For Those Who Need to Know the “Why”

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Meet the Packaging Around Your Central Nervous System

Your brain and spinal cord are extraordinarily important.

Your body treats them accordingly.

They are surrounded by bone, fluid, blood vessels, connective tissue and several protective membranes called the meninges.

There are three major meningeal layers:

Pia mater

The delicate inner layer closely follows the surface of the brain and spinal cord.

Arachnoid mater

The middle layer is associated with the space containing cerebrospinal fluid.

Dura mater

The tough outer layer provides substantial mechanical protection.

And it's the dura that we're interested in here.

Your Dura Isn't Floating in Space

It can be tempting to picture the spinal cord sitting inside a completely independent protective tube.

Real anatomy is considerably more interesting.

The dura has mechanical relationships with structures around it.

Inside the skull, cranial dura attaches firmly at various locations.

Around the spinal cord, the dural sac travels through the vertebral canal and has important attachments and relationships at the upper cervical region and farther down the spinal canal.

Researchers have also identified something particularly interesting near the base of the skull:

The Myodural Bridge

Yes, anatomists actually named it that.

The myodural bridge describes connective-tissue connections between certain small muscles and fascial tissues beneath the skull and the cervical dura.

In other words, some of the tissues responsible for moving and stabilizing your head have anatomical connections with tissue surrounding your spinal cord.

That doesn't prove that every tight neck muscle is pulling on your spinal cord.

But it does tell us something important:

These systems aren't completely mechanically isolated from one another.

Why Would That Connection Exist?

Researchers are still investigating its complete function.

Several roles have been proposed.

The myodural bridge may help maintain appropriate dural mechanics during head and neck movement.

It may help prevent unwanted folding or movement of the dura.

It may participate in proprioception—the nervous system's awareness of movement and position.

Researchers have even investigated whether these structures could influence cerebrospinal-fluid dynamics.

These are fascinating possibilities.

But possibilities aren't the same thing as established clinical facts.

So rather than saying:

“Your tight neck is pulling on your dura and stopping your cerebrospinal fluid.”

We take the more careful approach:

“There are known mechanical relationships between these tissues. Let's determine whether changing those mechanical inputs changes your function.”

Then we can test it.

Can the Dura Feel Pain?

Yes.

The meninges contain sensory innervation.

This is particularly important inside the skull, where pain-sensitive structures associated with the meninges and their blood vessels participate in headache mechanisms.

That's one reason researchers have been so interested in understanding mechanical and neurological relationships involving the dura.

But there's another important distinction:

Pain near the dura does not automatically mean the dura is causing the pain.

Neck pain and headaches can come from many structures.

Muscles.

Joints.

Nerves.

Blood vessels.

Discs.

Ligaments.

And sometimes conditions requiring medical evaluation.

Good examination comes before good treatment.

So What Is “Dural Tension”?

Here's where terminology gets tricky.

There isn't a universally accepted medical diagnosis called:

“Dural Tension Syndrome.”

When we use the term dural tension, we're describing a clinical concept involving mechanical forces and movement relationships associated with tissues surrounding the nervous system.

We're looking for findings suggesting that certain movements or positions are producing an unusual mechanical or neurological response.

That's different from claiming we measured the dura and found it “tight.”

There isn't a little dura tension gauge hiding in the treatment room.

At least not yet.

How Do We Evaluate It?

The examination begins with movement and neurological function.

Depending upon the patient's presentation, we may assess:

Head and Neck Movement

Does turning, bending or positioning the head change the finding?

Spinal Movement

Do certain spinal positions reproduce or change the pattern?

Muscle Tone

Are the small muscles around the base of the skull unusually guarded or asymmetric?

Neural Mobility

Do positions that place mechanical load on neurological tissues change symptoms or movement?

Neurological Findings

Does changing head, neck or spinal position alter another measurable neurological finding?

Symmetry

Does one side behave differently from the other?

And most importantly:

Can we reproduce the finding?

If we can't find it consistently, it's very difficult to know whether we've changed it.

What Is Dural Tension Release Actually Doing?

This is another place where language matters.

We're not manually grabbing the dura.

We're working with structures that can influence the mechanical environment surrounding the nervous system.

Treatment may therefore involve carefully selected:

• Upper-cervical techniques

• Suboccipital soft-tissue work

• Spinal positioning

• Gentle manual therapy

• Neural mobilization techniques

• Movement exercises

• Breathing

• Other sensory or neurological interventions

The exact approach depends upon the examination.

The intention is to change mechanical and sensory input into the system and then determine whether the original finding changes.

Neural Mobilization

Another related area of research is called neurodynamics or neural mobilization.

Nerves need to tolerate movement.

When your arm, leg, neck or spine moves, peripheral nerves and associated neural tissues must accommodate changes in length, position and mechanical load.

Clinicians can use specific movements to assess this mechanosensitivity.

Treatment can then involve carefully controlled movements intended to improve tolerance to movement and mechanical loading.

Sometimes these are called:

sliders

or

tensioners.

The names sound like tools you'd find in the garage.

They're actually controlled movement strategies.

The goal isn't to aggressively stretch a nerve.

Nerves generally don't appreciate being treated like hamstrings.

The goal is to provide an appropriate amount of movement and mechanical input.

What Does the Research Say?

There are several different levels of evidence we need to separate.

The anatomy is real.

The dura and other meninges are well-established anatomical structures with known attachments, innervation and mechanical relationships.

The myodural bridge is real.

Multiple anatomical studies have demonstrated connective-tissue relationships between upper-cervical muscles/fascial structures and the cervical dura.

Neural tissues respond to mechanical forces.

Neurodynamic research supports the concept that peripheral nerves and associated neural tissues move and respond to mechanical loading during normal movement.

Manual and neural mobilization techniques can help some musculoskeletal conditions.

Clinical research has found benefits from neural mobilization approaches for certain types of musculoskeletal and nerve-related pain.

But here's where we draw the line:

Current evidence does not allow us to say that we can reliably identify generalized “dural tension,” manually release the dura, and thereby treat a wide range of neurological conditions.

That's a much bigger claim.

And we don't need it.

We have something better:

A testable clinical hypothesis.

If a particular movement or neurological finding changes predictably with mechanical loading…

…and an appropriate intervention changes that finding…

…and the patient's actual function improves…

then we have useful information.

Our Approach

Dural Tension Release follows the same philosophy you'll see throughout our neurological care.

1. Assess

Identify the patient's symptoms and establish reproducible functional findings.

2. Load

Determine whether particular positions or movements change those findings.

3. Treat

Apply an appropriate manual, movement or neurological intervention.

4. Unload

Allow the nervous system and surrounding tissues to respond.

5. Reassess

Repeat the original test.

Did range of motion change?

Did tension change?

Did neurological function change?

Did the patient's symptom change?

6. Look for Function

This is the most important part.

A change on the treatment table is interesting.

A change that helps someone move and function better is meaningful.

What Are We Trying to Accomplish?

Depending upon what we find during the examination, treatment may be intended to improve:

• Comfortable movement

• Neck mobility

• Spinal mobility

• Neural mobility

• Mechanical sensitivity

• Muscle guarding

• Movement symmetry

• Neurological function

• Functional tolerance

We're not trying to “loosen your brain.”

We're trying to create a healthier mechanical environment in which your nervous system can do its job.

Because your nervous system already has a difficult enough assignment.

It doesn't need the surrounding tissues making the job harder.