Master Counterstrain Overview with Picmonic for Medicine

Counterstrain is an indirect technique, meaning the physician positions the patient’s dysfunction towards a point of ease, away from the restrictive barrier.

Counterstrain is a passive technique, meaning the forces used during treatment come from the physician. The patient is instructed to remain relaxed and to refrain from muscle contraction during treatment.

The predominant theory on the pathophysiology of counterstrain points involves inappropriate proprioceptive firing. Overload of a muscle (the agonist) causes reflexive and defensive contraction. When stretched, the agonist muscle’s spindle fibers sense the strain, and the alpha neurons defensively contract the agonist. The opposing muscle (the antagonist) will be stretched and may then reflexively contract, resulting in a “counter strain”. The counterstrain technique is meant to reset muscle proprioception.

The physician finds a discrete point of tissue texture change in myofascial tissue that is locally tender. Tender points are hypersensitive but do not radiate pain to other areas of the body. Tender points are usually found in muscle, most often the muscle belly or tendinous attachment, but may also be found in other fascial tissues. Tender points are found in consistent locations from person to person.

When palpating a tender point, the physician should establish a pain scale with the patient, such as 0 (not tender) to 10 (severely tender). The physician then tells the patient to consider the pain from the tender point a 10, in order to accurately measure pain reduction. Some prefer to use a percentage scale. For example, pre-treatment pain may be rated as 100%, and complete elimination of tenderness would be 0%.

After establishing a pain scale, the physician places the patient in a position of maximum comfort. This means that palpation of the tender point causes pain rated as 3 or less on the pain scale, or at least a 70% improvement.

The physician holds the patient in the position of maximum comfort for 90 seconds while the patient remains relaxed. This amount of time is sufficient to treat most tender points. A notable exception is the treatment of rib tender points, which should be held for 120 seconds.

During the 90-second hold, the physician may palpate a pulsing sensation in the tender point being treated. This is not necessary for treatment success but usually indicates an adequate response to treatment. This should not be confused with the “local twitch response” observed in myofascial trigger points.

After 90 seconds, the physician slowly returns the patient to neutral, or pre-treatment position. It is important for the patient to remain relaxed during this step.

After returning the patient to neutral, the physician reassesses the tender point and any associated somatic dysfunction.