Intro To Counterstrain

Question 1

What is counterstrain?

Answer 1

A gentle passive indirect OMM technique for MSK pain

Focuses on tenderness, not preference of motion

Question 2

Describe the history of counterstrain

Answer 2

Founded by Dr. Lawrence Jones when treating a pt with psoas pain
Put the pt in a comfortable position for a while and afterwards the pt stood up with no pain
Continued this tx and started noting specific posterior tender points and their tx positioning
Noted the importance of palpating the tender point during tx

Question 3

How was counterstrain refined?

Answer 3

Kept shortening the time the pt would be held in the comfortable position - 90secs seemed best*
Only positioned the region of complaint

Question 4

Trigger point vs tender point location

Answer 4

Trigger point is located only in muscle

Tenderpoint is in muscle, tendon, ligaments and fascia

Question 5

Trigger point vs tenderpoint characteristic pain

Answer 5

Trigger point has characteristic pain pattern

Tenderpoint has no characteristic pain pattern

Question 6

Trigger point vs tenderpoint radiation

Answer 6

Trigger point locally tender and radiates pain

Tenderpoint only locally tender

Question 7

Trigger point vs tender point taut band

Answer 7

Trigger point presents with taut band of tissue that will twitch when palpated
Tender point has no taut band or twitch response

Question 8

What are the indications for counterstrain?

Answer 8

Useable with very fragile or sensitive pts and pts with recent trauma/surgery
Only requirement is that the pt must be able/willing to be positioned and relax

Question 9

What are the contraindications of counterstrain?

Answer 9

Severe trauma/illness/instability where management beside OMM is indicated
Pt cannot voluntarily relax
Unable to position pt without extreme pain or due to anatomical changes

Question 10

What is a tenderpoint?

Answer 10

A non-radiating area of tenderness located within muscle/tendon/ligaments/fascia that reduces when placed into a position of ease

Question 11

What is the diagnostic nomenclature for counterstrain?

Answer 11

-Laterality, anterior/posterior and the vertebra
Ex. LPC4 = left posterior cervical 4

-Or by the anatomical structure that is being treated
Ex. L psoas = belly of left psoas muscle

-If multiple tenderpoint at that segment it will further define anatomy
Ex. LPC4 midline (spinous process) or lateral (articular process)

Question 12

What is the treatment nomenclature for counterstrain?

Answer 12

Tx position/position of ease 
-Flex or extend (F/L)
-Sidebend away/toward (Sa/St) 
-Rotate away/toward (Ra/Rt) 
Ex. Dx = RPC6, Tx = E SaRa (away = left in this case)

All relative to the tenderpoint

Question 13

What does it mean if lower case or upper case letters are used in the treatment nomenclature?

Answer 13

SaRA = sidebend a little away, rotate a lot away

f-F = little to a lot of flexion

Question 14

What is a maverick?

Answer 14

Tenderpoint with Tx position opposite of rest of region

Question 15

What is the nociceptive perspective of tenderpoints?

Answer 15

Initiated by nociceptors in strained tissue (ex. Muscle, tendon, ligaments, fascia)
Produces reflexive contraction to protect tissue
Stuck in reflex loop
Ex. Ligament muscular reflex during ankle strain

Question 16

What is the propioceptive perspective of tenderpoint?

Answer 16

Muscle spindle fibers monitor length of muscles
Spinal gamma motor neurons (LMN) involved
Rapid stretch without recovery (injury/trauma) of muscle spindle fiber will cause protective contraction
This contracture is maintain by gamma motor system (separate from conscious motor cortex)

Question 17

What are the spinal gamma motor neurons (LMN)?

Answer 17

Balances length of agonist and antagonist muscles
Uses alpha motor neurons to control length of muscles and to prevent sudden changes
Associated with the propioceptive perspective

Question 18

What are the consequences of prolonged contraction/nociception?

Answer 18

Sustained contracture which leads to overwhelmed normal sympathetic/parasympathetic regulation of muscle perfusion, reduced metabolic recovery of muscles and build up of lactic acid causing sensitization of nerve endings
Nociception also produces cascade of neuropeptides which produce local edema and also sensitizes nerve endings

Question 19

Explain pathologic neutral

Answer 19

Contracture of muscles produced by both nociceptive and propioceptive models becomes the new pathologic neutral
Neutral = muscles most relaxed
Pathologic neutral is where we position our indirect techniques

Question 20

Describe a brief overview of the physiologic basis of tender points

Answer 20

Injury -> nociceptive and propioceptive perspectives (muscle spindle/gamma motor neurons)

• produces substances pathologic muscle contraction producing TART/somatic dysfunction
• site will be tender to palpation -> tenderpoint

Question 21

What are the phases of counterstrain?

Answer 21

1. Relaxation phase
2. Normalization of nociceptive and neuro input phase
3. Washout phase
4. Slow return to neutral phase

Question 22

What is the relaxation phase of counterstrain?

Answer 22

After tenderpoint is found, the body is placed into a position of ease
Muscle/tissues are shortened and relax
Palpatory findings
-tissue texture abnormality will resolve
-should not be able to reproduce tenderness in this position

Question 23

What is the normalization of nociceptive and neuro input phase?

Answer 23

Nociceptive input resolves in position of ease

Spindle fiber length resets and gamma loop is restored to normal input

Question 24

What is the washout phase of counterstrain?

Answer 24

Metabolic washout begins at 10-15 seconds after optimal position achieved
-palpatory finding: therapeutic pulse may be felt
Peak washout occurs at approx 1 min

Question 25

What is the slow return to neutral phase of counter strain?

Answer 25

Tissues are now moved back to normal neutral
-rapid return could reactivate spindle cell acitivty
-muscle spindles remain facilitated for up to 24 hours after tax
Remind pts to take it easy for a day after tx

Question 26

What are the counterstrain steps?**

Answer 26

1. Find most significant tenderpoint
2. Physician establishes tenderness scale
3. Monitor tenderpoint throughout
4. Place pt in position of ease of at least 70% improvement
5. Hold 90 seconds
6. Slowly return to neutral
7. Recheck tenderness
   - Do NOT skip steps

Question 27

Explain the finding a tenderpoint step of counterstrain

Answer 27

Begins with a TART screen
At region of most TART find palpable nodules of TTA
This will likely correlate with mapped out tenderpoints
“Is this tender?”
“Out of these, which is most tender?”

Question 28

Explain the physician established a tenderness scale step of counterstrain

Answer 28

Physician determines level of tenderness
-scale 1-10, scale 1-100
“On a scale of 0 to 10 where 10 is the most tender this is a 10 out of 10 tenderness)

A novice technique that allows one to manipulate even if not familiar with anatomy or even with poor palpatory skill

Question 29

Describe the monitoring tenderpoint throughout step of counter strain

Answer 29

TTA must reduce to properly localize
Just monitor no need to push
If you let go you will likely not find the exact same point (do not let go)

Question 30

Describe the place pt in position of ease of at least 70% improvement step of counterstrain

Answer 30

“Fold and hold”
Approximate a muscle
Position of ease of each point is what you must know

Question 31

Describe the last few steps of counter strain (wash out and slow return to neutral phases)

Answer 31

5. Hold 90 seconds - you may feel therapeutic pulse
6. Slowly return to neutral - if not you may reactivate muscle spindles
7. Recheck tenderness

Question 32

Which steps of counterstrain are in the relaxation and normalization of nociceptive and neuro input phase?

Answer 32

3. Monitor tenderpoint throughout and 4. Place pt in position of ease