Neuromuscular therapy

Neuromuscular therapy (NMT) is a form of massage. It is distinguished from other types of massage in that a quasi-static pressure is applied to the skin with the aim of stimulating specific areas of skeletal muscle. Often these areas of muscle are myofascial trigger points.

The application of NMT is dependent on several key factors:

• The location of myofascial trigger points
• Force has to be applied perpendicular to the skin surface if muscle is to be stimulated.^[1]

History

During the last several decades, neuromuscular therapy (NMT) has emerged as a significant methodology for assessing, treating and preventing soft tissue injuries and chronic pain. NMT, a series of manual treatment protocols based on the practitioner’s skill, anatomy knowledge and precise palpatory application, has found its home, not only in the treatment rooms of massage therapy, but also in occupational and physical therapy, nursing, Naturopathic, chiropractic, osteopathic and physical medicine clinics worldwide, as well as in many forward-looking Primary Care practices.

With a foothold planted in both holistic and traditional medicine, NMT emerged in both Europe and North America almost simultaneously over the last half-century. It is interesting to note that the early developers knew little, if anything, about each other, yet the theoretical basis of all the modern protocols are similar since they are each rooted soundly in physiological principles.

Between the mid-1930s and early 1940’s, European-style neuromuscular techniques (as NMT is called in Europe) first emerged, was developed by Stanley Lief and Boris Chaitow. These cousins, trained in osteopathy and naturopathy, studied with teachers like Dewanchand Varma and Bernard Macfadden and integrated assessment and treatment steps for soft tissue dysfunction. Their practice of NMT was set in Lief’s health resort, Champneys, at Tring in Hertfordshire, England where they were presented with a wide variety of conditions on which to test their theories and methods. Many osteopaths and naturopaths, including Peter Lief, Brian Youngs, Terry Moule, Leon Chaitow and others, have taken part in the evolution and development of European neuromuscular techniques. NMT, now taught widely in osteopathic and sports massage settings in Britain, forms an elective module on the Bachelor of Science (BSc(Hons)) degree courses in Complementary Health Sciences at the University of Westminster, London, a program developed (in part) by Leon Chaitow, DO.

A few years after neuromuscular techniques emerged in Europe, Raymond Nimmo and James Vannerson first published their newsletter, Receptor Tonus Techniques in America, where they wrote of their experiences with what they termed ‘noxious nodules’. Over the next several decades, a step-by-step system began to emerge, supported by the writings of Janet G. Travell and David Simons. Travell and Simons’ two volume set of textbooks, Myofascial Pain and Dysfunction: The Trigger Point Manual provided the medical, dental, massage and other therapeutic communities with documentation, research and references for myofascial trigger points.

Several of Nimmo’s students began teaching their own treatment protocols, based on Nimmo’s work. Among Nimmo’s students was Paul St. John [1], who began teaching his own system in the late 70’s. In the mid-1980’s, Judith (Walker) DeLany [2] became an instructor of the St. John Method of neuromuscular therapy (St John NMT).

St. John continues to treat patients and further refine his methods through the St. John-Clark Pain Treatment Center in Clearwater, Florida (see references above). He also teaches and trains professionals internationally in Integrative Neurosomatic Therapy the current version of St. John method of NMT.

DeLany (then Judith Walker) worked with Paul St. John for five years (1984-89), where she assisted in the development of NMT techniques and protocols for massage therapy application and began scholarly writing on NMT. In 1989, the two separated. Paul St. John taught the St. John Method of NMT, while DeLany developed, taught and wrote about the NMT American Version. Both systems still focus on Nimmo's original material, although each developer has imbued his or her own particular methodology with unique insights and new techniques.

European and American versions of NMT have a similar theoretical platform yet subtle differences developed in the applications. In the exploration to uncover contracted bands or muscular nodules, American-style neuromuscular therapy uses a medium-paced (thumb or finger) gliding stroke whereas European-style neuromuscular techniques use a slow-paced, thumb-drag method of discovery. They also have a slightly different emphasis on the method of application of ischemic compression when treating trigger points. Both versions emphasize the need to develop a home-care program and encourage the patient's participation in the recovery process.

In 1996, a landmark event for American NMT occurred when NMT American version was overviewed in Leon Chaitow's Modern Neuromuscular Techniques, as contributed by Judith DeLany. This significant text was the first to offer both the European and American methods within the same volume. Chaitow and DeLany have since published three definitive texts integrating the American and European versions of NMT. Clinical Application of Neuromuscular Techniques, Vols. 1 & 2, with accompanying Case Study Exercises, which aims to standardize the training of NMT techniques.

History, Influences and Genesis of European NMT

John Sharkey (Exercise Physiologist, Dublin Ireland) is the founder and developer of European Neuromuscular Therapy. A distinction is needed between the term "neuromuscular techniques" as opposed to "neuromuscular therapy". In this context, many different "therapies" such as Osteopathy or Chiropractic may include the use of neuromuscular techniques such as finger drags or thumb technique for the investigation or manipulation and treatment of soft tissues. In Ireland, the National Training Centre (NTC), in association with Chaitow and DeLany, introduced the first formal course of studies providing a National Qualification Scheme at both certificate and higher diploma level in neuromuscular therapy. It is intended that a masters degree programme in NMT will be available in 2009/2010.

The following is an excerpt from John Sharkey's new book "The Concise Book of Neuromuscular Therapy" a trigger point manual with the forward by David Simons M.D.

Neuromuscular techniques are a comprehensive system of non-invasive soft-tissue manipulation techniques, valuable in both a diagnostic and therapeutic mode that were initially developed in the 1930s. Credit is due to Stanley Lief who was born in Lutzen in the Baltic State of Latvia in the early 1890s as being the developer of neuromuscular techniques. Like Joseph Pilates, and other pioneers of physical or movement therapies, Stanley Lief was a child who grew up with health problems and then noticed a magazine in his fathers store that promoted health and fitness. That publication was to change the course of his life. The magazine Physical Culture inspired Stanley Lief to travel to America to study with Bernarr MacFadden the father of health related fitness in the USA. Both Lief and his cousin Boris Chaitow, with qualifications in chiropractic, osteopathy and naturopathy, further developed NMT. In 1925 Lief founded the British College of Naturopathy. This author was influenced by the notion of physical activity and nutrition as a health contributor along with bodywork therapy being the perfect combination for lifelong pain free living. Continuing this tradition the modern day publications of Leon Chaitow, have provided a major contribution to the establishment of European Neuromuscular Therapy as an important physical therapy in today’s world of complementary medicine.

Neuromuscular techniques provide a therapist with information regarding tissue tone, fibrosity, oedema and areas of soft tissue changes such as hypersensitivity, change in sensation or pain. Neuromuscular Therapy (NMT) can move painlessly from investigative to treatment mode in an instant, if deemed appropriate. Ireland’s National Training Centre (NTC) has been active in developing European NMT for many years and has been greatly influenced by developments of both complementary medical and primary medical practitioners in Germany, Austria, Czech Republic, Russia and other European countries. Pioneers such as Dr. A.A. Manakov a Russian physician practicing medical massage in the 1940s proposed a system known as stretching massage (SM). SM had a focus on providing a therapeutic effect on the neurovascular components. Earlier in 1926 J. Dejerine, a French physician demonstrated the anatomy and neurophysiology of the segmental innervation of the pelvis and lower limbs. This work led to the establishment of the concept of sclerotomes by Dr.’s Inman and Saunders in 1944.

Credit is due to German physical therapist E. Dickle whose lifetime of work in conjunction with Professor W. Kohlrausch, M.D. and Professor N. Veil, M.D. led to the establishment of another form of medical massage known as connective tissue massage. The work of German medical doctors Walter and Ferdinand Huneke deserves mention. They published papers on their work entitled, Unbekannte Fernwirkungen der Lokalen Anesthesie (remote effects of local anaesthetises). Originally called Therapeutic Anaesthesia, but later changed to segmental therapy. Their work was reported to have common points with Chinese acupuncture. Names may differ but one cannot help to recognize the similarity of the work of the Huneke brothers and dry needling for the treatment of trigger points.

In the 1940s the American orthopaedic surgeon Steindler began to relieve the symptoms of sciatic pain by injecting Novacain in what he termed “Trigger Points” in muscles of the lumbar and gluteal areas. In the 50s Travell extended the term to include “Myofascial” and that term has internationally been adopted leading to the modern day description of “Myofascial Trigger Points”.

Many other important developments including heads zones and segmental reflex massage have all had their influence on what is known today as European NMT. John Sharkey, Exercise Physiologist and Exercise and Nutrition Scientist, is the founder of European Neuromuscular Therapy and European Medical Exercise (the rehabilitative component of NMT). NTC has to date, put in place a Certificate level and higher diploma qualification programme in conjunction with a number of NMT innovators and pioneers including Leon Chaitow and Judith Delany (NMT American version). These educational developments demonstrate the synergistic influence of American Version NMT on the continuing development and genesis of European NMT.

In 2000, NMT made Olympic History at the Sydney Olympic games when John Sharkey became the first Neuromuscular Therapist to be included in an Olympic medical team as a fully accredited Olympic medical team member. Individual countries usually are accompanied by their own medical doctors of differing specialties and physiotherapists / Physical therapy^[2] to address musculoskeletal injuries both acute and chronic. Teams will often bring a sports massage practitioner, a chiropractor or osteopath but these excellent therapies have always remained outside full accreditation status.

NMT is an important aspect of the Irish Olympic medical team since that time. NMT has found its way into the Multidisciplinary clinic as an important part of the multidisciplinary medical approach to pain, injury, prevention and post rehabilitation. Medically trained professionals, such as the GP or orthopedic specialist, need to feel confident that should they refer a patient to a complementary medical therapist that the individual therapist they refer to can be trusted. This trust is based on the therapist having gained the appropriate education, skills, knowledge and professionalism necessary to provide the service, or therapy, appropriate to the patient’s needs. The neuromuscular therapist follows strict national standards and guidelines, code of ethical conduct and scope of practice.

As part of a multidisciplinary approach referrals are made to, and received from, orthopedic specialists, osteopaths, chiropractors, medical exercise specialists, general practice doctors, nutritionalists, dentists, naturopathic practitioners, health fitness instructors, personal trainers and other physical therapists. In Ireland, NMTs are included as a recognized therapy under the private health insurance offered through a number of leading insurance providers. This inclusion reflects the recognition of the efficacy of NMT as an important physical therapy.

NTC introduced the world’s first Equine Neuromuscular Therapy (EqNMT) educational (Certificate) programme. This hugely successful course of physical therapy provides the equine industry with a group of expert therapists that possess both sports massage skills and neuromuscular techniques for the treatment of trigger points. The EqNMT enjoys the respect of horse owners, trainers and jockeys alike. This reputation has grown through word of mouth based on the excellent work of NMTs. People who care for and love horses have an additional option of treatment when other approaches fail or fall short of complete return to form. That final ingredient, the missing link, is equine neuromuscular therapy.

In the hands of a qualified therapist, NMT may eliminate the cause of acute or chronic myofascial, muscular or osseous (bone) pain and discomfort. Through the application of neuromuscular techniques, which include soft tissue manipulations, intra-oral tissue release, myofascial release, positional release, muscle energy techniques, cranial manipulation and trigger point therapy, homoeostasis is restored between the nervous system, osseous system and soft tissue systems. NTC also embraces modalities utilizing dry needling and frequency specific micro current approaches but this is not part of NMT American Version.

Neuromuscular therapy enhances the function of joints, muscles, and the general arthrokinematics of the body. NMT can improve healing by facilitating the return of appropriate core (lumbo-pelvic-hip) muscle function throughout the entire kinetic chain. A special focus is given to the treatment of trigger points, local ischemia, neural interferences, postural and biomechanical dysfunctions, nutritional factors and emotional wellbeing.

Influences

Trigger Points: Welcome Home

European NMT has embraced the orphan tissue fascia and the epidemic that is known widely as trigger points. Janet Travell and David Simons are two physicians who, amongst others, have assisted in our understanding and treatment of trigger points. Simons (Lewit & Simons, 1984) has described the evolution of trigger points in the following way:

“In the core of the trigger lies a muscle spindle that is in trouble for some reason. Visualize a spindle like a strand of yarn in a knitted sweater….. a metabolic crisis takes place, which increases the temperature locally in the trigger point, shortens a minute part of the muscle (sarcomere) – like a snag in a sweater – and reduces the supply of oxygen and nutrients into the trigger point. During this disturbed episode an influx of calcium occurs and the muscle spindle does not have enough energy to pump the calcium outside the cell where it belongs. Thus a vicious cycle is maintained and the muscle spindle can’t seem to loosen up and the affected muscle can’t relax.”

Having tested his concept, Dr. Simons found that at the core of a trigger point there is an oxygen deficit compared with the muscle tissue, which surrounds it. Travell (Travell & Simons, 1992) has confirmed that the following factors can all help to maintain and enhance trigger point activity:

1. Nutritional deficiency, especially vitamin C, B-complex and iron;

2. Hormonal imbalances (low thyroid, menopausal or premenstrual situations, for example);

3. Infections (bacteria, viruses or yeast);

4. Allergies (wheat and dairy in particular);

5. Low oxygenation of tissues (aggravated by tension, stress, inactivity, poor respiration).

A primary focus of NMT is to understand the formation, etiology and treatment of myofascial trigger points (TrPs). In NMT a special effort is made to locate the source of referred pain including any perpetuating influences and eliminating them while paying attention to correct negative postural patterns.

People interested in learning more about European NMT should visit [www.ntc.ie]

References

1. ^ Bereznick DE, Ross JK, McGill SM (2002). "The frictional properties at the thoracic skin-fascia interface: implications in spine manipulation.". Clin Biomech 17 (4): 297–303. doi:10.1016/S0021-9290(02)00014-3. PMID 12034123. 
2. ^ www.wcpt.org