Interview with Diane Jacobs - Part II

The first part of the interview is here.

Diane:

From that point on I became an ectodermalist. I deliberately gave up worrying about muscle function, joint alignment, posture, all that stuff. I became mainly interested in helping people downregulate pain, manually, but since then I've focused my efforts on learning all I can about that first layer that is contacted in manual therapy, about how it reads contact from another nervous system.

This has taken me into learning about the brain faster than anything ever did previously. I've read all I can lay hands on about pain, how the brain works, how it evolved, how it produces movement, pain, and perception as output, how it "feels" its environment, how it constructs strategies for its own survival and for that of its "organism". As fast as I can learn, more info is being produced. Is it possible to ever know enough?

I've learned about the cutis-subcutis layer, how it regulates homeostasis, about the importance of the cutaneous nervous system in this regard, how although it doesn't innervate "muscle" it is still "motor" in that it has autonomic efferent function as well as afferent sensory function.

I've done a dissection of the arm, to learn how the underlying cutaneous nerves (which run parallel to the skin) send off many mechanosensitive disseminating twigs that embed into skin from below, via tubular skin ligaments. I was allowed to photograph this work, about which I'm currently writing an article.

All this sensitivity built into skin is adaptive, and can be construed as the brain's own sensors, feelers, into the environment. Touch skin in a therapeutic context and it is as if you are touching someone's brain, on many levels. Knowing the levels and knowing how to help them downregulate themselves properly is the whole knowledge base that helps manual therapy make more sense.

I'm involved in a study to determine the effects of a completely nervous system based form of treatment, which I have called "dermoneuromodulation", on pain. It considers the cutaneous nervous system closely, tries to move it carefully according to the principles of neurodynamics.

I am still in the process of de-programming myself from all the mesodermalist learning I took on, but have made a lot of progress. Instead of viewing manual therapy as something I do "to" someone's body, I see it now as interaction "with" someone's nervous system.

Matthias:
"From what we heard so far - it seems that your approach could be described as helping people heal/help themselves - pointing their brain in the right direction. It seems to me that this dermoneuromodulation is different from other treatment methods because you emphasize downregulating much more than others which are more about adding strength here, increasing mobility there and so on and so forth. Your treatment is more about removing obstacles so that the brain/body can heal itself. Would you agree with this assessment?"

Diane:
I would agree with you in general, especially the part about obstacle removal. But I wouldn't say my treatment does this - when the brain is ready to change its output, it does. That's all.
The whole illusion that I, the therapist, create change in someone else's nervous system, is fantasy. I like to think of my work as pointing out possibilities to the patient's brain.

I feel like I just hold up a flashlight while the patient's brain gets busy fixing the "problem". :) I think my presence is necessary so the nervous system can get a good "read" or "fix" on some body part, but it does all the heavy lifting - my role is to feel the changes as they occur.

Matthias:
"It sounds to me that by using skin and it's cutaneous nerve system you are in a way talking directly with the patients brain - trying to establish “first contact” so to speak. What role does the patient play during this treatment process? What are your instructions to them? Should they try to move the part of their body that is being treated? Should they just observe?"

Diane:
The patient plays an observing role, but it's a lot bigger than it sounds: I ask them to let me know immediately if they experience any discomfort. Most people willingly take this task on - it not only gives them a tiny, manageable, focused task to do, it reminds them that they have charge of that all important "locus of control" - they become treatment manager/gate keeper, in a way.



Several other important objectives are met. They immediately realize they must be engaged in the process, mentally. They came in thinking it was I who would do all the work and they would just lay there, but now they realize it's about them focusing, breathing, staying in the process. All this from just one simple instruction - "I can't 'feel" your body the same way you can.

I want you to tell me if you experience any discomfort, because there is no point in reinforcing any pain pathways - that would be completely counterproductive - and besides, if you are experiencing discomfort it will be harder for you to relax and let your nervous system change itself."

Then I ask them to feel their breath go past their nose, on the way in, and on the way out. If I have a rapid or shallow breather to deal with, I ask them to breathe out for twice as long as they breathe in. That's about all.

It's like learning to meditate. The outward mechanics are rather simple, but a lot of processing goes on. I let them figure out how to do that themselves. Our connection is through the skin, and they've been instructed to tell me about any discomfort they might feel. Some people go for complete silence immediately. Others like to stay in more verbal contact.

I let them decide what level of engagement with the process they want - it's up to them, and I realize they need to establish rapport with me in their own time. As long as they can process something, dip in and out of the process even, it will be fine. Lots of people give me a running commentary of what they are sensing.

A useful metaphor is skin diving. Skin diving is the process. On one level it looks like I'm the one "doing" the skin diving, but in reality, I'm the one left on the boat managing the lines, staying alert to danger, and the patient is the one doing the dive, for the first time perhaps, diving right into their own processes, sometimes scary, sometimes wonderful, but it is they who have to do the "work", exploring, bringing up the sunken treasure - which turns out to be a fleeting realization that they can in fact move some part without pain, if they like.

They realize they have an option. It's a lot like mirror therapy I think. Instead of accessing a visual part of the cortex to convince the motor map that movement is possible, the kinesthetic sensing part of the cortex (or perhaps subcortical maps as well) are accessed somehow. And most patients will choose freedom to move over pain.

A space opens up, an opportunity to move without pain, and the patient accepts the possibility as their new reality. This decision-making is done well back of their "ordinary" decision-making capacities - it's quite automatic, although they get to be aware of it in the moment.

Certainly they are free to move in the moment if they would like, but usually I ask them to sit up periodically to move, see if they can move more easily. Most of the "movement" during treatment is palpable to me - it feels like physiology - little pulses start up then fade away, elongations occur, muscles twitch or feel as though they gently writhe,... small things that signal something rather large and non-conscious is happening below the surface.