Five Questions

[Diane]

Lately I treated a woman who is one of the warm ones. She even said, "My feet get so hot that they burn.. I strap ice packs to them so I can go to sleep." She certainly had lots going on between the blades...

The autonomic system has always flummoxed me. I've never understood it well enough to be able to convince myself I can predict what it can/will do, or that anyone else who sounds like they have it down pat, really does. And I've never believed that popping backs somehow enhances or normalizes its function.

I've just acquired another Burnstock book, called Comparative Physiology and Evolution of the ANS.. Haven't started it yet.. if I can make head or tail of it, I'll let you know. All I know right now is that in lots of different species including our own, autonomics make skin change color and hair lift up. Also that skin has ten times the amount of blood flow it needs for its own maintenance, so it can be a metabolic heat radiator/entropy radiator. Meanwhile, for pain, I think it's safe to say that producing any kind of change in autonomics into the opposite direction of wherever they seems stuck, is beneficial. Maybe the rule could be, if it's cold make it warm, if its hot, make it cool.

The other big clue I got was finding out not that long ago that autonomics do the opposite thing in the skin than they do in muscle. I'm still composting that. It's so big that it's taking quite awhile.. it makes sense that the blood shunting mechanism would be different for mesoderm than for ectoderm and endoderm, thinking embryologically. It makes me more convinced than ever that skin is the key to the mansion, not only for pain diminishment but also for autonomics.. just trying to work out why and how.

[Jon Newman]

Hi Diane,

You may be interested in the following. This is a side bar and if anyone wants to discuss it further maybe a new thread can be started. The current one has a good flow right now but I do think this is pertinent to the discussion.

One of the poster presentations at the APS conference was titled Skin potential as a measurable correlate of moderate to severe chronic pain--a case report and was authored by Donald D'Angelo.

Introduction

There exists a perceived need for an objective measure of pain and pain relief. There is a device used in veterinary medicine to perform bilateral measurements of the electric charge of the skin, skin potential (SP). SP can be used to detect distinctive asymmetries caused by the autonomic nervous system as it responds to moderate to severe persistent pain. SP can accurately reflect changes in the ANS. The goal of this study was to determine if this device might reliably assess pain in humans.

While the methods and results are certainly important, I will simply summarize as this is 'only' a case study. The measuring device is trademarked as PainTrace manufactured by Biographs LLC, Bayville, NY. Here's a quick summary of what they are measuring:

If both palms produce equal voltage, the linear trace will be a flat, horizontal line down the center of the graph paper. We take this line as the X axis of our graph, with the arrow of time to the right. This functions as a neutral baseline with a value of zero. When the right palm is producing higher SP than the left, the linear trace will be above the neutral baseline on the graph. When the right palm is producing lower SP than the left, the linear trace will occur below the neutral baseline.

The picture they show is simply a nickel sized electrode placed in the palm of each hand with the leads running to a chart recorder.

The asymmetrical SP can be accounted for by the ANS innervation of the skin. It has been found in numerous mammalian species that an autonomic response is demonstrated with persistent pain. At the onset of acute pain, the ANS raises sympathetic tone and accordingly blood pressure and heart rate, which have been shown to normalize with respect to time. The activation of baroreceptors by elevated BP, triggers an increase in vagal tone in an attempt to restore homeostasis. This increase in vagal tone has been demonstrated to provide an opioid-mediated partial anti-nocicipetion in both animal and human models. The primary pathway for this effect is mediated via the right cardiac vagal trunk. In addition to the heart, the vagus affects other physiologic changes including a lowering of SP. Thus, during moderate to severe chronic pain, skin on the right side has a lower SP than on the contralateral side, while mild pain fails to trigger the baroreceptors and therefore does not produce changes in SP. After pain relief, vagal tone moves back towards normal, with a coincident fall in SP on the right side.

This D'Angelo fellow by the way is an MD working for New York Harbor VA medical center in the dept. of anesthesiology.

Summary: In all five sessions for this individual, SP was lower on the right side during moderate to severe chronic pain (VAS 4-10). After pain relief, SP on the right rose. Distinguishing between painful and pain-free states in this patients was as simple as seeing whether the trace was above or below the neutral baseline.

It will be interesting to follow whether this technology, if validated, comes into play in future pain studies.

[Diane]

Thanks Jon.

At the onset of acute pain, the ANS raises sympathetic tone and accordingly blood pressure and heart rate, which have been shown to normalize with respect to time. The activation of baroreceptors by elevated BP, triggers an increase in vagal tone in an attempt to restore homeostasis. This increase in vagal tone has been demonstrated to provide an opioid-mediated partial anti-nocicipetion in both animal and human models. The primary pathway for this effect is mediated via the right cardiac vagal trunk. In addition to the heart, the vagus affects other physiologic changes including a lowering of SP. Thus, during moderate to severe chronic pain, skin on the right side has a lower SP than on the contralateral side, while mild pain fails to trigger the baroreceptors and therefore does not produce changes in SP. After pain relief, vagal tone moves back towards normal, with a coincident fall in SP on the right side.

It still doesn't make sense yet. In other words, I still can't quite "see" it yet. I see a vague random rise and fall, sort of like the sea heaving around but I can't make out what is calming it down and what is making it rise. My confusion is directly proportional to the lack of focal length/ability to see a big(ger)/ the big(gest) picture, and was based originally on a category mistake named "peripheral/central" instead of "ectodermal/mesodermal/endodermal".

Other thoughts/beliefs I've held about the ANS that need closer looking/ deconstruction:
1. parasympathetic good for pain, sympathetic bad for pain
2. touching improves parasympathetic function
3. exercise increases sympathetic function
4. autonomics are essential for breathing, digestion, heart function
5. that there must be consistency somewhere in it that I'm missing (maybe there isn't any consistency or fixedness or predictability, maybe there is only perpetual dialectic)

Definitely, let's start a new thread. (I started one awhile ago.. can't find it just now.. I posted a picture of an interneuron. The thread died and got lost. I'll repost the picture.)

[Barrett Dorko]

A new thread about the autonomic state in pain and during correction sounds good. To me, it's the least well understood portion of the "five vitals" equation. Jon's attendance to that conference is really paying off for all of us here.

Time for the fourth question : Which ways do you want to move and how does that make you feel?

I always ask my classes at this point - How do I ask this question?

Any takers?

[Diane]

How do I ask this question?

Manually.

[Barrett Dorko]

Diane,

You're right, of course. And the only way I know how to do this and acquire the information I want is to employ Simple Contact or your mild and intricate skin stretching stuff. You really do need to come up with a name for that.

If a student doesn't answer as you do but rather says, "Ask them which movement they would prefer to do in order to relieve their pain" I know I haven't gotten several key points about abnormal dynamics, ideomotion and autonomic change across - all of which they should know by now.

What answers am I looking for? Here's a hint

[Diane]

the only way I know how to do this and acquire the information I want is to employ Simple Contact or your mild and intricate skin stretching stuff. You really do need to come up with a name for that.

I called it sensory motor neuromodulation. I guess it could be manual neuromodulation. It's still too long. Lateral skin stretch is accurate but has no cache. Ruffini ruffling? If you have any suggestions I'd be glad to entertain them.

That's a very broad hint.

[Barrett Dorko]

While the rest of the world thinks about what to call Diane's method let's wrap up this hread with the fifth question: Where do your legs rest when you lie supine?

Take a look at post #7 of this thread for a clue.

[Diane]

Skinipulation. Skinotherapy. Skinovation.

Where do your legs rest when you lie supine?

I know your system says, if they lie there like Barbie legs in internal rotation they are working too hard. As legs develop embryologically and post birth they spiral in and drag their nerves along, into a loose inward spiral. In supine ordinary gravity should suffice to pull the feet/legs into outward rotation. If this does not happen the nervous system is protecting itself from hypoxia, usually obturator or saphenous nerve, above in the inguinal ligament, or even deeper within the pelvis.

Of course, if the nervous system is protecting itself from hypoxia of something shallower, i.e., the lateral cutaneous nerves of the trunk, and/or superior cluneal nerves as they flow over the lateral side of pelvis to the greater trochanter, one might see outward rotation of the legs that is protective rather than normal.

The best way I know to find out is to pick up the heels slightly/slowly, pull the skin over them in a caudal direction, and see if the skin "slides down" both legs evenly. There should be a perceptual fantasy of both legs actually elongating. A leg that doesn't feel like it lengthens will have a PNS that is hung up somewhere, often behind the knee but not always. While the feet are suspended, one can test the hip system for internal and external rotation, which should offer no resistance whatever.

My point is that a leg that looks like it might be in "normal" external rotation, may not be.. it may offer quite firm resistance to being turned inward. In that case, the more superficial PNS along the outside or back of the leg/body likely needs help.

[Barrett Dorko]

Diane,

Skindippity Just a thought.

I think our handling and interpretation diverge at this juncture. That's okay because I think we're both largely correct and can defend how we approach this posture therapeutically as well as our interpretation of it. Everybody else, of course, is essentially thoughtless and wrong. At least, that's my message to the classes.

After I see what people choose to do, I work to see what they can and cannot do, and then investigate what they want to do, all the while making sure they notice how this all relates to their symptoms and their breathing and the characteristics of correction.

This final question naturally leads me to review what they've learned so far and quite commonly allows me to begin adding some Feldenkrais movement therapy to their home program.

In supine lying I can show them what I eventually want from this position, how to acquire it spontaneously and how to maintain it. A little enforced internal rotation and adduction of the hip(s) brings the connections within the nervous system quite dramatically to their attention. It's a great position to work and teach from.

[Barrett Dorko]

Diane,

Skineration?

Okay, I got nothin'

I think this thread has run its course and I'm very pleased with the results. I thought I might clarify several important issues regarding my evaluative scheme and that has certainly happened. The branching thread regarding autonomic states in pain should be required reading for every therapist. I think it brings to light Butler's statement, "We aren't treating anatomy, we're treating physiology." Upon this we agree.

I can send my classes here after I do the "End of Evaluation" bit with complete confidence. Of course, as one Shakespearian character says famously to another in one of his plays, and I'm paraphrasing here, "Anyone can call up ghosts and apparitions from other worlds - the real issue is, Will they come?"

[Diane]

I agree. Maybe we should sticky this thread.

All I really know about autonomics is, when they aren't good, and when pain is a feature, some part of the nervous system somewhere likely can't breathe, and one must try to coax the system in a better direction.

Thanks for helping try to think of a name for skin work.. as you can see, it's not easy.

I thought of a name, based on the fact that skin is the brain's interface with the physical world around it. Are you ready? Interfacial Ectodermotherapy. What? Too cumbersome?

How about "Interfacial Release"? Just kidding.

[Jason Silvernail]

Awesome.

This thread is required reading for the student I am working with now. Perhaps she'll post if she feels up to it.

This thread symbolizes why I come here, we are discussing important things that I don't see anyone anywhere else talking about. I learned a lot.

Thanks everyone as always for the ongoing education.

J

[nari]

Jason

Your input is also much appreciated.

Nari

[stregapez]

Diane,

I kind of like Ruffini Ruffling. Skindippity is cute too (though possibly a little too cute)

Dana