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  • nari
    started a topic Nari's thread: Skin rules!!

    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

  • Diane
    replied
    Skin Facts

    Liz MacShields on Facebook provided all these links to factoids about skin. Delicious!!
    One square inch of skin
    Anatomy skin quiz
    Medical Assisting
    Cornell

    Leave a comment:


  • Diane
    replied
    Skin Has an Internal Clock

    All about something called Krüppel-like-factor (Klf9) in keratinocytes.

    Leave a comment:


  • Diane
    replied
    Nari mentioned this article a long time ago in another context, and I recently unearthed it. I thought it would be fitting to bring it here.
    The topic is on circadian rhythms found in skin cells. I'll see if I can find the actual article and post a link to this thread.

    Leave a comment:


  • Diane
    replied
    I don't know if this Lumpkin article on mechanical transduction was ever added to this thread, but I'm doing it now.

    Leave a comment:


  • Diane
    replied
    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.

    Leave a comment:


  • Diane
    replied
    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.
    Attached Files

    Leave a comment:


  • Bas Asselbergs
    replied
    Thanks Eric.

    Leave a comment:


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

    Leave a comment:


  • Bas Asselbergs
    replied
    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...

    Leave a comment:


  • Diane
    replied
    Eric, that's hilarious.

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

    Leave a comment:


  • EricM
    replied
    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

    Leave a comment:


  • Diane
    replied
    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.

    Leave a comment:


  • nari
    replied
    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

    Leave a comment:


  • Barrett Dorko
    replied
    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.

    Leave a comment:

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