Monday, March 12, 2012

Guest post at on Dermoneuromodulation

This is a copy of a guest post on dermoneuromodulation Joe Brence asked me to write for his blog, ForwardThinkingPT. com published earlier today. It contains the DNM roundup from yesterday.

I want to thank Joe for the opportunity to write a guest post for his blog about dermoneuromodulation. Even though I’ve been writing about it in one way or another for many years, it is hard to encapsulate this in under 1000 words and still be able to convey what I think needs to be conveyed. So, what I've done is present a brief outline, with a list of links at the end to blogposts, which discuss the topics in more detail, and which link to other posts for even more detail. 
HISTORY OF THE TERMThe term originated with a little bit of help from SomaSimple friends in the mid-2000’s as I struggled, as we all struggled, to become more conscious and articulate about manual therapy in general, and discuss problems inherent within it. David Butler’s neuromobilization workshop in the late 90’s, and discovering Melzack’s neuromatrix model of pain in 2003, plunged me into cognitive dissonance from which I have yet to emerge. In 2006 a colleague at the U. of Saskatchewan, and I, began a case series study (scheduled for write-up/ publication this year). Results indicated "weak but statistically significant" results, about what one would expect from a case series on any kind of manual treatment.
MEANING OF THE TERM: The word “dermoneuromodulation” simply means skin/nervous system/change. It does not imply that the practitioner is the one “doing” something called “change” “to” something anatomical in another person. It does not exclude the nervous system of the patient as change agent under its own auspices, thus DNM is as close to being an interactive model of manual care as opposed to an operator model as any kind of manual therapy approach can be, while still handling bodies of other (live, conscious) people. Other than “skin”, the surface all of us touch regardless of whatever else we might conjecture about what we are doing/affecting/handling, sensory endings, and cutaneous nerves, there is no mention of “tissue”. 
OPERATOR VERSUS INTERACTOR MODELS IN MANUAL TREATMENTI have considered this quite closely, and all I want to say about it here is that I think, in the clinic, one should know when one is in one mode or the other, and be fluent in both. 
NERVOUS SYSTEM: Bearing in mind that we are treating live integral humans, conscious, awake, and usually presenting with pain , we have to (I think) consider their nervous system, and focus on creating a context that will favour their ability to change how they think and feel about their pain. We should share whatever information we may have about what “pain” is, how it behaves, with the patient, so we can both be on the same page. I wrote an extensive series of blog posts about developing the therapeutic container, called “New treatment encounter”. I present the nervous “system” as a signalling entity woven throughout the body, derived directly from the embryonic “builder”, ectoderm, continuous in a human adult from skin cell to sense of self. 
NEUROMATRIX MODEL: New Treatment encounter Part VI is specifically about the neuromatrix model, understanding it’s use for treatment, getting clear about our inputs (including manual therapy), and what we want to see happen with outputs. An elaboration of that can be found here
TUNNEL SYNDROMESPain experienced as persistent or recurrent and relatively localized (i.e., most mechanical “MSK” pain) is conceptualized as nerve pain.
NEURODYNAMICS: Peripheral nerves come all the way out to supply skin, sooner or later, proximally or distally, making them fairly easy to affect mechanically regardless of where or how one makes contact with skin. 
PERIPHERAL DISSEMINATION OF CUTANEOUS NERVES: A dissection of cutaneous rami done in 2007 revealed the macrostructure of cutaneous rami to the underside of skin
SKIN CONTACT: Skin is well supplied with exteroceptive receptors of all sorts and fibers that transmit information to the brain using fast dorsal column pathways and non-nociceptive slow spinothalamic pathways, to centers in both the internal regulation system and the primary sensory cortex of the brain. As long as the handling is mostly non-nociceptive, it will be physically safe for most pain presentations. A sensory ending known as the Ruffini ending is particularly capable of transducing lateral stretch to skin. It is slow adapting, which means it will actively fire the entire time a skin stretch is held, allowing the nervous system time and stimulation to alter its motor output and pain output at spinal cord and more rostral levels. 
IN SUMMARY: Research in manual therapy tells us that there is little or no interrater reliability for palpation or application, little or no agreement on what constitutes the overall best approach, and that success in terms of favourable outcomes depends a lot on context and treatment relationship. Applications differ widely in amount, intention, length, depth, angle, and zone of contact. I am of the opinion that manual therapy is optional, yet often may be optimal, to acheiving successful outcome in terms of pain reduction and movement improvement. The real trick in treatment is to leave the locus of control with the patient while still providing them with professional physical contact as required, by them, as individuals, in the moment, and within the context of a therapeutic relationship. I do not know what should be ruled out in order to show the world that manual therapy is useful; I only think that these items I’ve discussed should be left ruled in.
1. Dermoneuromodulation (diagram, gearing up)
2. Dermoneuromodulation: Where it came from
3. Dermoneuromodulation: Ruffini sensory endings and dorsolateral prefrontal cortex
4. Dermoneuromodulation: Neurodynamics, tunnel syndromes, cutaneous nerves.
5. Dermoneuromodulation: The neuromatrix model of pain
6. Dermoneuromodulation: Ascending pathways

Submitted by Diane Jacobs, March 11/2012

AFTERTHOUGHT: 7. Therapeutic Domain

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