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Putting back the "Neuro" in Neuromuscular

I really enjoyed this short case study that Seth Will, one of the PNMT teaching staff, sent me. It is one that therapists will likely encounter on a regular basis. This case exemplifies how understanding neural implications will transform the way you look at your patient’s symptoms and treatment. Enjoy!

Patient “G” had come into my office with complaints of low back pain, mid-scapular pain (mostly left sided), and hip pain (left sided) with extremely “tight” hamstrings. The symptoms of tight hamstrings was expressed by G as she was active and noticed their reluctance to change during stretching and how often the hamstrings were accompanied by a sense of tightening and sometimes painful cramping.

I went through a questioning of all of the standard things that you could imagine pertaining to background of issue. The key factors that seem to arise where the mid-scapular pain seemed to come on more throughout the day, as did the back and hip pain, especially with sitting. She had attempted various exercises and stretching to alleviate the issues; movement would temporarily feel good to do, the results were always short lived and would come back to a continual state of pain or ache depending on the activity and stress of the day.

During the examination, one of the first things we checked was her hamstrings (not because it seemed like a key factor, but G had seemed particularly bothered by the issues she had with them). In assessing range in hamstring length, both sides were restricted (the right surprisingly more so) and gave G the returning sense of the hamstrings “clamping” down and tightening. I first quickly checked for neural involvement in the “tight” hamstrings, but nothing symptomatic showed. I then performed some “neuroreflexive muscular inhibition” techniques taught in the Precision Muscular Mobilization (PMM) class. The range quickly increased and now as hamstrings relaxed and eased into hip flexion and knee extension, G reported that she felt quite a different sensation deeply in her hamstring, through the hip and into the back. Upon further testing, the previously non-existent neural provocation tests had now become active with the relaxation of the hamstrings. This is one of the key lessons learned during this class.


Once the muscular guarding is taken away the nerve symptoms show their true nature. Again quick testing showed all of G’s symptoms to be directly related to neural tension. Now when she extended her knee into a straight leg raise, she was stopped half way by the less tense but now more uncomfortable pull and pain of neural sensitivity. Realizing that the spinal cord needed to be assessed, I had G go through various movements until the way forward became crystal clear. Bending forward (flexion) brought on her symptoms (but only when done repetitively) and bending backwards relieved the radiating symptoms (again, only when done respectively). Identifying these movement preferences and intolerances are key to proper treatment.

We then set to doing spinal extension movements that were adapted to insure that no pain was felt during the movement. This form of treatment was kept up for about 2 to 3 minutes and then I had G sit up to reassess the previous movement intolerances (movements that created the pain she was experiencing). She could now do a pain free and complete hamstring stretch (90 degrees of hip flexion with knee extended) and spinal flexion was more comfortable in all parts of the spine and hip. Treatment time that had elapsed was about 7 minutes. When your hypothesis is correct about nerve involvement, relief can and often should respond that quickly. (PS, the symptoms dramatically improved with these simple movements, but this was the first stage in dealing with other underlying issues of the neural continuum to insure long term results, for instance the tension created from the non-symptomatic right leg neural movement during the hamstring stretch)

Notice that it was movements of the back into extension that actually improved and eliminated the pain of the hamstrings. When considered from a standard biomechanical view, this is completely unexpected; but this is where we need to think neuromechanics. The concepts of compression and tension of neural structures are what is important. To ignore this is to be at the mercy of any nerve related disorder.

You may perhaps think that you do not see many nerve related disorders, but nerve related issues can present exactly the same as muscular issues. The only way of determining is through differentiation testing. Once identified, the principles of treatment are simple, but they are often at complete odds with what a biomechanically inclined therapist would consider. Become a better therapist with truly beginning to understand the “neuro” in Precision Neuromuscular Therapy!

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