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  • CT A deeper interaction

    this thread reminded me of this thread... not specifically related to needling, but speaks to the issue of whether or not a minimal approach is necessarily the best choice.

    I think that needles could conceivably be perceived as non threatening, but i agree with Mark that do no harm, no matter how small the risk is needs to be attended to first and foremost.

    Assuming we are choosing from a range of manual therapy approaches of which we are sure do no harm (not needling, not cracking necks), I still havent settled on the idea that gentle handling (gentle to the extent that only the skin is affected by the hands) is necessarily "better" for every client.

    Aren't we dealing with one big fuzzball? Can it not be so that manual therapy applied at a depth/pressure that moves/affects nervous tissue that is housed deeper (than skin) is effective?

    For example, I consistently observe "better" decreases in pain and improved shoulder movement from an AP glide of GHJ in supine vs skin stretching in and around the UT, scap region and upper limb. I've also tried to simulate my AP glide technique in a gentle manner so as to isolate the skin stretch that accompanies my deeper technique from the joint glide.

    But consistently, the deeper approach is more effective. I continue to start all treatment with education, context building (as best i can in my environment), gentle skin stretch and attempt my own rudimentary version of SC. For some clients it is sufficient for pain resolution, for many others, a deeper approach, in which i glide or unload or sometimes even load a joint (read use accessory joint motion to affect nervous tissue deeper than the skin) seems to be more effective.

    Can anyone suggest reasons why we should limit our interaction with the nervous system to those nerves that are housed in the skin? Does it not make sense to attempt to provide novel and non threatening interoception as well as exteroception?

  • #2
    Skin vs. muscle somatotopic organization

    Henderson (2007) and Henderson (2011) is on to something and has highlighted cortex insularis "muscular" somatotopic organization. It seems that "deep somatic" tissue has its own representation.

    Worth ignoring?
    Jan K. Huus
    "Curiosity happens when we feel a gap in our knowledge" - somewhere on SomaSimple

    Comment


    • #3
      Skin (dermis and hypodermis layers, not epi) has plenty of sensitive interoception. Given that the blubber layer is plenty thick already, and its interoception can pick up on external forces applied from the outside, and decode them just fine, I see no great value in trying to dig through it. Nerves can be moved just fine without heavyhandedness, in most cases. And I should think it's important to not (adversely) affect vasculature, i.e., veterbral arteries, etc.
      I'm sticking with the skin layer for most of my patients, and just about ALL of my clinical reasoning.

      I suspect one gets in a rut (conceptually) because of how one's hands were trained, conflated with what was poured into one's mind, once upon a time, i.e. joint-based mesodermal madness.
      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


      • #4
        Great question Patrick. These are questions that swirl around in my head daily as well. I continue to apply joint mobilizations with most patients. The difference is my explanatory model. I no longer explain that I'm breaking up adhesions or scar tissue in capsule since we know this is impossible. There is evidence that manual therapy can affect suprspinal regions that can lead to descending inhibition. I'm sure that this could be accomplished through DNM or SC as well. I guess I stick with my mesodermal approach since they were techniques I was taught in school. The only difference is the deeper explanatory model that I had to learn outside of university.

        I use Mulligan techniques alot since I beleive you get a skin stretch with joint mobilization and movement all at once. I also like having a comparable sign such as shoulder abduction that the patient can notice an improvement in immediately.
        Rob Willcott Physiotherapist

        Comment


        • #5
          Stimulating joint receptors seems pretty reasonable to me, only I'd try not cause any nociception trying to dig through the skin to stimulate said joint receptors. And I seem to be doing it a lot less that I used to, don't seem to need to anymore. Maybe I'm getting lazy?
          Dave

          Comment


          • #6
            Hi Dane,

            I'm sticking with the skin layer for most of my patients, and just about ALL of my clinical reasoning.
            My bold.

            Could you elaborate on those exceptions, if any? Or did I misunderstand your statement?
            Erik
            If things didn't change we'd stop noticing them very quickly.
            - Barrett Dorko.

            Comment


            • #7
              Originally posted by Electerik View Post
              Hi Dane,

              Could you elaborate on those exceptions, if any? Or did I misunderstand your statement?

              OK, most, means "virtually all" of them.

              just about means "nearly"
              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
                Then I guess those exceptions would be the ones you don't treat.

                There was one intervention that you did at the DNM class in Prévost/Québec that caught my attention. I mulled it over and over but I still have an itch about it, so I have to ask.

                I can't remember who it was you were treating but we were on the shoulder, around the supra-scapular nerve I believe. You didn't get the result you were looking for. The shoulder still seemed to be a bit "constrained". Then you went "Ah-HA! I know which muscle it is, it's the omo-hyoïde. That horrible muscle that was maybe of use to us when we were four legged animals and needed to chew away at our food like wolves". You then went about treating that area in DNM fashion, (which isn't covered in the manual) and bingo! You got the result you wanted and the shoulder seemed more at ease after you handled it.

                You still seemed to have a mesodermal train of thought to seek out the problem and then went about positioning the head and shoulder to better access to those deep nerve bundles, associated with the omo-hyoïde.

                So my question is: does mesoderm still apply in your treatment approach, at least your reasoning, to justifiably target an area?
                Erik
                If things didn't change we'd stop noticing them very quickly.
                - Barrett Dorko.

                Comment


                • #9
                  Originally posted by Electerik View Post
                  There was one intervention that you did at the DNM class in Prévost/Québec that caught my attention. I mulled it over and over but I still have an itch about it, so I have to ask.

                  I can't remember who it was you were treating but we were on the shoulder, around the supra-scapular nerve I believe. You didn't get the result you were looking for. The shoulder still seemed to be a bit "constrained". Then you went "Ah-HA! I know which muscle it is, it's the omo-hyoïde. That horrible muscle that was maybe of use to us when we were four legged animals and needed to chew away at our food like wolves". You then went about treating that area in DNM fashion, (which isn't covered in the manual) and bingo! You got the result you wanted and the shoulder seemed more at ease after you handled it.

                  You still seemed to have a mesodermal train of thought to seek out the problem and then went about positioning the head and shoulder to better access to those deep nerve bundles, associated with the omo-hyoïde.

                  So my question is: does mesoderm still apply in your treatment approach, at least your reasoning, to justifiably target an area?
                  Hi Eric,
                  I remember that. I unfairly blamed mesoderm, didn't I? .. committed the heuristic I've been trying to unlearn and trying to help other people unlearn. I blame decades of indoctrination of the wrong kind for that. Sounded like a contradiction, did it?

                  When the neck or body pulls down a certain way, and hurts in a certain way, the mesodermal puppet string does still appear sometimes on the inner screen (en moi). Not that it's the string's fault - it's just a tool used by the nervous system trying to protect something else in there, but ends up deforming something else, neural. And the string certainly has no control over what some therapist visualizes in the moment.

                  The way I learned that system was that muscles were being shortened, deliberately, so they could relax. I think now that's most likely wrong wrong wrong, that instead a neural tunnel situation is relieved - but the nerve didn't come into my head, instead a muscle did. Such is the ease with which wrong ideas are taught, conflated into otherwise perfectly useful technical applications. Sorry for passing that one along. Oops.

                  I'm currently making more slideshows, this time the three upper plexuses (which sort of blur into each other, almost worse than the bottom two do). But I'm tackling them one nerve root at a time, like I did before, so stay tuned. I consider them de-indoctrination de-programs. Especially for me.
                  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


                  • #10
                    Thankyou Diane,

                    I see no great value in trying to dig through it.
                    Please know that i dont endorse any digging/poking type methods or any methods i conceive to be nociceptive.
                    Skin (dermis and hypodermis layers, not epi) has plenty of sensitive interoception. Given that the blubber layer is plenty thick already, and its interoception can pick up on external forces applied from the outside, and decode them just fine, I see no great value in trying to dig through it. Nerves can be moved just fine without heavyhandedness, in most cases. And I should think it's important to not (adversely) affect vasculature, i.e., veterbral arteries, etc.
                    So your conceptual perspective is that exteroception/interoception from the skin is (virtually) always sufficient for pain reduction (assuming appropriate context)?

                    Conceptually, I agree but the clinical outcomes i observe seem to conflict with my conceptual understanding i.e sustained novel/non threatening positioning of a joint sometimes brings about better pain reduction than skin stretching. Sometimes the reverse is true.

                    I don't pretend to know why this is the case (the variable outcomes), and I'm not arguing that we should "go with whatever works". But my concern is that if one limits oneself to only interacting with the nervous tissue embedded in skin, for the purpose of adhering to a conceptual framework (that says the skin provides sufficient exteroceptive/interoceptive capacity for pain resolution), one may run the risk of limiting treatment efficacy. I think we can interact with deeper (than skin) neural tissue without violating the deep model espoused here on SS. Unless of course, someone can think of an answer to the following.

                    Can anyone suggest reasons why we should limit our interaction with the nervous system to those nerves that are housed in the skin (all skin components- not just epidermis)?



                    I'm looking for a reasons other than ones that goes like this...
                    • my clinical outcomes dictate that interacting with the nervous tissue at the level of the skin is all that is needed to achieve pain resolution
                    • my conceptual understanding is that the skin always contains sufficient interoceptive/exteroceptive potential for pain resolution

                    Comment


                    • #11
                      Sometimes it's good to add some bending of a body or body part to alleviate some sort of (presumably - but what other kind would it be?) neural distress deeper inside.
                      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


                      • #12
                        i absolutely think it would be neural stress. I am not attempting a mesodermal argument here. I'm wondering why the skin should be our only conceptual gateway to the nervous system?

                        We say that the skin is the outside of the brain, does this mean the brain attends to sensory information from the skin preferentially (over sensory info from nerves that innervate deeper (than skin) tissues)

                        Comment


                        • #13
                          I think the brain prioritizes/prefers to attend to input from
                          1. Novel exteroception ahead of interoception
                          2. Noci-interoception from inside nerves ahead of noci-interoception from outside nerves
                          3. Noci and non-noci interoception from vascular structure ahead of any other sort of mesoderm, i.e., structural
                          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


                          • #14
                            1. Novel exteroception ahead of interoception
                            Why do you think this is the case? I think in another thread we discussed this from an evolutionary perspective... We have evolved to attend to external stimuli as such stimuli has the greatest potential to threaten survival.

                            It makes sense conceptually... Yet I regularly see outcomes in the clinic that contradict this I.e. Better results from maneuvering/positioning/gliding a joint vs applying skin stretch. The reverse often occurs too.

                            I reason that pain reduction (or at least the component attributable to the provision of novel and non threatening exteroception/interoception) may be traced back to deeper (than skin) neural structures when joint positioning/maneuvering/gliding proves more effective than skin stretch.

                            I don't think I could use this in a predictive way but it does lead me to think that it would be premature of me to choose only interact with a client's nervous system at the level of the skin.

                            Am I on my own with this thinking?

                            Comment


                            • #15
                              Whether you think you are or not, if you are applying manual therapy, you are touching skin long before you are pushing into a joint. I don't know how you could eliminate this as a confound.
                              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

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