Are things getting hot on twitter?

[Diane]

Nathan,

Do you think that if you press harder you get "deeper"?

I second that question.

[proud]

Nathan,

Do you think that if you press harder you get "deeper"?

It's such a fantastic question.

[nari]

Do you think that if you press harder you get "deeper"?

It's such a fantastic question.

I like it too.

Nari

[Evanthis Raftopoulos]

Do you think that if you press harder you get "deeper"?

You always stay at the skin of course, but depending on where you press, you can usually mobilize deeper than skin layers. How deep is a different story and depends on variables like force, direction, point of application, adipose tissue, etc. Even gentle hands on interventions can mobilize deeper than skin tissues, like let's say "mfr" like treatments. The fact that we can mobilize deeper than skin tissues does not necessarily mean that at any given time we can affect the deeper tissues and their neural branches in a meaningful way and in the context of pain resolution (or even just temporary pain relief), but we can also argue the same about the skin and its neural branches. Unless we are talking about gentle touch only(and even that can be debatable), anything that involves stretching/mobilizing the skin also influences at least the adjacent layers below (we are talking about millimeters difference). Nevertheless, what matters more IMO is that the heavy pressure is encoded differently in the brain than the light pressure, and always sensitive to context.

[Diane]

Pain science is touched on (very lightly) in the Level 3 courses. You have to wait until Level 3 to even be introduced to this. I'm not sure if they feel people aren't bright enough to comprehend this information before this level or if they don't feel it is important enough to include this in the Level 1 course. Regardless, by the time pain science is introduced, people have already been immersed in the biomechanical model so deeply that it is hard to pull them out of this mindset.

Aaron

Conspicuity.

When tissue focus is taught first, it introduces an incredibly sticky, permanent bias in clinical reasoning. It's deliberately induced inattentional blindness.

Conspicuity refers to an object's ability to catch a person's attention. When something is conspicuous it is easily visible. There are two factors which determine conspicuity: sensory conspicuity and cognitive conspicuity. Sensory conspicuity factors are the physical properties an object has. If an item has bright colors, flashing lights, high contrast with environment, or other attention-grabbing physical properties it can attract a person’s attention much easier. For example, people tend to notice objects that are bright colors or crazy patterns before they notice other objects. Cognitive conspicuity factors pertain to objects that are familiar to someone. People tend to notice objects faster if they have some meaning to their lives. For example, when a person hears his/her name, their attention is drawn to the person who said it. The cocktail party effect describes the cognitive conspicuity factor as well. When an object isn’t conspicuous, it is easier to be intentionally blind to it. People tend to notice items if they capture their attention in some way. If the object isn’t visually prominent or relevant, there is a higher chance that a person will miss it.

From a blogpost I wrote lately:

At McGill University, and for historic reasons unique to Canada, the law program prepares its students for the world by teaching civil law and common law simultaneously. It's done that way because it was noted that in the past, if one set of law was taught before the other in a linear manner, students would prefer whichever version they were taught first, that form would take over their brains, and from then on they would consider that form more important than the other form. So, the instructors decided to teach them simultaneously because both are equally important in Canada.

I think it would be a lot better if nervous system/skin/afferent signalling/pain science were taught first. Then manual therapy and reasons for doing it would likely make a lot more sense. Even if it were taught with tissue-based reasoning, everyone would get that it was just for mental convenience, not believe it as true fact the way they do now. Allowing it to continue to be taught the way it is right now is like teaching everyone to drive by only looking in the rear view mirror. They really won't look where they are going. Inattentional blindness. What gorilla?

[zendogg]

Nathan,

Do you think that if you press harder you get "deeper"?

No I don't. My only assertion is that deeper tissues also provide afferent info to the brain. I am not advocating mashing of any sort. We have discussed before at length the inclusion of techniques in Diane's manual that utilize deeper pressures. Whether one's mental construct is that skin and embedded nerves are the ONLY theraputically viable tissue or that deeper tissues provide information that could be crucial to a modulation of pain, we cannot separate out hick did which.

Barrett, if by "deeper" you mean greater, more positive effect, my answer is no. I have occasionally found that I could not generate softening or ideomotion in some clients and have attempted broad contact perpendicular pressure to say a buttock. Softening then occurred. Skin mediated? Deeper tissue assisted? Deeper nerve assisted? My context and handling? I really don't know.


Nathan

[Diane]

Since the nervous system only cares about itself, I can imagine it might care about the vessels that feed the 72 kilometers of nerves, and in particular the innervated feeder vessels particularly if those become kinked. These enter the nerve from wherever, also drainage vessels exit from wherever, 360 degrees around the nerve, wherever the vessels happen to be juxtaposed against the nerve anywhere in the body. They are more vulnerable to mechanical deformation than anything else that exists in there. The NS cares about that 20% of all the metabolic fuel it hogs at every passing moment. It stands to reason (mine anyway) that it might have managed to evolve a lot of mechanosensitive nociception right at those feeder vessels. I have no way to prove that of course, so I'm using my finely honed cherry-picking confirmation bias to see if there is anything out there on the topic. The only clue I have to date is that ancient image Bove found in 1995 or whatever from some other ancient paper from the 60's, showing a cartoon of nerve innervation of itself and it's vasculature which I coloured, and use in my slideshow.

Honestly, I don't think it cares about the fascia surrounding muscle. There are neurons in there but nothing mechanical stimulates them, NOTHING, unless/until they are activated by local inflammatory soup, and they are sensitized
Once activated they shouldn't be further provoked, IMO. Same with silent nociceptors in joints.
The other stuff is proprioception. It's there to guide motor output during motor output.
Why we think we can affect that therapeutically from outside somebody's body is beyond me. It's a tale often told by chiropractors. Sure, I believe every word they say. Not.

[Barrett Dorko]

Okay, it's the movement that stimulates the receptors beyond the level of the skin, not the depth of the pressure imposed by the therapist's hands.

I can live with that.

Now all we need to do is to get therapists to understand that.

[zendogg]

Diane,

I hope you are not reading me as saying I can therapeutically effect some tissue located deeper than skin. Only that my contact could elicit afferent information sufficient to modulate pain output. Take your technique at the AC joint: deep pressure with a pencil eraser or something to move a deep nerve such that it could breathe better.
You cannot know that skin, deeper nerve displacement or other embedded receptors have given rise to change seen in the patient.

[Diane]

Or maybe move some hook-up between a nerve and its vessel.

I'm pretty sure the brain doesn't much care about embedded receptors unless they start to signal crankiness because their internal milieu is off, chemically. Not mechanically, chemically.

[zendogg]

Diane:

Honestly, I don't think it cares about the fascia surrounding muscle. There are neurons in there but nothing mechanical stimulates them, NOTHING, unless/until they are activated by local inflammatory soup, and they are sensitized

I was not aware that proprioceptors were not mechanically stimulated. If I mechanically deform/stretch a slack bicep by pushing it laterally wouldn't that stimulate spindles? Isn't this why there is no such thing a passively moving a patient? The system is always tracking its length/tension relations to keep structures safe.

[I AM NOT ADVOCATING MASHING MEAT. Just curious as to the interactive engagement of pressure beyond skin depth.]

Nathan

[Bas Asselbergs]

Diane, I will still not discount the possibility that a deeper sense of pressure can trigger a neurophysiological response that can modify pain output. I agree with Nathan: we can not discount the possibility.
I do not think he is saying it will, or that he can pinpoint it with manual care.

[zendogg]

Diane, I will still not discount the possibility that a deeper sense of pressure can trigger a neurophysiological response that can modify pain output. I agree with Nathan: we can not discount the possibility.
I do not think he is saying it will, or that he can pinpoint it with manual care.

Yes that is what I'm driving at. With the foundation of DO NO NOCICEPTING, my aim is always the patient's brain. Quite often I can help it change output with VERY light skin stretch. Sometimes the skin stretch doesn't do anything until I move the limb somewhere. Sometimes I press deeper, slowly and always with my eyes, ears, hands on the spoken and unspoken verbing of the system.

Nathan

[Jo Bowyer]

Facilitating apical lobe expansion is pretty good for moving the forequarter. The patient doesn't need to alter their breathing purposefully for this to happen under the hands of the practitioner. A side lying position with knees bent seems to work well.

[Diane]

Diane, I will still not discount the possibility that a deeper sense of pressure can trigger a neurophysiological response that can modify pain output. I agree with Nathan: we can not discount the possibility.
I do not think he is saying it will, or that he can pinpoint it with manual care.

I'm sure the brain reads every input, but in terms of pain, it will veto anything it isn't interested in just then.

My understanding of proprioception is that there has to be some kind of "active" contraction before the "proprio"(self) ceptors/muscle spindles could ever be activated, apart from ordinary (sudden) stretch reflex elicited e.g., by reflex hammer or rib bounce.

Sure, if you get somebody to contract their muscles a little bit isometrically or something while you're outside them giving them a bit of resistance, in order to unload a nerve, e.g. a suboccipital nerve for example, fair enough. That's a kind of treatment. (It doesn't always work for pain, but it's a common kind of treatment for increasing range, at least..)

But I just do not buy the idea that when you press on a muscle in a buttock, you are "softening" it by activating proprioceptors, which, if they activate, usually help the muscle contract more, not less, and would be canceled out anyway by brain computation by a brain interested in defending its organism from an outside threat. If such a muscle "softens", under external pressure, I'm pretty sure that phenomenon is secondary to some pretty elaborate autonomic pathways that involve descending modulation, not direct mechanoreceptive input from muscle or other (mesodermal/structural) tissue.

That's how I understand it. I invite correction by good information. What is good information? No confirmation bias that places muscle in the middle of the scientific universe. It will have to be nervous system research please, and it will have to relate to pain research.