The document discusses neurovascular therapy, which assesses the vascular components of the body to identify issues like vascular insufficiency. It notes that some patients do not fully respond to other treatments due to underlying vascular dysfunctions affecting the autonomic nervous system. The author then details their assessment protocol for neurovascular therapy, which involves evaluating pulses at different points, palpating neurovascular points, and assessing angiosomes for signs of vascular issues like reduced elasticity. The goal is to identify any abnormalities in the vasculature that may be contributing to a patient's chronic pain or lack of response to other treatments.

1. Aaron Driver
Doctor of Physiotherapy

2. What is it?
 Neurovascular therapy is the act of assessing the vascular
component of the human body in order to identify vascular
insufficiency, vascular inextensibility and autonomic
neurological signs and symptoms.
 The idea that there are possible vascular dysfunctions that affects
the autonomic nervous system especially, the sympathetic and
possibly parasympathetic branches grew from clinical
observation with complex pain patients demonstrating
sympathetic overtones during treatment.
 Resistance to treatment had to have some pathogenic process
that has not been identified in western medicine... So where did
it come from?
 The vascular tree of the human body!

3. Clinical observations
 During a treatment session I usually will methodically and
meticulously assess the neurological system using
principles of neural mobilisation described by Butler and
colleagues, then I will assess the myofascial slings, chains
and trains described by Meyers and colleagues, possible
trigger points located in soft tissue as described by Travel
and Simons, unusual functional vertebral complex
regions, I also assess the cranio sacral rhythms to identify
rhythm insufficiency. All these things are integrated into
ancient principles that our ancestors left for humanity to
prosper in good health and longevity from the gift of
Buddism our ancient and wise enlightened guide.

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The results are amazing greater than 90 percent of patients will benefit from treatment, however
what about the 10 percent.
Is it simply a matter of they cannot be helped with physiotherapy, osteopathy, chiropractic or any
other alternative treatment? Could it be that their answer lies in the pathoanatomy and require
surgical or injection intervention? Absolutely... but does that mean that we cannot ease their pain and
suffering until surgical intervention is available. Waiting times can be a long process and patients
need some sort of intervention that will help them during these difficult times.
However, some patients may not respond favourably to surgical and or injection intervention, these
poor souls may only be 1 - 3 percent of the population but hey... they deserve help just as much as
anyone else. It is not good enough to settle for less, and dismiss their pain and suffering as
malingering and/or hypochondriac episodes.
So with these issues at hand, autonomic overtones that were elicited with manual therapy came to my
attention during treatment sessions with chronic patients, especially symptoms such as; burning hot
and cold zones, changing phenomena such as
trophoedema, hyperhidrosis, allodynia, hyperalgesia, vasomotor dysfunction and neuropathic
symptoms such paresthesia, numbness and weakness that have no dermatomal, sclerotomal or
myotomal patterns.
I researched the involvement of the autonomic nervous system in chronic pain and came across
articles describing sympathetic fibres that flow into the upper and lower limbs along neurovascular
tracts, with slips that then flow along vascular vessels into the superficial fascia through arterioles
that pierce the deep fascia called neurovascular points before forming vascular beds in the cutaneous
membrane of the skin. These cutaneous zones are called angiosomes.

5. Fasciocutaneous and
myocutaneous pedicles
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Further research investigating the anatomical neurovascular point demonstrated perforating vessels
that directly flow to the skin called cutanee directe vascularisation and indirect flow through
intermuscular fascia through the deep fascia called septo-cutanee vascularisation and vessels that
flow through muscles called musculo-cutanee vascularisation. (lambeaux)
The direct vascularisation comes from dorsalis pedis, superficial circumflex iliac artery, the superficial
and deep portions of external pudendal artery, superficial inferior epigastric artery, and superficial
superior epigastric artery, thoracodorsal artery, the anterior intercostals branch of the internal
thoracic artery the occipital artery, posterior auricular artery, supraorbital artery supratrochlear atery
the parietal and frontal branches of the temporalis artery and the parietal branch of the superficial
temporal artery. (lambeuax)
The myocutaneous indirect vessels send cutaneous vessels from the abductor
hallucis, gastrocnemius, hamstring muscles, vastus lateralis and vastus medialis muscles, rectus
femoris muscle, gracilis and tensor fascia latae, rectus abdominus and external oblique gluteus
maximus and latissimus dorsi, pectoralis major, trapezius and platysma muscles, finally the
anterior and posterior deltoid muscles.
The fasciocutaneous or septocutaneous branches arise from the posterior tibial artery, medial plantar
artery, calcaneal branch of the fibular artery, posterior and anterior tibial artery, fibular
artery, superficial sural artery and saphenous artery the femoral artery and profunda perforators, the
radial and ulnar arteries, the brachial artery, the profunda brachii branch aof the radial artery, the
posterior interosseous artery, the vertical and horizontal branches of the circumflex arteries.

6. Vascularisation neuro-cutanee ou
perforators
 Vessels that flow juxtaposed with the nervous system called
vascularisation neuro-cutanee ou perforators send vessels from
the anterior and posterior tibial artery, peroneal artery, anterior
lateral thigh and anterior medial thigh , the perforator branch of
profundus femori artery, the perforator branch of the deep
inferior epigastric artery, the perforator branch of the superior
epigastric artery, the perforator branch of internal mammary
artery, the perforator branch of supraclavicular artery, the
perforator branches of inferior and superior gluteal artery, the
perforating braches of the lumbar artery, the perforating branch
of the thoracodorsal artery and the perforator branch of
posterior intercostal artery, the perforator braches of radial and
ulna artery, the perforator branch of posterior interosseous
artery and the perforator branches of the metacarpal artery.

7. Angiosomes
 Vessels form vascular territories called
angiosomes, (Taylor) divided by a fascial plexus. Each
angiosome has its own direct flow from a perforator
vessel, however adjacent angiosomes have choke
vessels that communicate with each vascular territory.

8.  Artery and arterioles are composed of the tunica intima, internal
elastic lamina, tunica media, external elastic lamina and tunica
externa. A connective tissue sheath called the tunica adventitia
acts like the superficial fascia and forms a fibrous layer that
glides over the tunica media which is composed of smooth
muscles fibres and regular connective tissue much like the deep
fascia over muscle. Normal healthy artery and arterioles should
demonstrate elasticity and compliance when stretched which is
required with movement of the human body.
 When adhesions develop or swelling impacts on the tissue loss of
normal elastic and compliance properties is noted and reflected
in the loss of gliding seen in the angiosome and also in joint
arthrokinematic and osteokinematic function.

9. Assessment protocol
 Pulse reading is taken from the temporal and facial artery just in front of the
ear and on the line between the corner of the mouth and angle of the jaw bone
, auxillary artery just above the coracobrachialus muscle within the
armpit, radial and ulnar artery at the wrist, as well as the within the snuff box
of the wrist, the brachial artery at the medial intermuscular septum, the
external carotid artery at the superior medial border of sternocleidomastoid
muscle, the apical pulse between the 4th and 5th ribs just outside the mid
clavicular line, the inferior epigastric artery below the navel, the femoral artery
at the inguinal crease, the popliteal artery in the posterior capsule of the
knee, the tibial artery at the posterior aspect of the medial malleolus, dorsalis
pedis artery between the 1st and second rays over the junction of medial and
intermediate cuneiforms or between the metatarsal bones .
 The pulse is measured in minutes and compared. A healthy reading should be
identical between pulse readings across the body in a 1:1 ratio, abnormalities are
demonstrated with slower pulse readings between points. With mild
1:2, moderate 1:3 and severe 1:4 and emergency 1:5 ratios.
 Pulse points are also noted with pressure applied over the articular capsule of
the proximal joint or with regular blood pressure readings with inflated cuff.

10.  Two point differentiation is applied between pulse points assessing the stiffness
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and pulse rhythms between the two pulse points.
Neurovascular points from direct pedicles are assessed for oedema and
stiffness, and then compared to the relevant pulse points and associated direct
pedicles.
Neurovascular points from indirect fasciocutaneous pedicles are assessed for
oedema and stiffness and then compared with pulse points, associated direct
pedicles and fasciocutaneous pedicles.
Neurovascular points from indirect myocutaneous pedicles are assessed for
oedema and stiffness, and then compared to the relevant pulse points and
associated direct and fasciocutaneous pedicles.
Comparison between neurovascular points will demonstrate either the
qualities of compliance and elasticity or rigidity and stiffness, be aware of pulse
rhythms that conducted between the two points of concern, you should feel
the normal pulse frequency of 10Hz which is related to the systolic pressure
and other frequency overtones which may be faster or slower at shorter or
longer intervals.

11.  Ask the patient for conformation and awareness of pulse rhythms by a
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asking the open ended question; what do you feel? This allows the
patient to interprete what they are feeling attuning their interoception
with their consciousness. Allowing the patient to express their
awareness of signs and symptoms they are feeling.
Angiosomes are palpated for fascial alterations, loss of elasticity and
compliance between two angiosomes will alert the therapist of vascular
insufficiency.
Normal pulse readings have no overtones and have clear pulse rhythms
related to systolic pressure.
Healthy neurovasculature have no identifiable swollen neurovascular
points over the body.
Healthy vasculature have no loss in elasticity and compliance between
two points within an angiosome.
Anything else is considered abnormal and requires treatment to resolve
the issue.

12.  This is an exciting proposal and I am happy to share this
knowledge with the world in order to develop further treatment
strategies that are required for helping those in pain and
suffering.
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 Please E- mail aaronjdriver@yahoo.com.au for further
information and proposals to conduct further investigations. Or
visit my website www.goldcoastphysiotherapy.org
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 Kind Regards... In lak ech
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 (Aaron Driver) Doctor of physiotherapy