Positional Release: An Option for Acute Injury

image courtesy of openi beta

While OMPT Training at the University of St. Augustine and going through their DPT program, I met an Australian Physiotherapist who loved a technique called Strain Counterstrain.

He was convinced it was the next big thing and even completed a doctoral dissertation on studying the technique. He shared his research with me a while back, but I have misplaced it. I find the official SCS Technique and Assessment a bit too specific, but using positional release for acute injuries like ankle sprain, and even acute MVA happens to work well. Here is a brief overview of how to positionally release a tender point and when you should consider it.

Positional Release - What is it?

using passive painless positioning to improve increased tone and tenderness
slacking the muscle where there are tender points located as opposed to "stretching" it

How is it done?

find a tender point, normally with increased tone
if there are several along a certain area or pattern of tissues, trying releasing the most tender and/or proximal one first
palpate the tender point (with or without referral/twitch) lightly
"If this is 100% tender, let me know when it is about 30% tender."
"I will try to find a position of ease by moving your (insert body part here)."
"Do not help me."

slack the muscle according to it's action slowly and passively
it should not hurt, nor should it case pain anywhere else
if it works well, a decrease in palpable tone should be accomplished along with a decrease in palpable pain
if you can find a position that makes the tenderness 30% of what it originally was - or hopefully gone altogether, continuing holding it passively for 30-90 seconds (depending on what technique you're following, I do 60 on average)

"Do not help me on the way back. I am very slowly going to return your limb to it's resting position (neutral)."

this has to be passive, otherwise the tone will return
the theory is that passive will avoid previously overactive GTOs

if active those GTOs will fire the previously abnormal signal and the tone/tenderness will return

upon return, the pain/tone should stay improved, and overall pain free motion should be increased
release other tender points along the agonist and the antagonist

i.e. cervical paraspinals and SCM, scalenes

When Do I Use It?

there is a lack of evidence apparently for even reliably detecting TrPs, that is why I am not a fan of Strain Counterstrain's exact points of tenderness - there are 8 exact cervical points anteriorly and posteriorly and some of them are often millimeters apart - what if you have fat fingertips?
I use it when a patient comes in after an acute MVA, ankle sprain, etc... and wants more treatment than go home and rest
in other words, someone unable to move, AFTER a trauma, or major exacerbation that now has hypersensitivity to all but light palpation and slow passive movement

Case Examples

the last MVA that came in 1 day after a major acceleration/deceleration accident - cleared for instability by x-rays - had limited ROM/pain in all directions
light touch and counterstrain to several points along her cervical paraspinals, SCM, upper traps improved her pain free ROM in all directions by at least 25%, from 0 degrees with pain in all directions
that's not a huge improvement but got her moving a bit and significantly reduced pain
acute ankle sprain - moved into the slacked position of the peroneal musculature, palpating for decrease in pain/tone, holding for 60 seconds, then slowly passively returning the foot/ankle to neutral
patient coming in with a HA exacerbation and not being able to tolerate manual techniques to the occiput, cervical paraspinals, distraction etc...

often they will have very tender points with increased tone in the upper cervical area
releasing these by passive movement into upper cervical extension, with slight SB/rot depending on the side, often greatly decreases pain, increases ROM, then they may tolerate other techniques like the subcranial shear distraction after

It's not a technique I use often, but it does have it's uses, especially when a patient typically needs to rest after acute traumatic injury or has an exacerbation and allodynia to previously tolerated manual techniques or active exercises.

Keeping it Eclectic....