New and precise assessment and treatment techniques can enhance the overall well-being of your clients.
Osteopath and physical therapist Jean-Pierre Barral, DO, MRO(F), RPT, developed the Neural Manipulation technique. Together with his colleague, Alain Croibier, DO, Barral teaches manual therapy principles for creating freedom of movement within the nervous system.
(As Gail Wetzler, RPT, director of curriculum for The Barral Institute in North America, noted in her forward to Barral and Croibier’s book, Manual Therapy for the Cranial Nerves, “a nerve only functions correctly when it is able to move freely in its surrounding tissues.”)
Correct Neural Fixations
The specificity of the assessment and treatment techniques acquired in the Neural Manipulation curriculum allows you to access neural fixations, determine how they might affect the body both locally and globally, and then correct the dysfunction.
To this end, knowing your anatomy is essential. As Barral said, “It requires skills, but also the continuous pursuit for anatomical knowledge.”
Let us consider the following two questions along with the answers, as an exercise in understanding how your knowledge of anatomy will grow with Neural Manipulation:
Question: What do the knee joint capsule, the hip joint capsule, the sacroiliac joint, the adductors of the hip, pectineus, the ovary, and the popliteal artery all have in common?
Answer: The obturator nerve
The obturator nerve, arising from L2-4, has both a sensory and motor component that can affect or be affected by the structures mentioned above. An inflamed ovary in pubescent girls can compress the obturator nerve that passes behind it, causing medial knee pain.
This is often mistaken as pain from chondromalacia patella. Osteitis pubis is frequently diagnosed when the real perpetrator is compression of the obturator nerve somewhere along its length. A few items to consider in our assessment and differential diagnosis of the compression are viscera, a vertebral joint, a disc or fascia.
Question: What do the pleura, the parietal peritoneum, the capsule of the liver, the gall bladder, the subclavian muscle, the pericardium, the capsule of the shoulder joint and C4 all have in common
Answer: The phrenic nerve.
We take approximately 24,000 breaths a day. Our heart beats 120,000 times per day. The phrenic nerve is intimately involved with the function of these vital structures.
While the phrenic nerve is motor for the diaphragm and the subclavius muscle via the subclavian nerve and joins motor slips to the shoulder joint capsule, it is sensory for parietal peritoneum and pleural irritation.
This means that any lack of mobility in these structures could promote chronic spinal restrictions, muscle tension and should be considered when assessing frozen shoulder syndrome.
The key in Neural Manipulation is to find the most significant area of reduced mobility. According to Barral, mobilizing a nerve focuses on facilitating neural glide both in terms of its surrounding extra neural tissue, and intra neural connective tissue layers. This distinguishes his work from simple neural stretching.
We must consider the fascial rings and tunnels in which nerves exist, and restore the slide of the nerves within these structures to enhance their function. Our goals involve the following:
- Achieve overall balance in the nervous system. As the peripheral nerves are an integral part of a reciprocal tension membrane system enclosing the entire nervous system, an imbalance in the tentorium can be the underlying tension causing SI joint problems or a trigeminal nerve restriction can, over time lead to sciatica.
- Achieve extra neural mobility. Here we want to restore the slide and glide of the nerve and remove compression on the nerve imposed by the anatomical environment. Even mild compression can affect the health of the nervi nervorum and vasa nervorum supplying the nerve.
- Normalize the intra neural environment. This can be achieved by Step 1 and Step 2 above or by releasing specific intra neural pressure congestion, keeping in mind that a nerve hates compression and loves elongation.
- It is important to avoid increasing nociception at all costs. Pain receptors called nervi nervorum (nerve to the nerve) and the vaso nervorum (vessels to the nerve) are located in the intra neural connective tissue environment. Barral has said of neural palpation, “You think you are light. You are still not light.”
We must as manual therapists consider the relevance of the composition of a peripheral nerve. The connective tissue layers are the endoneurium, perineurium, epineurium and mesoneurium (blood supply).
Anatomically, a nerve is like a part of the brain sitting in the leg or the arm. If you look at a transverse section of a nerve you will see the continuation of the pia mater in the endoneurium, the arachnoid layer in the perineurium, the dura mater in the epineurium. This is why precise manipulation of the central or peripheral nervous system will have far-reaching results.
Mastering this work takes time, focus and dedication. As mentioned, the efficacy of your treatment depends on the accuracy of your assessment and the specificity of the application of gentle manual forces in three dimensions to promote the health of the nerve tissue and relief of restriction in the body. There can be an immediate response to treatment or a response that becomes apparent over several weeks as the body unravels a long-standing restriction.
I was introduced to Barral’s work in 1990 and cannot imagine my practice without these manual therapy tools. It is exciting, rewarding and challenging work. Neural, visceral and vascular manipulation will test your knowledge of anatomy and inspire you to learn more.
The Next Step
I leave you with these questions: How might the restriction of the superficial peroneal nerve be related to a sprained ankle that never fully resolves? Or equally, can an ankle sprain that heals in the position of injury, exert a pull on the entire neuromeninges?
If you don’t know the answers to these questions and feel your interest piqued, Neural Manipulation could be a rewarding next step on your massage therapy career.
Become Certified in Neural Manipulation
Jean-Pierre Barral, D.O, MRO(F) (France) is renowned for the research and educational curriculum offered through the Barral Institute.
His Visceral Manipulation, Neural Manipulation and Vascular Manipulation courses are taught in North America and in more than 60 countries by himself and a team of certified instructors who complete a rigorous training program with Barral.
He has held the positions of director (and faculty) of the Department of Osteopathic Manipulation at the University of Paris, School of Medicine, in Paris, France, and chairman of the Department of Visceral Manipulation on the Faculty of Medicine Paris du Nord.
Advanced Study in Neural Manipulation
The coursework in Neural Manipulation is extensive. It comprises of five course levels, each lasting three days:
- Neuromeningeal Manipulation: An Integrative Approach to Trauma and Whiplash
- Peripheral Nerve Manipulation of the Upper Extremity
- Peripheral Nerve Manipulation of the Lower Extremity
- Brain and Cranial Nerve Manipulation
- Central and Peripheral Connections
Each course level highlights detailed anatomy and function of the nerves being studied as well as typical pain patterns that arise from the dysfunction of the nerves.
You will learn specific evaluation and treatment techniques to facilitate normal function of the nerves. You will learn how to release restriction of nerves and the tissue directly or indirectly affecting the mobility of these nerves. You will learn indications and contraindications for this profound work in Neural Manipulation.
You will explore how to practically integrate these newly acquired assessment and manipulation techniques into your treatment sessions.
About the Author
Judy Russell, RPT, is a registered physical therapist. She graduated from University of Toronto in 1978 and currently practices in Vancouver, British Columbia, Canada. She wrote “Neural Manipulation: Hands-On Work to Promote Nerve Tissue Health” for the February 2018 issue of MASSAGE Magazine.