Integrated Naturopathic (manual) Physical Medicine Protocols

A  number of general ('universal'), constitutional manual approaches to health care emerged from a background of naturopathic medicine in the first half of the 20th century. Other general approaches have been developed by the osteopathic profession, and the research validation of these offers a useful supporting element to those used in naturopathic settings.

The purely naturopathic protocols are :

1. Collins' Universal naturopathic tonic Technique¹ (also known as (General Naturopathic Tonic Technique) - abbreviated to UNTT and GNTT.
2. Lief's² Neuromuscular Technique - abbreviated to NMT.

In addition general  (whole body, wellness, constitutional) massage can also be shown to offer the potential to assist homeostatic functions, irrespective of the nature of the symptoms, and should therefore be incorporated into this discussion.³ A lengthy list of conditions exist in which  'general massage' (i.e. non-specific) has shown itself capable of offering significant benefit almost universally in dozens of named conditions. ⁴

Osteopathic medicine has also evolved a number of integrated therapeutic manual protocols - using combinations of modalities also commonly employed in naturopathic practice.⁵ These methods, that usually include gentle rhythmic movements of the spine and extremities⁶, have been shown in both hospital and office settings to effectively enhance the individual's adaptive potential and self-regulating functions, as evidenced by a reduction in time required to remain in hospital before recovery from a variety of conditions, including pneumonia, pancreatitis and surgery of various types.

While there are some differences between these protocols and methods (see below), they contain a number of essential similarities, making it possible to suggest that almost all patients, whether hospitalized or seen in an office setting, can benefit from what may be termed general, non-specific, whole-body, often rhythmic/oscillatory mobilization, using simple, non-invasive, modalities and techniques, in combination with each other.

Evidence and opinion
Lederman⁷ has diligently compiled evidence explaining the effects of particular manual approaches, in particular relating to fluid movement and adaptation.
Lederman points out that: "Techniques that stimulate fluid flow play an important therapeutic role in manual therapy. These techniques are largely aimed at assisting the repair process and homeostasis in different tissues."
From a naturopathic perspective there could be little that is more important than encouraging self-regulation.

UNTT & NMT
Universal (General) Naturopathic Tonic Technique (UNTT or GNTT) is a constitutional, virtually generally applicable method, developed in the early part of the 20th Century by Frederick Collins MD ND, and described by Cordingly⁸ in 1924.
UNTT offers naturopaths (and others) the opportunity to evaluate biomechanical changes, and to modulate these as appropriate, in the context of a general mobilizing treatment.  According to Cordingly, the total time required to perform Collins' GNTT is 7 to 10 minutes.
UNTT can be used as a means of offering a non-specific, general 'loosening'/mobilising process, during which areas of mild restriction may normalise, while offering an opportunity for the practitioner to evaluate levels of compensation, adaptation, restriction, dysfunction,discomfort and asymmetry. This leads to enhanced circulatory (blood and lymph), neurological and mobility functions, benefiting the individual's adaptive potential.

Lief's NMT
 In its general application, Lief's NMT offers a similar, non-specific, global, whole-body opportunity for the practitioner to simultaneously evaluate, assess and (if appropriate) treat, dysfunctional biomechanical  (possibly viscerosomatic in origin) patterns, that may represent evidence of failed or failing adaptation, or of actual pathology.⁹
Peter Lief ND DC, son of the primary developer of NMT Stanley Lief ND DC, noted: "NMT is a type of specific soft tissue treatment which is followed [or accompanied] by a general mobilising articular manipulation."¹⁰
Boris Chaitow ND DC, cousin of Stanley Lief, and co-developer of NMT, has observed¹¹:
"The body's integrity and its functional efficiency depends not only on its chemistry, influenced by the food and drink we ingest, but also on effective nerve and blood circulation, free of mechanical and functional obstructions. To this purpose there is no formula devised by the osteopathic or chiropractic professions that will more effectively achieve the optimum result than….the technique [NMT] devised by Stanley Lief."
Clinically an average NMT treatment involving general mobilisation of the spine, pelvis and extremities takes approximately 15 minutes.
In terms of modifying structure to enhance function these approaches can be seen to represent a means whereby adaptive changes can frequently be recognized and potentially modified if appropriate, in the context of a non-specific therapeutic encounter.

Guidelines not instructions
In essence the constitutional approaches described comprise an integrated use of several of individual modalities - including neuromuscular techniques (NMT), massage and joint mobilisation methods. The formulae/protocols outlined below are therefore suggested as being broad blueprints, guidelines, not necessarily to be followed blindly, or as firm instructions.
More realistically, what both Lief's NMT and Collin's GNTT/UNTT suggest is that naturopathic health care should offer each and every patient a degree of biomechanical release from held patterns of restriction, as part of the treatment process. This should be the case whatever the named condition may be, and whatever the age or state of health, since all the constituent elements (modalities) including applied compression, stretching, mobilization etc., can readily be modulated to being applied extremely gently, or more robustly, depending upon the vitality and needs of the individual.

Comparison with constitutional hydrotherapy
In this way it is easy to reflect that constitutional manual approaches such as NMT, GNTT, and massage, should, in all particulars, be considered in the same way as constitutional hydrotherapy (CH). 
In use of CH the standard towel application (potentially involving variations in the degree of contrast of temperatures, and/ or other variables including amount of water in applied towels, length of time in contact with the skin etc) provides the foundation of the treatment. 
Along with the towel application, physical therapy electrical modalities can provide both a standard application or the potential for individualized treatment.  For example, the location of the front electrode during the abdominal electro-muscular stimulation  treatment, can be directed to the stomach, as in the standard approach, or over the umbilicus to treat the small intestine, etc).  Additional phases of treatment, involving different physiotherapy modalities, can focus the treatment to individual needs even further.¹
In bodywork the variables relate to the degree of stimulus offered. Different forces can be employed in physical medicine, and it is obvious that a few grams/ounces of digital pressure will have quite a different effect, and will engender quite a different response, as compared with kilos or pounds of pressure.
The degree of mechanical input, duration and speed, and the rhythm employed, will all modify what could superficially be seen to be a pre-determined set of mechanical maneuvers, where every patient receives the same series of modalities and manipulations.
Instead ,what emerges is a veritable orchestration of the variables to meet the particular needs of the individual.
All symphonies are not the same, even though they involve (more or less) use of the same instruments, and no two NMT sessions, GNTT sessions, or massage treatments, are the same, despite more or less following the same sequence, and utilising the similar therapeutic instruments.

Osteopathic evidence
In considering what support exists for the use of an integrated formulation of non-specific modalities and manual methods, it is useful to reflect on the evidence that has emerged from various osteopathic clinicians and researchers.
In all the examples listed below the term OMT is used to describe a range of approaches including Muscle Energy technique, myofascial release, positional release (Strain/counterstrain), high velocity, low amplitude methods, as well as a number of specific methods that focus on lymphatic and respiratory function ('lymphatic pump').
For example Clark and McCombs¹² have described a selection of basic techniques designed to support respiration, circulation, ventilation, and perfusion, in hospitalized patients, in order to augment recovery following a surgery.
They note that there are numerous examples where osteopathic manipulative treatment (OMT) has been shown to have a positive impact on the length of hospital stay for patients with a variety of diagnoses.
They refer to studies by Stiles,¹³  Radjieski,¹⁴ Cantieri,¹⁵ Noll et al,^{16 17} Sleszynski & Kelso,¹⁸ and others - all of which  show that recovery time from various conditions and situations can be reduced, and length of stay in hospital minimized, when combinations of modalities, clustered under a general heading of Osteopathic Manipulative (or Manual) Treatment (or Therapy), abbreviated as OMT, are used. It should be emphasized that although some of the OMT combinations, may have emerged from osteopathic medicine, most of the modalities incorporated into these general integrated sequences, are used universally by physical medicine practitioners of all schools.
Clark and McCombs note that :

• Radjieski et al’s,¹⁹ randomized controlled study demonstrated that in cases of pancreatitis, length of hospital stay was reduced by about one half when OMT involving 10 to 20 minutes daily of a standardized protocol, using myofascial release, soft tissue, and strain-counterstrain techniques was given, together with standard medical care. Patients who received OMT averaged significantly fewer days in the hospital before discharge (mean reduction, 3.5 days) than control subjects.
• Noll et al^{20 21} applied osteopathic manual methods to elderly hospitalized patients with pneumonia, and the result was that the length of stay in the hospital was reduced from a mean of 8.6 days, without OMT, to 6.6 day with OMT.  Additional benefits in this study, for those receiving osteopathic manual treatment, included reduced  length of use of intravenous antibiotics.
• Stiles²² demonstrated that patient's average length of hospital stay was reduced by roughly one day when appropriate general osteopathic methods were used on bed-ridden patients with a variety of health problems ranging from congestive heart failure, to obstetric and surgical conditions. Stiles observed²³ "In many cases patients with chronic problems thought to be neurotic were relieved. In other cases surgical measures were avoided as a result of structural examination and manipulation."
• Cantieri’s²⁴ study involving hospitalized patients with a variety of diagnoses, demonstrated that OMT, combined with normal medical care, reduced the length of hospital stay by an average of 1/2 a day, compared to normal medical care alone. 
• A study by Sleszynski & Kelso²⁵  compared thoracic pump technique to incentive spirometry techniques, in the prevention of post-operative atelectasis. Thoracic pump was used twice daily while spirometry was used three to four times a day. Both treatments were effective in reducing atelectasis from a 50 percent occurrence rate to a five percent occurrence rate; however the manual methods achieved the result with half the number of treatments, and patients’ recovery, as measured by pulmonary function tests, occurred more rapidly.
• Nicholas & Oleski²⁶ utilised a four-step protocol composed of rib raising, treatment of the thoracic inlet, respiratory diaphragm and pelvic diaphragm in treatment of post-operative pain. They report that: "Patients who receive morphine preoperatively and OMT postoperatively tend to have less postoperative pain and require less intravenously administered morphine. In addition, OMT and relief of pain lead to decreased postoperative morbidity and mortality and increased patient satisfaction. Also, soft tissue manipulative techniques and thoracic pump techniques help to promote early ambulation and body movement."
•  O-Yurvati et al ²⁷ documented the physiologic effects of postoperative osteopathic manipulative treatment (OMT) following a coronary artery bypass graft (CABG), to determine the effects on cardiac hemodynamics. 10 subjects   undergoing CABG surgery were recruited for postoperative OMT. The primary assessment compared, pre-OMT versus post-OMT, measurements of thoracic impedance, mixed venous oxygen saturation and cardiac index. Immediately following CABG surgery OMT was provided to alleviate anatomic dysfunction of the rib cage caused by median sternotomy, and to improve respiratory function. This adjunctive treatment occurred while subjects were completely anesthetized. Results suggested improved peripheral circulation and increased mixed venous oxygen saturation after OMT. These increases were accompanied by an improvement in cardiac index (P < or = .01).  The authors conclude that OMT has immediate, beneficial hemodynamic effects after CABG surgery when administered while the patient is sedated and pharmacologically paralyzed.
• Evidence is exists of the value of a non-specific osteopathic and soft tissue protocol, in treatment of chronic fatigue syndrome. ²⁸

 Clark & McCombs²⁹ , whose perspective derives from osteopathic medicine, observe that the natural sequelae of the cumulative insults to physiology that occur during surgery: "are seen daily in every hospital in America: atelectasis, ileus and venous stasis (edema, deep venous thrombosis, skin ulcerations). Allopathic medicine offers incentive spirometry, early ambulation, continuous passive motion equipment, anticoagulation drugs, and skilled nursing practices to counteract the effects described."
They suggest that early intervention with physical (osteopathic) medicine strategies may avert or reduce such adverse outcomes.
Their objectives in suggesting the physical medicine protocol summarized below are to :
1) Restore the cranial rhythmic impulse to its full rate and excursion.
2) Restore ventilation to full capacity.
3) Maintain and/or restore peristalsis.
4) Restore the third space fluid  (lymph) to circulation.
They suggest that a various techniques can be used to achieve each of these four goals, and that some of the techniques overlap, and meet multiple goals.

Clark & McComb's osteopathic protocol
Observing that the  results reported by Noll et al³⁰ were achieved by using a similar protocol (see below).
The methods employed by Noll et al, where these are different from those selected by Clark & McComb, are listed subsequent to this list:

• Condylar decompression (using a lateral approach if the head of the bed is inaccessible). This technique was also utilized by Noll et al.
• Sphenobasilar decompression (using a lateral approach if the head of the bed is inaccessible).
• Correction of cervical spine dysfunctions utilizing soft tissue technique and, if appropriate, high velocity low amplitude (HVLA) techniques. This approach was also utilized by Noll et al.
• Bi-Lateral rib-raising. This was also utilized by Noll et al.
• Re-doming of the diaphragm. This was also utilized by Noll et al.
• Lumbosacral decompression and balancing of the pelvic diaphragm, as indicated.
• Lymphatic pump, such as the pedal pump (not suitable in cases of deep vein thrombosis, or if there are central venous lines, or the patient is intubated, or if the leg is immobilized in a cast, or other fixation device). Noll et al employed thoracic lymphatic pump methods.

The techniques employed by Noll et al³¹ in treating elderly, hospitalized patients with pneumonia, that differed from the Clark & McComb protocol, included use of :

1. Bilateral spinal inhibition techniques
2. Myofascial release of the anterior thoracic inlet
3. Thoracic lymphatic pump methods³²

Within the framework of this protocol a great deal of flexibility was encouraged, directed by what was assessed in the individual patient. For example Noll et all report that:
"The application of each technique was fitted to each individual's unique somatic dysfunction found on structural examination. For example [those] giving the standardized protocol were able to spend more time applying muscle inhibition, or rib raising, on those paraspinal segments with somatic dysfunction, and less on those relatively free of somatic dysfunction. Where appropriate, attempt was made to achieve local tissue texture changes, myofascial release, or segmental function, before going on to the next region or technique."
In addition to the standardised protocol, Noll et al note :
"To address somatic dysfunction not adequately treated by the standardized protocol, each patient was seen by an OMT specialist, who was allowed to use any technique he felt appropriate to address specific somatic dysfunction."
The variability demonstrated in this example, in which individual needs are recognised within a framework of a general approach, re-emphasises the message mentioned earlier, that although the pattern remains the same this is not a standardised - 'one size fits all' approach.
This focus on individuality was also the case in the 1920's, when naturopaths employed the UNTT approach (as described earlier). Cordingly³³ proposed that the general UNTT should be given, followed by treatment of specific 'lesions', together with use of spondylotherapy, and dietetic counselling.

Rationale for Selection of Techniques used in the Clark & McComb Protocol
Clark & McComb report that the techniques listed were chosen because they are easily administered. Their objective was to suggest that even supervised students could adminster these relatively simple methods, with very low risk to the patients, and a high probability of successful outcome.
They note that the  Noll³⁴  protocol was administered by second year students who had received specific training in use of the protocol for treatment, designed to be administered to postoperative patients.
Clark & McComb observe that :

• The Condylar decompression technique was selected to offset the hyperextension necessitated by intubation, as well as possibly reducing compression and irritation of the vagus nerve pathway through the jugular foramen, so reducing the possibility of postoperative ileus.
• The sphenobasilar synchondrosis (SBS) decompression technique is also suggested to offer benefits in reducing the postoperative effects of anesthesia and intubation. Both condylar and SBS decompression can be applied from a lateral position, if a  hospital bed position precludes access from the head end.
• Treatment to the cervical spine is suggested to be beneficial since the phrenic nerve originates at C3, 4, and 5,  providing as it does innervation to the diaphragm. Neck extension during intubation stresses this area. They note that anecdotally, "many patients with postoperative singultus have dysfunctions of C3, 4, or 5." Manual treatment to this area may help normalize nerve supply to the diaphragm and eliminate the singultus.
• Rib-raising techniques were included in the protocol because of their ease of application and their extremely lengthy use in osteopathy (since 1890). Rib raising improves inhalation function, and helps restore autonomic balance. In addition it encourages  lymphatic drainage through the thoracic duct, and can be beneficial in maintaining and restoring peristalsis
• Redoming of the diaphragm improves respiratory function, stimulates peristalsis, and improves lymphatic flow.
• Willard³⁵  has shown that the diaphragm has significant lymphatic collection structures on its inferior surface, so that the the rise and fall of the diaphragm accelerates the collection of ascitic accumulations in the abdomen, returning them to lymphatic circulation.
• Lumbosacral decompression and balancing of the pelvic floor muscles, may assist in the maintenance and restoration of peristalsis and urinary function.

Noll et al³⁶ Technique selection
In a pilot study in 1999 Noll et al ³⁷ described  the use of OMT in treating seriously ill, elderly, hospitalized patients with a combination of conventional (intravenous antibiotics) and manual methods.
The manual methods used were provided twice weekly as follows:

• Bilateral paraspinal inhibition,
• Bilateral rib raising
• Diaphragmatic myofascial release
• Condylar decompression
• Cervical soft tissue technique
• Bilateral myofascial release of the anterior thoracic inlet
• Thoracic pump methods

They noted:
"All patients were treated while they lay supine in bed. The individuals giving the treatment would sit or stand on one side of the patient and administer paraspinal muscle inhibition and rib raising to the closest side. Then this individual would move to the opposite side of the patient and again administer paraspinal inhibition and rib raising. Next myofascial release would be given to the diaphragmatic area. Then the practitioner would move to the head of of the bed and administer condyler decompression, cervical soft tissue technique, and bilateral myofascial release of the thoracic inlet and the thoracic lymphatic pump. Each standardized protocol treatment was administered for a duration of 10 to 15 minutes, twice daily on Monday through Friday, and once at each weekend. The protocol continued until one of the end-points for the study were reached [normalization of fever, leukocytosis]."
In this 1999 pilot study Noll et al., demonstrated reduced need for antibiotic use (oral and intravenous) and length of hospital stay, when OMT was added to normal medical care.

At this point it is worth repeating  some of  Lederman's³⁸ compilation of evidence for the usefulness of manual therapy in various settings:

• Enhancement of local circulation and drainage ^{39 40}
• Reduction of swelling and improved washout of inflammatory chemicals⁴¹⁴²
• Assistance in normalization of trigger point myalgia ⁴³
• Modification of neural irritation caused by local oedema ^{44 45}
• Assistance in post-surgical recovery⁴⁶
• Encouragement of optimal regeneration and repair, particularly during the remodelling phase of tissue recovery.⁴⁷⁴⁸

How do osteopathic protocols compare with those for GNTT and NMT?
As discussed above, the two most fully described, and studied, osteopathic protocols, in recent years, are those of Noll et al and Clark & McComb.
It is possible to compare those approaches with very early general naturopathic and osteopathic protocols, for example the following approach described by Barber in 1898:

General Osteopathic Treatment (as described by Barber 1898)⁴⁹
"1 . Place the patient on the side; beginning at the upper cervicals, move the muscles upward and outward, gently but very deep, the entire length of the spinal column, being very particular in all regions which appear tender to the touch, have an abnormal temperature, or where the muscles seem to be in a knotty, cord-like, or contracted condition.  Treat the opposite side in a similar manner.
2. With the patient on the back, place the hand lightly over the following organs, vibrating each for two minutes, respectively: lungs, stomach, liver, pancreas, and kidneys.
3. Flex the lower limbs, one at a time, against the abdomen, abducting the knee, and abducting the foot, strongly as the limb is extended with a light jerk.
4. Grasping the limb around the thigh with both hands, move the muscles very deeply from side to side the entire length of the limb.  Treat the opposite limb in a similar manner.
5. Place one hand on the patient's shoulder, pressing the muscles down toward the point of the acromion process; with the disengaged hand grasp the patient's elbow, rotating the arm around the head.
6. Holding the arm firmly with one hand, with the other rotate the muscles very deeply, the entire length of the arm; also grasp the hand, placing the disengaged hand under the axilla, and give strong extension.  Treat the opposite arm in a similar manner.
7. Place one hand under the chin, the other under the occiput, and introduce gentle but strong extension/traction.
8. Place one hand under the chin, drawing the head backward and to the side; with the disengaged hand manipulate the muscles [that are under tension].  Treat the opposite side in a similar manner.  Also manipulate/mobilize, thoroughly and deeply, the muscles in front of the neck.
9. Place the patient on a stool; the operator places the thumbs on the angles of the second ribs, an assistant raises the arms slowly but strongly above the head, as the patient inhales; press hard with the thumbs as the arms are lowered with a backward motion; the patient relaxes all the muscles and permits the elbows to bend; move the thumbs downward to the next lower ribs; raise the arms as before; and repeat, until the fifth pair of ribs have been treated in a similar manner."

When asked whether delivery of a general osteopathic treatment to patients meant that they all received the same methodology, Mary LeClere DO observed (in 1922):
"I have been asked to describe my typical general treatment.  I might reply that there is no such thing as a typical general treatment.  Each patient is a law unto himself, and the treatment must be adapted to his particular needs and characteristics."⁵⁰
The objectives of osteopathic integrated interventions - currently and for over 100 years  - include enhanced respiratory, digestive, cardiovascular and circulatory (including lymphatic) functions - with a broad health enhancement outcome, as evidenced by a variety of studies demonstrating enhanced recovery from surgery and serious illness.

The description of Collins General Naturopathic Tonic Technique (GNTT), by  Cordingly,⁵¹ includes the following elements:

F.W. Collins MD DO ND performing mobilization as part of GNTT (1914)

GNTT (Modified)
Note: Different descriptions of the GNTT list variations in the sequence of modality application, and of the areas involved. Clearly the objective was to cover the territory as efficiently and effectively as possible, utilising soft tissue, mobilization and manipulation methods, as appropriate. The opportunities the use of these methods offered when used this way, to both evaluate and treat the patient, was very similar to those associated with Lief's Neuromuscular Technique use, as described earlier.

1. With the patient lying prone, the articulations of the spine should be mobilised by beginning at the vertebra prominens (7th cervical) and working downward. The articulations of the spine should also be mobilised ('opened'), beginning at the fifth lumbar and working upward . For example L2 and 3 are 'opened'  by placing the heel of the hand against the superior and inferior aspects of the spinous processes, respectively, and then delivering a light thrust, springing movement.
2. Standing at the left side of the patient the right hand should be placed on the right posterior crest of the right ilium, while the left hand cups the underside of the acromion process. The right hand pushes downwards at the same time that the left hand lifts, so opening the articulations of the intercostals on the left.
3. The right hand is then placed on the left posterior crest of the ilium, and the left hand cups the right acromion process, so that the procedure can be repeated, in order to open up the articulations of the intercostals on the right side,
4. Muscular contraction between the ribs are then released inferiorly, beginning at the first rib and working downward, by making-contact with the heels of each hand on each side of the spine, contacting the superior surfaces of the ribs at their angles and springing these in an oblique direction, caudally and toward the floor
5. The articulations of the ribs are then mobilised superiorly, beginning at the tenth pair of ribs, and working upward.
6. Still standing on the left side of the prone patient the circulation of the trapezius, and other back muscles, should be enhanced by placing the right hand on the contralateral anterior crest of the ilium, with the left hand on the right scapula.  Mobilization and stretching (or rhythmic rocking) can be achieved by holding the scapula towards the floor while lifting the pelvis. The opposite side is then treated by changing position to stand on the right.
7. The sternocleido-mastoid muscle is stretched (along with the scalenes and upper trapezius)  by having a heel of hand contact on the first three upper thoracic vertebrae while the head isrotated one way and then the other.
8. Apply 'the famous S-move' (rotating the first two fingers or thumbs deeply in the muscle mass) on the laminae of the thoracic and lumbar spines.
9. The patient lies supine with knees and hips flexed. The colon is then treated, beginning at the sigmoid flexure. Deep kneading is performed of the colon - up the left side of the abdomen, then across the transverse colon, and over the ascending colon on the right side.
10. The abdominal muscles are stretched from the hip to the shoulder on each side, by lifting the pelvis while pushing down just beneath ribs, and vice versa
11. Flex each knee and hip and rotate outward and inward.
12. Stretch the neck muscles and mobilize the cervical region.

NOTES:

• Item 1 would have similar effects to those noted in osteopathic paraspinal inhibition
• Items 2,3,4,5  would achieve very much the same effect as that noted in osteopathic rib raising.
• Items 6 and 7 address soft tissue stiffness, and to some extent influence the thoracic inlet, as in the osteopathic protocol described earlier
• Item 8 would have a similar effect to inhibitory pressure used in the OMT protocol, and would also have a general mobilizing influence
• Item 12 replicates what is done in OMT

GNTT and OMT compared
When GNTT is compared with OMT protocols, the following differences emerge:

• Unlike OMT usage, diaphragmatic release is not a part of the GNTT protocol, however much of the thoracic mobilization and the direct abdominal work would have some influence on this structure.
• Thoracic inlet release is less specific in GNTT than OMT, however a number of the movements are likely to assist in opening this drainage channel
• Specific lymphatic pump methods are not a part of GNTT, although the mobilizations described in its repertoire can undoubtedly assist in lymphatic movement
• Specfic paraspinal inhibitory pressure is not included in GNTT, although the 'S' bend method (item 8 in the GNTT sequence) would to some extent mimic this
• Condylar and/or sphenobasilar decompression are not included in GNTT

Would GNTT achieve the objectives set out by Clark & McComb, to :
1) Restore the cranial rhythmic impulse to its full rate and excursion.
2) Restore ventilation to full capacity.
3) Maintain and/or restore peristalsis.
4) Restore the third space fluid  (lymph) to circulation ?
The first objective is unlikely to be modified by GNTT, however the other 3 are certainly going to be beneficially influenced by this general mobilization approach.

A chiropractic perspective - and dysponesis
Unlike osteopathic approaches chiropractic interventions tend to be more localised, albeit with an intent (and it is claimed an effect) that is far more widespread - as outlined below. In truth much that is foundational in both osteopathy and chiropractic has a familiar ring to the ears of naturopaths.
A basic concept in chiropractic was, and for many still is, that of innate intelligence.
As Masarsky and Todres-Masarsky⁵² observe:
"Assessment of autonomic tone was an integral part of chiropractic analysis from the earliest years of the profession….Disturbed tone was considered the most readily observable manifestation of dis-ease. [This] was understood as a failure of [the] organism to adapt optimally to internal and external stressors because of loss of contact with the inherent organizing principle, or innate intelligence, found in every living organism ………that originated from the ancient idea of vis medicatrix naturae, or the healing power of nature."
The term dysponesis is now used in chiropractic to describe reversible physio-pathologic states, consisting of unnoticed, misdirected neurophysiologic reactions to various agents (environmental events, bodily sensations, emotions, and thoughts), and the repercussions of these reactions throughout the organism.
These adaptive changes, that are capable of producing functional disorders, consist mainly of covert errors in action-potential output from the motor and premotor areas of the cortex, and the consequences of that output.
The concept of dysponesis was first described by Whatmore &Kohli,⁵³ who stated their belief that :
"Most diseases consist of physiologic reactions that lead to organ dysfunction. These physiologic reactions constitute the response of the organism to some noxious agent, whether microbial, chemical, or mechanical."
This sounds remarkably like Selye's hypothesis of  adaptation exhaustion, which fits well with naturopathic thinking, since it incorporates the concept of being reversible.
As Kent and Gentempo⁵⁴ explain ; "Dysponesis relates to human health as a functional whole, rather than a sum of independent parts. It is philosophically and scientifically appropriate for a chiropractor to diagnose a patient with dysponesis, secondary to a vertebral subluxation complex (VSC)."
Masarsky and Todres-Masarsky⁵⁵ note that modern chiropractic envisages the subluxation as being a complex, sometimes termed the vertebral subluxation complex (VSC) in which resulting neural disturbance may lead to hypo-sympatheticotonia, including inappropriate vasodilitation. Associated neurodystrophy involves disturbed axoplasmic flow, and eventual immuno-suppression. ⁵⁶
Normalization ('correction') of the 'subluxation', or the VSC, then becomes the chiropractic key to restoring homeostasis, via focused manipulative methods, usually HVLA, rather than the generalised protocols suggested by those employing OMT, where HVLA might or might not be employed, subsequent to (or instead of) general mobilization.
Examples abound in the chiropractic (and to an extent osteopathic) literature of key areas of dysfunction ('subluxations') being manipulated as a precursor to rapid self-regulating processes manifesting, as a variety of health problems, ranging from pediatric  pyloric stenosis to nocturnal enuresis,  hypertension, perimenopausal symptoms, headaches, pre-menstrual syndrome, and more,  respond and improve.
In chiropractic thinking such responses represent examples of self-regulating ('vis' or 'innate') processes operating. ^{57 58 59 60 61 62 63 64}
Additional changes associated with VSC might include facilitation (hypertonia) of visceral pain pathways, resulting in 'simulated visceral disease'.
Masarsky & Todres-Masarsky conclude with these thoughts:
"Two aspects of the neurological component of the VSC model….are critically important. One is the possible disturbance of the anterior, lateral, or posterior horn of the spinal cord [implying] disturbance of tone throughout the body. The other critical aspect is the concept of abnormal articular nociception and mechanoreception, leading hypertonic or hypotonic autonomic function…….a possible source of systemic errors in energy expenditure (dysponesis)."
Chiropractors do not - as a general rule - offer a selection of general mobilization and soft tissue methods that equate with those described in OMT (above), or in earlier naturopathic protocols such as GNTT (although there are undoubtedly exceptions to this generalization).
Instead much mainstream chiropractic usually operates on the assumption that spinal dysfunctions (vertebral subluxation complexes) have widespread influences on health, correctable by manipulation. Whether these ideas can be fully, or only partially, reconciled with naturopathic beliefs is an open question, however in one essential they do totally agree, since all benefits are ascribed not to the manipulation, but to self-regulatory responses (innate) that follow from appropriate manipulation.

How would Lief's NMT methods compare with the OMT protocols?
Lief's NMT covers the territory from the cranial base to the mid-thigh, anteriorly and posteriorly, in its assessment mode, and incorporates methods such as Muscle Energy technique, Myofascial release, Positional release techniques, inhibitory pressure, rhythmical oscillatory motions, and a number of the lymphatic pump techniques, as well as joint mobilization, and if necessary HVLA manipulation,  in order to balance and normalize any dysfunctional patterns uncovered  during the assessment.
It therefore has the potential to offer - depending entirely on what dysfunctional patterns are elicited during assessment - all of the therapeutic inputs described in the OMT studies above, and possibly a number not described. Lief's methods are described in Chaitow L. Modern Neuromuscular Techniques (Churchill Livingstone, Edinburgh  2002)

And what about massage?
The list of conditions that have been shown to be helped by means of application of non-specific ('Swedish' or 'Wellness') general massage is so comprehensive that it is safe to say that this is a form of therapeutic input that should/could be offered to all patients, of whatever age or gender, or level of wellbeing or illness.
The very nature of massage ensures that, if applied with thought, compassion and appropriate intent, it can/must:

• improve circulation and drainage
• reduce levels of anxiety so improving autonomic function
• encourage enhanced respiratory and digestive function
• in general ensure that self-regulatory activities operate more effectively.

The Naturopathic context
In the context of a naturopathic therapeutic encounter, in which biomechanical, biochemical and psychosocial influences on health are being considered in relation to the patient's health concerns, a general, non-specific manual protocol may be seen to have a great deal to offer.
Irrespective of the foundational causes of the health problem, there is commonly going to be a requirement for enhancement of respiratory, digestive, circulatory, drainage and/or immune function.
The fact that evidence exists for such approaches being successfully and beneficially applied, and that there are studies validating integrated selections of modalities, offers confidence for routine inclusion of such methods in naturopathic practice.
The basic naturopathic injunctions to work with nature, to encourage self-regulation, and to do no harm, are all met by the appropriate application of NMT, 'Wellness' massage and/or GNTT - or one or other of the OMT protocols outlined above - all of which can be seen to be thoroughly naturopathic.