Dermoneuromodulation

What is Dermoneuromodulation?

Dermoneuromodulation (DNM), in a literal sense, refers to skin/nervous system/change. It is a system of techniques developed by Diane Jacobs, a physiotherapist who recognised the need to begin ‘treating the body as if the nervous system really mattered’. She explains it as 'a structured, interactive approach to manual therapy that considers the nervous system of the patient from skin cell to sense of self. Techniques are slow, light, kind, intelligent, responsive and effective. Positioning of limbs and trunk affects deeper nerve trunks (by shortening and widening their container), and is combined with skin stretch directed toward cutaneous fields of nerves that branch outward into skin (which may draw neural structure further through its container).' We  had the pleasure of attending and witnessing Diane's expertise at her DNM course last month, hosted by renowned physiotherapist Robin Kerr, who has been utilising these concepts in her practice in Noosa, Queensland for some time now.

I highly regard manipulative therapy to the spine and extremities in clinical practice, and have had clients experience miraculous results. Furthermore, there is a wealth of scientific literature supporting both the mechanical and neurological effects at multiple levels of the central nervous system hierarchy.

DNM is NOT re-inventing manual therapy but rather marrying pain science with cognitive psychology combined with osteopathic principles in practice. Indirect osteopathic techniques, such as strain-counterstrain and positional release enables a patient to essentially 'self-organise' and emerge to a state of 'improved regulation'. Utilising indirect osteopathic techniques along with specific skin stretches to enhance and ease peripheral nerve function, is what gave birth to dermoneuromodulation.

If you were to do a coast trek from Bondi to Manly, you would cover a distance of 60km.

Imagine then, that within one of the largest organs of your body , the skin, 72km of peripheral nerve is contained. Although it comprises roughly 2% of the entire body, it is responsible for 100% of function but uses 25% of all available oxygen and glucose, day and night.

It makes sense then, that to affect some sort of meaningful manual therapeutic benefit, the skin and it’s peripheral nerve innervation needs to be carefully considered.

Let’s contemplate the mechanisms behind what you experience as ‘pain’.

What you need to understand is that the sensory information that comes into the brain doesn’t change. Perception happens as much from the inside out as the outside in. In other words, pain doesn’t merely come from the body – pain is an output from the brain. It is a process conducted by the brain that has already established its realm and is constantly seeking to discover how the senses confirm or challenge its expectations. We don’t simply have a pain-detection system, it is more of a built-in threat or salience-detection system.

(Diane Jacobs, 2012)

The brain is not reactive, it is predictive!

You are designed to detect and orient your attention towards sensory events around you, and make a decision based on how it integrates with what you already know or what physiological events should follow.

Why is this important when we are treating you in our practice? While you are lying on the table, without much volitional attention and cognitive thought, you are taking in all your surroundings, level of lighting, temperature of the room and are engaged in the clinician-patient interaction (physical touch, language, patient comfort, bodily positioning, auditory stimulation). These external inputs don’t change your system. Your predictions based on what these inputs summate to, will emerge to change your system’s output based on your previous experience. When we are touching your skin and affecting your peripheral nervous system, what we really have, is an opportunity to change things at the level of your brain by giving it a different experience!

After all, it is the skin that begins embryologically as the same layer as the brain and nervous system. The appeal of using a DNM approach by using safe, comfortable positioning with gentle skin stretch techniques, is that we are essentially down-playing a negative predictive response and up-playing a positive predictive response to these inputs.

So-called "trigger points", "muscle knots" or "tender points" are essentially an expression of your nervous system and the determinant of the location of this aberrant tissue texture change, is not segmentally or anatomically specific.

A tender area on the surface is often the tip of the iceberg and not necessarily a reliable representation of a specific lesion or a good place to start treatment. This explains why it doesn't make sense to "poke and prod" at the perceived site of tenderness or what you may call a "muscle knot". Nor is inflicting pain to inhibit pain beneficial and serves little purpose in self-organizing a positive predictive response.

The illustration above emphasises the responsibility we have in the influence of your experience of pain while you are being treated and how we can work to enhance this by avoiding nociceptive (noxious) input.

Bodily processes are often chaotic and this means that a tiny provocation can have a large effect, or conversely, a strong provocation may produce very little lasting change. Predicting how anyone else will react when we touch them is, to put it mildly, a tricky business. When we choose the simple modality of touch we influence directly an organ that both protects and reveals other organs, processes, thoughts, and feelings in ways both subtle and obvious, predictably and unpredictably. (Dorko, Barrett. Shallow Dive: Essays on the Craft of Manual Care . Kindle Edition).

(Diane Jacobs, 2012)

 

As you can see in the illustration above, both therapist and patient play an important role in creating change - it's a joint effort!

In our practice, we believe that together, the sky is our limit and it is crucial for us to meet half way.

The idea of the neuromatrix encompasses the experience of pain as a result of different parts of the brain working together. The neuromatrix includes the spinal cord and various parts of the brain that generate sensory, emotional, cognitive, motor, behavioural and conscious responses. For me as a clinician to 'hack into' your pain neuromatrix, I am compelled to manipulate:  1) the cognitive-evaluative, 2) sensory-discriminitive and 3) motivational-affective inputs. As complex as this may seem, the majority of time you respond well to manual therapy isn’t purely due to the physical touch itself. I must seek to understand your cognitive drivers, motivations, behaviours, past experiences, expectations and threat perceptions (Safety In Me - SIMS and Danger In Me - DIMS) to ascertain the individual treatment, which will bring about an enhanced positive output to your system. (Moseley & Butler, 2017)

This diagram serves to expand on the neuromatrix model and show the relationship between all the dimensions of the pain experience.

So, next time you are visiting your clinician, ask what he or she is intending to do with applied physical therapy and touch. If the response is releasing a "muscle knot"?  aligning the pelvis/spine "back into place"? or "breaking up" scar tissue? Then you might want to seek another healthcare professional.

Something to think about...

References:

Jacobs, D., DermoNeuroModulating (2016), Tellwell Publishing

Moseley, G. L & Butler, D. S., Explain Pain Supercharged - The Clinician's Handbook (2017), Noigroup Publications

Dorko, B., Shallow Dive: Essays on the Craft of Manual Care (1996), Kindle Edition