Nari's thread: Skin rules!!

[nari]

I was going to post into the section where Diane was talking about skin Rx but could not find the thread...and probably too lazy to hunt...

I saw a patient today whom I mentioned before - years of chronic pain, hypermobile, highly intelligent, depressed, etc...I could not elicit ideomotion, and in her own words she said: I have too many conscious controls, I can never let them go.. and she cannot get past warming and softening. So I thought Dianesian and gave her long term painful ankle (actually the cuboid area) a skin stretch for about three minutes.

Bingo. No pain, full movement; her plantarflexion became normal (about 200 degrees!) for the first time. Next hot spot was the neck - and that resolved with nuchal line--> C6/7 skin stretch, extremely light. She can now do them herself. We both regretted not being able to move into ideomotion, but maybe down the track a bit.

Yeehah!

Nari

[Barrett Dorko]

Nari,

I would say that this sort of session is common for me as well, but I don't think that ideomotion is absent just because I can't see it. I can't see the heart beating either but I can easily feel it. I speak to the patient about what I sense and we see whether or not that matches their experience. After all, the warmth is the most important of the corrective characteristics, in my opinion.

Somewhere long ago I read, "There is no movement without sensation and there is no sensation without movement."

I think that this is pretty much true, and if blood flow ensues, I have to conculde that the movement I can't see is corrective in nature.

[nari]

Barrett,

On hindsight, she remarked how comforting my hand felt on her neck; she mentioned what she called an 'immediate relaxation'. Interestingly, I felt the softening but she didn't. She made the point to me that, during many previous massages she had received from masseurs, the sensation of relaxation was never experienced due to expectation of feeling pain. That expectation was absent today, completely, she told me.

This lady is complex, but the change in her demeanour, conversation, (plus lots of smiles) between the first and third session (over one month) is remarkable. Her pain perception has plummeted.
If I only get her to forget about the previous endless PT experiences, being forced to exercise intensely to build strength and avoid doing this and that thing, then I am satisifed; I suspect she will be too.

Nari

[Diane]

Nari, it's too easy isn't it? Like the big red telephone right to the brain. Glad you felt the melt. Is that the first time you ever tried skin stretch?

"There is no movement without sensation and there is no sensation without movement." The body is always "moving" in that there is always bodily activity that gets sceened out from conscious awareness; think how distracting it would be if we felt our heart pounding all the time or our GI grinding away on what we put into it. When one takes up skin stretching as a major tactic, and treat lots of different people with it, one will become aware of many sorts of nervous systems and many kinds or grades of responsiveness on a continuum from not conscious to suddenly conscious. Keep it up and before long you'll have patients who see colors and feel "energy" moving.. It's important to tel them about their nervous systems first so that they aren't creeped out by this. What is rewarding is not just the huge amount of downregulation of pain that usually occurs with this, but also the patients who learn to sense their bodies in a new way, and whose brains seem to soak up the new kinesthetic tool automatically. To me, the first part is the excuse for them having come in (the need state). The second part is what will keep them out (they've learned to "fish" well enough to feed themselves).


Barrett.. I had been lumping skin induced responses together as sensory-motor, and thinking ideomotor was either in a class of its own or else was a subcategory of sensory motor that involved more active non-conscious participation from the patient.

[Jason Silvernail]

I must say I've had some successes with the skin stretching stuff I've heard Diane talk about all this time. Great range of movement and decreased pain without doing "joint mobilization" or anything any deeper. Can't believe I never A) thought of it myself before or B) Was taught it at school. Too busy "hanging out at the joint" I suppose.:rolleyes:

Thinking about it, I'm not sure I could separate the effects of this from ideomotion, as I think probably some of that is happening as well, the skin stretch just reduces the nociceptive input in the local area, I think.

In Nari's example specifically, I'm not sure we could attribute the improvement she saw to just the reduction of input from the skin. Thoughts?

J

[Diane]

In Nari's example specifically, I'm not sure we could attribute the improvement she saw to just the reduction of input from the skin. Thoughts? I agree Jason. The improvement was more likely to have come from increase of input through the skin.
I've been working on figuring this out all my life. I think several things have to happen in sequence to get a good result, including setting up a good therapeutic container in the first place, but here are a couple of physiological ideas:
1. Increase in input through Ruffinis (they're like the golgi's of the skin, built the same way) which fire continuously with lateral stretch.. are non-nocioceptive;
2. Something to do with autonomics;
- Skin has 10 times the amount of circulation it needs for its own maintenance, because the human organism (a mammal) is heat dissipative.
- Stretching skin stimulates brain (sensory cortex) without stimulating defense (initial contact would stimulate sympathetics, and cause withdrawal of blood from skin toward mesoderm).
- Instead, non-nocioceptive contact/skin stimulation through those convenient ruffinis accomplishes the opposite.
- Brain checks, then registers no threat. It creates motor outflow that results in decrease of blood flow to underlying mesoderm (making it soften, be less turgid) and/or eccentric lengthening.
- The change of sensory input that comes from the patient experiencing increased and pain reduced movement helps their brain tip over into eliciting its own appropriate placebo response.
- With any luck their brain will take the new experience as the new norm. Provided their yellow flags were successfully furled first.

[Diane]

Here are some other thoughts I've entertained on the topic of skin/brain/ectoderm:
In my own wee world, one of the things I'm missing is a real good source of corroboration of some ideas I think are important, like differentiated sensitivity of various peripheral nerves. My idea is that the motor branches and sensory branches are differently sensitive. I.e., the brain, while it may be equally alert to both, will produce "pain" from irritation of one more than the other. M and S branches differ not so much categorically (because both kinds carry both kinds of fibres), but differ in proportionality and number of actual afferents/efferents of both ordinary and autonomic fibres.

It seems to me (i.e., my prediction is) that
1. the closer a branch comes to the skin,
2. the sooner it has branched off the main trunk,
3. the longer it has to travel under the skin to get to its "receptive field",
4. the more autonomic fibres it has to drag along, because of how much blood flow there is to skin...

...the MORE SENSITIVE it will be, or rather the more sensitive the brain will be TO it. Rather than saying "the more sensitive the brain is to it" maybe I should say, the more the brain builds up a pain story as an output to alert the conscious awareness/sense of self part.

I think it makes sense evolutionarily, i.e. the nonconsciousness parts of the brain want to make the conscious awareness part of the brain take an action or let it (nonconscious) take an action, get the cougar off its organism, stop inhibiting the organism from running away, moving, whatever.

I think the brain/CNS is sensitive to all of it, and deals with it however it can, i.e. noise from the PNS, but I think it feels more threatened or helpless about hurt or hypoxia being done to the more cutaneous/sensory as opposed to the deeper/more motor nerves. But I've got no proof, just tantilizing suggestions from the Tunnel Syndrome book, and another chapter I found online in a work rehab book, downloadable. Argh. Guess I'll have to bite a bullet and get my hands on the articles referenced in the tunnel syndrome book and see if I can find the trail.

Cutaneous nerves don't only have to pick up info, they have to motorically innervate the capillary beds in skin to cool down the whole organism.

To me there is something important here that pain science hasn't bothered trying to figure out yet, let alone PT.. That is, what is the sort of nervi nervorum input from cutaneous as opposed to motor branches of nerves, given the same circumstances of hypoxia (chemoreceptors alerted) or lack of movement (mechanoreceptors not firing in proper array) with subsequent build up of biochemical irritants (chemoreceptors alerted another way, different firing array perhaps..) If they are indeed different. My work with patients tells me they are. But I want to know, not merely guess or have a theory or a hunch.

Too many questions, too little time.

[emad]

Diane ;

Why is it called Stretch ? Why not movement or mobilise ? Is it actually a stretch ?
The thing which i like there is no protective reflex or defence mechanism like muscle-stretch ,Is this sure ?

Really ,interesting i still remember when my teacher duing my undergarduate study taught us concerning burn ,he told us superifical burn is more painful than deeper one .

Cheers
Emad

[nari]

Hi Jason

I think you make a valid point; but I have to agree with increased input, not decreased. With her foot across my thigh in sitting, I demonstrated a skin stretch on an inocuous part of her leg; and she sort of nodded, yeah OK, that's fine. When I moved to the foot, in an area superior and inferior to the cuboid, within 2 or 3 seconds she said: That feels so....funny. When I said funny what - peculiar? she said , no, it feels as though something was dissolving, it feels SO good. Within 10 seconds her expression was saying it all.
Then, following on with her education from me, she said: It really does feel like it's directly communicating to the brain...that's weird! And she laughed.
(in the first session, there was only tears, no smiles or laugh)

Other factors come into this:
Previous education on pain;
Placebo;
Increasing nonnociceptive input;
Trust;
Expectation;
Motivation;

..and you know all that anyway. It can all be lumped together as multifactorial, probably. If she had gone the full gamut into ideomotion, she would have been intensely surprised. But as it was, she was very surprised.

Nari

[Diane]

Emad, it's called stretch because it is stretch. Plain and simple.

[nari]

Diane, it is simple. Almost too simple to be credible, but them's the facts. Woops, there's no such thing as facts in this therapy business...;)

Emad,
Have you tried a skin stretch on yourself? Pick an accessible spot, say, the top of your thigh.
Place one thumb (or, as I did, cross the index over the middle finger and use middle finger; for me, that enables more control) and place another finger or thumb about 10 or 12 cm away, in a line more or less.

Don't push into the flesh, just very light pressure, just enough to enable a hold on the skin. Stretch by lengthening the surface, the skin, so where your fingers are looks slightly wrinkly; the skin between the fingers looks and feels longer.
Hold the stretch for a while; after about ten seconds my patient reported changes. You may not notice much, but a patient with a painful subdermal/mesodermal structure will notice.

Diane, does that sound OK? It certainly got results.

Nari

[Nick]

Diane,

Can you explain when, why, and how you would stretch laterally rather than longitudinally? I've seen you make reference to this before and I'm not clear on what you are describing.

Thanks,

Nick

[Barrett Dorko]

I refer to this as "playing with your pressure." Passive movement of the outermost layer of the skin will recruit stretch-activated ion channels not previously affected will then become so, and thus lead to a reflexive response not previously seen or sensed. "Stretching" isn't the worst term to use for this and Diane is happy with it, but it implies a sort of coercion too many therapists remain desperate to do.

To say that the skin should be deformed without trying to teach in which direction or with any certain amount of force or timing is probably the best way to instruct this, I think. The patient's response then becomes the therapist's guide to changing their contact, their pressure, and their "stretch" of/on the skin.

[nari]

Barrett,

That is a good point, because of the implications of coerciveness behind the word 'stretch'.
When is a stretch not a stretch? Maybe when it is a lengthening, a word that has been useful on SS threads...?

Nari

[EricM]

I like the idea of deforming rather than stretching the skin, regardless of how much force one uses. It leaves room for a much wider array of possibilities, without the conceptual baggage that comes along with a term like stretching.

eric

[Diane]

Hi Nick,
Can you explain when, why, and how you would stretch laterally rather than longitudinally? I've seen you make reference to this before and I'm not clear on what you are describing. You would stretch laterally if longitudinally doesn't help the brain reduce the pain or if there is still a crabby nocioceptive quality to the bit you are palpating after you've tried stretching the skin longitiudinally.

How do you know in advance which bit of vasa nervorum needs lifted? How can you tell? You can't really, although you can get good at guessing/predicting after many trials. You can bet however that the nerves and tunnels that convey them are embedded in skin. So when you get on the skin and start to pull gently one way or another, the brain will respond somehow.

Fool around until some odd little vector you've never tried before comes into your mind like a lightbulb. Think how windy and twisty and three dimensional it all is in there, all the nerve branches weaving through the mesoderm this way and that. You won't "know" what direction will work until you give it a try, so leave enough time to correct your own errors.

Another way is to feel what the nervous system is trying to do in there, under your hands.. if it feels like blood flow is bubbling and fizzing and pulsing, all is well. If it feels like muscles are writhing and shifting, that's good too. If it feels like the skin moves and lengthens, by itself, after you've stopped moving it and are just holding, all good. If the patient complains that it feels uncomfortable (as they've been instructed to if they feel that way), or the "spot" still hurts, change course/vectors. Use your own awareness and wade in. You can't lose.. the brain will take advantage of any little chance it gets to take new 'sk-input' (no matter how inept you might feel delivering it at first), to reduce the motor noise it has been enduring and expressing.

Barrett, I definitely call it skin stretching, because that's what I do. Maybe you do something different.. but what I do is let my fingerprints stick to the patient's skin, then try to increase the distance between the two hands. To me, that's a stretch of skin. On tatoos, the image distorts. Because the skin stretches, why else?

Nari, you did it/described it perfectly.

[BB]

I would just like to add that patience is really a virtue. I'm finding that the less I am in a hurry to move on to the next spot, the less areas I end up having to treat. I'm spending up to 5 minutes on one patch of skin if I'm still feeling the changes that long, or if I feel that the patient could benefit from just wading in the warmth for a while.

I also found one of Barrett's essays to be useful. Keep the vase (http://www.barrettdorko.com/articles/vase.htm)in mind while handling the skin. It helps me anyway.

[emad]

Oh, Nari& Diane :

Diane,I do use skin stretch (whatever we call it ) as i see it within the pictures you attached before in different threads ,with personal reflection from my practice in diofferent cases with very good outcome ,espicially that tension feel from the patient in the axillary region .

Just we are discussing further , i am a person can NOT at all refuse my cortex /brain questioning ,that active cortex sometimes cause problems ,that is why i spoke about naming the technique "stretch "

Anyway,Stretcht for me means lengthening beoynd certain available motion/mobility ,but what we rfeally apply is very gentle not passing the deformation point of skin tissues !

Do you think in case of pain and sensitivity skin mobility is affected/limited ?? Could you experience this practically ? I ask this question because in all literature in massage and soft tissue techniques ,usually mentioning about skin changes ,as well i think there is something mentioned in the thread strat concerning melting skin under the hand /touch (of the therapist) really i have not experienced skin melting under my hands during those techniques ,may be i sould activate more my cortex .

Actually , i see practically how skin and fascia limitation in orthopedic post-operative cases affect negatively the mobility ,this is very clear ,which address through management and lead even to cases of drop wrist (nerve injury) to good outcome .

Cheers
Emad

[nari]

Cory, you are right.

I think this time. which was the first time I have lengthened the skin area on a 'real' patient, I was a bit rushed; especially as the effect was so rapid to begin with.
I will slow down next time...

Nari

[EricM]

I think another really interesting thing about skin is how different it is on different people. On older people you have to move it alot further before any slack is taken up, but not always. Some people are hard to stick to wether its because they are greasy or dry and just plain slippery, whereas on others my hand sticks like glue. You have to be able to adapt to each one.

eric

[Diane]

All good points; go slow, take your time, wait until the brain has had its fill before you move on, be gentle, let your own nervous system be interactive, don't create more nocioception, let your mind sink thoroughly and nonverbally into what you're feeling, appreciate the differences there are between skins, how different skins have different qualities (I have a sign on my door that says, "no scents, no lotions"), call it stretching or deforming or whatever you want (just not MFR....!), although surely we can come up with a better name. Skinotherapy, integumentals.. I'm sorry, my mind has refused to deliver up a name that is sticky.

In any case, the technique is applied laterally, as if you were using your fingerprints to engage, then pull a thin cover of film over the water in a child's wading pool, trying to not press into the water. Nerve roots attached to the skin from underneath will be pulled gently up and out from their skin ligament tunnels. Of course they won't be uprooted, but they will definitely fire. That's the whole point, and the only point.

Usually I do this in combination with a positional idea for a limb, or some part of the trunk or neck, not all by itself very often.

[emad]

oh, i see why stretch ,because simply you are moving gently most nerves laterally !

Cheers
Emad

[JaneS]

Diane,

I know I have only just tuned into this discussion but I just want to check my understanding of your reasoning for lateral stretch. I'll paraphrase it as I understand - please correct me if I am wrong.

The stretch, either way, activates A-beta receptors in the skin. Activation leads to stimulus modulation in the dorsal horn. The supraspinal response also contributes to modulation of pain - ie the patient is more relaxed and less apprehensive, hence the psychological component of neuromodulation. The difference with lateral stretch is that the skin is more resistant to being moved in that direction and the initial stimulus (of A-beta r's) is slightly greater. Providing this does not reach threshhold of A-delta's or C receptors, the neuromodulation will be more effective. Have I got this right?

If so, Eric's point about the different types of skin fits perfectly. Older people often have lax skin which requires more stretch to produce similar levels of stimulation.

I won't plough in any further in case I have forgotten a couple of basics and am barking up the wrong tree.

Jane

[Diane]

Hi Jane,
I appreciate your interest in this. That all sounds about right..
The Ruffini endings connected to slow-adapting type II A-betas that fire continuously with lateral stretch and are non-nocioceptive. I expect it doesn't take much stretch to engage them. They comprise 19% of all fibres. (That's courtesy of p. 87 of Challenge of Pain.) Makes sense to barrage the CNS with non-noxious novel input to dilute former input/shift the neuromatrix, doesn't it?

Nocioceptive-free skin stretch is one portion of the effort and the main contact consideration, but the other part of the story is that I'm going after sore spots. The nocioceptive bit that is being targeted, usually some little hard spot just under the skin, is often a fair distance away, sometimes on the other side of the body wall completely, or on another side of a limb, or far away in another segment of limb. In fact the further away from the cranky spot you can stretch skin and still produce an effect, the better it seems to work (Weber-Fechner).

I am on the cranky bit, but lightly, not enough to hurt it, just to sense it with my own fingers.. the skin over that bit does not move. I am contacting and pulling away skin on some other bit of body quite often within the same cutaneous field as the cranky spot but one does not really have to be.. tune in with both hands, and feel the skin as it goes a bit taut between/under the two sets of fingers. Just as it goes a bit taut,.. the cranky spot disappears. It's as if the stretch creeps up to that point, and something gets pulled out from underneath the cranky point. You can check with the patient by pressing it a bit harder and they say, yup, it's gone. Are you pressing as hard as you were before?

I've done this enough 100s of 1000s of times by now to get that when;
a) the tissue texture over the cranky spot changes and normalizes,
b) it feels that something that was formerly hard under there softens,
c) the skin is held stretched away from that at the right distance, in the right vector, for a long enough time, the pain will be gone and the patient will get increased range right after.

So I think some sort of cutaneous nerve tunnel has been mobilized in this way. But I can't prove that, and no one has transparent skin with contrastingly colored nerves, so I can't see it.. I can only make an hypothesis based on 1. kinesthetic input of my own, and 2. patient outcome, which we know is favorable to all sorts of things/pretty much anything/everything.

[JaneS]

Hi Diane,

I'll have to think that one through. When you started talking about a distant 'cranky spot' I thought you were about to embark on DNIC (diffuse noxious input control) but not so. I'm not sure I know how you suspect a cutaneous nerve tunnel. The wrist would be a good place to start playing around with this theory. Have you found many spots thereabouts?
You're right about there being no 'walking anatomy atlases'. However, some people with lack of pigmentation or some skin problems can have virtually transparent skin. If you wanted to follow it through, would there be a dye which could assist in the process of identification.

It gets me thinking

Jane

[Diane]

Hi Jane,
I'm not sure I know how you suspect a cutaneous nerve tunnel.
Let me put it this way.. I don't think suspecting anything else can put us on the right tissue or system, nerve/ectoderm.

The Skin Ligament article (Sounds of Silence) is where I got the idea.. after all, nerves have to get to skin somehow don't they? Skin ligaments provide conduits. Several of the pictures I've posted lately, in the protected tunnel syndrome folder, show reflected skin with the nerves untouched. According to the diagrams, the cutaneous nerves split up somewhat, fan out before they dive upwards through the skin ligament tunnels into the skin.

It's not the size of the nerve that matters when noise comes through from mechanoreceptive or chemoreceptive nocioceptors. It's where nerves bend sharply, branch and/or divide or when they are tractioned that they are most vulnerable. A small nerve can make a huge noise. Even a small noise can be assessed as threat and amplified into a big pain. Agreed?

What interests me is that there is greater length overall of sensory nerve in the body than there is motor.. cutaneous nerves are much longer, and branched at 180 degree angles many of them, and most of them are bent at at least 90 degree angles. Which is fine as long as there is enough motion going on.. (take a look at Bas's "Scary Flexibility" thread..) but will start to take a toll with sedentary life.

I'm curious why you would start with wrists. If I had access to a cadaver lab to look at skin innervation, I'd want to look at trunks first, limbs second.

I love that people think. :)

[nari]

As a bit of a follow-up on talking to the CNS; I saw someone yesterday (Pain Clinic, complex, etc) whose sciatic nerve was on fire from its roots to the great toe. The worst burning was the lateral mid-calf, and as allodynia was rampant, I avoided it. Instead, I tried a skin stretch much more proximally, around the area of posterolateral upper thigh. She jumped a bit, anticipating increased pain, then calmed down. After about 5 minutes the lateral calf calmed down. Fortunately she was slender at the thigh. She was pleased.

Diane, how much difference does it make on large adiposic thighs (or any area)compared to slender ones?

Nari

[Randy Dixon]

Diane, how much difference does it make on large adiposic thighs (or any area)compared to slender ones?-Nari

We can't say big fat thigh?

[nari]

Randy

Of course anyone can say that. I don't..that's all. I am a euphemistic sort of person, sometimes.

Nari

[mike]

nari,
Did you stretch the skin in traktion or lateral shift?
I sometimes finds it more easy with adipose thights to do lateral shift with the skin. Did you try tape on this pt or do you think that would give problem regarding the allodonia?

Regards
Mike

[Diane]

Nari, it doesn't make much difference at all. Skin is skin, and nerve roots are nerve roots, it makes no difference how much or what type of mesoderm they encircle or plow through. The cutaneous roots flow outward (more superficially) at an oblique angle, and what's interesting in the leg as I study Clemente, is that roots of all nerves flow/fan superficially both directions, like ribbons round a maypole. Also, there is a deep branch of the obturator, the posterior branch, that dives in behind the knee to supply the joint. I just noticed that yesterday. Live and learn.

Anyway, nice result! Good positive reinforcement for continuing. And you Mike? How is skin stretching going for you?

[Bas]

"Cutaneous neurologic manual therapy"

[Barrett Dorko]

Hey Bas,

Doggonit, I was just getting used to "skin stretching."

[emad]

Diane ; allow me to comment please !

Cutaneous is TOO suitable .
Neurological is VERY unsuitable
Manual is Suitable
Therapy is unsuitable
Manual Therapy is long
modulation ?
Cortex ?


Cheers
Emad

[Bas]

Barrett, you know me - spinner of obfuscative verbosity....

Actually, it is another attempt at bringing a cachet of elevated status to a gentle technique - it is so easy for "skin stretch" to be seen as "is that all you do" (even if it is!) by critics of neuromodulation/ideomotor - the expensive terminology may impress them....

Emad - why is therapy unsuitable?
And neurological? Isn't that the ONLY avenue of change? (cortical or deeper?)

[nari]

Mike

I did a horizontal stretch, along the approximate path of the nerve. I did not try taping, because I knew this patient very well and it would have annoyed her, having to deal with tape. She is near the end of her tether but her solid determination to help herself will not let go..fortunately. She has a great sense of self-efficacy and at least the skin lengthening is something she has full control over and can do without any passivity component.


emad

Can you say a bit more about your list? I don't understand fully what you mean.

Nari

[Diane]

How about integumental cutaneality/(ies)? Too polysyllabic?
Cutaneality reality?
I'm just blowing smoke. Never mind.

[emad]

Nari;i was just comment regarding bas,s proposal of naming the technique "Cutaneous neurologic manual therapy" in post number 32 .


Bas,
I think this technique is not neurological ,but it is neuro. ! Is there a difference ? Really,i do not know !
As for therapy ,therapy to some exteent for me meaning endoderm (please ,Diane correct me if i am wrong it is my first time to use this term) ,it is better to to speak/name ectoderm( CNS and cortex).

Cheers
Emad

[nari]

Hope someone decides on a name soon. :) .......

In my own notes I have started to write cutaneous therapy; but in the report to the referring medico, I'm stuck. Usually I don't write anything about it. Our pain specialist will not allow us even to write 'central sensitisation' in case the referring doc thinks we are referring to a nutty patient. Ah well...

Nari

[Diane]

I usually just write NM for neuromodulation or SS for skin stretching. When I add position to the mix, I write SS and PRT or NM and PRT.
I think the name "ectodermotherapy" would do the trick, includes and would cover skin and brain and anything neuro or neural or neurological in between.

[EricM]

Why not just Soft Tissue Manual Therapy?

eric

[JaneS]

There are so many various tests,, therapies (proven & otherwise) with fancy names. My immediate reaction to names which sound right out of a textbook is to ask;
1) Is it really what the words suggest
2) Is there any biological rationale/credibility - or all just hot air.

How about the putting the KISS principle into operation. Something like skin-stretch neuromodulation. It doesn't sound fancy but it conveys the message pretty quickly. SSNM or SSN as an abbreviation. I know a lot of other people like myself who are wary of complex names. The more complex the name, the more sceptical we are likely to be.

Jane

[emad]

soft tissue manual therapy performers /practionners do not think of the cortex /brain /CNS on spot (while the perform the technique)

Cheers
Emad

[Diane]

Why not just Soft Tissue Manual Therapy?
That works... STMT or SST for soft tissue technique, at least it is acceptable in treatment notes in a medical legal sense..at least in BC.

I used those terms for years, but I'm trying to move on from there.. I don't want my stuff to be defined any more by a treatment acronym that means "anything and everything that is left over if you don't perform joint mob/manip." I've become bored with "vague." Since I'm going to the bother of discerning this stuff out of the other stuff by elucidating why's and wherefore's, I'm working on a name for it, but it sure seems hard to develop one. None of them seem very sticky. Ectodermotherapy comes the closest, but it still falls short.

Jane, skin-stretch neuro mod (SSNM) is descriptive, it has that going for it, just not very catchy or sticky.

Emad, if people don't think of the brain when they're on the spot, they should. Have they never heard of the sensory cortex?

[emad]

I think they had heared of sensory cortex during undergarduate study ,but i propose teaching of this cortex using to kids even and in schools in learning .


Cheers
Emad

[mike]

And you Mike? How is skin stretching going for you?
Thank you for asking. Well I'm still using it but I find often that I can not shut down the tender spot even if I try differnt directions of skin stretch. I still have some problem with those tender gluteus and sometimes the paraspinalmuscles in the T/L junction area. It feels like the tender spots in these areas are deeper. But of course we are talking of feelingsand palpatoric illusions here. I'm waiting for that book of yours...teeth:

About "Soft Tissue Manual Therapy" The conception has already been established and thats why I think people in our business will mixe up the concept with different kinds of massage and triggerpoint techniques.
Neuromodulation by skin stretching, NMbSS now how's that for your title on your callingcard...guess not;)
I'm still using the term "skin stretch" because as Diane said that is what you actually are doing.

Mike

[Barrett Dorko]

I'd agree that the term "soft tissue" has been rendered meaningless, mainly because it can mean just about anything.

Mike,

My advice for dealing with those "tender spots" you find so troublesome: Ignore such things entirely before, during and after care.

Not that you asked or anything.

[Diane]

I still have some problem with those tender gluteus and sometimes the paraspinalmuscles in the T/L junction area. Try using one or two those nice padded door stop chiro gizmos known as SOT blocks; stick them in side by side under a prone patient's hip on the side opposite to the one you're treating; sit on the doorstop side of the patient, then bend the patient slightly sideways around the fulcrum; one hand is grasping the outside of the foot/pulling skin all the way down the outside of the leg, the other is reaching across them to palpate their cranky spot with the other hand. Very handy for the tough bits by T/L and on outside of pelvis.

Sometimes I add what I call the "headbutt technique" (warning patient first of course..); I'm sitting on the blocked side of the patient pulling their leg, sidebending them slightly around the fulcrum, I take up all slack, then I put the top of my head against the side of the pelvis or right on the trochanter and load in slowly, pushing with it, literally. Gives me the equivalent of a third hand. The pressure adds increased proprioceptive sidebend, a wee bit of lateral translation maybe and a third point of contact, which either enriches the input to the sensory cortex or confuses it sufficiently such that the patient's cranky bits can relax even more. Perhaps there's something useful going on biomechanically although I'm guessing it's mostly confined to mechanoreceptors not joints.

PS: If that doesn't work, take Barrett's advice.

[Nick]

Diane,

How about neurodermal release?

I know you'll hate release thanks to the MFR crowd.

How about neurodermal contact? Or neurodermal convergence?

Nick

[Diane]

Thanks for the idea Nick. I like the neurodermal part. I think I could live with Neurodermal Therapy. NDT. I think it could even grow in stickiness. As long as the acronym isn't already associated with something else, like neurodynamic technique.

[EricM]

I think Neurodevelopmental Therapy already has NDT.
Neurocutaneous Therapy? NCT?

[nari]

Cutaneal therapy?

Neurocutaneal Tx?

Neurocutaneal modulation?

Neurocutaneal stretch?

Ectocutaneal something?

The visual thesaurus online might help. A few free searches are allowed.

Nari

[Diane]

I had an epiphany :lightbulb about this on the way to work this morning. I am going to call everything I do, NeuroDermoModulation.

NDM.

Thank you Nick for the first two bits. Thank you Ron Melzack for the last bit. I like it because it covers everything ectodermal, does not include anything mesodermal, has a nice sound (no c or k or t sounds in it), and hasn't been taken yet. So it's MINE! All MINE!!! :D :D You read it here first with a date affixed. Haha.

It has Neuro in it, so we can guess brain is involved. It has Dermo in it so we can guess skin is involved. It has Modulation in it, so we know something active, some sort of change in the nervous system is going on in a treatment or interactive sense. I really like this one. It even has MOM in it, and MOD in it, to soothe the subliminalists. It's big enough to include all sorts of technical stuff, all sorts of social grooming approaches, without any baggage or mesodermal memeplexes from our soft tissue past. It's specific enough to be about the nervous system without having to have "pain" as a word spelled out. Most of all I like that it is neuromodulation but with skin consideration added right in the middle, the tasty bit of the name sandwich.

[nari]

That's great, Diane, but just a reminder that neuromodulation exists as a word in itself, as electrical stimulation, widely practised with little gadgets the docs and researchers play with.
A tad confusing to the uninitiated?? maybe not...

Nari

[Diane]

The word neuromodulation also exists in the pharmacological world, dripping this or that drug onto/into nervous systems to see how they respond. Putting "dermo" right into it takes care of potential confusion with either of those two huge research rivers of exploration. Neurodermomodulation can be a river of exploration of the human nervous system with the dual objective of reduced threat/pain, increased survival/function used by us human primate social groomers.

[Bas]

Now what the heck is wrong with:

"interactive inhibitory and exitatory integumental manual and digital nervous system fascilitation technique"

Jeez - so simple...

[Luke Rickards]

Bas,

In the current therapy climate, there is no doubt that from a marketing perspective your suggestion would be far more suscessful.:teeth:

[Diane]

Bas, certainly, "IIEIMDNSFT" as you have described it above, would find a home within the scope of or under the broad umbrella of NDM, but I doubt it would displace it entirely or ever replace it. ;) :D

[bernard]

What about a S4
Soft Sensory Skin Stretch.

[Bas]

:D OK, NDM. Blah. What am I going to do with that? Makes waaay too much sense...
Seriously - good one Diane! Get that circled TM behind it soon!

[Diane]

Sounds lovely Bernard and is a very short acronym (a pleasant change from most..)
It definitely fits under the NDM umbrella, but I don't think it can replace it.. could get confused with something like Reiki in peoples' minds. NDM is much broader than that, can encompass many more things.

[Diane]

Bas, how does one get a circled TM? Do I register somewhere or just put it up? Do I really want to do that? NDM is for all ectodermal physiotherapists after all.

[bernard]

® => registered trade mark

Diane, justcopy the character.

[Luke Rickards]

So Diane,

Any is there an estimated time frame for the publication of "Neurodermomodulation®: a clinician's manual" ? ;)

Luke

[bernard]

I think it would sound more pleasurable if you remove a "MO" since it sounds MoMo?
NeuroDerModulation ®.

[Diane]

..MMMM... nice idea but I think too confusing Bernard. Makes it sound too German for one thing.. "dermo" pertains to skin in almost any language; "Der" especially capitalized, doesn't make any sense, in English anyway.. and last thing I'd want would be to have trademarked something that is at worst an insult or a joke (too sticky in the wrong way) or at best completely inscutable (just would not be sticky at all).

Luke, time frames just don't seem to exist for me. It's still just whirling chaos inside my head. Besides all the compost I mean.

[emad]

Bernard ;

Correct in Neurodermomodulation ,MO repeating makes it long ,complex,boring .

DermoNeuroModulation DNM could work !

[Luke Rickards]

Emad, I think your suggestion is very logical, as neuromodulation is a common term and dermoneuromodulation describes both the sequence of technique and process quite nicely.

Luke

[emad]

Luke , yes i do agree it is very suitable ,as you are first English Speaker and Diane from English Language point of view what is the difference between :
DermoNeuroModulation
NeuroDermoModulation


Cheers
Emad

[Luke Rickards]

Emad,

I think because neurodermal is a common term it feels more instinctive to say it like this - but the order is not set in stone.

Since neuromodulation is also a common term and Diane's approach starts with contact of the dermis (which is then registered in the NS, which is then modulated), I think DermoNeuroModulation fits quite well. But that's just me..

Luke

[Diane]

I agree it could work either way. Sort of like how one country puts the day, month and finally year down to denote date, while another puts the month first, then day then year. Other people can use DNM if they want. Why not?

One reason for putting Neuro ahead of Dermo is that neuro can modify dermo, much the same way that ecto modifys dermo. You wouldn't say, "dermoecto" , you would say "ectodermo"...
Neuro sounds better than ecto however.. seems to encompass the whole system better, CNS and PNS.

I'll stick with NDM. It felt good today writing NDM in my notes. It felt like another piece was right, finally, congruent.

[emad]

One reason for putting Neuro ahead of Dermo is that neuro can modify dermo, much the same way that ecto modifys dermo. You wouldn't say, "dermoecto" , you would say "ectodermo"...
Neuro sounds better than ecto however.. seems to cover more of the whole system

This is what i was asking about what can modify the other ( My English makes me handicapped ) because i remember very well that the issue of adverb ,ojective and subjective which can modify the other and the location to each other can affect the meaning which can modify the other ,it was long lesson in English language .

To skip over thus could take ;

NeuroModulationDermo , Wow,hahaha it looks like a person speaks to another person by his/her back not face !!!!!:teeth:

Cheers
Emad

[EricM]

I also tried out using neurodermomodulation (NDM) in my notes today. Sometimes I try Nari's cutaeous neuromodulation (CNM) too. My brain can't settle on anything yet.

eric

[JaneS]

Hi Emad,

I like playing with language and this is just my guess;

Dermoneuromodulation (DNM) is the process of neuromodulation, using the skin as a medium. This would separate it from neuromodulation using, for example, psychological means - which could be given the label of 'Psychoneuromodulation'

Using the same logic, I would say that Neurodermomodulation could be the procedure of modulating the skin via neural mechanisms.

As the ultimate aim is to achieve neuromodulation, I would go for DNM. This has got nothing to do with how it sounds, only grammar. Actually, the process of combining several words is very German, anyway. (I have helped name a few racehorses, and know how challenging it can be to find the right name. On one occasion we got our 8th choice for the racehorse, which was both dissatisfying and embarrassing but also amusing).

I wouldn't worry about a trademark. If DNM really takes off, I reckon it would be more prestigious to be associated with a generic process than a single commercial modality. Have you thought of writing up any case studies and getting them published along with your presentation of the process and its rationale? That could start other people thinking and you might get the opportunity to take it further (ie a prospective study or even RCT).

Jane

[emad]

Hi Jane ;

Correct ,really interesting to use language like that ,language has to comply with our needs ! Language is lovely when it reaches the most appropriate .
By the way ,we have a nice-german member here called Daniel who can tell us about german language mixing to optmimize the need of naming something .

DNM DermoNeuromodulation = Modulating Cortex Via Skin
NDM NeuroDermomodulation = Modulating skin Via Cortex

yes i agree with your views ,you are right .

Cheers
Emad

[Diane]

OK, Jane, I see your points, and agree. DNM makes more sense than NDM the way you have spelled it out. I bow to your common sense.

Jane, I've thought of doing studies etc., Butler thinks a cadaveric skin study would be good to start with, and now that the name has finally been sorted out, I think the last major cognitive obstacle has disappeared. The only hurdles left between me and publishing studies etc., are that I lack the requisite hawkishness (drive), contacts, formal education (graduated 35 years ago before PT was steeped in this), and know-how. I'd love if someone else took on the academic aspects and I just kept on peacefully writing my non-academic book about the whole body.

[Diane]

I'm wondering if anyone else sees the impossibility of continuing to ignore the fact that skin receptors are the ends of actual dendrites. I was cloudy on this for a good long time, thought that only axons were inside nerves. Gray's finally straightened me out. It's a crucial bit of info that is never emphasized, and if forgotten or misplaced or never taught properly in the first place, as a basic principle, you'll be left to wander down so many dead end garden paths, lost in the maze.

Since August, I contacted an anatomy professor at UBC who said she'd let me into the lab to look closer at skin, in the New Year. Also, an ex-classmate of mine with a PhD in research design, offered to set up a SSRD with me to study the effects of DNM, longterm. This fell from the sky into my lap, and I accepted with gratitude.

This is already starting with the first subject due for treatment in January. I've been meaning to ask her, and will ask her tomorrow, but in the meantime, does anyone know the official length of time researchers have declared to be long-enough term results that they can't be brushed off as "placebo"?

[Diane]

No bites.
Any rough ideas? Six weeks? Six months? Six years?

[EricM]

Diane, I'm not sure I understand your question, specifically the relationship between duration of treatment effect and placebo. I'm not sure you can say that because a treatment effect lasts for x amount of time that it is or isn't due to placebo.

If it was me, I'd do a follow up at the most 3 months down the road, maybe less. Any longer than that and well, lots of life can happen leading to any number of potentially confounding factors. Much easier for you too. You're less likely to lose track of your subjects.

Eric

[nari]

If a treatment effect lasts x months, it may be due to placebo and treatment. Placebo (or nocebo) response is present in every situation or encounter, so I'm not sure you could ever separate the two effects....
Wonder if David might have some clues on that? Try NOI.

Nari

[Diane]

Thanks Narie and Eric. I know that placebo is desireable as per Wall.. the best kind is the kind that is elicited by the patient's own brain etc.

As far as I'm concerned the best kind is the permanent form of Wall's version. I'm certainly not trying to avoid eliciting placebo. All I'm doing is trying to find out how long an effect that is positive has to last before it's no longer considered "merely" placebo according to whatever official researcherdom decides is the cutoff time when official non-desireable imaginary placebo "effect" usually wears off.

I asked my research friend and she didn't actually have any answer either. Maybe there isn't one. Three months sounds good Eric.

[EricM]

I don't think there's an answer to that Diane. You'd probably be better off looking at other statistical parameters like the size of the effect and the probability that the effect is due to more than chance alone.

eric

[EricM]

Oops, forgot you're only planning on doing a single subject design. My suggestions for statistical analysis may be off target. I'm definately no statistician.

[bernard]

I'm wondering if anyone else sees the impossibility of continuing to ignore the fact that skin receptors are the ends of actual dendrites.

Many dendrites end in muscles, bones... :angel:

[Diane]

Yes, but you can't "touch" them, and even if you could they don't make it quickly up to S1. :angel:

[bernard]

Diane,

I'll play the Devil's advocate and say that muscles have the fastest mechanoreceptors and nerves "protect" their muscles fibres at the center. (It doesn't matter if the sensitive part is injured, It does if you can't move). :angel:

I think if is not necessary to be touched, it is necessary to be moved and the skin is thus "touched". :angel:

[Diane]

I wouldn't disagree with that Bernard.

[Bas]

Diane, from what I know, there is NO standard time frame for placebo effect. NONE. It is not considered a parameter in the interpretation of placebo.

[Diane]

Hmmnnn. :cool:
Well, isn't that interesting.
Thanks Bas. :)

Does this mean that the tossing out of the derisive, "That's just placebo effect" by mesodermalists means zip? :D

[Barrett Dorko]

Diane,

"Zip" may be a little harsh. I would more likely say, "They don't really know what they're talking about."

Does that sound better?

In Erie PA a few months ago a woman in the class said while watching someone change quite beneficially while in my hands that this was just because I was "a charming man." Immediately several in the class objected. "He's not charming at all," said one in the front row.

So, I guess placebo doesn't explain much about my success either, when it does occur.

[Bas]

That is FUNNY, Barrett.
I agree though - saying "it's just placebo" is a sign of ignorance indeed. The fact that the time frame of placebo is not even on the radar of many scientists, tells us that it still is considered "a scientific variable" in controlled studies - NOT a valuable avenue of exploration. Hence the pooh-poohing of biofeedback as a valid rehab tool, because its studies were not properly "placebo-controlled".....
Placebo-controlling a technique that aims at the very brain/system the placebo takes place in.....Mmmmh, now how are YOU going to do that Diane?:D

[Diane]

Mmmmh, now how are YOU going to do that Diane? :D

:( Alas, Bas, I will have to do 3 month to 3 year to 3 decade followups. I guess when the subjects finally die without having any pain recurrance, we will be able to assume that either
1. the treatment effect was not "just placebo", or..
2. it was placebo that lasted the rest of their lives, which in retrospect will have to be reframed as not such a bad thing at all..

That's likely the only thing that will convince mesoderm-for-brains out there.. :cry: :cry: :cry: :cry: :cry:

[Bas]

That's likely the only thing that will convince mesoderm-for-brains out there.. :cry: :cry: :cry: :cry: :cry:


"mesoderm-for-brains" - I love that.

BTW, I am meeting with a local new MD who is starting a chronic painclinic in town with a few more MDs - He had heard about me (always a scary idea!) via via, and wants to see if I could bring "my ideas and expertise" to the table.....

Could we be that lucky? A chance to yack about skin, motion, brain, etc etc... I can see what their approach is and hopefully I can convince them that they don't have to get carried away with injection-type therapy :angry: , but I am only mildly optimistic.....Even if they will use PT as an option to refer chronic pain pts to, I will be happy. At least a possibility of MD-recognition of chronic pain as something other than "depressed personalities"....

Just had to let that out. ;)

[Barrett Dorko]

Bas,

Best of luck. You'll need it by the way. My personal refusal to pose as a personal trainer that the insurance company will pay for or a pseudochiropractor somehow acceptable to the medical community has generated enough disinterest and apathy to all but end my clinical practice, and that's not far off.

I think we often have ideas about what the physician wants for their patients that have nothing whatsoever to do with reality. It's certainly the case that the physician has no clear idea of what some of us know or might do. Nor do they care.

At least, not in Ohio.

[nari]

Dunno about people ignoring the placebo effect...doctors tend to generally dismiss it, but 4-5 years ago a lot of Oz PTs figured that there was no real way the placebo response could be excluded from treatment, so we should make the most of it.

Quite a few of PTs I have come across over the last several years figured that most of physiotherapy is primarily placebo-based in effect, but we had to make a show of being all objective and importantly mesodermal to look good, and separate us from the complementary practitioners. Probably true. And maybe a lot to do with the fact that many Aussies don't tie themselves in anguished knots over whether they are 'doing it right' or not.

I fib...I added the importantly mesodermal bit. They didn't. Skin has not been invented yet here. ;)

Nari

[Diane]

Hey Bas, good luck being a PT ambassador to this pain clinic guy.
If you make even a dint it will be very good. Dint with all your might.
Nari, maybe someday Aussie therapists will evolve skin. We can only hope.
Barrett, when you don't have the ball and chain of the clinic you can retire into full time teaching. :)

[EricM]

Bas, I recently wrote a letter to an anesthetist who runs a local pain clinic. To be as specific as possible about what I do without condemning myself as a therapy side-show I wrote that the aim of my treatments are to "optimize the cognitive-evaluative, sensory-discriminative and motivational-affective inputs to the body-self neuromatrix in order to positively influence its output." I figure if he's worth the car he drives in that should mean something to him. I haven't heard anything yet.

Eric

[Diane]

Eric, that's hilarious. :D

Anything over two syllables could make him miss that red light.

[Bas]

Barrett - I have the distinct feeling that I will need all the latest research and papers memorized (the latest Newsletters from our Canadian CPPSG included) to make even an impression of having some knowledge of chronic pain and some options for its treatment. It is not likely they will appreciate my (our) particular approach, since there is not much for them to do - at least not things they LIKE to do...

Eric, that is funny. I might steal your line....

I do want to talk about skin to them and gentle handling and motion. Plant a seed - provide them with a link to SS and the great stuff you all have been posting and the "Great conversations" and "Deconstructions"...

Don't hold your breath...

[EricM]

Sebastion, it's straight out of Melzack's article in the Journal of Dental Education, it comes complete with a picture.

[Bas]

Thanks Eric.

[Diane]

I thought I would come back to this thread started by Nari so long ago now, to put down the piece I wrote for the May CPPSG newsletter (there a lot more in it than just this piece, so I'm attaching the entirety of it again, here, as well).

What I'd like is that anyone who feels this small article, separated out and printed off, complete with a picture of a cutaneous nerve attached to skin, would be in any way helpful in supporting their credibility, please feel free to download and use it. Free. Straight up. No holds barred. No restrictions. Nada.

Toward a deeper model for Manual Therapy
Cutaneous Innervation, Skin Ligaments, and Small Scale Neurodynamics
By Diane Jacobs


Figure 1: Right arm view from medial to lateral. Lateral cutaneous nerve of the forearm (LCNF) and its cutaneous rami, still sleeved in skin ligament tunnels, are shown in black. Superficial branch of radial nerve is shown in red anastomosed to LCNF. Medial cutaneous nerve of the forearm is shown in green, partly dissected.

For decades I’ve been a soft tissue kind of manual therapist, using gentle means to elicit pain relief in patients. My preference for kindness to both tissue and patients was instilled during neurorehab days and has carried over into private practice. A large part of the process in neurorehab is about treating in modest amounts followed by watching and waiting for the patient’s system to self-correct rather than about perfecting one’s treatment “technique”. This kind of handling seemed to work well for most types of pain, so I just plugged along doing my best. Over a decade ago I came across Butler’s first book1 on neurodynamics. In what appeared to be a long step forward, his theory combined the idea of neural tunnels, manual treatment, and good pain science.
Fast forward a few years: an article appeared that discussed skin ligaments (SLs), responsible for holding the skin onto the body and the various layers of skin to each other, and this statement jumped out: “When a blood vessel or nerve was present, the fibers of the SLs formed a fibrous sleeve around the structure/s”.4 I wanted a chance to see these structures for myself and how nerves were conveyed to the skin, what their general orientation was, and how did it all look in situ?
Eventually an opportunity arose to dissect skin to take a look at it from the inside out, explore cutaneous nerves and their skin ligaments, and photograph the results. There were some surprises in store, such as how firmly the cutis is connected to subcutis, how extensive the ligament system is, and how thick the cutis/subcutis (CsubC) is compared to how small the musculoskeletal system is (e.g., biceps were only about an inch and a half in diameter, but the CsubC was a half inch thick in the upper arm). Through past research I have gained much appreciation for the role played by CsubC and its innervation in terms of physiology and homeostasis. Therefore, since dissecting a few cutaneous nerves and their branches, it has become increasingly clear to me how considerate and careful handling might have large positive effects on common persistent pain at a basic physical level. All these sensors and autonomic effectors are directly embedded into the CsubC from underneath. My working hypothesis has expanded to include the following: stretching the skin introduces motion into the cutaneous rami below, relative to each other and also between individual rami and their own little sleeves or “neural tunnels” (SLs). Mechanoreceptors of deeper (but still soft) tissue are affected, not just surface cutaneous mechanoreceptors.
When dealing with people in pain I’ve noticed all along that they seem to relax a lot better if their exteroceptive input (i.e., contact from me) remains mostly non-nociceptive. Since studying the layout of neural “twigs” into skin, even in only one arm, I can now understand more clearly from a practical point of view why some grips and methods are more comfortable and relaxing for patients than other ones.

Are there broader implications? I think there may well be.
At the moment, physiotherapists who want to treat pain manually are confronted by a bewildering plethora of methods and techniques each accompanied by its own explanation; many involve handling or needling of the superficial layer of the body, often with muscles or fascia or ‘trigger points’ in mind. Orthopaedic manual therapy targets, mobilizes, manipulates, tries to improve joint motion. Australian neurodynamic approaches based on modern pain theory are relatively new manual applications that introduce movement between large deep nerves and their tissue containers1.2.3. Many PTs use combinations of all of them, but with no consistent model to guide them, they tend to shift from one entire treatment construct to another as well. Many of these treatment constructs are dubious and outdated.
In general I think it’s fair to say this important and sensitive layer of the body has been ignored for too long by most manual therapists– certainly the cutaneous nerves have. It seems obvious to me now, post dissection experience, that any form of manual therapy, whether it is targeted to superficial tissue, superficial nerves, deep tissue, or deep nerves, whether it is based on pain theory or some other theory, cannot be performed without first mechanically deforming and thereby neurologically affecting the outer layer. Therefore I’m of the firm opinion that a good detailed survey of these little structures and of the CsubC everywhere in the body would be of good use to manual therapy as a whole. Letting this layer and its nerves remain “unknown” is to let them remain a potential confounding factor to continued scientific investigation of manual therapy applications. To this end I encourage manual therapists everywhere to approach anatomy labs, study the physical layout of the cutaneous nervous system, its branching patterns and everything it supplies, and add these findings to our collective understanding.

ACKNOWLEDGEMENTS My sincere thanks and appreciation to Dr. Donna Ford at UBC for facilitating this study, and to Dr. Wayne Vogl for permission to photograph. A full article is being written.

REFERENCES
Books
1. Butler DS; Mobilization of the Nervous System, Churchill Livingston 1991
2. Butler DS; Sensitive Nervous System, Noigroup Publications 2000
3. Shacklock M; Clinical Neurodynamics; Elsevier 2005


Articles:
4. Nash, LG et al.; Skin Ligaments: Regional Distribution and
a. Variation in Morphology; Clinical Anatomy 17:287–293 (2004)

See attached.

[Diane]

I decided to move a copy of this thread from the PPP forum to the DNM forum. Nari started it, so I renamed this copy, "Nari's thread".

For the longest time skin stretch had no name. In this thread is the sequence of interactions that led to the adoption of the name, dermoneuromodulation, and, I suppose, eventually to the creation of a forum to put the thread into.

[Diane]

I don't know if this Lumpkin article on mechanical transduction (http://www.somasimple.com/forums/showthread.php?t=4647&highlight=Lumpkin) was ever added to this thread, but I'm doing it now.