Leon Chaitow ND DO MROThere are few more satisfying, non-invasive, gentle and safe methods for easing muscular contraction,tension or spasm than the various methods which involve ‘positional release’.
These methods all call for the positioning of an area, or the whole body, in such a way as to produce a combination of neurological and circulatory changes which produce pain relief and relaxation of soft tissues.
The developer of Functional Technique, Harold V. Hoover DO used the term ‘dynamic neutral’ to describe what it was that was being achieved as disturbed tissues were positioned in a state of ‘ease’.1
As we examine the mechanisms of what is taking place when tissues are placed in a balanced state the terms ‘ease’ and ‘bind’ will frequently be used to describe the extremes of restriction and freedom of movement.
It was Lawrence Jones DO who first developed an approach to joint and soft tissue dysfunction which he termed ‘Strain and Counterstrain’ (SCS).2
Walther Describes Jones Discovery3
‘Jones’ initial observation of the efficacy of counterstrain was with a patient who was unresponsive to treatment. The patient had been unable to sleep because of pain. Jones attempted to find a comfortable position for the patient to aid him in sleeping. After twenty minutes of trial and error, a position was finally achieved in which the patient’s pain was relieved. Leaving the patient in this position for a short time, Jones was astonished when the patient came out of the position and was able to stand comfortably erect. The relief of pain was lasting and the patient made an uneventful recovery.’
The position of ‘ease’ which Jones found for this patient was an exaggeration of the position in which spasm was holding him, which provided Jones with an insight into the mechanisms involved.
Many hospitalised patients have been treated for their current pain and discomfort, without leaving their beds, using these methods.4
SCS requires verbal feedback from the patient as to pain in a ‘tender’ point, being palpated by the operator as a monitor while a position of ease is sought.
Where there is a language barrier, or someone has lost the ability to speak, or is too young to cooperate a need exists for a method which allowed the operator to achieve the same ends without words, in which the operator determines a position of ease by means of palpation alone, assessing for a state of ‘ease’ in the tissues.
1. Exaggeration of Distortion
This is an element of SCS methodology.
Consider the example of someone bent forward in psoas spasm/’lumbago’ in considerable discomfort or pain. The person would be posturally distorted – bent into flexion,together with rotation and sidebending.
Any attempt to straighten towards a more physiologically normal posture, pushing through the ‘barrier of resistance’ would produce pain.
However moving the area away from the restriction barrier (in this case bending forwards more), increasing the degree of distortion displayed would normally be easy and painless. After 60 to 90 seconds in such a position of ease, a slow return to neutral will commonly leave the patient somewhat or completely relieved of pain and spasm.
2. Replication of Position of Strain.
This is another element of SCS methodology.
If as someone bending they slip or their load shifts they might remain locked into a distorted position as in example 1.
If, as SCS suggests, the position of ease equals the position of strain – then they need return to flexion in slow motion until tenderness vanishes from the monitor/tender point and/or a sense of ‘ease’ is perceived in the hypertonic tissues. By adding ‘fine-tuning’ positioning to the position of ease achieved by flexion, greater reduction in pain can usually be achieved. This position is held for 60 to 90 seconds before slowly returning to neutral at which time a some resolution of hypertonicity and pain should be felt.
The position of strain is often an exact duplication of the position of exaggeration of distortion – as in example 1.
Limited Value
These two elements of SCS are described as examples only, since it is not a frequent occurrence to have patients describe precisely in which way there symptoms developed. Nor is obvious spasm such as torticollis or ‘lumbago’ the norm. Ways other than ‘exaggerated distortion’ and ‘replication of position of strain’ are needed to enable identification of positions of ease.
3. Jones’ Tender Points5
Through years of clinical experience Jones compiled lists of tender point areas relating to strain of most of the joints and muscles of the body. These ‘proven'(by clinical experience) points are usually found in tissues shortened at the time of strain, rather than those which were stretched.
New points are periodically reported – for example recent sacral foramen points relating to sacroiliac strains.6
Jones provided directions for achieving ease tender points being palpated involving maintenance of pressure on the tender point, or periodically probing it, as a position is achieved in which:
a/ there is no additional pain, and
b/ the monitor point pain reduces by at least 75%.
This is then held for an appropriate length of time (90 seconds according to Jones, however there ways of reducing this).
The person with acute low back pain, locked in flexion,will have a tender point in the abdominal muscles short at the time of strain (when the patient was in flexion). The position which removes tenderness from this will, as in previous examples, require flexion and probably some rotation and/or side-bending.
The problem with Jones’ formulaic approach is that the mechanics of the particular strain with which the operator is confronted may not always coincide with Jones’ guidelines. An operator relying on Jones’ formulae may find difficulty in handling a situation in which the prescription fails to produce results. It is suggested that a reliance on palpation skills and other positional release variations offers a more rounded approach to dealing with strain and pain.
4. Goodheart’s Approach7,8
George Goodheart D.C. (the developer of Applied Kinesiology) has described an almost universally applicable formula which relies more on the individual features displayed by the patient, and less on rigid formulae as used in Jones’ approach.
Goodheart suggests that a tender point be sought in the tissues opposite those ‘working’ when pain or restriction is noted. If pain or restriction is reported or is apparent on any given movement, the antagonist muscles to those operating at the time pain is noted will be those that house the tender point(s).
In examples 1 and 2, of a person locked in forward bending with acute pain and spasm, using Goodheart’s approach, pain and restriction would be experienced as the person moved into extension from their position of enforced flexion.
Irrespective of where the pain is noted when trying to straighten from this position, the tender point would be sought (and subsequently treated by being taken to a state of ease) in the muscles opposite those working when pain was experienced – i.e. it would lie in the flexor muscles (probably psoas) in this example.
Tender points which are going to be used as ‘monitors’ during the positioning phase of this approach are not sought in the muscles opposite those where pain is noted, but in the muscles opposite those which are actively moving the patient or area when pain or restriction is noted.
Goodheart has added various refinement which reduce the amount of time the position of ease needs to be maintained, from 90 seconds to 30 seconds.
5. Functional Technique9,10
Osteopathic functional technique ignores pain as its guide to the position of ease and relies instead on a reduction in palpated tone in stressed (hypertonic/spasm) tissues as the body (or part) is being positioned or fine-tuned in relation to all available directions of movement in a given region.
One hand palpates the affected tissues (moulded to them, without invasive pressure). This ‘listening’ hand assesses changes in tone as the operator’s other hand guides the patient or part through a sequence of positions which are aimed at enhancing ‘ease’ and reducing ‘bind’.
A sequence of evaluations is carried out, each involving different directions of movement (flexion/extension, rotation right and left, sidebending right and left etc) with each evaluation starting at the point of maximum ease discovered during the previous evaluation, or at the combined position of ease of a number of previous evaluations. In this way one position of ease is ‘stacked’ on to another until all directions of movement have been assessed for ease.
Were the same patient with low back problems(examples 1, 2) being treated using Functional Technique the tense tissues in the low back would be palpated. A sequence of flexion/extension, sidebending and rotation in each direction, translation right and left, translation anterior and posterior, and compression/ distraction, would be painlessly attempted, involving all available directions of movement of the area, until a position of maximum ease is arrived at and held for 30 to 90 seconds. This produces a release of hypertonicity and reduction in pain.
The precise sequence in which the various directions of motion are evaluated is irrelevant, as long as all possibilities are included. Only very limited range of motion would be available in some directions during this assessment and the whole procedure would be performed very slowly.
The position of palpated maximum ease (reduced tone) in the distressed tissues should correspond with the position which would have been found were pain being used as a guide, as in either Jones’ or Goodheart’s approach, or using the more basic ‘exaggeration of distortion’ or ‘replication of position of strain’.
6. Any Painful Point as a Starting Place for SCS.
All areas which palpate as painful are responding to, or are associated with, some degree of imbalance, dysfunction or reflexive activity which may well involve acute or chronic strain (see March, April and June articles in this series).
We might therefore consider that any painful point found during soft tissue evaluation, massage or palpation, including a search for trigger points, could be treated by positional release, whether we know what strain produced them or not, and whether the problem is acute or chronic.
The response to positional release of a chronically fibrosed area will be less dramatic than from tissues held in simple spasm or hypertonicity. Nevertheless, even in chronic settings, a degree of release and ease can be produced, allowing for easier access to the deeper fibrosis.
Treatment of painful tissue using positional release, is possible whether using reducing levels of pain in the palpated point as a guide or whether the concept of assessing a reduction in tone in the tissues is being used (as in example 5 above).
Anything from 20 to 60 seconds are suggested for holding the painless position of ease.
7. Facilitated Positional Release (FPR)11
This involves the positioning of the distressed area into the direction of its greatest freedom of movement starting from a position of ‘neutral’.
The seated patient’s sagittal posture would be modified to take the body or the part (neck for example) into a more ‘neutral’ position – a balance between flexion and extension – following which an application of a facilitating force would be introduced. No pain monitor is used but rather a palpating/ listening hand is applied (as in Functional technique) which senses for changes in tone in distressed tissues as positioning is performed. The final ‘crowding’ of the tissues, to encourage a ‘slackening’ of local tension, is the facilitating aspect of the process. ‘Crowding’ might involve compression applied through the long axis of a limb, or directly downwards through the spine via cranially applied pressure.
The position of ease is usually suggested at just 5 seconds.
8. Induration Technique12
Marsh Morrison DC suggested very light palpation, using extremely light touch, as a means of the feeling a ‘drag’ sensation (see March issue of JACM) alongside the spine (as lateral as the tips of the transverse processes). Drag results from hydrosis, the physiological response to increased sympathetic activity, an invariable factor in skin overlying trigger and other forms of reflexively active myofascial areas. Once drag is noted pressure into the tissues normally identifies pain.
The operator stands on the side of the prone patient opposite the side in which pain has been discovered in paraspinal tissues.The point is held by firm thumb pressure while, with the soft thenar eminence of the other hand, the tip of the spinous process most adjacent to the pain-point is very gently eased towards the pain (ounces of pressure only) crowding and slackening the tissues being palpated, until pain reduces by at least 75%.
Somewhere within an arc involving a half circle, an angle of push towards the pain will be found to abolish the pain,lessening any palpated tension. This is held for 20 seconds after which the next point is treated. A full spinal treatment is possible using this extremely gentle approach which incorporates the same principles as SCS and Functional technique.
9. Integrated Neuromuscular Inhibition Technique13
INIT involves using the position of ease as part of a sequence which commences with the location of a tender/pain/trigger point, followed by application of ischemic compression (this is optional and is avoided if pain is too intense or the patient too fragile or sensitive) followed by the introduction of positional release (as in number 6 above).After an appropriate length of time during which the tissues are held in ‘ease’ the patient is asked to introduce an isometric contraction into the affected tissues for 7 to 10 seconds after which these are stretched (or they may be stretched at the same time as the contraction – if fibrotic tissue calls for such attention).
10. Fascial Release
Soft tissues are gently moved towards the direction of their greatest ease until ‘release’ occurs. The process is repeated until there exists symmetry of motion in all directions of possible motion.
11. Cranial Methods (applicable anywhere on the body)14
Restricted structures/tissues are taken towards their direction of greatest ease of motion, at which time this position is held until there is a sense of an attempt by them to return towards the direction from which they have come. This is gently resisted for a short time. Subsequently the barrier usually retreats and the tissues can be taken into greater ease in previously restricted directions, and the process is repeated.
Summary
All methods require positioning to be performed slowly without introducing any additional pain to the patient.
In all variations a slow return to neutral is advised following the holding of the position of ease.
Most of the positional release methods involve movement towards ease, away from bind, using a slackening or crowding of dysfunctional tissues in order to facilitate muscle spindle resetting and improved function.
Despite the gentleness of the methods there is almost always a reaction involving stiffness and possibly discomfort on the day following treatment, as tissues adjust to new their situation and adaptation processes accommodate to these changes.
References
1. Hoover H Collected Papers Academy of Applied Osteopathy Year Book 1969
2. Jones L Strain and Counterstrain Academy of Applied Osteopathy Colorado Springs 1981
3. Walther D Applied Kinesiology Synopsis Systems DC Pueblo Colorado 1988
4. Schwartz H The Use of Counterstrain in an acutely ill in-hospital population J. American Osteopathic Association 86(7)pp433-442 1986
5. Jones L op cit
6. Ramirez M et al Low Back Pain – Diagnosis by six newly discovered sacral tender points and treatment with counterstrain technique J American Osteopathic Association 89(7) pp905-913 1989
7. Goodheart G Applied Kinesiology Workshop Procedure Manual 21st Edition (Detroit – privately published) 1984
8. Walther D Applied Kinesiology Synopsis Systems DC Pueblo Colorado 1988
9. Hoover H op cit
10. Bowles C Functional Technique – a modern perspective J American Osteopathic Association 80(3)pp326-331 1981
11. Schiowitz S Facilitated Positional Release J American Osteopathic Association 90(2)pp145-156 1990
12. Morrison M Lecture Notes presentation/seminar Research Society for Naturopathy, London 1969
13. Chaitow L Integrated Neuromuscular Inhibition Technique British Journal of Osteopathy Vol13 1994 p17-20
14. Upledger J & Vredevoogd J Craniosacral Therapy Eastland Press Seattle 1983
Leon Chaitow DO, former editor of JACM, practices at The Hale Clinic London (0171-631-0156). He teaches widely in the UK, Europe and the USA, and is author of major textbooks including ‘Soft tissue Manipulation’ . He is a senior lecturer on the University of Westminster’s MA in Therapeutic Bodywork course.
Senior Lecturer, University of Westminster
Jim Strohecker
Daniel Redwood DC