POSITIONAL RELEASE:Strain-Counterstrain

Theresa A. Schmidt, DPT,MS,OCS,LMT,CEAS

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Sponsored by CROSS COUNTRY EDUCATIONCopyright c 2009 Theresa A. Schmidt

Disclosure To comply with professional

boards/associations standards, I declare that I do not have any financial relationship in any amount occurring within the last 12 months

with a commercial interest whose products or services are discussed in my presentation.

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Theresa A. Schmidt

Integrated Neuromuscular Re-education

Cross Country Education, Inc.

INTRODUCTION:

NEUROPHYSIOLOGY

We treat muscle problems:

stiffness, weakness, pain, etc.

MUSCLE LENGTH influenced by:• Our security system:

•MONOSYNAPTIC REFLEXES

•PROPRIOCEPTIVE REFLEXES

MUSCLE SPINDLE

Extrafusal & Intrafusal Fibers Extrafusal: Alpha motorneuron

monitors length of muscle

Intrafusal: Gamma mn monitors length and rate of change in length

Spindle bias is the present sensitivityto changes in length and rate of change

Golgi Tendon Organ

GTOs monitor tone, when stretched, GTOs fire 1B, results: inhibits alpha motorneuron

Inhibits contraction

If sensitized, may weaken muscle

ABNORMAL FACILITATION

Stress overexcites nerves, lowers threshold for stimulation, facilitates afferents, overloads adjacent segments: FACILITATED REFLEXES

Local: at the myofascial level: TPs, taut bands, tension

Segmental: at spinal nerve level, spasm, edema, ANS dysfunction in several spinal levels

TRIGGER POINTS: TPs

Dr. Janet Travell: “hyperirritable foci lying within taut bands of muscle which are painful on compression and which refer pain or other symptoms at a distal site”

(Chaitow, p.59)

TRIGGER POINTS: EMGs

Persistent contraction

Calcium buildup

Oxygen deficit, can’t pump out Ca++

Selective shortening of sarcomeres

Must clear TPs to relax muscle(Chaitow/Headley)

POSITIONAL RELEASE OR

STRAIN/COUNTERSTRAIN:

Technique using tender points

as diagnostic indicators of joint

dysfunction

and position of comfort to

release abnormal muscle

tension and pain

INDIRECT RELEASE

Move in the direction of ease

“Passive treatment”

THEORY OF PRT

• Dr. Lawrence Jones, DO: Correction of Somatic Dysfunction

• EMG studies by Howell et al showed changes in EMG after use of strain/counterstrain

• (J. Amer. Osteopathic Assn.)

SOMATIC DYSFUNCTION

–Altered tissue tone

– Limited joint play

– Loss of ROM

–Muscle Weakness

–Postural distortion

–Adhesive fibrogenesis

– Inflammation(Chaitow)

NEUROMUSCULAR REFLEXESAberrant Firing

–Local proprioceptors

–Monosynaptic reflexes

–Facilitated segment indicated by TPs

PALPATE TRIGGER POINTS

People jump, twitch, or cry out in pain

TPs are diagnostic indicators of joint dysfunction

Faulty biomechanics

PRT TREATMENT

POC – position of comfort

– Reduction of tenderness

– Reduction of tone

– Palpable softening of muscle

PRT THEORY

Abnormal firing of

proprioceptors

Elevated spindle sensitivity

based on position of relative

stretch, load and velocity

COUNTER STRAIN:

JONES DEFINITION:

Mild strain (overstretching) applied in a direction opposite to that false and continuing message of strain from which the body is suffering: SHORTENING!

STRAIN/COUNTERSTRAIN

JONES’ RULES

Pain is position oriented

Joint dysfunction is due to abrupt reaction to strain

POC is held still for

90 seconds

the rate of return to the

neutral position must be

slow for success

Joint dysfunction behaves

as if it is constantly

strained:

muscle spindle is the culprit

Dr. Jones said:

Position the tender point muscle in its maximally shortened

position:

Dr. Schmidt says: this is NOT necessary in practice

OUTCOMES OF PRT:

Decreased

tissue tension

Decreased pain

Increased

strength

(Wong, 2004)

PRECAUTION WITH PRT

As you shorten the

TP muscle, you

stretch the

antagonist, may

create delayed

onset muscle

soreness, let clients

know to use ice!

PRT - INDICATIONS

Muscle guarding

Acute injury

Joint hyper/hypomobility

Fascial tension

Painful tender/trigger points

Structural dysfunction

ADL restoration

CONTRAINDICATIONS TO PRT

Infection

Nonunited fracture

Open wound

Hematoma

Healing Sutures

Hypersensitivity precautions

When motion is contraindicated

EVALUATION OF TP

Perform a full exam

Document TP location,

pain scale

Prioritize per severity, treat

worst first

PRT is part of the Plan of

treatment, may relax

muscle to allow for ROM

or contraction with ease

UPPER TRAPEZIUSExtend/ sidebend neck to affected side,

rotate contralaterally, & elevate scapula

HIP FLEXORS

Flex hip over 90, may add ext.

rotation for psoas, sit or lie

SHOULDER: SUBSCAPULARIS

Extend, int. rotate, retractworks better in sitting or sidelying

WRIST / FINGER EXTENSORS

Extend fingers/wrist, supinate

CLINICAL CASE STUDY

Identify a TP on your partner

Measure pain scale, check tone

Determine a position of comfort

and release the TP

Re-evaluate!

EVIDENCE FOR PRT1. Wong CK, Schauer CS. Reliability,

validity, and effectiveness of strain

counterstrain techniques. J Manual

Manipulative Ther 2004;12:107-112.

2. Wong KW, Schauer-Alvarez, C. Effect of

strain counterstrain on pain and strength in

hip musculature. J Manual Manipulative

Ther 2004;12:215-223.

MORE PRT RESEARCH3. Collins CK. Physical therapy management of complex regional pain

syndrome I in a 14-year-old patient using strain counterstrain: a case

report. J Manual Manipulative Ther 2007;15:25-41.

4. Howell JN, Cabell KS, Chila AG, Eland DC. Stretch reflex and Hoffman

reflex responses to osteopathic manipulative treatment in subjects with

Achilles tendonitis. J Am Osteopath Asso 2006;106:537-545.

5. Wynne MM, Burns JM, Eland DC, Conatser RR, Howell JN. Effect of

counterstrain on stretch reflexes, Hoffman reflexes, and clinical outcomes

in subjects with plantar fasciitis. J Am Osteopath Assoc 2006;106:547-

556.

6. Lewis CL, Flynn TW. The use of strain counterstrain in the treatment of

patients with low back pain. J Manual Manipulative Ther 2001;9:92-98.

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