Syllabus-scsi

Jones Institute Originators of the Strain Counterstrain Technique

Strain Counterstrain I For the Spine

Course Syllabus

Developed and compiled by Randall S. Kusunose, P.T., O.C.S. from the work and concepts of Lawrence Jones, D.O., F.A.A.O. Copyright 1995 Artwork by Shanti Del Maestro

7937 Corte Domingo Carlsbad, CA 92009 Phone: (760) 942-0647 Fax: (760) 942-0645

w w w. j i s c s . c o m Strain Counterstrain I for the Spine

Table of Contents Introduction................................................................................... 3 Technique......................................................................................5 General Rules................................................................................. 6 Anterior Cervicals...........................................................................8 Posterior Cervicals.........................................................................12 Anterior Thoracics..........................................................................16 Posterior Thoracics.........................................................................20 Anterior Ribs – Depressed...............................................................24 Posterior Ribs – Elevated.................................................................26 Anterior Lumbars...........................................................................28 Posterior Lumbars..........................................................................32 Anterior Pelvis and Hip...................................................................36 Posterior Pelvis and Hip..................................................................40 Posterior Sacrals............................................................................44 Evaluation...................................................................................... 47 Home Program...............................................................................51 Reference Articles..........................................................................55

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Strain Counterstrain Definitions: 1. A passive positional procedure that places the body in a position of greatest comfort, thereby relieving pain and dysfunction by reduction and arrest of inappropriate proprioceptor activity that maintains somatic dysfunction. 2. A mild overstretching applied in a direction opposite to the false and continuing message of strain, which the body is suffering. Origin of Strain Counterstrain 1. First observation:

2. Second observation:

Rational for Strain Counterstrain: Based on Proprioceptors and Somatic Dysfunction” by Irvin Korr, Ph. D. Proposed neural basis for joint dysfunction incriminating the muscle spindle.

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Tender Point Definitions: 1. Small zones of tense, tender, edematous muscle and fascial tissue about 1 cm in diameter. 2. Sensory manifestations of a neuromuscular or musculoskeletal dysfunction. Use tender points to make diagnosis and monitor the effectiveness of the treatment technique.

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Jump sign & grimace.

Documenting the diagnosis. 5

Similarities & differences to other systems that use points

Tender points are at least four times more tender than the patient’s normal tissue to palpation. Push with enough pressure to elicit a mild response from the patient’s normal tissue. FINDING THE POSITION OF COMFORT Two ways of finding the position of comfort: 1. Patient feedback. 2. Palpating for the mobile point. Mobile Point Definition: Point of maximum tissue relaxation beneath your monitoring finger where joint movement in any direction will increase tissue sensation.

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How Strain Counterstrain fits into your armamentarium: 1. Acute 2. Fragile (Osteoporotic) 3. Pregnant 4. Pediatrics 5. Chronic 6. Post-Op 7. Neurologic 8. In conjunction with: a. articular techniques b. muscle energy c. Myofascial Release d. exercise e. modalities TECHNIQUE 1. Locate tender point 2. Find position of comfort or mobile point. 3. Monitor point response but take pressure off tissue. 4. Hold 90 seconds. 5. Return to neutral slowly. 6. Recheck tender point-70% improved. GENERAL RULES 1. Hold position of comfort for no less than 90seconds. 2. Return to neutral very slowly. 3. Anterior tender points are usually treated in flexion. 4. Posterior tender points are usually treated in extension. 5. Tender points on or near midline are treated with more flexion and extension. 6. Tender points lateral from midline are treated with more rotation and side bending. 7. With multiple tender points, treat the most severe first. 8. If tender points are in rows, try treating the one in the middle first. 9. Tender points in the extremities can be found on the opposite side of pain. 10. Warn patient that they may get sore following a Strain Counterstrain treatment. 11. No contraindications. 7

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ANTERIOR CERVICALS LC 1 Tender Point:

(p. 46) Find by palpating the position of the transverse process of C1. The mastoid process and the transverse process of C1 are approximated on the involved side. Tender on lateral tip of TP. Push medially.

Treatment:

Patient supine. Side-bend - slightly toward the side of the tender point to exaggerate deformity.

AC 1 (Regular) Tender Point:

(p. 43) Posterior surface of ascending ramus of mandible 3 cm superior to mandibular angle. Approach tender point posteriorly. Push anteriorly.

Treatment:

Patient supine. Flexion - or extension-none Side-bend - away slightly Rotate - away markedly Direct the motion of treatment with pressure on top of the head.

AC 1R (Rare exception) Tender Point: 2 cm anterior to the angle of the mandible along the inferior surface. Push superiorly and laterally along its’ inner edge. Treatment:

AC 2 Tender Point: posteriomedial. Treatment:

AC 3 Tender Point: posteriomedial.

Patient supine Flexion - marked Side-bend - toward slightly Rotate - away (p. 44) Anterior surface of tip of C 2 transverse process. Push Patient supine. Same as AC 1 Flexion - little if any Side-bend - away slight Rotate - away (p.44) Anterior surface of tip of C 3 transverse process. Push

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Treatment:

Patient supine Flexion - marked Side-bend – away, sometimes toward Rotate - away

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AC 4 Tender Point: posteriomedial. Treatment:

AC 5 Tender Point: posteriomedial. Treatment:

AC 6 Tender Point:

(p.44) Anterior surface of tip of C 4 transverse process. Push Patient supine Flexion - slight to moderate, sometimes likes slight extension Side-bend - away Rotate - away (p.44) Anterior surface of tip of transverse process of C 5. Push Patient supine Flexion - moderate Side-bend - away Rotate - away (p.44) Anterior surface of tip of C 6. Push posteriomedial.

Treatment:

Patient supine Flexion - moderate Side-bend - away Rotate - away

AC 7 Tender Point:

(p. 45) Posteriorsuperior surface of proximal clavicle. 3 cm lateral to the medial end. Push inferiorly and anteriorly on the posterosuperior edge of the clavicle.

Treatment:

Patient supine Flexion - marked; support lower posterior neck. Side-bend - toward markedly Rotate - away slightly

AC 8 Tender Point: Treatment:

(p. 45) Medial end of clavicle. Push laterally. Patient supine Flexion - slightly Side-bend - away slightly Rotate - away markedly

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TR Trachea Tender Point:

(p. 48) Along the sides of the trachea as high as hyoid bone and as low as suprasternal notch. Push medially. Used to treat chronic unproductive coughs.

Treatment:

Patient supine Flexion - marked, support lower neck Side-bend - toward slightly Rotate - away slightly

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POSTERIOR CERVICALS PC 1 Inion (Exception) (p. 39) Tender Point: On medial border of main posterior muscle mass of neck (semispinalis capitis), 3 cm below inion (posterior occipital protuberance). Push anteriorly. Treatment:

Patient supine Flexion - marked (tuck chin) Side-bend - toward slightly Rotate - away slightly

PC 1 (Regular) Tender Point:

(p. 40) On occiput below nuchal line, lateral to main muscle mass. 3.5 cm from midline. Push anteriomedial.

Treatment:

Patient supine. Extension - at level of C 1. Lift head to flex lower cervicals, allowing marked extension of C 1 Side-bend - away slightly Rotate - away slightly NOTE: Augment extension of C 1 by hand pressure on top of head.

PC 2 Tender Point:

(p. 40) 1. On occiput, below nuchal line, in lateral belly of the main muscle mass of neck, 1/5 cm lateral to midline. Push anteriorly. 2. Also found on either side of the superior surface of the spinous process of C 2. Push inferiomedial.

Treatment:

Patient supine Extension - same as PC 1 Side-bend - away slightly Rotate - away usually

PC 3 (Exception) (p. 40) Tender Point: On either side of the inferior surface of the spinous process of C 2. Push superiomedial. Treatment:

Patient supine Flexion - marked Side-bend – away, sometimes toward Rotate - away

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PC 4 Tender Point:

(p. 41) 1. On either side of the spinous process of C 3 in the depression below the spinous process of 2 C. 2. In muscle mass between C 4 spinous process and C 4 transverse process. NOTE: Sometimes need to forward bend the neck to find this point.

Treatment:

PC 5,6,7 Tender Point: vertebrae above.

Patient supine. In the supine position suspend the head over the end of the table. Extension Side-bend - away Rotate - away usually (p. 42) On either side of spinous processes of the corresponding

Treatment:

Patient supine Extension - marked Side-bend - away usually Rotate - away NOTE: The more posterior the head is placed the lower the action from PC 4 through PT 2.

PC 8 Tender Point:

(p. 42) Posterior surface of the tip of transverse process of C 7. Approach anterior to the trapezius at the base of the neck by palpating posteromedial toward transverse process. Push anterioinferior on the posterior surface of transverse process.

Treatment:

Patient supine Extension - slight Side-bend - away markedly Rotate - away

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ANTERIOR THORACICS AT 1 – AT 6 Midline Points Points AT 1 Tender Point: Treatment:

AT 2 Tender Point: Treatment:

AT 3 Tender Point: Treatment:

AT 7 – AT 12 Bilateral (p. 57)

Midline in suprasternal notch. Push inferiorly. Patient seated with hands on top of head. Operator places arms around patient and locks hands over the manubrium. Patient slides down operator’s torso producing thoracic flexion. (p. 57) Middle of manubrium. Push posteriorly. Patient seated, same as AT 1 but lock hands lower at junction of manubrium and sternum. (p. 57) On sternum just below sternal angle. Push posteriorly. Patient seated with arms dropped back and off edge of table. Operator pulls backwards on patients arms creating a fulcrum at the desired level. Operator uses his chest and abdomen to force patient’s thoracic spine into flexion. Augment thoracic flexion by internally rotating arms. Flexion

AT 4 (p. 57) Tender Point: On the body of the sternum at the level of 4th interspace. Push posteriorly. Treatment:

Patient seated same as AT 3. Flexion

AT 5 Tender Point:

(p. 58) On the body of the sternum at the level of 5th interspace. Approximately nipple line. Push posteriorly.

Treatment:

Patient seated with arms at side. Operator locks his fingers anteriorly over the tender point. Flexion is created by pulling the patient backwards using medial edges of hands as the fulcrum. Operator leans against patient’s upper thoracic area. Flexion

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AT 6 Tender Point: Treatment:

(p. 58) Xiphisternal junction. Push posteriorly. Patient seated with arms at side. Same as AT 5 but lower. Flexion

AT 7 (p. 58) Tender Point: 1. Under the costochondral margin of 7th rib. Push superiolateral. 2. 1 cm below the xyphoid. 1 cm lateral to midline. Treatment:

Patient seated. Operator has his foot on the table opposite of the tender point. Patient has opposite arm resting on pillow on the operator’s thigh, who stands behind him. Patient’s feet on table on side of tender point. (Side sitting) Flexion - created by sitting Side-bend - toward by translating trunk to opposite side. Rotate away by placing patient’s tender point side arm across front of body. Operator tunes with hip movement.

AT 8 Tender Point: Treatment: AT 9 Tender Point: posterior. Treatment: AT 10 60) Tender Point: posterior. Treatment:

(p. 58) 2 cm below AT 7. 1.5 cm lateral to midline. Push posterior. Same as AT 7 (p. 60) Just above umbilicus. 1.5 cm lateral to midline. Push Same as AT 7 (p. Just below the umbilicus. 1.5 cm lateral to midline. Push 1. Patient supine. Raise the head of the table. Rest patient’s flexed legs on operator’s thigh. Operator stands on side of the tender point. Produce marked flexion at the level of dysfunction. Side-bend - toward Rotate - toward 2. Straight table technique. Patient supine if needed. Place pillows under hips of patient to obtain flexion of pelvis and lumbar spine. Then proceed as above. 24

AT 11 Tender Point: midline.

(p. 60) Suprapubic region at the level of the ASIS. 2 cm lateral to

Treatment:

Same as AT 10. Fine tune.

AT 12 Tender Point:

(p. 60) Crest of ilium at mid-axillary line. On inner table of iliac crest. Roll palpating finger over the top and push inferiorly.

Treatment:

Same as AT 10. Fine tune.

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POSTERIOR THORACICS Thoracics 1-5 often have the most sensitive points on the sides of the spinous processes. The lower thoracic tender points are usually most sensitive paravertebrally or just lateral to spinous processes. At the thoracolumbar junction the most sensitive tender points are found on the posterior tips of the transverse processes or spinous process tender points will be the most tender. With posterior thoracics, the closer the tender point is to the midline the more force in extension is needed. The farther the tender point is from the midline, the more side bending is needed. PT 1-2 51) Tender Point:

Treatment:

(p. On the sides of the spinous processes of T 1 and T 2. Sometimes PT 1 also has a tender point at the elbow 5 cm above lateral epicondyle. Patient prone with the arms along side body. May also be treated supine with the head hanging off the end of the table. Extension - if prone, cradle side of face in flat of hand, extend to

level. Side-bend - away Rotate - away PT 3,4,5

(p. 51 &

52) Tender Point:

Treatment:

On the sides of the spinous processes of T 3,4,5. Sometimes PT 4 also has a tender point at the elbow 5 cm above medial epicondyle.

Patient prone with the arms resting along side of head, in diving position. Extension- Cradle side of face in flat of your hand. Extend to level Side-bend - away Rotate - away

PT 6,7,8,9 Tender Point: common. Treatment:

(p. 52) Lateral to spinous processes in paravertebral area is most

Patient prone with arms resting along side of head. Extension- Cradle side of face in the flat of you hand, extend head to level. Use pillow under patient’s chest to assist the thoracic extension to level. 28

Side-bend - away Rotate - away Alternate Technique Treatment: Patient prone. Arm of tender point side along side of head. Operator stands adjacent to patients’ head and grasps tender point side axilla. Axilla is pulled up in a cephalad direction. Extension – moderate Side-bend – is major force away Rotate - toward

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PT 10,11,12 Tender Point: Treatment:

PL 1-5 (p. 53 & 72) Lateral to spinous processes or on posterior aspect of transverse processes is most common. Patient is prone. Raise cephalic end of table to extend to level. Pull back on anterior pelvis on tender point side to side-bend and rotate. Extension- primarily motion with midline tender points. Side-bend - away, slight with midline points. More side-bending required with lateral points. Rotate - toward, 30-45 degrees

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ANTERIOR RIBS – DEPRESSED AR 1 Anterior First Rib – depressed (p. 65) Tender Point: On the first costal cartilage beneath the clavicle adjacent to the manubrium. Treatment:

Patient supine Flexion - mild cervical Rotate - toward markedly Side-bend - toward. This is the greatest force applied. Point patients’ chin toward the tenderpoint.

AR 2 Anterior Second Rib – depressed 65) Tender Point: 1. On second rib, in the mid clavicular line. 2. High in medial axilla. Treatment:

(p.

Same as first rib depressed

AR 3-AR 6 Anterior Third through Sixth Ribs – depressed (p. 64) Tender Point: On anterior axillary line inferior rib margins at corresponding levels. Push medially. Treatment:

Patient sitting Flexion - sitting is enough Side-bend - toward tender point. Support patient’s opposite axilla on the knee of the operator who stands behind him. Sidebend toward by gently translating patients’ trunk away from tender point side. Can increase side-bending toward by asking patient to place feet on the plinth on the tender point side. (side sitting) Rotate - toward. Let involved side arm hang behind patient to augment rotation.

RIBS INTERSPACE INT 4 – INT 6 Interspace Rib Dysfunctions (p. 59) (also called anterior lateral thoracics) Fourth through Sixth Tender Point:

On or between the costal cartilage just lateral to sternum at the corresponding level. 34

Treatment:

Patient seated with opposite side axilla supported on operator’s knee, who stands behind patient. Patient’s feet on table on side of tender point. Flexion - trunk Side-bend - toward by translating trunk to opposite side. Rotate away by placing patient’s involved side arm across front of body.

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POSTERIOR RIBS ELEVATED PR 1 Posterior First Rib – elevated Tender Point: Superior aspect of posterolateral arch of first rib. Push inferiorly in front of trapezius at base of neck. Treatment:

Patient sitting. Opposite axilla over operator’s thigh. Lean patient mildly toward opposite side. Position head and neck. Extension - slight Side-bend - away slight Rotate - toward moderately

PR 2 – PR 6 Posterior Second through Sixth Ribs – elevated (p. 66 & 67) Tender Point: Posteriorly at angle of ribs on superior surface. Move scapula laterally to allow palpation of rib angles by crossing arm over chest. Treatment:

Patient sitting. Rest axilla of affected side over operator’s thigh, who stands behind patient. Hand of opposite arm behind body. Patient’s feet on table on the opposite side of tender point. (side sitting) Side-bend - away by translating trunk toward tender point side. Rotate trunk away. Operator tunes using his hip. For second rib rotate neck away also.

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ANTERIOR LUMBARS AL 1 (p. 60) Tender Point: Medial surface of anterior superior iliac spine. Push laterally, ¾ inch deep. Treatment:

Patient supine. Raise the head of the table if possible. Rest patient’s flexed legs on operator’s thigh. Operator stands on side of the tender point. Produce marked flexion at the level of dysfunction. Flexion Side-bend - toward usually Rotate - toward tender point side.

AL 2 (p. 73) Tender Point: Inferior-medial surface of anterior inferior iliac spine. Push superiolateral. Treatment:

Patient supine. Operator stands on opposite side of tender point. Flexion - patient’s legs flexed 90 degrees Rotate knees away from tender side 60 degrees (markedly). Side-bend away slightly by pushing feet toward floor.

AbL 2 Abdominal Tender Point: Treatment:

(p. 74) 5 cm lateral to umbilicus. Push posteriorly. Patient supine. Operator stands on same side as tender point. Flexion - more than regular AL 2. Rotate knees toward tender side 60 degrees Side-bend - away by elevating feet upwards

AL 3 Tender Point: medially. Treatment:

(p. 75) Lateral surface of anterior inferior iliac spine. Push

Patient supine. Operator stands on opposite side as tender point. Flexion - flex thighs 50-90 degrees over operator’s thigh. Side-bend - away markedly by pulling feet toward operator. Rotate - slightly to fine tune

AL 4

(p. 75) 40

Tender Point: Inferior surface of anterior inferior iliac spine. Push superiorly. Treatment:

Same as AL 3 with fine tuning.

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AL 5 Tender Point:

(p. 70) Anterior surface of pubic bone, 1.5 cm lateral to pubic symphysis. Push posteriorly on tender point.

Treatment:

Patient supine. Operator stands on same side as tender point. Flexion - flex thighs 60-90 degrees. Side-bend - away slightly Rotate knees toward side of tender point.

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POSTERIOR LUMBARS PL 3 Iliac Tender Point:

(p. 71) 3 cm below margin of ilium and about 7 cm lateral to posterior superior iliac spine. Push anteriorly.

Treatment:

Patient prone. Operator on opposite side of tender point. Extension – lift leg of affected side, support on thigh of operator. Adduct – slightly Rotate – marked external rotation. The operator’s lifting hand placement will determine the amount of rotation. The higher the hand the greater the rotation.

PL 4 Iliac Tender Point:

(p. 71) 4 cm below margin of ilium and just posterior to the border of the tensor fascia lata. Push anteriomedial.

Treatment:

Patient prone. Operator on opposite side of tender point. Extension – lift leg of affected side, support on thigh of operator. Adduct – slightly Rotate – moderate external rotation

UPL 5 Upper Pole (p. 71) Tender Point: Superior medial surface of the posterior superior iliac spine. Push inferiolateral on posterior superior iliac spine. Treatment:

Patient prone. Operator on opposite side of tender point. Extension – lift leg of affected side, support on thigh of operator Adduct – slight Rotate – mild external rotation

LPL 5 Lower Pole (p. 72) Tender Point: 1. 2 cm below posterior superior iliac spine in small saddle between posterior superior iliac spine and posterior inferior iliac spine. 2. Found on the sacral promontory (first sacral spine) in midline. Treatment:

Patient prone. Operator seated on side of dysfunction. Leg on tender point side is dropped off of table, resting on operator’s thigh. Patient’s hip flexed 90 degrees. Patient’s hip is adducted slightly. Flexion – hip to 90 degrees. Adduct – hip slightly 45

QL Quadratus Lumborum (Not in book) Tender Point: 1. On the lateral tips of the transverse processes of L2-L4. Push medially. 2. In the angle between the transverse process of L1 and the 12th rib. Push anteriorly. Treatment:

Patient prone. Side-bend trunk toward tender point. Side-bend legs toward tender point. Abduct and extend hip and fine tune with hip rotation. Extension – hip mildly, if patient lacks hip extension treat in neutral. Abduction – hip moderately Rotate – Play with external rotation to fine tune.

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ANTERIOR PELVIS AND HIP LISI Low Ilium – Sacroiliac (p. 81) Tender Point: Lateral ramus of pubic bone on superior surface. 2 cm lateral to pubic symphysis. Push inferiorly. Treatment:

Patient supine. Flex hip markedly on the tender point side. Flexion – 90-110 degrees Side-bend – none Rotate – none

LIFO Low Ilium – Flareout (p. 82) Tender Point: Inferior medial surface of the descending ramus of the pubic bone. Push superiolateral. Treatment:

Patient supine. Flex patient’s thigh. Abduct femur moderately to accentuate the low flare out. Rotate femur externally – marked by keeping the foot on midline.

AMT Anterior Medial Trochanter or Sartorius (p. 88) Tender Point: 1 cm lateral to the anterior inferior iliac spine (AIIS). Push posteriorly. Treatment:

Patient supine Flex hip – 130 degrees Abduct – 0 degrees Rotate – 0 degrees

ALT Anterior Lateral Trochanter Tender Point: Flex the hip to find this trigger. 2 cm lateral to the AIIS. Push posteriorly. Treatment:

Patient supine Flex hip – 90 degrees Abduct – moderate Rotate – external, little or none

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IL Iliacus Tender Point:

(p. 87) 4 cm medial and caudad to ASIS (Anterior Superior Iliac Spine) in iliac fossa. Push in all directions to check fossa area.

Treatment:

Patient supine. Patient’s ankles supported on operator’s thigh. Extreme flexion of hips, abduction and external rotation of femurs of both legs.

Ing Inguinal Ligament (p. 89) Tender Point: Lateral surface of pubic bone just below the inguinal ligament attachment. Push medially. Treatment:

Patient supine. Operator stands on same side. Flexion – Flex both legs 90 degrees and rest on operator’s thigh. Move the unaffected leg over the top of the affected leg crossing knees. Adduction – of femur Rotate – internal of femur

Add Adductors Tender Point:

(p. 89) Origin of adductors to pubic bone and along the length of the belly of muscle.

Treatment:

Patient supine Adduction – marked. Cross leg of affected side over top of opposite leg. Flexion – slight

Gmi Gluteus Minimus (p. 88) Tender Point: Anterior border of gluteus minimus muscle. Superior and posterior to the greater trochanter. Push posteriorly. 51

Treatment:

Patient supine Flexion – hip to 90 degrees Abduction – slight Rotate – marked internal

TFL Tensor Fascia Lata (p. 88) Tender Point: Belly of the tensor fascia lata muscle. Superior and anterior to the greater trochanter. Treatment:

Same as gluteus minimus

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POSTERIOR PELVIS AND HIP HISI High Ilium Sacroilliac 79) Tender Point: 3 cm lateral to the posterior superior iliac spine. Direct palpating finger medially. Treatment:

(p.

Patient prone Extension – hip supported on operator’s thigh Abduction – slight

HFO-SI High Flare-out Sacroiliac 80) Note: May be associated with coccygodynia.

(p.

Tender Point:

1. Is found 4-7 cm below and slightly lateral to the posterior superior iliac spine. Pushing medially on to the lateral borders of the sacrum. 2. Occasionally on the ischial tuberosity. Push superiorly.

Treatment:

Patient prone. Operator on opposite side. Extend leg on the tender point side high enough to clear opposite leg and adduct across, scissoring the legs. Occasionally the opposite leg is extended and adducted.

MPSI Mid-Pole Sacroiliac (also called Flare-In SI) (p. 83) Tender Point: Middle of the buttocks in a slight depression. Direct palpating finger medially with superficial pressure. Buttocks should accordion up the middle. Treatment:

PIR Piriformis 92) Tender Point: Treatment:

Patient prone Flexion – slight or possible slight extension Abduction – of hip, is the major component (p. In belly of piriformis muscle, on a line between the lateral border of sacrum and greater trochanter. Push anteriorly. 1. Similar to LP 5 (Lower Pole 5th) Patient prone. Operator is seated on tender point side. Leg on the tender point side suspended off table, with patient’s foreleg resting on operator’s thigh. Flexion – hip approximately 90 degrees Abduct – hip horizontally 55

Rotate – slight internal if flexion is above 90 degrees. Slight external if below 90 degrees.

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PLT Posterior Lateral Trochanter (Not in book) Tender Point: Posterosuperior lateral surface of the greater trochanter. Push anterior & inferior. This indicates a dysfunction of the external rotators of the hip. Treatment:

Patient prone. Operator on same side. Extension – hip, operator places knee under patient’s thigh to support extension. Abduction – slight Rotate – marked external

PMT Posterior Medial Trochanter (also called Gemelli) (p. 93) Tender Point: On a line from the ischial tuberosity to the lesser trochanter, along the bottom of the gluteal fold. Push anteriosuperior. Treatment:

Patient prone. Operator on opposite side. Patient flexes knee. Operator bends over to pin patient’s ankle in his axilla then stands up. Extension – hip, moderate Adduction – marked Rotate – marked external

LT Lateral Trochanter (p. 93) Tender Point: 12 cm below trochanter on lateral side of the shaft of the femur. Push medially. Treatment: Patient prone Abduction – hip Rotate – hip, internal or external rotation, slight. GM Gluteus Medius 91)

(p. 57

Tender Point: Treatment:

On a line 1 cm below the iliac crest. Push anteriorly.

Patient prone. Operator on same side. Extension – hip, operator places knee under patient’s thigh to support. Abduction – moderate Rotate – marked, internal

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POSTERIOR SACRALS PS 1 Tender Point: Treatment:

(p. 85) 1.5 cm medial to the inferior aspect of the PSIS bilaterally. Patient prone. Apply a downward pressure with heel of hand on the opposite corner of the sacrum (sacral apex) from which the tender point is found. Produces a backward torsion around an oblique axis.

PS 2 Tender Point: spines. Treatment:

Patient prone. Scoop the sacrum into extension by applying downward pressure to the apex of the sacrum in midline. Produces sacral extension around a tranverse axis.

PS 3 Tender Point: spines. Treatment:

(p. 85) Midline on sacrum between the second and third sacral

Patient prone same as PS 2. Apply a downward pressure to the apex of the sacrum in midline.

PS 4 Tender Point: Treatment:

(p. 85) Midline on sacrum between the first and second sacral

(p. 85) Midline on sacrum just above the sacral hiatus.

Patient prone. Apply a downward pressure to the sacral base in midline.

PS 5 (p. 85) Tender Point: 1 cm medial and 1 cm superior to the inferior lateral angles bilaterally. Treatment:

Cyx Coccyx Point 85) Tender Point:

Patient prone. Apply downward pressure on the opposite corner of the sacrum from which the tender point is found, (sacral base) Produces forward sacral torsion around an oblique axis. (p. Either side of tip of coccyx.

61

Treatment:

Patient prone. Extend sacrum by applying a downward pressure to the apex of sacrum toward side of tender point by twisting your hand in a clockwise or counter-clockwise direction.

Strain Counterstrain Evaluation

62

63

NAME:____________________________________ DATE:_________________ 1 POS CERV IN PC1 PC2

2 ANT RIBS AR1 AR2 AR3

POS RIBS PR1 PR2 PR3

KNEE MM MH PCL

PC2

AR4

PR4

ACL

SH

PC3 PC4

AR5 AR6 INT 4 INT 5 INT 6 ANT LUM

PR5 PR6

PTE LM

MC LC

LH

SUB

SO

PL1

PAT

LD

PL2 PL3

PES ANKLE

ADD PAC

IO MA S STY

PL4 UP 5

LAN

SUP

FRO

EXA

MTS2

LC

LP5 QL POS PELVIS HISI HFO MPSI

MAN FAN

LTS2 POS

ZY SQ

TS3 TMJ TMI TRP

PA PO

PC5 PC6 PC7 PC8 ANT C E R V

AL1

AC1 AC1 R AC2

AL2

AC3 AC4 AC5 AC6

AL4 AL5 ANT PELVIS LISI LIF O IL ING POS THOR

ABL 2

AL3

AC7 AC8 LC1 TRA ANT T H O R AT1

3

POS LUM

5

4

TAL FMC FOOT MCA

POS SAC PS1 PS2 PS3

LCA FCA DCU NAV

PT1

PS4

CUB

PT2

PS5

H.NA V

SHLDR AAC BUR LH

6 CRANIAL OM SB SP LA M CO R NAS

ELBOW RAD CND MOL

LOL WRIST 64

AT2 AT3 AT4 AT5 AT6 AT7 AT8 AT9 AT10 AT11 AT12

PT3 PT4 PT5 PT6 PT7 PT8 PT9 PT11 PT12

CYX ANT HIP AMT ALT ADD GMI POS HIP PIR PLT PMT LT GME

M1 M2 M3 M4 M5 DM1 DM2 DM3 DM4 DM5 BUN

PWR DWR HAND CM1 INT ECM

65

NAME:___________________________________ _________

DATE: 1. DATE: 2.

_________ DATE: 3. _________ DATE: 4. _________

ANTERIOR CERVICAL L1C A1C A1CR A2C A3C A4C A5C A6C A7C A8C TRA

RIGHT [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] []

[] [] [] [] [] [] [] [] [] [] []

L1C A1C A1C R A2C A3C A4C A5C A6C A7C A8C TRA

POSTERIOR CERVICAL

LEFT [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] []

[] [] [] [] [] [] [] [] []

ACOL 2 ACOL 3 ACOL 4 ACOL 5 ACOL 6

[] [] [] [] []

LEFT ACOL [] [] 2 [] ACOL [] [] 3 [] ACOL [] [] 4 [] ACOL [] [] 5 [] ACOL [] [] 6 []

A2T

[] []

[] [] []

[] []

A4T A5T

[] []

P2C P3C P4C P5C P6C P7C P8C

[] [] [] [] [] [] [] [] []

1N []

[]

[]

[]

P1C []

[]

[]

[]

P2C []

[]

[]

[]

P3C []

[]

[]

[]

P4C []

[]

[]

[]

P5C []

[]

[]

[]

P6C []

[]

[]

[]

P7C []

[]

[]

[]

P8C []

[]

[]

[]

[]

[] [] [] [] []

ANTERIOR THORACIC A1T

P1C

LEFT

[]

ANTERIOR LATERAL COLUMNS RIGHT [] [] [] [] [] [] [] [] [] [] [] [] [] [] []

1N

RIGHT [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] []

POSTERIOR LATERAL COLUMNS RIGHT [] [] PCOL2 [] [] [] PCOL3 [] [] [] PCOL4 [] [] [] PCOL5 [] [] [] PCOL6 []

[] [] [] [] []

PCOL 2 PCOL 3 PCOL 4 PCOL 5 PCOL 6

LEFT [] [] [] [] [] [] [] [] [] [] [] [] [] [] []

[] [] [] [] []

POSTERIOR THORACIC [] [] []

[] []

P1T

RIGHT [] []

[]

P1T

LEFT [] []

[] 66

A3T

A7T A8T A9T A10T A11T A12T

[]

[] [] []

RIGHT [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] []

[]

[] [] [] [] [] []

A6T

A7T A8T A9T A10T A11T A12T

[]

[] [] []

LEFT [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] []

[]

P2T P3T

[] [] [] [] [] []

P4T P5T P6T P7T P8T P9T P10T P11T P12T

[] [] [] [] [] [] [] [] [] [] []

[] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] []

[] [] [] [] [] [] [] [] [] [] []

P2T P3T P4T P5T P6T P7T P8T P9T P10T P11T P12T

[] [] [] [] [] [] [] [] [] [] []

[] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] []

[] [] [] [] [] [] [] [] [] [] []

SCALENES RIGHT [] [] SCA2 [] [] [] SCA3 [] [] [] SCA4 []

[] [] []

LEFT [] [] SCA2 [] [] [] SCA3 [] [] [] SCA4 []

[] [] []

RIGHT [] [] SCA5 [] [] [] SCA6 [] [] [] SCA7 []

[] [] []

SCA5 SCA6 SCA7

LEFT [] [] [] [] [] [] [] [] []

[] [] []

67

NAME:___________________________________ _________

DATE: 1. DATE: 2.

_________ DATE: 3. _________ DATE: 4. _________

THORACO-LUMBAR ERECTOR SPINAE TLES6 TLES7 TLES8 TLES9 TLES1 0 TLES1 0 TLES1 1 TLES1 2

RIGHT [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] []

[] [] [] [] [] [] [] []

TLES6 TLES7 TLES8 TLES9 TLES1 0 TLES1 0 TLES1 1 TLES1 2

LEFT [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] []

TRANSVERSOSPINALIS

[] [] [] [] [] [] [] []

ANTERIOR RIBS

A1R A2R A3R A4R A5R A6R INT 4 INT

RIGHT [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] []

LEFT [] [] [] [] [] [] [] []

RIGHT [] [] TRAN1 [] [] [] TRAN2 [] [] [] TRAN3 [] [] [] TRAN4 [] [] [] TRAN5 [] [] [] TRAN6 [] [] [] TRAN7 [] [] [] TRAN8 [] [] [] TRAN9 [] TRAN1 [] [] 0 [] TRAN1 [] [] 1 [] TRAN1 [] [] 2 []

A1R []

[]

[]

[]

A2R []

[]

[]

[]

A3R []

[]

[]

[]

A4R []

[]

[]

[]

A5R []

[]

[]

[]

P1R

A6R []

[]

[]

[]

P2R

INT4 []

[]

[]

[]

P3R

INT5 []

[]

[]

[]

P4R

[] [] [] [] [] [] [] [] [] [] [] []

LEFT [] [] TRAN1 [] [] [] TRAN2 [] [] [] TRAN3 [] [] [] TRAN4 [] [] [] TRAN5 [] [] [] TRAN6 [] [] [] TRAN7 [] [] [] TRAN8 [] [] [] TRAN9 [] TRAN1 [] [] 0 [] TRAN1 [] [] 1 [] TRAN1 [] [] 2 []

[] [] [] [] [] [] [] [] [] [] [] []

POSTERIOR RIBS RIGHT [] [] [] [] [] [] [] [] [] [] []

[] [] [] []

P1R P2R P3R P4R

LEFT [] [] [] [] [] [] [] [] [] [] []

[] [] [] [] 68

5 INT 6 SA

[] []

[] [] [] [] []

[] []

INT6 []

[]

[]

[]

P5R

SA []

[]

[]

[]

P6R FRI B SPI

ANTERIOR LUMBAR A1L A2L AB2L A3L A4L A5L

RIGHT [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] []

[] [] [] [] []

A1L []

[]

[]

[]

P1L

A2L []

[]

[]

[]

P2L

AB2 [] L

[]

[]

[]

P3L

A3L []

[]

[]

[]

P4L

A4L []

[]

[]

[]

A5L []

[]

[]

[]

UP5 L LP5 L PRL 2

ANTERIOR PELVIS LISI LIFO IL ING FLS PD

RIGHT [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] []

[] [] [] [] []

[] []

[] [] []

P5R P6R FRI B SPI

[] [] [] []

[] [] [] []

RIGHT [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] []

[] [] [] [] [] [] []

P1L P2L P3L P4L UP5 L LP5 L PRL 2

LEFT [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] [] []

[] [] [] [] [] [] []

POSTERIOR PELVIS

LEFT []

[]

[]

[] [] [] [] [] [] [] [] []

POSTERIOR LUMBAR

LEFT []

[]

[] [] [] [] [] [] [] [] []

HI-ILSI HFOSI

LISI []

[]

[]

[]

LIFO []

[]

[]

[]

IL []

[]

[]

[]

MPSI

ING []

[]

[]

[]

OI

FLS []

[]

[]

[]

GMX

PD []

[]

[]

[]

RIGHT [] [] [] [] [] [] [] [] [] [] [] [] [] [] []

[] [] [] [] []

LEFT [] [] HI-ILSI [] [] [] HFOSI [] [] [] MPSI [] [] [] OI [] [] [] GMX [] [] [] []

[] [] [] [] [] []

69

Strain Counterstrain Home Program

70

Strain Counterstrain Home Program General Rules: 1. Monitor tender point if possible 2. Find most comfortable position that reduces tenderness and feels good. 3. Hold that position for two to three minutes. 4. Return to neutral very slowly. 5. Repeat twice daily.

UPPER ANTERIOR CERVICAL Lying: Palpate point behind jaw just below the lobe of the ear. Turn head away from painful side until tenderness diminishes.

MIDDLE ANTERIOR CERVICALS Lying: Head supported on a pillow against a headboard in moderate flexion. Palpate point on side of the neck. Turn head away from the painful side until tenderness diminishes.

POSTERIOR CERVICALS Lying: Palpate point on posterior spine. Slide your head slowly off the edge of the bed allowing the neck to gently extend. Turn head away from the painful side until tenderness diminishes. Remember: This position must feel comfortable.

UPPER ANTERIOR THORACICS Sitting: Palpate point midline on the sternum. Slowly slump in the chair, gently folding your body over the point until the tenderness diminishes. MIDDLE ANTERIOR THORACICS Sitting: Palpate point in the upper abdomen just off midline. Lean the non-painful side up against the armrest of the sofa using pillows. Bring your feet up by your side. Rest opposite hand on pillows. Accentuate gentle side bending toward the point until the tenderness diminishes. 71

POSTERIOR THORACICS Lying: Prop pillows under your chest to create increased extension in the upper to middle back. Raise arms up over pillows. Turn head away from the side of the point until you find a comfortable position.

ELEVATED AND DEPRESSED RIBS Sitting: Lean you side up against the armrest of sofa using pillows to support your arm. Bring your feet up by your side. Rest opposite arm behind back. Accentuate gentle side bending toward your feet until you find a comfortable position.

ILIACUS Lying: Palpate point in the lower abdomen. Lie in front of a sofa with a pillow beneath your buttock. Place your feet on the sofa with the bottoms together. Allow your knees to fall gently out to the sides until the tenderness diminishes and you feel relaxed.

ANTERIOR LUMBARS Lying: Palpate point on the lateral pelvic bones. Lie in front of a sofa with a pillow beneath your buttocks. Place your feet on the sofa. Allow your knees to fall slowly away from the side of the point until the tenderness diminishes.

PIRIFORMIS Lying: Lie on your stomach so that the affected side is nearest to the edge of the bed. Draw the affected hip up until you have close to a 90-degree angle at the hip. Adjust the hip out to the side while supported on the bed until you find a comfortable position.

72

73

Reference Articles

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