1. 90 seconds to Pain relief; Using the Strain- Counterstrain Technique Andrea Gordon, MD Richard McKinney, MD Integrative Medicine for the Underserved August 8, 2015

2. 90 seconds? Who are we kidding? You may be wondering: How can you relieve pain that fast? How much training do I need? Will patients accept this? Is it too late to go to another breakout session?

3. By the end of this session you will: By the end of this session you will: 1. Understand and explain : ◦the theory of muscle spasm and ◦how it can be relieved by s/cs 2. Be able to demonstrate using s/cs to relieve spasm of ◦Trapezius ◦Upper back  (not like that  ) ◦Piriformis

4. You will also 3.Be able to teach this technique in terms understandable by someone not familiar with medical terminology or anatomy. ◦So you can also teach your patients or their families to do this 4. Elicit admiration and gratitude from those you treat!

5. So what is this technique? Developed by Dr. Lawrence Jones, DO His definition describes “a passive positional procedure that places the body in a position of greatest comfort, thereby relieving pain by the reduction of the inappropriate proprioceptor activity that is maintaining somatic dysfunction”. Huh?

6. More simply put: Jones found that tender points can be relieved by a position of comfort After this position is maintained for 90 seconds, the patient is passively returned to neutral Use tender point throughout to monitor effectiveness

7. How does it work? When one muscle is forcibly stretched, that is the strain The paired muscle is forcibly shortened- that is the – yup- counterstrain The shortened muscle is more “irritable” and tightens up when you try to get it back to normal length Shortening and then passively bringing it back to normal allows it to relax

9. What is a tender point? “Small, discrete, edematous areas on the body that elicit pain when palpated: “-e.g. are tender Foci of hypertonicity from inappropriate reflexive muscular contracture The spot that hurts the most in the muscle

10. Tenderpoints are not trigger points Trigger points often radiate Trigger points can be relieved by injection or spray and stretch technique They are more often due to chronic musculoskeletal issues, where tender points can be due to acute or chronic problems.

11. Where are tenderpoints? Sometimes patients can show you, but the area of pain is not always the tenderpoint So how do you find them?

12. Tenderpoint maps exist

13. But you can find them Feel for spot that may be a little tense or edematous Get feedback from the patient

14. Now make them better! Call your starting point “10”. Keep your finger on the point but don’t press except when getting feedback on pain level Move the muscle to a position of comfort where the pressure on the point is only at a level of 2 or 3.

15. Once you have the position Stay there for 90 seconds or so ◦Sometimes you have to wait for them to really relax and then give it 90 seconds YOU move the muscle back to full length – the movement needs to be passive

16. How do I find the position of comfort? Someone has already done this for you! there are charts and classes But you don’t have to take a class to do this.

17. Think about how to shorten the muscle For example, to shorten your rhomboids you would bring the shoulder blade closer to the spine Feel it on yourself

18. It’s ok to play “warm or cold?” Move in one direction and get feedback Correct in that plane, then try in others Make small, gentle movements if you are not sure which way to go at first Try to get your patient to really relax the muscle being treated- this can be the hardest part

19. Fine points Keep your finger on the tenderpoint This lets you monitor it and retest as needed You may feel pulling or twitching as the muscle loosens –just wait until it stops Otherwise wait 90 seconds After returning the muscle to full length retest!

20. Here are the looks you may get:

21. Positions for some common points and pain patterns Trapezius Treat by raising arm, leaning ear to shoulder if needed

22. Piriformis Abduct, flex and, if needed, internally rotate

23. Posterior Neck Remember –you are folding around the point, so extend, then sidebend toward the point BUT in the neck you will rotate AWAY from the point Think of bringing the facets on that side together – or just remember it.

24. Rhomboids Think of bringing the scapula closer to the spine You can do this sitting or lying down Can teach patients to do this for themselves in a chair

25. Practice these Try it on loved ones! They will look like this: And you will feel like this:

26. You can do this now! Live long and prosper!