Course Notes: Dermoneuromodulation

What? You Mean You Have to Touch Someone???!!?!?

My gluttony for punishment continues. This time, I had the pleasure of learning Diane Jacobs’ manual therapy approach called Dermoneuromodulation (DNM).

My travels took me to Entropy Physiotherapy and Wellness in the Windy City. These folks were arguably the best course hosts I have ever had. We had lunch!!!! Both days!!!!! That is unheard of, so a big thanks to Sandy and Sarah for putting the course together.

I took DNM out of curiosity. I have been lurking around Somasimple on and off for the past couple years, and wanted to learn more about the methods championed there.

Believe it or not, I have yet to take a pure manual therapy course, DNM seemed like a great way to get my hands dirty. That darn PRI has lessened the hand representation in my somatosensory homunculus!


The representation shrinks by the day.
What my homunculus actually looks like.

One reason I haven’t taken a manual course is due to the explanatory models many classes are presenting. It seems as though few are approaching things with a neurological mindset, but I was pleased to hear Diane’s model. It is the best explanation I have heard yet.

I know that I usually list my favorite quotes at the end of the blog, but I wanted to share the best quote of the weekend right off the bat:

“I don’t know why.”

I heard this phrase so much throughout the course and it was quite refreshing. Diane made few claims about her technique, admitted who she “stole” from, and embraced the uncertainty that goes along with how her technique works.

Diane didn’t advertise her method as the end-all-be-all, and encouraged all of us to make up techniques of our own. She is just offering a non-painful sensory input that works quickly.

I wish more courses were this way.

Let us now press onward to a fantastic explanation for manual therapy.


Well done Diane, well done.
Well done Diane, well done.

Manual Therapy – An Interaction Between Two Nervous Systems

Diane started off with manual therapy’s theoretical basis. Manual therapy works predominately through your nervous system. We are made up of a brain, spinal cord, and nerves that extend from the cord.

The brain can be simply broken up into two components: the human brain and critter brain. The human brain sits our higher activity centers, and the critter brain runs the processes that keep us alive.

Under threat, the critter brain is going to do everything in its power to keep us alive, and this change can involve the protective mechanisms that go along with pain.

Aka Kevin Costner circa 1992.
Aka Kevin Costner circa 1992.

The critter brain carries out its processes through the body’s nerves. Nerves in the body tell the brain what’s going on, and the brain then tells nerves how to respond.

In order to calm our critter brain down, the clinician can communicate with the nervous system through cutaneous nerves. Our goal with our interventions is to touch the patient without hurting them. Hurt could irritate the critter brain. Instead, we want an enjoyable context for touch.

Kinda like Kevin Costner....circa 1992.
Also like Kevin Costner, circa 1992…minus the sexual implications

The patient’s role…Wait, what???!!!

Yes, the patient’s role in the manual therapy process is to guide the clinician to what feels best. It is this interactive and interoceptive model that helps reduce threat perception.  This context allows for the patient to be a little more in control of the manual therapy process.

It Rubs the Lotion on Its Skin

The skin is a pretty cool organ that can hold 20% of our blood supply and maintain temperature homeostasis. It has both peripheral (PNS) and central (CNS) nervous system influences. The PNS automatically activates to maintain skin temperature and the CNS can express itself through the skin. Those times in which you are embarrassed or scared reflect CNS status through your skin.

Due to the skin’s high innervation and vascularity, anytime we touch the skin we affect the neurovascular array. This change occurs through facilitating mechanoreceptors and physically altering cutaneous rami position.  The nervous system then evaluates this information to determine if the touch is a threat or not.

Tissue information is received through receptors. There are tons of them, but we have  a few major players:

Dermal receptors

  • Rapidly adapting mechanoreceptors – Turns on and shuts off by itself
  • Thermoreceptors – Responds to temperature change for duration of stimulus.
  • Nociceptors – Responds for stimulus duration. Can be set off by going perpendicular on skin.
  • Pacinian corpuscles – Turns on with stimulus onset and removal. Will continuously fire if stimulus fluctuates.
  • Meissner’s corpuscle – Turns on with stimulus onset and removal
  • Ruffini endings – respond to lateral skin stretch and are non-nociceptive. Slow adaptors to stimulus. Can fool the brain to alter muscle tone with skin stretch.

Epidermal receptors

  • Merkel cells – slow adapting to stimulus.


There is just a lot of stuff here.
There is just a lot of stuff here.

All the above receptors respond to stimuli and communicate information to the brain along sensory nerves. It turns out sensory nerves are incredibly long. Many of these nerves go directly from the skin to the brain. One cell! Anytime you touch the skin you are touching a direct extension of the brain.

Sensory input travels via the mechanoreceptors through the dorsal columns and spinothalamic tract in the spinal cord. Interestingly enough, the spinothalamic tract does not only carry nociception, temperature, and crude touch. Pleasant touch can also travel along this pathway.

The Dorsal columns input goes to the thalamus, which sends information to the somatosensory cortex. The spinothalamic tract goes to the thalamus first as well, followed by the somatosensory cortex, anterior cingulate cortex, and the insular cortex. These three areas are what Diane noted as “threat evaluation areas.” These areas are part of your critter brain.

Once the brain receives this information, it essentially talks to itself to determine if this information is important or not. If important, an output occurs to respond to the input.


We've all done it.

Many brain areas are a part of this conversation. The following locations contribute to the desired output in a particular way:

  • Limbic system – emotional experience.
  • Venteromedial cortex – pleasure, reward, meaning, creates positive reinforcement
  • Anterior cingulate cortex – bridge between instinct and rational; makes us worry about pain.
  • Orbitofrontal cortex – defers, suppresses, differentiates touch, interprets emotions (if you are in a bad mood, this is how your patient will know it…so be happy!).
  • Dorsolateral prefrontal cortex – Chooses behavior. This area is where therapeutic neuroscience education targets.

Explain Hyperalgesia

Pain is one possible output in response to various inputs. If pain is the desired output, changes can occur to increase sensitivity.

One possibility is hyperalgesia, in which noxious stimuli becomes extra sensitive.  Hyperalgesia can be primary or secondary.

To understand the two, we should first look at a sensory neuron.


A sensory neuron has two ends. The end that connects to the tissue is the terminal pole, and the end that travels to the spinal cord is the central pole.

Primary hyperalgesia affects the terminal pole.  Substances released by injured tissue activate nociceptors at this pole, creating the information cascade sent to the brain described previously.  We also know this as inflammation.

As the inflammatory process progresses, nociceptors send substances out to the tissues to promote enhanced firing. This change creates peripheral sensitivity, and is normal.

Secondary hyperalgesia (aka central sensitivity) has more fun at the central pole. TRPv1 is a receptor at the central pole that increases spinal cord and blood-brain barrier permeability, which allows for more nociceptive transmission to be received. Serotonin can descend from the brain to the spinal cord and sensitize these receptors as well.

Other changes that occur in secondary hyperalgesia include glial and satellite cells lowering the threshold at which nociceptors fire. The name of the game is to increase the nociceptive information coming in.

Both of these algesic mechanisms can simultaneously occur to protect a potentially compromised area. However, pain may not necessarily be experienced. Nociception involves threat detection, whereas pain involves threat perception. The two are not equal entities.

“The labeling of nociceptors as pain fibres was not an admirable simplification but an unfortunate trivialization.” ~Patrick Wall

Nerves n’ Stuff

The neurovascular bundle is connected via regional feeder vessels. These vessels ought to slide and glide with the nerves so blood supply is maintained. Movement is what keeps this system healthy.

Red - artery; Yellow - Nerve; Blue - vein; entire pic - Amazing
Red – artery; Yellow – Nerve; Blue – vein; entire pic – Amazing

These connections are vulnerable and can become sensitive to mechanical deformation.  Too much or not enough movement can decrease the nerve’s oxygen and glucose supply. A nerve will let you know if it does not get fed.

And if you listen quietly, the nerves will actually say that.
And if you listen quietly, you can hear the nerves saying that.

Deformation could translate into neuropathic pain, which is defined as pain caused by a lesion or disease in the somatosensory system. Neuropathic pain is not a diagnosis, but a descriptor.

The way one could determine if neuropathic pain contributes to one’s complaint is done quite algorithmically.  The following must be present:

  • Leading complaint must be pain.
  • Pain distribution must be neuroanatomically plausible.
  • History should suggest relevant lesion or disease.
  • Negative or positive sensory signs contained to lesioned area in question.
  • Diagnostic testing confirming lesion or disease explaining neuropathic pain.

The fewer of these criteria positive, the less chance there is of having neuropathic pain.

Theory into Therapy

Diane stressed that a therapeutic context must be established before implementing a manual intervention. This foundation occurs via a 4-step process

  1. Listen – Allows the patient to map you in their story. Your listening models how they listen to themselves.
  2. Interact  – Explain pain. This part will plant seeds to regulate future stressors.
  3. Treat – Provide non-nociceptive therapy, making sure to give the patient locus of control.
  4. Wait – Do not correct; wait for physiology to change and the desired output to emerge.


The object is to create the largest amount of descending modulation possible. We therefore mobilize the cutaneous nerves via “yesiceptive” contact and interaction.

DNM 101

Though Diane does not believe in trigger points, she does believe in sore spots that often have a different feel about them. Our goal is to change these sore spots without worsening them.

Cutaneous nerves anastomose in various ways, so everyone’s anatomy is going to be slightly different. Thus, there can be no precision or specificity with treatment. We just have to somehow move nerves in a fashion that results in reduced pain.

The assessment process was my one gripe with the course. Each technique was given clinical situations that they may work with. We then assessed with active movement followed by palpating tender spots. However, these spots can be present on many people even if pain is relieved, are unreliable to assess, and do not always contribute to the patient’s complaint. How can we say that performing this intervention is the right thing to do for this patient?

Well Diane freely admitted palpation’s unreliability, she has also been practicing long enough that she has the pattern recognition to know when techniques ought to be implemented. Novice clinicians likely lack this skill. There must be some way to provide an assessment that may lead you to performing one mobilization compared to another.

I espouse Charlie Weingroff’s principle of “can your treatment beat my tests.” Since I am a PRI enthusiast, I used those objective measures to test treatment efficacy. When implemented thoughtfully, DNM can change PRI objective measures fairly quickly and in a pain-free manner.

Zac = sold on both counts.

DNM is actually fairly simple to perform. The technique is a combination of positional release with skin stretch; fine-tuning performed throughout to maximize treatment effect.

Diane gave us many techniques that seem to work over specific areas, but really you can stretch skin in any fashion. Here are some examples of the basic techniques utilized in the course.

Longitudinal distraction – Nerves move up.

Shearing distraction – Nerves are lifted and twisted.

Unloading – Nerves move up.

Contralateral unloading (the balloon) – Go to the opposite side of the sore spot.

Rotational shearing

Circumferential unloading

 Once these techniques are implemented and symptoms change; exercise ought be to given to reinforce the changes. Though no specifics were given, Diane suggested ideas of using positioning strategies, taping, self-DNM, etc. Her objective was to give us the manual technique, then supplement with our exercise strategies of choice.


Overall I really enjoyed Diane’s course. She has given the best manual therapy theoretical explanation I have heard, and the technique is very gentle and effective.  She can beat my tests. I think that if these maneuvers are implemented into a sound assessment, you can add a very powerful sensory input to your repertoire.

Verdict: Do it. The neuroscience alone is worth the price of admission.

Manual therapy will be yours, do as you please!
Manual therapy will be yours, do as you please!

Fun Facts

  • Nerves slide and glide like a telescope.
  • A rete is a dense convoluted birds nest of cutaneous nerves over a bony prominence. These are over most every bony prominence.

Dianetics (See what I did there??)

  • “We belong to our brain more than our brain belongs to us.”
  • “We’re not treating anatomy, we’re treating physiology.”
  • “Spinal cords have not got much smarter since fish days.”
  • “You can’t trust the brain pretty well. It makes up stories.”
  • “It’s never a good idea to treat someone who is feeling better than you are.”
  • “Therapeutic neuroscience education is accurate and relevant pain information.”
  • “Pain is physiological.”
  • “You are only as old as your C-fibers.”
  • “It probably serves us well to not believe everything our brain tells us. “
  • “Pain is the story built from all inputs.”
  • “Pain descriptors are more of a way for the patient to export their feelings.”
  • “Having a license to touch people is an enormous privilege.”
  • “I can’t think of a better thing then using human brains to help other brains.”
  • “The less you do the better results you are going to get.”
  • “I have to tell you up front. I am a trigger point atheist.”
  • “Evolution is weird, and it’s not that smart actually.”
  • “When I don’t have a monitoring hand I’ll use my head to push the skin on the butt. I call it the head butt technique.”
  • “There will be asymmetric positions people adopt. It’s their comfort position.”
  • “We’re asymmetric in our behavior.”
  • “We’re not going to deal with your ovary by the way.”
  • “Those who have IT band syndrome, I don’t even know what that means.”
  • “I found this on the internet so it must be true.”
  • “The pelvic floor holds up a bunch of stuff. And you don’t know what you’ve got ‘til its gone.”
  • “Heels just love to be cranked on.”
  • “Let your brain be creative when you treat.”
  • “It’s [DNM] soft and easy so you can die comfortably at your job.”
DNM is soft and easy, no matter what your job is.
DNM is soft and easy, no matter what your job is.

Movement Chapter 13: Movement Pattern Corrections

This is a chapter 13 summary of the book “Movement” by Gray Cook.

Back to the Basics

Mobility deficits ought to be the first impairment corrected. Optimizing mobility creates potential for new sensory input and motor adaptation, but does not guarantee quality movement. This is where stability training comes in. In order for the brain to create stability in a region, the following ought to be present:

  • Structural stability: Pain-free structures without significant damage, deficiency, or deformity.
  • Sensory integrity: Uncompromised reception/integration of sensory input.
  • Motor integrity: Uncompromised activation/reinforcement of motor output.
  • Freedom of movement:  Perform in functional range and achieve end-range.
FREEDOM!!!! Of movement. And if the Road Warrior says we need to move free I listen.

Getting Mobility

There are 3 ways to gain mobility:

1)      Passively: Self-static stretching with good breathing; manual passive mobilization.

2)      Actively: Dynamic stretching, PNF.

3)      Assistive: Helping with quality or quantity, aquatics, resistance.

Getting Stability

In order to own our new mobility, we use various stability progressions to cement the new patterns. There are three tiers in which stability is trained:

1)      Fundamental stability – Basic motor control, often in early postures such as supine, prone, or rolling.

2)      Static stability – done when rolling is okay but stability is compromised in more advanced postures.

3)      Dynamic stability – Advanced movement.

We progress in these stability frames from easy to further difficult challenges.

Assisted → active → reactive-facilitation/perturbations

I would black my face out to if someone was having me do this exercise.
I would black my face out too if someone was having me do this exercise.

Since stability is a subconscious process, we utilize postures that can challenge this ability while achieving desired motor behavior. We can also group the various postural progressions into 3 categories:

1)      Fundamental – Supine, prone, rolling (requires unrestricted mobility).

2)      Transitional – Postures between supine and standing such as prone on elbows, quadruped, sitting, kneeling, half-kneeling.

3)      Functional: Standing variations to include symmetrical and asymmetrical stance, single leg stance.

The only legit way to practice single leg stance.

Movement Chapter 7: SFMA Introduction and Top-Tier Tests

This is a chapter 7 summary of the book “Movement” by Gray Cook.


The SFMA’s goal is to assess functional capabilities. This system is based on Cyriax differentiation and grading principles. Instead of describing things as strong, weak, painful, or painless; the following descriptors are utilized:

  • Functional nonpainful (FN): Unlimited movement and able to complete a breath cycle at end-range. Called the dead end.
  • Functional painful (FP): Called the marker, reassessed.
  • Dysfunctional nonpainful (DN): Limited, restricted, impaired mobility, stability, or symmetry. Labored breathing with movement also implicates this choice. Called the pathway, where treatment occurs.
  • Dysfunctional painful (DP): Called the logical beehive because we do not know if pain is causing poor movement or vice versa. It is an unreliable place to work unless acute situations.
Cee Lo is still pushing for the FU to get recognized in the SFMA.

SFMA corrective and manual therapy lie in treating the FP’s and DN’s. The order at which things are treated also matters, so the order listed below for the top tier tests is also typically where treatments should hierarchically begin.

  • Cervical spine patterns (CSP)
  • Upper extremity patterns (UEP)
  • Multi-segmental flexion (MSF)
  • Multi-segmental extension (MSE)
  • Multi-segmental rotation (MSR)
  • Single leg stance (SLS)
  • Overhead deep squat (ODS)

We then operate the SFMA in the following fashion:

Explain Pain Section 6: Management Essentials

This is a summary of section 6 of “Explain Pain” by David Butler and Lorimer Moseley.

Management 101

The most important thing you can understand is that no one has the answer for all pains. Pain is entirely individualistic, hence requiring different answers. There are several strategies which one can undertake to triumph over pain.

Tool 1: Education

Knowing how pain works is one of the most important components to overcoming pain. Instead of no pain, no gain, the authors like to use “know pain, or no gain.” Understanding pain is essential for squashing fear of pain, which leads best toward the road to recovery.

Here are some important concepts to be known about explaining pain.

  • Anyone can understand pain physiology.
  • Learning about pain physiology reduces pain’s threat value.
  • Combining pain education with movement approaches will increase physical capacity, reduce pain, and improve quality of life.
And I mean anyone.

Tool 2: Hurt ≠ Harm

It is important to understand that when someone feels pain it does not equate with damage. The same can be said with recurring pains. These pain types are often ways to prevent you from making the same mistake twice. If your brain sees similar cues that were present with a previous injury, the brain may make you experience pain as a way to check on you and make sure you are okay.

Just because hurt does not mean harm does not mean you can get crazy though. Because the nervous system is trying to protect you, it will take drastic measure to prevent re-injury. Therefore, the best option is to gradually increase activity levels without pressing past the nervous system’s threshold.

If only there was a neurosignature that helped me stop drinking Redline. So bad yet so good.

Tool 3: Pacing & Graded Exposure

All the body tissues are designed for movement, therefore this is how we will increase activity. Here are the steps to pacing and graded exposure.

  1. Select an activity you want to do more of.
  2. Find your baseline – The amount of activity you can do that you know will not cause a flare-up. A flare-up is an increase in pain that leaves you debilitated for hours to days.
  3. Plan your progressions.
  4. Don’t flare up, but don’t freak out if you do.
  5. It is a lifestyle change, requiring a little bit more planning.

Take walking for example. Suppose you know you could walk for 5 minutes, but if you did 7 you would pay for it over the next couple days. You might walk for 5 the first day, then 5:15. Eventually, you would work up to past 7 minutes, then so on and so forth.

Access the Virtual Body

Just like the body, the virtual body can be exercised as well. Ways to work on the virtual body are as follows:

  1. Imagine movements – a la graded motor imagery.
  2. Alter gravitational influences or surfaces.
  3. Add varying balance challenges.
  4. Vary visual inputs – Eyes closed challenges the virtual body even more. Use a mirror to give the brain visual input and further decrease threat.
  5. Alter the activity environment.
  6. Move in different emotional states.
  7. Add distractions.
  8. Perform the desired movements in functional activities.
  9. Break down functional movements.
  10. Perform sliders.
  11. Perform movements with the surrounding tissues in relaxed positions that do not hurt.
  12. Work out of your glitches – If you walk with a limp from an ankle you sprained in 1962, try changing how you walk.
  13. Let your mind go.
Open your mind…Open your mind.

Explain Pain Section 5: Modern Management Models

This is a summary of section 5 of “Explain Pain” by David Butler and Lorimer Moseley.

So Many Clinicians

There are several people who would like to help someone in pain, with each person offering a different explanation and solution for someone’s pain. Research has shown these conflicting explanations can often make things worse. The one who has the most power over pain is the person who is in pain.

Here are some general guidelines for someone dealing with pain.

  1. Make sure any injury or disease which requires immediate medical attention is dealt with. All ongoing pain states require a medical examination.
  2. Make sure any prescribed help makes sense and adds to your understanding of the problem.
  3. Get all your questions answered.
  4. Avoid total dependence on any practitioner.
  5. Make sure your goals are understood by you and the clinician.

The clinician’s ultimate job is to assist you in mastering your situation.

Teach you to master your pain, we will.

Models of Engagement

There are 5 interchangeable models which enable both the patient and the clinician to identify the processes underlying pain.

  1. The orchestra model – Pain is a multi-component process that manifests itself in the brain and goes through many pathways. There are many players involved in the pain experience, hence the orchestra, with the brain as the maestro.
  2. The Onion Skin Model – Helps describe all the factors that go into the pain experience; including nociception, attitudes and beliefs, suffering, pain escape behaviors, and social environment.
  3. Fear-based models – Fear of pain and reinjury are major forces behind the development and maintenance of chronic pain.
  4. An evolutionary model – Pain protects the tissues in order to ensure species survival.
  5. A clinician decision-making model – Pain is very personal, and therefore a plan of care should be developed exclusively for that person.

When working with a healthcare provider, they should be able to answer the following questions:

  1. What is happening in my body?
  2. How long will it take to get better?
  3. What are all the options for management?
  4. What can I do for it?
  5. What can you do for it?
  6. Is there anything that requires special attention?
  7. What do my physical findings really mean?


Coping aims to reduce the threat value of the stimulus and the associated emotions and altered biology.  There are various ways coping can be done, with some better than others. Generally, active copers manage pain and other health issues better than passive copers.

The active coper…

  • Learns about the problem.
  • Explores ways to move.
  • Explores and nudges the edges of pain.
  • Stays positive
  • Makes plans.

Whereas the passive coper…

  • Avoids activity.
  • Does nothing.
  • Waits for something to happen.
  • Believes someone else has the answer.

Relating to Pain

There are several patterns in which we react to pain.

  • Hurts don’t do it – Pain kicks in at a certain amount of activity, then we stop once it starts. Over time we can perform less and less activity before pain occurs, leading to disability, disuse, and likely depression.

pain graph 1

  • Boom-bust – Pain comes on but you push through it and ignore it until suddenly the pain becomes unbearable. Here, your nervous system busts. A cascade of danger chemicals floods the nervous system leaving you completely wiped out for days to weeks.

pain graph 2

The commonality between these two patterns is that both lead to eventual activity limitation. We want to be somewhere in the middle.

Course Notes: Graded Motor Imagery

I recently attended another great course through the NOI Group called “Graded Motor Imagery” (GMI) taught by Bob Johnson. These guys are the industry leaders in all things pain so please check them out. It was great connecting with Bob and learning what I think will be an excellent adjunct to what I am currently doing. So here is the run down on GMI.


GMI is a three-pronged sequential process of establishing early, nonpainful motor programming. Johnson calls this synaptic exercise to limit negative peripheral pain expression. GMI is a 3 step process:

1)      Laterality reconstruction (Implicit Motor Imagery).

2)      Motor imagery (Explicit Motor Imagery).

3)      Mirror Therapy.

The Neuromatrix Paradigm & Pain States

Before delving into the neuromatrix, we first must define pain. Pain is a multiple system output or expression by an individual-specific pain neuromatrix that activates when the brain concludes that body tissues are in danger and action is required.

The neuromatrix, like I talk about in this post here, is the nervous system’s coding space and network. It is first and foremost affected by genetics, sculpted by experience, and constantly evolving. It is the entity that makes us who we are—the self.

The neurosignature, or neurotag, is an output’s representation in the brain. For example, regions in the brain will activate in response to produce the pain output. This sequence is the neurosignature. Some common activated areas when pain is expressed include both primary and secondary somatosensory cortices, insula cortex, anterior cingulgate cortex, thalamus, basal ganglia, and the cerebellum. However, areas activated differ among individuals.

A way to akin the neurotag is that of several movies occurring throughout the brain that represent past, present, and future. The United Airlines map is another example.

Just looking at this is starting to induce my pain neurotag.

Neurotags have an activation threshold which can be modified by various ways. Some examples are the context of injury, beliefs, perceptions, feelings, and sensory input. Previous injury can also activate this neurotag and increase nervous system sensitivity.

If pain persists because the brain perceives the body as threatened, the pain neurotag becomes sensitized and disinhibited. These changes result in smaller inputs creating painful outputs and pain locations spreading.

There are several of these representations in the brain—motor, endocrine, immune, limbic, etc—but most famous is the somatosensory homunculus.

There are several key features of this homunculus

  • Somatotopically organized – meaning different body parts are represented next to one another.
  • Areas that require more sensation are larger, such as the hands
  • These representations are dynamic throughout the day.
  • They can be fooled.

What can be problematic is that in certain pain states smudging can occur, in which the representation is not seen as well in the brain. This change occurs in both acute and chronic pain states, though the brain activity is different. Areas can also become smudged depending on which parts a person may use more. The hand representation of a musician will likely be larger than a non-musician. It can also take on nonorganic parts, such as a wedding ring or a watch.

Graded Exposure & the Pain Neurotag

Graded exposure is a way to expose the brain to painful activity without activating the pain systems. This tactic can be performed by breaking down movements or changing the movement context.

To begin graded exposure, the patient’s baseline for each task must be found first. The baseline is the amount of activity that one can do without flaring up. A flare-up is when a certain amount of activity is performed that maintains the pain neurotag sensitization with the corresponding activity. This is a line we would ideally like to avoid, but is not something to freak out about if we hit.

TT = Tissue tolerance PBP: Protect by pain barrier FUL: Flare up line BL: Baseline
TT = Tissue tolerance
PBP: Protect by pain barrier
FUL: Flare up line
BL: Baseline

There are three strategies in which people approach graded exposure.

  • Fear-Aviodance (bad): Do less and less and not move toward the baseline.
  • Boom-bust (bad): Ignore flare line and push through the pain barrier.
  • Graded Exposure (good): Knock on the door where pain resides and slowly push farther and farther. Do not do too much or too little.

In order to perform graded exposure, the first step is to identify both physical and contextual fear-related challenges based on the painful movements. Physical challenges include performing the activity through a larger range of motion or for a longer duration. The activity can also be broken down into parts. Contextually, the activity can be changed several different ways.

  • Threat and threatening equipment.
  • Changing vision.
  • Changing emotion.
  • Changing meaning (kicking a ball instead of a straight leg raise).
  • Non-contaminated representations.
  • Expectation.
  • Place.
  • Distracting.
  • Gravity.
  • Change neighboring tissues.
  • Time
  • Metaphors.

But what if you try all of these ways and still get a pain response? Use your imagination…Literally. This is where GMI comes in, as it has the ability to fly under the radar of the pain neurotag yet still activate motor receptors.


If utilizing GMI, the above order must be performed, as research has shown that if you perform mirror therapy after laterality retraining there are negative benefits.

Implicit Motor Imagery (IMI)

IMI, or laterality retraining, is the ability to determine whether a presented image is left or right. Performing IMI disengages the primary motor cortex while simultaneously activating premotor cells. This activity may lead to decreased pain neurotag activity while still activating motor areas.

Left/right discrimination appears to be delayed in acute, expected, and chronic pain states. Some of the below conditions are affected per research.

  • Complex regional pain syndrome (CRPS).
  • Spatial neglect.
  • Amputation.
  • Back pain.
  • Neck pain.
  • Knee pain.
  • Carpal tunnel syndrome.
  • Cervical dystonia.
  • Focal dystonia.
  • Congenitally absent hand.

Here are some normative values for IMI, though Bob suggested that normal will be very much patient-specific.

  • Accuracy of 80% or above.
  • Speed of 1.6 ± 0.5 s for necks and back. 2 ± 0.5 s for hands and feet.
  • Accuracy and response time should be fairly symmetrical.
  • Patient results should be stable for at least one week; should not fade out with stress.
  • Personal relevance of responses should take precedence.

Other rules of thumb, typically reaction time increases with age, males are faster than females, and left handed people are faster than right handed (score).

Add to the list of things lefties are superior in.

Here are some potential indicators that would indicate a possible trial of using IMI.

  • Ongoing pain.
  • Some less obvious pain states.
  • Variable diagnoses.
  • Cold sensitivity.
  • Tender away from injured site.
  • Bilateral pain.
  • Unpredictable treatment responses.
  • Chasing pain.
  • Everything hurts.
  • Immune imbalances.
  • Disembodiment metaphors.
  • Cyclical.
  • Two-point discrimination changes.

There are several ways to train IMI. The use of flashcards in various positions, finding body parts in magazines, digital cameras, basically any activity which challenges left and right discrimination is useful. The challenge of the pictures can also be increased depending on orientation.

Easy---little challenging---that was tough---OMG
Easy—little challenging—that was tough—OMG

You can also change the context of the pictures to further increase difficulty.

  • Speed.
  • Image number
  • Image context (hand on plain background versus hand in patterned background).
  • Different/abstract body parts (Painted or animal hand).
  • With distraction.

If performing laterality retraining of the affected body region is painful, then adjacent or distal areas

The most important thing when training IMI is that accuracy is emphasized before speed and that the activity is relatively pain-free.

Explicit Motor Imagery (EMI)

EMI is imagining moving your own body without actually moving it. This activity leads to movement neurotags, namely the preparatory and initiating ones, to activate.

Intention → preparation→ carrying out→ evaluating

Observed, imagined, and performed movements activate many of the same brain regions albeit to varying degrees. Working from observation all the way to performance is essentially graded exposure from a top-down approach.

Research has actually demonstrated that imagining movement has been shown to increase pain and swelling in patients with CRPS type I. Therefore, sometimes this activity can be too much for patients. If you activate the pain neurotag, you may have to take a step back. Even if IMI is too much, then watching someone move is likely the most ideal.

To perform EMI, it is very important to imagine all movements in the first person. Imagining in first person makes the activity more kinesthetic than visual. It is very important to make the task individualized to facilitate best outcomes. Here are some ways to make EMI more effective.

  • Have the eyes open/closed
  • Imagine the affected body part in the starting position.
  • Describe the environment.
  • Demonstrate the movement.
  • Use words to describe the process.
  • Use cues from the 5 senses.
  • Recall memories.
  • Prior relaxation techniques.
  • The activity should be imagined as long as it takes to do in reality.

Typically, here is the EMI progression that can be utilized.

Watch the activity –> Hold affected body part in static position –> dynamic imagery –> manipulate an object.

Terrible pun but I am still going to use it.

Mirror Therapy

Mirror therapy is a novel way to trick the brain into thinking the moving limb is the hidden limb. When the limb is viewed in a mirror, the motor cortices in both brain areas are activated. This activation is more than in EMI, but less than actual movement. Mirror therapy is another step in graded exposure.

Sometimes with mirror therapy dysynchiria may occur, which is when the person feels pain or pins and needles in their hidden limb. This phenomenon most often occurs in patients with CRPS. If this does occur, it is important to advocate to the patient that nothing is being damaged because the hand is not even moving.

Here are some general guidelines to utilizing mirror therapy.

  • No jewelry or cover tattoos on the affected side.
  • The more severe the problem, the less movement amplitude and increased frequency may be needed.
  • The patient cannot see the other side.
  • Feel comfortable with the movement before progressing to a more challenging movement.
  • Once you feel comfortable with a movement, change the context.

Here is a way to progress/regress mirror therapy.

Threat value Hand inside box Hand outside box
Less threatening Hand resting. Hand resting. Just observe.
Hand resting. Rotate the hand.
Hand resting. Finger opposition.
Hand resting with a slight bend in the fingers. Slow fists.
More threatening Bend the wrist up/down within pain limits. Bend the wrist up/down through full mobility.
Finger opposition gently touching together. Forceful finger opposition.
Make a fist into some discomfort in time with outside hand. Fist for repetitions.
Full mobility. Copy hand in box.
Most threatening Tool manipulation. Copy hand in box.

The Clinical Reality

Before GMI is implemented, the patient must first be educated on pain. Educating patients on pain physiology has been shown to have many benefits including decreased pain thresholds, improved pain beliefs and attitudes, and improving outcomes of therapeutic approaches.

The big keys that must be advocated include that the brain changes undergone with pain experiences do not equal brain damage. The nervous system is just unhealthy. These effects are reversible and take time. It is similar to learning to play a musical instrument. Jimmy Page didn’t become a great guitarist practicing two times a week for 4 weeks.

Hyooge hand representation.

Many times patients may get the feeling that you are suggesting the pain is in the head which is not the case. However, the brain decides whether or not you will experience pain. A good example is an ankle sprain. Say you sprain your ankle on the street when all the sudden you notice a bus coming your way. Does the ankle sprain hurt at that moment? Not likely because your brain is going to be focused on you moving out of the bus’ way.  Changing the patient’s mindset is key to having the most successful outcome.

Great Bob Johnson Quotes

  • “The goal is pain freedom. Even if it hurts, I am less threatened.”
  • “Ask with every patient how the nervous system is involved.”
  • “If you say the neurodynamic tests involves only the median nerve you are lost.”
  • “50% of people have joint noises. It is just the way your body protects you.”
  • “The [nervous] system will do what it needs to survive.”
  • “Get the patient to think they can get better and they will get better.”
  • “One cannot have pain with just physical damage.”
  • “Pain holds on because the patient is misunderstood, not broken.”
  • “Just because the police are at the scene doesn’t mean they committed the crime.”
  • “The motor homunculus doesn’t think muscles, it thinks movements.”
  • “Glia are immune cells for the CNS. They are gates that turn the system on and off.
  • “Movement is an antigen.”
  • “Ask patients how stressed they were when they hurt themselves.”
  • “Our goal is to get the patient moving without turning on the system.”
  • “The two biggest factors for chronic pain development are work and home satisfaction.”
  • “Two point discrimination treatment changes brain sensitivity and cortical reorganization.”
  • “Emotion is lotion.”
  • “I don’t take medical histories; I need to find out who the patient is.”
  • “Imagining impossible movements are possible with phantom limbs.”
  • “25% of premotor neurons are mirror neurons” This is why watching movement works.

Final Verdict

Overall, I thought this was a fantastic course, and put more skills into my clinical skillset. It may take some time for me to implement GMI into my practice (I need to make a lot of laterality cards), but I bet this will be very useful.

I also wonder if there are potential for using this modality in a performance aspect. Imagery has been used with great outcomes in athletes, but laterality retraining and mirror boxes have not. Could this be another way to increase performance? Only time will tell.

To sign up for more NOI courses, check out


The Sensitive Nervous System Chapter XI: Neurodynamic Testing for the Spine and Lower Limb

This is a summary of Chapter XI of “The Sensitive Nervous System” by David Butler.


For today’s chapter, I have decided that the best way to learn these tests is to show you. I will write in any pertinent details you need for a good test performance.

The Straight Leg Raise (SLR)

SLR hacks.

  • Add sensitizers (dorsiflexion, plantarflexion, etc) to determine nervous system involvement.
  • Add cervical flexion or visual input to enhance responses.
  • Be mindful of symptoms before and after pain responses.
  • If this test is positive post-operation, it will likely be inflammatory in nature.
  • You can preload the system further with cervical flexion or sidebending the trunk away from the test side.

Here are some other ways to perform the SLR with sensitizers first. (I apologize for the way the camera shot in advance).

For tibial nerve-bias.

For fibular nerve bias.

For sural nerve bias.

Passive Neck Flexion (PNF)

Here is how to perform the test.

PNF Hacks.

  • Add SLR to further bias the test.
  • Be mindful of Lhermitte’s sign, which is an electric shock down the arms or spine. This is a must-refer sign as there is potential spinal cord damage.

Slump Test

Here is how to perform the slump.

Slump Knee Bend

In the book itself, Butler uses the prone knee bend as his base test. However, NOI does not teach this motion as much and now favors the slump knee bend. This movement allows for much more differentiation to be had.

And the saphenous nerve (just so you get a break from seeing me).

Final Words

Have some fun with these tests, and be mindful that you are not too aggressive.

The Sensitive Nervous System Chapter VIII: Palpation and Orientation of Peripheral Nervous System

This is a summary of Chapter VIII of  “The Sensitive Nervous System” by David Butler.


Palpation is a major component to therapeutic touch, and gives us a way to build rapport and interact with our patients. When palpating the nervous system, it is important to palpate in sensitive positions so the nervous system is placed on load. Here are some general nerve anatomical rules.

  • Where a nerve has fewer fascicles and less connective tissue, palpation will be more sensitive (ulnar nerve).
  • Where there is a lot of connective tissue, there will be a more localized and less “nervy” response.
  • Where there is increased sensitivity does not mean there is damage locally. Damage could have occurred more proximally (that whole nerves fire in both directions thing).

You must also be mindful that anatomical variations are common, especially if symptoms seem anatomically weird. Here are some of the more common ones:

  • Martin-Gruber anastomosis: Median and ulnar communicate distally.
MN - Median Nerve; UN - Ulnar nerve; CB - Communicating branch.
MN – Median Nerve; UN – Ulnar nerve; CB – Communicating branch.
  • Rieche-Cannieu anastomosis: Deep branch of ulnar and recurrent branch of median nerve.
MN - Median Nerve; UN - Ulnar nerve; CB - Communicating branch.
MN – Median Nerve; UN – Ulnar nerve; CB – Communicating branch.
  • Absent musculocutaneous nerve.

Palpation 101

Here are some basic nervous system palpation guidelines.

  • Nerves feel hard and slippery.
  • Palpate with your finger tip or thumb, and follow it proximally or distally.
  • Use sustained pressure up to 30 seconds.
  • Twang if easily accessible.
  • If using a Tinel’s, tap the nerve 4-6 times.
Do not play Stairway on the superficial fibular nerve.

Spinal Nerve Palpation

Here are the craniocervical nerves.

The Trunk

Upper Extremity Nerve Palpation

Brachial plexus

The median nerve

The Ulnar nerve

The Radial Nerve

The Musculocutaneous Nerve

Lower Extremity Nerve Palpation

First, the nerves palpated anteriorly.

And then posterior.

Last Words

Grab a partner or yourself and palpate away.