The Vulcan Nerve Pinch - Cultural Iconography Anchors the Proposal of a Novel Manual Approach, the Bow-String Technique

International Journal of Complementary & Alternative Medicine

Clinical Paper Abstract The Vulcan Nerve Pinch has a memorable and unique place in the cultural Volume 5 Issue 5 - 2017

to anchor the proposal of a novel technique preliminarily described here. The techniqueiconography may of possess Star Trek. both The diagnostic proposed and Bow-string therapeutic technique implications uses forthis somatic image University of Otago, Dunedin, New Zealand dysfunction in the cervical region. It is based upon the established viscoelastic properties of collagen, in particular time-dependent stress-relaxation. The *Corresponding author: M. C. McGrath, University of Otago, technique is reliant upon a high level of patient-centred engagement and Dunedin, Country Practice Ltd. East Taieri, Mosgiel 9024 New Zealand, Email: co-operative and runs for 2-4 minutes. It theoretically engenders significant intervenes at the contralateral side to a patient’s active muscle effort. It is gentle, Received: October 26, 2016 | Published: February 21, collaginous material change (lengthening) through the stress-relaxation 2017 characteristic of collagen associated with the imposition of a fixed mechanical strain. It is anticipated that the technique may possess a considerably greater persistence of effect when compared with shorter duration, repetitive passive stretch techniques, reliant on patient relaxation.

Introduction human and animal testing, it is unlikely that the VNP will ever be formally tested and future ethical approval in either case seems According to a variety of sources the Vulcan Nerve Pinch (VNP) unlikely given that the procedure has been described to cause the is a rapidly immobilising manual procedure usually performed by

it is nevertheless generally well known. It may therefore serve a horsedeleterious (equus ‘rupture ferus caballus) of nerve has fibers’. been recorded Nevertheless, [4]. In a this pragmatic equine a Vulcan [1,2]. While considered the province of science fiction useful purpose as an iconographic aide memoir, anchoring a novel example,example oftwo the keyVNP differencestechnique applied emerge to when an animal, compared specifically to the a manual technique that may have potential for both diagnostic and application of the VNP technique upon humanoids. First, the VNP therapeutic utility. technique was applied to the horse at a different location, namely The VNP is embodied by the application of manual force to the dorsal caudal aspect of the equine cranium at its junction through digital pressure at a region located lateral to the junction of the head and neck of the target subject. While a similar location humanoids there appeared a rapid loss of consciousness, in the is replicated in the proposed and novel Bow-string technique, casewith of the the most horse cephalad the animal point slowly of theadopted neck. a Second,recumbent whereas position in observation of the VNP suggests that the successful application of and did not appear to lose consciousness [4]. Empirical observation of the multiple applications of the hand-neck relationship [3]. In this way and in contradistinction VNP technique under varying conditions provides substantive the technique does not appear to be reliant upon a highly specific to the VNP the novel Bow-string technique will be shown to be generic information [2], indicating widespread agreement that the junction of the base of the neck with the ipsilateral shoulder is a designated general point of application. However, the precise reliantThere on isspecified a paucity anatomical of data placement.regarding the formal testing of the both manual procedures. In the case of the VNP, empirical anatomical location of the VNP remains elusive. This has led observation suggests that when the technique is applied by Vulcans it appears to lead to dependable and effective immobilisation anatomical structures likely to be implicated. Furthermore, [3]. In contrast, the delivery of the VNP by non-Vulcans suggests whetherto persisting such uncertaintyanatomical consideration regarding the is specific indeed underlyingnecessary considerably diminished reliability and effectiveness [1]. Formal remains moot as it has been alleged that the putative effect may in vivo testing of the VNP procedure by Vulcans on humans seems be entirely psionic [7]. Indeed, it seems established that humans either unknown or undocumented. Whether data exists for in vivo testing between Vulcans also appears unknown as no formal record capability to attempt the procedure with any realistic expectation ofmay reliable not only success lack sufficient [7]. manual strength but adequate psionic

is identified at the Vulcan Academy of Science [5,6]. In the case of

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Irrespective of the precise location or of the alleged effect of nevertheless be drawn to its broad application and position ofthe application VNP technique and inthe science relevant fiction human iconography, anatomy attention of potential may association with cultural iconography to introduce a novel manual technique,clinical significance. referred to The as theaim Bow-string of this commentary technique. is to employ an Regional Anatomical Considerations - A Tale of Two Points Anatomical consideration of the region highlights its underlying complexity. The posterior triangle of the neck is formed embryonically from the division of a single large muscle mass into two muscles, the sternocleidomastoid and trapezius muscles. The posterior triangle is notionally formed within the anterior border of the middle portion of the trapezius muscle, the posterior border the sternocleidomastoid, and has as its base the middle third of the clavicle [8,9]. The posterior triangle is three boundaries are formed by the inner margins of the anterior Figure 1A: superficial to and encompasses the deeper scalene triangle whose rib. Original depiction of .. the location of Erb’s Point and middle scalene muscles, and the superior border of the first Ranney [10] highlighted this region when anatomically relevanceredefining liethe within‘thoracic the outlet’ boundaries as the ‘cervico-axillary of the posterior canal’. triangle, Two described landmarks or ‘points’ of key anatomical and clinical is the observation that the latter point, the Punctum Nervosum doesnamely not Erb’s appear Point coincident and the Punctum with the Nervosum. general application Of iconic interest of the approximated by it. Neither though could be associated with any VNP, though the former point, Erb’s Point, may more closely be attributionErb’s point of the alleged instantaneous ‘effect’.

German neurologist Wilhelm Heinrich Erb, who described it in his Figure 1B: Erb Point: brachial plexus anatomy schematic. 1883Erb’s text Point of electrotherapeutics [11] is an eponymous as, ‘a circumscribedpoint named by point, the eminentabout 2- 3 cm above the clavicle, somewhat outside of the posterior border provides electro- accessibility of C5 and C6 roots, suprascapular of the sternomastoid and immediately in front of the transverse The most superficial location of a portion of the brachial plexus

nerve and nerve to subclavius. SupraS: suprascapular; Subcl: nerve to subclavius; SUP: superior trunk brachial plexus; MID: middle trunk withprocess the of cervical the sixth plexus) cervical [10],vertebra’ corresponding Figure 1A, [12]. to the The superior location dorsalbrachial rami. plexus; DS: dorsal scapular nerve; P: phrenic nerve; LT: long trunkof Erb’s of Point the brachial at the upper plexus cervical (derived outlet from (nb. the not C5 toand be C6 confused roots), thoracic nerve; LC: nerve to longus colli; S: nerve to scalenes; DR: together with the suprascapular nerve and nerve to subclavius, and the bifurcation of the trunk into the posterior and lateral Punctum nervosum cords. This structural conglomeration may be visualised in Figure 1B. Erb termed this point of neurological electro-accessibility, Over time, confusion appears to have arisen between the in contraction of the ‘deltoid, biceps, brachialis anticus, and more superiorly, referred to in Latin as the Punctum Nervosum the ‘supraclavicular point’, in which electro-stimulation resulted location of Erb’s Point and another point located significantly Point provides utility for electro-diagnostic motor conduction studiessupinator of longusthe C5 muscles’.and C6 roots The superficialpotentially accessibilityinvolving the of lateral Erb’s ramior ‘nerve of C2- point’ C4 and [13,14]. critically This possesslatter point close is spatial associated relations with withfour cord (musculocutaneous nerve - biceps, brachialis), the posterior primecutaneous moving nerves muscles that are and the fasciasuperficial of the branches region. ofA theschematic ventral cord (radial nerve - brachioradialis and axillary nerve - deltoid), depiction of the location of the Punctum Nervosum and posterior and the suprascapular nerve and nerve to subclavius. cervical triangle is portrayed in Figure 2.

Figure 3: The Punctum Nervosum (centre, encircled) gives rise to four splaying cutaneousSketch nerves, of two the nervesascending of the - the Punctum greater Nervosum. auricular nerve (GA), Figure 2: Location of the Punctum Nervosum and posterior triangle of the neck. externalthe lesser jugular occipital vein nerve (EJ), (LO);and one one inferior anterior-the - supraclavicular transverse cervical nerve, The posterior triangle of the neck is the triangle formed within the nerve (TC), coursing on the sternosceidomastoid (SCM) deep to the borders of the sternocleidomastoid muscle, trapezius muscle, and clavicle at the base. A black point demarcates the location of the giving rise to three branches, medial (MSu), intermediate (ISu) and Punctum Nervosum at the mid-point of the posterior border of the lateral (LSu). The muscles, trapezius (T) and levator scapular (LT) are identified, as is the accessory nerve (AN).

sternoscleidomastoid muscle (SCM). T: trapezius; C: clavicle; S: splenius muscles; LS: levator scapula; SM: middle scalene; SA: anterior Descriptivescalene; OH: omohyoid.anatomy: The Punctum Nervosum or ‘nerve approximately halfway along the posterior border of the sternocledomastoidpoint’ lies within the muscle posterior at the cervical approximate triangle level and of isC3 located [8,15]. Four cutaneous branches splay out in a cruciform manner from the Punctum Nervosum. Two cutaneous branches divergently ascend (lesser occipital - C2, greater auricular-C2.C3), one cutaneous branch passes anteriorly (transverse cervical C2.C3 with an interconnection with the facial nerve (CN.VII) and one cutaneous branch descends giving rise to three further branches (supraclavicular C3.C4 -medial, intermediate and lateral branches) [8,16]. When considering the Punctum Nervosum and its four intimately associated cutaneous nerves, consider that each has moved from deeper levels between adjacent muscles, tracking

3. toward their respective superficial cutaneous destinations, Figure The ascending loops of the lesser occipital nerve and greater auricular nerve initially pass between the upper part of levator scapula and splenius capitis overlain by the sternocleidomastoid Figure 4: muscle, before looping around the posterior border of Cross-hatched shaded area depicts the approximate region supplied sternocleidomastoid. The lesser occipital nerve continues its Schematic depicting cutaneous territories head and neck. ascent following the posterior border of sternocleidomastoid territorial region of the lesser occipital nerve (LO). More posterior to arise through the deep fascia near the mastoid, becoming still,by the toward greater the midline auricular lies nervethe territory (GA); of immediately the greater occipital posterior, nerve the cutaneous and also linking with the greater occipital and greater auricular nerves. It variably supplies an approximate 2 - 3 cm region(GO), andinnervated below, theby the dorsal supraclavicular rami C3 (DR); nerve the and transverse its branches. cervical The area of cutaneous scalp that immediately surrounds the pinna nerve lies at the anterior neck (TC); below and behind this, lies the of the ear, from the mastoid process posteriorly to a vertical line ophthalmic (Op), maxillary (Mx) and mandibular (Mb) are also shown. bordering the anterior margin of the pinna Figure 4. territories of the fifth cranial nerve (V), (trigeminal) and its branches,

Schematic depiction of the approximate cutaneous treatment is not readily distinguishable either by an observer or by territories at the head and neck the patient, except by clinician intent and disclosure. The sensory confounding of both these elements is ubiquitous and cautionary. The greater auricular nerve emerges at the Punctum In the tactile milieu of manual palpation such procedures of Nervosum and continues to loop superiorly as it ascends on the examination and treatment are inevitably interdependent. sternocleidomastoid, deep to platsyma with the external jugular vein to become cutaneous [8,15,16]. At the level of the parotid (cognition, perception, expectation) possessed by both the patient gland, it divides into anterior and posterior branches. The Consider the omnipresent central influence of cortical input former links with the facial nerve (CN.VII) within the gland and is manual pressure on low threshold afferent mechanoreceptors of cutaneous over the parotid region. The latter is cutaneous over the touch,and by pressure the clinician, and vibration together and with their the associated peripheral wide influence dynamic of mastoid and back of the ear, linking with the lesser occipital nerve, the auricular branch of the vagus (CN.X) and posterior auricular partiesrange inter at the neurons point inof laminamanual IV engagement and V at the [17]. dorsal The horn. resultant Such variable territory covered includes much or all of the pinna, the central and peripheral influences occur simultaneously in both regionbranch below of the the facial pinna nerve that (CN.VII) includes (Gray’s the lateral Anatomy neck and 2005). adjacent The quality that degrades rapidly in a proportional manner with both angle of the mandible and may also include the region overlying thesensory time and melange the intensity is a minefield of the manual for objectivity, clinical engagement. a vital clinical and anterior to the temporomandibular joint Figure 4. In recent times, the functional and clinical anatomy of fascia in The transverse cervical nerve also loops along a similar general and of the neck in particular has attracted growing attention course though tracking more anteriorly, emerging at the Punctum from manual therapies. For example, there is a wider acceptance Nervosum to pass anteriorly across the sternocleidomastoid deep to platysma to the anterior border of the muscle. Here it divides attendant clinical implications [18]. Nevertheless, descriptions of into ascending and descending branches, the former ascending regionalof the anatomical cervical fascia description remain ofchallenged the ‘Myodural by inconsistencies Bridge’ with itsof to the submandibular region to link with the cervical branch of nomenclature [9]. Fortunately, more recent work appears to have addressed this by providing a coherent description of this fascia platysma to be cutaneous, serving the anterolateral aspects of the [19]. With the attribution of multiple physiological functions neckthe facial down nerve to the (Gray’s sternum Anatomy Figure 205) 4, [8]. and the latter, arising from [20] and their attendant clinical implications [21-23] fascia has become a growing consideration in manual practice and its role in branch, emerging at the Punctum Nervosum to descend deep to platysmaThe supraclavicular and to fan out distally nerve is at thethe onlyclavicle superficial into three descending branches, theThe Bow-string Bow-string technique technique appears potentially significant. the medial, intermediate and lateral supraclavicular nerves. Collectively, a cutaneous region is served that spans the upper and The biomechanical relevance of connective tissue: The posterior parts of the shoulder to the median plane anteriorly and biomechanical characteristics of fascia and muscle may have the second rib inferiorly Figure 4. tissues and the relevance that this may have with respect to the Other well-known neurological structures of the region lie in presenceclinical relevance, or absence particularly of somatic with dysfunction. respect to theA biomechanical ‘feel’ of these relatively close proximity to the Punctum Nervosum. Moving in a understanding of the basic constituent material, collagen becomes lateral direction from the ventral midline these include the vagus necessary. nerve, the middle cervical sympathetic ganglion and the phrenic nerve. The vagus nerve and middle cervical sympathetic ganglion lie deep to and close to the common corotid artery and internal juguar vein. The phrenic nerve lies lateral to the internal jugular When considering the ‘feel’ or ‘texture’ of ‘myofascia’ in general vein. Collectively, these lie to the front of the anterior scalene and fascia in particular, underlying processes of ‘thickening’, muscle at the level of C5 and C6. [23,24].‘strain-hardening’ While such and changes fascial may ‘densification’ remain notionally have been distinct described from in addition to alterations of ‘viscosity’, ‘fibrosis’ and ‘adhesion’ Manual Intervention - Potholes, Pitfalls And Fascia neurologically based moment to moment changes in position increases in muscle tonicity, which may better reflect and modulate This preliminary report highlights anatomical considerations and movement, how muscle and fascia may be distinguished of the lateral neck and thoracic outlet with two potential issues in and objectively evaluated solely by palpatory feel remains to be properly described and validated. It appears that sonographic conditions for the presence of somatic dysfunction and second, imaging may also have a valuable investigative clinical role to play potentialmind. First, treatment diagnostic utility. utility Fromby clinical a diagnostic palpation perspective under specified the in this regard, as fascial thickening [25,26] may be associated with proposed Bow-string technique may help discern the nature of myofascial pain states that a priori encompass states of somatic dysfunction with its accompanying aberrant state of muscle tonus and transverse plane (axial). It remains a subject for further and tissue textural change. investigationmotion and tissue to determine restriction whether in the frontal the relative plain (lateroflexion)contributions Using an experimental scenario that relies on collagen gel, arising from articular, muscle and fascial structures may be a model of the mechanical behaviour of collagen protein in the reliably and validly discerned by observation and palpation alone. body [27] may potentially assist in the development of a rational When considering manual palpatory techniques it often appears that a clear separation between examination and quantification of the physical description (duration, applied stress and strain) of the proposed Bow-string technique. Shen and

colleagues explored the stress-relaxation mechanisms in collagen that is, between disaccharide units made up of D-glucuronic acid

linkages in addition to the inter- molecular hydrogen bonds matrices under the influence of cross-linking and hydration. and D-N-acetylglucosamine linked by β1.4 and β1.3 glycosidic theStress-relaxation material and maintained. is a mechanical The stress characteristic in the material of viscoelastic is seen to to mechanical stiffening of collagen, increasing its rigidity. degradematerials over like timecollagen as it wherebyundergoes a rapid viscoelastic fixed strain deformation. is imposed (This on between collagen fibrils. Such enhanced hydrogen bonding leads In the application then of manual techniques designed to and maintained. The tissue undergoes subsequent viscoelastic of external therapeutic loads, whether applied across the skin or deformationprocess is distinct over time, from lengthening ‘creep’ where in the a process). fixed stress It is frequently is applied bypurportedly axial or appendicular ‘release’ fascia leverage, or ‘myofascia’ the time through constants the application and initial unclear or unstated in manual therapy whether one or other, or [28] would appear to be an important biomaterial characteristic fascia or myofascia are undertaken. tissue strain derived from the work of Shen et al. [27] & Yang et al. both these effects apply when techniques purporting to ‘release’ worthy of clinical consideration. As previously stated, 2 minutes may be the appropriate time over which to consider the application peaks for collagen matrices at 0.3 second - 1 second, 3 seconds - 1.5Critically, minutes, Shen and and greater colleagues than identified 200 seconds three (~ stress-relaxation 3.5 minutes). They hypothesized that these three relaxation peaks represent ofI. aIntroducing fixed strain tothe a bow-stringmyofascial structure. technique - general description a hierarchy of collagen tissue stress-relaxation embodied in Bow-string technique arose from the use of a standard palpatory respectively. This hierarchy appears consistent with the fact that examinationThe Spock-like of the insight cervical that and resulted thoracic in theoutlet hypothesis as part of the inter-fiber relaxation; inter-fibril relaxation, and fibril relaxation, routine requirement to clinically evaluate the region. As the name (Bow-string) implies, it conceptualises the individual muscles relaxationfibril cross-linking time constant. appears the more durable property under of the region (upper portion of trapezius, levator scapular and long-term load, giving rise to the longest (slowest) fibril stress-

placementthe middle ofscalene) an arrow as ‘bow-strings’and the subsequent and considers draw by the the utility archer of andCiting molecular the work sliding of at Yang approximately et al. [27] who1 second identified and 1 two minute, time applying an additional external pivot to the ‘string’, much as the constants for ‘native’ collagen, attributing these to inter-fibril bow. Increasing strain (lengthening of the bow-string) engenders ancreates increase an additionalof tensile stress pivot in point the betweenbow-string. the In fixed considering points ofthe a consideredcompared withthose cross-linkedresults consistent collagen with the fibrils range where of time they constants found 3 seconds and 250 seconds (~4 minutes), Shen and colleagues bow and arrow, the tensile stress of the string and elasticity of the bow serve to propel the arrow. In the case of the Bow-string mechanisms. They also showed that the rate of stress-relaxation technique, the tensile stress is developed in the ipsilateral resting ofthat collagen they had matrices identified increased for inter-and linearly intra-fibril with themolecular initial slidingstress myofascia of interest as the contralateral contraction is instigated level, an observation consistent with the essential biomechanical by the patient leading to the implementation of contralateral axial properties of skin and tendon. The opposite relationship between stress level and stress-relaxation exists in ligamentous material, structures against the impinging external pivot provided by the where the rate of stress-relaxation decreases with higher stress clinician.rotation or The lateral clinician flexion, may which judge tightens the rate the ofipslateral stress generationmyofascial level, ligaments providing the requisite rigidity and stable tensile within the myofascial tissue undergoing increasing strain and stress under load. simultaneously observe the commensurate degree of contralateral motion. that approximately 30% of the stress-relaxation of the deep fascia Pavan et al. [21] cite the work of Stecco et al. [29] highlighting Further consideration of this potential technique suggested that a more sustained application of the Bow-string technique stress that purportedly represents 90% of the stress-relaxation may possess a potential to modulate the resting length of regional overof the an leg observationoccurred within time the of first 4 minutes. 2 minutes, The a reduction implication in tissue here myofascia through the stress-relaxation characteristic of affected biomaterials (collagen) previously described thereby potentially tissueis that strain. the lion’s Two share minutes of stress-relaxationmay then be the relevant may be experimentaltheoretically considerationachieved within to import 2 minutes into the from clinical the onset setting, of together an applied with fixed the influencingIt is emphasised regional that somatic any dedysfunction. novo expression of this technique whether in manual testing or in the quest of potential therapeutic utility is bereft of data attesting to reliability and validity both in More recently Xu et al. [30] discussed the importance of the idea of the application of a fixed strain. putative manual assessment and in any potential for treatment hydration levels of connective tissue and collagen in particular, utility. The prima facie indication is a requirement for the highlighting the biphasic nature of collagen. They described modulation of regional somatic dysfunction. Thus far the Bowstring how the solid phase is characterised by the collagen network technique is descriptive and anecdotal. Use of this manual technique either in evaluation or in therapeutic intervention which may be tightly bound to collagen molecules or may be could be considered experimental and therefore may be subject free.and theIn the liquid former, phase it stabilises is characterised the collagen by themolecules interstitial and leads fluid, to ethics approval. Relative and absolute contraindications may to extensive inter- and intra- molecular hydrogen bonding. Together, these two phases facilitate the viscoelastic properties accorded to regional neurovascular and lymphatic structures and of collagen. More tightly packed collagen manifest in dehydration theirtheoretically potential apply for anatomical in a clinical variation. setting with specific consideration results in stronger and shorter intra-fibril hydrogen bonding,

II. The Bow-string technique - specific considerations to help establish a diagnostic clinical impression. The patient As described, the Bow-string technique relies on the and where necessary may retreat from and advise the clinician of the‘controls’ presence the ofmanoeuvre discomfort. based upon their perceived discomfort, portionapplication of trapezius, of an external levator fixed scapular, pivot (clinician’s middle scalene) palpating in a fingers)manner placed firmly between the origin and insertion of a muscle (upper anteriorly and a little deeper, encountering the levator scapular muscle.The clinician’sA similar technique examining is fingersreapplied, may except next in be the emplaced case of increasethat takes-up of material or reduces strain the within ‘slack’ the in muscle. the muscle The untilpatient a state is then of requestedmoderate resistance to steadily may move be the felt. region This is in the a mannerfirst step that in creating lengthens an the distance between the origin and insertion of the ipsilateral furtherthis muscle again the to motionthe middle requested scalene. of While the patient gently is restraining lateral flexion this myofascia under a direct external imposition of an external digital myofascialaway from structure the clinician. avoiding The clinician’sunnecessary fingers or direct may bepressure moved pivot. Importantly, this may occur when the patient contracts on the nearby adjacent neurovascular structures, the patient the contralateral muscles. The pressure of the manually applied once again turns their neck in contralateral axial rotation away external pivot on the relaxed ipsilateral side should be maintained from the side of the external pivot. The relaxed ipsilateral levator continuously as the contralateral movement occurs. The clinician scapula muscle may be constrained from bow-stringing. may feel the reaction force of the underlying myofascia increase As described, in each instance and on each side this putatively as the mechanical strain (lengthening) within the soft-tissue escalates. The patient continues with the movement unless therapeutic intervention by the increase of time spent in the excessive tenderness or pain supervenes until a point is reached diagnostic manual technique may be modified toward potential constraints discussed previously associated with a theoretical grip approaches the limit of what may comfortably and readily occupation of a fixed strain loading. Accordingly, the time when the reaction force against the clinician’s external firm duration of application required to induce collaginous stress- relaxation may be considered by the clinician. considered to be applied and critically, neither the clinician nor patientbe constrained should alter by the the clinician.mechanical At thisstatus point, quo, aparticular fixed strain if the is technique is being employed from a therapeutic rather than diagnostic perspective. When used as a diagnostic tool, the assessment of contralateral movement with its pro rata developing ipsilateral tension (felt easily evaluated. When employed as a possible therapy, the point ofunder maximum the fingers strain of should the clinican) be maintained with or for without a period pain of not may less be than 2 minutes and not longer than 4 minutes. The former period of the stress-relaxation of local collagen discussed previously, orof 2in minutes the case is of coincident the latter, withencompassing the acquisition all the of peaks a ‘lions of stress-share’ relaxation associated with collagen. Further technique specifics border of the suprascapular aspect of the upper portion of trapeziusEmplacement of the ofseated the clinician’s or standing fingers patient. against The the clinician ventral thegrips neck, firmly, when preventing the patient theis requested muscle fromto turn bow-stringing their head away, with or Figure 5: External clinician manual position and technique. subsequent contralateral axial or lateral movement of a patient’s The clinician places both hands on one side of the neck of the patient, depending on the myofascial structures engaged by the clinician - from the junction of the neck along the anterior border of the trapezius,to laterally levator flex their scapular, head and anterior neck away/ middle from scalene. the side of contact, suprascapular aspect of the upper portion of the trapezius muscle,

anterior border of this muscle as much turning force in a manner proportionate to the mechanical firmly emplacing the trapezius muscle with the fingers against the The clinician ‘constrains’ the muscle while the patient applies Discussion strain (and potential discomfort) felt under the clinician’s gripconstraining that does fingers. not vary Once from a the peak start tolerable of the manoeuvre point reached, appears the Pinch spans Generations. It may provide a helpful association for criticalpatient movesto the theoreticalno further. The success clinician’s of the maintenance technique. The of a resultant constant theThe introduction cultural iconographyof a novel technique, of Star Trek the andBow-string the Vulcan technique Nerve degree of ipsilateral muscle strain and the speed with which it based on the therapeutic position of the intervening clinician in develops in association with the contralateral movement may help relation to a patient, in addition to the clinician hand placement. to indicate regional tissue change. Diagnostically, the position of This novel technique relies on an understanding of the underlying time constants associated with the visco-elastic property of strain may be held by the patient briefly (a few seconds) in order

Citation: Technique. Int J Complement Alt Med 5(5): 00162. DOI: 10.15406/ijcam.2017.05.00162 McGrath MC (2017) The Vulcan Nerve Pinch - Cultural Iconography Anchors the Proposal of a Novel Manual Approach, the Bow-String The Vulcan Nerve Pinch - Cultural Iconography Anchors the Proposal of a Novel Manual Copyright: 7/8 Approach, the Bow-String Technique ©2017 McGrath stress-relaxation that has been shown to occur in collaginous soft- Potential Positional Limitations that may occur in the pre-strained collaginous tissue does so The technique appears simple to apply, requiring of minimal overtissue known exposed time to constantsa fixed strain. where, The sustained subsequent over stress- a period relaxation of two force and should be conducted with the patient in a seated or upright position. The technique is impractical in a supine viscoelastic yielding effect. minutes it may be considered to capture the ‘lions share’ of the Most involved in manual therapy may readily attest to the reductionposition as in substantial axial column modification load and change to head, in position. neck, scapulocostal, This occurs whenand scapulothoracic the muscle reaction relations forces develops required because to control of athe significant mass of the cranium, maintain neck posture and control movement are frequent clinical finding of an aberrant state of muscle tension provided instead by the surface of an examination table. It appears establishesin the neck-shoulder a list of potential region, underlying whether causes at the of ‘headache’headache that or is‘outlet’ truly aspectsa litany ofof thetribulation. thorax. The The simplest role of the of literaturetrigemino-cervical searches in the designated myofascia, with the patient in a supine or prone position.very difficult or impossible to create sufficient mechanical strain as much as 47% of the global population suffer with headache of whichreflex issome well 15 established - 20% are [31,32] described with as the cervicogenic literature reporting[33]. Thoracic that References outlet syndrome and in particular its variant of neurological 1. http://memory-alpha.wikia.com/wiki/Vulcan_nerve_pinch thoracic outlet syndrome presents yet another clinical syndrome whose basis can frequently be related to or associated with 2. https://en.wikipedia.org/wiki/Vulcan_nerve_pinch#Physiology sustained aberrant patterns of muscle tonicity, with manual 3. https://www.youtube.com/watch?v=TgMjV3Yse3U 4. https://www.youtube.com/watch?v=VYezfpJvFsw The Punctum Nervosum may possess clinical relevance therapy and management providing a first line of intervention. 5. http://memory-beta.wikia.com/wiki/Main_Page when considering the Bow-string technique for in considering the application of the Bow-string technique and the imposition 6. of tissue strain upon the muscles adjacent to and surrounding 7. http://memory-alpha.wikia.com/wiki/Vulcan_Science_Academyhttps://www.quora.com/How-do-you-properly-perform-a-Vulcan- the cutaneous nerves of the cervical plexus, a theoretical nerve-pinch-on-someone impingement may arise between the two, potentially leading to referred dysthesia or pain projected over the cutaneous 8. th distribution. The greater auricular nerve and the lesser occipital of Clinical Practice. (39 edn), Elsevier Churchill Livingstone, Gray, Henry, (2005) Gray’s Anatomy 2005 The Anatomical Basis nerve, with or without facial nerve involvement would appear to be potential candidates for this effect. It is anticipated that this 9. Edinburgh, Scotland, pp. 534. may potentially occur as these cutaneous nerves undergo a mild regional neuropraxia, consequent to the pinching myofascia of Guidera AK, Dawes PJD, Stringer MD (2012) Cervical fascia: a 10. terminological pain in the neck. ANZ J Surg 82(11): 786-791. the upper part of levator scapula and splenius capitis overlain makes clinical sense. Clin Anat 9(1): 56-52. by the sternocleidomastoid muscle. It may conceivably also be Ranney D (1996) Thoracic outlet: An anatomical redefinition that more likely to occur when the pre-existing state of myofascia in 11. Tubbs RS, Loukas M, Salter GE, Oakes WJ (2007) Wilhelm Erb and 12. Erb’sErb W Point. (1883) Clin HandbookAnat 20(5): of 486-488. electro-therapeutics 1883. In: Putzel suchthe region as the could variation be clinically of course considered taken by a priorithe cutaneous as ‘shortened’ nerves or in‘tight’. single A numberindividuals, of additional which might potential encompass explanations a description may exist, of 13. L(Ed), William Wood and Company, New York, USA, pp. 122-124. normal anatomical variation. Further morphological investigation nose and throat surgeons know where it is? - Letter to the Editor. is required. ClinicalCarswell Anatomy AJ, Clamp 23(1): PJ, Titoria 127. P, Reddy V (2010) Erb’s Point - Do ear, Of interest to those involved in manual care are palpable and 14. diabolicum - Letter to the Editor. Clin Anat 23: 128. Tubbs RS, Loukas M (2010) Errare humanum est perservare cervical region, which includes the anatomy of the sub-occipital, 15. Netter FH (2003) Atlas of Human Anatomy. 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