1. Strain and Counterstrain
Positional Release techniques for the Treatment of Selected Spinal Dysfunction

2. Strain and Counterstrain
1. A passive positional procedure that places the body in a position of greatest comfort, thereby relieving pain by reduction and arrest of inappropriate proprioceptive activity that maintains somatic dysfunction. (Indirect technique)

3. Somatic Dysfunction
Impaired or altered function of related components of the somatic (body framework) system: skeletal, arthrodial, and myofascial structures and related vascular, lymphatic, and neural elements.

4. Strain and Counterstrain
2. The use of a mild over-stretching applied in a direction opposite to the false and continuing message of strain which the body is suffering. Accomplished by markedly shortening the muscle that contains the malfunctioning muscle spindle while the antagonist undergoes mild stretch.

5. Strain and Counterstrain
3. A system of evaluation and treatment of joint pain based on the understanding that joint pain results from a strain of the neuromuscular reflex that results in a muscle imbalance and joint dysfunction.

6. Strain and Counterstrain
4. Technique based on the fact that a stretch of the myotonic joint in the direction of maximum comfort held for 90 seconds, will release the bind of tonic neuromuscular reflex spasm of somatic joint dysfunction.

7. Origin of Strain and Counterstrain
Dr Lawrence Jones, DO,FFAO
Manipulative thrust
Patient responses to certain procedures and positions
Further development
1988-Present Jones Institute establishes
Teaching and ongoing research

8. Origin of Counterstrain
First Observation - Persistent Psoitis
Second Observation - Psoitis (anterior tender points)
Third Observation - Slow return from a position of strain

9. Theory
1. Proprioceptor Model
2. Nociceptor Model
3. Circulatory Model

10. Proprioceptor Model
Based on a neurologic model first proposed by Dr Irvin Korr in 1975
“Proprioceptors and Somatic Dysfunction”

11. Proprioceptor Model *Rational Manual Therapies (Chapter 13)
Strain and Counterstrain by Randall S Kusunose
“Muscle Spindle & Somatic Dysfunction” pp
*See article
“High Gamma Gain” muscle spindles falsely report to the spinal cord that their muscle, actually in a shortened contracted state, was stretched to nearly its maximum.

13. Nociceptor Model Original trauma produces physical tissue damage
With tissue injury, nociceptive reflexes are established
Counterstrain position shuts down the nociceptive reflex

14. Nociceptor Model *See article
“Nociceptive Considerations in Treating with Counterstrain”
Mark Bailey, PhD, Lorane Dick, DO
JAQA Volume 92 No. 3 March 1992

15. Circulatory Model
Rathbun and Macnab found that an infusion of a micro-opaque suspension injected into the arm of a cadaver with its arm at the side allowed no filling of the zone of avascularity of the supraspinatus muscle.

16. Circulatory Model
However, when the suspension was injected into the opposite side with the shoulder in passive abduction, there was almost complete filling of all vessels due to relaxation of tension on the supraspinatus muscle.

17. Circulatory Model
Unopposed arterial filling may be the same mechanism that occurs in the living tissue during the 90-second counterstrain treatment.
*Rathbun JB, Macnab I: The Microvascular Pattern of the Rotator Cuff. J Bone Joint Surg 1970; 52:

18. Basis for 90 Second Hold
Somatic Dysfunction: A Neurophysiologic & Osteopathic Overview
by Antonius J Tsompanidis
AAO Journal (Summer ‘92)
“90 Second Hold - Why?”

19. Basis for 90 Second Hold Phase 1 Myofascial articulation
“Finding position of comfort”
Phase 2
Spindle reset
“Takes just a few seconds”

20. Basis for 90 Second Hold Phase 3 Vasodilation “20-40 seconds or more”
Slow return to normal
*See article

21. Tender Points Definition:
1. Small areas of muscle and fascial tissue that are tense, tender and/or edematous.
2. Sensory manifestations of a neuromuscular or musculoskeletal dysfunction.

22. Tender Points
Tender points are at least 4 times as tender as a patient’s normal tissue would be to similar palpation
Tender points are monitored, not treated
If “exquisitely” tender - “jump” or “grimace” sign will be evident
Tender points give you immediate feedback on success of your positioning/treatment

23. Tender Points Pressure is taken off the tender points during treatment
At least 200 tender points have been identified throughout the body
Counterstrain tender points are located deeper than points used in other treatment approaches, ie “acupuncture”

24. Tender Points
Tender points cease to report tenderness when normal function is restored to the connective tissue related to the joint

25. Tender point vs Trigger point

26. Strain/Counterstrain Steps in Treatment
1. Locate a significant tender point
2. Place patient in position of comfort or mobile point
3. Fine tune to decrease tenderness as much as possible and monitor the point but take pressure off the tender point

27. Strain/Counterstrain Steps in Treatment
4. Maintain the position for 90 seconds. On a really acute patient, occasionally 120 seconds
5. Return to neutral position slowly, especially the first portion of the return
6. Recheck the tender point - if technique was successful, it should be at least 70% less tender

28. Principles to Follow with Counterstrain
1. Move very gently and slowly into and out of the position of treatment.
2. Hold the position of treatment (comfort) a minimum of 90 seconds.
3. Anterior tender points are usually treated in a position of flexion
4. Posterior tender points are usually treated in a position of extension or backward bending

29. Principles to Follow with Counterstrain
5. More flexion or extension is required for tender points on or near the midline
6. With tender points more lateral to the midline, more rotation and/or side bending is required
7. Tender points in the extremities are often found on the side opposite of where the patient complains of pain

30. Principles to Follow with Counterstrain
8. If multiple tender points are present, treat the most severe first
9. When there are several tender points in a row, treat the one in the middle first
10. Start proximally with your treatment and work distally.
11. Treat large regions before small

31. Principles to Follow with Counterstrain
12. Work from the midline first and progress laterally
13. Preferred positions/movements by patient may be a guide to initial treatment selection
14. Explain to the patient that he/she may be sore in the hours following a treatment (30%)
15. No contraindications

32. Position of Comfort Found by:
1. Patient feedback relative to tenderness/pain
2. Find mobile or wobble point - maximum relaxation point
3. Use palpatory skills extensively

33. Position of Comfort
-Positions are guides only, subtle variations exist from patient to patient
Think about direction that shortens the muscle containing the dysfunctional muscle spindle
At least 30% of relaxation occurs in the last 2°-3° of positioning
Find point where movement in any direction will increase tissue tension

35. Communication System During Treatment
% of improvement
Pain scale 1-10
Poor - Fair - Good - Excellent
Monetary Comparison - start with $1.00 worth of pain!
Develop preferred method with each individual client
1/4, 1/2, 3/4, completely gone

36. Why Do Tender Points Come Back?
1. Not doing the technique correctly
- Not finding the mobile point
- Not holding for 90 seconds
- Not returning slowly
2. Doing the wrong technique for the tender point
3. Missing multiple tender points within a single muscle

37. Why Do Tender Points Come Back?
4. Missing a tender point in a pattern of dysfunction
5. Have you cleared enough dysfunction in the body region?
6. Underlying mechanical dysfunction
- Joint or soft tissue adhesion
7. Is it a tender point or trigger point?

38. Why Do Tender Points Come Back?
8. Improper sequencing of tender points
a. Proximal points
b. Most severe points
c. Areas of highest accumulation
d. When in rows, treat the one in the middle first
KEY INDICATIONS:
a. Specific pain versus diffuse pain
b. Ease versus bind
c. Postural asymmetries
PERPETUATING FACTORS:

39. Why Do Tender Points Come Back?
9. Underlying pathology
a. Fractures
b. HNP
c. Soft tissue tear (ie rotator cuff, meniscus)
d. Tumor
e. Bony asymmetries (short leg, scoliosis)
f. Systemic disease (RA, fibromyalgia)
g. Bacteria or viral infection
h. Toxicity
i. Pregnancy
j. Poor posture

40. Why Do Tender Points Come Back?
10. Patient activities
11. Poor nutrition
12. Psychological factors
a. Stress
b. Psychological trauma
13. Sleep disorders
14. Instabilities
15. Visceral disease/dysfunction

41. How does it fit in your treatment regimen?
Acute
Children
Chronic
Osteopathic
Pregnancy
Fragile
Elderly

42. Strain and Counterstrain
Used first, it enhances mechanical treatment by decreasing unbalanced forces acting on the joint.

43. SCS - Terminology PT3R - posterior third thoracic on right
AC2L - anterior second cervical on left
PR1R - posterior first rib on right

44. Home Program Tips: 1. Monitor tender points when/if possible
2. Find most comfortable position (feels good and decreases tenderness)
3. Hold position 2 minutes
4. Return to neutral very slowly
5. Repeat 2 times/day

45. Evidence
Trigger point dry needling versus strain-counterstrain technique for upper trapezius myofascial trigger points: a randomised controlled trial. Segura-Ortí E, Prades-Vergara S, Manzaneda-Piña L, Valero-Martínez R, Polo-Traverso JA. Acupunct Med Jun;34(3):171-7
CONCLUSIONS: There were no differences between the sham SCS, SCS, and DN groups in any of the outcome measures. DN relieved pain after fewer sessions than SCS and sham SCS, and thus may be a more efficient technique. Future studies should include a larger sample size.

46. Evidence
The effectiveness of strain counterstrain in the treatment of patients with chronic ankle instability: A randomized clinical trial. Collins CK, Masaracchio M, Cleland JA. J Man Manip Ther Aug;22(3):119-28
27 subjects (13 SCS, 14 sham SCS)
DISCUSSION: Although SCS may not have an effect on subjective ankle function in individuals with CAI, preliminary evidence suggests that SCS may lead to an improvement in dynamic ankle stability and the subjective sense of ankle instability.

47. Evidence
Strain-counterstrain to treat restrictions of the mobility of the cervical spine in patients with neck pain: a sham-controlled randomized trial. Klein R, Bareis A, Schneider A, Linde K. Complement Ther Med Feb;21(1):1-7.
CONCLUSIONS: Strain-counterstrain as a single intervention did not have immediate effects on mobility and pain over a sham treatment. Future studies should probably focus on the investigation of full osteopathic treatment.

48. Evidence
Strain counterstrain technique to decrease tender point palpation pain compared to control conditions: a systematic review with meta-analysis. Wong CK, Abraham T, Karimi P, Ow-Wing C. J Bodyw Mov Ther Apr;18(2):
CONCLUSIONS: This systematic review and meta-analysis found low quality evidence suggesting that SCS may reduce TP palpation pain. Future studies with larger samples of better quality studies with patient populations that assess long-term pain, impairment, and dysfunction outcomes could enrich the literature.