The Massage Therapist’s Guide to Neuromuscular Therapy

Neuromuscular therapy is a manual therapy for pain management, rehabilitation and prevention. 

It is a treatment for myofascial trigger points, which are small contractions in muscle fibers that cause pain, weakness and discomfort in a referred area.

In the right hands, neuromuscular therapy is a highly effective treatment for chronic pain, muscular trauma resulting from an accident or injury, or strain caused by overuse.

The Massage Therapist’s Guide to Neuromuscular Therapy will cover what neuromuscular therapy is; protocols used to examine and address soft tissue; benefits for clients and therapists; research; neuromuscular therapy education; where a massage therapist trained in this technique may practice, and how to build clientele with neuromuscular therapy.

What is Neuromuscular Therapy?

Neuromuscular therapists are highly skilled in muscle anatomy, connective tissue work, trigger point therapy and manual therapy. The goal of neuromuscular therapy is to reduce pain, discomfort and stress in the body by using precise manual techniques that maintain relaxed and lengthened muscles.

Neuromuscular therapy first appeared in Europe in the mid-1930s. In the 1950s it emerged in the U.S. with the work of Raymond L. Nimmo, DC, a chiropractor who conceptualized the trigger-point phenomenon in soft tissue manipulation.

Nimmo’s work was furthered by Janet Travell, MD (1901–1997), a leader in neuromuscular therapy research who co-wrote, with David G. Simons, MD (1922–2010), the most widely used textbook on neuromuscular therapy, Myofascial Pain and Dysfunction, The Trigger Point Manual.

Travell theorized that the buildup of metabolic waste products in stressed muscle fibers stimulates nerve endings in muscles, which in turn sends impulses through nerve pathways that activate a pain response to a specific area of the body.

Those areas are known as referred pain zones and are theoretically activated by trigger points.

One of the factors that differs neuromuscular therapy from general deep tissue massage is most neuromuscular therapy sessions will focus treatment on the area of discomfort and may not include a full-body massage.

Neuromuscular therapy can be integrated into a full-body massage; however, most neuromuscular therapists find that about half the time of the first session with a client is intake and assessment and the other half is manual treatment.

Once treatment progresses, they are able to integrate neuromuscular therapy with a full-body massage without taking time away from addressing the client’s chief complaint.

Protocols Used to Examine Soft Tissue

Recipe-based massage that teaches a set routine for specific conditions like thoracic outlet syndrome, carpal tunnel or lower back pain is a thing of the past. Today’s neuromuscular therapists are trained to be critical thinkers and problem solvers, said the educators we spoke to for this article.

“It’s not recipe therapy,” said Judith DeLany, LMT, a neuromuscular therapist, educator and director of NMT Center–Neuromuscular Therapy American Version. “It also is not the shotgun method where you treat everything and hope you get the right stuff along the way. It’s not by chance; it’s by being thorough and precise in everything that we do.”

The specificity is what sets neuromuscular therapy work apart from general deep tissue massage. On the spectrum of massage therapy and bodywork, neuromuscular therapy falls on the medical side of massage, and neuromuscular therapists are expected to have an above-average knowledge base of human anatomy and physiology.

The neuromuscular therapy field has evolved in the eight decades of its existence and emphasis has moved to therapists using critical thinking to address muscular dysfunction. The success of a treatment rests heavily on a neuromuscular therapist’s thorough assessment of their client’s pain condition, identification of the muscles affected, and ability to create a strategy to address them.

“It is imperative to have an understanding of a number of possible explanations for a client’s pain and then triage through those potential causes as quickly as possible,” said Douglas Nelson, LMT, a neuromuscular therapist, educator and founder of Precision Neuromuscular Therapy Seminars.

Doing so requires good knowledge of assessment techniques, functional anatomy and palpation skills, Nelson said.

“That’s where the science meets the artistry. Neuromuscular therapy is very science-based, but in that science the artistry emerges because you have to make choices,” said Nelson, added that neuromuscular therapy offers therapists many avenues to treat pain — and when one doesn’t work, they have a plan B and plan C.

This technique requires extensive training and knowledge of the fascial connective tissue system; nervous, skeletal and other major systems; and how they interact with one another. Although neuromuscular therapy therapists will vary in their approach to the technique, a neuromuscular therapy session will generally include the following components:

• Assessment of the client’s condition to develop strategy for pain management with massage therapy.

• Manual massage therapy using neuromuscular therapy and trigger-point techniques.

• Stretching and strengthening training to rehabilitate client within the scope of massage.

• Collaborating with other health care professionals to assist in client’s rehabilitation process.

• Educating clients about their body and teaching them how to alter behaviors that result in or trigger pain.

There are four elements associated with the hands-on aspect of neuromuscular therapy. Those include assessment, positional release, palpation skills and PNF stretching.

Assessment

“The most important thing is that assessment. It is going to help us figure out how to best help the client heal from pain and injury,” said Kirsten Staley, director of training and program development at National Holistic Institute.

In the assessment, a neuromuscular therapist examines a client’s posture and range of motion, and reviews their medical intake form and asks questions — many questions. They perform various muscle tests to identify the source of pain, which can be but are most likely not the muscles where the client feels pain.

Neuromuscular therapy takes a science-based approach to pain resolution by narrowing down the affected areas based on the results of the assessment. Some therapists will know right away what muscles to work based on their experience, but even experienced neuromuscular therapists may find themselves working several areas before finding the trigger point for the referred pain zone.

Positional Release

Positional release, also known as strain-counterstrain, is a passive technique that releases tight muscles and trigger points by putting the muscles in a position of ease and holding it for several seconds before releasing.

This technique is typically used by neuromuscular therapists prior to massage.

Palpation Skills

One of the distinguishable factors of neuromuscular therapists is their exceptional palpation skills. This skill takes time to develop and involves the accuracy of touch.

Therapists trained in this technique are able to palpate muscle fibers and move the hands through the many layers of tissue accurately and without injury to the client. We will look into this further in the next section.

PNF Stretching

Proprioceptive Neuromuscular Facilitation (PNF) is a stretching technique that contracts and stretches the targeted muscle group at the same time. It is widely used in rehabilitation and sports training to increase range of motion, flexibility and strength.

Other types of assisted stretching are also used in neuromuscular therapy. Some states require additional licensing to practice assisted stretching, and in those states neuromuscular therapists can refer clients for further treatment to health care providers specializing in this modality.

Techniques Used to Address Soft Tissue

Palpation skills are what sets neuromuscular therapy techniques apart from general massage. “If you can’t find it, you can’t fix it,” said DeLany.

“Neuromuscular therapy is a very precise treatment that uses soft tissue work to solve very specific problems,” said Nelson. This means being precise down to a millimeter when working on a muscle, Nelson explained. In that same regard, it also means having an understanding of how muscles work together.

“In the simplest way, no one muscle does anything. All muscles work in groups. If you understand who is in that group and understand their relationships, you now have the ability to create an intended effect,” Nelson said.

The consensus among experienced neuromuscular therapists is that an effective treatment rests on a thorough assessment of the client’s chief pain complaint. Without that, the manual therapy itself is likely to be unsuccessful at minimizing a client’s pain.

Once a proper assessment has been completed, the plan of action for the therapist’s manual therapy includes techniques that most massage therapists are familiar with.

“There are no new techniques. What we use are the strategies that massage therapists and other manual therapists use and that have been around for thousands of years,” DeLany said.

Effleurage is applied to warm up muscles before deeper work is performed, as are compression, cross fiber, thumb gliding, separating muscles, wringing and static pressure.

There are more specialized techniques that come from myofascial release therapy, which include myofascial spreading, mobilization and skin rolling. These techniques break up adhesions, restrictions and scar tissue in the connective tissue that can cause pain, reduce mobility and house trigger points.

Neuromuscular therapy is very specific massage. Therapists have a working knowledge of the direction of muscle fibers, the synergist muscle and antagonist muscle. They also understand the kinesiology of movement and how postural imbalances can trigger the stress-tension cycle.

A misunderstanding about neuromuscular therapy is that it is deep and painful work for the client. Manual technique in neuromuscular therapy is not about the amount of pressure used; rather, “it’s about the precision and accuracy of your technique,” said Nelson.

“Our job is to find those areas of discomfort and dysfunction,” he added. “When we find them, the common response from the client is ‘Oh my goodness, that is sensitive,’ followed by, ‘I’ve been waiting years for someone to do that.’”

Experts agree that neuromuscular therapy is not about the kind of deep pressure that causes clients to cringe in pain.

“If you’re going that deep, you’re causing tissue damage,” said Cynthia Ribeiro, BCTMB, an advanced neuromuscular therapy manager and education specialist with National Holistic Institute. She explained that the concept of deep pressure is not from the amount of pressure the therapist applies but rather when a therapist is on a trigger point, the slightest amount of pressure can feel quite deep.

Ribeiro recalls a statement Travell made when she met her. She said the lightest touch creates the greatest response. This shaped the path for Ribeiro to study neuromuscular therapy

work because after years of working hard and wearing out her hands she learned of a method that would allow her to use less pressure in her hands and get a better response.

“You have to have a knowledgeable touch to find what is creating the pain on the client’s body and when you find it, it feels like a deep pressure but you’re not applying much at all,” said Ribeiro.

Benefits to the Client

Continued research in the field of massage and neuromuscular therapy has shown the benefits it has on the body in stress reduction, rehabilitation and prevention of chronic pain.

Neuromuscular therapy is a tailored bodywork session with the goal of reducing pain, rehabilitating connective tissue and promoting well-being in both the body and mind. It is effective at breaking the stress-tension cycle by promoting a parasympathetic response in the body through manual techniques that lengthen and relax muscles and move metabolic waste products, which irritate nerves, out of muscle tissue fibers.

The benefits of neuromuscular therapy for clients, according to the National Holistic Institute’s Staley and Ribeiro, are:

• Tailored sessions. It is a customized massage that targets areas affected by pain or discomfort.

• Goal-specific sessions. Therapists have the client’s goal in mind and the tailored massage is designed to work toward that goal.

• Collaboration with other health care providers. Neuromuscular therapists are considered specialists in pain and rehabilitation in the field of massage. As recognized health care providers, they form relationships with other providers such as chiropractors, physical therapists, yoga instructors, athletic trainers, Pilates instructors and doctors, who refer clients for treatment.

“Manual therapy is one component [of] the overall recovery of soft tissue,” Ribeiro said. “The manual therapy component diminishes the pain but it must be followed up by strengthening and stretching, which is why it is good to collaborate with other health care providers that specialize in that. We can also offer it if we have the knowledge to do so.”

• Pain resolution. Neuromuscular therapists are problem-solvers at heart and use numerous muscle testing, postural analysis and other assessment tools to discover the root cause of the client’s pain and resolve it.

• Client lifestyle improvement. Neuromuscular therapy gets clients back to a healthy lifestyle, doing the activities they want to do.

• Educational. Neuromuscular therapists teach clients about their bodies, how to strengthen their bodies (if doing so is within scope of practice) and be in better physical condition.

• Corrective action. The goal for neuromuscular therapists is to help clients alter behaviors that result in pain.

• Emotional release. Neuromuscular therapy also helps the body release emotional tension that can be repressed by the subconscious mind. Donald W. Scheuman, author of The Balanced Body, A Guide to Deep Tissue and Neuromuscular Therapy, describes this: “As muscle tissues are freed from their chronic gripping an associated feelings surface, the client may experience a loosening of blocked emotions along with the muscular release.

“Depending on the source of the original inhibition, an emotional outpouring can manifest in a number of ways, including crying, laughing, a feeling of great relief or insight regarding the nature of the physical-emotional blockage.”

According to Staley, “The benefit for the client is that we are willing to spend the time with them to bring their pain and healing to full resolution so that it is not lingering for 10 or 20 years.”

Benefits to the Therapist

Massage therapists also benefit from neuromuscular therapy. The principles of neuromuscular therapy are on understanding the body and where pain originates. By releasing those trigger points, massage therapists are able to work more accurately, achieve faster results for the client, and build a rapport with them based on their expertise.

Massage therapists also benefit from the idea of working smarter and not harder to achieve results. This saves their hands from the wear and tear of deep tissue work on areas that don’t need it. Blindly applying deep pressure on tissue that tightens and fights back can injure the client as well as the massage therapist.

“What we found through neuromuscular therapy … is that it is not about how hard you work, it is about how knowledgeable is your touch," Ribeiro said. "Because if you have a knowledgeable touch you know how to place yourself in the proper angle of entrance and find what is creating the pain and discomfort for the client."

Research on Neuromuscular Therapy

Research in the field of neuromuscular therapy and pain management is rich, but it is not the only area in which researchers are finding it beneficial.

A study found neuromuscular therapy had sustained improvement on motor symptoms, including finger tapping and tremors, in patients with Parkinson’s disease and some improvement in mood, a non-motor symptom. Another study cites neuromuscular therapy as a noninvasive and a valid therapeutic alternative to pharmacology therapy for patients with dysmenorrhea.

Women with thoracic outlet syndrome experienced relief for numbness symptoms lasting over a year without additional treatments, according to a study published in the International Journal of Therapeutic Bodywork. The massage protocol included techniques used in neuromuscular therapy.

Research in the field of neuromuscular therapy is progressing and may one day validate the ongoing and expanded use of this technique for average clients and medical patients alike.

Neuromuscular Therapy Education and Certificate

There are several ways to learn neuromuscular therapy and earn a certificate. Find a reputable educator in your area that is accredited, has experience and is approved by the massage board in your state or by the National Certification Board of Massage and Therapeutic Bodywork (NCBTMB).

If there are no local neuromuscular therapy programs, reach out to established educators in the field. Many of them travel throughout the U.S. to teach neuromuscular therapy seminars.

Neuromuscular therapy is typically taught in three-day or weekend trainings that are broken up by region of the body that include: cervical and cranium, shoulders, thoracic, upper extremities, lower extremities, lower back, and ankles and feet.

Depending on the schedule of trainings, Neuromuscular therapy education may take one to two years to complete. The National Holistic Institute, for example, offers an advanced 450-hour neuromuscular therapy massage program that consists of five 90-hour modules.

Learning neuromuscular therapy requires time, diligence and practice.

Nelson said most students successfully integrate neuromuscular therapy into their practice after a year or two.

“Just showing up at a seminar does not mean that you have a deep understanding and can integrate what you learned," he said. "Even if you can pass a written test on the material, that doesn’t mean you can execute it in the clinic."

“It takes time,” Nelson added. “Palpation skills don’t develop overnight; functional anatomy skills don’t develop overnight. It takes a lot of diligent effort to make that happen. It takes reflective practice; there are no shortcuts.”

Build Clientele with Neuromuscular Therapy

Neuromuscular therapy is a field to get into for those who have a drive for solving problems and a curiosity for human anatomy.

For those in the field, the benefits are big. Not only do neuromuscular therapists experience a sense of accomplishment and satisfaction from their work in seeing results in their clients’ lifestyle, they also become the go-to experts for pain relief and are highly sought-after by clients and other medical professionals.

“There is no shortage of people in pain,” Nelson said.

A 2016 Centers for Disease Control report estimated that 20 percent of U.S. adults, approximately 50 million people, have chronic pain, and it is the most common reason adults seek medical care.

Roughly 20 million people within this demographic have high-impact chronic pain, which impacts their lifestyle by limiting the activities and work they can do. Massage therapy is recommended for pain management by numerous research studies in comparison to no treatment at all.

The beauty of neuromuscular therapy for the therapist is they can build a practice specializing in pain management or can offer their expertise to clients in a general practice setting, such as a spa.

Whichever route, clients and therapists both benefit from the additional attention to detail. One client’s experience of walking in with pain and walking out without it is enough to set the stage for future customers seeking the same relief.

Where You Can Practice Neuromuscular Therapy

Aside from offering a targeted population a solution to their health concern, neuromuscular therapy offers an opportunity for massage therapists to work closely with other medical professionals, through referrals and networking. This opens the door to working with chiropractors, orthopedic surgeons and doctors, physical therapists, athletic trainers, sports teams and sports rehabilitation centers, and hospitals.

Having an additional certificate and experience in neuromuscular therapy could place a massage therapist at a more accepted level within the medical community or on an integrative health care team.

Nelson conducted a survey of his graduates and how successful they were at integrating neuromuscular therapy into their practices. “We found that their practices are full to the point of overwhelming, just because so many people are in pain out there,” he said.