Transcript Strain and Counterstrain

Strain and Counterstrain
Positional Release techniques for the
Treatment of Selected Spinal
Dysfunction
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)
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.
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.
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.
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.
Origin of Strain and
Counterstrain
Dr Lawrence Jones, DO,FFAO
• 1938-1955 Manipulative thrust
• 1955-1969 Patient responses to certain
procedures and positions
• 1969-1975 Further development
• 1988-Present Jones Institute establishes
– Teaching and ongoing research
Origin of Counterstrain
• First Observation - Persistent Psoitis
• Second Observation - Psoitis (anterior
tender points)
• Third Observation - Slow return from a
position of strain
Theory
1. Proprioceptor Model
2. Nociceptor Model
3. Circulatory Model
Proprioceptor Model
• Based on a neurologic model first
proposed by Dr Irvin Korr in 1975
• “Proprioceptors and Somatic
Dysfunction”
Proprioceptor Model
*Rational Manual Therapies (Chapter 13)
Strain and Counterstrain by Randall S Kusunose
“Muscle Spindle & Somatic Dysfunction” pp 329331
*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.
Nociceptor Model
• Original trauma produces physical tissue
damage
• With tissue injury, nociceptive reflexes are
established
• Counterstrain position shuts down the
nociceptive reflex
Nociceptor Model
*See article
“Nociceptive Considerations in Treating
with Counterstrain”
Mark Bailey, PhD, Lorane Dick, DO
JAQA Volume 92 No. 3 March 1992
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.
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.
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; 52:540-553
Basis for 90 Second Hold
Somatic Dysfunction: A Neurophysiologic
& Osteopathic Overview
by Antonius J Tsompanidis
AAO Journal (Summer ‘92)
“90 Second Hold - Why?”
Basis for 90 Second Hold
Phase 1
Myofascial articulation
“Finding position of comfort”
Phase 2
Spindle reset
“Takes just a few seconds”
Basis for 90 Second Hold
Phase 3
Vasodilation
“20-40 seconds or more”
Phase 4
Slow return to normal
*See article
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.
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
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”
Tender Points
• Tender points cease to report tenderness
when normal function is restored to the
connective tissue related to the joint
Tender point vs
Trigger point
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
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
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
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
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
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 24-48 hours following a
treatment (30%)
15. No contraindications
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
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
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
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
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?
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:
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
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
How does it fit in your
treatment regimen?
•
•
•
•
Acute
Children
Chronic
Osteopathic
• Pregnancy
• Fragile
• Elderly
Strain and Counterstrain
Used first, it enhances mechanical treatment
by decreasing unbalanced forces acting on
the joint.
SCS - Terminology
• PT3R - posterior third thoracic on right
• AC2L - anterior second cervical on left
• PR1R - posterior first rib on right
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
Evidence
• Trigger point dry needling versus straincounterstrain 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. 2016 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.
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.
2014 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.
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. 2013 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.
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.
2014 Apr;18(2):165-73.
• CONCLUSIONS: This systematic review and metaanalysis 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.