The pelvis contains several parallel nerve groups. One of which is the lumbar plexus and its sensitive branches. This nerve web arises from the anterior rami of lumbar spinal nerves L1 to L4 and T12 from the thoracic spinal nerve. 

Nari Clemons instructs the remote course, Lumbar Nerve Manual Assessment and Treatment, which addresses assessments for the contributory nerves from the lumbar plexus, anatomy, differential diagnosis, and objective findings for specific nerves of the lumbar plexus. This advanced-level course also provides twelve lab techniques for manually treating the nerves of the lumbar plexus. 

Peripheral lumbar plexus nerves included in this course are Iliohypogastric, Ilioinguinal, Genitofemoral, Lateral Femoral Cutaneous, Femoral, and Obturator Nerves. These nerves are vital for the functioning of the lower extremities, including maintaining the ability to extend the knee, flex the hip, and adduct the thigh. 

When a nerve becomes restricted, it disrupts the nerve signal allowing for symptoms to present as possible pain, weakness, numbness, or tingling. The lumbar plexus is vulnerable to injury when its bony protection, the pelvis, is compromised. Based on research from Anthony Chiodo, retroperitoneal hemorrhage, superior ramus fractures, traction, and penetrating injuries all can cause injury to the lumbar plexus. There are also a variety of conditions such as herniated disc, spinal arthritis, repetitive activities, and even poor posture that can lead to lumbar nerve pain, or a pinched nerve.

Nari explains in the Lumbar Course anatomy lecture that, "Dura matter covers the brain, spinal cord, and peripheral nerve. If you have tension in the peripheral nerves it can cause tension in the central nervous system and vice versa. When working with the nerves it is important to down-train the nervous system. Because the nerves run continuously it is always important to down-train and practice pain theory." She continues to explain that "The osteopathic approach to the fascial system of the peripheral nerve does not have a grounding in scientific research and is based on clinical experience from individuals using peripheral nerve palpation as a method for the evaluation of the nerve's function."

This means that there is not a singular proven technique that is more helpful than another when addressing nerves. The Lumbar Nerve Manual Assessment and Treatment course is essentially a melting pot that pulls from multiple studies and research. The evidence-based, step-by-step approach to treating the lumbar nerve includes

• Decompression to clear the path of the nerve and potential sites of restriction. 
• Fascial techniques, just like those that we use with the other fascia of the body.
• Slacking the nerve towards its origin to create ease.
• Gliding the nerve in a pain-free manner.
• Strengthening the weakened muscles. 

Differential diagnosis and treatment of these lumbar plexus nerves can allow patients to return to full daily function. Learn manual assessment and treatment techniques from Nari Clemons in the next Lumbar Nerve Manual Assessment and Treatment remote course, scheduled for September 11-12, 2021.

Tibial nerve stimulation has been shown in the literature to be effective for individuals experiencing idiopathic overactive bladder in randomized controlled trials. A systematic review was performed by Schneider, M.P. et al. in 2015 looking at safety and efficacy of its use in neurogenic lower urinary tract dysfunction. Many variables were examined in this review, which included 16 studies after exclusion. The review looked at:

1. Acute stimulation (used during urodynamic assessment only)
2. Chronic stimulation (6-12 weeks of daily-weekly use)
3. Percutaneous or transcutaneous (frequencies, pulse widths, perception thresholds, durations)
4. Urodynamic parameter changes baseline to post treatment
5. Post void residual changes
6. Bladder diary variables
7. Patient adherence to tibial nerve stimulation
8. Any adverse events

The exact mechanism of these types of neuromodulation stimulation procedures remains unclear, however it does appear to play a role in neuroplastic reorganization of cortical networks via peripheral afferents. No specific literature is currently available for the mechanism on action related to neurogenic lower urinary tract dysfunction. Different applications of neuromodulation however have been studied in the neurogenic populations.

One of the randomized controlled trials they report on included 13 people with Parkinson disease. The researchers looked at a comparison between the use of transcutaneous tibial nerve stimulation (n = 8) and sham transcutaneous tibial nerve stimulation (n=5). Transcutaneous tibial nerve stimulation (TTNS) or sham stimulation was delivered to the people with Parkinson disease 2x/week for 5 weeks, 30-minute sessions (10 total sessions). Unilateral electrode placement was utilized, first electrode applied below the left medial malleolus and second electrode 5 cm cephalad. Confirmation of placement was obtained with left great toe plantar flexion. It is important to note the use of the stimulation intensity is reduced to below the motor threshold during the active treatment to direct the stimulation via peripheral afferents.

Urodynamic testing was performed at baseline and post treatment and revealed statistically significant differences with greater volumes at strong desire and urgency in the TTNS group. Additionally, the TTNS group experienced a 50% reduction in nocturia whereas in the sham group nocturia frequency remained the same. A three-day bladder diary completed by each of the groups also revealed significant positive changes in frequency, urgency, urge urinary incontinence and hesitancy only in the TTNS group.

Conservative management of neurogenic bladder in populations such as Parkinson disease is very important. These individuals experience lower quality of life ratings related to lower urinary tract dysfunction, higher risk of falling with needs to rush to the bathroom, their caregivers experience a higher level stress and burden of care, and tolerance to anticholinergic medications is very poor with multiple unwanted side effects that compound and worsen other symptoms that might be present from the disease process.

Please join us for Neurologic Conditions and Pelvic Floor Rehab to learn how you can help your patients using this modality as one option. Participate in a lab session to learn electrode placement and other parameters to achieve best clinical results for your patients.

1. Perissinotto, M. C., D'Ancona, C. A. L., Lucio, A., Campos, R. M., & Abreu, A. (2015). Transcutaneous tibial nerve stimulation in the treatment of lower urinary tract symptoms and its impact on health-related quality of life in patients with Parkinson disease: a randomized controlled trial. Journal of Wound Ostomy & Continence Nursing, 42(1), 94-99.
2. Schneider, M. P., Gross, T., Bachmann, L. M., Blok, B. F., Castro-Diaz, D., Del Popolo, G., ... & Kessler, T. M. (2015). Tibial nerve stimulation for treating neurogenic lower urinary tract dysfunction: a systematic review. European urology, 68(5), 859-867.