Neuromuscular Techniques (NMTs)

Neuromuscular Techniques (NMTs) is an umbrella term including a variety of interventions affecting the nervous and muscular systems simultaneously. Trigger Point Therapy is perhaps the most common. Myofascial release and Positional Release are other examples.

​Applying static pressure to by compressing can profoundly affect the underlying tissues. Such techniques are an integral part of deep tissue massage, acupressure, and shiatsu. These techniques are reasonably simple and very effective. They can promote the flow of energy within the body, calm the mind, normalise muscle tone, and improve muscle function. Additionally, they are effective for reducing tightness as well as alleviating local and referred pain.
 
NMTs originated thousands of years ago and exist in one form or another in most Easter and Western bodywork modalities. They were more formally researched and introduced in recent times by Stanley Lief and Leon Chaitow in the 1930s. The term ‘trigger point’ (TrP) was first used in 1942 by Janet Travell and defined as: “a highly irritable localised spot of exquisite tenderness in a palpable taut band of skeletal muscle.”
 
As the name suggests, NMTs affect the interaction between the nervous and the muscular system. Excessive tension can accumulate in a small area of a muscle. This can make the muscle tight, weak, restrict its range of motion and even cause local or referred pain. It is essential to engage the nervous system as it is the one governing muscle tone.
 
Effects of NMTs

• Reduce pain. Clinical evidence shows that myofascial pain can be largely eliminated in 3-10 days and chronic conditions significantly improved in 6 weeks.
• Increase Range of Motion (ROM) of joins. By alleviating excess tightness, the muscles return to their normal length. When this is achieved in all surrounding muscles, the joint itself restores its full mobility.
• Restore muscle function. The uneven tightness of the muscles compromises its ability to contract effectively and relax to its full length. This compromises its function and can have a detrimental effect on adjacent joints. By eliminating local tightness NMTs restore optimal functioning.
• Improve posture. With the alleviation of tightness and pain, it is less likely that a person would embody postural deviations for comfort.

 
Common causes of TrPs

• Poor posture. This is one of the most common causes. Poor posture keeps muscles in awkward positions for long times. This creates imbalances causing opposing muscles to become tight or weak. Both of these pre-dispose the muscle to developing TrPs.
• Lack of activity. Long sitting and sedentary life, in general, are common culprits.
• Repetitive activities. Any movement repeated enough times would aggravate a muscle. As a way of protecting itself, it may develop tightness leading to a trigger point.
• Past trauma. Part of the healing process of a muscle involves the laying down of scar tissue. If this is not broken down with soft tissue therapy or targeted stretching it may lead to the development of TrPs.

 
 
More about TrPs
 
There are about 620 referenced TrPs spread throughout the body. Each one has a specific recognisable pain or dysfunction and may have an associated referral pattern. Some TrPs, however, may be latent, i.e. not causing spontaneous pain but causing a dysfunction. It is observed that older people tend to have more latent TrPs while younger people more active.
 
TrPs can develop in any muscle as well as in scar tissue, ligaments, tendons, joint capsules, and skin. The ones found in the myofascial network are most mapped and recognised. There may be multiple TrPs in a single muscle. The primary or central one is always in the muscle belly, while the secondary or satellite ones can be spread throughout. It is essential to always treat the primary first as the secondary ones may dissipate spontaneously, while the reverse is rarely the case.
 
TrPs can be as small as a pinhead all the way to the size of a pea. What they all have in common though is that they are all tender to pressure. The pain they cause is usually described as deep and dull.
 

Recognising a TrP
 
Usually, a TrP will feel stiff and painful, nodules/bands in the muscle, it may elicit symptoms and be characterised by a local change in temperature. Taut tight sarcomeres can be located by lengthening the muscle, which exaggerates the band.
 
Muscles with TrPs cause pain at the end of their range of motion. By avoiding the pain and therefore stretching them the cycle of shortening and tightening is perpetuated. There can be a sudden ‘twitch’ when full extension is reached. This pain response is not to be mistaken with contraction or spasm. With every twitch, the TrP releases toxins containing irritating biochemicals. These acidify the surrounding tissue and while the body detoxifies them, nausea fatigue and exhaustion can be felt. ​​

By Davidparmenter (Own work) [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons

​How TrPs appear
 
At present, there is no definitive agreement about how TrPs develop. Here are some suggested explanations:

• According to the Motor Endplate Hypothesis, the major cause of TrPs is the dysfunction in the region of extrafusal motor endplates. In short, chronic pain and low-grade tension in the muscles create inflammation around the terminal parts of the sensory and motor neurons. The body responds by activating local fibroblasts. Collagen is laid down around nerve ending forming ‘collagen cuffs’. This further irritates the nervous system, creates pain and inhibits blood supply to the area.
• The Energy Crisis Theory, on the other hand, suggests that TrPs form because of a lack of ATP in the muscles due to insufficient arterial circulation. The authors use active healthy athletes as an example of people developing TrPs without any peripheral nerve abnormalities. According to this theory, as the muscle tone increases gradually in resting muscles there is local vasoconstriction. This limits delivery of nutrients and elimination of wastes. As a result, there is ATP exhaustion, interstitial edema, and formation of TrPs.
• The integrated hypothesis unites the two proposed views above to provide a reasonable explanation for TrPs.
• Another theory, suggests that the main pathological culprit for TrPs is the spinal nerve causing secondary muscle changes.

​There is still controversy around these theories and more research is needed. Regardless of the culprit, muscles with TrPs begin the day tired and exhaust more easily and quickly. Strengthening is not the answer because giving them more work when they are starved for energy makes no sense.

How NMTs work
 
Nerve endings fire excessively in TrPs. One theory suggests that the application of pressure further aggravates and therefore overload and fatigues the nerve. It is very likely, though that there are additional factors at play in this overly simplistic explanation.
 
It is likely that the application of deep sustained pressure is also effective because it creates an ischemic compression of the underlying tissue. A build-up of pressure is created behind the area of compression by deliberately inhibiting local circulation. Upon release, fresh blood surges through the muscle. By alternating deep sustained pressure with effleurage, a pumping effect is created. Each time the fresh blood enters the area it promotes and accelerates the removal of waste products.
 
It is more plausible that these two factors coupled with the interruption and resetting of the neural messages to the muscle produce the effects of NMTs. They alter the reflex pattern which holds the muscle in its hypertonic state. In a clinical environment, the client is encouraged to relax as the painful stimulus is gradually increased through pressure. This response as opposed withdrawal helps to restore the normal resting length of the muscle and eliminate the TrP.
 
NMTs also can reset reflex patterns. Injured or inflamed areas cause pain when stretched or even at their normal resting length. The central nervous system signals the muscle to contract and shorten to alleviate the discomfort. The problem is that this new contracted, hypertonic position becomes the new ‘normal’ state.
 
An effective NMT uses a painful TrP as a way of engaging and adjusting the neuromuscular reflex. With client communication and skilful application, the natural response of contracting and tensing further during compression pain is replaced with gradual relaxation and letting go.
 
Ultimately, NMTs aim to achieve the following:

1. Remove the protective muscular tension in the muscles with active TrPs.
2. Eradicate the hypersensitivity of the peripheral receptors and pain receptors in particular.
3. Circumvent the pain-processing system of the patient
4. Trigger a vasodilation reflex
5. Restore normal blood supply to the area

 
Treating TrPs with NMTs
 
Let’s suppose that a client presents themselves with ‘tension’ headaches, neck pain, and pain behind the eye. This common upper trapezius TrPs referral pattern is confirmed when palpating the muscle.
 
There are two possible approaches for addressing the issue:

• Invasive techniques – trigger point injections and/or dry needling.
• Noninvasive techniques – NMTs, muscle energy techniques (METs), myofascial/soft tissue release (STR), massage therapy, cross fibre friction.

 
The most effective way of treating and alleviating TrPs would include a combination of techniques from the list above and the client’s preference. An approach focusing on NMTs may look like this but is by no means the only approach:

• Identify the location of the active TrP.
  • Usually, TrPs are easy to identify while performing deep slow friction and massage strokes.
  • Using palpation and client feedback the most painful area can be identified.
  • Reference charts with mapped TrPs are also a very helpful tool.
• Briefly warm up the area with effleurage.
• Apply progressive, horizontal, penetrating pressure to the centre of the TrP using (reinforced) fingers, (reinforced) thumb, or elbow.
  • It is important to avoid any abrupt, forceful or jarring pressure.
  • It needs to be applied slowly and increased progressively to allow time for the underlying tissues to respond and alter.
  • The pressure may be uncomfortable but must stay within the client’s pain tolerance, ideally reaching a level of 7 or 8 out of 10. The pressure must be firm enough to be between ‘strong’ and outright ‘painful’.
• Sustain the pressure for up to 90 seconds or until there is a noticeable decrease in the discomfort reported by the client and a corresponding softening of the tissue.
  • If the TrP is particularly painful or tender, the pressure may need to be increased gradually as the client’s discomfort diminishes. Therefore, effective communication with the client is essential.
  • Given that the outbreath triggers the relaxation response of the body, it is helpful to invite the client to deepen their breathing and lengthen their exhalation. This is also the ideal time for increasing the pressure if necessary.
• Withdraw the pressure.
  • One piece of advice is to withdraw the pressure slowly in order to allow the underlying tissues time to adapt.
  • Another line of reasoning suggests withdrawing the pressure rapidly to maximise the intensity of fresh blood inflow in the area to effectively restore normal circulation.
• Complete the protocol with effleurage to flush the released toxins and stretch the muscle to its normal resting length.
  • This final component is essential as otherwise there is likelihood the TrP will build up again.

 
Some technical considerations when applying the described NMT include:

• It is advisable to make contact with the client in other places while pressuring a TrP. For example, the fingers of one hand can be used for support and additional sensitivity around a thumb used as the primary medium.
• When applying pressure with the elbow, the other hand can be gently wrapped around it. This prevents the likelihood of slipping and finetune the positioning of the olecranon.
• Creating a relaxing environment for his intense experience is essential. Speaking in a calm and reassuring manner, encouraging the client to prolong their exhalation and using effective body mechanics are all important in this regard.  

 
As previously stated, including additional techniques will make the release of TrPs more effective.
 
In conclusion, be mindful, notice the build-up of tension before it develops into a TrPs. If you get one or a few, don’t worry. A capable soft tissue therapist would be able to help you resolve them.