Guest Post: Neurokinetic Therapy a DPT's Perspective | Modern Manual Therapy Blog

Guest Post: Neurokinetic Therapy a DPT's Perspective



Thanks to Dr. Kris Bosch, PT, DPT, ATC, FAAOMPT, a former mentee of mine from Buffalo, NY who moved to Las Vegas shortly after completing fellowship.



I used to call him "The Muscle Whisperer" due to his extensive continuing education in Pilates, he could get muscles to facilitate like magic! Kris has taken both NKT 1 and 2 and is currently working that and the SFMA into his practice. I asked him to give a DPT's perspective on this particular method of assessment and treatment. Thanks Kris!



Neurokinetic Therapy (NKT) – A DPT’s Perspective

Over the past year or so, thanks largely to social media and the ability to network with colleagues and professionals worldwide, I was exposed to Neurokinetic Therapy. Admittedly, I was initially skeptical of some of the various Facebook and blog post I was seeing from professionals using NKT within their clinical practice. In clinic, my co-worker and I would regularly converse during lunch about things we had read, and our NKT-related conversations usually stated like this: “Hey, did you see the Voodoo post this morning?” “Yep.” (insert head shaking and glances of major confusion here). Treatment focus was zeroing on soleus to restore function of psoas, glute max, & quadratus lumborum resulting in restoration of multisegmental flexion and the patient being able to touch their toes without pain for the first time in months – What??? While this is just a made up scenario for sake of example, it’s not far off from what is reported. So first lesson – evaluate things critically, but keep an open mind, as we never have all the answers and the only thing a closed mind will do is limit ourselves to possibilities or modalities that may benefit our practice and our patients. Fortunately for me, the lack of understand I had of NKT also sparked a fascination which pushed me to attend the level 1 & 2 courses in San Francisco earlier this the year.

What is Neurokinetic Therapy?

Neurokinetic Therapy was developed by David Weinstock, and expert Bodyworker who has been practicing & teaching in the field of Bodywork for over 35 years. He developed NKT while on a journey to solve the age old question that many of us as rehabilitation and wellness professionals eventually end up asking ourselves at some point in our careers: “Why do patients/clients come in with pain, go through a treatment session, leave pain-free or with significant improvement noted, and then return the next week with the same symptoms (often times over and over again)?” Whether you are a Physical Therapist, Chiropractor, Athletic Trainer, Massage Therapist/Bodyworker, or Pilates Teacher, at one point or another we experience this phenomenon. I am not going to go into all of the what, how, and why of NKT in this blog post, but hopefully it will shed some light on the topic. To get many of those details, I would encourage reading David’s book “Neurokinetic Therapy, an Innovative Approach to Manual Muscle Testing.” The book is an excellent read in giving you a more detailed history of where NKT came from, a more detailed explanation of the following key concepts, and an organized framework for performing the manual muscle testing to build consistency in positioning and technique when performing them.

Briefly, NKT is a technique that ultimately looks at compensation patterns from a motor control perspective. Neuroscience tells us that the Motor Control Center (MCC) of the brain in the Cerebellum stores movement patterns, and this occurs in normal development, in response to our repeated habits and activities, or as a result of injury as the body attempts to protect itself and avoid pain. Often times these movement patterns may be faulty or dysfunctional, and pain results from imbalance, overuse, or overloading of tissues, and the site of pain may not even be in the area of the dysfunction, but merely is a result of it. NKT utilizes manual muscle testing to identify and address compensation patterns in which muscles may test weak (or inhibited) and other muscles are forced to work harder and become over active (or facilitated). Another concept looks at the idea of relational inhibition, whereby one muscle when activated results in inhibition of one or more other muscles. Relationships can be found when looking at muscles that are functional opposites (traditionally we think of agonist/antagonist scenario), synergists (as discussed by Shirley Sahrmann as Synergistic Dominence), or along functional fascial lines (good resource here would be Anatomy Trains by Thomas Meyers).

The manual muscle testing in NKT can be looked at as the key to unlock the MCC to elicit lasting change in movement patterns. The MCC is open to learning most effectively by failure, that is, you perform muscle testing and find a muscle that is inhibited. The lack of a successful outcome (ie a ‘strong’ test) engages the MCC which now has a window of opportunity to learn from the failed muscle test. It is attention to the motor control component which is often missing and drives the question posed above about why treatment effect does not stick. Take neck pain for example; upper traps & levator are tight, occipitals and paraspinals are tight, soft tissue is generally all tender to palpation and of increased tone. Traditionally what is done? Soft tissue work to release the occipitals, paraspinals, traps, levator; stretch the traps & levator; posture correction, cervical retractions, you get the idea. You’ve treated the tissue and that patient feels better, but in a short period of time the posterior chain becomes tight and painful, maybe even worse that it was prior to treatment. From another perspective, maybe those tight & hypertonic muscles did not need to be stretched and released because they were tight, but because the were facilitated and attempting to provide stability because the cervical flexors are inhibited. Maybe there is something else in the chain causing inhibition of the cervical flexors which again forces the posterior chain to work excessively hard. This is just part of the NKT thought process.

It is also important to recognize that the MMT is not utilized in the traditional sense of strength testing and rating on a 0-5 point scale as I had learned in PT school using the Kendall & Kendall method. Teaching of MMT in our University DPT programs may be a future blog topic, as I am seeing most of our students come through and perform a static isometric break test in which they basically load the limb with a ton of resistance and I watch as the patient holds onto the table, grips and braces with all of their might, holds their breath, and grimaces like a power lifter – and the student gives them a 5/5. The testing in NKT is done very lightly, and it’s a key into the nervous systems response, either it activates or it does not. Again, more on this in David’s book, and the best way to understand this is by going to a course and getting it in your own body! It’s really not something to be learned by reading, but rather by doing (and no disclaimer needed, as I do not have any ties to promoting the courses other than I believe in the work!)

Initial Experiences and Clinical Application

So the next question is, "Who can you use NKT with?", and "How do you use NKT in the clinic?"  This is a technique that can be utilized with almost anyone, from young to old and sedentary persons to professional athletes and dancers. It has been fun to utilize with our athletes to correct movements in their workouts or address acute & chronic injuries, as well as with our general orthopedic patients. NKT can be used a variety of ways, and really depends on the practitioner. Some use NKT & Manual Therapy primarily, with a little corrective exercise to reinforce and reeducate. I personally like using the FMS/SFMA as a movement screen. This then gives me an idea of where to target treatment and focus manual therapy and correctives, and NKT becomes a bridge between the assessment & treatment. It is an assessment in that it helps identify the relationships and compensations in muscle balance (inhibition/facilitation) and has manual therapy built into part of the NKT reset. You can then retest your top tier SFMA after treatment and see where you stand and what effect your intervention had. Dr. E has had prior blog posts on The Manual Therapist Blog discussing the necessity of having a system. The beauty with SFMA and NKT is that as you get comfortable and proficient in the system and working outside the box & in the grey area, change in your patients happens quickly. A colleague gave me a statement equation earlier in the year which said: SFMA + NKT = Game Changer! My response at this point would have to be: #Agreed #DrinkingTheKoolAid. Again, this is just how I am using it and I am still very much ‘green’ in this process.

Criticisms of NKT

I have heard a few grumblings recently about the lack of a literature base surrounding NKT, about the subjectivity of MMT and its lack of usefulness clinically or functionally, and that it does not make sense anatomically based on the relationships being explained. My response to all of this in no particular order is: Again, NKT is not utilizing MMT in the traditionally taught manner, otherwise I would agree with the subjectivity criticism as the difference and relevance of a 3+/5 versus a 4-/5 and the reliability of that methodology is questionable. Fascial relationships and connections are being studied more and more and understoos; once we get out of the very localized micro view of origin-to-insertion of a muscle defining its function, we can then appreciate how truly interconnected the body is. As for a literature base, most techniques and methods start by extrapolating from other disciplines and sciences as a way to explain and justify what is happening in that technique. The technique is refined, applied, and utilized in the clinic and can then be studied in an effort to build a body of literature around it. It is up to us as clinicians and professionals to become more involved in this process rather than waiting for our colleagues in Academia to get to it. I was fortunate to have a great Mentor and excellent Researcher, Academic, & Clinician as the director of my OMPT Fellowship program who stated that “What works in the clinic often pre-dates the research by at least a decade.” My challenge would be to take a course, then make a formal stance on effectiveness and relevance.

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Great post Kris! Also good to have both pluses and minuses of NKT and thoughts from someone I know very well! Best of luck with your new practice. Be sure to like Kris' facebook page and I will be posting links to his blog as soon as it gets off of the ground!


4 comments:

  1. Any evidence for this in a controlled study? I wonder what the physiological basis is? "Anatomy trains" are unproven. All I can think of is Vladimir Janda's theories of shortened muscles firing first, out of sequence, with goal being to restore the proper coordination of muscles firing. But he did not emphasize static muscle breaking tests but rather palpation of muscles firing in or out if sequence with movement. There's no evidence still that pain can be attributed directly to muscles firing out of sequence.

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  2. No evidence, just a lot of cases being posted on their facebook pages. The patterns do not make sense to anyone who has not taken the courses (including me!)

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  3. Kristopher D. BoschNovember 6, 2013 at 11:39 PM

    No there are no hard studies yet with NKT™, so from an EBP perspective you are left wanting...The purpose of NKT™ is not just muscle sequencing as in poor timing or altered order of muscle activation. It looks at a muscle activate or not, playing on the lines of inhibition versus facilitation. If a muscle is inhibited, something else is likely going to take up the job of the inhibited muscle, especially in high level movers who have a lot of compensation strategies at their disposal. NKT™ is simply one tool to assess and target your manual intervention. Also, Janda's approach is not simply short versus long and which fires first. He did discuss the idea of inhibition back in the 1960's, and the DNS approach is growing, as are other movement based approaches like the SFMA & PRI.

    I do get that EBP matters, and I strive to use it as much as possible. However, I do acknowledge the idea of "Science-based" versus "Evidence-based." It's only Evidence-based when someone does the research and gets it published. I honestly say that I do not foresee there being much hard research on this anytime soon, mostly due to the difficulty that exists in creating a methodology that is qualitative and be performed in a protocol with every patient receiving the same treatment, as most requires. Best you will get are case studies, and you may just see one from me if I can get one accepted for publication.

    Anyhow, I am by no means giving NKT™ a 'bye' in relation to requiring and evidence base, I just think (as I said in the blog post) that we are not there yet, that doesn't mean it shouldn't be used and tested in the clinic. And yes, Dr. E -- you may need to take the course to get how the patterns work, and if we finally host your course here in Vegas I will show you on you! Cheers!

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  4. You're on Kris! Excited to get back to Vegas next year!

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