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  • Nari's thread: Skin rules!!

    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

  • #2
    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.
    Barrett L. Dorko

    Comment


    • #3
      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

      Comment


      • #4
        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.
        Diane
        www.dermoneuromodulation.com
        SensibleSolutionsPhysiotherapy
        HumanAntiGravitySuit blog
        Neurotonics PT Teamblog
        Canadian Physiotherapy Pain Science Division (Archived newsletters, paincasts)
        Canadian Physiotherapy Association Pain Science Division Facebook page
        @PainPhysiosCan
        WCPT PhysiotherapyPainNetwork on Facebook
        @WCPTPTPN
        Neuroscience and Pain Science for Manual PTs Facebook page

        @dfjpt
        SomaSimple on Facebook
        @somasimple

        "Rene Descartes was very very smart, but as it turned out, he was wrong." ~Lorimer Moseley

        “Comment is free, but the facts are sacred.” ~Charles Prestwich Scott, nephew of founder and editor (1872-1929) of The Guardian , in a 1921 Centenary editorial

        “If you make people think they're thinking, they'll love you, but if you really make them think, they'll hate you." ~Don Marquis

        "In times of change, learners inherit the earth, while the learned find themselves beautifully equipped to deal with a world that no longer exists" ~Roland Barth

        "Doubt is not a pleasant mental state, but certainty is a ridiculous one."~Voltaire

        Comment


        • #5
          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.

          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
          Jason Silvernail DPT, DSc, FAAOMPT
          Board-Certified in Orthopedic Physical Therapy
          Fellowship-Trained in Orthopedic Manual Therapy

          Certified Strength and Conditioning Specialist


          The views expressed in this entry are those of the author alone and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the US Government.

          Comment


          • #6
            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
            www.dermoneuromodulation.com
            SensibleSolutionsPhysiotherapy
            HumanAntiGravitySuit blog
            Neurotonics PT Teamblog
            Canadian Physiotherapy Pain Science Division (Archived newsletters, paincasts)
            Canadian Physiotherapy Association Pain Science Division Facebook page
            @PainPhysiosCan
            WCPT PhysiotherapyPainNetwork on Facebook
            @WCPTPTPN
            Neuroscience and Pain Science for Manual PTs Facebook page

            @dfjpt
            SomaSimple on Facebook
            @somasimple

            "Rene Descartes was very very smart, but as it turned out, he was wrong." ~Lorimer Moseley

            “Comment is free, but the facts are sacred.” ~Charles Prestwich Scott, nephew of founder and editor (1872-1929) of The Guardian , in a 1921 Centenary editorial

            “If you make people think they're thinking, they'll love you, but if you really make them think, they'll hate you." ~Don Marquis

            "In times of change, learners inherit the earth, while the learned find themselves beautifully equipped to deal with a world that no longer exists" ~Roland Barth

            "Doubt is not a pleasant mental state, but certainty is a ridiculous one."~Voltaire

            Comment


            • #7
              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.
              Diane
              www.dermoneuromodulation.com
              SensibleSolutionsPhysiotherapy
              HumanAntiGravitySuit blog
              Neurotonics PT Teamblog
              Canadian Physiotherapy Pain Science Division (Archived newsletters, paincasts)
              Canadian Physiotherapy Association Pain Science Division Facebook page
              @PainPhysiosCan
              WCPT PhysiotherapyPainNetwork on Facebook
              @WCPTPTPN
              Neuroscience and Pain Science for Manual PTs Facebook page

              @dfjpt
              SomaSimple on Facebook
              @somasimple

              "Rene Descartes was very very smart, but as it turned out, he was wrong." ~Lorimer Moseley

              “Comment is free, but the facts are sacred.” ~Charles Prestwich Scott, nephew of founder and editor (1872-1929) of The Guardian , in a 1921 Centenary editorial

              “If you make people think they're thinking, they'll love you, but if you really make them think, they'll hate you." ~Don Marquis

              "In times of change, learners inherit the earth, while the learned find themselves beautifully equipped to deal with a world that no longer exists" ~Roland Barth

              "Doubt is not a pleasant mental state, but certainty is a ridiculous one."~Voltaire

              Comment


              • #8
                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
                :rose:

                Comment


                • #9
                  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

                  Comment


                  • #10
                    Emad, it's called stretch because it is stretch. Plain and simple.
                    Diane
                    www.dermoneuromodulation.com
                    SensibleSolutionsPhysiotherapy
                    HumanAntiGravitySuit blog
                    Neurotonics PT Teamblog
                    Canadian Physiotherapy Pain Science Division (Archived newsletters, paincasts)
                    Canadian Physiotherapy Association Pain Science Division Facebook page
                    @PainPhysiosCan
                    WCPT PhysiotherapyPainNetwork on Facebook
                    @WCPTPTPN
                    Neuroscience and Pain Science for Manual PTs Facebook page

                    @dfjpt
                    SomaSimple on Facebook
                    @somasimple

                    "Rene Descartes was very very smart, but as it turned out, he was wrong." ~Lorimer Moseley

                    “Comment is free, but the facts are sacred.” ~Charles Prestwich Scott, nephew of founder and editor (1872-1929) of The Guardian , in a 1921 Centenary editorial

                    “If you make people think they're thinking, they'll love you, but if you really make them think, they'll hate you." ~Don Marquis

                    "In times of change, learners inherit the earth, while the learned find themselves beautifully equipped to deal with a world that no longer exists" ~Roland Barth

                    "Doubt is not a pleasant mental state, but certainty is a ridiculous one."~Voltaire

                    Comment


                    • #11
                      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

                      Comment


                      • #12
                        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
                        Nick Matheson, PT
                        Strengthen Your Health

                        Comment


                        • #13
                          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.
                          Barrett L. Dorko

                          Comment


                          • #14
                            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

                            Comment


                            • #15
                              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
                              Eric Matheson, PT

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