A key difference between neuromuscular therapies (see page 192) – which this book describes – and neuromuscular technique (i.e. Lief’s or European NMT – see Box 9.3) is that the former incorporates under its’ definition, a host of complementary physical modalities – including Lief’s NMT. This chapter describes the range of physical modalities. It is worth noting that not all of these are ‘manual’, as they include hydrotherapy and, potentially, acupuncture and dry needling.

Box 9.3 European (Lief’s) neuromuscular technique (Chaitow 2010)

European-style NMT first emerged between the mid-1930s and early 1940. The basic techniques as developed by Stanley Lief and Boris Chaitow are described within this text but there exist many variations, the use of which will depend upon particular presenting factors or personal preference. European NMT’s history is discussed more fully in Volume 1, Chapter 9.

European NMT thumb technique

Thumb technique as employed in both assessment and treatment modes of European NMT enables a wide variety of therapeutic effects to be produced. A light, non-oily lubricant is usually used to facilitate easy, non-dragging passage of the palpating digit, unless dry skin contact is needed (such as in texture or thermal assessment).

• The tip of the thumb can deliver varying degrees of pressure by using:

– the very tip for extremely focused contacts

– the medial or lateral aspect of the tip to make contact with angled surfaces or intercostal structures, for example

– the broad surface of the distal phalanx of the thumb for more general (less localized and less specific) contact.

• In thumb technique application, the hand is spread for balance and control with the palm arched and with the tips of the fingers providing a fulcrum, the whole hand thereby resembling a ‘bridge’ (Fig. 9.2). The thumb freely passes under the bridge toward one of the finger tips.

Figure 9.2 NMT thumb technique: note static fingers provide fulcrum for moving thumb

(reproduced with permission from Chaitow & DeLany 2008).

• During a single stroke, which covers between 2 and 3 inches (5–8 cm), the finger tips act as a point of balance while the chief force is imparted to the thumb tip. Controlled application of body weight through the long axis of the extended arm focuses force through the thumb, with thumb and hand seldom imparting their own muscular force except when addressing small localized contractures or fibrotic ‘nodules’.

• The thumb, therefore, never leads the hand but always trails behind the stable fingers, the tips of which rest just beyond the end of the stroke.

• The hand and arm remain still as the thumb moves through the tissues being assessed or treated.

• The extreme versatility of the thumb enables it to modify the direction and degree of imparted force in accordance with the indications of the tissue being tested/treated. The practitioner’s sensory input through the thumb can be augmented with closed eyes so that every change in the tissue texture or tone can be noticed.

• The weight being imparted should travel in as straight a line as possible directly to its target, with no flexion of the elbow or the wrist by more than a few degrees.

• The practitioner’s body is positioned to achieve economy of effort and comfort. The optimum height of the table and the most effective angle of approach to the body areas being addressed should be considered (see Volume 1, Fig. 9.10)

• The nature of the tissue being treated will determine the degree of pressure imparted, with changes in pressure being possible, and indeed desirable, during strokes across and through the tissues. When being treated, a general degree of discomfort for the patient is usually acceptable but he should not feel pain.

• A stroke or glide of 2–3 inches (5–8 cm) will usually take 4–5 seconds, seldom more unless a particularly obstructive indurated area is being addressed. In normal diagnostic and therapeutic use the thumb continues to move as it probes, decongests and generally treats the tissues. If a myofascial trigger point is being treated, more time may be required at a single site for application of static or intermittent pressure.

• Since assessment mode attempts to precisely meet and match the tissue resistance, the pressure used varies constantly in response to what is being palpated.

• A greater degree of pressure is used in treatment mode and this will vary depending upon the objective, whether to inhibit neural activity or circulation, to produce localized stretching, to decongest and so on (see Volume 1, Box 9.4).

European NMT finger technique

In certain areas the thumb’s width prevents the degree of tissue penetration suitable for successful assessment and/or treatment. Where this happens a finger can usually be suitably employed. Examples include intercostal regions and curved areas, such as the area above and below the pelvic crest or the lateral thigh.

• The middle or index finger should be slightly flexed and, depending upon the direction of the stroke and density of the tissues, should be supported by one of its adjacent members.

• The angle of pressure to the skin surface should be between 40° and 50°. A firm contact and a minimum of lubricant are used as the treating finger strokes to create a tensile strain between its tip and the tissue underlying it. The tissues are stretched and lifted by the passage of the finger which, like the thumb, should continue moving unless, or until, dense indurated tissue prevents its easy passage.

• The finger tip should never lead the stroke but should always follow the wrist, as the hand is drawn toward the practitioner, so that the entire hand moves with the stroke and elbow flexion occurs as necessary to complete the stroke. The strokes can be repeated once or twice as tissue changes dictate (see Volume 1, Box 14.8).

• The patient’s reactions must be taken into account when deciding the degree of force to be used.

• Transient pain or mild discomfort is to be expected. Most sensitive areas are indicative of some degree of associated dysfunction, local or reflexive, and their presence should be recorded.

• If tissue resistance is significant, the treating finger should be supported by another finger.

Variations

Depending upon the presenting symptoms and the area involved, other applications may be performed as the hand moves from one site to another. There may be:

• superficial stroking in the direction of lymphatic flow

• direct pressure along or across the line of axis of stress fibers

• deeper alternating ‘make and break’ stretching and pressure or traction on fascial tissue

• sustained or intermittent ischemic (‘inhibitory’) pressure, applied for specific effects.

A constantly fluctuating stream of information regarding the status of the tissues will be discernible from which variations in pressure and the direction of force are determined. The amount of pressure required to ‘meet and match’ tense, edematous, fibrotic or flaccid tissue will be varied. During assessment, if a ‘hard’ or tense area is sensed, pressure should actually lighten rather than increase, since to increase pressure would override the tension in the tissues, which is not the objective in assessment.

In evaluating for myofascial trigger points, when a sense of something ‘tight’ is noted just ahead of the contact digit as it strokes through the tissues, pressure lightens and the thumb/finger slides over the ‘tight’ area. Deeper penetration senses for the characteristic taut band and the trigger point, at which time the patient is asked whether it hurts and whether there is any radiating or referred pain. Should a trigger point be located, as indicated by the reproduction in a target area of a familiar pain pattern, then a number of choices are possible. Each of the following is discussed in this chapter or in Volume 1.

• The point should be marked and noted (on a chart and if necessary on the body with a skin pencil).

• Sustained ischemic/inhibitory pressure can be used.

• A positional release (PR) approach can be used to reduce activity in the hyperreactive tissue.

• Initiation of an isometric contraction followed by stretch (MET) could be applied.

• A combination of pressure, PRT and MET (integrated neuromuscular inhibition technique – INIT) can be introduced.

• Spray-and-stretch methods can be used.

• An acupuncture needle or a procaine injection can be used if the practitioner is duly licensed and trained.

Whichever approach is used a trigger point will only be effectively deactivated if the muscle in which it lies is restored to its normal resting length. Stretching methods such as MET can assist in achieving this.

Areas of dysfunction should be recorded on a case card, together with all relevant material and additional diagnostic findings, such as active or latent trigger points (and their reference zones), areas of sensitivity, hypertonicity, restricted motion and so on. Out of such a picture, superimposed on an assessment of whole-body features such as posture, as well as the patient’s symptom picture and general health status, a therapeutic plan should emerge.

It is a characteristic of neuromuscular therapy/technique (NMT) – of either tradition – to move from the gathering of information into treatment, almost seamlessly. As the practitioner searches for information, the appropriate modification of degree of pressure from the contact digit or hand can turn ‘finding’ into ‘fixing’, or at least having an intent to ‘fix’ what is not working optimally. One modality accompanies another as a rather ‘custom-made’ application is created that not only varies from patient to patient, but should also vary from one session to the next for a particular individual, as the condition changes.

These concepts will become clearer as the methods and objectives of NMT and its associated modalities become more familiar. This chapter reviews the modalities and choices discussed in Volume 1 and assists in determining which modalities are best suited for particular conditions. After consideration of the current status of the dysfunction (acute, subacute, chronic, inflamed, etc.) the determining factor of which method to employ is frequently reduced to which method(s) the practitioner has mastered and feels confident to use. One technique may ‘work’ as well as another, so long as it is appropriate for the conditions being addressed.

The global view

In this text, we have considered a number of features that are all commonly involved in causing or intensifying pain (Chaitow 2010). While it is simplistic to isolate factors that affect the body – globally or locally – it is also necessary at times to do this. We have presented models of interacting adaptations to stress, resulting from postural, emotional, respiratory and other factors, which have fundamental influences on health and ill health.

One such model suggests consideration of three categories under which most causes of disease, pain and the perpetuation of dysfunction can be broadly clustered:

• biomechanical (postural dysfunction, upper chest breathing patterns, hypertonicity, neural compression, trigger point activity, etc.)

• biochemical (nutrition, ischemia, inflammation, hormonal, hydration, hyperventilation effects)

• psychosocial (stress, anxiety, depression, hyperventilation tendencies).

NMT attempts to identify these altered states, insofar as they impact on the person’s condition. The practitioner can then either offer appropriate therapeutic interventions which reduce the adaptive ‘load’ and/or assist the self-regulatory functions of the body (homeostasis). When this is inappropriate or outside the practitioner’s scope of practice, she should offer referral to appropriate health-care professionals who can support that area of the patient’s recovery process.

While these health factors have tremendous potential to interface with one another, each may at times also be considered individually. It is important to address whichever of these influences on musculoskeletal pain can be identified in order to remove or modify as many etiological and perpetuating influences as possible (Simons et al 1999); however, it is crucial to do so without creating further distress or requirement for excessive adaptation. When appropriate therapeutic interventions are used, the body’s adaptation response produces beneficial outcomes. When excessive or inappropriate interventions are applied, the additional adaptive load inevitably leads to a worsening of the patient’s condition. Treatment is a form of stress and can have a beneficial or a harmful outcome depending on its degree of appropriateness. When patients report post-treatment symptoms of headache, nausea, achiness or fatigue, they are often told it is a ‘healing crisis’. Whether ‘healing’ or not, it is a ‘crisis’ all the same and often avoidable if basic measures are taken to reduce excessive adaptation responses to treatment by managing the amount and type of treatment offered.

Selecting an adequate degree of therapeutic intervention in order to catalyze a change, without overloading the adaptive mechanisms, is something of an art form. When analytical clinical skills are weak or details of techniques unclear, results may be unpredictable and unsatisfactory (DeLany 1999). Whereas, when such skills are effectively utilized and intervention methodically applied involving a manageable load, the outcome is more likely to be a sequential recovery and improvement.

In Volume 1, we noted: ‘The influences of a biomechanical, biochemical and psychosocial nature do not produce single changes. Their interaction with each other is profound’. This axiom is also true in reverse. When therapeutic modification of the influences of these factors is applied, with the objective of restoring health by removing negative influences, balancing the biochemistry and/or supporting the emotional components of wellness, the effects seldom produce single changes. Remarkable improvements can occur, sometimes rapidly. In some instances, intervention can be applied to more than one sphere of influence if homeostatic functions can efficiently handle the adaptive burden. This ‘lightening of the load’ has significant effects on the perception of pain, its intensity and the maintenance of dysfunctional states.

• Hyperventilation modifies blood acidity, alters neural reporting (initially hyper and then hypo), creates feelings of anxiety and apprehension and directly impacts on the structural components of the thoracic and cervical region, both muscles and joints (Gilbert 1998). If better breathing mechanics can be restored by addressing the musculature that controls inhalation and exhalation, emotional stability (regarding grief, fear, anxiety, etc.) may be enhanced and better breathing techniques employed, so that all that depends upon the breath (and what does not?) has potential for (often significant) improvement.

• Altered chemistry (hypoglycemia, alkalosis, etc.) affects mood directly while altered mood (depression, anxiety) changes blood chemistry, as well as altering muscle tone and, by implication, trigger point evolution (Pryor & Prasad 2002, Brostoff 1992). Therefore, addressing dietary intake, digestion and/or assimilation could result in significant changes in soft tissue conditions as well as psychological well-being, which may influence postural function.

• Altered structure (posture, for example) modifies function (breathing, for example) and therefore impacts on blood biochemistry (e.g. O₂: CO₂ balance, circulatory efficiency and delivery of nutrients, etc.), which impacts on mood (Foster et al, 2001). Stretching protocols, soft tissue or skeletal manipulations and ergonomically sound changes in patterns of use, all serve to restore structural alignment, which positively influences all other bodily functions.

It is most important not to offer too much too soon. Take, for example, a first treatment session, which is largely taken up with a variety of tests and assessments. This might theoretically lead not only to an introduction to bodywork and/or movement therapy, but also to suggestions for the patient to change what he is eating, how he is sitting, how much or little he is exercising, to drink more water, cut out caffeine, increase dietary fiber, avoid junk foods, take more supplements, stretch his muscles, arrange his schedule around frequent therapy sessions and, in general, to adopt a new lifestyle altogether. It is probable that the patient will not be seen again. This much change – too much, too fast, too soon – is likely to prove overwhelming to the body and to the person who lives in that body. A priority-based plan, with modifications for special needs or challenges, with step-by-step additions that would eventually impact as many influences as possible, may result in a long-term commitment to lifestyle changes. Above all, the patient needs to have a clear understanding of why each change is suggested and how it is likely to either reduce the adaptive burden he is carrying (the analogy of a tightly stretched piece of elastic may help) or how it might improve his ability to handle the adaptive load through improved function.

A home care program can be designed appropriate to the needs and current status of the patient, for both physical relief of the tissues (stretching, self-help methods, hydrotherapies see Chapter 7) and awareness of perpetuating factors (postural habits, work and recreational practices, nutritional choices, stress management). Lifestyle changes are essential if influences resulting from habits and potentially harmful choices made in the past are to be reduced (see notes on concordance in Volume 1, Chapter 8)