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Old 08-08-2011, 11:58 AM   #1
Barrett Dorko
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Default Angelo's Endings

When Angelo Ruffini discovered the endings now named for him my parents were not yet born. My Grandfather Dorko had recently entered the US illegally and my Grandmother Hinske was conforming to Victorian era behavior in Cleveland. Her father knew how to carve wood.

An anatomist with a special interest in normal and abnormal pathology, Ruffini became famous not only for his discovery of a structure, but for his understanding of how it responded to various pressures. Now, thanks to Diane Jacobs' brilliant work, we can understand why and how to connect our manual care to this 19th century genius.

Diane has sent me her power point presentation, Somatosensory Processing, and I’ve gone through it several times. It’s beautiful, and I almost hate to reduce it in any way by simplifying it, but I have the sense that most therapists handling others want a “bottom line” regarding technique as soon as I can provide it.

This is it:

Quote:
Ruffini endings are found in the dermis and are attached to slow-adapting, non-nociceptive nerves. Their wide receptive field responds to a steady, lateral displacement of the skin.

To me, this translates to a method of manual management that should include a recruitment of Angelo’s endings. This, of course, means lateral displacement of the skin. When deemed necessary, that displacement should include an enduring and variable lateral stretch – thus the use of appropriate tape. (Notice the repetitive use of the word lateral here?)
As usual, the simple solution lies on the far side of a complex issue. In this case, an answer to the question: What are the properties of the materials we’re dealing with?

Tomorrow: Why poking is a bad idea.
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Old 08-08-2011, 12:30 PM   #2
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Quote:
enduring and variable lateral stretch
Barrett, would you mind elaborating a bit more on what you mean by "variable" here? Would that be a change in direction of the lateral stretch?
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Old 08-08-2011, 12:34 PM   #3
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Direction and amount of pressure.

I am driven to change what I'm doing as soon as the patient's own ideomotion tells me to. All I do is follow.
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Old 08-08-2011, 05:05 PM   #4
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Default boat analogy for facilitating ideomotion

A description, that I think Gil Haight used in one of his courses, and that seems to make a lot of sense to me is pulling on boat strings (the skin is the boat string, and you apply a pressure and feel/see the response of the boat on water). How much pull and what direction you use really depends on the movement of the boat. If the goal is to get the boat to a landing point, then you have to respond to, and pull against, the wind, the current, the weight of the boat....all those variables. And it's easy to apply this lesson as when YOU have a goal (moving the boat/extremity) somewhere, you just pull against resistance, in any direction that you find it (traditional PROM for example).

The HUGE difference is that when working with the person in pain, your goal is not to move the pt, it's to help the pt allow for their own movement.....You are allowing for, or helping them to allow movement in response to their own ideomotion - or like the boat analogy, you are helping that boat find that it can allow itself to move in response to the current and the winds around it....but that boat is scared and hasn't been in a context before where anyone allowed it to move, everyone just pulled on it in the past to get it somewhere...and now it's suppose to just let go and go.....may be scary at first.

Anyway, you apply a minimal force, attend to the response of the boat and follow it. Like if you were pushing that boat away from a pier on it's way out of the dock...you know what direction to try because you can see/feel it....but you are only really there to help faciliate movement (the engine does most of the work).

When working with a person, you only use as much force as needed to allow you and your patient to discover that movement is there, and in whatever direction you don't have to force movement (don't push against the pier, a rock, the boat next to you, a strong wind, etc). Try not to have an idea of where to push/pull (you don't know what's the best path until the pt begins to move freely), just try a few ways and see which one is best by if the person allows movement or not. You press/pull and follow, that's it....the only concerns that I think are realistic to hold are to make sure that boat doesn't hit anything dangerous as it moves, and to make sure you follow the movement so you can continue to support the person as they learn how to move. As soon as they start to move freely without as much assistance from you to discover what pathways are available, start taking your hands away....that's the goal, and that's their HEP - move on their own with the current/winds they feel as soon as they learn again how to tune in and allow it)!

Lots of water references lately...sorry...must be summer in Minocqua!
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Old 08-08-2011, 05:10 PM   #5
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Thank you for finally getting around to talking about Ruffini's, Barrett. I've attached the pdf I sent to Barrett - it's enormously abbreviated - just wanted to point that out to people.

I left out a long stretch of repeated step-by-step slides that explain the different brain zones (the orange, blue and white areas in that brain image from Mayo Clinic Medical Neurosciences) different colour based on how thick/how many cell layers there are in the cortex, and what each zone does in terms of processing. I left out a long bunch of cortical processing slides showing the step-by-step of cortical column processing, only included the final one. I left out all the slides showing the connectivity relationships indicating signaling reciprocity between sensory, motor, and premotor cortex, and the thalamus, and the internal regulation (brainstem, hypothalamus, anterior cingulate and insular cortex) life-support threat-detector system.

All Barrett wanted was the Ruffini info. But there is way more to it than just input, and I still put in enough slides, I hope, to show that the brain makes a very big computation out of anything coming into itself from skin or from any other sensory organ. Whoever finally persuades me to teach has to realize they will be subjected, in the first hour, to the entire premise, which is 98 slides long. And that is about half the length it used to be - I took out the evolution and embryological arguments.
Attached Files
File Type: pdf somatosensory processing.pdf (9.36 MB, 34 views)
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Old 08-08-2011, 05:47 PM   #6
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Diane,

I wish I had the words to convince you to teach in course form any of the info you have in your head....even just a start with a day or 2 on something of interest to you that relates to treatment of people with a nervous system. At my clinic/hospital, I already know that we would get you in here in a second...and we are patiently waiting for you to decide to do move more officially into the teaching arena. I talk about you and others on this site all the time and very positively, and through my relating of the people and the info they bring to this amazing place, Patience Lamers, and OT I work with, says that she is familiar with you and your work too and met you at some course some time in the past, and we are 2 of the 3 on our educational committee. If you even think of considering teaching....please PM me and I will bring it to the group (already know you are).

Please please please seriously consider it....Anything would help, but specifically:
  1. post surgical pain complaints/treatment strategies,
  2. lymphatic management,
  3. chronic pain populations,
  4. nervous system anatomy and function and it's applicability post stroke/CVA or post other neurological insult,
  5. applying manual techniques in ANY population, including people with and without pain (for direct comparison and reasoning skills to decide when to do what to do for what dx/impairments, etc),
.....to give you some ideas of common struggle points I see here....it's hard trying to find "good" education in all the CE courses we have to sift through, and that's a main reason I am practically begging. Beyond that, I would love in my lifetime to have the opportunity to officially meet you.

And another option would be a lunch-time discussion on any of the above, where we go over literature/clinical scenarios related to any of the above....it wouldn't have to be terribly official, if that's a limitation for you.....and I think we can seek credits from our organizations vs. having to have you go through the work....anything to make it easier for you. I hope Wisconsin doesn't seem that far for you to travel, and I'm sure we can work out travel arrangements/payment, etc. as well!

And thank you for the info!
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Old 08-08-2011, 05:50 PM   #7
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Quote:
At my clinic/hospital, I already know that we would get you in here in a second...


I'd be there in a heartbeat if I could get invited to attend...Steph's location is about 3 hr from me and I have family nearby I could stay with!

Edit: AND I'd bring cookie dough! (Little Facebook based joke at Will Stewart's expense LOL)
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Old 08-08-2011, 05:53 PM   #8
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Actually it wasn't that all I wanted was the Ruffini info. I have the sense that our community will only tolerate a little at a time, and that little bit of information had better contain the most immediately relevant, clinically applicable stuff that can be learned - preferably in about 10 minutes.

In fact, many would be happy with my saying, "Push the skin sideways gently and wait. Don't slide."

There's a lot more, I know, but, in my experience, therapists are overwhelmed very, very easily.
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Old 08-08-2011, 06:00 PM   #9
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Steph, I just don't see myself as having enough energy to do all that... traveling, or... interfacing. I'm sorry, but I'm cursed with being an introverted hermit. I can't handle teaching except in very rare occasions and small doses, and even then it burns me out for several weeks. This forum is about as close to interchange as I can manage, mostly.

The Pain Science Division/CPA is, however, navigating/exploring to find out how we might bring our virtual symposium on pain to US PTs via APTA. If that's of any help.
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Old 08-08-2011, 06:36 PM   #10
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Diane,

Yes I think it will be helpful as an additional option (the virtual symposium)!

And I respect your current perspectives, I was just jumping at the chance to convince you.

I know some great caffinated beverage places, if that would help in the energy department!

I'm glad there's a place like this for brilliant hermit types like yourself to shine.....and I get it (the exhaustion/effort and lack of response post is underwhelming), and I've only taught 2 lectures to date......
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Old 08-08-2011, 10:18 PM   #11
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I know Ruffini is SA, large receptive field, but does ruffini follow lateral stretch around an axis or reference point? Is lateral stretch different at the wrist versus the forearm?


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Old 08-08-2011, 10:35 PM   #12
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Pick a point.

Now, move in any of the 360 degrees that eminate from it.

All will be lateral to it.

All will stimulate Ruffini endings.
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Old 08-08-2011, 11:10 PM   #13
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Quote:
Originally Posted by Barrett Dorko View Post
Pick a point.

Now, move in any of the 360 degrees that eminate from it.

All will be lateral to it.

All will stimulate Ruffini endings.
Exactly.
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Old 08-08-2011, 11:12 PM   #14
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Thanks Diane and Barrett.

Posts and attachments like this are incredibly useful.
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Old 08-08-2011, 11:30 PM   #15
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Glad to hear how helpful this has been.

I really think that the question about "axis or reference point" reveals how complex this simple, simple thing can be made.

I'm glad it was asked.
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Old 08-08-2011, 11:46 PM   #16
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Quote:
Originally Posted by Diane View Post
Thank you for finally getting around to talking about Ruffini's, Barrett. I've attached the pdf I sent to Barrett - it's enormously abbreviated - just wanted to point that out to people.

I left out a long stretch of repeated step-by-step slides that explain the different brain zones (the orange, blue and white areas in that brain image from Mayo Clinic Medical Neurosciences) different colour based on how thick/how many cell layers there are in the cortex, and what each zone does in terms of processing. I left out a long bunch of cortical processing slides showing the step-by-step of cortical column processing, only included the final one. I left out all the slides showing the connectivity relationships indicating signaling reciprocity between sensory, motor, and premotor cortex, and the thalamus, and the internal regulation (brainstem, hypothalamus, anterior cingulate and insular cortex) life-support threat-detector system.

All Barrett wanted was the Ruffini info. But there is way more to it than just input, and I still put in enough slides, I hope, to show that the brain makes a very big computation out of anything coming into itself from skin or from any other sensory organ. Whoever finally persuades me to teach has to realize they will be subjected, in the first hour, to the entire premise, which is 98 slides long. And that is about half the length it used to be - I took out the evolution and embryological arguments.


great stuff Diane.

I for one would be interested in the un-abbreviated version

regards

ANdy
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Old 08-08-2011, 11:56 PM   #17
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Diane and Barrett,
I second Dave Nolan. Great posts, very useful, insightful.
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Old 09-08-2011, 12:16 AM   #18
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I think the unabbreviated version is a thing of beauty.

Teaching and working as I have, I'm fairly certain it would lose a few.

More's the pity.
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Old 09-08-2011, 01:17 AM   #19
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Quote:
Originally Posted by amacs View Post




great stuff Diane.

I for one would be interested in the un-abbreviated version

regards

ANdy
I'm sure I posted it around here somewhere.. I'll hunt. If I can't find it, I'll post the whole thing as a pdf.

Thank you for being interested.
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“If you make people think they're thinking, they'll love you, but if you really make them think, they'll hate you." ~Don Marquis

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Old 09-08-2011, 01:52 AM   #20
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You'll find the latest version as pdf attachment in post 5 of this thread.
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"Rene Descartes was very very smart, but as it turned out, he was wrong." ~Lorimer Moseley

“Comment is free, but the facts are sacred.” ~Charles Prestwich Scott, nephew of founder and editor (1872-1929) of The Guardian , in a 1921 Centenary editorial

“If you make people think they're thinking, they'll love you, but if you really make them think, they'll hate you." ~Don Marquis

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Old 09-08-2011, 04:04 AM   #21
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Thank you Barrett. Thank you Diane.
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