtroom where she has worked for the past 23 years.

Summary

Proper intent, desire and training are prerequisites to becoming a qualified NeuroMuscular Therapist. Opening one's heart and mind to an endless realm of healing opportunities that ultimately benefit the patient is what integrative NeuroMuscular Therapy is about. It is my sincere desire that a more comprehensive, multidisciplinary approach to pain erasure and management will be achieved in the future. Not only must we deal with a patient's existing value structure but those of other healthcare modalities as well.

When we have broken down the barriers and boundaries that exist in current healthcare delivery models, and we have physicians, chiropractors, dentists, osteopaths, psychiatrists, physical therapists, podiatrists and surgeons who understand the three dimensionality of pain and the efficacy of this type of bodywork, then we will have truly created integrative medicine.

Suggested Reading

Travell JG and Simons DD. Myofascial Pain and Dysfunction: The Trigger Point Manual. 2 Vols. Williams and Wilkins. Baltimore. 1983.
Chaitow Leon. Modern Neuromuscular Techniques. Churchill Livingstone Publishers. New Jersey. 1996.
Caillet Rene. Low Back Pain Syndrome. FA Davis Company. Philadelphia. 1988.
Upledger JE. Craniosacral Therapy and Craniosacral Therapy II: Beyond the Dura. Eastland Press. Chicago. 1987.

1 - Postural Distortion

2 - Postural Distortion

3 - Postural Distortion