Section 4 Biomechanical

chapter 109 Strain and Counterstrain Manipulation Technique

Harmon L. Myers, DO David Rakel, MD
What Is It? 1149
History of the Therapy 1149
Pathophysiology of a Tender Point 1150
Strain-Counterstrain 1150
Occupational Repetitiveness 1151
Tender Points Not Related to a Strain or Injury 1151
Evaluating the Patient for Therapy 1151
General Guidelines for Therapy 1151
Steps in the Treatment of Tender Points 1152
Examples of the Technique 1152
Trapezius Muscle 1153
Levator Scapula Muscle 1153
Sternocleidomastoid Muscle 1154
Piriformis Muscle 1155
Benefits 1156
Limitations 1156
Resources for Further Education 1156
What Is It?

Strain and counterstrain is a manipulative technique that has been found to be helpful in
reducing pain and spasm in the myofascial system. It can act as an excellent therapeutic
adjunct in the primary care setting to facilitate relief of pain related to muscle and fascial
layers. It is a safe, indirect technique that does not incorporate manipulation against
mechanical barriers. Strain and counterstrain simply involves putting a muscle group in a
position of relaxation that results in inhibition of the neurologic reflex cycle that may
cause and maintain myofascial dysfunction and muscle spasm. The therapy is also known
as positional release therapy.

History of the Therapy

The therapy was originated by an osteopathic physician named Lawrence Jones, who
took pride in his ability to relieve pain with the use of manual techniques. He encountered
a challenging case, in which the patient had severe low back pain with restricted
movement. After multiple attempts to relieve the pain had failed, Jones decided to simply
place the patient in a position of comfort so he could rest. Upon returning to the room
where the patient lay, Jones observed that the patient's pain had significantly improved.
The discovery resulted in the development of a therapy that focused on relieving
myofascial pain by shortening muscles and placing them in positions of comfort.[1]

Pathophysiology of a Tender Point

Tender points of the myofascial system date back to the Chinese Tang dynasty (618 AD),
when they were called Ah Shi points. Descriptions of these points in Western medicine
have included terms such as trigger points, fibrositis, muscle callus, chronic myositis, and
muscular nodules. It appears that the underlying mechanism of pain and inflammation is
the same. Tender points are the result of the following three mechanisms:

Neurologic (proprioceptive) response to acute muscle strain or injury.

Neurologic (nociceptive) response to visceral disease, muscle strain, or injury that
persists owing to lack of response to treatment.
Reflex response to increased tone of the sympathetic nervous system that can result
from anxiety and pain.

As a result, there is an accumulation of pro-inflammatory and vasoconstrictive chemical

mediators, including histamine, prostaglandins, bradykinin, and potassium. These
mediators team with an influx of calcium ions, leading to overactivity of muscle
stimulation, thereby causing a neurologic reflex arc that creates taut bands of painful
muscle. The underlying trigger of this phenomenon can be an acute injury, repetitive
strain, imbalance of muscle use, visceral disease, or chronic stress and tension.

Strain-Counterstrain

Jones described the underlying pathophysiology of a tender point in regard to a strain on

a pair of antagonistic muscles of a joint. Figure 109-1 depicts what happens with a
misstep or injury and helps describe this theory. Two muscles (A and B) are present on
either side of the joint, and a schematic at the bottom of each view shows electrical
proprioceptor activation of the muscles. View 2 shows a condition that results in strain of
muscle A. The corresponding schematic shows increased electrical (proprioceptive)
activation of muscle A when it is strained, which prompts the body to try to return the
joint to the normal balanced state. At the same time, the hypershortened muscle (B) has
decreased proprioceptive electrical activity. Muscle A is shortened in response to the
strain, leading to a rebound stretching of muscle B. As muscle B quickly lengthens in
response to the shortening of muscle A, the proprioceptive nerve endings in muscle B,
which respond mainly to rate of length change, become overstimulated. This state results
in a theoretical massive nervous discharge that causes the muscle to register strain before
it even reaches its resting length. The joint is thereby prevented from returning to its
neutral state, as is seen in view 3, which shows the status of the joint after injury, with the
tender point arising from the overstimulated muscle B. This point becomes the primary
source of persistent muscle dysfunction. An analogy that may make this concept easier to
understand would be catching a ball of lead in your hand when you were expecting a ball
of paper. The rebound contraction of your biceps muscle pushes up against the weight,
triggering the dysfunction in the triceps muscle, which is rapidly lengthened.

FIGURE 109-1 Jones neuromuscular model. (From D'Ambrogio KJ, Roth GB: Positional Release Therapy: Assessment and Treatment
of Musculoskeletal Dysfunction. St. Louis, Mosby, 1997; modified from Jones LH: Strain and Counterstrain. Newark, Ohio, American
Academy of Osteopathy, 1981.)

In treatment of the tender point in muscle B, the focus is on shortening this muscle to
reduce the electrical activity that results in a disruption of the neuromuscular reflex arc
keeping the joint in an imbalanced state and the muscle in spasm. Shortening the muscle
to reduce the inappropriate proprioceptor activity leads to lessening of pain and
inflammation in the tender point and return of the joint to its normal state.

Occupational Repetitiveness

A sedentary lifestyle and occupational repetitiveness limit the number of muscles used on
a regular basis. This situation leads to overuse of a small percentage of the body's
muscles with atrophy of others, resulting in a reduced ability to tolerate loads or strains.
The chronically stressed tissues lead to tender points in muscle groups that have greater
postural demands. Repeated microtrauma to these muscles results in a pain (nociceptive)
response that affects the proprioceptor electrical stimuli, much as described previously.
An example is pain in the trapezius, levator scapula, and suboccipital muscles in someone
who spends most of the day sitting at a desk working on a computer. A regular exercise
program can help keep a balanced tone in all muscle groups, helping prevent strain of
atrophic muscles and tender points in chronically stressed muscles.

Tender Points Not Related to a Strain or Injury

Many trigger points are not related to a specific strain or injury, as can be seen in diseases
such as fibromyalgia and trapezius muscle discomfort related to tension. This clinical
finding makes one appreciate the close association between the mind and the body and
how stress and anxiety can act as triggers to this inflammatory cycle. It is well established
that stress leads to an overactivity of the autonomic nervous system and sympathetic
discharge. This overactivity is a key ingredient in myofascial dysfunction and pain.
Attention should be given to any chronic condition that may have this condition as an
underlying perpetuating factor, so lifestyle and relaxation recommendations can be made
to help prevent recurrence and reduce the pain threshold.

Evaluating the Patient for Therapy

The clinician should evaluate a patient for strain-counterstrain therapy as follows:

Take a history of the length, severity, and location of the discomfort. Address a
 history of trauma, strain, occupational repetition, activity, and level of stress and
tension.
Appreciate referral patterns. Location of pain may result from a referral pattern
arising from a distant trigger point. With experience, the practitioner will learn of
common referral patterns of tender points related to muscle groups.
Learn what a tender point feels like. A nodule can often be palpated in involved
muscle groups that will help guide therapy.
Find what positions cause discomfort. Usually, stretching the dysfunctional muscle
causes discomfort.
General Guidelines for Therapy

The general guidelines for therapy are as follows:

Move the affected part gently and slowly into and out of the position of treatment.
Hold the position of treatment (comfort) for no less than 90 seconds.
Anterior tender points are generally treated in a position of flexion.
Posterior tender points are generally treated in a position of extension.
More flexion or extension is used for tender points on or near the midline.
More rotation and side bending are needed for points lateral to the midline.
Tender points in the extremities are often found on the side opposite the side where
the patient complains of pain.
If there are multiple tender points, treat the most severe first.
When tender points are in rows, treat the one in the middle first.
Explain to the patient that she or he may be sore in 24 to 48 hours after a treatment.
Steps in the Treatment of Tender Points

Tender points are treated with strain and counterstrain as follows:

1. Find a significant tender point.

2. Put the patient in a position of comfort.
3. Fine-tune the position to get maximum relief of the tender point as you monitor it
with your finger (use the palpable response of the trigger point beneath your finger
as well as the subjective response of pain relief from the patient to fine-tune the
therapeutic position).
4. Release pressure while maintaining contact of your finger on the tender point
during treatment.
5. Maintain the position of comfort for at least 90 seconds.
6. Slowly return the patient to a neutral position.
7. Recheck the tender point. It should be at least 70% improved.
Examples of the Technique
Two of the most common myofascial complaints seen in the primary care setting are neck
pain (trapezius spasm, suboccipital neuralgia) and low back pain, particularly sciatica that
involves posterior gluteal pain with referred pain down the back of the leg. To explain
how this technique can be used in the primary care setting, we consider a group of
muscles that are commonly involved in these complaints. It is important to realize that
the practice of this technique involves a unique evaluation of each patient, whose pain
may involve numerous muscle groups that are not discussed here owing to space
limitations.

Trapezius Muscle

The trapezius muscle, a large muscle of the upper back, can have multiple trigger point
locations, each with a different treatment. We focus on the most common two points
which occur bilaterally and are depicted by the Xs in Figure 109-2A .

FIGURE 109-2 The manipulation technique applied to the trapezius muscle. See text for details. A, Tender points. B, Pain referral
pattern. C, Treatment position.

Tender points: Location in the fibers of the upper part of the muscle at the junction
of the neck and shoulder; can be medial or lateral.
Referral pattern: Pain can be located in the posterior neck, the suboccipital area, and
the temporal area ( Fig. 109-2B ).
Treatment position for more medial tender points: Place your finger over the trigger
point, and side-bend the cervical spine toward the side of pain until you feel the
muscle relax (fold the neck over the tender point).
Treatment position for more lateral tender points: Bring the arms 150 to 170 degrees
overhead, as shown in Figure 109-2C , and apply cephalic traction.
Levator Scapula Muscle

The levator scapula muscle is a common source of pain that is seen in persons with
tension and anxiety (chronic shoulder shrug) or who hold a phone between the ear and
the shoulder ( Fig. 109-3 ).

FIGURE 109-3 The manipulation technique applied to the levator scapula muscle. See text for details. A, Tender point. B, Pain referral
pattern. C, Treatment position.

Tender point: At the superomedial aspect of the scapula between the scapula and the
nape of the neck ( Fig. 109-3A ).
 Referral pattern: Pain at the junction of the neck and shoulder, extending to the
midcervical area above and the spine of the scapula below ( Fig. 109-3B ).
Treatment position: With the patient supine, adduct the arm approximately 30
degrees with the elbow flexed. Flex the shoulder slightly and apply a cephalic force
through the shaft of the humerus to elevate the scapula. Side-bend the neck toward
the side of the tender point. Imagine the patient holding an orange between the ear
and the shoulder as you push the elbow toward the ear ( Fig. 109-3C ).

As you palpate the tender point, fine-tune with slight flexion/extension of the shoulder
until you feel the tender point release.

Sternocleidomastoid Muscle

It is important to always check for tender points on the side of the body opposite to the
location of the pain. In this case, check for anterior pain along the sternocleidomastoid
muscle if the patient complains of posterior neck pain. As a rule, patients do not complain
of any discomfort in the anterior neck.

Tender point: Anywhere in the body of either the sternal or the clavicular division of
the muscle. Squeeze the belly of the muscle with your thumb and index finger to
help find the tender point. The most common area is two or three fingerbreadths
above the sternoclavicular joint ( Fig. 109-4A ).
Referral pattern: Pain into the suboccipital area, ear, temporomandibular joint,
forehead, or eye ( Fig. 109-4B ).
Treatment position: With the patient supine, support the head as you markedly flex
the neck, side-bending toward and rotating away from the tender point. Imagine
pushing the patient's ear toward the sternoclavicular joint ( Fig. 109-4C ).

FIGURE 109-4 The manipulation technique applied to the sternocleidomastoid muscle. See text for details. A, Tender point. B, Pain referral
pattern. C, Treatment position.

Fine-tune until you feel the tender point release or the patient reports subjective
improvement.

Piriformis Muscle

The sciatic nerve and the piriformis muscle are in close proximity ( Fig. 109-5 ). In fact,
in 5% of the population, the nerve runs through or over the muscle, making irritation of
the nerve much more likely when the muscle is inflamed. This condition, called
piriformis syndrome, is a common cause of buttock pain with radiation of pain down the
back of the thigh.
 FIGURE 109-5 The manipulation technique applied to the piriformis muscle. See text for details. A, Tender point. B, Pain referral pattern.
C, Treatment position.

Tender point: Located in the piriformis muscle, which is 3 inches medial and
slightly cephalic to the greater trochanter. Halfway between the midsacrum and the
greater trochanter of the proximal femur ( Fig. 109-5A ).
Referral pattern: Buttock and the back of the thigh ( Fig. 109-5B ).
Treatment position: Patient is prone. Therapist sits on the same side as the tender
point. The patient's leg on the tender point side is suspended off the table with the
patient's anterior ankle resting on the therapist's thigh. Flex the hip 120 to 130
degrees, abduct the hip to tolerance, and slightly rotate the hip internally by gently
pulling outward on the foot ( Fig. 109-5C ).
Benefits

The strain and counterstrain technique is beneficial because it:

Provides immediate relief of discomfort.

Helps the body regain normal function and range of motion that may have been
limited by chronic myofascial dysfunction.
Is enjoyable and rewarding to perform.
Enables you to touch the patient, increasing a sense of caring and rapport in a time
when technology is creating a barrier between practitioner and patient.
Always has the patient in a position of comfort.
Limitations

The limitations of strain and counterstrain therapy are as follows:

Pain relief can be transient, with recurrence likely if a holistic understanding of why
the pain may be continually triggered is not attempted.
A localized technique such as this may not be the best approach for someone with
diffuse and disseminated tender points in conditions such as fibromyalgia.
The technique is conceptually easy to learn but takes practice. The practitioner
should start with a few muscle groups and then progress from there. When able, one
should practice on children; their limited soft tissue mass allows for easy palpation
of tender points and maneuverability for treatment positions.
Resources for Further Education

The Tucson Osteopathic Medical Foundation offers hands-on classes in

Strain/Counterstrain, taught by one of the chapter authors (HM) twice a year. Classes are
divided into upper and lower aspects of the body. Contact information: (520) 299-4545 or
www.tomf.org/

Many courses in manual medicine, including strain/ counterstrain, are offered annually by
the American Academy of Osteopathy: www.aao.medguide.net

Books that provide further clinical information on positions of therapy are listed in the
references. [1] [2] [3]

REFERENCES
1. Jones LH: Jones Strain-Counterstrain. Boise, Idaho, Jones Strain-Counterstrain, Inc.,
1995.
2. D'Ambrogio KJ, Roth GB: Positional Release Therapy: Assessment and Treatment of
Musculoskeletal Dysfunction, St. Louis: Mosby; 1997.
3. Travell JF, Simons DG: Myofascial Pain and Dysfunction: The Trigger Point Manual,
Baltimore: Williams & Wilkins; 1992.

Recommended Resources
Korr IM:: Proprioceptors and somatic dysfunction. J Am Osteopath Assoc 1975; 74:638.
Levin SM:: The importance of soft tissue for structural support of the body.
Spine 1995; 9:357.
Lowe JC:: Functional Soft Tissue Examination and Treatment by Manual Methods.
In: In Hammer WI, ed. Treatment-resistant myofascial pain syndrome, Gaithersburg,
Md: Aspen; 1991.