Vol. 14 Issue 4
Treating Tender Points
A look at a revolutionary paradigm–the Jones strain-counterstrain technique
Strain-counterstrain is a gentle manual technique used by physical therapists and other manual therapy practitioners in the treatment of pain and certain musculoskeletal dysfunctions. It was developed by Lawrence H. Jones, DO, FAAO, in the 1950s.
Dr. Jones defines strain-counterstrain as 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."1
Dr. Jones discovered strain-counterstrain in the 1950s while treating a patient with chronic lumbar pain that caused a stoop forward posture (psoasitis). The patient had been unable to find a comfortable position for months, which prevented him from sleeping.
Dr. Jones devoted one treatment session to finding a comfortable position for this patient. The patient was placed in an extreme position, in which he was nearly rolled into a ball, with the pelvis rotated 45 degrees and laterally flexed 30 degrees. Dr. Jones then left the patient in that position while he treated another patient.
When he returned and moved him out of that unusual position, the patient was suddenly pain free and could stand erect.1 It was this patient scenario that initiated Dr. Jones' experimentation with positional release, which later developed into the treatment technique known today as Jones Strain-Counterstrain.
Dr. Jones defines strain-counterstrain as:
1. The relief of rheumatic pain by placing a joint in its position of greatest comfort.
2. The relief of false messages of continuing strain arising in dysfunctioning proprioceptor reflexes, by applying a strain in the direction opposite that of the false messages of strain. This is accomplished by shortening the muscle containing the false strain message so much that it stops reporting strain.2
Thus, strain-counterstrain is a nontraumatic, indirect technique that utilizes positional release to relieve somatic dysfunction.3 The basic premise involves decreasing muscular tension (and thus tenderness) at specific points in the body called "tender points."3
Strain-counterstrain treatment is based on the presence of palpable myofascial tender points that relate to specific somatic dysfunction.1 According to Dr. Jones, tender points are small zones of tense, edematous muscle and fascial tissue about a centimeter in diameter.1
These tender points are found by using moderate palpatory pressure. Not only are tender points used as a diagnostic tool for identifying which areas to treat, but they also can be used as monitoring points. During treatment, the therapist monitors the tender point for changes in tissue tension as well as the patient's feedback regarding reduction in tenderness. When significant reduction in tenderness of the tender point occurs, the point is referred to as a "mobile point" and it signifies the ideal position for release.1
The Role of the Muscle Spindle
Not only is the musculoskeletal system the recipient of efferent outflow from the central nervous system, it is also a source for sensory input from the body to the central nervous system.4 In addition to an efferent nerve supply, muscles have afferent nerve endings that enable the muscle to signal its state of contraction to the central nervous system (CNS).5
This muscular feedback, along with feedback from tendons, ligaments and joint capsules, provides an awareness of the joint position and rate of movement to the CNS. This afferent nerve supply arises in the muscles, ligaments, etc., in structures known as muscle spindles (or neuromuscular spindles) and Golgi tendon organs, to name a few.
These proprioceptive nerve endings in muscles and joints are sensitive to pressure, stretch, vibration, and speed. It is these proprioceptors that can be the neural basis of a somatic dysfunction. When a muscle is in a state of strain, the afferent nerve endings deliver increased sensory input from that muscle to the CNS.
Strain-counterstrain involves positioning the segment in a maximally short position to reduce the firing of the afferent nerve supply from the muscles to more normal levels. The actual neurophysiological principles behind the abnormal activity of the muscle spindles and other proprioceptive nerve fibers are much more detailed and beyond the scope of this article.
During strain-counterstrain, the therapist locates tender points on a patient's body, which usually correspond to the area(s) of dysfunction. The therapist then passively positions the body part in a position of ease or comfort while monitoring the tension of the tender point.
This position involves moving the dysfunctional segment away from a position of pain or barrier.1 When this position of comfort is found, there is typically minimal to no tenderness of the specific tender point being treated.
During this passive positioning, the therapist is monitoring (by finger palpation) the tender point for changes in tissue tension and by subjective reports from the patient of decreased tenderness under that finger. The therapist holds the body part in this position for no less than 90 seconds as the tension in the tender point is reduced.
During the 90 seconds, the therapist's palpatory pressure is reduced, but the finger is kept on the same spot for periodic monitoring during the treatment and to make sure the treated tender point is not "lost" by letting go of the area. The patient's body part is slowly and passively returned to the original position, and if the treatment is successful, there will be minimal to no tenderness of the corresponding tender point.
Consider the following application of strain-counterstrain to a tender point found in the piriformis muscle. The piriformis is found deep in the buttock and is an external rotator of the hip joint. It originates from the anterior sacrum and inserts on the greater trochanter.
With the patient in the prone position, the therapist palpates the piriformis muscle beginning at the posterior corner of the greater trochanter, and proceeds medially and superiorly. The tender point is usually found approximately eight centimeters medial and superior to the greater trochanter.
The therapist positions himself on a seat on the tender point side, and passively suspends the same side leg off the table with the patient's anterior ankle resting on the therapist's thigh. The hip should be flexed to approximately 120 degrees, strongly abducted and slightly internally rotated using one hand; the other hand continues to monitor the tender point.
When the tender point feels as if it is "softening," the therapist then applies moderate pressure and asks the patient, "Is that less tender than when I first pressed on this spot?" If the point is indeed softer, and the patient indicates it is much less tender (70 percent better at least), the therapist holds the leg in this position for a minimum of 90 seconds as the patient stays relaxed (see photo).
At the end of that time, the therapist passively and slowly lifts the leg back up on the table and immediately re-checks the tender point, asking "Is that less tender?" Usually, if the technique is successful, the patient says, "Yes, much better" or "That is not tender at all."
Another example of the use of strain-counterstrain, in this case to treat an upper trapezius tender point, can be described this way. The upper trapezius muscle originates from the occiput, ligamentum nuchae and cervical spinous processes. It inserts at the lateral clavicle, acromion and part of the spine of the scapula. The tender point can be found anywhere in the fibers of the upper trapezius muscle, but is more commonly located in the medial portion.
In such a case, Dr. Jones recommends sidebending of the neck toward the tender point side, flexion of the arm above the head, and traction of the scapula/arm by pulling on the arm in a cranial direction. The same procedure of passive positioning, monitoring the tender point, holding the tender point for 90 seconds and so on, as described above, applies to treatment of this muscle as well.
In his book Strain and Counterstrain,2 Dr. Jones mapped hundreds of tender points in the body and documented recommended positions for treatment of each point. Typically, during the examination for tender points, the therapist should palpate structures of both the anterior and posterior sides of the body. It may be surprising, for example, that a patient who presents with posterior neck pain may actually have several tender points on the anterior side of the neck.
Rationale and Application
Strain-counterstrain can be an effective technique in the treatment of muscle/tissue that is considered to be in a state of "strain." By passive positioning of the strained muscle/tissue in a shortened relaxed position ("counterstrain"), the abnormal afferent proprioceptive activity is reduced, enabling the muscle to relax and return to a more normal state.6
Strain and counterstrain can be useful for both acute and chronic conditions. Because it is a gentle and nontraumatic technique, it can be especially beneficial in treatment of the acute-care patient. Patients with restricted range of motion may benefit from strain and counterstrain because of its effectiveness in reducing pain and muscle guarding.6
Further, strain-counterstrain may be integrated with other treatment techniques including modalities, therapeutic exercises, muscle energy technique, massage and myofascial release techniques, to name a few.
• Continuing education courses are taught throughout the United States by the Jones Institute. Contact the institute at (760) 942-0647 or www.jonesstraincounterstrain.com for more information.
1. Kusunose, R. (1993). Strain and counterstrain. In: Basmajian, R.E., Rational manual therapies. Baltimore: Lippincott, Williams & Wilkins.
2. Jones, L., Kusunose, R., & Goering, E. (1995). Jones strain-counterstrain. Boise, ID: Jones Strain-Counterstrain Inc.
3. Ramirez, M., Haman, J., & Worth, L. (1989). Low back pain: Diagnosis by six newly discovered sacral tender points and treatment with counterstrain. Journal of the American Osteopathic Association, 89(7), 905.
4. Korr, I. M. (1975). Proprioceptors and somatic dysfunction. Journal of the American Osteopathic Association, 74, 638-650.
5. Brossman, R. (1995). Jones' Tender Points and Travell's Trigger Points. Retrieved Jan. 17, 2003, via the World Wide Web, http://184.108.40.206/professional%20papers/strain.html
6. Kusunose, R. (1995). Strain and counterstrain in the manual medicine armamentarium. In: Jones, L. H., Kusunose, R., & Goering, E. Jones strain-counterstrain. Boise, ID: Jones Strain-Counterstrain Inc.
Wendy Powers is an outpatient therapist at New Hanover Regional Medical Center in Wilmington, NC. The author thanks Randall Kusunose, PT, OCS, director of the Jones Institute, for reviewing this article.