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POSITIONAL

RELEASE

&

JONES’ STRAIN COUNTERSTRAIN

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Course Description

So many people suffer with painful muscle trigger points as the

result of stress, tension, and injury. Functional impairments and participation restrictions result from the pain and motion limitations associated with TPs.

In this program, learn to manage painful trigger points (TPs) and muscle spasm, and the neurophysiological reflexes that

modulate muscle tension. The use of gentle positioning to relax and release abnormal muscle tension is described. Specific positions are demonstrated, based on the Strain-Counterstrain

principles described by Dr. Lawrence Jones, DO, to reduce painful TPs and improve mobility and function. Research review indicates the efficacy of using gentle positioning to improve

flexibility, strength, reduce pain and improve performance. Imagine being able to reduce painful TPs in just 90 seconds!

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AGENDA

Hour 1

• History of strain counterstrain/positional release, description, theory of neuromuscular reflex function, and evidence-basis for positional release (PRT).

• Definition and assessment of trigger points (TPs) and their relationship to neuromuscular reflexes, abnormal tension and pain.

Hour 2

• Illustration and description of specific positioning interventions to reduce painful TPs, release abnormal tension and improve function and pain.

• Research discussion of evidence for the positive outcomes of positional release.

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Learning Outcomes

1. Discuss the theoretical basis and evidence-based research for positional release (PRT).

2. Identify trigger points (TPs) and their

relationship to neuromuscular tension and pain.

3. Apply specific positioning interventions to reduce the painful sensitivity of TPs, release abnormal neuromuscular tension and improve functional

mobility.

4. Discuss the research evidence for the positive outcomes of positional release.

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Welcome from Theresa A. Schmidt, DPT,MS,OCS,LMT,CEAS,DD

Physical therapist specializing in

orthopedic rehab, muscle energy, joint

mobs, myofascial release,

craniosacral & visceral manipulation, precision exercise, medical massage,

bioenergy, functional training and

evidence-based integrative therapy at

Flex Physical Therapy and Educise

Resources Inc, Northport, NY.

www.educise.com

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CASE REPORT

Client presents with R sided pain and spasm in her neck and shoulder after 3

hours of computer work.

You palpate a tight R upper trapezius and she jumps due to the pain

What can you do to relieve her

discomfort to allow her to resume her work?

What can she do to manage this recurring problem? 8

OUCH! IT HURTS

People present with muscle

problems:

pain

stiffness,

weakness,

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4

GOAL: TELL THE MUSCLES

It is safe to let go now!

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MUSCLE BIOMECHANICS

Remember the rules of biomechanics: the length-tension

rule:

Muscles contract with greatest force at or near their resting length or

slightly longer

Too long or too short: muscles will be weak

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WHAT DO YOU SEE?

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5

POSTURE

Look around the room

How do people hold their bodies?

What about YOU?

13

POSTURAL ALIGNMENT

Posture= the relative alignment of body parts

How we hold ourselves up (or down)

all day

Does it matter?

14

POOR POSTURE ALTERS

MUSCLE LENGTH

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INJURIES ALTER MUSCLE

LENGTH

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NEUROPHYSIOLOGY of MUSCLE PAIN

MUSCLE LENGTH influenced by:• Our security system:

•MONOSYNAPTIC REFLEXES

•PROPRIOCEPTIVE REFLEXES

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MONOSYNAPTIC REFLEXES

The muscle spindle:

Sensory receptor in the muscle

bellies

Detects change in length of muscle during stretch and strain

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MUSCLE SPINDLEcomponents

Extrafusal: Alpha motoneuronmonitors muscle length: CONTRACTION

Intrafusal: Gamma motoneuron

monitors muscle length and speed: causes CONTRACTION

Spindle bias is the present sensitivityto changes in length and speed of

change 19

Golgi Tendon Organ

GTOs: sensory receptor located in the muscle tendons

Monitor tone

when stretched, GTOs fire 1B, results: inhibits alpha motoneuron

Inhibits contraction

If sensitized, may weaken muscle

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ABNORMAL= “FACILITATED” REFLEXES

Stress overexcites nerves, lowers threshold for stimulation, facilitates

afferents, overloads into adjacent spinal cord segments

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8

TYPES OF FACILITATED

REFLEXES

Local:

•at the myofascial level: Trigger points (TPs), taut bands, tension

Segmental:

•at spinal nerve level: spasm, edema, ANS sympathetic dysfunction in several spinal levels 22

EXAMPLE

RSD / Complex Regional Pain Syndrome / Sudek’s Atrophy:

A chronic pain syndrome characterized

by severe sensitivity and pain to touch, shiny glossy dry skin, edema,

cyanosis, even osteopenia and abnormal skin and hair

Usually due to injury23

CRPS/ RSD Interventions

Requires many interventions, including Positional Release PRT

PRT resets the abnormal facilitated

segmental reflex that caused sympathetic vasoconstriction,

As circulation improves, more oxygen

reduces pain and helps healing

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CAUSES OF ABNORMAL

REFLEXES

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HOW DO YOU KNOW THERE

ARE FACILITATED REFLEXES?

A.R.T.

Abnormal posture or joint position

Range of motion is limited

Tissue tension is elevated, Trigger Points are present (TPs)

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WHAT ARE TRIGGER POINTS?

Dr. Janet Travell: Trigger Points=

“hyperirritable foci lying within taut bands of muscle which are painful on compression and which refer pain or other symptoms at a distal site”

(Chaitow, p.59)

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TRIGGER POINTS: on EMG

Areas of persistent contraction

Calcium buildup in t-tubules

Oxygen deficit, can’t pump out calcium

Selective shortening of sarcomeres

Must clear TPs to relax muscle

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Trigger Point EMG Research

• 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

• The muscle is too inhibited!

• (From: Headley, Barbara.Myofascial Exams and Biofeedback: Can Emg Validate Trigger Points?

ISBN 0929538080) 29

POSITIONAL RELEASE OR JONES’ STRAIN-COUNTERSTRAIN:

•Technique using trigger points as diagnostic indicators of joint

problems and

•A position of comfort to release

abnormal muscle tension and pain

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TYPES OF RELEASES FOR JOINT DYSFUNCTION:

•Direct release

•Indirect release

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DIRECT RELEASE

Direct techniques:

Practitioner moves the joint in the direction of tension or stretch, known

as the direction of bind

The position the joint goes into a stretch or strain

LENGTHENING- pulling

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INDIRECT RELEASE

Indirect techniques:

Practitioner moves the joint in the direction of freedom, known as the

direction of ease

The position the joint goes into readily in which it relaxes

SHORTENING- passively folding

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JONES’ COUNTERSTRAIN THEORY

Abnormal proprioceptive firing

results from strain/stress to the

system

Stress elevates muscle spindle

sensitivity

As spindles fire, muscles contract39

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WHAT ARE YOU DOING?

• During positional release, practitioners apply stretching to

muscles on one side of the joint while folding or shortening muscles on the

opposite side of the joint

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HOW DOES PRT WORK?

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RECIPROCAL INHIBITION

More reflexes are at work:

• Muscle spindle reflexes are activated by stretching, causing agonist

contraction to protect against tearing

-Agonist contracts

• By reciprocal inhibition, the antagonist is

inhibited by agonist activity, so

-Antagonist must relax

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SELF INHIBITION

• Practitioners “fold and hold” the muscle in a maximally short position to

reduce the firing of the muscle spindles that were causing the muscle to

contract, resulting in relaxation

• See text by Anderson: Muscle Pain Relief in 90 Seconds, the Fold and

Hold Method

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Jones’ COUNTERSTRAIN=

“Mild strain (overstretching) applied in a direction opposite to that false and continuing message of strain from which the body is suffering”

= SHORTENS THE TP MUSCLE!

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STRAIN/COUNTERSTRAIN

JONES’ RULES

Pain is position oriented

Joint dysfunction is due to abrupt reaction to strain

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• POC is held still for 90

seconds

• the rate of return to the neutral position must be slow

for success

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Joint dysfunction behaves

as if it is constantly strained

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Muscle spindle maintains

joint dysfunction

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Dr. Jones said:

Position the tender point muscle in its maximally shortened

position: actually this is NOT necessary in practice

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SUMMARY OF PRT

PRT is done in slow motion

It takes at least 90 seconds of holding to work

It takes longer in CNS lesions: spasticity takes time (several minutes)

Temporary lowering tone ( Sharon Weiselfish PT)

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OUTCOMES OF PRT:

Decreased

tissue tension

Decreased pain

Increased strength

(Wong, 2004)

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RESEARCH ON PRT: EFFECT

ON PAIN & STRENGTH

Wong and Schauer 2004, Touro College

Randomized 49 adult subjects with hip muscle TPs and weakness

Outcomes:

Visual analog pain scale 0-10

Strength using hand held dynamometer,Nicholas muscle tester

Pre and post counterstrain intervention57

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RESEARCH ON PRT: EFFECT ON PAIN & STRENGTH

3 groups: counterstrain, (SCS) exercise and combination

Intervention: counterstrain for 90 secs. to hip abductor’s TPs 2x/wk for 2 wksResult: Significant 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)

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WHAT HAPPENED?

Reflect:

Pain is a neurogenic inhibitor of muscle

Relieve the pain,

Muscles are able to contract

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TREATMENT PRINCIPLES:

Flex the flexors, extend the extensors

Abduct the abductors

Place the muscle in its passively short position

Takes about 90+ seconds to hold to release TPs

Use all actions of the muscle

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PRECAUTION WITH PRT

If you shorten muscles on one side of the joint,

you stretch muscles on the

opposite side

Possibility of delayed onset

muscle soreness,

Let clients know!

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PRT - INDICATIONS

Muscle guarding

Acute injury

Joint hypomobility

Fascial tension

Postural dysfunction

WHO IS WITHOUT ANY

TRIGGER POINTS!62

RESULTS

Normalize muscle tone and

length

Normalize fascial tension

Improve joint mobility

Improve circulation

Reduce pain

Improve strength63

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CONTRAINDICATIONS TO PRT

Infection

Nonunited fracture

Open wound

Hematoma

Healing Sutures

Hypersensitivity (precaution)

When motion is contraindicated

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PRECAUTION!

MEDICAL CLEARANCE must be obtained prior to working on

clients with medical conditions!

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ASSESSMENT OF TPsPalpate and record TP location and pain pattern

TPs: Areas of hard, dense,

tender spots that do not yield easily to pressure

Client twitches, jumps or cries

out from pain when you push on the TP

Use pain scale: 0-10 to grade

severity, 10 is worst pain 66

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ASSESSMENT OF TPs

Prioritize by severity, treat the worst first

PRT is part of the Plan,

clients may need

strengthening and stretching exercises

Teach home programs with self-care

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TECHNIQUES

After assessing areas of concern:

• Flexibility

• Pain

• Weakness

• Poor performance in specific activities

Discuss needs and set goals

Design a program to meet the goals

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KEEP GOALS REASONABLE

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TRY POSITIONAL RELEASE

• If the client is stiff and in pain, use the positional release prior to their exercise

program.

• If they are sore post-workout, they may again apply the positional release on

their own to relieve the muscle tension.

• Even a single repetition of the position of comfort will help.

• Use as needed.70

PRT TECHNIQUE

Posterior Cervical (most TPs)

Extend neck

Sidebend toward TP, and rotate away

from or toward the TP

Ipsilateral rotators= erectors, splenius,

suboccipitals

Contralateral rotators= upper

trapezius, sternocleidomastoid origin71

POSTERIOR CERVICALS

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PRT TECHNIQUE

Upper Trapezius

• Extend neck

• Sidebend toward TP

• Rotate away from the TP

• Elevate (shrug) the scapula

• Contralateral rotator

• Combine one or more motions

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POSTERIOR CERVICALS

Spinalis cervicis Suboccipitals

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UPPER TRAPEZIUS muscle belly

75

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POSITIONING

• For upper traps:

• TP is in the supraspinous fossa over the muscle belly or at posterior skull attachment

• Be sure the muscles can relax

• Try sitting with pillow behind their head, leaning on something for support

• Try supine or sidelying with pillow

• Can you try it in prone? May be difficult76

UPPER TRAPEZIUS, LEVATORUpper trapezius Levator scapula

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WRIST: COMMON EXTENSORS,

Lateral epicondyle

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POSITIONING

• For wrist/finger extensors: extensor digitorum communis, extensor carpi

radialis, extensor carpi ulnaris, supinator, brachioradialis

• TP is at lateral epicondyle or in the

muscle belly of specific muscle

• Extend the wrist and fingers and add

supination if it helps

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WRIST, FINGER EXTENSORSExtensor digitorum Extensor carpi radialis

80

WRIST, FINGER EXTENSORSsupinator extensor carpi ulnaris

81

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SHOULDER: SUBSCAPULARISAnterior lateral scapula or anterior

medial border

82

POSITIONINGFor subscapularis

• TP is found by elevating shoulder above 90 deg., palpate the front

surface of scapula as it moves forward on the thorax (not the ribs). Ask client

to internally rotate to make it easy to feel

• Place arm behind back into extension

and internal rotation as they relax

• May also use scapula retraction with shoulder extension for stiff clients

83

SUBSCAPULARIS

84

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ANTERIOR LUMBAR/ HIP: Hip flexor iliopsoas

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ILIOPSOAS

86

POSITIONINGFor Iliopsoas:

• TP is in the combined tendon where it passes just below and inside the hip

joint (ASIS) along the inguinal ligament

• Position the hip in flexion > 90 degrees and slight external rotation and hold for

several minutes

• Do in sidelying with knee to chest and

pillow between legs, supine knee to

chest, or sitting bending forward, or yoga kneeling child’s pose 87

30

KNEE: HAMSTRINGS behind the thigh and knee

88

POSITIONING

• For semimembranosus, semitendinosus, and biceps femoris

• TP is between ischial tuberosity and

posterior knee, in muscle belly or tendon

• Position: flex the knee and extend the hip

• Opposite hip is flexed for comfort or lumbar

spine arches too much

• Use sidelying, holding ankle, or supine,

hang leg off table, or standing holding above ankle or using a strap

89

HAMSTRINGSsemitendinosus biceps femoris shorthead

90

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HAMSTRINGS

semimembranosus biceps femoris longhead

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CLINICAL CASE STUDY

Identify a TP on your partner

Test the ROM and muscle strength

Determine a position of comfort

and release the TP

Re-test for results!

92

CASE STUDY: TRY PRT

find TPs on your partner

Rhomboids

Gastrocnemius

Opponens pollicis

Right lumbar erector spinae

Scalenus anticus

Plantar fascia

Carpal tunnel syndrome93

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EVIDENCE FOR POSITIONAL RELEASE OR

STRAIN COUNTERSTRAIN

94

EFFECT ON LOCAL PAIN UPPER TRAPEZIUS

Meseguer: RCT of 54 subjects with upper trap TPs

3 groups: classic PRT, PRT with

stroking, and control

Outcomes: pain scale VAS with 4.5kg/cm2 pressure at 2 min after tx.

2 groups had significant pain reduction but no difference between PRT alone

or PRT with stroking the TP(Mesenguer et al., Clin Chiropractic 9/06) 95

EFFECT ON BACK PAIN TPS

Lewis & Khan: RCT of 28 with low back pain & TPs

Outcomes: Low Back disability index,

pressure pain threshold, electrical detection threshold EDT and electrical

pain threshold EPT

PRT reduced TP pain but not maintained after 24-96 hrs., Control group had

increased EDT and EPT

(Lewis, Khan et al., Man Ther 12/10)96

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EFFECT ON CHRONIC ANKLE INSTABILITY

Collins: RCT of 27 adults with instability

Outcomes: isokinetic strength, dynamic balance (Ft Ank Ability Measure), Instability (Star excursion balance test and global rating of change)

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

2 groups: PRT+exercise & sham+exercise

No effect on strength/subjective ankle function but dynamic stability improved (Nova Univ., 2010)

97

EFFECT OF COMBINED WORK

Nagrale: RCT of 60 adults neck TPs

2 groups: 1) muscle energy/ischemic compression and 2) muscle energy, ischemic compression and PRT to TPs for 4 wks

Outcomes: pain, neck disability index, and ROM cervical sidebending

Measured 2 and 4 wks post intervention

Most significant improvement in group with combined PRT, muscle energy and

ischemic compression(Nagrale, et al., Jnl Man Manip Ther 3/10)

98

INIT Effect on TPs in Upper Trap

RCT 30 adults 18-35, dx. Mech. Neck pain, in 2 groups

1: HP, INIT, strength/stabiliz ex,

ergonomics, posture

2: all except no INIT

6 sessions x 2 wks

Results, VAS pain, Neck disability

index, tenderness improved significantly with INIT added(Aggarwal, 2018)

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MET/SCS for Acute LBP

RCT 50 pts. In 2 groups: MET or MET+SCS

Tx: 2 sessions on 2 days

Results: Oswestry Index and Roland

Morris Q, VAS pain, lumbar ROM

Both groups showed significant

improvement with no diff. between groups

Addition of SCS did not alter results.(Patel, 2018)

100

PRT vs. Taping or Control

RCT 45 people with myofascial neck pain in 3 grps.

SCS, kinesiotape, and control. Tx 2 wks

3x/wk x 20 mins.

Measured VAS pain, NDI, PPT

Result:

SCS had greater effect on NDI, pain

and pressure pain threshold than kinesio or control(Abdelfattah, 2018)

101

SCS for Jaw Muscle TPs

RCT of 99 people 18-24 with TPs in masseter, temporalis, int. pterygoid

muscles

2 groups: SCS vs control placebo.

Measured maximal opening of the jaw and bite force 1 min pre and 5 mins

post tx.

Results: signif. improvement in jaw

opening, and stronger bite force (Blanco,

2019)102

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PRT for Office Worker TPs

RCT of 38 office workers 26-61 y/o with neck and shoulder pain.

Measured NDI, NPRS, and algometer

for pain.

Levator, SCM, traps, subocciptals.

Result: signif decrease in pain, and

increase in ROM(Bockowski 2019)

103

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RESEARCH

Aggarwal, S. and Bansal, G., Efficacy of Integrated Neuromuscular Inhibition

Technique in Improving Cervical Function by Reducing the Trigger Points on

Upper Trapezius Muscle: A Randomized Controlled Trial. Muller Jnl of Medical

Sciences and Research, 2018(9)1:1-6.

Amini, A., Goljaryan, S., Shakouri, S. K., & Mohammadimajd, E. (2017). The Effects

of Manual Passive Muscle Shortening and Positional Release Therapy on Latent

Myofascial Trigger Points of the Upper Trapezius: A Double-Blind Randomized

Clinical Trial. Iranian Red Crescent Medical Journal, 19(9).

Blanco, CR, Figallo, MA, et al, Short Term Application of the Muscular Inhibition

Method of Strain/Counterstrain in the Treatment of Latent Myofascial Trigger

Points of the Masticatory Musculature: A Randomized Controlled Trial. Clinical

Advances in Health Research. 2019(1)1: From:

http://clinicaladvancesinhealthresearch.com/index.php/clinadvheares/article/view

/9

Bockowski, r., and Gebska, M, Assessment of Trigger Points Therapy Effectiveness

with Positional Release Method among Office Workers, J Educ Health Sport.

2019(9)3:Collins CK. Physical therapy management of complex regional pain

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Manual Manipulative Ther 2007;15:25-41.

D’Ambrogio KJ, and Roth GB. Positional Release Therapy Assessment &

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DiGiovanna, Eileen, D.O., and Schiowitz, D.O., An Osteopathic Approach To

Diagnosis And Treatment. Philadelphia, Pennsylvania: J.B. Lippincott

Company, 1991.105

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Falsiroli Maistrello, L., Geri, T., Gianola, S., Zaninetti, M., & Testa, M.

(2018). Effectiveness of Trigger Point Manual Treatment on the Frequency, Intensity, and Duration of Attacks in Primary Headaches: A

Systematic Review and Meta-Analysis of Randomized Controlled

Trials. Frontiers in neurology, 9, 254. doi:10.3389/fneur.2018.00254

González-Ravé, JM, Sánchez-Gómez, A, and Santos-García, DJ. Efficacy

of 2 different stretch training programs (passive vs. proprioceptive

neuromuscular facilitation) on shoulder and hip range of motion in older

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Howell JN, Cabell KS, Chila AG, Eland DC. Stretch reflex and Hoffman reflex responses to osteopathic manipulative treatment in subjects with

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Lewis, C, Khan, A, Souvlis, T, Sterling, M, A randomized controlled study examining the short-term effects of Strain-Counterstrain

treatment on quantitative sensory measures at digitally tender

points in the low back Man Ther 2010 Dec: 15(6):536-41

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SPECIAL THANKS

Sam Barrow of Primal Pictures Ltd. provided copyright permission to use

the anatomy pictures from the Primal Pictures. Ltd. DVD: Interactive

Functional Anatomy, Second Edition

www.primalpictures.com

Primal Pictures Ltd. 4th Floor, Tennyson House, 159-165 Great Portland St.

London, W1W5PA, UK110

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Get your FREE course on

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38

Disclosure

To comply with professional boards/associations standards, I declare

that I do not have any financial relationship in any amount occurring

within the last 12 months with a commercial interest whose products or

services are discussed in my

presentation.

Theresa A. Schmidt

EDUCISE RESOURCES INC. 112

LONG ISLAND SUNSET

113