Let’s Have a DNM
By Leah Dwyer
As a new graduate, I had many questions regarding manual therapy and what I may or may not be doing with my hands. As a long standing recipient of massage due to a complex neuromuscular condition called Dystonia, and as a busy remedial massage therapist, I knew that massage felt good and could make people feel better temporarily but I had questions regarding some claims being made. When I discovered the biopsychosocial model and Explain Pain duo, Lorimer Moseley and David Butler, things began to make more sense to me. DNM fits nicely into the current understanding of pain and the role of the nervous system. This intrigued me even more.
I recently had the pleasure of attending Diane Jacobs’ three day DNM workshop in Melbourne along with other massage therapists, osteopaths, myotherapists and a physiotherapist. I became intrigued by Diane Jacobs’ work after reading her posts and comments on social media, so this was an exciting opportunity.
In the Beginning
Jacobs developed DNM after hearing David Butler speak in Canada during the late 90s about nerves, the nervous system and pain. Jacobs began to question the role of cutaneous nerves and embarked on a journey to increase her nerve knowledge then researched cutaneous nerves. Out of this Jacobs developed DNM, which she has been teaching since 2007.
Embrace The Nerves
I have been fascinated by the human nervous system for years because of my Dystonia and because I’m a neuroscience nerd. DNM brings together everything I’ve learned about neuroscience, neurodynamics and current pain science.
DNM is a scientific explanation for slow, attentive manual therapy rather than a treatment model and the overall goal of DNM is to reduce pain via the nervous system and nerves.
A therapist with a good grounding in pain science and kind, minimally invasive, hands could, according to the premises of DNM, be a catalyst for change. Over the three days, we learnt manual techniques that gave me a better understanding of the directions that the cutaneous nerves run in the body and how to manually influence them.
Many manual therapy treatment models still target muscles that lie deep under the skin. However, if we accept the principles of DNM and current pain science, pain is a nervous system phenomenon and manual therapists cannot touch anything except skin.
DNM is a slow, gentle manual therapy much like lymphatic drainage. DNM discourages causing nociception and instead encourages less invasive manual therapy that does not add to the nociceptive load that a client may already be carrying. Persistent pain is likely due to an overly sensitive nervous system and brain, therefore we as therapists should not add to a positive feedback loop by further sensitising the client’s nervous system.
In DNM, special attention is given to the cutaneous nerves, which have been overlooked in most manual therapy techniques. In our workshop, we learnt that sore spots on the surface correspond to grommet holes or exit points for cutaneous nerves.
Once a tender spot is found, the irritable spot is unloaded by gently dragging the skin away from the spot and not compressing it further. Holding the skin in a stretched position away from the tender spot for a period of time allows the client’s nervous system to process the new information.
This gentle stretching of the skin away from sore spots then allows the backed up nerve to move more freely. Palpating for tender spots then unloading the spot by stretching the skin gently away rather than compressing the spot facilitates a reduction in tenderness and the nerves can move more freely within their compartment tunnels.
Most of the DNM techniques require the client to be in a side-lying position because it puts the body in the least amount of neural tension; our peripheral nervous system evolved while we were quadrupeds. Palpation skills are important in this treatment model. I thought of it as a bit like reading Braille. Gentle palpation and constant communication with my massage partner yielded the best results. If tenderness or secondary hyperalgesia did not accompany what I felt then I moved on to another area.
I learnt that not every lump and bump means something.
The brain and the nervous system are the big Kahuna and pain is a nervous system phenomenon. It makes perfect sense to me therefore to be mindful of the nervous system in our treatments. DNM taught me to:
- consider the directions that nerves run
- be aware of the grommet holes where nerves emerge into cutaneous tissue
- gently palpate for sore spots and drag the skin away in the direction of the nerves
- understand tunnel syndromes
- move slowly and allow the client’s nervous system time to change
- explain to clients that moving nerves with our hands may help a lot without hurting them more because healthy nerves that move freely in their compartments do not contribute to a client’s pain
- teach clients how to move their own nerves.
During my first week back at work after the course I began massaging more slowly and experimenting with skin stretching and holding areas, like the neck, for longer periods. I have also been experimenting on my own neck by slowly pulling my skin away from the tender spots. Dystonia causes constant muscle tension so having a quick way to ease that tension that doesn’t hurt has been priceless. I’ve also had a positive experience with a cranky case of De Quervain’s which has been bothering me for months. Gently sliding the skin away from the grommet holes and pulling my skin up rather than pushing down has worked a treat.
I have always been known as the ‘gentle one’ at work and DNM fits nicely with everything I teach my clients about their nervous system and pain. My massage mantra has always been ‘do no harm’. DNM reinforces my understanding of pain, human neurophysiology and effective touch.
Dermoneuromodulating: Manual Treatment for Peripheral and Especially Cutaneous Nerves (2016) by Diane Jacobs
DNM at the 2019 AMT Conference
Robin Kerr is presenting a 2-day workshop on DNM at the 2019 AMT Conference on 1 and 2 November 2019. Places are filling fast. You can register here.
About the Author
Leah Dwyer is a Remedial Massage Therapist at Ryde Natural Health Clinic. Leah lives with chronic pain due to Cervical Dystonia and as a result has a keen interest in pain science. Leah is a member of the Painaustralia Consumer Advisory Group and has discussed opioids, chronic pain and pain management with the media. She is passionate about massage therapy, educating people about pain, neurophysiology and the simple power of effective touch.