Treating Trapped Nerves - a Myoskeletal Approach
This September we are delighted to be returning to London to present the third in our series of Myoskeletal Alignment Techniques seminars. This workshop will see the first introduction of the incredibly popular Myoskeletal approach to Treating Trapped nerves in the UK. Training will focus and addressing the structures that commonly entrap nerves, assessment for the presence of neural tethering and techniques to restore free movement of the major nerve branches in the upper and lower extremities. Below is an excerpt written by me from ‘Myoskeletal and Sports Therapy’ to give context to some of the techniques covered in this results focused seminar.
Introduction to Myoskeletal Alignment
Over the last three decades I have been fortunate enough to study with many of the great practitioners of our industry, to benefit from their expertise and be influenced by their work. Without a doubt, the most significant of these has been the practice of Myoskeletal Alignment techniques.
Myoskeletal Alignment is a comprehensive approach to bodywork developed by Dr. Erik Dalton. Erik began his career studying the human mind, earning a PhD in Clinical Psychology from the University of Oklahoma. It didn’t take long for him to see that mind and body cannot be separated. This lead him to pursue training and practice in massage therapy. As Erik began to see predictable pain patterns occur in his[if gte vml 1]><v:shapetype id="_x0000_t75" coordsize="21600,21600" o:spt="75" o:preferrelative="t" path="m@4@5l@4@11@9@11@9@5xe" filled="f" stroked="f"> <v:stroke joinstyle="miter"></v:stroke> <v:formulas> <v:f eqn="if lineDrawn pixelLineWidth 0"></v:f> <v:f eqn="sum @0 1 0"></v:f> <v:f eqn="sum 0 0 @1"></v:f> <v:f eqn="prod @2 1 2"></v:f> <v:f eqn="prod @3 21600 pixelWidth"></v:f> <v:f eqn="prod @3 21600 pixelHeight"></v:f> <v:f eqn="sum @0 0 1"></v:f> <v:f eqn="prod @6 1 2"></v:f> <v:f eqn="prod @7 21600 pixelWidth"></v:f> <v:f eqn="sum @8 21600 0"></v:f> <v:f eqn="prod @7 21600 pixelHeight"></v:f> <v:f eqn="sum @10 21600 0"></v:f> </v:formulas> <v:path o:extrusionok="f" gradientshapeok="t" o:connecttype="rect"></v:path> <o:lock v:ext="edit" aspectratio="t"></o:lock> </v:shapetype><v:shape id="officeArt_x0020_object" o:spid="_x0000_s1028" type="#_x0000_t75" style='position:absolute;margin-left:200.4pt;margin-top:14.25pt; width:131.35pt;height:307.4pt;z-index:1;visibility:visible;mso-wrap-style:square; mso-wrap-distance-left:4pt;mso-wrap-distance-top:4pt; mso-wrap-distance-right:4pt;mso-wrap-distance-bottom:4pt; mso-position-horizontal:absolute;mso-position-horizontal-relative:margin; mso-position-vertical:absolute;mso-position-vertical-relative:line' wrapcoords="0 35 21600 35 21600 21600 0 21600 0 35" strokeweight="1pt"> <v:stroke miterlimit="4"></v:stroke> <v:imagedata src="file:///C:\Users\carole\AppData\Local\Temp\msohtmlclip1\01\clip_image001.png" o:title=""></v:imagedata> <w:wrap type="through" anchorx="margin" anchory="line"></w:wrap> </v:shape><![endif][if !vml][endif][if gte vml 1]><v:shape id="_x0000_s1027" type="#_x0000_t75" style='position:absolute;margin-left:354.1pt; margin-top:14.25pt;width:119.3pt;height:306.15pt;z-index:2;visibility:visible; mso-wrap-style:square;mso-wrap-distance-left:4pt;mso-wrap-distance-top:4pt; mso-wrap-distance-right:4pt;mso-wrap-distance-bottom:4pt; mso-position-horizontal:absolute;mso-position-horizontal-relative:margin; mso-position-vertical:absolute;mso-position-vertical-relative:line' wrapcoords="0 35 21600 35 21600 21600 0 21600 0 35" strokeweight="1pt"> <v:stroke miterlimit="4"></v:stroke> <v:imagedata src="file:///C:\Users\carole\AppData\Local\Temp\msohtmlclip1\01\clip_image003.png" o:title=""></v:imagedata> <w:wrap type="through" anchorx="margin" anchory="line"></w:wrap> </v:shape><![endif][if !vml][endif] clients he set out to develop a streamlined yet comprehensive way of effectively addressing pain. He studied with industry leaders such as Ida Rolph for soft tissue work, Philip Greenman for osteopathic techniques and collaborating with reachers such as Andry Vleeming, Aaron Mattes and long time friend Tom Myers. He was particularly influenced by the work of Vladimir Janda.
Dr. Vladimir Janda was a Czech neurologist and physiatrist. Janda's primary interest was the treatment of chronic musculoskeletal pain. Through clinical research he established predictable patterns of dysfunction he termed upper crossed and[if gte vml 1]><v:shapetype id="_x0000_t202" coordsize="21600,21600" o:spt="202" path="m,l,21600r21600,l21600,xe"> <v:stroke joinstyle="miter"></v:stroke> <v:path gradientshapeok="t" o:connecttype="rect"></v:path> </v:shapetype><v:shape id="_x0000_s1026" type="#_x0000_t202" style='position:absolute; margin-left:200.4pt;margin-top:18pt;width:281pt;height:60.5pt;z-index:3; visibility:visible;mso-wrap-distance-left:12pt;mso-wrap-distance-top:12pt; mso-wrap-distance-right:12pt;mso-wrap-distance-bottom:12pt; mso-position-horizontal-relative:margin;mso-position-vertical-relative:line; v-text-anchor:middle' wrapcoords="-4 -18 21596 -18 21596 21582 -4 21582 -4 -18" o:gfxdata="UEsDBBQABgAIAAAAIQDkmcPA+wAAAOEBAAATAAAAW0NvbnRlbnRfVHlwZXNdLnhtbJSRQU7DMBBF 90jcwfIWJQ5dIISSdEHaJSBUDjCyJ4nVZGx53NDeHictG4SKWNrj9//TuFwfx0FMGNg6quR9XkiB pJ2x1FXyY7fNHqXgCGRgcISVPCHLdX17U+5OHlkkmriSfYz+SSnWPY7AufNIadK6MEJMx9ApD3oP HapVUTwo7SgixSzOGbIuG2zhMESxOabrs0nCpXg+v5urKgneD1ZDTKJqnqpfuYADXwEnMj/ssotZ nsglnHvr+e7S8JpWE6xB8QYhvsCYPJQJrHDlGqfz65Zz2ciZa1urMW8Cbxbqr2zjPing9N/wJmHv OH2nq+WD6i8AAAD//wMAUEsDBBQABgAIAAAAIQAjsmrh1wAAAJQBAAALAAAAX3JlbHMvLnJlbHOk kMFqwzAMhu+DvYPRfXGawxijTi+j0GvpHsDYimMaW0Yy2fr28w6DZfS2o36h7xP//vCZFrUiS6Rs YNf1oDA78jEHA++X49MLKKk2e7tQRgM3FDiMjw/7My62tiOZYxHVKFkMzLWWV63FzZisdFQwt81E nGxtIwddrLvagHro+2fNvxkwbpjq5A3wye9AXW6lmf+wU3RMQlPtHCVN0xTdPaoObMsc3ZFtwjdy jWY5YDXgWTQO1LKu/Qj6vn74p97TRz7jutV+h4zrj1dvuhy/AAAA//8DAFBLAwQUAAYACAAAACEA CVHqtwcCAAD6AwAADgAAAGRycy9lMm9Eb2MueG1srFPBjtsgEL1X6j8g7o3tbDZOojir7a62qlS1 lbb9AIwhpgKGAomdv++As9m0vVX1ATMD82bem2F7NxpNjsIHBbah1aykRFgOnbL7hn7/9vRuRUmI zHZMgxUNPYlA73Zv32wHtxFz6EF3whMEsWEzuIb2MbpNUQTeC8PCDJyweCjBGxbR9Pui82xAdKOL eVkuiwF85zxwEQJ6H6dDusv4Ugoev0gZRCS6oVhbzKvPa5vWYrdlm71nrlf8XAb7hyoMUxaTXqAe WWTk4NVfUEZxDwFknHEwBUipuMgckE1V/sHmuWdOZC4oTnAXmcL/g+Wfj189UR32rqxv6kW1mteU WGawV1N19z4SaH+gkkmswYUNxjw7jIrjexgx8MUf0Jk0GKU36Y/xBM9R9tNFajFGwtF5c7tc5VQc z+rlalEvE0zxGu18iB8EGJI2DfWpgITKjp9CnK6+XEnuAFp1T0rrbPh9+6A9OTJs+3pRVWU5xWrX s8k7Xy/Wuf2YMkzXc/rfcLQlAxKc1xhPOMP5lJpNZVhIyfL4GBVxhrUyDV2U6Tsz0TbVIvIUnmtO 8k0ypV0c2/GsaQvdCSUdcBIbGn4emBeU6I8WW31brlL6eG34a6O9NuzBPACyrihhlveAs86jz+wt 3B8iSJXVS/mnpEg7GThgWYDzY0gTfG3nW69PdvcLAAD//wMAUEsDBBQABgAIAAAAIQD52QJT4AAA AAoBAAAPAAAAZHJzL2Rvd25yZXYueG1sTI/LTsMwEEX3SPyDNUjsqE1b0hLiVFAJsUDl0fYD3HhI osbjyHba8PcMK1jOzNGdc4vV6DpxwhBbTxpuJwoEUuVtS7WG/e75ZgkiJkPWdJ5QwzdGWJWXF4XJ rT/TJ562qRYcQjE3GpqU+lzKWDXoTJz4HolvXz44k3gMtbTBnDncdXKqVCadaYk/NKbHdYPVcTs4 DbthMRw/hnmL67fw9DJ73Wze66T19dX4+AAi4Zj+YPjVZ3Uo2engB7JRdBrmSrF60jDLuBMD99mU Fwcm7xYKZFnI/xXKHwAAAP//AwBQSwECLQAUAAYACAAAACEA5JnDwPsAAADhAQAAEwAAAAAAAAAA AAAAAAAAAAAAW0NvbnRlbnRfVHlwZXNdLnhtbFBLAQItABQABgAIAAAAIQAjsmrh1wAAAJQBAAAL AAAAAAAAAAAAAAAAACwBAABfcmVscy8ucmVsc1BLAQItABQABgAIAAAAIQAJUeq3BwIAAPoDAAAO AAAAAAAAAAAAAAAAACwCAABkcnMvZTJvRG9jLnhtbFBLAQItABQABgAIAAAAIQD52QJT4AAAAAoB AAAPAAAAAAAAAAAAAAAAAF8EAABkcnMvZG93bnJldi54bWxQSwUGAAAAAAQABADzAAAAbAUAAAAA " fillcolor="#941100" stroked="f" strokeweight="1pt"> <v:fill opacity="19275f"></v:fill> <v:stroke miterlimit="4"></v:stroke> <v:textbox inset="4pt,4pt,4pt,4pt"> <![if !mso]> <table cellpadding=0 cellspacing=0 width="100%"> <tr> <td><![endif]> <div> <p class=Body align=center style='text-align:center'><span style='font-size:13.0pt;font-family:Baskerville'>Dr. Vladimir Janda</span><span lang=EN-US style='font-size:13.0pt;font-family:Baskerville;mso-ansi-language: EN-US'>’s Crossed syndromes</span><span lang=EN-US style='font-size:13.0pt; font-family:Baskerville'> </span><span style='font-size:13.0pt;font-family: Baskerville;mso-fareast-font-family:Baskerville;mso-bidi-font-family:Baskerville'><o:p></o:p></span></p> <p class=Body align=center style='text-align:center'><span lang=EN-US style='font-size:12.0pt;font-family:Baskerville;color:#931100;mso-ansi-language: EN-US'>Line A </span><span lang=EN-US style='font-size:12.0pt;font-family: Baskerville;color:#434343;mso-ansi-language:EN-US'>indicates muscles prone to tightness or shortness </span><span style='font-size:12.0pt;font-family: Baskerville;mso-fareast-font-family:Baskerville;mso-bidi-font-family:Baskerville; color:#434343'><o:p></o:p></span></p> <p class=Body align=center style='text-align:center'><span lang=EN-US style='font-size:12.0pt;font-family:Baskerville;color:#931100;mso-ansi-language: EN-US'>Line B </span><span lang=EN-US style='font-size:12.0pt;font-family: Baskerville;color:#434343;mso-ansi-language:EN-US'>indicates muscles prone to weakness or inhibition</span></p> </div> <![if !mso]></td> </tr> </table> <![endif]></v:textbox> <w:wrap type="through" anchorx="margin"></w:wrap> </v:shape><![endif][if !vml][endif] lower crossed syndromes. These crossed syndromes still provide a useful insight for corrective bodyworkers today.
The current Neuroscience research incorporated into the Myoskeletal approach is shedding new light on our understanding of Janda's crossed syndromes. In particular, the roll of the Pontomedullary Reticular Formation (PMRF) as the epicentre for postural control. What can start as a soft tissue problem becomes a learned neurological response in the PMRF, perpetuating the dysfunction.
As Erik says, ‘Clients with PMRF disorders commonly present with an upper cross syndrome pattern - forward jutted chin, internally rotated arms, protracted shoulder girdle, and thoracic spine hyperkyphosis. In this population, the PMRF is unable to neurologically resist slumping, which causes connective tissue and joint adaptations in the Myoskeletal framework’. This new understanding shapes our approach to treatment with a greater focus on the outcomes achieved through nervous system response.
Nerve slides and glides
‘Treatment of the soft tissues that impede neural motion, combined with specific nerve mobilisation techniques can quickly address neural adhesion and improve function’
The concept of neuromobilisation was originally based on research by physiotherapists, Geoffrey Maitland, Michael Shacklock and David Butler. Over the years, other researchers have added to the volume of scientific literature supporting the hypothesis that nerves require unimpeded movement for full pain-free function.
According to Michael Shacklock, “The entire nervous system is a continuous structure. It moves and slides in the body as we move and the movement is related to critical physiological processes such as blood flow to neurones. This movement is quite dramatic and it is not hard to imagine that fluid such as blood in the nerve bed, a constricting scar, inflammation around the nerve or a nerve having to contend with arthritic changes or proximity to an unstable joint could have damaging effects, some of which could lead to pain.”
Acute compression of a normal peripheral nerve doesn’t necessarily produce symptoms such as pain, but the client may experience nocturnal numbness, motor weakness, and related symptoms. So it is with nerve root lesions. Mechanical entrapment of a normal spinal nerve root may initiate similar sensory and motor impairment in the complete absence of pain. However, mechanical factors that induce intra-neural nerve root oedema may lead to hyperexcitability, protective muscle spasm, fibrosis and pain. For example, it has not been shown that lumbar nerve root compression necessarily causes leg pain or neurologic dysfunction, but in the presence of prolonged compression of neural and perineural tissues, an inflammatory response may trigger chemoreceptor and nociceptor hyperexcitability causing the brain to react with a pain response.
The following is a section Erik contributed to Nerve flossing chapter in ‘Myoskeletal and Sports therapy’:
Any alteration of joint function is carefully monitored by the brain and spinal cord and may influence muscular function. The mechanosensitivity of neural tissues is affected by altered joint position. The joint position and centration is affected by soft tissue tension, trauma, and repetitive movements combined with gravitational exposure. When muscles and joints entrap and injure a nerve, the brain may try and protect the area through chronic inflammation and adhesive scar tissue formation.
Mobilising joints through muscle manipulation is a key factor in the success of MAT. Therefore, soft tissue manoeuvres have been developed to release osseous fixations, relieve protective spasm and improve nerve gliding through all the body’s synovial joints.
The word mobilisation is loosely used to describe the various kinds of manual therapy treatment techniques and many are helpful in cases of neural entrapment. When combining soft tissue mobilisation modalities such as Myofascial release, active isolated stretching and Muscle Energy Technique with gentle joint mobilisation manoeuvres such as traction and gliding, the benefit is mobilisation of the nervous system. The Myoskeletal goal is to relieve pain and protective spasm while restoring pain-free functional movement.
The good news is that the Myoskeletal and Neural Glide techniques described in this chapter can show you how to release painful neural entrapments and restore pain-free movement. By combining joint stretching, soft tissue work and nerve mobilisation manoeuvres, you will quickly be able to normalise movement and provide nerve pain relief. Often this nerve pain relief is instantaneous! (In Touch - Erik Dalton).
Assessment for the presence of neural tethering
‘Presentation for a client with neural tethering can range from loss of strength or sensation to chronic pain and paresthesia’
A client with a neurological condition can have a pretty wide range of possible symptoms. In some cases they will describe their experience as shooting or radiating pain. Others will have loss of sensation and describe areas as feeling numb. While
others still will have loss of strength or power. Nerve pain can also mimic common conditions such as Plantar fasciitis and Morton's neuroma, Tennis elbow and Golfer's elbow. It’s easy to distinguish if this is the case as the orthopaedic tests, such as resisted dorsiflexion for Plantar fasciitis and Morton's squeeze for a neuroma will test negative despite the client appearing to have the classic pain pattern for these conditions. Neural tensioning will often provoke the client’s recognisable pain.
Referral to a neurologist should always be considered, particularly if a client’s symptoms persist beyond 3 or 4 sessions or are bilateral (affecting both sides of the body). If neural tethering is the cause resolution is usually quite quick, so persistent symptoms may indicate underlying complications. The primary concern with bilateral symptoms is that the spinal cord may be affected.
If in doubt, refer out! Referral to a neurologist is always worth the time and possible expense as it can provide clear guidance, especially in ruling out underlying complications.
Home care for neural mobility
‘As with all treatment outcomes, home care for neural mobility is essential to maintain the benefits of therapy’
Home care for neural mobility begins with ‘nerve flossing’. This means performing specific a manoeuvre to place a mild tension on a particular nerve. Just enough to elicit a mild sensitivity but not discomfort. From this position the client tucks the chin towards the sternum and flexes the torso. At the same time the lower limb is eased back out of the tensioned position. This pulls the nerve proximally. As the head is brought back to a neutral position the leg is brought further into the position that pulls on the specific nerve being addressed. This draws the nerve in a distal direction. The home care follows the same principal described in treatment: the ideal is to maintain a mild tension on the nerve throughout in order to floss and not pull to aggressively on the nerve.
In the later stages of home care, when the nerve is gliding freely and no sensitivity is felt, the focus can shift to neural tensioning. This tensile stress will stimulate collagen production to protect the nerve while retaining independent movement of the nerve in relation to the surrounding tissue. This is achieved by pulling distally and proximally at the same time
Aubrey Gowing is a college director and program developer at Holistic College Dublin and lectures internationally. He was introduced to yoga practice and massage as a child by his very progressive parents, and this inspired Aubrey to begin studying bodywork in 1989. Aubrey is now coming into his 30th year inclinical practice and has been teaching therapies for 25 years. He has published many DVD's on Massage and Sports Therapy and this year his first book "Myoskeletal and Sports Therapy - Lower Body".Aubrey is the only certified Myoskeletal Instructor outside the US approved to teach Erik Daltons Myoskeletal courses. He maintains a thriving practice, Orthopaedic & Sports Therapy Clinic in Ireland dealing with repetitive strain, overuse and sports injuries, and chronic pain syndromes.
To book onto the London CPD course in Myoskeletal techniques, please contact Julia Oyeleye at MyTherapy CPD via firstname.lastname@example.org who is facilitating the event at the University College of Osteopathy, 275 Borough High Street, London SE1 1JE on 14th & 15th September 2019, 9am - 6pm both days. This is worth 15 CPD points and costs £315.00.
The images in this article are copyrighted to Audrey Gowing and cannot be reproduced or copied without express permission.