7 – Principles of Counterstrain Technique – Flashcards
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Counterstrain was developed by:
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- by Lawrence Jones, D.O. in 1955
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What did Jones do?
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- he placed the patient in a position of comfort - optimal time to hold is 90 seconds - Jones identified discrete areas of tenderness associated with specific dysfunctions 'tender points'
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Is counterstrain direct or indirect?
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INDIRECT
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Similar techniques (indirect) to counterstrain
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- Functional - Facilitated Positional Release (FPR) - Balanced Ligamentous Tension (BLT) - Ligamentous Articular Strain (LAS)
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Functional Technique
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- developed by Harold Hoover D.O., etc. - Palpating for ease of motion of segment. - Uses gentle pressure and respiratory assist
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Counterstrain Technique Definition
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- 'An osteopathic system of diagnosis and indirect treatment in which the patient's somatic dysfunction, diagnosed by an associated myofascial tender point, is treated by using a position of spontaneous tissue relaxation while simultaneously monitoring the tender point.' → Body is moved to a balance point, position of ease, or away from the motion (restrictive) barrier
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Counterstrain and the CNS/PNS
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- Constant feedback required through the *Autonomic and Circulatory systems* - Two main components of PNS: → *Afferent (sensory) pathways* provide input from the body into the CNS → Sensory Nerve Endings (receptors) constantly monitor variation in temperature, ischemia, inflammation, and body position (proprioception) - *Efferent (motor) pathways* carry signals to muscles and glands
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Intrafusal fibers: function
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- Register changes in muscle length
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Intrafusal fibers: sensory receptors
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- Central region has non-contractile fibers innervated by afferent sensory receptors → *1a afferent annulospiral* - sense for length & velocity of length changes → *2a afferent flower spray* - only sense change in length
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Intrafusal fibers: gamma motor efferent nerves
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- responsible for change in muscle tone to maintain constant tension on central portion of muscle spindle → *Gamma 1 (dynamic)* - sensitive to rate of change → *Gamma 2 (static)* - sensitive to degree of stretch primarily innervate nuclear chain fibers, causing tonic activity in Ia fibers
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Increased firing of gamma motor efferent receptors
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- Increased firing of gamma motor efferent receptors to contractile fibers increase *tension* on central portion - This increases the afferent sensory receptors feedback - This increases the alpha motor neuron firing causing contraction of the *Extrafusal Muscle Fibers*
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Golgi tendon organs
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- Located in the collagen tissue fibers at the musculotendinous junction - Respond to the force of active contraction - When Golgi tendon organ is stimulated, this: → Inhibits motor firing to this (agonist) muscle → Stimulates firing to its antagonist muscle group
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Theoretical Basis of Counterstrain: Event/trauma & muscle response
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- Event/trauma produces rapid lengthening of a muscle - Afferent feedback indicates possible myofascial damage from a strain - The body tries to prevent myofascial damage by rapidly contracting the affected tissues (shortening the agonist) - This produces a rapid lengthening of the antagonist muscle - The rapid shortening of the agonist and lengthening of the antagonist produces an inappropriate reflex that is manifested as a tender point in the antagonistic muscle
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Theoretical Basis of Counterstrain: Event/trauma & neurochemical response
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- Trauma produces change in myofascial tissue at the microscopic and biochemical levels - Force of trauma causes damage to myofibrils and their microcirculation - A neurochemical response is triggered to preserve further tissue injury & repair damaged tissues → Tissue oxygen/ph low - Bradykinin formed and Substance P released which results in vasodilation & tissue edema → Prostaglandins released furthers inflammatory response
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Theoretical Basis of Counterstrain: Event/trauma & resulting edema
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- Resultant edema from tissue damage reduces normal circulation by compressing arterioles, capillaries, venules and lymphatic vessels - Tissue injury and the presence of these chemicals lowers the sensitization to mechanical stimulation - The tissue disruption and the subsequent metabolic & chemical changes produce nociceptive activity which can result in increased sensitivity to touch or a *'TENDER POINT'*
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Counterstrain: What is the purpose of placing tissue at rest?
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- In placing injured tissue at rest or shortening injured tissue maximally, the neural excitation keeping the muscle hypertonic and/or painful is *dampened or resets the gamma motor neurons*
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Counterstrain: Fold & Hold Mechanism
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- By placing patient's tissues (tender point location) at ease- → The abnormal afferent (incoming) input normalizes, causing a reduction or normalization in the efferent (outgoing) signals - Shorten (relax/soften) muscle decrease spindle tension lowers incoming signal → Thereby, decreasing resultant outgoing signal and increasing intrafusal fiber's distance to each other
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Counterstrain: Fold & Hold Result
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- Normalization of muscle length/tension and resultant decrease in dysfunction and associated pain!
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Counterstrain: Fold & Hold (teaching benefit(
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- One of the early methods used to teach counterstrain → Find a tender point associated with somatic dysfunction and collapse the tissues around it → Most effective if encircling the point using x, y, & z axes (also, translation) - better than memorizing all 200+ locations
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Tender point Definition
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- often palpable as an area of swelling of fascia, muscle tendrils, connective tissue, nerve fibers and changes in vascular elements - acute tenderness on pressure palpation - often in the belly of a muscle or at the musculo-tendinous junction - specific location associated with somatic dysfunction, not generic tenderness as found in fibromyalgia
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Tender points may be related to:
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- Point where nerve pierces through fascia and/or myofascial structure - Viscerosomatic dysfunction - Referred pain from viscera - Infection and inflammation → Therefore, careful history and physical is important to the complete care of the patient and not just a symptom!
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Procedure in Performing Counterstrain Technique: Diagnose & Identify
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- Through musculoskeletal exam, *diagnose somatic dysfunction - Identify tender point* associated with somatic dysfunction → Pad of finger, not fingertip on tender point (probe)
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Procedure in Performing Counterstrain Technique: Probe & Quantify
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- Press or probe to identify pain → Not heavy or therapeutic pressure → More like a quick probe or impulse (on/off) → Only enough to identify pain is present - *Quantify the initial tenderness → Tell patient "remember this a "10"* as a scale for easy patient understanding → DO NOT ASK patient to rate the pain on a scale of 0-10
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Procedure in Performing Counterstrain Technique: Positioning
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- Place the patient in the position of maximum/optimal comfort while monitoring the tender point → First obtain a gross reduction of tenderness in the typical or 'classic position' recommended for this tender point location and dysfunction - Fine tune position through small arcs of motion until tenderness is completely alleviated, or as close to 100% as possible, but at least 70% → Finger does not apply constant pressure on the point; pressure is applied intermittently to evaluate success of positioning
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Procedure in Performing Counterstrain Technique: Holding
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- Hold this position of maximum comfort for a *minimum of 90 seconds*. → *Two minutes if related to costal dysfunction* - The patient must be reminded to relax - The finger should be lightly maintained on the tender point to: → palpate/assess changes in the tender point → periodically re-assess positioning of the patient by intermittently pressing on the tender point
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Procedure in Performing Counterstrain Technique: Returning
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- As the somatic dysfunction resolves, you will have a palpatory sensation of ease of tissue tension (softening/melting) - Very slowly return the patient 'passively' to the neutral position → *Remind the patient to remain totally relaxed and do not help* - Recheck the tender point! → At least 70% reduction of the original tenderness is required for success - Reassess diagnostic components of somatic dysfunction (ART)
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Positioning rules
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Position of comfort follows certain rules for tender points - Anterior - forward bend (flex) - Posterior - backward bend (extend) - Lateral to midline- sidebend
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Counterstrain Treatment: Success
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- *Most effective if 100% of the pain is alleviated with positioning!* - If the level 10 assigned pain is reduced to a 3 post-treatment, you can assume that you were 70% effective or reduced 70% of the pain in 90 seconds!
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Counterstrain Treatment Positioning - For articular somatic dysfunctions
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- For articular somatic dysfunctions, i.e. C5 ESRRR patient positioning follows the indirect nature of the technique → Tenderpoint for this dysfunction is usually opposite rotational/sidebending freedom! - Therefore, positioning for C5 ESRRR → Extend, Side bend right, Rotate right → This equates to the mnemonic ESARA → Tender point located left articular pillar of C5
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Treatment Descriptions/Acronyms
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- 'Maverick' tender points-cervical - Fine-tune with small arcs of motion - Side bend away/rotate away → SARA - Side bend-towards/rotate away → STRA
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Counterstrain Tips
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- Treat most acutely tender point first - Treat generally no more than 3 tender points in an area of the spine, and no more than 6-8 per treatment - Use re-evaluation of what you treated in a prior visit as a way of evaluating the "effectiveness" of treatment or response to treatment
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Counterstrain: Advantages
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- Non-traumatic - Increases patient confidence quickly - Relatively easy - Effective
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Counterstrain: Disadvantages
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- Stoic patients - Quantifying pain - Takes time to treat - Treatment reactions: some may have reactions 1-2 days post treatment that can last up to 24-36 hours (Acetaminophen and water!) - Some patients (particularly geriatric) cannot be placed in appropriate treatment position because of other positional considerations - Some patients are unable to relax their muscles sufficiently for treatment positioning or the return to neutral to be truly passive
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Non-responsive Conditions
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- Conditions such as → Costochondritis, referred pain, etc. may not respond to counterstrain - Certain conditions may have increased morbidity in counterstrain due to → Hyperpositioning/Extension (e.g. neuroforaminal encroachment)
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Somatic Dysfunction Diagnosis
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- Observation - Static Asymmetries - Spinal Regional Range of Motion- Active/Passive - Layer by layer palpation for: → Muscle-Fascial-Tendon-Ligament → palpate tender point ?? - Intersegmental Motion palpation for: → Articular-Capsular (Joint restriction) → Document, e.g. C6 ESRRR - Where are the tender points? - Anterior or Posterior or Both? -How would you position them?
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Combination Therapy: Counterstrain and Myofascial Soft tissue & Myofascial Release
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- Add further neurophysiologic, as well as, textural changes in affected tissue so that ongoing nociceptor firing is decreased.
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Combination Therapy: Counterstrain & Muscle Energy
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- May potentiate the resetting and dampening of excited neural components - May treat the articular and soft-tissue components of somatic dysfunction.
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Combination Therapy: Counterstrain and HVLA
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- May treat the articular and soft-tissue components of somatic dysfunction
