Intro to counterstrain Flashcards
Counterstrain developed by
-Lawrence H. Jones
Counterstain Definition
- an osteopathic system of diagnosis and indirect treatment in which the patient’s SD is: diagnosed by an associated myofascial tender points
- treated by using a passive position, resulting in spontaneous tissue release and at least 70% decrease in tenderness
Counterstain Treatment Guidelines
- relevant structural exam
- regional TP examination
- find worst TP
- establish a tenderness scale
- place patient in position of ease
- hold for 90 seconds continuously monitoring TP for tenderness and tissue texture changes with periodic checks
- slow, passive return to pretreatment position (first few degrees of motion are most important)
- re-check TP
- examine region to assess remaining TART changes, assessing need for further treatment
Expanding Role of Muscle Spindle
- muscle spindles are complex receptors and the stretch reflex is only one constituent of an entire informational spectrum
- gamma motor neurons set and fine-tune the activity of the moment-to-moment fine adjustment of posture and locomotion
Sherrington’s Law
-when a muscle receives a nerve impulse to contract, its antagonists, receive, simultaneously, an impulse to relax
The muscle spindle
- through the gamma system, provides proprioceptive info and mediates proprioceptive reflexes
- SD caused by sudden contraction of the biceps causes triceps to have increased gamma activity and to be reflexively contracted
Counterstrain Treatment
-by brining a hypertonic muscle, whose spindles “report strain where there is none,” into a shortened position the physician can reverse the hyperactivity of the spindles, restoring the normal stretch reflex and the normal range of motion
Evidence base for Counterstrain
- single blind randomized controlled trial of crossover design showed no electrically recorded reflexes of calves observes in response to treatment
- peak force and time to reach peak force both increased in the post-treatment measurements
- significantly more pronounced in the counterstain mode
- significant relief of symptoms, most pronounced immediately after treatment and still present 48 hours later
Tissue Trauma Pathogenesis
- trauma produces changes in myofascial tissue at microscopic and biochemical levels
- more specifically trauma causes damage to myofibrils and their microcirculation
- nociceptive information carried to the CNS
- the tissue disruption an subsequent chemical changes cause the tissue to become more sensitive and may contribute to the formation of a tender point
Three Proposed pathways of tissue trauma pathogenesis
- strain-counterstrain: reflex mediated through gamma motor neuron pathway
- trauma–direct injury to tissues results in nociceptive maintained TPs
- secondary to SD: TART
Respiratory/Circulatory Model Micro level
-The TTA associated with a TP indicates compromised circulation on a cellular level
Respiratory/Circulatory Model Macro level
- superior thoracic aperture is bounded by: T1, the first ribs, the costal cartilage of the 1st rib and the superior border of the manubrium
- restore microcirculation
Posture/Motion model
-balance posture and function
Behavior model
optimize function
Neurologic model
interrupt pathophysiologic reflexes and pain pathways
Metabolic model
-improve physiology and exercise ability
16 yo with ankle pain. Playing basketball and had an inversion sprain 2 weeks ago. He has lateral ankle pain. PE has a preference for inversion at the ankle. What most likely describes the underlying neuropathology involved in this patient’s described somatic dysfunction?
-increased gamma motor activity of the inverters
Indications for Counterstrain treatment
- presence of a tender point
- can be found in acute and chronic musculoskeletal conditions
- may be associated with a viscerosomatic reflex
- may be the primary indication of a somatic dysfunction
- may be secondary to another primary (ex. joint restriction)
- reluctant/afraid patients
- frail patients
- trial of OMT to assess patient tolerance
Absolute Contraindications to Counterstrain
- fracture
- torn ligament
- patient refusal
Relative Contraindications to counterstrain
- stressed patients who can’t relax
- uncooperative children
- severe osteoporosis
- C-spine treatment in patients with vertebral artery disease
- severely ill patients who may not tolerate a treatment reaction (metastatic cancer, cervicals in RA, medically not stabilized)
Finding Tender Points: History
- may be primary (i.e. from a strain)
- examine area of CC for TPs
- knowing the position of the strain can help determine the muscles involved and the position of treatment
- may be secondary to another type of somatic dysfunction (arthrodial, myofascial, viscerosomatic)
Finding Tender Points: PE
- postural examination may give clues to TPs
- TART changes: TPs are usually associated with TART
Tender Point Identification
- usually located in the muscle belly or the tendinous insertions
- typically discrete, small, tense, and edematous
- usually 4x as tender as adjacent tissue
- enough force to blanch your fingernail
- significant TP results in patient wincing
- Viscerosomatic TPs will return in minutes to hours
Tender Points in Testing and monitoring
- normal tissue requires 4x the level of digital pressure to elicit tenderness as the amount of pressure necessary to elicit tenderness in a counterstrain point
- TP checks should be administered in short, quick pushes
- Observed TTA changes should be confirmed with TP checks
- Maintain monitoring finger on TP at all times
4 Reasons to maintain contact with a TP
- TTA change can be monitored more easily and aid in determining the end point of treatment
- TP may need further ‘fine-tuning’ while maintaining the optimal position of comfort, because the position may change slightly during treatment
- Both the patient and the practitioner can be confident of the location of the TP
- observation of the ‘therapeutic pulse’–possibly related to localized, sympathetically-mediated vasodilation
Folding toward TPs
- passive process
- when TTA changes occur recheck TP: goal is for a “3” or less on tenderness scale; if not <3 continue to explore for optimal position
- maintain light contact with TP
- initial positioning usually requires large, slow movement, then “fine-tuning” is necessary
Presence of therapeutic pulse in counterstrain indicates
good myofascial relaxation
Inability to reduce tenderness to zero means
that there is usually another associated TP
Anterior TPs typically require
flexion
Posterior points typically require
extension
Midline TPs typically require
pure flexion (anterior)/extension (posterior) -increased deviation from midline requires more rotation and/or side bending
Post-treatment instructions for counterstrain
- starts before the patient leaves the table
- warn patients not to test previously restricted motions and avoid extremes of motion for several days (especially true if the movement approximates the original position of injury)
- emphasize hydration with H2O (optimal hydration maximizes waste elimination; abstinence from alcohol is recommended for 3 days)
- post-treatment soreness is not uncommon
- follow-up recommended in 3-7 days after initial treatment
Triggerpoints
- described by Janet Travell, MD
- specific referral patterns/radiation
- firm/taut band of muscle with localized tenderness of palpable nodule
- treated with dry needle, injection, or topical vapocoolant–spray and stretch
- may occur in any skeletal muscle
- single or multiple
- latent TrPs are, most likely, tender points
60 yo female with lower back pain. Cannot stand up straight. What is the most likely tender point?
AL2
Chapman’s Points vs TPs
- considered a viscerosomatic reflex
- consistent association between structures
- palpatory findings–pea sized tapioca ball (boba), TTA…
- generally doesn’t respond to CS treatment
