Strain Counterstrain - The Theory - Jo Holmden

The definition given by Jones 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. It is an Indirect Technique where the action is away from the restricted barrier.

When an already shortened muscle is forcibly stretched the proprioceptors in the muscle spindle report strain before that muscle has reached its normal length. This situation has the effect of increasing the "gamma gain" (gamma impulses that are calling for a sudden contraction of the fibers to oppose the induced stretch). This opposes the return to normal by exaggerating the afferent firing from the muscle spindle. A good example of this is when a muscle is being overstretched at the same time as it is trying to contract, ie. the injury occurs faster than the body can react. Another example is when a muscle is unexpectedly shortened and slackened in an unguarded passive movement.


EXAMPLE
Assume the forearm is forcibly extended suddenly putting stretch on Biceps ---THIS IS THE STRAIN.
Triceps is then shortened and proprioceptive reflexes come into action to contract Biceps and counteract the sudden loading. Korr suggests that this action and the silencing of the spindles in Triceps (due to it's initial shortening) causes the gamma gain to be turned up (increased) causing Triceps to contract---THIS IS THE COUNTERSTRAIN.

The central nervous system regains the spindle information at the expense of the shortened Triceps because it is reporting to the CNS that it has been stretched before it had reached a neutral length.
Flexion is thus restricted by a tonically shortened Triceps caused by inappropriate high gamma gain.
Clinically the elbow will move easily into extension but would resist flexion.
All of this has taken place within the normal length of the muscles concerned and maintained by the increased gamma gain in Triceps effectively resetting the forearms neutral position towards extension.


The inappropriate response is reduced by applying a mild sustained strain for 90 seconds to its antagonists which then allows the malfunctioning muscle spindle to shorten.

Diagnosis is (1) by history, where if possible assessment of the type of injury, the position of the patient, and the direction of forces involved must be made.

(2) by the presence of tender points in muscle and fascial tissue. These ate usually found in the
or insertion the belly or the musculo-tendinous junction. Tender points tend to be more segmental in origin ---points along the vertebral column tend to indicate dysfunction at the corresponding level.

Jones emphasises the importance of tender points on the anterior aspect of the body, which may not appear to be related to local subjective pain especially on the posterior surface.
Tender points are often found in tissue where there is no complaint of pain by the patient.
There may also be oedema and tenseness at these points.


Treatment

The principle behind treatment is to passively position the joint or muscle in its position of original strain.
Treatment is directed at the dysfunction that causes the Tender Point.
In the example by approximating the ends of Triceps by placing the forearm into extension, thus recreating the direction of the original force.
Korr suggests this allows the "gamma gain" to be gradually reduced by the central nervous system, which in turn allows the muscle to return to its easy normal at its resting length.


This is achieved by:


( 1 ) Palpation of the tender point/s and assessing the degree of pain by asking patient to score the pain on a scale of 1-10 with 10 being most painful.
(2) Positioning the joint or muscle SLOWLY into its position of ease using flexion or extension as the prime movements, with sidebending and or rotation added as necessary until the patient reports a patn score of 3 or less. This position is maintained for 90 seconds. The effect of treatment may be enhanced by minutely exaggerating the combination of the movements at the position of ease. This is called fine tuning. Often the palpating/monitoring finger can detect a "give" or plasticity of the tissue. The patient needs to be as relaxed as possible during the entire procedure. A simple rule of thumb is that for Anterior tenderpoints we use Flexion with SB/ROT towards the tenderpoint side, and for Posterior ones, Extension with SB/ROT away from it.
(3) The pressure of the finger should remain constant throughout the procedure, and the return to the resting position should be SLOWLY carried out.
(4) The muscle/joint is then retested in the same manner noting the patient's pain evaluation.
(5) Jones has suggested that for tender points near the mid-line more flexion is needed for anterior points and extension for the posterior ones. As the points become more lateral mote sidebending and or rotation may need to be introduced.

It has been suggested that the 90 seconds allows the local circulation to improve due to the release from
chronic sympathetic stimulation.

Treating a tender point may resulting in;

(1) becoming softer and less tender.
(2) becoming warmer.
(3) Pulsating.
(4) Relaxing of the muscle and / or surrounding area (fascial unwinding).

The overall effects may be summarized as "Removing Restrictive Barriers of Movement" by:
[1] Reducing muscle hypertonicity.
[2] Normalising fascial tension.
[3] Increasing joint mobility.
[4] Increasing local circulation and reducing swelling.
[5] Decreasing pain.
[6] Increasing strength.

Although Jones maps out his tender points specifically, you will find others that do not correspond to his
charts, but can be treated in the same way using the basic principles.

APPLICATIONS

The most striking things about Strain and Counterstrain technique is that

(1) It is very patient friendly in that they are able to give constant feedback to the practitioner.
(2) It is minimally invasive and therefore suitable for:(
(a) Acute onset of musculo-skeletal symptoms
(b) Nervous patients
(c) Aged patients
(d) Bedridden patients, whether for acute conditions, or to help with musculo-skeletal pain in patients with metastases where conventional techniques would be contraindicated.

The technique of Strain and Counterstrain can be applied and adapted to suit the needs of a wide variety of patient types as well as the practitioner.

CONTRAINDICATIONS

Obvious contraindications are treating tender points where there ate open wounds, sutures, local skin lesions or infections, haematoma and hypersensitivity of the skin.
Care must be taken when treating the neck and skull tender points not to position the head or neck in a position which could possibly provoke any vertebrobasilar compromise.
Therefore it is of paramount importance, as with all patients, to take a full case history.

4th Year Technique Syllabus

Technique - General Osteopathic Examination

During technique practice it became apparent that I need to do more active examinations as well as how important it is to perform a sitting examination as it can give lots of information about the pelvis and leg length as well as whether a patients scoliosis is functional or structural.

13/11/09 - Kiera Kinch Tutorial - Knee Examination

It wasn't until Keira Kinch gave us a tutorial that I really appreciated how observation is the first key step to assessment. When a fellow student was asked to perform a knee examination to the rest of the tutorial group. She did as I would ... stand the patient up and look at their knees etc and then get them straight onto the table to perform a passive examination.

When the tutor repeated the examination she look at the patient in greater detail and got the patient to do active movements. She asked the patient to engage their quads whilst standing to see how the patella tracks and she asked the patient to do squats to see how the different muscle groups engaged.

25/01/2009 - Anatomy Trains


Something that I don't feel the course at the BSO has given me is a very good understanding of fascia and how muscles are interconnected. Obviously I understand why we need to learn the individual muscles and there origins and insertions, however through clinical experience I have learnt to appreciate how important myofacial connections are. An example of this is whilst treating a patient with lateral knee pain. It wasn't until I started working more globally on the 'Superficial Back Line' that I really did make some functional changes to my patients pain whilst running.

INTRODUCTION

Well this is the first of many entries to my Osteopathic Journal Blogg ..... not that this entry is going to have anything of osteopathic relevance to it as I just need to work out how this thing works hehehe .... but here goes ... I expect great things from myself ;-)