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Soft Tissue Injuries 112 – hour 1 of 2:  Strain/Counterstrain 

Instructor:  Linda Simon, DC 

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Section I: Strain/Counterstrain - Development and Theory Strain/counterstrain is a very powerful technique developed by Dr. Lawrence H. Jones, an osteopath determined to understand and treat neuromuscular dysfunction in relation to joint disorders. His research involved the study of the behavior of joints under stress. There were several clinical observations of him and his colleagues as well as incorporating the theories of the osteopathic lesion at the time. The treatments of joint dysfunction were based on the theory that the condition was traumatically induced. Treatments available were forceful manipulative thrusts, craniosacral respiratory mechanisms, functional techniques and resistive techniques. Dr. Jones was most intrigued by TJ Ruddy, DO, who focused on malfunctioning nerves and muscles instead of mechanical functional disorders. Dr. Jones then redirected his focus to neuromuscular dysfunction as the basis of joint disorders instead of trauma. In studying rheumatic pain, he used the perspective that pain can be worse depending upon position. This fact was used to educate the patient in avoidance behavior but had never been used in a treatment protocol. From his years in practice, Dr Jones observed that the pain cycle and spasm can be permanently reduced if a “position of greatest comfort” is passively held for a period of ninety seconds, then passively returned to neutral very slowly. His initial intention was to offer a particular patient some relief so that he could sleep at night. This 30 year old man with severe back pain for 4 months was not receiving relief for his condition after 40 days of Dr. Jones’s care. Frustrated and hoping to prevent this patient from becoming addicted to pain medication, he placed this patient in many variations of positions to help him find a position of comfort for sleep. When he was done, the patient seemed contorted into a bizarre posture but was at last comfortable. Dr Jones did not have the heart to move him which would bring him back into pain so he propped the patient up with pillows and left to treat another patient. When he returned, the patient was still comfortable and they discussed how he could reproduce this at night. When the patient arose, the pain did not return and the patient stood upright for the first time in months almost pain free. The patient did not need to remain in this contorted position to

be comfortable. Dr Jones was dumbfounded. This was the start of the development of Strain/counterstrain. Dr Jones experimented with varying positions to relieve back pain in differing regions of the back. He discovered that the body must be returned slowly with complete support or the pain will return. He also learned that tender points were observed and were objective findings since the patient was not aware of them unless they were palpated. He also discovered that these points were not limited to the posterior paravertebral spine but can be located on the anterior of the body as well. He then later discovered that these points are not limited to the spinal structures but can be found near any joint in the body. Years of clinical research lead Dr Jones to discover a determined set of tender points throughout the body near joints that related to the antagonists of spastic muscles. The definition of this developing technique by Dr Jones was: *Relief of traumatic pain by placing a joint in its position of greatest comfort. *Relief of false messages of continuing strain arising in dysfunctioning proprioceptor reflexes by applying a strain in the direction opposite that of the false messages of strain. This is accomplished by shortening the muscle containing the false strain message so much that it stops reporting strain. The body in normal positions can suffer this pain for years yet have it stopped in ninety seconds of the opposite strain. Further study revealed that the tender points in the arms and legs were not found in the muscle strained but in its antagonist. The antagonist muscle had suffered no strain but had a maximal shortening at the time of injury which was followed by a sudden panic type lengthening. He focused on statements he had heard from patients in which their pain began when they began to “straighten up” from a bent over posture. The example from which he drew upon for his theory was, when an individual’s back is injured, maximum pain is produced when he attempts to stand up, using the antagonists. He realized that the continuation of pain was not from the muscle that was strained but the antagonist which was traumatically stretched after maximal shortening. For the antagonist muscle, it then behaved exactly as if it were being strained whether the joint was in neutral position or not. The more the antagonist muscle was stretched, the more it hurt. Treatment consisted of maximally shortening the antagonist muscle and stretching the perceived injured muscle. If the muscle was truly injured, stretching it would hurt. In this instance there is no pain when stretched. The theory was that the false message of strain in the antagonist muscle stopped even after months or years of dysfunction when it was made so short it could not continue to report to the brain as if in a strain. In trying to explain this phenomenon, Dr. Jones researched the work explaining the neurological reflexes associated with proprioception, namingly the Rufini and Golgi tendons.

1-1 In an article written by Dr. Irvin M. Korr in the Journal of The American Osteopathic Association (1975) titled “Proprioceptors and Somatic Dysfunction”, he stated that, “To a physiologist it seems much more reasonable that the limitation and resistance to motion of a joint that characterizes an osteopathic lesion do not ordinarily arise within the joint, but are imposed by one or more of the muscles that traverse and move the joint.” He further described the Rufini, Golgi and primary or annulospinal proprioceptor reflexes in the muscle spindle. His hypothesis blames the “rise of exciting gamma outflow in response to the momentarily silent proprioceptor input from the spindle of the hypershortened antagonist muscle causing an inappropriate gain in the primary proprioceptor reflexes in its muscle spindle.” In other words, when the antagonist is restretched, it overreacts and reports strain before any real strain is reached. This led Dr. Jones to the following conclusions:

1. This is not a lesion but an ongoing noxious process. 2. For success the hypershortened muscle must return to neutral length slowly. 3. In spite of subjective pain and weakness in the strained muscle objective evidence

(tenderness, contraction, edema) were in the antagonist of the painful muscle. 4. Position of comfort and lasting relief come with maximum shortening of this antagonist

and a repeated stretch of the painful muscle, followed by a slow return to neutral lengths. Slow return does not restart the dysfunction.

By shortening this antagonist muscle past where it triggers a premature strain response, the proprioceptive information becomes changed and the antagonist muscle can then stretch without reporting a “false” strain or pain. Dr. Jones further hypothesized that if the antagonist muscle is not returned to its normal reporting position, inflammation and eventually degeneration of tissues will result. The physiological manifestation of this neurogenic problem is a somatic dysfunction consistent with tissue changes, asymmetry, change in the range of motion of certain muscles and joints, and tenderness that is manifested through the palpation of the patient’s body. These manifestations are recognized as specific tender points identified by Dr. Jones. The particular tender points will be discussed in later sections relating to each part of the body. The tender points that have been demonstrated have an intimate relationship with the neurological joint receptors in the joint that is related to the strained and antagonist muscle. The power of strain/counterstrain in affective treatment for pain and dysfunction syndromes can only be known by the practitioner through the experience of trying this technique and observing

its immediate and long term results. It is fast, easy and the results can amaze you and your patients.

Section II: Strain/counterstrain - Physiology and Practice In order to understand the manifestation of tender points, Dr. Jones describes the osteopathic somatic lesion. He states, “These somatic dysfunctions are detectable through the physiologic manifestations we recognize as tenderpoints. It is through the appreciation of this internal concept that we are able to perform the maneuvers of strain/counterstrain.” Somatic dysfunctions or somatic osteopathic lesions require the knowledge of the neurology at the joint sites. There are three types of mechanoreceptors and a nocioceptor. Mechanoreceptors: Type I: Located within the more superficial layers of the fibrous capsule of the joint, they are postural and kinesthetic sensors responsible for pain suppression and are found in the neck, limb, jaw and eye muscles. Type II: Found in the fibrous capsules of the deeper layers of the fibrous capsule of the joint, they involve pain suppression and information relayed from the neck, limb, jaw and eye muscles. Type III: Found in ligaments and in tendons, they have an inhibitory effect on motor neurons. Nocioceptor: Type IV: Located in the fibrous capsules of joints and the walls of articular blood vessels and articular fat pads, they relay information from the neck, limb, jaw and eye muscles. They respond to the evocation of pain, and chronic pressure and are involved in respiratory and cardiovascular reflexogenic effects. Nocioceptors are believed to register tissue damage or toxic stimuli. They can be activated by chemicals (bradykinen, potassium, serotonin and hypoxia) and mechanically (firing in the presence of prolonged muscle contraction or ischemia due to metabolite buildup). The creation of a tender point is a manifestation of the relationship between the somatic dysfunction and the sympathetic nervous system known as a “facilitated segment”. This facilitated segment can be identified by the changes in tissue texture, asymmetry, alteration in the range of motion and tenderness at the site of the dysfunction as well as at the referred tender point. Chronic pain can lead to long term alterations of the soft tissue. As the theory of strain/counterstrain was being proved, an understanding of muscle types became important as tender points manifest in these tissues. Slow twitch fibers (Type I) are found in postural muscles and possess more endurance. They also have more spindle fibers. Fast twitch fibers (Type II) are within phasic muscles and fatigue more easily than postural muscles. These differences allow for different responses to irritation. Slow twitch will shorten upon irritation and fast twitch will weaken. This information helped Dr Jones determine that some tenderpoints existed not only in the postural muscles but in the phasic muscles as well. With phasic muscles, tender points occur with weakness on exertion. With postural muscles, tenderpoints occur with shortening. These are treated by shortening the offended muscle. Information from the muscle to the brain occurs in five types of afferent fibers; muscle spindles, golgi tendon organs, pacinian corpuscles, free nerve endings (Type IV nocioceptors), and mechanoreceptors (Type III). Muscles spindles and golgi tendons act in conjunction in the regulation of tension and control movement.

2-1 The muscle spindles respond to stretch and rate of change. They are sensitive to changes in length and when stretched to a certain point will induce reflex contraction of the same muscles and help in the process of reciprocal inhibition of the antagonistic muscles. Postural muscles possess more spindle fibers. These muscles create more fine movement as opposed to the gross movement of phasic muscles which possess less spindle fibers. Golgi tendon organs are important in monitoring the tension of the muscles spindles. They are imbedded in the distal ends of the muscles and measure tension and are sensitive to stretch during contraction. Stimulated golgi tendons will result in inhibition of the muscle innervated and its synergists and facilitate the antagonists. This is known as the relief reflex. Irritation (mechanical or chemical) registered by the nocioceptors can not only create but maintain spastic or weakened muscle states depending whether they are phasic or postural. Over time, chronic spasm or weakness will lead to hypoxia and toxic results. Thus a tenderpoint is formed. The position of most comfort will allow the mechanoreceptors to receive different more normal information over a period of time so as to alter the neurological input and correct the misinformation. The severity, acuteness and chronicity will all determine the length of treatment necessary for resolution of the somatic dysfunctional lesion.

2-2 Muscles around a joint will react in specific ways. Around a neutral joint, muscles will be in a state of mild tonic tension. Around a strained or challenged joint, muscles will normally react so that one muscle shows a great increase in proprioception activity from excessive stretch; and the other muscle which has been abnormally shortened will show a complete drop in proprioceptor activity. This condition can resolve within a few days without pain or dysfunction resulting if the joint is redirected to its normal state. In an unexpected and painful strain, the antagonist will react with a stretch. The speed of stretch will cause it to report itself in a strain even before reaching a neutral length. This causes proprioception information in the antagonist to lead to dysfunction and the muscle cannot further stretch toward neutral length. Treatment required is to hypershorten the antagonist so that it can once again send information to the brain that it is shortened, not stretched as the brain believes it to be. Ninety seconds will achieve this goal and the pain will cease and dysfunction will stop. A tender point can be palpated as an area of hypersensitivity beneath the skin smaller than a finger tip. They are usually four times as sensitive as normal tissue. Palpation should be gentle. Each tender point is specific for one source of irritation. There may be more than one tenderpoint for a particular pain complex. The most painful point should be treated first. When the position of maximal comfort is found, there is a rapid relaxation felt at the tenderpoint. During the 90 seconds of treatment, the tender point will continue to relax. This is due to the reabsorbtion of edema. Several tenderpoints may need to be treated in a particular region. Tenderpoints can be found anteriorly as well as posteriorly. There are 3 rules that should be followed with all strain/counterstrain procedures:

1. Stretch the affected joint passively into its position of greatest comfort. 2. Completely support the region being treated so that the patient has no opportunity to

contract their muscles. Feel for the weight of their limb or head to determine the level of passivity. Particularly watch for shoulder muscle contraction and make sure you feel the entire weight of the shoulder and arm.

3. Return the patient slowly enough and under your full control so that the pain does not return.

4. Always avoid any sudden return, even if the position is painful. Usually here it is best to just back off a little and wait a few seconds and then proceed slowly again.

Strain/counterstrain is highly affective in a variety of conditions and all ages of patients. It is noninvasive and safe. Conditions that respond best to strain/counterstrain are:

1. acute injuries 2. chronic injuries with or without associated arthritic degeneration or adhesive capsulitis 3. torticollis 4. post-operative pain

There are several steps that need to be followed for the most affective care. These steps for the sequencing of treatment are important for maximum effectiveness. The rules are as follows:

1. Treat the proximal tender points before the distal tender points. 2. Treat the most sensitive tender points first. 3. Treat the areas of highest accumulation of tender points first. 4. When tender points are in rows, treat the one in the middle.

Strain/counterstrain is a valuable technique that can be used alone or in conjunction with other techniques to affect the maximum results in a given condition. It can relax muscles, decrease swelling and significantly reduce pain with immediate results. For the remainder of this course, the regions of the body will be discussed for the best understanding of the practice of this powerful and highly useful technique.

Section III: Strain/counterstrain – The spine The muscles associated with the spine are strained in particular patterns due to their structure and function of a given region. Of course, each individual will present with differences but typical firing patterns are common from patient to patient. That is why one would find trigger points as well as tender points in similar areas from patient to patient. When treating the spine there may be clusters of tender points. Considerations to the sequence of treatment as well as posture need to be addressed. Those are sequencing, posture, and type of pain. Sequencing is defined as the order in which the practitioner chooses to work on specific tenderpoints. The direction of ease versus bind needs to be understood. For example, if a patient has an anterior cervical tenderpoint that would be eased with flexion and a posterior tenderpoint that needs to be eased in extension, which do you choose first? Ranges of motion tests determine that there is a greater mobility of flexion in the spine. Therefore, the anterior tenderpoint eased in flexion will be treated first to follow the theory of greatest comfort. Attention must be paid to the pain level at the posterior since the position of flexion could exacerbate the pain at the posterior point. The correct position will allow for comfort all around. Posture is another consideration for locating and prioritizing points for treatment. A lumbar or cervical hyperlordosis or a thoracic hypokyphosis will indicate posterior points. A thoracic hyperkyphosis or a cervical or lumbar hypolordosis will indicate points on the anterior spine. Treatment priority would go to those points that the position of most comfort will exaggerate the alteration of the curve; e.g., hyperlordosis, hyperkyphosis. Specific pain in which the pain pattern is in a particular location, the tenderpoints will more than likely be in that region. When the pain is posterior and more diffuse, the tenderpoints will most likely be anterior and should be the priority points. Cervical Spine There are anterior and posterior points. All cervical points are performed with the patient supine.

3-1a 3-1b The points above show the anterior and posterior treatment points for the entire cervical spine. Those identified as 1 and 2 refer to the upper cervical spine.

Posterior cervical points: The tenderpoints on the spinous processes are usually found slightly lateral from the midline depending upon which side is injured. Inion – this point is on the medial side of the muscular attachment to the inion and is found about 1 inch below this anatomical region. Treatment entails forward flexion of the head on the neck.

3-2 Posterior cervical point 1 is located low on the occiput 2 centimeters lateral to the main muscle mass at the back of the neck. Pain is often in or around the eye. It is treated with full extension of the occipito-atlantal joint with lateral bending and rotation away from the side of tenderness. Posterior cervical point 2 is located on the superior surface or the spinous. Symptoms are similar to posterior point 1. Treatment is in the position mentioned for posterior point 1.

3-3 Posterior cervical point 3 has two locations, one at the inferior of the spinous of C2 and the other on the posterior aspect of the transverse process of the vertebral body of C3. The patient’s head is extended with lateral flexion and rotation away. This can also be treated with the patient’s head in flexion which must be determined by the position of greatest comfort. These points are common with patients suffering from vertigo.

3-4 Posterior cervical point 4 is more difficult to find. It exists over the top of the spinous of C3. Flex the patient’s neck to expose the spinous process. Tenderness here will accompany pain that radiates up the back of the head. Patient’s who complain of jaw pain can exhibit this tender point. Treatment is performed with the patient’s head hanging over the edge of the table. Posterior cervical point 5 exists on the spinous of C4. Diffuse headaches are common with this point. Treatment is as above.

3-5 Posterior cervical points 6 and 7 are found on spinous processes 5 and 6 respectively. Symptoms are usually diffuse neck pain and stiffness. Treatment is with the patient supine and their head and neck suspended over the end of the table with support from the practitioner. Their neck is stretched back and rotated and lateral bent away from the tender side. Posterior cervical 8 can be found on the transverse process of C7 anterior to the trapezius. The patient’s neck is minimally extended and laterally flexed away with marked rotation away.

3-6 Postero-lateral cervical points exist just 3/8th of an inch lateral to the posterior points. These are relieved by neck extension, rotation away from the painful side and some lateral flexion toward the painful side.

Anterior cervical points: These are found on the anterior surface of the tips of the transverse processes except Anterior cervical points 1,7 and 8. Those will be described below.

3-7 Anterior cervical point 1 can produce ear and eye pain, nausea or represent TMJ dysfunction. It is located on the posterior surface of the ascending ramus of the mandible. The practitioner places the patient’s head in full rotation away from the point with possibly 5-10 pounds of pressure in over-rotation.

3-8 Anterior cervical point 2 can produce pain in the forehead or around the eye. The patient’s head is rotated fully with some lateral bending. Anterior cervical 3 can produce vertigo as well as eye pain and headaches. The patient’s head is flexed to C3, laterally flexed and rotated away. However, the position of most comfort may be

with the neck laterally flexed toward the treatment side. This is to be determined at the time of treatment.

3-9 Anterior cervical 4 can produce vertigo and frontal headaches. The patient’s head is placed over the edge of the table and their neck is flexed to C4,5 junction. Their head is laterally flexed and rotated away. Anterior cervical 5 can produce parietal headaches and posterior neck pain. The patient’s head is flexed to C5,6 junction and laterally flexed and rotated away. Anterior cervical 6 can produce suboccipital headaches. The patient’s neck is flexed to C6,7 and laterally flexed and rotated away. Anterior cervical 7 can be found with levator scapulae and rhomboid spasms. The point is on the superior medial clavicle between the attachments of the SCM. The patient’s head is flexed to C7,T1 with lateral flexion towards and rotation away. Anterior cervical 8 refers to the point (not a vertebra) and is associated with lower neck and upper shoulder pain commonly found with acceleration/deceleration injury. It is located on the medial clavicle. The patient’s head is flexed, rotated away and slightly laterally flexed. Lateral first cervical points: Lateral first cervical 1 point is found by pinching the tips of the mastoid processes between the index fingers and thumbs of both hands. Allow the finger tips to move down and more deeply medially to feel the tips of the transverse processes of the vertebrae just below. Laterally flex the head on the neck to find the position of most comfort. Anterior lateral cervical points: These points exist lateral to the throat. Take caution as to approximating the carotid sinus as loss of consciousness can result from pressure there. Treatment is flexion of the head and neck and rotation away with lateral flexion toward the tender point. Some muscles show tender points and can be treated as follows:

3-10 Levator scapulae – With the patient seated, the practitioner contacts the tender point near the attachment to the scapula. The practitioner then grasps under the patient’s axilla lifting their shoulder and arm until there is no further pain.

3-11 Rhomboids and middle trapezius – Patient is prone. Tender points are located at the lateral edge of the scapula and can also be found at the rib articulations. The scapula should be brought into the position of most comfort with the possible additional inclusion of clockwise rotation by lifting the patient’s arm and shoulder.

Section IV: Strain/counterstrain – The Spine (continued) Thoracic Spine and Ribs Most tenderpoints can be identified with the patient prone, however, these points tend to be more painful when the patient is supine and palpation occurs under them. There are posterior thoracic points, posterior thoracic points with deviated spinous, lateral posterior thoracic points, anterior thoracic points, anterior lateral points for the thoracic spine. There are costovertebral points that are anterior and considered depressed ribs and costovertebral points that are posterior and considered elevated points.

4-1 Posterior thoracic spine points:

4-2 Posterior points T1-3 are treated with the patient prone, their arms dropped over the sides of the table, their head supported by cupping the chin. The spine is placed in extension to the segment. Rotation and side bending are minimal and usually away from the offending side.

4-3 Posterior points T4-6 are treated the same as above but the patient’s arms are placed overhead moving the angle of the spine for effectiveness.

4-4 Posterior points T7-9 is as T4-6 but with support under the chest to raise the spine.

4-5 Posterior points T10-12 require the patient to have support under their chest not their chin. The treatment is accomplished with extension and rotation. Rotation is accomplished by grasping their pelvis at the ASIS and rotating it 45 degrees. The side of the pelvis that is chosen for rotation will be determined by position of maximum comfort.

4-6 Posterior thoracic points with deviated spinous are treated with the patient’s shoulder lifted caudally and rotated backward to accommodate for the deviation. The shoulder that is lifted is the one that is away from the side of the deviation. Lateral posterior thoracic points demonstrating more tenderness, are found midway between the spinous and transverse process or on the transverse process itself. The treatment is consistent for points 1-12 with the patient prone. Their arm of the affected side is up near their head. The action is side bending away with slight rotation toward. Their face is turned away from the side of pain for the upper points and toward the side of pain for the lower points. The practitioner contacts their arm under the axilla and pulls cephalid. Too much rotation will be ineffective. Side bending is more applicable. Anterior thoracic points indicate intervertebral dysfunction and are all treated with the patient in flexion. They can be discerned from internal abdominal issues by flexion as the tenderpoints

will decrease in tenderness upon flexion. Abdominal issues will not change on flexion. Dr Jones has determined these points to be associated with chronic fatigue.

4-7 Anterior points T1-7 are on the sternum at the midline. Anterior points T8-11 are on the abdomen at the midline. Anterior point T12 point is found laterally over the ASIS.

4-8 Anterior point T1 is on the suprasternal notch, point T2 is on the manubrium. They are treated with the patient’s upper back against the practitioner’s chest with their arms over head. The practitioner will flex the patient’s neck and press cephalid while palpating the tenderpoints. Make sure to have full control of the patient when they are returned to neutral.

4-9 Anterior points T3-4 are at the level of the corresponding costal cartilage and is treated as points 1-2 but the patient’s arms are in extension and internal rotation as the practitioner grasps them pushing the patient into flexion. The practitioner’s hands do not contact the tender points in this particular set of points.

4-10 Anterior points T5-8 are treated with the patient’s upper back against the practitioner’s thigh. The thigh is used to maneuver the patient’s torso into the correct flexion posture. Flexion is accomplished to the level being treated. Anterior point 5 is above the xiphoid, point 6 is at the xiphoid junction, point 7 is at the tip of the xiphoid and point 8 is below it.

4-11 Anterior points 9-12 are usually found in patients who have difficulty extending their spine. They are treated with the patient supine, their pelvis in flexion (supported) and their knees drawn to their chest. A pillow under the patient’s buttocks will assist. The patient’s pelvis is rotated slightly to achieve the position of maximum comfort, usually toward the tender side. The practitioner controls the level of hip flexion by contacting the patient’s anterior leg.

4-12 Anterior lateral points are found at levels 5-8 and are at the costal cartilages close to the side of the sternum. Dr Jones has determined these points to be responsible for epigastric pain. The treatment is flexion, ipsilateral side bending and contralateral rotation. The patient is seated with their arm over the practitioner’s knee on a pillow, their head resting on the pillow, the ankle of the unaffected side is tucked under their thigh. The practitioner allows for lateral bending and flexion corresponding to the vertebral level.

4-13 Costovertebral points are usually associated with intervertebral points because they usually occur together. The most significant points are the top five with occasional attention to the 8th and 10th regions. Usually, more tender points are treated first but with the costovertebral points, Dr Jones recommends that the intervertebral points are treated before the costovertebral ones. The two conditions that are addressed are depressed ribs defined as those relieved by depression and elevated ribs, those relieved by elevation.

4-14 Depressed rib 1- This point is below the clavicle lateral to the sternum. Depressed rib 2 is 1 ½ inches below the clavicle. With the patient supine, the practitioner lifts their head and neck to 40 degrees, rotating and laterally bending it towards the painful side. Although these points are anterior, the patient’s symptomatology is posterior.

4-15 Depressed ribs 3-8 – their points are on the anterior axillary line. This is best located just below the outer edge of the pectoralis major muscle. Treatment is accomplished with the patient seated. The patient is slightly laterally bent to the side of pain, contralaterally rotated with the addition of some flexion. It is best accomplished with the patient’s arm over the practitioner’s thigh with a pillow between them.

4-16 Elevated 1st rib point is located on the rib at the base of the neck at its superior surface near the spinal attachment. With the patient seated, their neck is in extension and slight ipsilateral rotation.

4-17 Elevated 2nd rib point is found posteriorly and the patient is seated with their neck in flexion and rotation toward the painful side.

4-18 Elevated ribs 3-6 are treated posteriorly and are located by moving the scapula laterally (patient places their arm across their chest). These ribs will be less prominent upon palpation as opposed to depressed ribs which appear more prominent. With the patient seated, they are laterally flexed and rotated away from the painful side. Intercostal muscles: Strain/counterstrain can be introduced for spasm of an intercostal muscle. It is necessary to shorten the muscle by laterally flexing the torso to approximate the ribs. Rotation of the torso can be added to lateral flexion for this technique depending upon which direction the intercostal muscle fibers are running. For the intercostalis external rotation would be downward and forward. For the internal and innermost, the rotation would be upward and backward. Upper Rhomboids: Strain/counterstrain – With the patient prone, the practitioner contacts the most tender point in the muscle and brings the patient’s shoulder posterior and superior by grasping their anterior shoulder.

Middle rhomboids Strain/counterstrain – With the patient prone treatment is as above, but the shoulder is brought posterior and scapula is brought medial to the body by using the leverage of the patient’s arm cradled in the doctor’s hand.

Section V: Strain/counterstrain – The Spine (continued) and Pelvis Lumbar points There are posterior lumbar spine points and anterior lumbar spine points. The posterior lumbar points will be discussed as PL5, PL3 and PL4 in the order of significance. They are all treated with the patient prone. There is also lower pole L5 point and tender points on the spinous process of L1-L5. The anterior lumbar points are considered AL1, AL2, AL3, AL4, AL5 and abdominal L2, and the patient is treated supine. They are just inferior and medial to the ASIS on a palpable ridge except for AL5 which is on the pubic bone.

5-1 Posterior lumbar points: These points are treated with the patient prone and their ipsilateral leg in extension. The variations on treatment are in the amount of rotation and extension. When the contact hand on the patient’s leg is below the knee, the lift will allow the knee to remain straight and the femur and lower lumbar spine will extend. If the lifting force is applied 6 inches above the knee, the effect on the low back will alter from extension to extension with rotation. L5 point will be treated with the lift below the knee, L4, just above the patella and L3 will be lifted mid thigh.

5-2 Posterior lumbar point L5 (PL5) is treated first since the tender points for L4 and L3 may subside after treatment of this point. The practitioner contacts the superior medial edge of the PSIS and below the patella and lifts the thigh into extension about 15 degrees with their hand upon the patient’s knee.

5-3 Posterior lumbar point L3 (PL3) is treated as the practitioner contacts PL3. This point is midway PL5 and the point for PL4 which is one centimeter posterior to the attachment of the tensor fascia lata and midway between the crest of the ilium and the greater trochanter. The practitioner then contacts the thigh and lifts it about 25 degrees with their hand about 6 inches above the knee.

5-4 Posterior lumbar point L4 (PL4) is treated as the practitioner contacts the point and just above the patella and lifts the patient’s leg about 20 degrees.

5-5 Lower pole L5 is a tender point that is located an inch below the PSIS. With the patient prone, their affected leg is off the table with the femur vertical and the knee at 90 degrees pushed slightly under the edge of the table top.

5-6 Spinous process points L1-L5 are treated with the patient prone. There is no extension in this treatment but the patient’s low back is rotated toward the side of pain by the practitioner who grasps the ASIS and rotates the pelvis about 45 degrees. Anterior lumbar points:

5-7 Anterior lumbar point 1(AL1) is contacted one inch medial to the ASIS. The patient is rotated about 60 degrees toward the practitioner away from the affected side. Their hips and knees are flexed 90 degrees. Any discomfort from the position can be alleviated with pulling behind the flexed knee. Anterior lumbar point 2 (AL2) is contacted one inch inferior to the ASIS and one inch medial. The position is as above.

5-8 Anterior lumbar points 3 and 4 (AL3) and (AL 4) are found one inch inferior to the ASIS whereas AL3 is more lateral, AL4 is more inferior. With the patient’s knees and hips flexed 90 degrees, their legs resting on the practitioner’s knee which is on the table. The practitioner then pulls the patient’s feet away from the involved side to produce lateral bending.

5-9 Anterior lumbar point 5 (AL5) is performed with the contact on the front of the pubic bone within a centimeter of the pubic symphysis. The patient’s knees and hips are flexed; the knees 90 degrees, the hips at 135 degrees. The knees are pulled a little toward the side of pain.

5-10 Abdominal lumbar 2 point is performed like the AL2 point but the contact is in the abdominal wall 2 ½ inches lateral to the umbilicus and a half inch inferior. The patient’s thighs are flexed 135 degrees, and their knees are flexed 90 degrees resting on the practitioner’s knee. The patient is rotated toward the affected side and laterally bent away from the side of pain by the practitioner lifting the feet with their knee. Pelvis: For strain/counterstrain, the pelvis and hip differ from the spine in that it functions to move one side of the body in relation to the other side. In the spine, movement is directed to move the entire spine in a particular direction. Landmarks are used to determine where the points are located. Posteriorly are the PSIS, greater trochanter and tensor fascia lata. Anteriorly are the lateral rami of the pubic bone, a point superiorly on the symphysis and in the perineum on its descending ramus. The points are described according to the abnormal position of the posterior of the ilium in relation to the ipsilateral sacrum. In reference terminology, a posterior sacrum (sacral base) would be described as a high ilium. A low ilium would be a posteriorly oriented sacral apex. Think of the listings as more of a rotation between the bones over a transverse axis than a A-P shearing type strain. Pelvic Points: These points are described as high ilium which refers to a posterior ilium, high ilium with flare out, low ilium which refers to an anterior ilium, low ilium with flare out, and sacroiliac flare in. High ilium points and sacroiliac flare in are treated prone. Low ilium points are treated supine. Restless leg syndrome is also discussed.

5-11 High ilium - The point for a high ilium is found by pressing against the lateral side of the PSIS. The patient’s thigh is extended and rested on the practitioner’s thigh that is on the table. The practitioner holds the patient’s leg below the knee as it is lifted to produce extension of the ilium on the sacrum. The femur is adducted or abducted to find the position of most comfort.

5-12 High ilium with flare-out – Flare out refers to a gapping of the upper portion of the sacro-iliac joint with a compression of the lower portion. This point is 1 ¾ inch below and ¼ inch medial to the lower edge of the PSIS. The thigh is extended and pulled back behind the other leg as the practitioner holds the patient’s knee. This treatment has been successful in stopping coccygeal pain.

5-13 Low ilium – This is treated with the patient supine and their knees and hips flexed as far as they can go. The point is on the superior surface of the lateral ramus of the pubic bone about 1 - 1 ½ inches from the midline. Pain is usually in the back or side of the hip or thigh.

5-14 Low ilium with flare out – This is treated with the patient supine. The point is in the perineum on the medio-inferior side of the descending ramus of the pubic bone. This can be a vulnerable region for treatment and documentation here is important for explanation in treating this point. It is best found by palpating the ischial tuberosity and moving up toward the symphysis pubis about 1-1 ½ inches. The supine patient has their hip flexed, abducted and externally rotated resting their foot on the practitioner’s knee. This can be treated without holding the tender point and just putting the thigh and hip into the correct position.

5-15 Sacroiliac flare in – This is treated with the patient prone and their leg abducted. The point is at the middle of the gluteus maximus muscle about 4 inches below the PSIS and slightly lateral. This point is successful in treating dysmenorrheal. Results usually present themselves by the 2nd menstrual period after treatment.

5-16 Restless Leg Syndrome – With the patient supine, their leg is extended and dropped off the edge of the table. Tender point is on the superior surface of the pubic bone near the symphysis.