Skin stretch (DNM), Neurodynamics case studies thread

[kongen]

Hi all!

I'm currently in the process of trying to grasp the different aspects of applying skin stretching (DNM) and neurodynamics (sliders and tensioners) to help resolve pain in the patients I'm seeing (being freed from muscles, joints and all that :-)). I'm digesting Butlers and Shacklocks books at the same time. I'm sure there are plenty of both active and passive members here having the same goals as myself.

Trying out new things with patients, succeeding and failing is all part of learning new concepts and improving onces practice.

I know that having a good basic understanding of neuroanatomy and physiology is key to succesfully applying these concepts. Having said that, I for one, often get an "aha!!" moment when reading the experiences and reasoning of others.

I would like to present an idea for a thread containing short, simple case studies/reports describing treatments of patients in pain, where the clinician has reasoned that mainly interventions with DNM and neurodynamics helped to resolve the complaint of pain.

The aim of this thread would not be to "increase the tool box", or forming some "recipe treatment" for different conditions, but help with creating a deeper understanding of these concepts/methods and how they could help our patients.

What do you think?

Anders.

[Diane]

Anders, a column such as this would be a very welcome addition on here. Go for it!

[nari]

Go for it, Anders.

Nari

[BB]

:thumbs_up

[Javier Gonzalez]

I think is a great idea.

[Xaniel]

First case:

20 year old female complaining of low back pain during sitting in a car and sitting in a lecture. Hypothesis: Smells like "slump". First I checked the PAIVMs and found nothing. That means IV+++ and no complains from the patient. Next I checkes the slump and BINGO.
All I did was teaching her to do the slump slider and how to change her posture when sitting in a car and/or a lecture. That was it! I saw her 4 times over all and every time we worked on the slump only. She then was free of comlpains.

For me that is a typical case for neurodynamics-only-treatment. What should be wrong with the back (bones, ligaments, etc.) of a 20yo?
There are some more cases in my files at work but now it is too late for me - have to go to bed. But more is to be come...


Xaniel

[nari]

Anders, a good example.

If the woman had been 50 years old, what difference do you think that would have made, if any?

Nari

[bernard]

A young case of mines:
A 15 yo sportive (Tai boxe) boy "stretched" his knee over the limit. The surgeon diagnose was a "definite" ACL problem but I found the other side flexible as the R painful one.
MRI negative and walking hurts and running is made impossible.
No neurodynamic signs: Only a slight IR problem. Pain was located on the interior side of the knee.
The boy was sent 3 months after the initial injury.

I tried "normal" neurodynamics but failed to improve the condition until I suspected it was a small but superficial nerve problem => Stretched and a session later, nothing.

I was fooled by the initial diagnose and the injury condition. :embarasse

[kongen]

Hi all!

Thanks for presenting some cases! Interesting reads..

Sorry for not kicking off this thread myself, but I think the following case is interesting and I sure do remember it well :)

A middle aged woman came to see me for anterior right shoulder pain, with occasionally radiating pain to the lower arm and fingers. She had difficulty determining which fingers. Almost all her shoulder movements was painful and restricted by pain. She also complained of weakness. Symptoms had gradually developed over the previous week, and was now severly limiting her function. The shoulder was also aching at night. No complaint of neck pain/restriction. No history of truma.

Proceeded with standard orto tests for the shoulder, but very quickly realised this was not going to lead anywhere. Upper limb tension tests were difficult to interpret because of pain.

Layed her down in prone, and palpated the neck. Pressure over the facet joints of c5-c6-c7 on the right side reproduced her anterior shoulder pain. She was overweight and had quite a "thick" neck, so accurate palpation was very difficult. I proceeded to mobilise the segments with postero-anterior pressure, which reproduced her pain, but it did not change.

Explained my findings and that I thought that her pain was coming from the nerves themselves etc.. Scheduled an appointment in 2 days, but it left me with the feeling of not having accomplished that much.

Saw her 2 days later, she was amazed and reported a dramatic reduction in pain and improvement in movement the morning after our previous treatment. She had a very minor "feeling of ache" remaining in the shoulder. I repeated the treatment and told her to get back to me if the symptoms did not completely resolve. This was 2 months ago.

Neurodynamics at the nerve root (ginger style)? DNM?

[Xaniel]

@nari:

For me and my clinical reasoning there is a difference between a 20yo and 50yo indeed. I assume that the 20yo has young healthy joints in mint condition and the 50yo does not. Over the last two years I often saw young people - mostly female - in the age between 12 to 23 with referred pain and/or a headache as well. The P/E of that kind of patients often lead me to the conclusion that there is nothing wrong with their muskulo-skeletal system. That is why I started to put neurodynamics on these patients. Now, for me this is a typical clinical pattern. There is another case which may explain my clinical reasoning:

12yo female, very sporty, quite tall for her age. She complains of a headache that often forces her to take a nap right after school. My thoughts: young tall female - biologic growth goes in episodes not linear - let us do a slump test. And that was it. She performed a cervical slider for homework and after a couple of weeks she was just fine.
By the way: There may be some physios which may go directly to the muskulo-skeletal structures of a 12yo girl, but not me. That is what clinical reasoning and life long learning told me.


Xaniel

[nari]

Xaniel,

I would still look at the neurodynamics of a 50 yr old first. A joint not in mint condition can still be blameless for pain!

Mobilisations do work; but it is tough on the PT and I suspect CMs ginger-style could be tough on the patient as well. But I have no doubts that they work - I have resolved persistent headaches on pts with 5 minutes of post/ant cervical movement at C1C2. I suspect it has absolutely nothing to do with the 'joint' or whatever else is hanging around subdermally.

58 yo woman with increasing loss of internal and external rotation in the (R) shoulder; night pain; pain and stiffness present for about 4 weeks. Abduction about 60 degrees. Scapulohumeral rhythm decreased. Intermittent back pain, since about 8 weeks ago. No history worth looking into.

ULNTTs all positive but unable to be completed - proximal movements only.
Proceeded with distal work, and crept up from there. After about three weeks, one session a week, ROM improved, pain slightly less at night.
After 6 weeks, pain gone and ROM rapidly resolving.
All I did was education on pain and movement based on ULNTT1 and 3. No ROM exercises; no gadgets; no pressure to perform.
Shoulder pain and back pain resolved after another week or so. Patient became fully functional in her job as a fulltime carer for her disabled husband.

Nari

[aburton]

Being new to the site. I want to thank you for the case studies. Just wanted a bit of clarification on what a cervical slider and slump sliders are.

Thanks again.
Alice Burton, P.T.

[kongen]

Nari,

In your case, did you give the woman any homework? Or did you only work on her neurodynamics in the clinic?

Anders.

[Xaniel]

Welcome Alice,

here is my "slump slider" for you

http://www.pt2001.de/hideout/SEQT0301-small.JPG
http://www.pt2001.de/hideout/SEQT0302-small.JPG
http://www.pt2001.de/hideout/SEQT0303-small.JPG
http://www.pt2001.de/hideout/SEQT0304-small.JPG
http://www.pt2001.de/hideout/SEQT0305-small.JPG
http://www.pt2001.de/hideout/SEQT0306-small.JPG
http://www.pt2001.de/hideout/SEQT0307-small.JPG
http://www.pt2001.de/hideout/SEQT0308-small.JPG


Xaniel

[nari]

kongen,

Doing 'homework' is fairly important, but with neurodynamics, one has to be soooo cautious because patients get carried away and think more is better.
From memory, 5 repetitions of proximal contralateral neck flexion; no holds even for a second; then, after a pause, some distal work: wrist, fingers.

Altogether about 40 seconds of "work"; then an hour later, or thereabouts, another 40 seconds or so. She was to visualise what the nerves were doing, and forget about muscles and joints and things. This adds to the care and softness that must be taken with neurodynamics, especially in the upper trunk.

Everybody, of course, is different, so no one patient ever had the same program as another.


Nari

[aburton]

Xaniel,

Thank you for the picture of the slump slider. At least I was thinking along the right track but wanted to verify to make sure I wasn't assuming...
Thanks again.

Alice Burton, P.T.

[nari]

Thanks also, Xaniel. Good photos.

It may be helpful for the person performing the slider to rest the extended leg on something; if the sliding progresses more distally, it is easier for dorsiflexion of the ankle if the leg is supported.
The same applies to the upper limb; resting the arm in a ULNTT position, well short of pain, on a cabinet or table or similar makes things easier.
Just a suggestion I found useful.

Another useful position for posterior lower leg pain is to sit with the affected leg crossed over the thigh of the other leg. If that starting position is well tolerated, progression is controlled more easily to forward neck flexion/ext plus or minus ipsilateral knee/ankle movement.
If the starting position is not painfree, then it can be a technique on its own, with or without lumbar spine extension/ neck flexion/ etc.

Nari

[Xaniel]

Thank you, nari! Sometimes you go blind by doing the same things every day again and again...

One question to the second part - I think you want to add ADD and IR of the hip: Do you position the hip more in F (e.g. plant the foot on the floor) or in E (e.g. just lay one leg over the other)?


Xaniel

[nari]

Xaniel,

I am not sure what you mean...if the (R) leg is crossed over the (L), then it is already adducted and internally rotated, slightly flexed beyond the basic sitting postion, and the foot cannot reach the floor.
It is a starting position which challenges the sciatic path to begin with, which is why I mentioned it as a treatment position.
Maybe you and I are seeing different 'leg crossings'?

Nari

[mike]

I all!
During treatment with DNM I have very often felt a pulsation under my monitoring finger.
The pulsation usually starts after a minute or two and I wonder if others have had the same experience?
Could it be that after a while when the skin is being stretch further my finger end up palpating a vessel or is it really more circulation to the area that is being felt?

Regards
Mike

[Baecker]

hi

i experience the same i feel like under my finger stuff is moving/wobbling kind, actually i wait for that to proceed to next spot. But i am sure Diane has more insight and experience with it.

[emad]

Well , in Pain-state the blood supply and venous return change ,the issue of feeling pulse in touch I have not experienced ! however ,which finger are you using ? thumb or idex ...which area are you treating ? Is that general in any area applied to it DNM !

In medical literature regarding headache ,there is a category of pulsating headache .

I think the issue needs scientific study or research for assessing pulsating in pain and non-pain state .

cheers
Emad

[EricM]

Mike,
The pulsing, bubbling (just don't call it a release!) you feel under your finger is common in my experience. I like to ask the patient a) if they feel it too, and b) how they are feeling about that area at that time. Not all will feel it but invariably they will tell you they feel good. So whatever it is, it can't be a bad thing. Hang on to that spot for a little while longer and you're bound to get some good lasting changes there.
My guess is it has to do with either blood flow or a reorganisation of muscular contractions within the area.

[Diane]

Well, about that pulsing; I think a clue may be gained by reading this thread, Control of the Cutaneous Vascular System by Afferent Neurons (http://www.somasimple.com/forums/showthread.php?t=4041), a book chapter out of Autonomic Innervation of the Skin. In it's summary it states: The experimental data surveyed here identify a group of fine primary afferent neurons to be involved in the control of microcirculation and thereby disclose a significant, new aspect for the neural regulation of the cutaneous vascular system. Pharmacologically characterized by their sensitivity to capsaicin, these afferent neurons take part in the autonomic control of vascular functions by way of release of vasoactive transmitters from their peripheral fibres. There is multiple evidence to implicate CGRP as the principle transmitter of afferent nerve-induced dilatation of arterioles whilst SP is the major mediator of increased venular permeability. These peptides regulate vascular effector systems both by an action on the vessels themselves and by interaction with other microvascular control systems. The dynamics of this interaction change with time, and imbalances in the interactions are liable to cause pathological changes in the vascular system and in mechanisms depending on the vascular system. I must confess that I didn't realize up to now the extent to which blood flow is controlled locally, in the skin, by afferents, ones we are likely stimulating. These are nociceptors, but as long as we don't hurt the patient, i.e., stimulate nociception so much that the patient's CNS can't keep it out of his or her insular cortex, the patient won't mind his or her nociceptors being stimulated peripherally to drop out substance P or Calcitonin gene-related peptide to increase either arteriolar or venular activity. :)

I suspect the "pulsing" comes from some sudden activity of mini-vasculature, based on this information, but of course I don't have access to a physiology lab set up to determine the physiological effects of manual treatment. Too bad. On the other hand repeated mechanical stimulation was shown to have an effect of some kind. It's in that chapter somewhere.

[Diane]

Here is something else, from Chapter 8 (http://www.somasimple.com/forums/showthread.php?t=4093), which I am currently bringing.
SMOOTH MUSCLE RESPONSES

Sympathetic efferent activity can produce contractions of pilomotor muscles and contraction or relaxation of vasomotor muscles (Bell et al 1985; Roberts and Foglesong 1988; Jänig 1991). These mechanical responses may change the pressure acting on mechanosensitive afferents and/or may change the mechanical compliance of tissues in which afferents are embedded, thereby producing changes in the excitability of the sensory receptors/skin complex to extrinsic mechanical stimuli (Figure 8.2).

When one considers that sympathetics are all there are out there in the cutis/subcutis in the human, it begins to make sense that there could well be organism problems with the dual functions that sympathetics have to do. Makes me wonder if our big brains might have evolved to be big just to cope with/suppress effects from some random little glitch-like mutation that would have rendered us helpless otherwise, bogged down by incoming conflicting interoceptive information that would distract us from the important things in life - survival, finding food, finding mates... i.e.: danger? Vasodilate. Danger? Vasoconstrict. How weird really, that our fight/flight mechanism has to do both but not at the same time. Other animals have it a bit easier perhaps.

[Sarah]

Yes, I often experience this twitches and pulses, which is what I refer to as the patient's nervous system talking (in layman's terms). I agree that it is wise to hang out there a little longer until the movement is done. While the microcirculation aspect is interesting, I find it difficult to fathom that one could palpate such a tiny arteriole pulse. I have difficulty palpating a radial pulse on some people! To me, it feels more like fasciculations in the muscle fibers, maybe just a motor unit or two, depending on the size of the muscle. Any other theories?

Sorry to high-jack your case study forum Kongen! I'll add a case if you'd like: 65 yr-old thin female with history of severe radiculopathy years ago on the same side, diagnosis lumbar DDD. c/o pain in left SI joint region sometimes radiating into the thigh and lower leg, worse first thing in a.m. No apparent change with traditional spinal treatment. Positive SLR and Slump. Gave her sliders first in supine, then in slump position as tolerated. Pain resolved in 2 weeks. Easy one, I know, but the only case I can recall in enough detail right now. I'll jot some more down at work next week and bring them here. I've got some real complicated patients currently.

Sarah

[mike]

Interesting indeed, thanks for the references!
I have actually compared the pulsation with the patients heart rate on some patients and found that that it is the same as the pulsation I experience under my finger. I did this to rule out the possibility that it was my own pulsation that I was feeling. It feels like this is something good and that you should hang on to that pulsation for a while.

Regards
Mike

[Diane]

Patients can't really feel it but it's easy enough to feel through fingertips. I think it's easier to feel than regular pulses, but it's very unpredictable, so there's no point in trying to measure it I guess. It might not be one arteriole Sarah, but a whole bunch at once in a cluster - at least it's a possibility should it turn out some day that it's arteriolar change based on CGRP release by nociceptive afferents secondary to mechanical input.. or venule change based on SP release by nociceptive afferents secondary to mechanical input..

[kongen]

Sarah: no worries! :) I have not had the time to follow up with my own little case studies yet, still working to incorporate DNM in my treatments, and as I use it together with other techniques, it is difficult to measure what effect it has.
I also feel pulsations under my hands/fingers, and I have tried to make sure that its not from the patients breathing cycle and my own ideomotion. I've had some success with a "SI-joint separation mobilisation" in prone in patients with acute low back pain and a positive active straight leg raise (pain and impossible to lift leg even a couple of centimeters). Quite interesting..

[mike]

Any suggestions for treatment of the anterior and lateral cutaneus nerves?
I have tried to "shut them off" with skin stretch over the belly in a lateral stretch but had a hard time making any differences with this particular patient.
The patient hade pain in the lumbar that we resolved, but now he feels more pain lateral/ventral toward the groin.

Kongen,
Was the "SI-joint treatment" a static skin stretch over that area or was it a dynamic mobilisation i.e SI-joint mobilisation?

Mike

[Diane]

Mike, check and rule out or treat if necessary iliohypogastric (http://www.somasimple.com/forums/showthread.php?t=2772).

There are other "groin" nerves to deal with. Sidelying is a useful position in which to treat pesky long superior cluneal nerves that dangle down as far as or over the trochanter. Don't forget lateral cutaneous nerve of the thigh.

[kongen]

Mike:

If I were to "mobilise" the left SI-joint, I stand on the right side of the patient, with my right hand just medial to the left SIPS "pushing" it laterally, as if I were to gap the joint. At the same time my left hand is applying a PA pressure just medial to the right SIPS, on the sacrum. I always start very slowly, only taking up the slack in the skin, and see if I can sense pulsations and then I hold for a little while, and monitor the pain (as the patient often have pain just lying in prone). After a few minutes I apply an oscillating movement, to see if this affects the pain. The pressure is really gentle, so I believe the effect can not be explained only by movement of the joint.

I use this primarily on patients with painful ASLR. I retest ASLR after applying the technique and have in all cases seen less pain and increased ability to lift the leg. On the next visit (usually 3 days) the patient is always considerably improved both in pain level and functionally.

Try it and let me know how you do!

[kongen]

Just to add:
After retesting ASLR and seeing an improvement, I stand the patient up and have them walk around and they usually report less pain and increased ability to walk etc.
Would manipulation of the joint produced the same or even better effect? Maybe, but this is a far better alternative in my mind, and can be applied to ALL patients.

[Diane]

I seriously doubt you are moving SI kongen (I doubt it's necessary in the first place).

It sounds like you are "mobilizing" the medial cluneal nerves, on the right side anyway, which just happen to fan out over the SI zone, and probably the medialmost superior cluneal nerve. On the right side you are affecting iliohypogastric. So congratulations. Your mental focal length is a tad deep, but otherwise your hands sound good. Especially, if you feel that weird little pulse.

[kongen]

Diane, I also doubt that I'm moving the SI-joint and that the effects I see probably come from affecting skin only. Give me a few more months and I will be a total convert :) Old habits die hard..

[Diane]

:) Take all the time you need.

[Diane]

Here's a case from the last two weeks.

Woman, 38, fit, desk job, pain in left shoulder for 10 years, made worse by work, slow onset but worse after caring for a 10 month old baby, holding him while sitting upright on a bouncy gym ball (which the baby found soothing enough to go to sleep) for many cumulative hours, until her shoulder got so painful she could no longer sleep lying down, at which point she decided to get help.

First visit: neck range restricted especially left rotation. Left shoulder range a bit restricted in elevation but good IR. Pain mostly interscapular left side and at medial upper angle. Working dx, entrapment dorsal scapular nerve, and some of the dorsal cutaneous nerves (especially T2 - it's long.)

Treatment: cleared occipital nerves and superficial cervical plexus first, as usual, moved on to dorsal cutaneous nerves of neck and upper T spine, then dorsal scapular nerve.

Visit number 2 a week later: Patient reported feeling 97% better (she came up with that). She could sleep laying down again, and it make a gigantic difference to her sense of well-being. O/E she still had restricted neck rotation to left. Spent an hour treating the various bends/twists/depths of dorsal scapular nerve. At the end of the hour, she had full neck range, no pain. Discontinued with home program of ideomotor movement.

[mike]

Kongen,
Your technique sounds very much as DNM since you hold on for a few minutes witch is good (time for the brain to change its output). Thank you for your explanation.
It would of course be interesting to see if the patient felt better even without the oscillating movement. We can try that and report here what results we got. I do the same thing i.e end up doing oscillating/mobilisation movement after or before DNM just to be sure that the patient doesn’t feel that “I didn’t do anything”.

Mike

[jlsmithivan]

I am really enjoying this thread. I find the DNM ideas logical and fascinating. i intend to most certainly share some case examples but had to share that i just returned from a strain counter strain course that (that i was delegated to attend) and i now find myself speculating that some of their ideas may be of some value in the DNM approach. i most certainly do not want to at all drag the discussion off track and particularily want to express my appreciation of your thoughts. i can't at the moment think of a case to share that is of sig value compared to cases already presented, but i look forward to stepping forward and sharing further as time allows.

[Diane]

Hi jl,
I learned SCS out of a book a couple decades ago. Most of the positions I could not attain (not built long-limbed like Jones), and developed my own, eventually evolving what I do now. I think (it gradually dawned on me) that most of the SCS techniques target cutaneous nerves, especially at the "grommet holes" in the fascial layers where they poke out through and then immediately branch. I like the techniques of SCS, but they are taught with absolutely no idea about what is being affected or why, as near as I can make out. :thumbs_do

Mike, you were wondering what to do with anterior and lateral nerves.. some of those positions might work for these. Just today I treated a woman's ACN's over the sternum, with some positions that were Jones-like/Jones-esque.

[jlsmithivan]

Diane. i completely agree with you. During the course I was thinking quite a bit about direct impact on nerves moreso than the joints etc and tried to raise some discussion. It ended up with me being kept a bit at arms length the rest of the weekend. It is nice to know that there is so much more to learn from this site. I look forward to exploring the DNM experience. thanks.

[Diane]

Glad I'm not the only one who has noticed how biased the manual therapy world is against considering nerves, and toward thinking ony about "joints" ... even when it makes no sense to think about joints, as in SCS.. my, we have a lot of mountain left to move. Mount Mesoderm.

[jlsmithivan]

I do think some of the ideas about positioning to relieve local tissue tension merit some consideration for use when applying dermal techniques. It seems most of the techniques are considerate of 3 dimensions and from a simple mechanical perspective this might be compatible with assisting DNM's being more comfortable. That being said, i really only have a very peripheral view of the concepts and techniques used for DNM and have been going on an intuitive level with what i can discern from what i have been reading here. Hopefully i will pick up more of a sense of what to do as i read/participate more. I just also have to share (because my replies to Barrett's recent post about cognitive dissonance did not post- i am a bit illiterate with computeres and web sites) that i can see why many mesodermists turn their backs to these ideas. They are competitively unsettling when juxtaposed with traditional manual thoughts and in my case i felt the need to "lurk" until i felt i knew enough to be "worthy" of particitipating- that is until i read about the cognitive dissonance concept. it created some personal understanding of my hesistance and freed me up to take a risk and try posting. I really enjoy what i am finding here. thanks.

[BB]

Hi JL,

I can relate. I was the same way regarding needing to feel worthy. I was lucky to find this site in its infancy when only a few posters were around. It made it easier to jump in and post.

I think you'll find that you learn as much from posting as you do reading. It helps you organize your thoughts, find a way from what you think you want to say, to actually saying it. There is a lot to be learned through that process.

I can understand why people lurk because I used to as well. But, boy am I glad I eventually jumped in.

[Anne Bower]

Hello!

I'm fairly new here, but sure enjoying your contributions, Diane. I'm a new grad working in a fairly traditional OMPT practice, so I have to be a bit cautious about introducing new techniques. However, I did try out DNM on my receptionist who has had chronic neck and periscapular pain the last 2 years. She told me her symptoms felt like they "melted away". I found this quite impressive, given that she is a LMT who really likes deep tissue massage. She found it a bit surprising too.

One of these days, I'll get her to give up the theracane!

Anyway, thanks so much for putting your ideas out there. I'll add more as I do a bit more experimenting.

[Diane]

Thanks for posting on this Anne - it was brave of you to try out something "new". :)
As you can likely tell, though, from your first apparently successful foray, there isn't much to it; people don't feel threatened by the (minimalist) physicality of it, they can relax into it etc. Neurophysiology explains it and the brain of the patient does all the heavy lifting. What could be easier, really? Save the hands, you'll need them to still function when you are old. :D

[jlsmithivan]

My simple question: is there a specific thread where i can get some of the basics for DNM techniques. the wordy version: I thought i already had some of the gist of it but i work in a high volume outpatient practice where I just got "fired" by my occupational med doc (patient was referred her back to ortho and d/c'd from PT) while using a more DNM (i think) approach in a work comp patient with shoulder issues who is really bound up in her trunk and upper quarter. Improvement has been slow the past 3 weeks but she went from 90 to 135 degrees overhead motion with pain now down to 3-5 versus 5-8 prev. No sig injury, just chronic pain. Prior to PT an ortho workup had noted sig loss of GH joint space and they had tried an injection which really stirred her up. She has all along been poor/slow to let go and experiment with movement despite alot of coaxing (i think she would not let go of the pain). Most of the work i did focused on the upper arm and about the clavicle/scapula. I think her impatience with any pain fueled her transfer to ortho, but i am wondering if there may have been a better site for me to have worked on that would have helped more with the pain sooner and helped her to buy in. Do you have any reccs as to how to prioritize where to look first ie proximal before distal etc or are there any gen guidelines for DNM type approaches? As i look back at this note i guess the pt fired me, so maybe i was not as gentle/minimal as i thought i was. thanks.

[Diane]

Hi jl,
Short answer is , no, ther is no short thread. Try looking through the "Light at the end of the Tunnel" threads for some help. Did you download the manual yet? It's the shortest version in existance so far.

Also, don't beat up on your self too hard. By the time you tried DNM on your patient her "flags" could have already been turned from a pale buttercup yellow to neon flaming yellow by her life and the "treatment" by injection. There may not have been a thing you could have done to turn the pain down by then, but as a rule, on someone like that, don't touch them until they've had a chance to kvetch to you, with you remaining neutral and supportive. Then go ten times lighter and ten times slower than you would ordinarily, while treating.

[kongen]

jlsmithivan: I have also seen a number of upper quarter pain patients, who are stopping by for some pain relief ("massage helps for a while" type) on their way to some ortho "specialist" for examination and sometimes surgery. Most of the times I find they have an abnormal neurodynamic and I know that they will not get helped by any ortho approaches. These patients place me in a dilemma. Do I give them what they except and what they think will help them, or should I go all out and tell them what I believe the problem is and how we possibly can help it? Possibly adding even more frustration and undermining the "specialist"?

Like you, I have some gist with the individual DNM techinques, but still working out how to apply them in the different patient presentations. Where to begin really.. proximal? distally? Maybe restore arm elevation first? etc. etc.

[Diane]

kongen, if you're going to start proximally, starting with arm elevation (in sidely, lateral cutaneous nerves) is a good choice.

Sitting here and reflecting, I realize I usually start proximally, with occipital nerves in fact. Neck (occipital nerves and superficial cervical plexus, supraclavicular nerves) plus axillary nerve, in supine; axilla (lateral cutaneous , subscapular nerves, musculocutaneous and lateral pec nerves, intercostobrachialis n.) in sidely; then the rest of the shoulder girdle/elbow/arm nerves (suprascapular branches, dorsal scapular, all their windings, all the lateral, medial and posterior cutaneous nerves of the arm/forearm, any bits of median and ulnar and radial that can be got at the elbow) in prone. The cutaneous roots into forearm and hand while I'm at it. It'll be in the manual.

[Diane]

Just wanted to add that today I had a chance to try out DNM on a woman who had a stroke 8 months ago. She had been through months of neurorehab, and has all function back - from the stroke. But the two weeks she spent not able to move, left her with a big pain in the upper right shoulder girdle, arm and a hand that although it works fine, gives way and goes numb. She couldn't lift the arm up much past about 60 degrees, couldn't get it behind her back, also had about 50% restricted neck range in rotation. After treatment, neck range was nearly full, shoulder elevation was up above 90 degrees, she could bend her arm behind her back although it didn't go up very high (not yet). I threw a bit of tape across her T spine and she left happy and in a lot less pain.

I'm happy about this. She was a MD referral, an MD who does acupuncture, and had already tried that, 8 times. He has sent several people my way this summer, including his own mom.

[jlsmithivan]

well, despite not having completely read the manual for DNM i have tried it a bit (on more of an intuitive basis) and would like to share one experience. i have a 37 y.o. female chronic back pain patient who is a single parent of 4. She is quite obese and out of shape. Her problem is persisting low back pain and left leg pain 1 year after discectomy. My mesodermal take was deconditioned/weak core/provocative slump/mechanics. I had been working some flossing with her and focused on gradual increase in ex volume with pt showing some gradual increase in tol to ex and some increased ease in knee ext ROM during slump (she did have one flareup/setback while learning to self pace this ex). For the heck of it I did a quick screen in prone of posterior trunk skin mob and she seemed pretty mobile in all directions. i also checked her posterior thighs and sensed more tension than i found in the trunk, so i focused there. skin glides to the left on either leg produced "sharp pricking" sensation on the associated lateral hip. mobility in this direction was limited compared to moving to her right which also did not provoke any sxs on either leg. i tried some sustained glides to the right on both legs taking up slack as it presented. i used a very light "grip" where i bunched her skin to catch it (i think gently) between my finger pads and thenar eminence (i am suspecting this is not as shallow an angle as you have talked about- or was this "ballooning"). afterwards glides to her left no longer provoked at the hips and her seated slump gained almost 10 degrees on knee extension. she remarked she felt "looser" and i actually think her gait stride length looked increased afterwards. i had her teach her husband this for trial at home and she returned today (5 days later) suprised to say that her pain was very low, the lowest it has been in a long time. Again i apologise for not being up on my homework, but 1) is this a bit of what DNM is? and 2) is the "balloon" technique the forming of a hollow skin roll/space above underlying tissue? I feel a bit awkward asking but it is time to jump in deeper for me. thanks

[Diane]

Hi Jim,
1) is this a bit of what DNM is?
Yup! :thumbs_up

2) is the "balloon" technique the forming of a hollow skin roll/space above underlying tissue?

I'm not sure, but whatever you tried, you must have helped the nerves breathe, so good for you. Just keep going. I shall have to try to get some pictures of this balloon technique up on here.

I feel a bit awkward asking but it is time to jump in deeper for me.

Ask away.

[bernard]

Had a young 36 years old man who had surgery 15 days ago.
All was fine until last week. He walked last Sunday with trekking shoes and started to pain in these areas. (dull, sharp).

Tried neuromobs but pain is to high. Tried DNM but failed for same reasons. Moving the ankle is painful, too.
Pains are dwran in red.

[Diane]

Bernard, go much lighter, and in areas other than the painful areas.
Maybe try pulling the skin down over the midfoot, or squeezing and wringing the foot slightly, or handle the opposite side of the ankle and balloon the pain side. Anything to surruptiously and painlessly bend, move or stretch the skin where the pain is, without increasing the pain.

[jlsmithivan]

diane would you please give just a bit more description of the " ballooning" technique especially as related to bernard's picture. thanks.

[Diane]

I'll try, but later. Got to go to work.

[kongen]

Wanted to lift this thread with a "success" story.

A 56 year old male patient came to see me 3 days ago, with severe right sided headache radiating from the base of the skull to the top of the head / behind the right eye. Not constant, but like "lightning" when he moved his neck in certain positions, each "lightning strike" lasting about a minute of severe pain. Hair and scalp sensitive to touch. Difficulty sleeping. No pain meds helped. Complaint started 2 weeks earlier, gradually after having a cold, gradually worsening. Prior history of similar type headache, but "nowhere near this intense". Patient had high blood pressure and some other issues for which he was undergoing further tests (brain MRI etc.), so I was a bit wary.

Patient was clearly impacted by the pain and lack of sleep. Neck was laterally flexed to the left. Lateral flexion and rotation to the right provoked "lightning" pain. Very tender to touch / "tight muscles" at right c1, c2, c3 and palpation around c2-c3 provoked the "lightning" pain.

In prone I did some PA mobs / DNM type work over c1, c2, c3 on the right, varying my direction of skin pull and depth of the pressure for about 10 minutes (provoking some pain, but also staying clear of it). Some supine "traction" of c0-c1 (mostly skin pull). Patient felt a little "softer" afterwards.
A little pain education / reassurance to go.

Second visit today, came in with NO pain, full neck movements and smiling :) All was good, and it made my day :) And no cracking of bones or other work.. I can get used to this!

[Luke Rickards]

I saw a 9 year old boy 2 days ago with a completely immobile neck and upper thoracic following a trampoline injury 4 days prior. The first pain had started after a whiplash type movement while bouncing very shortly after which he lost balance and landed off the trampoline onto the back of his neck, hearing a loud crack. The pain had been worsening over the past 4 days.

On presenting the only movement he could manage was about 10' R rotation. The pain extended to T8 and also referred to the back of his arms. No HA or other hard neuro S/S. He was maintaining an antalgic posture with an elevated R shoulder girdle. Thoracic rotation in both directions cause pain down his right arm.

In supine I used a broad contact over the posterior neck and gently dragged the skin with just enough pressure to produce a gentle traction sensation into the thoracic spine, slowly increasing as adaptation to the thoracic sensation was evident. He was extremely sensitive, so progression of cephalic drag pressure was minute. After 15 mins I repeated the same process over the anterolateral neck, for 5 mins. Then in the sitting position I did 5 mins of SC, during which there was significant intermittent trembling of his upper body, occasional minute movements into R rot, and warmth in the arms.

When he left there was no significant change in pain or ROM.

His mother called me today to tell me that by 12pm the following day he was significantly improved and he had gone back to school today.

[nari]

It is a very good feeling that such a soft, precise action has this effect on pain, and as a result from that, a quick or sometimes a gradual, return to function. No 'exercises', no pushing about or provocating pain...

I think an important aspect of DNM is that anyone can do it (with a good background of neural anatomy!) and the risk factor must be zero or close to it. Even passive mobs to spinal joints are not completely risk-free, especially in the neck.

Nari

[Barrett Dorko]

Luke,

I especially like this fact that he wasn't miraculously better in terms of range or pain during the course of your care, but you noted the warming, and, in my experience, nothing is more important.

You have a lucky patient there - lucky to have found you.

[Diane]

Way to go Anders. Careful or before you know it you'll be all the way out of the orthodigm and there'll be no going back. ;)

Nice examples. I agree with Nari. About the warming, I don't know that it's any more important than any of the other C's of C.. but it's pretty indicative all right.

[kongen]

Diane,

I would say that I am out of the "orthodigm" now, and I know my handling and attention to skin has changed dramatically since I joined this site. This benefits the type of patients that I see, as they seldom have any acute mesodermal injuries.

In the example above, there was no joint/cervical movement with my techniques, even though I wrote "PA mobs". All that moved was the skin and the underlying soft tissues.
I adopted a reasoning that "there is nothing wrong with the joints (why would it be the last 2 weeks?), but the nerves might be sensitive to normal (for that person) mechanical stresses, so let's target the nerves."

[Diane]

Yup, that's the big door out of the orthodigm. Common sense.
Way to go Anders.

[kongen]

I'm actually going to see the same patient for his anterior thigh pain and "strange sensations" that has troubled him for the last 3-4 years after he had a total knee arthroplasty with epidural anaesthesia. I have not done an exam yet. Anyone seen any similiar cases? Things to look out for?

[pht3k]

here's my first case. back in 1999.

adductor strain not healing for more than a year hold. she had infiltrations, strengthening, stretching, etc. without results. dont remember exactly the history.

came back from butler course and had this case. so i test the obturator nerve, which was positive. teached the neuodynamic exercice. she then called a week later to say she will not come back to the clinic. i ask her: why... the answer: i dont have any pain to treat :)

[Diane]

the answer: i dont have any pain to treat :) Beauty.
Anders, be sure to put the saphenous nerve in your sites as being a likely suspect.

[nari]

I had similar results with longstanding problems all labelled "fasciitis", or "fibrositis" or some sort of "chronic muscle strain" - nearly all responded to neural mobilisation and needed nothing more.

These were not athletes; just ordinary folk wanting to get on with life.

Anders,

Saphenous for sure, and I would also include femoral for the heck of it.



Nari

[Bas]

Just wanted to briefly add my first case with DNM as the only "modality" used (other than verbal education, which every patient gets).
Accident in May 2007, whiplash while sitting sideways in parked car.
Since then, lots of meds, aggressive PT X3 (which was stopped every time after 2 visits - then on to the next one), finally injections - nerveblocks. On presentation, major hypersensitivity at right neck, upper trap, down right arm into fingers; was not rotating neck at all, had right arm tucked against ribs in flexed position - her body generally spoke of DEFENSE only.
Was like this for 6 (!) months.

Won't go into assessment - suffice it to say her right brachial plexus was showing signs of double crush (of radial, median, ulnar and musculocutaneous); lesser occipital at the right SCM, long thoracic, and medial and lateral pectoral nerves were all involved. Pain 8-9/10

Talked at first quite a bit - I had to UNDO so much, from low expectations, fear of PTs, fear of movement, to fear of being permanently stuck with the diagnosis "chronic pain". You all know this type of personal misery.

Worked with gentlest of DNM touches/"stretches" on right neck, pec minor area, subclavial, and right SCM. I felt for the area of most (albeit subtle) resistance and gently "took up the tension" - and waited for the body to respond easily - which it did (warming - loosening).
I have seen her three times now and the neck moves 50%, pain is at 1-2/10, walks and does more, and her right arm moves almost fully normal.

I'd like to think sometimes that my verbal education is my most effective aspect - but I now fully accept that the gentleness of DNM - especially on these poor pts - is essential to help them through the mire.

[marcelk]

Hy,

Before I came to this site and heard of "Dnm" ; I was familliar with Muligan concept (snags/nags/mwm's : I had variable results) later the idea's of David Butler made a whole lot of sense (to add to me and my work).

Anyways (still before),... I develloped a technique that might combine the 3 concepts for upperlimb pain induced by full movement and/or Cerv. pain mainly for limited painfull rotation.

Saw a patient today (now his fifth session) ; shortly he was reffered for acute tendinitis in the left arm, his story and presentation didn't look like that at all ; after a bit of inquiering he told me he had 3 whiplash accidents in 4 years. (almost all symptoms one can have : he had)

So today I did that technique with him : limited painfull rot. Cerv. and painfull elevation of upper limbs with irradiation to scapula and below pectoral muscles.
Less then 15 minutes work of both of us (it's an active technique)
rotation painless (more ROM) same with arm movements.

I asked him " what do you feel now? " ,.... he said : "it feels like I had 3 months of rest"

[Diane]

Way to go Bas.
Marcel, it makes sense to be doing something with skin while getting someone to move their mesoderm at the same time. The brain gets a distraction, and there is probably a bigger differential movement created between neural structure and container.

[marcelk]

Diane, the technique I develloped requires active movement of the patient. I believe the most logical explanation is a combined stimulation of skin and joint-capsule afferents where the latter can have a direct influence on neuromuscular control and both stimuli can logically normalize pain transmission i.e perception.
The least logical explanation for Mwm's etc. is the "positional fault" theory which mainly is focussed mechanically (I think).

[Diane]

Hi Marcel,
Your post here, and your new thread on bone innervation reminded me of the concept of "sclerotomes", which I first heard about in a DO manual therapy class. I went to look it up, and found this article, The evidence for the spinal segmental innervation of bone (http://www.ncbi.nlm.nih.gov/pubmed/17948287) (which I will track down as it is quite recent).

With just a bit more looking I found an old book, Peripheral Nerve Injuries: Principles of Diagnosis (http://books.google.ca/books?id=rAqpCUQUQdsC&pg=PA47&lpg=PA47&dq=sclerotomal+innervation&source=web&ots=wGbB3uTzDm&sig=BqhCGd_-x6VWQHmygBEHDKfO5q8&hl=en) and a DC chart (http://www.dcfirst.com/sclerotome.html). Looks like the system doesn't operate in such a neat and tidy way as it's forming. Instead of innervation of bones (other than perhaps innervation to/from the vertebrae themselves, and to/from the axial musculature, which remains quite segmental), specific innervation to most bone (and probably to most joint) is quite mixed, doesn't follow the conceptual hallucination depicted in the chart or conceptualized in the book. (This is important to me because classes I once took at URSA suggested this idea was factual throughout the body.)

It looks like a largely irrelevant idea that still being kept alive in acupuncture/DC/osteo circles... Pain theory likely overrides it.

Why am I going on about this? Because I never found that worrying about joints or afferents from joints ever served me well in what I really wanted to do in life, which was to help patients to downregulate pain with hands-on work. The longer I have lived and worked, the more superficially I have learned to "treat." By now I've pretty much tossed any importance I might ever have attached to afferents of joint capsules being relevant to pain downregulation.

But by all means, though, carry on - I'm pretty sure the main input you are delivering is through skin, by contact, and the distraction provided to their brains by giving them a movement task, not from the patient's movement feedback, and not through afferent stimulation from their capsules, but who am I to say for sure? ... Given the Uncertainty of Everything... :D
Also, the idea of receptive fields (everywhere in the skin/cord/brain) might be more useful overall.

[marcelk]

Hi Diane,

If I'm correct sclerotomes reffer to periost innervation, in the other post the art. describes "deep" innervation of the bone.
A direct clue to why in dystrophia bone structure can change much more rapidly then would be explainable via mechanical loading principles (theory from : "Wolf" if I remember correctly).