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POSITIONAL RELEASE session 203THERESA A. SCHMIDT,

DPT,MS,OCS,LMT,CEAS,CHy Cross Country Education

Leading the Way in Continuing Education and Professional Development. www.CrossCountryEducation.com

POSITIONAL RELEASE:Strain-Counterstrain

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

www.educise.com

Sponsored by CROSS COUNTRY EDUCATIONCopyright c 2012 Theresa A. Schmidt

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INTRODUCTION: NEUROPHYSIOLOGY

We treat muscle problems: stiffness, weakness, pain, etc.

MUSCLE LENGTH influenced by:• Our security system:

•MONOSYNAPTIC REFLEXES•PROPRIOCEPTIVE REFLEXES

MUSCLE SPINDLEExtrafusal & Intrafusal Fibers

Extrafusal: Alpha motorneuronmonitors length of muscle

Intrafusal: Gamma motorneuronmonitors length and rate of change in length

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

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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

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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”

Indicators of joint dysfunction

(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)

Trigger Points

• Barbara Headley, PT showed trigger points can also be areas of abnormal electrical silence on EMG studies, where the muscle has too little activity, also causing a trigger point

• (Headley, Barbara.Myofascial Exams and Biofeedback: Can EMG Validate Trigger Points? ISBN 0929538080 (0-929538-08-0)

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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

Moving the joint through a range of motion

in the direction of ease

“Passive treatment” per Jones

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JONES’ THEORY

Abnormal firing of proprioceptors

Elevated spindle sensitivity based on position of relative stretch, load and velocity

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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!

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STRAIN/COUNTERSTRAIN JONES’ RULES

Pain is position orientedJoint 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

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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)

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EFFECT ON PAIN & STRENGTH

Wong and Schauer: RCT of subjects with hip muscle TPs and weakness, n=49

Outcomes: VAS, HHD MMT post intervention

3 groups: SCS, EX, combined SCS+EX

Intervention: SCS hip TPs 2x/wk for 2 wks

Signif. Increase in strength in SCS and SCS+EX group

All groups had TP pain reduced and greater strength 2-4 wks post intervention(Wong & Schauer, Jnl Man Manip Ther 2004)

EFFECT ON CHRONIC ANKLE INSTABILITY

Collins, doc. dist. RCT n=27 with instability

Outcomes: isokinetic strength, dynamic balance (Ft Ank Ability Measure),

Instability (Star excursion balance test and global rating of change)

1x/wk for 4 wks with home exercise for all groups

2 groups: PRT+EX and sham+EX

NO effect on strength or subjective ankle function but dynamic stability improved

(Nova Univ., 2010)

EFFECT ON MASSETER TP PAIN AND ROM OF TMJ

Ibanez Garcia et al, RCT, n=71, 3 groups

NM technique, PRT, and control groups 1x/wk: 3 wks

Outcomes: Pressure pain threshold, AROM open jaw, VAS with 2.5kg/cm2

1 wk post intervention: No signif. diff. between tx groups, small diff compared to control(Ibanez Garcia, Jnl Man Manip Ther 1/09)

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EFFECT ON LOCAL PAIN UPPER TRAPEZIUS

Meseguer RCT n+54 with upper trap TPs

3 groups: classic PRT, PRT with stroking, and control

Outcomes: VAS with 4.5kg/cm2 2 min after tx.

2 groups had significant pain reduction but no difference between PRT alone or PRT with stroking the TP(Meseguer et al., Clin Chiropractic 9/06)

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!

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PRT - INDICATIONS

Muscle guarding

Acute injury

Joint hyper/hypomobility

Fascial tension

Painful tender/trigger points

Structural dysfunction

ADL restoration

CONTRAINDICATIONS TO PRT

InfectionNonunited fractureOpen woundHematomaHealing SuturesHypersensitivity precautions

When motion is contraindicatedObtain medical clearance!

EVALUATION OF TPPerform 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

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UPPER TRAPEZIUSExtend/ sidebend neck to affected side, rotate contralaterally, & elevate scapula

HIP FLEXORS:IliopsoasFlex hip over 90, may add external

rotation for psoas, sit or lie

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SHOULDER: SUBSCAPULARISExtend, int. rotate, retract

Also in sitting or sidelying

WRIST / FINGER EXTENSORSExtend fingers/wrist, supinate

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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!

SUFFICIENT RESULTSThe body of evidence for positional release, strain-counterstrain is growing. Try this simple intervention which takes only an average of 90 seconds to evaluate the outcomes for your clients.

Follow PRT with neuromuscular re-education, exercise, functional activities and patient education/ home programs.

Make a difference in their quality of life!

www.educise.com

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THANK YOU!