An Introduction To Neuromuscular Therapy

Michael Porter, N.M.T., L.M.T.
Michael Porter, N.M.T., L.M.T. is Clinical Director of Advanced
Therapeutics Rehabilitation Center, Inc. in Jacksonville.

"The physician ought to be acquainted with many things, and among others, with friction; for friction could
brace a joint when unseasonably relaxed, and relax it when unseasonably hard. "Friction can relax,
brace, incarnate, attenuate: hard—braces; soft—relaxes; much—attenuates; and moderate—thickens."¹
Hippocrates, 400 B.C.E.

Introduction

Neuromuscular Therapy (NMT) is a late-twentieth-century version of Hippocrates' aforementioned "friction". NMT incorporates different treatment modalities to restore balance between the musculoskeletal system and the central nervous system, thus relieving myofascial pain. According to Drs. Travell and Simons, myofascial pain syndrome is caused by trigger points (TrPs) which consist of a focal hyperirritability in muscle that can strongly modulate central nervous system functions. In addition, the self-sustaining characteristic of TrPs depends on a feedback mechanism between the TrP and the central nervous system." ² NMT corrects this feedback mechanism by inactivating the trigger points and thus relieving their pain, tenderness, autonomic phenomena, and associated dysfunction. There are only a few conditions in which NMT is contraindicated. These include large bruises, phlebitis, varicose veins, open wounds, undiagnosed lumps, and skin infections. Some of the most common indications for NMT are listed in Table 1.

Table 1. Indications For Neuromuscular Therapy
Arthritis Back Pain Brachial Plexus Entrapment Bursitis Carpal Tunnel Syndrome Chronic Pain Dental Occlusion Problems Headaches Joint Immobility Migraines Muscle cramping Neck Pain	Postural Distortions Repetitive Strain Injuries Skeletal Problems Sciatica Scoliosis Spinal Disc Herniation Sports Injuries Sprains Strains TMJ Dysfunction Stress Whiplash

History And Evolution Of Neuromuscular Therapy

During the twentieth century, there have been a number of researchers who pioneered the study of myofascial pain. Among them, Janet Travell, M.D., (1901-1997) is credited with the concept of myofascial trigger points (TrPs). Between 1942 and 1990, Dr. Travell published more than 40 papers on myofascial trigger points. Except for a short detour as White House Physician under Presidents John F. Kennedy and Lyndon B. Johnson, Dr. Travell never strayed from her primary focus on the diagnosis and management of myofascial pain syndromes caused by trigger points.² Dr. Travell and David Simons, M.D., Clinical Professor of Rehabilitative Medicine, Emory University School of Medicine, published "Myofascial Pain and Dysfunction: The Trigger Point Manual" in 1983. The 1999 edition is considered the definitive study of myofascial pain and dysfunction.

Other pioneers in Neuromuscular Therapy were researchers Raymond Nimmo, D.C., and James Vannerson, D.C., who in 1957, published a series of monographs on what they called "noxious nodules" (myofascial trigger points).³ Drs. Nimmo and Vannerson developed a treatment called receptor tonus technique, which concentrated on these "noxious nodules", or myofascial trigger points.

During the last half of the twentieth century, many individuals in various clinical specialties have built on the work of Drs. Travell, Simons, Nimmo, Vannerson, and other pioneers to create today's neuromuscular therapy program of correction, restoration, and prevention.

Principles Of Neuromuscular Therapy

Neuromuscular Therapy is based on five physiological principles:

Postural Distortion;
Biomechanical Dysfunction;
Trigger Points;
Nerve Compression/Entrapment; and
Ischemia

Postural Distortion

Postural Distortion occurs when there is an imbalance of the musculoskeletal system resulting from movement of the body off the coronal, midsagittal or horizontal planes. When the body tries to compensate in an effort to maintain structural balance, muscle contraction, body distortion, and pain result. For example, lower limb-length inequality (LLLI) can cause a tilted pelvis, which usually results in a compensatory scoliosis that is maintained by sustained muscular effort, which is a potent perpetuating factor for TrPs in those muscles.²

Biomechanical Dysfunction

Biomechanical Dysfunction is caused by adaptive movement patterns that become muscular "habits" that must be re-educated. These adaptive movement patterns can be caused by:

Poor posture — Chronic muscle strain (Ex: poor positioning at a work surface);
Misfitting furniture — Poor upper or lower back support (Ex: chairs and car seats);
Abuse of muscles — Poor body mechanics (Ex: leaning over to lift an object);
Immobility — Lack of movement through full range of motion, especially when the muscle is in the shortened position (Ex: due to injury or disease); and
Repetitive movement overload — Repetitive use of the same muscles in the same way for long periods of time. (Ex: computer keyboard operators).

Trigger Points (TrPs)

Drs. Travell and Simons define Myofascial Trigger Point as "a hyperirritable spot in skeletal muscle that is associated with a hypersensitive palpable nodule in a taut band. The spot is painful on compression and can give rise to characteristic referred pain, referred tenderness, motor dysfunction, and autonomic phenomena."² Disturbance of motor functions caused by TrPs include spasm of other muscles, weakness of the involved muscle function, loss of coordination by the involved muscle, and decreased work tolerance of the involved muscle.

Nerve Compression / Entrapment

Nerve compression/entrapment results from pressure on a nerve by osseous or cartilaginous structures or by musculature. The role of the soft tissue in nerve compression/entrapment is vital. Failure to treat the associated soft tissue often treats the symptom without eliminating the cause of the pain. Both myofascial TrP syndromes and peripheral nerve entrapments, including radiculopathies, are very common.² An EMG study of TrPs in lumbar muscles that also examined for early EMG evidence of nerve compromise found a significant correlation⁴ which was reinforced by a subsequent study.⁵

Ischemia

Ischemia is a deficiency of blood in a body part, due to functional constriction or actual obstruction of a blood vessel. NMT releases muscle spasms and frees constricted blood vessels. This allows normal blood flow to carry nutrients and oxygen to the musculature.

Five Stages Of Neuromuscular Therapy Rehabilitation

Neuromuscular Therapy rehabilitation of soft tissue/muscle injuries consists of five stages that are carefully administered in a specific order.

Therapy to eliminate hypercontractions and muscle pain — Muscle tissues are a primary target of the wear and tear of daily activities. Despite their painfulness, myofascial TrPs are not directly life threatening, but their painfulness can, and often does, devastate the quality of life. Trigger point pressure release is the "application of slowly increasing, nonpainful pressure over a trigger point until a barrier of tissue resistance is encountered. Contact is then maintained until the tissue barrier releases, and pressure is increased to reach a new barrier to eliminate the trigger point tension and tenderness."²
Correction of structural problems to restore proper biomechanics — Body structure and muscle function serve as the basis for NMT evaluation and treatment. Body structure can be distorted due to a specific injury, disease process, cumulative stress, or other cause. The goal of NMT treatment is to normalize dysfunction and deviation from the norm. The stressful movement or conditions responsible for the activation and perpetuation of TrPs in a particular muscle must be identified and eliminated or modified to prevent the same stresses from reactivating and perpetuating the TrPs following treatment.² To identify these perpetuating factors, the NMT therapist performs a structural evaluation of seven horizontal planes to determine how and where the forces of torque are disrupting the body. (Refer to Table 2 for a description of the planes.) Examination of these seven horizontal planes shows how the body is torqued. In addition, evaluating gait patterns and posture, and measuring the positioning of the body on the coronal, midsagittal and horizontal planes, provide the NMT therapist with reference points to determine distortion patterns. NMT is then used to improve body alignment and muscle function.

Table 2. Structural Evaluation
Body structure and muscle function serve as the basis for Neuromuscular therapy (NMT)
evaluation and treatment. NMT begins with a structural evaluation of seven horizontal planes
to determine how and where the forces of torque are disrupting the body. The planes are:

Talus in the ankle in the supine position
Patella in the supine position
Anterior superior iliac spine of the pelvis in the supine position
Occipital ridge at the cranial base in the supine position
Auditory canal in the temporal bones in the standing position
Anterior superior iliac spine of the pelvis in the standing position
Acromio-clavicular joints of the shoulder in the standing position

Restoration of flexibility and re-education of neurological pathways — Through specific passive, assisted, and active movement therapies, Neuromuscular Therapy increases flexibility and re-educates the patient's neuromuscular system regarding movement, balance, coordination, kinesthetic sense, posture, and proprioception.
Restoration of strength through a specific program of exercises — Long-term recovery depends on adherence to the sequence of each treatment stage and on completion of each stage before going on to the next. For example, if a patient exercises to rebuild strength in the injured tissue before hypercontractions (TrPs) have been eliminated and before flexibility has been restored, new injuries or re-injury are likely to occur. "The weakness and loss of work tolerance are often interpreted as an indication for increased exercise, but if this is attempted without inactivating the responsible TrPs, the exercise is likely to encourage and further ingrain substitution by other muscles with further weakening and deconditioning of the involved muscles."²
Building of endurance through conditioning exercises — After completion of the first four stages of Neuromuscular Therapy rehabilitation (muscle and soft-tissue treatment, postural and biomechanical correction, and flexibility and strength restoration), a structured exercise program to build endurance is begun. Increased endurance will decrease chances of new injuries and of re-injury. The goal is that of prevention. The patient is instructed in the importance of self-responsibility in maintaining physical conditioning.

REFERENCES

The Internet Classics Archive. On the Articulations, By Hippocrates. Translated by Francis Adams. Http:classics.mit.edu/hippocrates/artic.html.
Simons D, Travell J, Simons L. Myofascial Pain and Dysfunction: The Trigger Point Manual, Vol 1(2), 2nd ed. Baltimore: Williams & Wilkins; 1999.
Nimmo R, Vannerson J. The Receptor. A series of 7 monographs privately published by RL Nimmo, Granbury, TX; 1957.
Chu J. Dry needling (intramuscular stimulation) in myofascial pain related to lumbosacral radiculopathy. Eur J Phys Med Rehabil. 1995; 5(4):106-121.
Chu J. Twitch-obtaining intramuscular stimulation: its effectiveness in the long-term treatment of myosfascial pain related to lumbosacral radiculopathy [abstract] Arch Phys Med Rehabil. 1997; 78:1024.

Lisa Shock and Linda Benford assisted in researching this article.