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What is Dermoneuromodulation and How it Can Be a Part of the Solution to Your Patient's Pain
By: Diane Jacobs, PT; Megan Zhu, MScPT Student

Introduction

For many, manual therapy looks like aggravating the patient and leaving them feeling more in pain than when they came in, but Diane Jacobs introduces a structured, interactive approach to manual therapy called Dermoneuromodulation, that provides a different way of approaching the problem. 

To begin, most of our training as physiotherapists and healthcare professionals hardly includes the sensory nervous system. It may have been mentioned, but it was not investigated. When learning about the nervous system, the sensory division was often not taught as part of a context for us being out in the world, treating patients.

But how else are we going to get information into another person's nervous system or new input into it unless we consider the sensory nervous system? 

Our brains get information from the environment through the sensory nervous system - whether it be the eyes, the ears, etc. And then the brain will do all sorts of predictive processing and the brain will decide to believe whatever it wants.

The brain wants to believe what it wants to believe. And that goes for absolutely everybody and absolutely every patient. So we have to deal with that factor, which is kind of a hurdle.

We're going to begin by exploring how critical the nervous system is for our function and then learn how to communicate with it.

 

What is the Nervous System?

The nervous system consists of two main parts. Our brain and spinal cord make up the central nervous system, and the 72 kilometers of peripheral nerves that run throughout our body make up the peripheral nervous system. Compared to other systems in our body, the nervous system has the most excitable cells, meaning they don’t require a lot of stimuli to fire and are quite responsive to touch and to being treated. Furthermore, our nervous system is responsible for 100% of our function, even when we are asleep or awake. It makes sure we are breathing, making our heartbeat and rolling over if we need to.

With such an extensive job, it requires a lot of fuel, about 25% of our available glucose and oxygen at all times to be precise. So what happens when it doesn’t get the fuel it needs? Well, it will get grumpy and let you know it’s not happy (might give you pain), however, it won’t completely stop functioning. Therefore, for our nervous system to be running optimally, it’s essential that it has good blood flow as that is how the blood and oxygen will get delivered. With every nerve, there will always be an artery accompanying it to deliver oxygen to it, and delivering blood to the nerve isn’t the problem as it is a high-pressure vessel. The main concern is poor drainage from a nerve often due to a lack of movement. This can lead to nerves being filled with deoxygenated blood and becoming thicker making them more susceptible to becoming trapped.

 

Sensory Nervous System:

Now that we understand how our nervous system plays such an essential role in our function, it begs the question of how do we start communicating with it? Well, It begins with the sensory nervous system. 

We're going to explore the sensory nervous system because that is our best option to help patients. Somatosensory receptors are either interoceptive or exteroceptive. In physical therapy school, we learn about all the different types of receptors in our somatosensory system with a focus on muscle spindles. However, spindles don't register exteroceptive input. They register interoceptive input. On the other hand, cutaneous receptors register exteroceptive input, meaning they inform us when stimuli are applied externally to our bodies. 

Cutaneous nerves are found all over the body. You can think of a cutaneous nerve as a long highway that may travel from your hindbrain as far down to your big toe. On the highway, there are many different lanes that are subdivisions of the highway and run down it longitudinally. You can think of these lanes as fascicles, long tubes that contain cutaneous rami. Along the highway, you may need to eventually exit to arrive at a specific location. These exit roads are cutaneous rami, branches of the nerve that eventually innervate your skin. So, as soon as you're on the skin, you're actually moving and touching cutaneous neural rami.

 

Watch This Video To Learn More:

 

What is Pain & How Can Manual Therapy Help With It?

Okay, so many of your patients come in and report they are experiencing some sort of pain. Before we begin about what we can do for it, let’s talk about what pain is.

3 Truths About Pain

1. Commonly people may equate pain with nociception, but they are two separate things

  • Nociception is a sensory input that encodes noxious stimuli
  • Pain is an output from a combination of cognitive, emotion-related and sensory signaling brain areas


2. Pain is an emotional experience associated with actual or potential tissue damage 

  • Requires conscious perception to have pain 
  • Pain is hard to ignore and interferes with movement


3. Pain is often due to a grumpy or unhappy nerve

  • When patients perform repetitive movements for a prolonged time or there is a lack of movement, it can result in poor blood drainage of their nerves
  • Poor blood drainage can lead to nerves becoming thicker and make them more susceptible to being  entrapped

How Can Manual Therapy Help With It? 

1. Manual Therapy can be thought of as a novel stimulus provided to the nervous system to self-correct the underlying issue

    • The nervous system is predictive and not reactive. With manual therapy, we are deliberately providing an external stimulus that is novel to the nervous system. When a novel stimulus is introduced that is appreciated and welcomed, we are hoping it will persuade the brain to change what it is currently doing and self-correct. 

2. Using manual therapy to provide new feedback that hopefully from some top-down mechanism can decrease the firing 

    • Most likely due to descending modulation 
      • The nuclei in the brainstem receive stimuli for the environment
      • Neurons from the brainstem nuclei descend onto the dorsal horn at various spinal cord levels
    • Along with the sensory neuron that goes up to the brain, there are also collateral branches that inhibit the transfer of nociceptive information. 
    • Nociceptive neurons are heavily modulated by both descending mechanisms and large fibre collateral branches in the spinal cord.

3. Manual Therapy can improve the vascular function of the nerves in the case there is insufficient drainage or entrapment

    • Due to a whole host of reasons such as:
      • Metabolic conditions
      • Tension patterns related to misuse or disuse 
      • Nervous move through tight tunnels formed by stiff tissue boundaries
    • The regional vessels that accompany nerves can be deformed and as a result, perform inadequately
    • Manual therapy can help these regional veins drain blood more effectively.
      • When we move the skin organ around, we’re also moving the cutaneous rami around too and the regional vessels that follow them
      • By moving  these regional vessels that may be in a suboptimal position for drainage → facilitate blood flow to nerves  

Learn more with Diane Jacobs

 

Dermoneuromodulation - What is it?

Dermoneuromodulation 

Dermo → Skin

Neuro → Nervous System

Modulation → Change 

Dermoneuromodulation (DNM) is an interactive and light form of manual therapy used to facilitate change in the nervous system. It adopts the idea that in order to facilitate changes in pain and motor outputs, the focus of the treatment needs to be on the nervous system. By moving the skin in a slow and light fashion away from the area of pain, it helps create more space for the grumpy nerve to move. Furthermore, DMN utilizes comfort-inducing positions to ease the mechanical deformation of nerves and may help reduce noxious stimuli. By introducing these comforting and soft stimuli, the intention is for the nervous system to recognize it and correct itself through a top-down approach. As DNM is an interactive form of manual therapy, having excellent communication with the patient and ensuring they are in charge is essential. DNM will not replace everything that physical therapists have learned in the past, as well as it is an adjunct to other parts of therapy. 

 

In this Online Course by Diane Jacobs You Will Learn: 

  • Increased awareness of the role the nervous system plays in pain production, and in response to manual therapy
  • An Introduction to the Neuromatrix Framework of Pain 
  • Appreciation of the sensory nervous system 
  • An introduction to neurovascular physiology and dynamics 
  • Increased understanding of different peripheral nociceptive mechanisms and how manual therapy can help in those cases
  • A science-based method of manual therapy handling that takes into account what has been learned in neuroscience and pain science over the last couple of decades 
  • Better palpation skill, and motivation to have manual therapy hands that are warm, slow, light, effective, responsive, and intelligent

 

Audience:

 Anyone with a license to touch people who treat patients with pain.

Click Here for the Full Course!

Diane Jacobs
PT
Diane Jacobs graduated from U. Sask with a physiotherapy diploma in 1971, started using manual therapy in1983, and went solo in 1994. She has been interested in pain science and working cutaneous nerves into the manual therapy story since 1998; she calls this ‘dermoneuromodulating’. She helped to found the Canadian Physiotherapy Association Pain Science Division in 2009 and served on it until 2014. In 2016 she published a book, DermoNeuroModulating. Her time is spent treating, writing, teaching internationally, and presenting. 

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