Another DNM success

[clarett]

I've been treating a 50yr old woman with a right hemi following stroke - that was 5 months ago. For the last 3 months she has been having nightly shoulder pain when lying on both left & right sides. Specifically when she's left sidelying any degree of right shoulder extension brings on huge amounts of pain. To say the least she's not been sleeping well! We had successfully taped the scapula but she can't tolerate the tape and there aren't any other kinds available here - not even softroll to put underneath.

I tried DNM with her today and with treating the musculocutaneous & subscapular nerves she got total relief from her pain, including an added bonus of being able to push up into sitting with her right arm which she hasn't done in a while. Beautiful!
I'm going to be following her progress to see how long the effects last etc.
So far she is one happy lady.

[Diane]

Wow. I wouldn't have expected it to work with someone without an intact nervous system! Wonderful news. Please keep this thread updated.

I never thought of treating hemis with DNM. Maybe someone could do a little study. :)

[nari]

Diane, when you think that the pain experienced by many stroke patients is mostly "musculoskeletal" in origin, classically the shoulder girdle....it makes good sense to try DNM!! :angel:

Nari

[Diane]

I guess I thought to get effects there had to be an intact central nervous system up past the cord. Maybe most of the effects are just at a cord level. Which makes me wonder, what would happen trying it with a spinal cord injury?

[Barrett Dorko]

Isn't it of primary importance that the nerve itself be moved? You don't need an intact brain for this - it's what I saw Bobath do with painful post-stroke shoulders for three days in 1973.

I suppose that this is where DNM and Simple Contact differ in emphasis though I doubt the effect is different in any significant way.

[Diane]

It is of primary importance that it be affected, easy enough to do where they plug up into skin. I don't know if all of them can be "moved"... especially the deep ones. With DNM alone I mean.

[ginger]

Last year I spent time in an inpatient setting in a regional hospital, the first for fifteen years , a timely and interesting experience for me. I had occasion to assess and treat numerous post CVA in and out patients complaining of typical shoulder pain. In the old days this would have been accepted as part of the deal with the sequelae of stroke , put in to a brace or sling and given pain relief , while attempts were made to get them walking while teaching coping skills. In my six month period there It was my pleasure to discover that many of these people had entirely treatable and in most cases fixable shoulder pain arising from stiff vertebral spines. No surprises really , not after having spent the previous fifteen or more years dealing with the very same cause and effect in a different and much healthier demographic, unaffected by CVA .
The speechless ( literaly in some cases ) looks of gratitude and relief was palpable and memorable. Just by doing what I would for those in pain with no disability, treating with CM and gentle dural stretches. All too often the disabled are dismissed as untreatable or live lives of needless pain , unaware that manual therapies that work for others may well be appropriate, safe and effective. Well done Clarett, have you any more cases ?

[nari]

Ginger

I had some success with post-hemi shoulders using Butler's neurodynamics, but it was patchy. Then I left the Rehab field and by the time I did Butler's SNS I wasn't seeing strokes. It all makes sense to me, and I still get the horrors of seeing Pts put stroke patients on pulleys even 10 years ago......:eek:

Diane - I am wondering about a combination of DNM first (have a nice word with the CNS) followed by neurodynamics. Sort of moving the top layer/s and then the bigger stuff with a few anchor lines slackened. ??

Nari

[Barrett Dorko]

Okay Nari, I see your point. I'm thinking of ringing a doorbell. This usually requires that the device at the door be depressed if only briefly, but there are security systems that note our presence without our doing even that.

Perhaps this is a decent analogy for what happens when we become present in a certain way near to a nervous system with a unique awareness.

[Jon Newman]

In the old days this would have been accepted as part of the deal with the sequelae of stroke--GingerI'm reminded of one of my favorite Leonard Cohen lines (from the song Famous Blue Raincoat)

Yes, and thanks,
for the trouble you took
from her eyes
I thought it was there
for good
so I never tried.

[ginger]

Jon you had no way to know this , but the local jazz club come cafe/restuarant around the corner from me , and a place I spend way too much time in , is called, "the famous blue raincoat". They regularly give me wall space to hang my paintings and treat locals like family. Now I know where they got the name . thanks.

[Diane]

Ginger, do you remove the dorsal cutaneous nerves from over the facets you think you are pushing on, first? Or do you simply ignore them as if they don't exist, discount any interaction you might be having with them? :) (I'd pick the latter if I were a betting woman.)

[ginger]

Oh and Nari , the pulleys are still there and being regularly put to use in hospitals across the country, stroke rehab, "Frozen" shoulder, the inquisition would be proud.

[ginger]

so quick , so testy, um and yes , its B.

[Diane]

B? OK, I win the toaster. So why are you in a DNM thread trying to argue for the efficacy of facet joint mobe-ing and ignoring dorsal cutaneous nerves, not necessarily in that order?
Just kidding, you can be here trying to convince readers that DCNs don't exist or don't have a kinesthetic "opinion" about being squeezed/squished/prodded, but no one will believe you anymore. :)

(By the way, were you to acknowledge/treat them first, and not mobe right through them, you could likely shave several minutes off your mobes and save your thumbs. :thumbs_up:thumbs_do)

[clarett]

This is the third person that I've treated with DNM that doesn't have an intact nervous system - the first I think I already posted who'd had bilateral tumour removal from the frontal lobes. He was suffering from huge amounts of pain in both his feet and it is working wonders. His rehab is going so much smoother because after treatment I can relieve his pain within 3 minutes and he is no longer waking up with daily pain, which means we start treatment pain-free and he is no longer taking any pain medication which was a daily occurence.
The second person funnily enough as Diane mentioned it has central cord syndrome - which occured at approx. C6. I hadn't posted yet as I was waiting for his next session to see the carry over effects. Anyway - he's been suffering with shoulder pain, tightness across his chest and pain in biceps. These are pains that I've been able to relieve with manual techniques but never for any length of time - after a few hours it's back.
At our last session I DNM'd neck, shoulders, arms including a balloon technique over biceps - he had blissful pain relief. And I say blissful because after finishing treating one side he was urging me to treat the other which has never happened with any other technique I've tried. He reported that his arms felt freer as well and his shoulder movement was smoother. I'm seeing him again on Friday so I'll get back to you.
I think I forgot to mention that the woman with the stroke described the technique as feeling delicious! I'm next seeing her on Monday which is when I'll be able to update but I'm planning to monitor her for a while. Shoulder pain is still a huge problem with stroke patients so DNM could change the lives of many people!

Diane - what do you mean by a study exactly? I'm very interested in seeing how DNM is effective in neuro patients.

[Javier Gonzalez]

I am wondering about a combination of DNM first followed by neurodynamics.
Nari

These days I have been in the Shacklock´s course and I have thougth at least 10 times about the same thing. I am looking foward to use both technics treating my patients in that way.
I will tell you more about it.

Cheers

Javier

[Diane]

Diane - what do you mean by a study exactly? I mean, a case study or a single subject research design on up.
I'm very interested in seeing how DNM is effective in neuro patients.
Wow, me too. :)

I'm thinking, with the cord guy, you were treating areas that still have intact sensation, from C6 up.. Anyway, nice to hear it helped him with what was probably just ordinary mechanical pain.

[Barrett Dorko]

I may be way off here but I've been teaching that in the absence of a joint in need of mobilization (fairly common) people with persistent pain were all neuro patents. I understand them in that way, handle them in that way and expect them to change while correcting in the ways neurological problems are known to; unpredicted progress and a nonlinear response to provocation, but progress nonetheless.

I'd handle a painful post-stroke shoulder in the same manner I'd handle a common complaint of backache.

[nari]

Barrett

You are not way off. All patients with pain that hangs around are neuro patients; even those who have brief pain after an energetic workout are neuro pts.
I am starting to think that even with pathology, (eg post stroke, cancer) both approaches could be useful; or either approach could make the difference between heavy and light medication. Neither involve forced movements or movement invented by the PT, and therefore would not pose any 'risk' to the patients.

Nari

[ginger]

Barrett, agree that those with peristant pain are indeed neuro patients

"that in the absence of a joint in need of mobilization (fairly common) people with persistent pain were all neuro patents. I understand them in that way, handle them in that way and expect them to change while correcting in the ways neurological problems are known to;"

Not certain what it was you were trying to say here though, either that those needing mobs were common ( I agree ) or that they were not ( would seem more likely your opinion given what I read on threads like these )
nevertheless, the common ground we share is important. That by altering the irritants involved in neural pain, methods like CM and DNM , give those whose persistant pain can , be shown to be neural in origin. The observations I make are very similar to those I have read here . The difference may be in the length of those positive outcomes, the speed and "depth" of the pain relief and possibly the range of situations applicable to their use .
It is common for me to treat those who have had attempts by others using maitland and/or mulligan style mobs that had been unsuccessful , and then go on to use CM to be effective. I suspect my persistance plays a role here , along with good thumbs.
Dianne, I haven't come across such proprietorial childlike attitudes since the neighbours cubby was built when I was ten. Put your considerable mind to work on matters that bring methods and minds to work together, I'm sure we can all get along.

[nari]

Ginger

I am dismayed to hear that pulleys are still being used to force movement. :thumbs_do
When will we ever learn?? (Sing appropriate song here :note::note:)

Common ground we do share, it's the physiological interpretation of good results that separates.
Do you concur that people can have stiff/hypo joints with no pain or dysfunction? This being the case, why is it so? Why did their alert nervous systems decide there was no cause for alarm? (Politics aside)

Nari

[ginger]

Nari, it is rare to find hypomobility in spinal facet joints not associated with a degree of irritation and pain when passively moved, also rare to find pain amongst those who do not have resistance to those same passive movement attempts. Replace rare , with extremely rare. So the premise that might have been difficult for my contentious remarks on facet involvement are , at least in my own quite considerable experience, not present. That being some inconsistancy betwen observed resistance to movement and pain . These two elements are the steam train that I hop on board each day.

[Diane]

I may be way off here but I've been teaching that in the absence of a joint in need of mobilization (fairly common) people with persistent pain were all neuro patents. I understand them in that way, handle them in that way and expect them to change while correcting in the ways neurological problems are known to; unpredicted progress and a nonlinear response to provocation, but progress nonetheless.

Agree. I didn't however realize that skin stretch type technique could work for reducing mechanical pain in nervous systems that have deficit. Makes me think the results might stem from something more peripheral (at least in the case of the hemis) therefore. Good news. Treatment loops may bypass areas of deficit.

Ginger, Dianne, I haven't come across such proprietorial childlike attitudes since the neighbours cubby was built when I was ten. Put your considerable mind to work on matters that bring methods and minds to work together, I'm sure we can all get along.
Not sure what you are implying. No one is 'proprietorial' around here and it sounds like you are trying to tell me how to be - which won't turn me into someone warm and friendly. I'm disagreeing with your focal length (as usual), that is all. I never said those thumbs of yours weren't good ones, just overused probably. I.e., mobes are rarely needed.

[nari]

Ginger

Were you excluded from the neighbours' cubby? ;)

One might say that both you and Diane are active participants in your roles to relieve pain; you both get good results; you both cite physiological reasons for resolution of pain. You both cite the nervous system as a player in resolution; you see it as a first or second violin, Diane sees it as the conductor. So far so good.

It is not the techniques that are really in conflict. It is the rationale behind the techniques. It is what we tell patients as the reason/s for pain. It's what we tell ourselves when faced with a patient in pain.

In the end, that is what counts.
If a patient goes to five different physios and receives five dissimilar reasons for five pain assessments...then the profession has a problem. What is being attempted here is a common understanding of pain physiology and its potential resolution.

Amen. (To the sounds of choirboys)

Nari

[Barrett Dorko]

Nari's right again.

Our efforts should emphasize how we can change ourselves, not our patients. They're already headed in the right direction. It's not possible for everybody's theory to be equally correct, and this is why we must answer those questions that challenge our conclusions about the deep model and how that drives technique.

Points should be deducted from those who constantly evoke anecdotal success and vast experience. I think that's way overrated.

[Diane]

Thank you Nari. Precisely.. :)

[christophb]

Ginger,

When you do a mob, how do you know that you are moving in the right direction? What changes are you paying attention to and how does the patient report they feel. Are there any characteristics to the correction?

Just curious,

Chris

[ginger]

Chris, I'm aware that I/we may may be subverting this thread to another line of enquiry, however the prospect of reaching a state where my credit points may be reinstated by a refusal to denote understanding on the basis of experience is compelling (if not daunting.)
The direction is simply the one that occurs by a natural attachment to a lateral mass when standing alongside the spine. In other words I use the movement made easy by my position near to the patient , rather than create movement based on any notion that one will be better than another. When doing unilateral mobs the movements will be a combination of rotation, side flexion and extension . Interstingly these are usually those which are most difficult when attempting active movements when pain and tightness is present. I'm not concerned at moving in any predescribed direction, really just the one that happens is fine. I do find however that as protective tone drops away < I am able to identify elements of high tone associated with pain and resistance in a slightly different direction. This seems to fit a picture explained by tone reductions of small muscles specific to any one movement, though in most cases altering the direction will not be necessary as results are immediate and lasting for tonal normalisation with one direction only for all the features of tightness around any one facet joint.
Patients feel some pain as I begin movements, this is most often followed by reductions in both pain and resistance after about thirty seconds of continuous mobs.. This reduction in tone and pain then continues till either resolution and pain free staus is accomplished ( may take up to ten minutes ) or a plateau is reached, depending on severity and individual differences.
The aim of CM is to restore normal movements back to facet joints and associated spinal structures , such that irritations to nerves are resolved. The method is very successful at both. Patient tolerance is very good. Results are lasting, referred events dissapear and my thumbs are fine as can be.

[bernard]

This seems to fit a picture explained by tone reductions of small muscles specific to any one movement

Where are these famous facet joints in this explanation?

[Jason Silvernail]

Nari said - It is not the techniques that are really in conflict. It is the rationale behind the techniques. It is what we tell patients as the reason/s for pain. It's what we tell ourselves when faced with a patient in pain.

In the end, that is what counts.
If a patient goes to five different physios and receives five dissimilar reasons for five pain assessments...then the profession has a problem. What is being attempted here is a common understanding of pain physiology and its potential resolution.

We ought to put this on a sign or something. Great point.

Barrett said - Points should be deducted from those who constantly evoke anecdotal success and vast experience.

Of course they should - the problem is that those two items are the only thing that has "ever" been offered regarding this particular method. Full credit to those who continue to engage hoping for a defendable theory, however. Hope has audacity (http://en.wikipedia.org/wiki/The_Audacity_of_Hope), I'm told...

[ginger]

"Where are these famous facet joints in this explanation?"
__________________
bernard

is this a serious question?

Hope certainly does drive me , along with faith andf confidence Jason. So perhaps a grade point system and a docking effect automated by the computer , winner of monthly points for,
# not alluding to experience as a guide ,
#refusing to follow instinct ,gut feeling etc
# railing against the tide of opinion regarding anything at all not proven
#remaining alert to unsubstantiated theory with repeated notes of disaproval when posters offer innovation, thoughts on creatively interpreting results or alluding to their own work if not published by regular peer reviewed method.

perhaps a copy of "the everymans guide to omphaloskepsism " for the monthly points winner.

[bernard]

is this a serious question?

Yes!

[ginger]

Bernard
pardon mon hésitation aller au-dessus ce terre encore, meilleur lire mon poteau dans RE, sous manuel thérapie, beaucoup détail être couvrir là. _ je espoir vous apprécier et convenir offrir votre considération sur ce forum. _

[bernard]

What a "google" translation! :angel:

[ginger]

you are too clever.

[bernard]

Ginger,

here is the picture, again.

http://www.somasimple.com/images/lumbar2.jpg


Questions:
1/ Is it possible to move a FJ without touching skin or muscles?
2/ Is skin more sensitive than any other internal organ? (exception of nervous tissues)

You may reply with yes or no. It is sufficient.

[ginger]

Merely moving or pressing on skin does not explain my results Bernard. If it did then it would not matter too much if in attempts at mobilisation , I didn't take pains to connect to the lateral mas. When I fail to do this there is no result. The best effects from CM , DO depend on actaully moving a solid piece of anatomy . You may be right to offer doubts that this solid object is a joint, my observations however of pre and post joint behaviour added to known joint physiology , the best observations I can make , and the thoughts and research from others give me very real evidence , that on balance, it is most likely a facet joint that is indeed being moved . Also that the joint is a known connector , neurologically , to muscles and other soft tisses locally , plus a plethora of meaningfull brain connections, feedback loops etc. . This being the case it is my considered opinion that I would be a fool not to continue to offer treatmets in this way. I'm keen also to try on different concepts that seek explanation bernard, just like you. I have yet to read of a worthy alternative however to my model for the physiology of spinal pain/dysfunction , as released here and on RE.

[bernard]

Merely moving or pressing on skin does not explain my results Bernard.
How do you know it since you reject a logical evidence.
I'm cleever as you said and, as so, I ask again that you give a simple response to my simple questions!

[Diane]

Actually, I agree with Ginger that "simply pressing on skin" is unlikely to do anything productive. The nervous system will just say "Huh?" and defend itself. Perpendicular exteroceptive entries into the body are seen by it as a threat and tend to cheese it off.

However, a low angle of shallow entry into skin, and a drag of nearly lateral (horizontal) angle, makes it pay much more interested attention; the nervous system is far more likely to take advantage of a situation of this sort, use the opportunity to sort itself out physiologically. See all the threads on cutaneous afferents and all the many physiological processes including blood flow that they have control of.

Of course, someone with lots of mechanical advantage and thumbs that can go forever (roboPT?) can overwhelm the first line of resistance and "force" compliance out of the system if they think they must push bones about for some reason. But why bother to "force" something (like the nervous system) that is a) in pain, b) eager to get out of it, c) is a learning machine? I'll never get why people do that, except willful disrespect for neurology.

[emad]

What is the contact between Facet joint and nerve ? Is there contact/connection between facet joint and Brain ?

Emad

[ginger]

It could be that you will need a demonstration of CM bernard , in order to take on board the myriad observations that go towards an intimacy with this method. Next time I'm in France mate. promise. Vive la frogs legs.

[nari]

Clarett,

Have you seen your lady again? Please update us if you have. :)

Nari

[clarett]

Hi Nari,

I won't be seeing her till Monday - I'll update then

[clarett]

Sorry about the very extended delay - we've had to rearrange several appointments in the last week as she's up to her neck in bureaucratic paperwork...

Anyway - latest update:
she was totally pain-free for 4 days, then it came on again, with no change in pain - same triggers/intensity. Those pain-free days are such a breakthrough - so many stroke patients suffer so much pain with usually only strong painkillers as a means of alleviation.

I treated her with DNM today - combining the subscapular skin stretch with musculocutaneous nerve skin stretch seems to be the most effective method - and plan to see her again to repeat the procedure in 3 days and then another 3 days after that - then either see how long she gets relief or gradually eke out the number of days inbetween - I haven't fully decided yet. Basically with the intention of getting a longer-lasting effect. Any suggestions on that plan are welcome.

I will keep updating.....

[nari]

Four painfree days is very significant, clarett.

I'm thinking about the suprascapular nerve (it's a major player in shoulder pain) - Diane, any further thoughts on this?

Nari

[Diane]

I do, especially if her shoulder looks drooped, she would definitely do well with some suprascapular unloading. Can she lay prone with her arm hanging down?

[clarett]

She finds it really difficult to get into that position (normally due to the pain in her shoulder) but I'll give it a go at our next session as we've managed to get a pain-free shoulder!!! :) maybe it's not so hard after all.

Clare

[Matthias]

OK - so here's my success story:
I'm treating a patient who - after thoracic surgery - has a hypersensitive sympathetic nervous system. She is sweating constantly, she is very nervous, ... - the whole nine yards of autonomic hyperactivity.

She had a "cranky" spot in her upper thoracic spine that the doctor couldn't get under control by "cracking" her back.

So I decided to give Diane's technique a try - and we both - me and the patient were amazed at how well it worked.

I simply "pulled" on her skin opposite the cranky spot and held for a couple of minutes. I moved up and down her spine and re-tested in between. Needless to say that the spot was gone after a short while.

It'll be very interesting to see what happens the next time she is in the clinic.

Thanks you Diane!

[Diane]

Hey Matthias, way to go! :angel::thumbs_up:clap2:

For the thoracic area of the back (and for painful necks/headaches, and mysterious non-cutaneous nerve pain anywhere in arms or shoulders) I have never found anything else that works better/quicker for long term pain relief than slow and methodical, attentive skin stretching between the scapulae, in any direction that brings out the most palpable local physiological response. I'm happy for you and your patient.

Please post again with updates.