Counterstrain

Question 1

Theories of somatic dysfunction initiating

Answer 1

Mechanoreceptor intiated

Nociceptor initiated

Nocifensive reflexes responding to nociception activation

Metabolic and blood flow imbalance

Question 2

Counter strain defined

Answer 2

Indirect treatment that passively places a segment of muscle(s) in the position of comfort

Halts inappropriate nocieption and proprioception actions

Question 3

Tenderpoint

Answer 3

Point on an anatomical location which exhibits tenderness when probed.

-usually at musculotendinous junctions to belly of muscles

Question 4

Generic tenderness is caused by what?

Answer 4

Inflammation, infection, tumors, or trauma

SOMATIC DYSFUNCTION IS NOT TISSUE DAMAGE often accompanies it though.

Question 5

Treatment of tenderpoint

Answer 5

Not actually treating the tenderpoint. Since it usually manifested via a somatic dysfunction of the involved joint and muscles that cross said joint.

Tenderpoints are not symptoms, they are signs

Question 6

Positioning phases during CS

Answer 6

Gross movement: actually placing patient in classic CS position

Fine tuning: small movements to the parts that further decrease the sensitivity at the tender-point

Treatment position is often very specific (too much or too little reduction can cause increased tenderness

Question 7

Why do we shorten the muscle for 90 seconds

Answer 7

Gives enough time for proprioception and mechanorecption to decrease. This allows the CNS to rest to normal resting length, remove pressure of small vessels, allow better blood flow, decrease noxious stimuli and increase tone of sympathetic nervous system.

Question 8

Treatment with regards to patient

Answer 8

Patient should remain relaxed throughout the treatment.

Physician finger should monitor the tenderpoint and and only apply pressure every 30 seconds to recheck

After treatment, Patient should remain relaxed and be placed back into neutral passively by the physician ONLY. Physician should move slowly and keep finger on tenderpoint

Question 9

Advantages of CS

Answer 9

Non-traumatic

Increases patient confidence quickly if done properly

Easy and effective

Easy to record diagnosis

Question 10

Disadvantages of CS

Answer 10

Size difference between patient and physician can be problematic

Quantifying pain is completely subjective to patient

Can have reactions afterwards up to 36 hours
- water and acetaminophen/ibuprofen should be used when needed

Question 11

Mechanism of a joint at rest

Answer 11

Primary sensory nerve endings of muscle spindle fibers send normal rate of impulse to the CNS to induce tonic muscle contraction

Question 12

Mechanism of strain

Answer 12

Severe overstretch of one muscle and understretching of another

Overstretched = increases impulses from primary and secondary nerve endings

Undertretched = decreased impulses from primary and secondary nerve endings

Results in imbalance of muscles which elects pain.

• Strain is almost always NOT the point of injury*
• can elicit a sharp reflex muscle contraction if returning to neutral too quickly*

Question 13

Nocifensive reflex

Answer 13

Seen in strains

understretched muscle cannot straighten out to normal and the overstretched muscle causes hyper stretching of B when it tries to return to neutral (pain).

Question 14

Mechanism of counter strain in patients with strain

Answer 14

Moving the patient back to the position of the strain turns off the CNS action. The physician then returns the understretched muscle or abnormal proprioceptive muscle to a shortened position.

This allows the overstretch muscle to return to normal when the CNS activity returns

Must be done passively to not reactivate understretched muscle and slowly to not reactivate muscle spindle fibers in the overstretch muscle.

Question 15

Difference between trigger and tender points

Answer 15

Trigger point:

• located in muscle tissue
• presents with characteristic pain pattern
• elicits radiating pain
• taut band is present
• elicits twitch response
• follows dermatome map

Tenderpoint
- all the opposites

Question 16

What muscles are mostly commonly the cause of thoracic and lumbar somatic dysfunctions?

Answer 16

Multifidus and Rotatores

Question 17

Syndromes where CS is very helpful

Answer 17

Arthropathies

Shoulder disorders

Lateral and medial epicondylitis

Carpal tunnel

De Quervain tenosynovits

Generalized hand pain

Question 18

Stature of liberty position

Answer 18

Alternative to classic supraspinatus positioning with just 135 degrees of flexion of the humerus, however it is difficult in patients with shoulder problems

Question 19

Levator scapulae

Answer 19

Patient lays prone w/ head ways from the tenderpoint

Physician grasps wrist, internally rotates, 10 degrees of abduction and mild/moderate traction alone affected arm.

• fine tuned with abduction and internal rotation

Question 20

Subscapularis

Answer 20

Tenderpoint is found between scapula and ribs inferior to arm pit

• requires extension, internal rotation and slight abduction of affected limb
• 4 o’clock when looking lateral, 7 o’clock when looking straight on
• fine-tuning = more internal rotation and some traction

Question 21

Biceps brachii short head

Answer 21

Tenderpoint = inferolateral coracoid process

Treatment = elbow and shoulder flexion of affect limb, horizontal adduction and internal rotation of shoulder

Fine-tuning = more adduction and elbow flexion

Question 22

Long head of biceps

Answer 22

Tenderpoint = in. Bicep groove just inferior and lateral to the head of the humerous

Treatment = flexion of elbow and shoulder, horizontal abduction of arm (10-15 degrees) and internal rotation of shoulder

scarlet O’hera position should be obtained = dorsal wrist or forearm laying on forehead

Fine tuning = abduction and elbow flexion

Question 23

Radial head (lateral)

Answer 23

Tenderpoint = anterolateral part of radial head usually at the point of extensor carpi radialis longus or supination muscle bellies.

Treatment = fully extend elbow over knee, supinate arm

Fine-tuning = applying a slight valgus force (abduction of elbow)

Question 24

Medial epicondyle (pronator)

Answer 24

Tenderpoint = anteromedial aspect of elbow, just distal to the medial epicondyle on the common flexor tendon and pronator teres muscle body

Treatment= flex elbow 90 degrees, pronate forearm and adduct arm

Fine tune= more pronation and adduction

Question 25

Extensor carpi radialis ME

Answer 25

Tenderpoint = dorsal surface of 2nd metacarpal assocaited with extensor carpi radialis muscle

• can also be in any other extensor muscle*

Treatment position: extension of wrist, radial deviation of fingers

Fine tune = more radial deviation

Question 26

Extensor carpi ulnaris

Answer 26

Tenderpoint = Dorsal surface of 5th metacarpal associated with extensor carpi ulnaris

Treatment = wrist extension, ulnar deviation of fingers

Fine tuning = more ulnar deviation

Question 27

Flexor carpi radialis

Answer 27

Tenderpoint = palmar aspect of wrist inbetween the base of the 2nd and 3rd metacarpal

Treatment = wrist flexion and radial deviation of fingers

Fine tuning = more radial deviation

Question 28

Flexor carpi ulnaris

Answer 28

Tenderpoint = Palmar aspect of wrist at the base of the 5th metacarpal

Treatment = flexed wrist and ulnar deviation of fingers

Fine tune = more ulnar deviation

Question 29

Abductor pollicis brevis

Answer 29

Tenderpoint = Palmar base of the 1st metacarpal usually in the belly of the abductor pollicis brevis

Treatment = wrist flexion and thumb is abducted away from fingers

Fine tuning - more thumb abduction

Question 30

Conditions where LE CS is helpful

Answer 30

Arthropathies

Lateral hip or thigh pain

Muscle/tendon strain

Ligament sprains

Inflammation within meniscus

General low back pain

Question 31

MCL/medial meniscus CS

Answer 31

Tenderpoint = antero-medial aspect of the meniscus at the joint line

Treatment= patient supine with affected side of table and leg at 60 degrees of flexion and resting on physician thigh

Physician internally rotates tibia with caudad hand on the ankle/foot and both stabilizes knee and applies a slight varus force to the tibia

Fine tuning = more internal rotation

Question 32

Lateral meniscus/ LCL CS

Answer 32

Tenderpoint: Anterior lateral aspect of the joint line of the meniscus

Treatment: patient lies supine with leg off table at 60 degrees of flexion and resting on physician thigh

Caudad hand on ankle/foot applies internal rotation of tibia with cephilad hand stabilizing knee and applying a slight valgus force on the tibia

Fine tuning = trying external rotation or more internal rotation (direction is variable)

Question 33

Medial hamstring (semimembranous) CS

Answer 33

Tenderpoint = two possible
1) front or behind the medial hamstring attachment (just lateral to radial head)

2) posterior thigh medial to the midline approximately halfway down femur

Treatment:
Patient lies supine or prone w/ hip and knee flexed to 90 degrees. Leg and knee are adducted with strong internal rotation and plantar flexion of ankle by compression on calcaneus.

Fine tune = more internal rotation and plantar flexion

Question 34

Lateral hamstring (Biceps femoris) CS

Answer 34

Tenderpoint: two possible
1) front or behind the lateral hamstring attachment (just lateral to fibular head)

2) posterior thigh medial to the midline approximately halfway down femur

Treatment:
Patient lies supine or prone w/ hip and knee flexed to 90 degrees. Leg and knee are abducted with strong external rotation and plantar flexion of ankle by compression on calcaneus.

Fine tune = more external rotation and plantar flexion

Question 35

IT band (lateral trochanter) CS

Answer 35

Tenderpoint = along IT band distal to the lateral trochanter

Treatment = patient supine or prone with hip/thigh slight abducted and slightly flexed

Fine tune = internal/external rotation and more abduction

Question 36

Tensor Fascia Latae CS

Answer 36

Tenderpoint = just inferior to the iliac crest in the body of the TFL muscle

Treatment = patient is prone or supine with hip/thigh markedly abducted and slightly flexed

Fine tuning = internal/external rotation of the hip and more abduction