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A Fresh Look At Manual Therapy

"What would happen if manual therapists focused on brain function, spinal cord function, and nerve function, instead of tissue?


I think we would listen very closely to patients’ accounts of their pain, explain nerves in detail, explain pain way better in ways patients could understand, with their own story details woven back in. I think we would teach our patients how to own and practice locus of control over treatment, and the importance of maintaining a boundary around their own relaxed comfort levels. I think any manual therapy provided, any results from it and from any movement homework afterward, would be considered by both parties, and both parties’ brains, as having been arrived at mutually, interactively. I think we therapists would enhance our abilities to elicit favorable descending modulation for pain from another’s brain, through awareness of how touch and handling of periphery and peripheral nerve is perceived by the brain attached, instead of imagining we were doing things to change structure or tissue. (...)

I think that that judicious sensory rehabilitation, first, can help people with non-medical pain move easier, feel more inclined to participate in motor rehabilitation, and thereby avoid unnecessary surgery. (...)"


- Diane Jacobs PT.

DNM in a Nutshell

1. Addressing skin, dragging it a little, activates exteroception, interoception, and also activates proprioception. No need to pretend one can bypass skin and focus on muscle or joints, or release fascia.

- Edin, B.B., and Johansson, N., 1995, Skin strain patterns provide kinaesthetic information to the human central nervous system. J Physiology 487.1 243-251

- Lundblad, L.C., Olausson, H.W., Malmeström, C., and Wasling, H.B., 2010, Processing in prefrontal cortex underlies tactile direction discrimination: An fMRI study of a patient with a traumatic spinal cord lesion. Neurosci Lett. Oct 15;483(3):197-200.

- Proske, U., and Gandevia, S., 2009, The kinaesthetic senses. J Physiol 587.17 p. 4139–4146

- Panek, I. , Bui, T., Wright, A.T.B., and Brownstone, R.M., 2014, Cutaneous afferent regulation of motor function. Acta Neurobiol Exp. 74: 158–171

- Collins, D.F., Refshauge, K.M, Todd, G., and Gandevia, S.C., 2005, Cutaneous receptors contribute to kinesthesia at the index finger, elbow, and knee. J Neurophysiol. Sep;94(3):1699-706


2. Cutaneous nerves [physically] innervate underlying [outer layer of] fascia and tendon. Just tugging on skin will drag on these inwardly disseminating rami a bit.

- Stilwell, D.L., 1957, Regional variations in the innervation of deep fasciae and aponeuroses. The Anatomical Record Volume 127, Issue 4, pages 635–653, April

-Stilwell, D.L., 1957, The innervation of tendons and aponeuroses. American Journal of Anatomy Volume 100, Issue 3, pages 289–317, May

- O’Brien, M., 1992, Functional anatomy and physiology of tendons. Clin Sports Med. Jul;11(3):505-20 - Doral, M.N., Alam, M., Bozkurt, M., Turhan, E., Atay, O.A., Dönmez, G., and Maffulli, N., 2010, Functional anatomy of the Achilles tendon. Knee Surg Sports Traumatol Arthrosc. May;18(5):638-43

- Uquillas, C.A., Guss, M.S., Ryan, D.J., Jazrawi, L.M., and Strauss, E.J., 2015, Everything Achilles: Knowledge Update and Current Concepts in Management: AAOS Exhibit Selection. J Bone Joint Surg Am. Jul 15;97(14):1187-95


3. Skin contact helps with pain.

- Mancini, F., Beaumont, A., Hu, L., Haggard, P.,Iannetti, G.D, 2015, Touch inhibits subcortical and cortical nociceptive responses. Pain: October, Volume 156 - Issue 10 - p 1936–1944

- Mancini, F., Nash, T., Iannetti, G.D., and Haggard, P., 2014, Pain relief by touch: A quantitative approach. PAIN Volume 155, Issue 3 , Pages 635-642, March

- Foster, E., Wildner, H., Tudeau, L., Haueter, S., Ralvenius ,W.T., Jegen, M., Johannssen, H., Hösli, L., Haenraets, K., Ghanem, A., Conzelmann, K., Bösl, M., and Zeilhofer, H.U., 2015, Targeted Ablation, Silencing, and Activation Establish Glycinergic Dorsal Horn Neurons as Key Components of a Spinal Gate for Pain and Itch. Neuron, Mar. 85: 1289-1304


4. Skin contact helps to grow more inhibitory neurons in the spinal cord.

- Shechter R, Baruch K, Schwartz M, Rolls A.; Touch gives new life: mechanosensation modulates spinal cord adult neurogenesis. Mol Psychiatry. 2011 Mar;16(3):342-52


5. Sensory neurons produce endogenous peripheral opioid receptors. Perhaps stimulating the skin organ deliberately can help create reduction in peripheral nervous system nociception.

- Kapitzke D, Vetter I, Cabot PJ; Endogenous opioid analgesia in peripheral tissues and the clinical implications for pain control. Ther Clin Risk Manag. 2005 Dec; 1(4): 279–297

-Stein C, Machelska H; Modulation of Peripheral Sensory Neurons by the Immune System: Implications for Pain Therapy. Pharmacological Reviews December 2011 vol. 63 no. 4860-881.

- Christoph Stein, Michael Schäfer, Halina Machelska; Attacking Pain At Its Source: New Perspectives on Opioids. Nat Med. 2003;9(8)

- Stein C; Opioid receptors on Peripheral Sensory Neurons. Madam Curie Bioscience Database. 2000-2013, Landes Bioscience. Bookshelf ID: NBK6242

"DermoNeuroModulating, or -tion, is 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).
It is prudent to remember that manual handling of a patient's physicality is only a small part of developing a complete therapeutic context for change - while optional, it can also be optimal."

- Diane Jacobs PT.