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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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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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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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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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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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“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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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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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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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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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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“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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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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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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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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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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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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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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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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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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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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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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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.

31


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'?

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