POSITIONAL RELEASE: Strain-Counterstrain. Theresa A. Schmidt, DPT,MS,OCS,LMT,CEAS,CHy.

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1 To comply with professional boards/associations standards: I declare that I or my family do not have any financial relationship in any amount, occurring in the last 12 months with a commercial interest whose products or services are discussed in my presentation. Additionally, all planners involved do not have any financial relationship. Requirements for successful completion are attendance for the full session along with a completed session evaluation form. Cross Country Education and all current accreditation statuses does not imply endorsement of any commercial products displayed in conjunction with this activity. POSITIONAL RELEASE session 203 THERESA A. SCHMIDT, DPT,MS,OCS,LMT,CEAS,CHy Cross Country Education Leading the Way in Continuing Education and Professional Development. POSITIONAL RELEASE: Strain-Counterstrain Theresa A. Schmidt, DPT,MS,OCS,LMT,CEAS,CHy Sponsored by CROSS COUNTRY EDUCATION Copyright c 2012 Theresa A. Schmidt 1

2 INTRODUCTION: NEUROPHYSIOLOGY We treat muscle problems: stiffness, weakness, pain, etc. MUSCLE LENGTH influenced by: Our security system: MONOSYNAPTIC REFLEXES PROPRIOCEPTIVE REFLEXES MUSCLE SPINDLE Extrafusal & Intrafusal Fibers Extrafusal: Alpha motorneuron monitors length of muscle Intrafusal: Gamma motorneuron monitors length and rate of change in length Spindle bias is the present sensitivity to changes in length and rate of change 2

3 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 3

4 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 ( ) 4

5 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 5

6 JONES THEORY Abnormal firing of proprioceptors Elevated spindle sensitivity based on position of relative stretch, load and velocity 6

7 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! 7

8 STRAIN/COUNTERSTRAIN JONES RULES Pain is position oriented Joint 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 8

9 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) 9

10 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) 10

11 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! 11

12 PRT - INDICATIONS Muscle guarding Acute injury Joint hyper/hypomobility Fascial tension Painful tender/trigger points Structural dysfunction ADL restoration CONTRAINDICATIONS TO PRT Infection Nonunited fracture Open wound Hematoma Healing Sutures Hypersensitivity precautions When motion is contraindicated Obtain medical clearance! EVALUATION OF TP Perform 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 12

13 UPPER TRAPEZIUS Extend/ sidebend neck to affected side, rotate contralaterally, & elevate scapula HIP FLEXORS:Iliopsoas Flex hip over 90, may add external rotation for psoas, sit or lie 13

14 SHOULDER: SUBSCAPULARIS Extend, int. rotate, retract Also in sitting or sidelying WRIST / FINGER EXTENSORS Extend fingers/wrist, supinate 14

15 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 RESULTS The 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 reeducation, exercise, functional activities and patient education/ home programs. Make a difference in their quality of life! 15

16 THANK YOU! 16

17 POSITIONAL RELEASE COURSE: POST-SEMINAR EXAMINATION Instructions: The following is a multiple choice question exam. Select the letter that best represents your answer. There is only one best answer to each question. 1. The is the preset sensitivity to changes in length or rate of change in length of muscles. a. extrafusal fiber b. intrafusal fiber c. spindle bias d. golgi tendon organ 2. The is an inhibitory receptor which turns off the muscle spindle in response to stretch of the tendon. a. extrafusal fiber b. intrafusal fiber c. spindle bias d. golgi tendon organ 3. is the lower threshold for excitation of the involved nerve receptors, with hyperirritability and excessive activation of the nerve. a. pathophysiology b. facilitation c. inhibition d. monosynaptic reflexes 4. Hyperirritable areas within tight muscle bands which react to palpation eliciting pain, muscle twitching or jumping are known as. a. trigger points b. tender points c. segmental points d. acupuncture points 5. Another name for Positional Release Therapy is. a. direct technique b. strain-counterstrain c. myofascial therapy d. muscle energy therapy 6. To reduce the pain in a trigger point, position the muscle in its length. a. longest b. midrange c. shortest d. none of the above 7. True or false: A joint dysfunction behaves as if it is constantly strained. a. true b. false 1

18 8. The average holding time for an effective positional release is. a. 10 seconds b. 30 seconds c. 60 seconds d. 90 seconds 9. Indications for positional release include: a. infection b. normalize muscle tension c. hematoma d. nonunited fracture 10. True or false: A precaution for positional release therapy is the possibility of delayed onset muscle soreness. a. true b.false 11. To reduce a trigger point in the upper trapezius, the BEST position is. a. neck extension, contralateral rotation and ipsilateral sidebending b. neck flexion, contralateral rotation and ipsilateral sidebending c. neck extension, ipsilateral rotation and contralateral sidebending d. neck extension, ipsilateral rotation and ipsilateral sidebending 12. True or false: If a client reports dizziness during the upper trapezius positional release, the practitioner should continue holding the release until the dizziness subsides. a. true b. false 13. To release a trigger point in the gluteus medius, the best position is. a. hip flexion with external rotation b. hip abduction with internal rotation c. hip adduction with internal rotation d. hip extension with external rotation 14. To release a trigger point in the iliopsoas, position the client in. a. hip extension b. hip flexion c. hip adduction d. hip abduction 15. To release a trigger point in the wrist flexor carpi radialis, position the client in. a. wrist flexion and ulnar deviation b. wrist flexion with supination c. wrist extension with pronation d. wrist flexion with radial deviation 16. To reduce a trigger point in the right posterior cervical muscles, the BEST position is. a. neck extension, contralateral rotation and ipsilateral sidebending b. neck flexion, contralateral rotation and bilateral sidebending c. neck flexion, ipsilateral rotation and contralateral sidebending 2

19 d. neck extension, ipsilateral rotation and contralateral sidebending 17. To reduce a trigger point in the subscapularis, the BEST position is. a. shoulder external rotation b. shoulder internal rotation c. shoulder flexion d. shoulder abduction 18. To release a trigger point in the wrist extensor digitorum or lateral epicondyle, position the client in. a. wrist flexion and ulnar deviation b. wrist flexion with supination c. wrist extension with supination d. wrist flexion with radial deviation 19. To release a trigger point in the neck flexors, position the client in. a. rotation b. extension c. flexion d. sidebending 20. Trigger points may limit range of motion. TRUE OR FALSE a. true b. false 21. A muscle with palpable taut bands and trigger point(s) is an indication of: a. weakness b. tightness c. strength d. biomechanical dysfunction 22. If a patient jumps or twitches during palpation of a muscle, it is evidence for: a. tender point b. trigger point c. limited flexibility d. weakness 23. Another name for positional release is: a. active isolated stretching b. muscle activation c. strain-counterstrain d. PNF 3

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