ABSTRACT Jan H. Sultan offers an overview of nerve work from a structural perspective. He describes how the work of physiotherapist David S. Butler and osteopath Jean-Paul Barral, DO, has led the way to understanding the role neural connective tissue manipulation can play in facilitating recovery from many chronic pain symptoms. Sultan maps out some ideas about nerve structure, cranial nerve paths, and the ligamentous nature of some people’s neural tissue. While Jeffrey Burch is also a structuralist, his discussion focuses on giving insight into his process of treating nerves. As a well-studied manual therapy technician and author, Burch has a few thoughtful examples to consider and where to apply caution.
Editor’s Note: This issue’s Caution Column is an article in two parts, two manual therapy experts to whom I asked three questions about what is commonly called ‘nerve work’. For more information about Jeffrey Burch, go to page 72 to read an interview about his life’s work and recent book, Assessment and Treatment Methods for Manual Therapists: The Most Effective and Efficient Treatment Every Time (2023).
The Questions
- Manual therapists include nerve work to effectively decrease people’s somatic disorganization, discomfort, and pain. Is targeting peripheral nerves while doing fascial manipulations to alleviate everyday aches and pains useful? What are the body processes that you think are involved with that efficacy?
- Once a manual therapist has located their neural tissue of interest under their contact, whether it be broad contact with a fascial region or pointed contact with fingertips locating nerve fiber, what caution would you advise practitioners to keep in mind?
- Can you think of a time when you had direct contact with some neural tissue and took it through specific interventions, and it had an immediate effect or something notable happened in the tissue?
Some Thoughts on Nerve Work
By Jan H. Sultan, Advanced Rolfing® Instructor
T he prevailing information that all of us in the healing arts, from massage therapists to surgeons, were taught is that the neural network is about the transmission of information, is vulnerable to direct pressure, and is easily damaged. We were directed to know where the nerves are, in order to avoid them.
This changed with the publication of David S. Butler’s landmark book, Mobilisation of the Nervous System (1991). Butler, a physiotherapist from Australia, focused his clinical interests on the structural role of the nerve in pain and motion restrictions. It should be noted that Butler and his colleague, Lorimer Moseley, have since moved to the study of how the role of perception of sensation can be addressed as a viable therapeutic avenue of relief. This is especially relevant in chronic pain that endures long after the local healing has happened.
Butler observed that the nerves are a structural element. As they traverse the body, they follow the arteries and veins, and lie in the septa. They also change levels and go from skin deep to penetrate muscle, deep fascia, and periosteal tissues on their respective pathways. The nerves are wrapped in a connective tissue sleeve. This element has implications in the various motion restrictions we find in the body. The nerve can act as a ligament and influence both contour and range of motion. Butler’s initial techniques were direct in nature, approaching the nerves as restricted elements, and using a ‘pin and pull’ approach to normalize them.
For example, when treating hand pain, we would anchor the radial nerve above the lateral condyle of the humerus, and then extend the forearm, perhaps pronating and then supinating it while bending, to induce long-axis stretching of the nerve. This is basically a direct technical approach. This can be effective in relieving extremity pain but, if applied too vigorously, may cause microbleeds in the local circulation around the nerve. This might lead to later scarring and restriction as an iatrogenic effect, so delicacy and care are needed in application.
Nerve work also appears in osteopathic practice. I don’t know the genesis of this branch, but Jean-Paul Barral, DO, developed a unique approach to nerve manipulation (Barral and Croibier 2012, Barral and Croibier 2013). In his approach, the nerves are contacted by palpation with a listening touch, the object of which is to induce a motile response. This can take the form of an unorganized wiggling or a long-axis pulsation, followed by a tone change and apparent normalization of the state of the nerve. A ‘troubled’ nerve can have a turgid feel and reduced motility. This is contrasted to ‘happy’ nerves that are softer and more challenging to palpate.
Between Butler and Barral’s approaches lies a range of what we see as ‘nerve technique’. Essentially, it is the old gross-to-esoteric spread or direct-to-indirect. Rolfer®-Chiropractor Don Hazen (1944-2011) furthered the integration of nerve work into structural integration through his study of chiropractic neurology (1999a, 1999b, 2005, 2008). Jonathan Martine, Certified Advanced Rolfer, Rolf Movement Practitioner, and continuing education instructor, has integrated Barral and Hazen’s inquiry into his own system of nerve work and teaches these ideas in his courses.
Nerve Structure
A couple of thoughts on nerve structure. Cranial nerves exit the confines of the skull through cavernous foramina, and some of the functions they supply include vision, olfaction, and facial expressions. On their extracranial journeys, they will pass inferiorly through distal tissues to the cranium and often travel along vascular structures. The brainstem extends into the space of the upper two cervical vertebrae and has the nuclei of the (famous) Vagus, as well as the glossopharyngeal nerves, among others.
Most cervical nerves have nuclei in the spinal cord and ramify through the foramina between vertebrae. Note that the axons of these spinal cord-based nuclei are continuous to their dorsal rami. They are not chains of connected nerves. By example, a brachial nerve that has its root in the spinal cord will terminate in the hand. On its way to the hand, it may change depths often. Usually there is a touch ring where the nerve traverses these depth changes, and this can often be a choke point, restricting the nerve. These ‘grommets’ can be the most accessible treatment points, although a nerve can also be contacted anywhere along its axis. Like I’ve already stated, a troubled nerve can have a turgid feel, like al dente spaghetti, and be easy to find. A happy nerve will be softer, and more difficult to locate.
Also note that in addition to the cranial nerves being intracranial, they ramify into the body cavity and have visceral regulatory functions via autonomic prevertebral trunks. This feature is the basis of chiropractic theory, which states that some organ problems are generated from nerve motion restrictions at the intervertebral levels. And by theoretical extension, chiropractic theory holds that health can be restored by mobilizing these restrictions. Probably not wholly wrong, although simplistic, considering the complexity. On a corresponding note, the hand pain that is the symptom may not be from a local problem in the hand but a motion restriction along the course of the axon or in the associated vertebral segment.
As the nerves are wrapped in a connective tissue sleeve, this may have some bearing on the larger motion restrictions we find in the body. The nerve can act as a ligament. Nerves generally do not like to be pushed around and prefer to be mobilized by motion induction and more subtle interventions. The pin-and-pull approach can work in the client’s favor, but if the ability of the nerve to respond is overrun, it can go into a defensive contraction and defeat your therapeutic efforts, if not compound the problems.
To include nerve work in your therapeutic ‘toolbox’, it is incumbent that you learn the anatomy of their origins and distribution. This mapping will deepen your understanding of peripheral pain symptoms and their potential origins. It takes a lot of practice time to bring nerve work into your manual therapy practice, and the potential therapeutic benefits are worth the trouble.
Jan H. Sultan’s initial encounter with Dr. Rolf was in 1967 as her client. In 1969, he trained under her. In 1975, after assisting several classes, Rolf invited him to become an instructor. After further apprenticeship, she invited him to take on the Advanced Training. Over the next ten years, Sultan taught several Advanced Trainings with Peter Melchior (1931-2005), Emmett Hutchins (1934-2016), Michael Salveson, and other faculty members, collaborating on refinements to the Advanced Training. Sultan currently teaches Basic Trainings, continuing education, and Advanced Trainings for the Dr. Ida Rolf Institute and continuing education to the extended structural integration community. He feels strongly that his responsibility as an instructor goes beyond simply passing on what he was taught; it also includes the development of the ideas and methodology taught by Rolf.
References
Barral, Jean-Pierre and Alain Croibier. 2013. Manual therapy for the cranial nerves. North York, ON: Elsevier Canada.
___. 2012. Manual therapy for the peripheral nerves. North York, ON: Elsevier Canada.
Butler, David S. 1991. Mobilisation of the nervous system. London, UK: Churchill Livingstone.
Hazen, Don. 2008. Peripheral nerve work – compare and contrast. Structural Integration 36(1):24-25.
___. 2005. Short legs and the neurology of posture. Structural Integration 33(3):11-13.
___. 1999a. Don Hazen’s neurological notes. Rolf Lines 27(3):13-14.
___. 1999b. Windows into the neuraxis. Rolf Lines 27(3):29-33.
First Barrier Engagement
By Jeffery Burch, MS, Certified Advanced Rolfer®
There are many different methods of working with peripheral nerves currently used in manual therapies. I can only speak to the methods I use. I will describe the way I work, and a method I have found to be highly effective at reducing pain and improving mobility and alignment.
The question being asked here is, “Is targeting peripheral nerves while doing fascial manipulations to alleviate everyday aches and pains useful?” It is important to recognize that macroscopic nerves have lots of connective tissue in them. By the current use of the term ‘fascia’, nerves are part of the facial network (Stecco and Schleip 2016).
For clarity, I object to broadening the use of the term fascia to include all connective tissue. On the one hand, this use of the term fascia emphasizes the continuity of all connective tissue in our bodies. On the other hand, this use of the term blurs the anatomic and structural differences between various parts of the connective tissue continuity. Rather than referring to all connective tissue as ‘fascia’, I would prefer a term such as ‘the connective tissue matrix’ to describe the whole and leave the term fascia to refer to certain membranes.
That said, each macroscopic nerve is 50% to 90% connective tissue. Each neuron has a sheath of connective tissue that serves, in part, as insulation, preventing cross-talk between neurons. Additional connective tissue provides structural support as part of each nerve.
For mechanisms of action, I can say that the way that I work with nerves restores the elasticity of the nerve itself and also the elasticity of the loose areolar tissue surrounding each nerve, thus improving the nerve’s ability to glide through adjacent tissue. Exactly how this improvement happens at a micro level within the tissue remains unknown. Several mechanisms have been proposed, and none as yet proven. I anticipate that several mechanisms will be found to contribute, rather than a single mechanism of action.
The way I usually work with nerves is called the ‘source and target method’ (Burch 2023). This method uses two long lever handles on the ends of a nerve. This effectively and safely treats the nerve without ever touching the nerve. One handle is the bony segments the nerve emerges from, either spinal or cranial. The other handle is the tissue the nerve supplies, the muscles and/or organs. From these two handles, bone to tissue, a first barrier engagement is made and maintained during a flossing process. This concurrently improved the elasticity of the nerve and the elasticity of the loose areolar tissue surrounding the nerve. This process is described in more detail in the example in the next section.
In manual therapy, the terms direct and indirect have a remarkable diversity of meanings. Using the definition where direct means working locally right on a structure and indirect means working through other tissues from a distance, we see ‘direct’ as synonymous with the ‘short lever technique’ and ‘indirect’ as synonymous with the ‘long lever technique’. In this sense, the source and target method is indirect, specifically a double-long lever technique.
An Example
Here is an example. The ulnar nerve is described as emerging from the C8 and T1 segments. This anatomical description is, however, approximate. In each individual, there may be contributions to the ulnar nerve from C6 to T3. Recognizing this anatomic variability, a broader initial spinal contact is necessary.
Begin by passively testing the mobility of the wrist, elbow, and shoulder joints.
Have the client lie supine. To work with the right ulnar nerve, sit on the client’s right side facing their torso. Place your left hand under the base of the neck with your fingertips placed to monitor low cervical and upper thoracic spinous processes. With the fingers of your right hand, gently grasp the right fifth finger. Gently distract the finger distally. If the nerve has a normal span, you should be able to distract the finger a little distance before any vertebrae under your left hand moves in response to the pull at the fifth finger. If one or more vertebrae move immediately, that indicates the nerve does not have adequate span. Then let the finger rest to neutral. Now, move the finger gently proximal. If the span of the nerve is appropriate, the vertebrae will not move. If the nerve is strung too tight, taking the finger proximal slacks the nerve and will cause a certain vertebrae to promptly move in a direction opposite to how pulling on the nerve causes it to move.
If these tests show the ulnar nerve to be too tight, move the finger proximal until the vertebrae stop moving. This represents a neutral position. Then, allow the finger to slowly spring back distally until the first hint of vertebra movement is felt. This signals that a first barrier load is established. Now, with your left hand, shift from monitoring vertebrae to controlling the vertebrae that moved in response to your handling of the fifth finger. While maintaining this first-barrier stretch load slowly move both hands in the distal direction. Recognize the first barrier load for the nerve through the tissue adjacent to it as well as the first barrier load along the length of the nerve. Glide the nerve distally until an anatomic limit is reached. Still maintaining the first barrier stretch load on the nerve, reverse direction and glide the nerve proximally. Glide the nerve back and forth several times. The distance between your hands will gradually increase as the nerve elongates; maintain the first barrier load as the distance changes. After several excursions proximal and distal accompanied by increments of release, a broader, more general release will be felt. At this signal, end the treatment episode, releasing your contact on both ends. Promptly retest wrist, elbows, and shoulder joint mobility.
Caution to be Considered
Be gentle. Use only forces at a first barrier level or less. Never obligate the tissue to do anything. Constantly track the client’s moment-by-moment responses to the work. At the slightest sign of distress from the client, lighten your force or stop.
Direct Contact with Neural Tissue
As mentioned above, I seldom work directly on neural tissue. There are, however, occasions when direct contact work is practical. Here is an example: working on the sciatic nerve and associated neural structures.
Observe the client standing and walking, with particular attention to pelvis orientation and to hip flexion in walking. Next, passively test hip flexion. Have the client lie supine. To test the right hip, stand at the client’s right side facing their thigh. Place your left hand on the iliac crest. Use this hand to control the ilium so it does not move as you perform the passive mobility test. Specifically, the ilium must not be allowed to rock posteriorly. Put your right hand under the middle of the calf. Lift the leg at a moderate pace to test hip flexion. Note both the effort required to flex the hip and the end point of the flexion range
Repeat this process on the left side. If one hip can flex less than the other, or if both hips have substandard flexion, consider lack of elasticity and glide in the sciatic nerve as a contributing factor. To assess this, first describe to the client what you propose to do and get their permission. For the right sciatic nerve, stand at the client’s right side facing their hip. Slide your right hand under the lower part of their right hip. Contact just lateral to the ischial tuberosity. Gently sink into the depth of the sciatic nerve. Attempt to stretch the nerve distally. Note its elasticity. Repeat on the other sciatic nerve for comparison.
To treat, sit at the client’s side facing the middle of their torso. Put one hand under the occiput. Place a fingertip of the other hand on the sciatic nerve as for the mobility test. Using the occiput and the sciatic nerve as handles, floss the proximal portions of the sciatic nerve and its roots, together with nerves of the cauda equina, and the dural tube.
After treatment, immediately repeat the hip flexion test. Usually, a marked improvement in hip flexion will be observed. Standing position and walking gait will be similarly improved.
My recent book (2023) contains many ideas like these, all clearly written out for practitioners to expand their toolbox of manual therapy interventions. [See page 72 for an interview with Jeffrey Burch.]
Jeffrey Burch received bachelor’s degrees in biology and psychology, and a master’s degree in counseling from the University of Oregon. He was certified as a Rolfer in 1977 and completed his advanced Rolfing® Structural Integration certification in 1990. Burch studied cranial manipulation in three different schools, including with French osteopath Alain Gehin. Starting in 1998, he began studying visceral manipulation with Jean-Pierre Barral, DO, and his associates, completing the apprenticeship to teach visceral manipulation. Although no longer associated with the Barral Institute, Burch has Barral’s permission to teach visceral manipulation. Having learned assessment and treatment methods in several osteopathically derived schools, he developed several new assessment and treatment methods that he now teaches, along with established methods. In recent years, he has developed original methods for assessing and releasing fibrosities in joint capsules, bursas, and tendon sheaths. He is also beginning to teach these new methods. Burch, as the founding editor of the IASI Yearbook, regularly contributes to it, as well as to other journals. In 2023, he published
Assessment and Treatment Methods for Manual Therapists: The Most Effective and Efficient Treatment Every Time.
References
Burch, Jeffrey. 2023. Assessment and treatment methods for manual therapists: The most effective and efficient treatment every time. London, UK: Handspring Publishing.
Stecco, Carla, and Robert Schleip. 2016. A fascia and the fascial system. Journal of Bodywork and Movement Therapies 20:139-140.
Keywords
nerves; neural tissue; contraindication; mobilisation; pain; connective tissue; fascia; direct technique; indirect technique; nerve structure; nerve sleeve; range of motion; ulnar nerve; nerve flossing; sciatic nerve. ■
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