THE PRIMARY TENETS OF THE DTM PROCESS
Dermal Traction Method (DTM) is a different type of manual approach in that it prioritizes the health of the neurology in painful movement patterns. Pain of nerve origin is called neuropathic pain but that term has historically been reserved for larger neurological structures such as nerve roots and peripheral nerves. Most physical medicine and rehabilitation targets so-called mesodermal structures (bone, joint, muscle, tendon, ligament) and considers painful movement to be reflective of inflammatorily mediated nociception. Historically, the health of the local neurology itself has not been a focus of practice. In the way that McKenzie allowed a reconception of spinal nerve root interface, and Alf Brieg, David Butler and Michael Shacklock advanced our understanding of peripheral nerve neurodynamics, DTM considers the neurodynamics of the superficial and cutaneous nerves.
HOW TO DTM
- Identify a painful movement
- Consider the spinal, peripheral and superficial neurology servicing that area
- Begin at the spine and rule in/out nerve root involvement. Re-assess the painful movement (link to page on endrange L-sp extension and cervical retractions)
- Move to the peripheral nerves and rule in/out involvement. Re-assess the painful movement (link to a page on neuro assessment including tension testing)
- Consider local superficial nerves and lift to create space around those nerves while performing the painful movement. Re-assess the painful movement
- If successful, show the patient how to create space around the painful nerves while moving
- Perform several times daily and before activity until the pain asscoiated with the movement is gone
- Address possible functional causes for the original injury and/or pain
Remember that everything is not associated with neuropathic pain. Before beginning the DTM process to address pain, see your doctor. If the DTM process is not fully addressing your condition, seek help from a healthcare professional to address other tissues that may be involved, such a tendons, muscles, ligaments, discs, etc.
WHERE’S THE EVIDENCE?
This work is relatively new, and research has yet to support its inclusion into practice. However, the extremely low risk, ease of understanding and implementation in many commonly seen clinical pain syndromes offers quickly explorable options to opioid medications, steroid injections and surgical interventions. It’s focus on patient education and establishment of locus of control for the patient on pain management reduces fear avoidant behavior and costs associated with passive types of palliative care. The focus on restoration of painfree movement and encouragement for more exploration of movement is in accordance with research on exercise and active care in pain management. For these reasons, we feel the dissemination of this information in a public health environment seeking alternatives to alleviate disability and costs associated with pain is warranted.
- “Unhappy” neuro can alter motor behavior
- Neuro can become “unhappy” when it’s mechanical interface with the tissues it interacts with is poor
- Poor mechanical interface of neuro may lead to pathological compression or tension of the neuro
- Pathological compression or tension may lead to venous congestion or ischemia in vasculorum nervorum>sensitization of nervi nervorum>neuropathic pain
- Improving blood flow to neuro and mechanical interface of neuro can quickly remove nociceptive signal in a painul movement
- Removing pain in the movement pattern, even temporarily, allows for reprogramming of previously painful movement patterns
I’M STILL CONFUSED, CAN YOU GIVE ME AN EXAMPLE?
When presented with a painful movement pattern, the DTM student first considers the neurology servicing that area. Those considerations include the spinal nerve roots, the downstream peripheral nerves, and the superficial neurology. We then apply an empirical “clinical audit process” (CAP) to explore the potential involement at each level of neurology.
A patient presents with pain in the plantar foot that has become chronic and has responded poorly to local interventions targeting the plantar fascia itself. Our investigation might first consider the health of the spinal nerve roots servicing that area. Using a McKenzie-oriented assessment (review the books of Robin McKenzie or the courses from MDT for detailed information), repetitive endrange extension might be applied, followed by a re-assessment of the painful movement to see if the movement is less painful. The peripheral neurology servicing the plantar foot might be screened using neural tension testing (see the work of David Butler and Michael Shacklock for excellent books, DVDs and courses) to attempt to reproduce the familiar pain. Neurodynamics may follow, if indicated, to address the mechanical interface of the peripheral nerves. Locally, the superficial nerves and their course through the painful area are addressed with a goal of “creating space” and improving bloodflow to the involved neurology. With a similar neurodynamics mindset, we lift the tissues around the involved neurology while the painful movement is performed to see if the symptoms improve. If these assessments greatly reduce or resolve the painful movement, then teach the patient to “create space” for the involved neurology and then move in ways to improve the mechanical interface of the neurology.
WHAT EXERCISES ARE INCLUDED WITH DTM?
The prescribed exercise movements are best thought of as manually assisted neurodynamic movements. They are individual to the patient and need not be very specific. Simply follow the principles of 1. Creating space around a painful nerve, 2. move the involved area in a way to “floss” the nerve painlessly through the tissues, 3. reperform the previously painful movement to normalize the body’s perception of the area with movement. The goal is to return the person to their desired activity without pain.
HOW DOES “FUNCTIONAL REHAB EXERCISE” FIGURE INTO THE DTM PROCESS?
The principles of functional movement assessment in rehab, suggests that pathomechanical movements may lead to tissue overload and subsequent injury. If a clinician is so inclined to include DTM and functional assessment into practice the goal is to use DTM to quickly allow the person to perform previously painful movements. The functional assessment may offer clues to movement patterns that may have resulted in tissue overload. Performance of those corrective exercises may theoretically reduce likelihood of injury or pain recurrence. The common statement “First move well, then move often” echoed in the FMS system might be applied here.
DOES DTM FIX EVERYTHING?
Of course not! Pain may be an indication of serious injury or organ pathology. For that reason, we suggest that a doctor evaluate anyone for presence of those serious pathologies prior to investigating with the DTM process. Once those items are ruled out, then using the DTM process to quickly and inexpensively assess the status of the neurology in the area of the pain may offer a very quick and easy intervention the patient can take part in.
CAN ANYONE APPLY THE DTM PROCESS?
Painful conditions should FIRST BE ASSESSED BY A DOCTOR TO RULE OUT SERIOUS PATHOLOGY!! Once that has been done, we encourage people without healthcare training to use the DTM process under the guidance of your healthcare professional (massage therapist, coach, personal trainer, acupuncturist).
WHO DEVELOPED DTM?
Dr. Phillip Snell and Dr. Justin Dean collaborated to develop the DTM process in their chiropractic practice in Portland, OR, USA.
Dr. Snell is adjunct professor at University of Western States, Clinical Director of Solutions Sports and Spine, Inc, and continues a clinical chiropractic practice in Portland, OR at the Hawthorne Wellness Center. He is also creator and content manager for MyRehabExercise.com and FixYourOwnBack.com, subscription based websites that help incorporate exercise interventions into the treatment of pain. MyRehabExercise is for clinicians and consists of a library of video tutorials of corrective exercises that can be emailed to patients to improve outcomes and patient compliance with treatment. FixYourOwnBack is for the general population suffering from painful lumbar disc herniation and sciatica. It combines evidence based education and a progressive exercise program to mend the disc and return subscribers to high levels of resiliency and function.
Dr. Justin Dean
Justin Dean is a Chiropractic Sports Physician who has sought out extensive continuing education from some of the top researchers and clinicians in the areas of functional rehabilitation, manual therapy and pain science. He previously lived and worked in Shanghai, China as a Sports therapist for some of that countries top track and field athletes. He currently resides Los Angeles, CA where he maintains a clinical practice.