Neurovascular therapy

Aaron DriverDoctor of Physiotherapy

What is it?Neurovascular therapy is the act of assessing the vascular

component of the human body in order to identify vascular insufficiency, vascular inextensibility and autonomic neurological signs and symptoms.

The idea that there are possible vascular dysfunctions that affects the autonomic nervous system especially, the sympathetic and possibly parasympathetic branches grew from clinical observation with complex pain patients demonstrating sympathetic overtones during treatment.

Resistance to treatment had to have some pathogenic process that has not been identified in western medicine... So where did it come from?

The vascular tree of the human body!

Clinical observationsDuring a treatment session I usually will methodically

and meticulously assess the neurological system using principles of neural mobilisation described by Butler and colleagues, then I will assess the myofascial slings, chains and trains described by Meyers and colleagues, possible trigger points located in soft tissue as described by Travel and Simons, unusual functional vertebral complex regions, I also assess the cranio sacral rhythms to identify rhythm insufficiency. All these things are integrated into ancient principles that our ancestors left for humanity to prosper in good health and longevity from the gift of Buddism our ancient and wise enlightened guide.

The results are amazing greater than 90 percent of patients will benefit from treatment, however what about the 10 percent.

Is it simply a matter of they cannot be helped with physiotherapy, osteopathy, chiropractic or any other alternative treatment? Could it be that their answer lies in the pathoanatomy and require surgical or injection intervention? Absolutely... but does that mean that we cannot ease their pain and suffering until surgical intervention is available. Waiting times can be a long process and patients need some sort of intervention that will help them during these difficult times.

However, some patients may not respond favourably to surgical and or injection intervention, these poor souls may only be 1 - 3 percent of the population but hey... they deserve help just as much as anyone else. It is not good enough to settle for less, and dismiss their pain and suffering as malingering and/or hypochondriac episodes.

So with these issues at hand, autonomic overtones that were elicited with manual therapy came to my attention during treatment sessions with chronic patients, especially symptoms such as; burning hot and cold zones, changing phenomena such as trophoedema, hyperhidrosis, allodynia, hyperalgesia, vasomotor dysfunction and neuropathic symptoms such paresthesia, numbness and weakness that have no dermatomal, sclerotomal or myotomal patterns.

I researched the involvement of the autonomic nervous system in chronic pain and came across articles describing sympathetic fibres that flow into the upper and lower limbs along neurovascular tracts, with slips that then flow along vascular vessels into the superficial fascia through arterioles that pierce the deep fascia called neurovascular points before forming vascular beds in the cutaneous membrane of the skin. These cutaneous zones are called angiosomes.

Fasciocutaneous and myocutaneous pedicles Further research investigating the anatomical neurovascular point demonstrated

perforating vessels that directly flow to the skin called cutanee directe vascularisation and indirect flow through intermuscular fascia through the deep fascia called septo-cutanee vascularisation and vessels that flow through muscles called musculo-cutanee vascularisation. (lambeaux)

The direct vascularisation comes from dorsalis pedis, superficial circumflex iliac artery, the superficial and deep portions of external pudendal artery, superficial inferior epigastric artery, and superficial superior epigastric artery, thoracodorsal artery, the anterior intercostals branch of the internal thoracic artery the occipital artery, posterior auricular artery, supraorbital artery supratrochlear atery the parietal and frontal branches of the temporalis artery and the parietal branch of the superficial temporal artery. (lambeuax)

The myocutaneous indirect vessels send cutaneous vessels from the abductor hallucis, gastrocnemius, hamstring muscles, vastus lateralis and vastus medialis muscles, rectus femoris muscle, gracilis and tensor fascia latae, rectus abdominus and external oblique gluteus maximus and latissimus dorsi, pectoralis major, trapezius and platysma muscles, finally the anterior and posterior deltoid muscles.

The fasciocutaneous or septocutaneous branches arise from the posterior tibial artery, medial plantar artery, calcaneal branch of the fibular artery, posterior and anterior tibial artery, fibular artery, superficial sural artery and saphenous artery the femoral artery and profunda perforators, the radial and ulnar arteries, the brachial artery, the profunda brachii branch aof the radial artery, the posterior interosseous artery, the vertical and horizontal branches of the circumflex arteries.

Vascularisation neuro-cutanee ou perforatorsVessels that flow juxtaposed with the nervous system called

vascularisation neuro-cutanee ou perforators send vessels from the anterior and posterior tibial artery, peroneal artery, anterior lateral thigh and anterior medial thigh , the perforator branch of profundus femori artery, the perforator branch of the deep inferior epigastric artery, the perforator branch of the superior epigastric artery, the perforator branch of internal mammary artery, the perforator branch of supraclavicular artery, the perforator branches of inferior and superior gluteal artery, the perforating braches of the lumbar artery, the perforating branch of the thoracodorsal artery and the perforator branch of posterior intercostal artery, the perforator braches of radial and ulna artery, the perforator branch of posterior interosseous artery and the perforator branches of the metacarpal artery.

AngiosomesVessels form vascular territories called

angiosomes, (Taylor) divided by a fascial plexus. Each angiosome has its own direct flow from a perforator vessel, however adjacent angiosomes have choke vessels that communicate with each vascular territory.

Artery and arterioles are composed of the tunica intima, internal elastic lamina, tunica media, external elastic lamina and tunica externa. A connective tissue sheath called the tunica adventitia acts like the superficial fascia and forms a fibrous layer that glides over the tunica media which is composed of smooth muscles fibres and regular connective tissue much like the deep fascia over muscle. Normal healthy artery and arterioles should demonstrate elasticity and compliance when stretched which is required with movement of the human body.

When adhesions develop or swelling impacts on the tissue loss of normal elastic and compliance properties is noted and reflected in the loss of gliding seen in the angiosome and also in joint arthrokinematic and osteokinematic function.

Assessment protocol

Pulse reading is taken from the temporal and facial artery just in front of the ear and on the line between the corner of the mouth and angle of the jaw bone , auxillary artery just above the coracobrachialus muscle within the armpit, radial and ulnar artery at the wrist, as well as the within the snuff box of the wrist, the brachial artery at the medial intermuscular septum, the external carotid artery at the superior medial border of sternocleidomastoid muscle, the apical pulse between the 4th and 5th ribs just outside the mid clavicular line, the inferior epigastric artery below the navel, the femoral artery at the inguinal crease, the popliteal artery in the posterior capsule of the knee, the tibial artery at the posterior aspect of the medial malleolus, dorsalis pedis artery between the 1st and second rays over the junction of medial and intermediate cuneiforms or between the metatarsal bones .

The pulse is measured in minutes and compared. A healthy reading should be identical between pulse readings across the body in a 1:1 ratio, abnormalities are demonstrated with slower pulse readings between points. With mild 1:2, moderate 1:3 and severe 1:4 and emergency 1:5 ratios.

Pulse points are also noted with pressure applied over the articular capsule of the proximal joint or with regular blood pressure readings with inflated cuff.

Two point differentiation is applied between pulse points assessing the stiffness and pulse rhythms between the two pulse points.

Neurovascular points from direct pedicles are assessed for oedema and stiffness, and then compared to the relevant pulse points and associated direct pedicles.

Neurovascular points from indirect fasciocutaneous pedicles are assessed for oedema and stiffness and then compared with pulse points, associated direct pedicles and fasciocutaneous pedicles.

Neurovascular points from indirect myocutaneous pedicles are assessed for oedema and stiffness, and then compared to the relevant pulse points and associated direct and fasciocutaneous pedicles.

Comparison between neurovascular points will demonstrate either the qualities of compliance and elasticity or rigidity and stiffness, be aware of pulse rhythms that conducted between the two points of concern, you should feel the normal pulse frequency of 10Hz which is related to the systolic pressure and other frequency overtones which may be faster or slower at shorter or longer intervals.

Ask the patient for conformation and awareness of pulse rhythms by a asking the open ended question; what do you feel? This allows the patient to interprete what they are feeling attuning their interoception with their consciousness. Allowing the patient to express their awareness of signs and symptoms they are feeling.

Angiosomes are palpated for fascial alterations, loss of elasticity and compliance between two angiosomes will alert the therapist of vascular insufficiency.

Normal pulse readings have no overtones and have clear pulse rhythms related to systolic pressure.

Healthy neurovasculature have no identifiable swollen neurovascular points over the body.

Healthy vasculature have no loss in elasticity and compliance between two points within an angiosome.

Anything else is considered abnormal and requires treatment to resolve the issue. 

This is an exciting proposal and I am happy to share this knowledge with the world in order to develop further treatment strategies that are required for helping those in pain and suffering.

 Please E- mail aaronjdriver@yahoo.com.au for further

information and proposals to conduct further investigations. Or visit my website www.goldcoastphysiotherapy.org

  Kind Regards... In lak ech  (Aaron Driver) Doctor of physiotherapy