Dermoneuromodulation: Neurodynamics, tunnel syndromes, cutaneous nerves.

Peripheral neurodynamics

In 1998 I attended David Butler's "Neuromobilization" workshop. I must admit, I was not orthopedic-y enough to be about to translate everything he was teaching into a "spine-out" logical flow. I admit to always having been an outside-in sort of interactor therapist, both physical and manual. I was called on the rug during clinical training for thinking it made sense to work with stroke patients by working with their hands first instead of their trunks. But's that's a whole other story.
Michael Shacklock, another ortho person turned neurodynamic guy, was dedicated enough to bring back to life the original book by Alf Brieg, Adverse Mechanical Tension in the Nervous System. (It's mostly about spinal cord neurodynamics, of more interest to ortho-types of manual therapists, deep into structuralism, steeped by it, than it is to me, who has always stayed more outside the spine, conceptually and operatively. I prefer to affect the nervous system from its sensitive surface membrane, also ectodermal in origin, i.e., the epidermis and related exteroceptive and interoceptive capacity of its many sensory endings.)

Yet, as I sat in Butler's class, I felt my manual therapy worldview cave in - everything he said in terms of nerves, what they were about, how nociception became established, then amplified inside them, inside the system itself, made such sense it took me over completely, and I've been a nerve girl ever since, never gave "tissue" a second thought after that, especially fascia. Everything he said was congruent with another body of knowledge I had examined, embryologic development. You know those pictures that fool the brain into seeing two things at the same time, and you think you see it one way, but suddenly it looks like something else entirely?
That was me. I hadn't seen the rabbit for looking at what I thought was the duck. Abruptly, I graduated from what I call my "mesoderm" phase, and plunged headlong into an "ectoderm" phase from which I'll never emerge. Because at least now we're talking about the right kind of 'tissue' -  skin, nerve, neural container, spinal cord and brain - all direct derivatives from ectoderm, all concerned with "management" of an organism. Not structural space-filler/moveable puppet part and their glued-together connectedness (bone, joint, muscle, tendon, ligament, fascia). It's all a lot more complex than this, of course, with different parts of the nervous system doing different jobs, and different parts of the brain running various subsystems of visceral afferent/efferent function, autonomic function and so on, but at least now, we no longer need to entertain the crazy idea that innocent tissue "causes" anything like "pain" or try to prove somehow that there is any sort of correlation between what we might do with our hands, when working with people, and any sort of pain reduction, based on having magically affected some sort of deeply buried "structure" with some goofy operator model of treatment, whether vitalistic or structuralist - that dualistic Descartes combination. It's about nervous systems interacting with each other, and stress reduction. How simple is that?


In 2007 I was fortunate enough to gain access to an anatomy lab and dissect out cutaneous nerves, which were the ones that interested me! They have feelings too. In live people that is. Michael Shacklock published a few of the photos in his newsletter. I wrote up a paper about it that is yet to be published somewhere. But, at least, it's now been done, and I figure, pulling gently on these little rami likely has some sort of beneficial effect on intrinsic circulation well up into the nerve they are part of, all the way up to the first synapse (neurologically) or into the dorsal root ganglia, maybe (physically, mechanically), especially if you handle body parts simultaneously, and make treatment stress free for the patient by eliminating gravity as much as possible.


Which brings us to the topic of tunnel syndromes.


I think that covers the topics on the right side of the dermoneuromodulation diagram, under "physicality".  These are the considerations I have while treating as a manual therapist. I'm still "operator" model enough to need to think about something physical as I treat. I'm not zen enough to be completely content-free, pure interactor.  Not yet anyway. But I'm a lot less "physical" and a lot more "therapist" than I was, once upon a time.


1. Michael Shacklock Clinical Neurodynamics
2. Dermoneuromodulation treatment manual (first draft) Diane Jacobs

1. Dermoneuromodulation (diagram, gearing up)

2. Dermoneuromodulation: Where it came from

3. Dermoneuromodulation: Ruffini sensory endings and dorsolateral prefrontal cortex

5. Dermoneuromodulation: The neuromatrix model of pain

6. Dermoneuromodulation: Ascending pathways

Projector? Or movie screen?

In "Yet another trigger point discussion" I discussed some of the comments in the long long comment section in Mike Reinold's blogpost about dry needling.

The trigger point true believers and dry needlers seem to think sore spots in the periphery are the "cause" or "source" of "pain."

This is a flawed mental trajectory, backward, inside out, upside down, and, well, just plain wrong. It supposes the following:
1. Set of tissue circumstances (not yet shown to be "real) --> "pain".
2. Solution: jab the tissue --> reduces "pain"
3. Mechanism? I don't know. Punishment of the body for merely existing?

A different (better-informed by pain science) mental trajectory is as follows:
1. Nervous system affects tissue; nervous system gets stressed, tells tissue the "wrong thing", tissue tightens up, possibly via efferent capacity of visceral afferent neurons into somatic tissue, especially cutis/subcutis (which is very thick) and neural tissue itself (peripheral nerves contain a lot of non-neuronal tissue).
2. Sore spots can be found on palpation.
3. They are the result of "pain" processing (i.e., they are areas of hyperalgesia secondary to central sensitization), not primary "causes" of pain.


Blaming tissue for pain is like blaming the screen for a bad movie, instead of the projectionist. Then poking holes in it to try to change the movie. It seems.. I don't know.. sort of futile, superstitious even.

Not to say peripheral soreness can't be "treated" however - a sore spot is just the peripheral end of a continuously looping verb called the nervous system - it usually will respond to exteroceptive attention paid to it, take advantage of novel stimulation to self-regulate/improve output behaviour. It can be projectionist, screen, movie, all the actors and directors and producers of any given movie, all at the same time.

Tissue though, tissue is just a surface acted upon from within. It does not act unless instructed to do so. And it is entirely innocent where pain is a problem.

TEACHING PEOPLE ABOUT PAIN

90 minute slide presentation by Lorimer Moseley, David Butler, Mick Thacker and Adriaan Louw, from WCPT 2011.

I took a look around in the abstracts from WCPT, and found an interesting poster abstract under "Pain Management" (see image). Here is a better link to it.

I'd like to point out a simple concept known as "mutual exclusivity". This means, two ideas can be so incompatible, so contradictory, that they can't both be true at the same time.

So, what is a person supposed to believe? A meat theory that has at its core a bunch of ritual behaviour, i.e., poking at never-proven-to-exist "trigger points" in "muscle" with needles? Or a nervous system based theory that has demonstrated its veridicality as seen in the screenshot of this abstract, where results from needling are obtained whether the needles are put into a real hand or a rubber hand? They cannot both be right.

Look. Here's the thing: if you took the entire human nervous system and laid it out in a straight line, it would be 100,000 miles long (Angvine). If you are a manual therapist or a needler of some persuasion or other, you would be at one end of that long line, the "affective" end. At the other end would be the "effector" function of that nervous system, which consists of output to muscles, joints, tissues, everything. Anything you might do to it has to go through the whole long system before any change can happen in the tissue you hope to "affect". In other words, you can't "do" ANYthing directly to tissue, without the nervous system's permission. The only reason a nervous system doesn't look linear is because it's all cleverly folded up into something that looks like a human organism.

David Butler Blogs

David Butler is a PT pain pioneer from Australia. He is researcher, clinician, university professor, and author of three books, two for therapists and one for people with pain. His website is www.noigroup.com ; there is a discussion forum attached to his site which has, alas, been closed for some time now, although it can still be accessed for reading.

This fall he began to publish three blogs. One of these is on Neuromatrix Training. The other two are linked into the banner of this one. I've also linked David's blogs into the menu on the right. Pay him a visit - he has much to offer.

I met David about 10 years ago as a participant in one of his dozens, possibly hundreds, of workshops he has taught all round the world. He certainly lit a fire under my brain, but I seriously doubt I'm the only PT to have been so affected. Carry on David, carry on.