Removing the Door

Barrett L. Dorko, P.T.


This is my latest analogy for handling related to Simple Contact. I’ve been working on it for a long time and I think someone out there might find it useful. 

Imagine yourself standing on one side of a swinging door. There’s no handle on your side, and your only task is to cross the threshold. Unfortunately, every time you press on the door, an equal and opposite pressure is exerted. The harder you press, the stronger it becomes. The opposing force perfectly matches your own timing, and it cannot be deceived. 

Given this, how do you get across the threshold? 

Typically, manual care presumes that an effect will follow a linear relationship between the force, direction and speed of the therapist’s hands. Much has been written about the possible consequences of external pressure, though precisely what actually happens remains open to question. I’m suggesting here that something needs be considered before we presume that our manual pressure will have any predictable effect, and that “something” is the potential connective tissue response. Fortunately, it has been thoroughly studied. 

Josef Threlkeld, PhD. P.T. studied the effect of manual care in the aptly titled essay The Effects of Manual Therapy on Connective Tissue (Physical Therapy Volume 72, Number 12/December 1992). Please note that this reference is the Journal of the American Physical Therapy Association. After a prolonged discussion of connective tissue (CT) properties (including fascia, of course), Threlkeld concludes, “If 100% of an externally applied force could be transmitted to a selected portion of a connective tissue structure, then it could be presumed that forces commonly produced during manual therapy could produce permanent elongation…the external forces, however, are not direct and are not completely transmitted to a preselected segment of a CT structure.” The dispersal of manual force is an inherent reaction to pressure, and evidence that manual force results in connective tissue elongation that is prolonged or therapeutic is extremely hard to find. (emphasis mine) 

Dispersing and reducing the force of any outside pressure is a primary function of the skin, and, as you might have already guessed, the skin is the “door” I’ve been alluding to. It reacts to force with efficiency and speed, and it does its best to match the force applied. Should it be powerfully overcome, injury is likely. This, for instance, is what the boxer seeks to do to his or her opponent. The skin is especially good at dispersing a slowly applied pressure or a pressure that does not include a relatively sharp edge, and methods of manual management that do not include rapidly applied force with the knuckle would predictably be ineffective, at least in the fashion they imagine themselves to be. In fact, this combination of factors led to the demise of bare-knuckle boxing; it was too damaging.  I’m not suggesting that coercive handling has no effect at all, only that the natural defenses offered by the skin cannot be ignored.  

You might reasonably wonder why the skin is so defensive and why it so clearly represents a door that resists our entry. 

In answer, I’d refer you to a passage from Ashley Montague’s classic text, Touching: The Human Significance of the Skin (Harper 1971): “The skin in common with the nervous system arises from the outermost of the three embryonic cell layers, the ectoderm.  The ectoderm constitutes the general surface covering of the embryonic body.  The ectoderm also gives rise to the hair, teeth, and the sense organs of smell, taste, hearing, vision and touch--everything involved with what goes on outside the organism.  The central nervous system, which has as a principal function keeping the organism informed of what is going on outside it, develops as the inturned portion of the general surface of the embryonic body.  The rest of the surface covering, after the differentiation of the brain, spinal cord, and all the other parts of the central nervous system, becomes the skin and its derivatives--hair, nails, and teeth.  The nervous system is, then, a buried part of the skin, or alternatively the skin may be regarded as an exposed portion of the nervous system.  It would, therefore, improve our understanding of these matters if we were to think and speak of the skin as the external nervous system, an organ system which from its earliest differentiation remains in intimate association with the internal or central nervous system.  As Frederic Wood Jones, the English anatomist, put it, “He is the wise physician and philosopher who realizes that in regarding the external appearance of his fellowmen he is studying the external nervous system and not merely the skin and its appendages.”  As the most ancient and largest sense organ of the body, the skin enables the organism to learn about its environment.  It is the medium, in all its differentiated parts, by which the external world is perceived.  The face and the hand as “sense organs” not only convey to the brain knowledge of the environment, but also convey to the environment certain information about the “internal nervous system.” 

“…Clearly, sensory stimuli at the skin level have to be interpreted at the cortical level and the appropriate motor reactions initiated.  The skin itself does not think, but its sensitivity is so great, combined with its ability to pick up and transmit so extraordinarily wide a variety of signals, and make so wide a range of responses, exceeding that of all other sense organs, that for versatility it must be ranked second only to the brain itself.  This should not be surprising, for as we have seen, the skin in fact represents the external nervous system of the organism.  The sensitivity of the skin can, however, be considerably impaired by the failure to receive the tactile stimuli necessary for its proper development.   In this respect, such influences as family, class, and culture play a fundamental role.” (emphasis mine) 

So, when you touch, deform or otherwise influence the skin you are actually altering something whose connection to the nervous system is rarely appreciated for its intimacy and embryologic, anatomical origins. In other words, to “get to” the nervous tissue, all you have to do is influence the skin. Unlike your efforts to influence the connective, contractile or vascular tissues, there is no intervening tissue to deal with-the skin is the nervous system, and when you understand that, you have removed the door. You don’t do this with force, stealth, deception or speed, but with knowledge and understanding. A distinct alteration in manual technique will surely follow.