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Investigating Neuromuscular Therapy: Efficacy of Application on Chronic Pain
Cover Page
Case Report
Investigating Neuromuscular Therapy: Management, Treatment and
Alleviation of Moderate to Severe Chronic Pain and Reduced Function in a
69-year-old male.
Taylor Sun
Acknowledgments
The author would like to express gratitude to Randall Clark, BS, LMT as clinical
supervisor and instructor. In addition, a thanks to all those who have influenced,
mentored and supported me through my education and pursuit of clinical
integration.
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Investigating Neuromuscular Therapy: Efficacy of Application on Chronic Pain
Abstract
Objectives: To study and record the efficacy of neuromuscular therapy (NMT)
interventions in management and alleviation of chronic and systemic pain states.
Methods: A 69-year old retired male diagnosed with congenital microtia, lumbago,
bilateral hip dysplasia, chronic osteoarthritis and hypothyroidism reported chronic pain
and a heightened reduction in functional capacity of consistent severity. Treatment
intervention consisted of 2 treatments weekly over a 4-week period. Each session was an
hour of treatment preceded by 30 minutes of quantitative data collection and qualitative
data collection.
Results: Chronic pain, functional capacity, levels of depression and levels of fatigue were
all significantly reduced after the first and second treatment and remained lowered
throughout the period of intervention.
Conclusions: NMT intervention in treating of pain, functional capacity, depression and
fatigue symptoms in patients exhibiting chronic complex conditions seem to be effective
in short term interventions. Further research and quantitative data in regards to how NMT
and/or Clinical Massage Therapy (CMT) may effect perceived pain particularly in
regards to elimination of pain in the long term after NMT and/or CMT intervention has
been applied.
Keywords:
Massage Therapy;
Pain Management;
Chronic Pain;
Musculoskeletal and Neural
Physiological Concepts;
Postural Balance
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Investigating Neuromuscular Therapy: Efficacy of Application on Chronic Pain
Introduction:
Chronic Pain
Pain is a symptom or state characterized by sensory and emotional experiences associated
with actual or potential tissue damage. Chronic pain, however, seems to have little value
(1). Perception of pain is dependent on experience, due to its variable expression in
individuals’ subjective
experience, association
with emotional trauma,
interpretation and
mediation by the
nervous system (1, Fig
1.1). It can be difficult
to track, manage,
define, explain and
treat in a clinical
setting. Prevalence of
pain varies across
different ethnic groups
(2) but is present in many professions (3, 4), populations (5, 6, 7), regions (8, 9) and is
Fig. 1.1 Mackey, Sean, MD, PhD. How the Mind Processes Pain.
Digital image. Wall Street Journal. Journal of Neuroscience,
Archives of Internal Medicine, 15 Nov. 2011. Web. 23 May 2014.
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Investigating Neuromuscular Therapy: Efficacy of Application on Chronic Pain
more common than 50 years in the past (20). It’s effect on physiology and quality of life
is widespread which can extend as far as to contributing to degradation of the brain by as
much as 11% (10). The economic burden associated with treating a managing pain is not
precisely known but is broadly thought of as high (11, 12, 13) and comparable to other
disorders such as headache, heart disease, depression and diabetes (12).
Lumbago
While Lumbago or Lower Back Pain (LBP) may be diagnosed by primary healthcare
physicians and is one of the most prevalent concerns in the adult population, up to 80%
(21, 22). LBP is commonly found in professions that work in offices (23, 24), manual
labor (25), in individuals who sit for a period of longer than 3 hours (26), those who
present with a flat or hyperkyphosis in the lumbar spine and in 6 to 15% of athletes (28,
29). LBP is not a specific disease with one clear mechanism (14, 16). Alternatively, LBP
is better thought of as a syndrome whose source and severity can be vast (15, 16) but the
main source is thought to be the end product of antecedents in the MSK system (16)
triggered by trauma, perpetuated by factors such as obesity, smoking, weight gain
associated with pregnancy, stress, poor posture and sleeping position (1, 16, 17, 18, 19)
then mediated, expressed, or not expressed; by the nervous system (1).
More than 33% work-related injuries include the individual’s torso (26), of which,
above 60% involve the lower back (27). A study published in Spine reported
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Investigating Neuromuscular Therapy: Efficacy of Application on Chronic Pain
While there is no doubt that many chronic back cases have psychological overlays, the significance of psychology for back problems is often greatly exaggerated. Dr. Ellen thompson (1997) coined the phrase “bankrupt expertise” when referring to spine docs who are unable to guide improvement in their patients and default to blaming the patients and their psychoses. These physicians either dismiss mechanical causation or assume that mechanical causation has been adequately addressed…
…a woman had suffered for five years on disability and had seen no fewer than 12 specialist from a variety of disciplines. Although several had acknowledged she had physical concerns, her troubles were largely attributed to mental depression…
...None of the “experts “ this woman had seen – including physical therapists chiropractors, psychologists, physiatrists, neurologists and orthopods – addressed mechanical concerns. This is not to condemn these professions but rather to suggest that sharing experience and approaches will help us to be more successful in helping bad backs, perhaps these professionals were unaware of the principles of spine function, the types of loads that are imposed on the spine tissues during certain activities, and how these activities and spine postures can be changed greatly to reduce the loads – in other words, the biomechanical components.
Mcgill, Stuart. Low back disorders: evidence-‐based prevention and rehabilitation. Human Kinetics, 2007.”
“IS IT TRUE THAT MOST CHRONIC BACK COMPLAINTS ARE ROOTED IN PSYCHOLOGICAL
FACTORS?
“total health care expenditures
incurred by individuals with back
pain in the United States reached
$90.7 billion and total incremental
expenditures attributable to back
pain among these persons were
approximately $26.3 billion. On
average, individuals with back
pain incurred health care
expenditures about 60% higher
than individuals without back pain
($3,498 vs. $2,178). Among back
pain individuals, at least 75% of
service expenditures were
attributed to those with top 25%
expenditure, and per-capita
expenditures were generally
higher for those who were older,
female, white, medically insured,
or suffered from disc disorders
(27).”
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Investigating Neuromuscular Therapy: Efficacy of Application on Chronic Pain
“The study suggests chronic pain changes the way information is processed in the brain, and the findings could explain why those who experience long-‐term pain frequently suffer other symptoms such as anxiety, depression, sleep disorders, and difficulty making decisions.
During the study, researchers used functional magnetic resonance imaging (fMRI) to scan the brains of 15 people with chronic low back pain and 15 pain-‐free volunteers while both groups were tracking a moving bar on a computer screen. Although the pain sufferers performed the task well, when researchers measured areas of the brain activated, differences emerged.
In the healthy brains all regions existed in a state of equilibrium — when one region was active, the others quieted down. But in those with chronic pain, a front region of the cortex mostly associated with emotion “never shuts up,” said Dante Chialvo, the study’s lead author and associate research professor of physiology at the Feinberg School. The region was stuck on full throttle, wearing out neurons and altering their connections to each other.
“The areas that are affected fail to deactivate when they should,” Chialvo said. “Where we were surprised is the difference in how much brain they used to do the task
compared with the healthy group. It was 50 times larger,” Chialvo told Reuters. This is the first demonstration of brain disturbances in chronic pain patients not directly
related to the sensation of pain. When certain parts of the cortex were activated in the pain-‐free group, some others were
deactivated, maintaining a cooperative equilibrium between the regions. This equilibrium is known as the resting state network of the brain. In the chronic pain group, however, one of the nodes of this network did not quiet down as it did in the pain-‐free subjects. Instead, a front region of the cortex mostly associated with emotion is constantly active, disrupting the normal equilibrium.
The researchers said disruptions in this default network could explain why pain patients have problems with attention, sleep disturbances and even depression.
This constant firing of neurons in these regions of the brain could cause permanent damage, Chialvo said. “We know when neurons fire too much they may change their connections with other neurons or even die because they can’t sustain high activity for so long,” he explained.
‘If you are a chronic pain patient, you have pain 24 hours a day, seven days a week, every minute of your life,” Chialvo said. “That permanent perception of pain in your brain makes these areas in your brain continuously active. This continuous dysfunction in the equilibrium of the brain can change the wiring forever and could hurt the brain.”
Chialvo hypothesized the subsequent changes in “wiring“ may make it harder for you to make a decision or be in a good mood to get up in the morning. It could be that pain produces depression and the other reported abnormalities because it disturbs the balance of the brain as a whole.”
“These findings suggest that the brain of a chronic pain patient is not simply a healthy brain processing pain information but rather it is altered by the persistent pain in a manner reminiscent of other neurological conditions associated with cognitive impairments,” the researchers wrote in their report.
Chialvo said the study’s findings show it is essential to research new approaches to treat patients not just to control their pain but also to evaluate and prevent the dysfunction that may be generated in the brain by the chronic pain. The study was supported by the National Institute of Neurological Disorders and Stroke, and is published
in the Feb. 6 issue of The Journal of Neuroscience.
"Chronic Pain Can Damage Brain." Red Orbit. N.p., 8 Feb. 2008. Web. 22 May 2014.
“PEOPLE WHO SUFFER CHRONIC PAIN HAVE CONSTANT BRAIN ACTIVITY IN AREAS OF THE BRAIN THAT WOULD NORMALLY BE AT REST”
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Investigating Neuromuscular Therapy: Efficacy of Application on Chronic Pain
Methods:
Case Study Design
It was the author’s intention to examine the
therapeutic effect of NMT, or CMT, as a
standalone method on treatment of perceived
pain. For all intents and purposes of
determining the efficacy of NMT, an
integrative, or collaborative care, approach,
while likely catalyzing in nature, were
intentionally not the chosen route so as to
eliminate as many factors on the practitioner’s
side of intervention as possible. Lifestyle
modification such as improving quality of
sleep, managing potential stressors, improving
social and emotional status were not discussed
by the author. Nor were dietary and exercise
interventions made by the author.
Neuromuscular therapy (NMT): an integrative system of bodywork designed to incorporate neurologic responses with myofascial tissue states; it addresses trigger points, hypertonicity in muscles, and postural compensation patterns to improve range of motion and reduce musculoskeletal pain and to restore balance between the nervous and musculoskeletal systems (31). Muscle balance: a relative equality of muscle length or strength between an agonist and antagonist; this balance is necessary for normal movement and function (34). Corrective exercise (CEx): a term used to describe the systematic process of identifying a neuromusculoskeletal (NMSK) dysfunction, developing a plan of action, and implementing an integrated corrective strategy (30). Corrective exercise continuum: the systematic programing process used to address NMSK dysfunction through the use of inhibitory, lengthening, activation and integration techniques (30). Inhibitory techniques: corrective exercise techniques used to release tension or decrease neuromyofascial tissues in the body (30). Posture: the position of the body with respect to the surrounding space. A posture is determined and maintained by coordination of the various muscles that move the limbs, by proprioception, and by the sense of balance (36). Tonus: the normal state of balanced tension in the body tissues, especially the muscles. Partial contraction or alternate contraction and relaxation of neighboring fibers of a group of muscles hold the organ or the part of the body in a neutral functional position without fatigue. Tonus is essential for many normal body functions, such as holding the spine erect, the eyes open, and the jaw closed (37).
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Investigating Neuromuscular Therapy: Efficacy of Application on Chronic Pain
Rationale for Neuromuscular Therapy
Many manual interventions for addressing MSK and neuromuscular (NMS) syndromes
often ignore underlying MSK and NMS imbalances from single traumatic events,
sedentary lifestyles or accumulation over time from sports injury, athletic activity, motor
vehicle accidents (MVAs), activities of daily living (ADLs), work related duties, poor
nutritional plans, poor lifestyle habits, environmental, emotional and physical stress,
which may result in weakened structure and lead to reduced functional capacity and
injury (30). Specific attention to structures that may be facilitated or inhibited (see
Postural Examination and Charting, Page 11) are rarely paid individual attention to and
addressed based on their level of excitation, or tonus. Additionally, much of the common
advice given to individuals, particularly in preventing and rehabilitating the back, in
social, professional and clinical settings stand on thin scientific foundation where the
literature yields little to no evidence to support these recommendations (33).
Individuals influenced by
the previously mentioned
antecedents, triggers and
perpetuates often contribute to
postural anomalies (31) which
highlight the magnitude of
muscular imbalance presented by
an individual. NMT interventions
made to fit the individual seeks to
address the individual expression of postural anomalies and down regulate painful stimuli
Figure 1.2 The Corrective Exercise Continuum. Digital
image. Active Aging Fitness. N.p., n.d. Web. 23 May
2014.
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Investigating Neuromuscular Therapy: Efficacy of Application on Chronic Pain
as primarily the 1st stage, and for qualified practitioners 2nd – 4th stages, of and integration
into the corrective exercise continuum (fig 1.2), personal training programs and strength
and conditioning programs by providing a means of identifying precursors to ill-health or
function by conducting postural examinations, range of motion tests, orthopedic
assessments, movement assessments and implementing inhibitory techniques that
decrease muscle reflex activity and inhibit motor-neuron excitability (54). If implemented
correctly, NMT can prove to play fundamental role in laying the foundation for physical
condition.
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Investigating Neuromuscular Therapy: Efficacy of Application on Chronic Pain
Postural Examination and Charting
The role of postural
examination in a clinical
setting to identify
imbalanced, dysfunctional
states is well documented
and discussed in several
bodies of literature (1, 17,
18, 19, 30, 34, 35).
Vladimir Janda, influenced
by Florence Kendall and
Alois Brugger, pioneered
several concepts surrounding
postural examination, muscle
imbalance and characterized
several common MSK
asymmetries which was
named and became known as
“upper-crossed,” “lower-
crossed,” (fig. 1.3) and
“layered,” postural syndromes (34). It has been common in the industry to discuss
Figure 1.3 Janda's Muscle Imbalance Syndromes. Digital image. The
Janda Approach to Chronic Pain Syndromes. N.p., n.d. Web. 23 May
2014.
Figure 1.4 The Autonomic Nervous System. Digital image. Web Biology.
N.p., n.d. Web. 23 May 2014.
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Investigating Neuromuscular Therapy: Efficacy of Application on Chronic Pain
“IF THE ELASTIC POTENTIAL HAS BEEN EXCEEDED, OR PRESSURE FORCES ARE SUSTAINED, A VISCOPLASTIC RESPONSE DEVELOPS AND DEFORMATION CAN BECOME PERMANENT. WHEN THE APPLIED FORCE CEASES, THE TIME TAKEN FOR TISSUES TO RETURN TO NORMAL, VIA ELASTIC RECOIL, DEPENDS UPON THE UPTAKE OF WATER BY THE TISSUES. THIS RELATES DIRECTLY TO OSMOTIC PRESSURE, AND TO WHETHER THE VISCOELASTIC POTENTIAL OF THE TISSUES HAS BEEN EXCEEDED, WHICH CAN RESULT IN A VISCOPLASTIC (PERMANENT DEFORMATION) RESPONSE.”
Chaitow, Leon, and Judith Walker DeLany. "Clinical
Application of Neuromuscular Techniques Volume 1: the Upper Body." 2002. Print.
muscular imbalances in a physiological sense as inhibited (hypotonic) and facilitated
(hypertonic) active structures which can be thought of as; being in a state of excess or
lack of tonus in a given physiological structure. This can result in the stimulation of either
the parasympathetic or sympathetic branches of the autonomic nervous system (fig 1.4),
although the latter is more typically seen and discussed. This is not to be confused with
viscoelastic and viscoplastic states of tissue which can also influence states of function or
dysfunction.
While the use of
postural examination in a
clinical setting seems to be a
useful tool for identifying
underlying causes for MSK
dysfunction, the reliability of
interrater and intrarater is not
precisely known as a review
of the literature yields minor
and mixed results (39, 40, 41,
42, 43). Of note is the
different possible methods
used to examine and record
posture along with how the
body may be adapting to its
Figure 1.5 postural Chart
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Investigating Neuromuscular Therapy: Efficacy of Application on Chronic Pain
environment during examination. Moving forward into the future of NMT and clinical
interventions, more updated and comprehensive postural analysis have been developed
and adopted. However useful, typical and general postural examinations are commonly
practiced while being seldom recorded. The use of a postural chart (fig 1.5) was selected
as a means of recording qualitative data, observing patient progression, identifying
individual postural abnormalities, creating an individualized treatment plan based on the
patients postural orientation and consulting with a clinical supervisor or a colleague about
what structures would be highly indicated for treatment after clearing painful stimuli,
which has been shown to alter muscular recruitment and proper muscle sequencing (44,
45, 46, 47, 48).
A three dimensional postural examination on the saggital, coronal and transverse
planes was completed and recorded on a postural chart. In standing, measurements were
taken from an anterior, posterior, lateral and superior view (standing on a stool for
measurements of the torso and cranium.). In supine, measurements were taken from an
anterior, superior and inferior view. In sitting, anterior and posterior measurements were
taken. Measurements were observed and recorded on a postural chart (fig. 1.5) by
palpating prominent bony landmarks and identifying the magnitude of imbalance by
bringing the practitioners eyes to the level of the structure being palpated to avoid
parallax distortion interfering with a true measurement.
Measurements evaluating left to right symmetry and coronal alignment were evaluated by
creating a straight line down the center of the body and at the lateral malleolus with a
plumb line.
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Investigating Neuromuscular Therapy: Efficacy of Application on Chronic Pain
Symptom Tracking
Severity of symptoms felt were tracked and recorded on Bournemouth Questionnaires
(Appendix A) along with practitioner recording subjective feedback in the lined areas of
the postural chart by patient interview prior to treatment. Updates on general and specific
neck, lower back and hip pain were taken along with sociability, mood, energy, activity,
functional capacity and anxiety were followed up on. General, neck, back and lower back
pain were individually recorded, graphed and charted. The severity of symptoms were
scored on a numerical scale of 0 – 10, 10 being the most positive perception of that
symptom and 10 being the worst indication. The questions on the Bournemouth
Questionnaire are found in appendix A.
Patient Profile
A 69-year old retired from work male diagnosed with lumbago, bilateral hip dysplasia,
hypothyroidism and congenital microtia presented severely reduced functional capacity,
using a medical four wheel rollator walker to move as observed by the author, attending
clinical supervisor and disclosed by the patient, communicated having experienced
ongoing pain since a single traumatic injury. The patient had fallen from a ladder in his
early 20’s and had experienced no lasting alleviation from generalized pain felt primarily
in the posterior lumbar spine at the level of approximately L2 -5 extending to the anterior,
lateral and posterior regions of the pelvis surrounding the sacrum, acetabulum, greater
trochanter, lesser trochanter and more precise pain just above the femoral triangle
running obliquely from the anterior superior iliac spine (ASIS) toward the pubic
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Investigating Neuromuscular Therapy: Efficacy of Application on Chronic Pain
symphysis where the rectus abdominis attaches. The secondary concern was pain and
“clicking” felt in the lower posterior cervical spine at the level of approximately C6 – C7.
Quantitative and qualitative data collection indicated the patient also had been
experiencing general fatigue, markedly reduced levels of functional capacity, moderate
levels of interference from pain with daily activity of daily living, mild interference with
societal and/or recreational activities, mild levels of anxiety, mild levels of depression
and mild loss of ability to feel in control of his condition. Qualitative postural
examination indicated several postural adaptations, particularly on the coronal plane at
the level of the pelvis and cranium in addition to on the sagittal plane and transverse
planes at the cranium, shoulders and pelvis.
Treatment
Treatment was applied over the course of 4 weeks with a frequency of 2 treatments a
week on Tuesday evenings and Friday mornings (with the exception of one treatment on
a Thursday due to Good Friday.) Duration of applied manual intervention was 60 minutes
in length with up to 45 minutes allotted prior to treatment for consultation and physical
examination.
An individual NMT treatment protocol was designed based on patient concerns,
regional pain, typical trigger point referral patterns and muscular imbalances indicated by
postural examination. Special consideration was paid to structures of palpably abnormal
tissue quality, observed imbalanced hypertrophy and structures that are not commonly
treated or thought about (ex. intraoral treatment of the pteryoid, masseter, temporalis,
glossal and palatine muscles. Sidelying treatment; subscapularis. Supine treatment;
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Investigating Neuromuscular Therapy: Efficacy of Application on Chronic Pain
infrahyoid, longus capitis, longus cervicis, splenius capitis and splenius cervicis. Prone
treatment; intercostal, rotatores and multifidi.).
The literature is scarce on what type of pressure and depth yields optimal results
so a communication was opened between the practitioner and patient to let us know
perceived sensitivity and pressure on a scale of 1 – 10 never to exceed the patient’s level
of tolerance. Typical application of NMT was used which includes soft fist compression,
digital static compression, thumb and index finger compression with opposition, pincer
type thumb and index finger static compression, thumb, digital, forearm and elbow
longitudinal (with the muscle pennation) along with transverse (across the muscle
pennation) strokes at the musculotendinous junctions and muscle bellies.
Results
The patient scored that, in general, perceived symptoms were moderate to severe in all
categories except for the low indication on Q4, Anxiety, (See Appendix A) prior to
beginning with intervention. Total symptom tally (ST) of perceived symptoms on 1st
treatment (April-14th) were the most significant (ST = 38) and had the most dramatic
reduction of symptoms treatment (ST = 38) to treatment (ST = 10). Also of note, after 1st
treatment the patient came in without the use of his walker indicating an increase of
functional capacity. Patient reported having higher levels of energy and ability to do more
throughout the day which allowed for the duration of activity to increase. Due to the loss
of pain, he felt more capable to carry out tasks he had not been able to perform such as
bending and lifting. After each treatment, patient continued to report increased levels of
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Investigating Neuromuscular Therapy: Efficacy of Application on Chronic Pain
energy and the perception of capability to perform. Spikes of symptoms on 3rd and 4th
intake were due to an increase in physical activity and an acute event of the patient
exiting the pool, respectively, with no consistent perpetuation from other activities. The
patient’s initial concern was lumbo-pelvic-hip complex pain which shifted to a secondary
concern governed by the neck pain/discomfort (patient described neck as “annoying”
with “clicking” more so than a pain). Unfortunately, a reduction of symptoms of pain in
the cervical spine was insignificant. This may be related to the congenital microtia (see
discussion).
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Investigating Neuromuscular Therapy: Efficacy of Application on Chronic Pain
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Investigating Neuromuscular Therapy: Efficacy of Application on Chronic Pain
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Investigating Neuromuscular Therapy: Efficacy of Application on Chronic Pain
Discussion and Endnotes
Therapeutic Relationship and Psychosomatics
Although the primary goal of the intervention was to observe the effects of NMT as a
sole treatment option, the author would like to express and suggest that other factors such
as the therapeutic relationship established between the patient and practitioner may have
played a large role in the down regulation of pain symptoms. A search of the literature on
the effects of engaging in a therapeutic relationship retrieves more than 1,000 (52)
findings and affects the magnitude of compliance and outcome in several clinical settings
and in several patient-practitioner relations. This suggests that just environmental, social,
psychological and the integrated interaction of these facets may influence the perception
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Investigating Neuromuscular Therapy: Efficacy of Application on Chronic Pain
and expression of symptoms for psychosomatic, physical symptoms that are caused of
significantly influenced by emotional factors (53), reasons. Of note regarding the
psychosomatic component of symptom expression; clinically, patients frequently express
their frustration in treatment interventions where the tending practitioner has dismissed
their case, negative physical reaction, poor and/or stagnant results due to the
psychosomatic component. The author would like to suggest that in an integrated or
collaborative model of healthcare the psychosomatic component not be dismissed but
rather considered and treated if it is an obstacle in a patient’s expression of symptoms.
Human Haptic Communication, Transmission and Perception
The role of haptic communication, or touch, is the subject of ongoing research in manual
therapy and, as the name implies, is a vital component in any manual therapy setting.
There are several components to the usage of haptic transmission which stems many
ideas about what is occurring physiologically and psychologically for the patient. The
ambiguity surrounding haptic communication in this case study is whether, pain, function
and psyche were mediated and downregulated primarily by means of the neural, or
mechanotransduction, the musculoskeletal, or viscoplastic-elastic, responses or of the
psychosomatic responses associated with haptic perception.
Stress Associated Symptoms
Studies suggest that massage, which NMT is a form of, promotes relaxation and quality
of life (55, 56). Literature has suggested that the level of perceived stress and regulation
of stress is a contributor to the expression of symptoms (57, 58, 59) and that stress
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Investigating Neuromuscular Therapy: Efficacy of Application on Chronic Pain
reduction reduces those symptoms (60). However, it must be considered that the
application of treatment methods are highly variable practitioner to practitioner and in
regards to NMT in particular, treatment may be more aggressive than typical massage
intervention. It is unknown as to whether significant changes were made to levels of
stress. Further research, testing and data collection is suggested. In future studies, the
usage of salivary and urinary diagnostics would prove useful in measuring cortisol
throughout treatment intervention.
Viscerosomatic Reflexes
The thought of how the tissue quality of organs may affect the body through a
viscerosomatic reflex is interesting. However, the literature in regards to the mechanism
of how organs may affect biomechanics and how treating organs may affect their
function is scarce so treatment in an effort to directly affect the organs was not used.
Indirectly, is not known. Conceptually, many of the body’s major organs are comprised
of muscular tissue, albeit different than skeletal muscle, and innervated by the nervous
system to maintain function so there may lie a relationship, however the literature is thin.
For the purposes of differential diagnosis and adding inventory to therapeutic
intervention, it is worth consideration for future exploration even if for disambiguation.
Lifestyle and Environmental Factors
It must also be illustrated that lifestyle factors be considered in patients perpetuates. The
position of their body at rest, physical activity, biomechanical patterns, nutritional habits,
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Investigating Neuromuscular Therapy: Efficacy of Application on Chronic Pain
hydration habits, sleeping habits, financial stability, emotional habits, among others, is
worth consideration when considering patient outcomes.
Structural and Anatomical Variation Considerations
In patients who present chronic, complex cases and treatment is yielding fluctuating
results, a structural rather than functional component may be worth consideration.
Features such as an anatomically short lower limb, wedged shaped vertebrae, small hemi
pelvis, Morton’s foot structure, cervical rib among other bony abnormalities may be
worth consideration for biomechanical adaptations which can perpetuate symptoms.
Individuals who present with or without muscles that others commonly don’t or do have
this can also represent a functional adaptation or change.
Summary
In this case study we observed a dramatic reduction of symptoms perceived. Although
significant attention was paid to the patients neck, we were unable to resolve the patient’s
neck concern by a measure that could be considered clinically significant which may be
attributed to the congenital microtia. In a study, Atlanto-axial, C1 – C2, fixation was
noted following surgery for microtia (61). If this is a similar case, this may have been a
factor in the chronic neck concern and may explain the “clicking” reported by the patient
if the cervical vertebrae below C2 became more mobile as a result of hypomobility of the
atlantoaxial joint.
Although NMT has proven to be substantially efficacious in this case report,
disambiguation as to which components of treatment had the most profound effects on a
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Investigating Neuromuscular Therapy: Efficacy of Application on Chronic Pain
tissue level would be highly interesting through usage of diagnostic tools such as EMG,
EEG, fMRI, Thermography, X-Ray, etc. The usage of functional medicine testing such as
salivary cortisol, stool sampling and blood serum collection may prove useful in
understanding the biochemical effects of NMT and massage therapy. The clearer a
practitioner understands what has the largest effect on the patient, the more capable a
practitioner can be in selecting effective tools for that particular patient as some may
require a more psychosomatic intervention while others may have more physical,
functional, mechanical dysfunction. Overall, NMT has shown to provide substantial short
term benefit in this case study. Larger and longer clinical studies are warranted in regards
to showing efficacy in qualifying the use and integration of manual intervention as a
common practice in medicine. The author suggests that collaboration with other
healthcare providers who specialize in addressing individuals on a biochemical level may
have an even greater positive patient outcome.
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Investigating Neuromuscular Therapy: Efficacy of Application on Chronic Pain
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Investigating Neuromuscular Therapy: Efficacy of Application on Chronic Pain
Appendix A
Bournemouth Questionnaire
Q1. Over the past few days, on average,
how would you rate your pain on a
scale where ‘0’ is ‘no pain’ and ‘10’
is ‘worst pain possible’?
Q2. Over the past few days, on average,
how much has your painful complain
interfered with your daily activities
(housework, washing, dressing,
lifting, walking, reading, driving,
climbing stairs, getting in/out of
bed/chair, sleeping) on a scale where
‘0’ is ‘no interference’ and ‘10’ is
completely unable to carry on with
daily activity’?
Q3. Over the past few days on average,
how much has your painful complaint
interfered with your normal social
Bournemouth Questionnaire
“As part of clinical practice, it is imperative that outcomes are assessed, not only to provide information to the clinician but also to the patient. It is now generally accepted that the focus of documenting outcomes should be placed on those reported by the patient rather than clinical measures that may have little relevance to the patient in his daily life. Because non-‐specific musculoskeletal conditions are multi-‐factorial and affect individual patients in different ways, there is a need to measure several outcomes, and this can lead to burdensome and complex patient self-‐report questionnaires.
The Bournemouth Questionnaire (BQ) is a comprehensive multi-‐dimensional core outcome assessing the patients’ outcomes in the routine clinical setting. It consists of seven scales and has been validated in back and neck pain patients (49, 50, 51).”
"Outcome Measures in Practice." Patient Reported Outcome Measures. Anglo-‐European College of Chiropractic, n.d. Web. 23 May 2014.
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Investigating Neuromuscular Therapy: Efficacy of Application on Chronic Pain
routine including recreational, social and family activities, on a scale where ‘0’ is
‘no interference’ and ‘10’ is ‘completely unable to participate in any social and
recreational activity’?
Q4. Over the past few days, on average, how anxious
(uptight, tense, irritable, difficulty in relaxing/concentrating) have you been
feeling, on a scale where '0' is 'not at all anxious' and '10' is extremely anxious'?
Q5. Over the past few days, how depressed (down-in-the dumps, sad, in low spirits
pessimistic, lethargic) have you been feeling, on a scale where '0' is 'not at all
depressed' and '10' is 'extremely depressed'?
Q6. Over the past few days, how do you think your work (both inside the home
and/or employed work) have affected your painful complaint, on a scale where '0'
is 'make it no worse' and '10 is 'make it very much worse'?
Q7. Over the past few days, on average, how much have you been able to control
(help/reduce) and cope with your pain on your own, on a scale where '0' is 'I can
control it completely' and '10' is 'I have no control whatsoever'?