Discovered serendipitously:
Dr. Lawrence Jones, DO in 1950's.. Jones Institute
Body positioning to establish a "position of comfort
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Use of tender points- specific ... red hot poker, grimace, flinch, pull away...
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Indirect Manual techniques: not where hot spot is.
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Tender Points: follow along
Acupuncture Points
Tender Point vs Trigger Points:
nm-dfxn (fascia related perhaps) v. ischemic compression
Tender Point -
Two primary causes of tender points neuro- muscular dysfunction within the muscle spindle and disruption within the serous membranes (related to fascia), visceral ligaments, visceral smooth muscle cells.
Some areas of tender-point pain:
PCL, ACL, upper trap, suprascap nerve, ribs common, pylorus valve, lung pleura, bladder
Trigger points-
Hypersensitive areas that tend to trigger a response
Treatment for Tender points -
Tend not to respond for more than 24 hours to the "HUM" approach. There are neurological issues that need to be addressed
Treatment for Trigger points -
Tend to respond more favorably to the "HUM" approach, ischemic compression, injections
Origin of Strain/Counterstrain First Observation - The Discovery Second Observation:
Missing tender points - anterior producing pain posterior - Tender points in extremities were not found in the muscle strained but in the antagonist PCL vs ACL - Treating extremities involves greater amplitude of movement
1st S-CS Definition:
A passive positional procedure that places the body in a position of greatest comfort, thereby relieving pain by reduction and arrest of inappropriate proprioceptor activity that maintains somatic dysfunction
2nd S-CS Definition:
A mild over-stretching applied in a direction opposite to the false and continuing message of strain which the body is suffering. This is accomplished by shortening the muscle containing the false strain message so much that it stops reporting the strain
Musculoskeletal Dysfunction Structural and Functional Models
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Structural Model:
associated with anatomic and postural deformation of tissue
Functional Model:
Biomechanical, non-linear somatic disturbance creating tissue changes resulting in pain, loss of motion/tissue extensibility, movement imbalances, leading to decreased function
Myofascial Model:
bunching and lines of pull
Rationale for Strain/Counterstrain: Based on the work of Irvin Korr, Ph.D "Proprioceptors and Somatic Dysfunction" Journal of The American Osteopathic Association, March 1975, Vol 74 (7): Proposed a ...
neural basis for joint dysfunction incriminating the muscle spindle
Musculoskeletal System and Proprioceptive Reflexes Ruffini Receptors -
found in joint capsule and report position, velocity, direction of movement
Musculoskeletal System and Proprioceptive Reflexes GTO -
musculotendinous junction and monitor excessive tension
Musculoskeletal System and Proprioceptive Reflexes Muscle Spindles -
located between muscle fibers and very sensitive to position, load, and velocity
Muscle Spindle's alpha motor neurons is triggered to contract
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Irvin Korr's Revelations:
Dysfunction that characterizes the osteopathic lesion does not arise in the joint, but are imposed by muscles that traverse the joint - Blames the primary or annulospiral proprioceptor reflexes in the muscle spindle. Increased gamma discharge exaggerates
Jones Neuromuscular Model: a strain is adjusted with a counter-strain
and that becomes an area of dysfunction
Jones's Postulates: Not a lesion but an on-going neuromuscular noxious stimulus. For success...
hyper-stimulated muscle must return to neutral length slowly
In spite of subjective pain and weakness in strained muscle, objective evidence in antagonist of painful muscle
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Jones's Postulates POC and lasting relief -
maximum shortening of antagonist and repeated stretch of painful muscle
Treatment does not cure, it decreases or eliminates irritation and allows body to heal itself
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The Facilitated Segment
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A lesion represents a facilitated segment of the spinal cord, maintained in that state by impulses of endogenous origin entering the corresponding dorsal root. All structures receiving efferent nerve fibers from that segment are potentially exposed to exc
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The Facilitated Segment
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When these impulses extend beyond their normal sensory-motor pathways, the CNS begins to misinterpret the information due to an
overflow of neurotransmitter substance within the involved segment
Facilitated Segment Exemplified by: hyper-excitability -
a minimal impulse produces excessive responses
Facilitated Segment Exemplified by: overflow -
impulse may "spill over" to adjacent pathways
Facilitated Segment Exemplified by: autonomic dystrophy -
sympathetic ganglia become over-stimulated which decreases healing potential
ART" Somatic dysfunction detectable by physiological manifestations in:
Asymmetry Restricted motion Texture abnormalities and tender points
Summary L.H. Jones, 1995 slide 24 : The muscle cant work right unless the muscle is reset. Initial disturbance to progression:
Nociceptive Input and Proprioceptive Input stimulates III and IV afferents> Gamma Motor Neurons> Muscle Spindle Apparatus> Ia, II Afferents> Alpha Motor Neurons> Alpha Motor Neuron Axon> Increased Muscle Tension> Compensatory Structural Changes Chronic Ir
Somatic Dysfunction:
Extra-articular. Manifestation of abnormal proprioceptive activity (muscle spindle). Inability of muscle spindle to reset is what maintains joint dysfunction
What is a Tender Point?
Small zones of tense, tender, edematous muscle and fascial tissue about 1 cm in diameter - Sensory manifestations of a neuromuscular or musculoskeletal dysfunction - Manifestation of facilitated segment - a diagnostic indicator
Jump Sign:
patient / athlete will respond to pressure by moving away
Grimace Sign:
visual representation of tender point
Goals of Strain/Counterstrain
An indirect technique to restore tissue to normal physiological function
Positioning of patient uses ..
2-3 planes of movement to place tissue in position of comfort (POC)
Position of comfort
POC is reached when palpable tenderness of TP softens and or decreases (comfort zone) by at least 75%
Finding the Position of Comfort..
Patient feedback... Palpating the mobile point which is the point of maximum ease or relaxation. It is the ideal position for a release... Palpating the "therapeutic pulse" gotta be good
Effects of Strain Counterstrain:
Normalization of muscle hypertonicity -Normalization of fascial tension - Reduction of joint hypomobility - Increased circulation -Decreased swelling - Decreased pain - Increased strength, movement, function
Treatment Techniques:
-Locate the tender point - Apply subthreshold pressure on tender point while finding POC or mobile point - Monitor point response but take pressure off - Hold for 90 seconds - Return to neutral slowly - Recheck tender point
General Treatment Principles:
Hold POC for no less than 90 seconds - Return to neutral slowly - Anterior tender points are usually treated in flexion - Posterior tender pints are usually treated in extension -Tender points on or near the midline are treated with more flexion and exten
General Treatment Principles: With multiple tender points...
treat the most severe first.. May get sore following treatment
If the tender points are in rows try treating
the one in the middle first
Treat area with ________ number of TP's first:
greatest
Tender points in the extremities are usually found on the ______ side of pain.
opposite
Postural deviations: Flattened forward curves or accentuated backward curves -
major posterior TP's
Postural deviations: Accentuated forward curves and flattened backward curves -
major anterior TP's
SCS: Pain specific in posterior region -
posterior TP's
SCS: Diffuse or large areas of pain -
anterior TP's
Scanning Evaluation:
Evaluate for multiple tender points - Record the severity of the tender points + jump sign - extremely severe + grimace - very tender -moderate
Contraindications / Precautions:
Open wounds Recent sutures Healing fractures Hematoma Hypersensitivity of the skin Systemic / localized infection Acute MI - Precaution THP - Precaution
Indications:
-Acute injuries, MVA (Sports!) -Fragile (osteoporosis) -Pregnant - Pediatrics - Chronic pain -Post-op (lumbar, knee, shoulder, hip, ankle, etc) -Neurologic
Used in conjunction with:
Articular techniques/joint mobs - Muscle energy techniques -Myofascial release -Exercise -Modalities
Post-Treatment:
-Always return slowly to neutral -Recheck TP after you return to neutral -Warn patient they may experience increased soreness 24-48 hours post
Case Study #1 Patient: 40 y/o male construction worker Injury: Carrying heavy load on shoulder, sustained neurotmesis of CN XI (spinal accessory), 3 years prior to injury... Referred to PT by IME physician to aid in disability determination after a 1 mont
after initial subjective interview was performed, SCS to the UT was performed for 90 seconds. Patient reported complete resolution of pain. Patient returned in 2 days, 1 week and 2 weeks for f/u and pain remained abolished.
Case Study #2 Patient: 63 y/o retired female... Injury: Insidious onset of upper back, left shoulder, neck and chest pain.. Neurological: normal... Pain: constant 5/10; increases to 8/10 when attempting to lift at work... Gait: antalgic... Palpation: TP's
iliacus TP with significant increase in trunk ROM; L4 and L5 TP's treated with full trunk ROM and no pain
Summary:
Scan body for TP (fq bony prominences), grade severity... Follow general rules... Monitor TP while finding POC... Maintain contact with TP while in POC... Hold POC until complete release... Return to neutral slowly... Recheck TP... Warn patient and avoid