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David Adamczyk -> Strain-Counterstrain Techniques (February 5, 2000 5:56:00 AM)

Members,
The following question was sent to RehabEdge via e-mail. Can you help?
____________________________________________

I need info on strain-counterstrain techniques especially for the spine. Is there any way you can help??
Thanks Angella



clevine -> Re: Strain-Counterstrain Techniques (February 6, 2000 5:59:00 PM)

Purchase the Jones' text Strain Counterstrain. There was a previous post re: this topic.



jayPT -> Re: Strain-Counterstrain Techniques (February 7, 2000 3:36:00 PM)

Two other great resources for SCS &/or PRT are Positional release therapy by D'Ambrogio and Integrative Manual therapy for the upper and lower extremities by Sharon Weiselfish Giammatteo. I find these more patient friendly with great pictures.


JayPT



edilling -> Re: Strain-Counterstrain Techniques (March 12, 2000 8:28:00 PM)

This is an old topic but I am curious about others experience. The positional release (much better name than strain-counterstrain, no disrespect for Jones) techniques have been very helpful for the extremities but I have had less success when using them on the thoracic and lumbar spine. Have others found this as well or is there any advice as to improve my technique?



jayPT -> Re: Strain-Counterstrain Techniques (March 13, 2000 6:55:00 PM)

I have had good luck with using SCS/PRT in the lumbosacral region for protective mm. tension of the illiopsoas, piriformis, and quadratus lumborum.

I often find muscle energy techniques more effective in the thoracic spine.

I use MET for joint imbalances and interarticular dysfunction and SCS/PRT for protective muscle/autonomic guarding.

What do others find?

jayPT



indacup -> Re: Strain-Counterstrain Techniques (May 9, 2000 5:18:00 PM)

I have spent an entire clincal doing manual therpay and often coupled scs/pr with mulligan mobs. the mobs were attempted first for the spine and thoracic rib area. the pt. usually left 75% less pain. if the pain returned rather quickly after the first treatment, then scs was sought to search for tender points that might contribute to spinal facet/rib malalignment. one thing you have to take in consideration was that this clincal was for the air force with a rather healthy, young, limber patient group.



Andrew M. Ball, MS, PT -> Re: Strain-Counterstrain Techniques (May 10, 2000 4:15:00 AM)

I'm confused,

Isn't being an expert technician of strain-counterstrain techniques kind of pointless? As I understand it, strain-counterstrain is based upon the assumption that the gamma-motor bias can be affected in humans through some kind of intervention.

Gamma-motor bias is a pretty neat concept that was brought into the world over 50 years ago on the basis of cat dissections and nerve conduction velocity (NCV) studies. The only problem is that humans do not have a gamma-motor bias (e.g. alpha-motor neurons fire long before the gammas do), and this error was pointed out over 30 years ago. In fact, unless I'm mistaken one of our own, Carl Kulkula, PhD, PT further explored this issue with NCV studies as part of his doctoral work or early post-doctoral research at Virginia Commonwealth University. He's now the Director of the Program down in Gainsville if anyone wants to contact him for more information or clarification.

Given these realities, what exactly is it that clinicians using strain-counterstrain think that they are accomplishing on the neurophysiologic level? Is there a new philosophical framework / explination (be it proven or unproven) for this technique of which I'm not aware?

I welcome clinical opinion answers to this question, but I'd rather deal with facts and articles on the subject if anyone can identify any. As Helen Hislop recently pointed out to a group of new graduates in central North Carolina, one evidence-based article of fact will always outweigh tens of thousands of clinical speculations.

What do students think?

Drew


[This message has been edited by Andrew M. Ball, MS, PT (edited May 10, 2000).]

[This message has been edited by Andrew M. Ball, MS, PT (edited May 14, 2000).]



wincon -> Re: Strain-Counterstrain Techniques (May 16, 2000 3:02:00 AM)

[QUOTE]Originally posted by Andrew M. Ball, MS, PT:
[B]I'm confused,

Isn't being an expert technician of strain-counterstrain techniques kind of pointless?

I believe that many therapies appear to work by means of placebo. I cannot comment specifically on scs, however, it wouldn't surprise me if yet another procedure involves a lot of assumption therapy which is quite prevelant in MFR and many soft tissue oriented procedures. You must have seen the 20/20 segment on TV where a woman had a hole drilled into her head originally thinking she was having a full operation to destroy certain 'out-of-whack' cells. Only the hole was drilled and her Parkinsons tremors ceased. I believe they returned later on however.

I'd say any true successes the above had was probably from the Mulligan Mobs, however, I'll qualify myself and say 'probably.' At least moving a joint to enourage it's proper function theoretically makes the most sense.

Best,

Mitch H., PT, Cert. MDT, NMT, CMT, CFT



Andrew M. Ball, MS, PT -> Re: Strain-Counterstrain Techniques (May 16, 2000 12:43:00 PM)

Hmmmm,

Placebo effect. Gutsy play Wincon, I admire that, but to invoke the "holy power" of placebo effect unleashes the wrath of a Healthcare Management Pandora's Box that I'm not sure the profession of physical therapy is equipped to deal with.

There is certainly place for placebo effect in physical therapy. That said, the problem is that many clinicians have lost sight of the fact that a placebo technique should not be the cornerstone of physical therapy intervention, nor should the charade be so convincing that the treating PT has deluded him or herself to neurophysiologic fact. The patient is supposed to be fooled . . . not the therapist!

Given the information on the subject that I currently have, and no one has yet disputed it, a knowledgeable and evidence-based PT,(understanding that S-CS is no more than placebo effect) doing strain-counterstrain as the cornerstone of intervention raises serious questions of ethics. Is is appropriate to bill an average of $600 for a back pain rehab program that hangs its hat on this technique? Maybe, maybe not. Furthermore, in such a case I have a hard time joining in the fight for professional territory against ATC's and DC's when the technique is placebo and sham anyway. Quacks don't get much sympathy from me when they loose their jobs, and now is certainly not the time in the current transformation of PT, to define ourselves with the manual therapy equivalent of a sugar pill.

The other end of the spectrum is the PT who marches to the drum of continuing education yet has not once picked up a journal article on ANY subject since graduation. Sure, there is a lot of smoke and mirrors promoted on the S-CS continuing education circuit, but not much of it holds up to any kind of real science. Are the PT's who've deluded themselves into the gamma-motor bias concept, who worse - - - teach this erroneous neuro-crap to their patients - - - committing malpractice? I'm not sure if I'd go that far, but if I'm right about all this gamma-motor bias stuff and how it blows the concept of strain-counterstrain out of the water, it treads dangerously close.

(That's not to say that I am correct about all of this. I've been known to be wrong from time to time, it HAS happened before . . .

The fact remains that if I am wrong about the way that I'm interpreting the literature, no one has pointed it out on this forum to date . . . that's telling.)

Drew

If however, there is a new theory out there to explain strain-counterstrain, then maybe I’m going to be the one quacking in a few posts . . . there was a lot of discussion on this thread until I asked for proof that this stuff was based on sound theory. It’s been mostly silent since then. Considering the number of ortho and sports PT’s on this forum, and the fact that I’m not . . . it’s concerning to me that a legitimate question has gone unanswered for so long.

Is anyone going to step up to the plate to defend this treatment technique with published facts and studies . . . or have some therapists been caught with their professional pants down?


------------------
Andrew M. Ball, MS, PT, MBA
PhD Candidate

[This message has been edited by Andrew M. Ball, MS, PT (edited May 16, 2000).]



mcap -> Re: Strain-Counterstrain Techniques (May 16, 2000 1:48:00 PM)

I will add my 2 cents to this issue:

Therapists consistently see what they think are good results with things like MET techniques and SCS. It is up to them to prove that is not placebo. I think it is.

So what.....If it works....it works. That is the popular refrain. Unfortunately therapists are not considering the long term follow-ups. In most studies to date, those patients who have had received manual therapy be it manipulation or osteopathic etc., short term benefits are not maintained at a year follow up. The NEMJ recently published a study in which Osteopathic tx by trained oseopathic physicians faired no better with low back patients than standard medical care.
Osteopathic treatment of Low back pain NEJM 2000 March 16;342(11):819

It would seem as if many therapists are oblivious to possibility of the placebo response. This is dangerous. Other medical professionals are oblivious as well but for them it may not matter. If some main-line medical therapies are discovered to be placebo their is no outcry to have people stop going to their doctor. When PT treatments don't fare better than sham or no treatment however....there is pressure to stop referrals altogether. That is why we have no choice be to confront these realities and to do better. If we don't, then we will be gone!!

In the previous few months I have heard many surprising things like fiber may not prevent colon cancer, estrogen increases a womans risk of heart disease, C-reacive protein is one of the most important risk factors for heart disease but is never tested (also....homcystine levels), most sinus infections are fungal and antibiotics can actually exacerbate them. There are many others. You will notice however that no one is ready to eliminate the physician. There are many reasons that including cultural issues, power and influence, perceptions, etc. Perhaps the most important reason is the systematic study of most medical interventions. Other disciplines are in a continous attempt to explore and validate their methods. This is why they can maintain credibility in the face of confusing findings.

I guess PTs are exempt from such requirements.

Oooopss....got a little off the topic. I'm going to step off of my soapbox and sign off.

-mcap



Barrett -> Re: Strain-Counterstrain Techniques (May 16, 2000 2:01:00 PM)

Drew,

I can truly appreciate your frustration as you wait for someone who practices in this fashion and explains it as Jones did, given what is now known. My advice is to not hold your breath.

The power that silence holds is commonly evident in our community. Keep asking.

------------------



Andrew M. Ball, MS, PT -> Re: Strain-Counterstrain Techniques (May 17, 2000 11:00:00 AM)

I've asked several faculty professors and continuing education instructors who teach the technique to come onto the forum and point out any errors in my thinking.

Invitations went out to "faculty" working for several well known continuing education rackets (which will remain nameless in order to protect their dignity, respect, and privacy should they choose not to respond), as well as several university professors who teach the technique. I'd expect they know a bit more about current strain-counterstrain theory than I do . . . and so this thread should get interesting.

Stay tuned!



Rich Gajdosik, PT, PhD -> Re: Strain-Counterstrain Techniques (September 22, 2000 2:05:00 PM)

Wow! I was beginning to think I was all alone in my profession...looking for the scientific evidence and bases to Positional Release Techniques (PRT/SCS). As an anatomist and educator, and out of curiosity, I registered for a "Continuing Educational Program" (as advertised) for PRT this past weekend. The brochure stated that...and I quote "These techniques (referring to PRT) have proven to be very valuable clinical tools for decreasing excessive tone, relieving muscle spasms, and increasing ROM". The presenter offered no scientific or clinical evidence to support these claims, other than opinions. Because no evidence was offered to support the claims, I could find no reason to learn the techniques. I politely removed myself and I am now seeking a refund. This was not education. Why don't others do the same? Maybe they do.

So...where is the evidence? If anybody, anywhere out there in the world can refer me to a refereed published article supporting any of these claims I would be very appreciative. Are there any controlled studies separating these techniques from things like "holding a limb and talking with the patient to encourage relaxation"? Seems like this would be easy to do for the muscle response claims.

Please help. I await the literature to review the science.

------------------



Andrew M. Ball, MS, PT -> Re: Strain-Counterstrain Techniques (September 23, 2000 8:59:00 AM)

Rich,

This thread was started 6 months ago. So far, no evidence. 4 months ago I wrote quite specifically to more than 10 clinicians "institutes" that either practice or preach this nonsense. So far . . . silence.

The point is, I wouldn't recommend that you hold your breath.

If you wouldn't mind, I'm sure we'd all be interested in knowing if you get your money back on the grounds of a "bait and switch".

Respectfully,
Andrew M. Ball, MS, MBA, PT



metapod -> Re: Strain-Counterstrain Techniques (September 26, 2000 12:59:00 PM)

These techniques cannot be so much described as they are experienced. Some modealities are experiential and must be taught directly from one practitioner to another with the flow of knowledge passing directly. There is no means for science to measure this type of interaction which has physical as well as psychoemotional and sometimes spiritual influence. How much is something of this sort worthh? You cannot put a price on it.



mcap -> Re: Strain-Counterstrain Techniques (September 26, 2000 1:20:00 PM)

metapod:

These interventions can be studied just like any other method. Compare them to standard exercise/treatment and see what happens.

You can't put a price on it?????? You do it all the time when you ask insurance to pay you for it.

mcap



Andrew M. Ball, MS, PT -> Re: Strain-Counterstrain Techniques (September 26, 2000 5:20:00 PM)

Easy Mcap, I thank you for your fevered pounce and I agree with you, but this one's faculty . . . this one's mine . . .

Metapod,

I've re-written this e-mail several times, and it still comes across hostile in text. It's not intended to be, but I sit here in sheer incredulity and have a viceral need to understand your comments.

I'm shocked that you have the perspective that you do. You have an earned PhD, yet you seem to suggest that, "There is no means for science to measure this type of interaction which has physical as well as psychoemotional and sometimes spiritual influence," but your forget that science is not neurophysiology alone. Besides, most PhD programs teach that if it ain't measurable, it ain't science. Are you suggesting that physical therapy should become more of an art form than a science? Have you been somehow immune or shielded from demands for outcomes research that our profession currently faces? Outcomes that will shape the autonomy . . . the very existence of the profession in the near future? Please tell me you're joking, and that you're not "passing on" this philosophy to unsuspecting students.

We have a means for testing the validity of our claims in the real world. It's called the scientific method. It involves testing and re-testing hypotheses, not guilting emerging evidence-based clinicians into questioning the "price they should put" on unproven techniques. No one is asking the camp of SCS to prove their neurology. They can't. But they shouldn't cling to a clearly flawed theory, nor charge others in an effort to perpetuate the error. I have to demand that they prove their effects with more than testimonials and case studies though. I'm tired of this, "I’m too busy healing the masses" crap. I've heard it for years, and you, a PhD, should know better than to suggest that they should do otherwise.

Didn't you learn that just because some change is subjective doesn't mean that it can't be measured? Sure, perhaps not on a neurophysiological level, but how about on a clinical outcome/social science level?

Why not examine things like sickness impact before and after Rx using the Rolland Morris or SF-36 (esp since we know per Worrel that once you drop the RM score under 18, that the risk of back surgery decreases dramatically - that would be clinically significant, objective, and evidence-based). What about comparing efficiency to achieving matched goals across groups receiving either SCS or a more traditional type of therapy . . . can't one of the ICC's (interclass corrolation coeficient) be used for calculation of this? How about an A-B-A-B study using two different techniques.

How much is an unproven technique worth you ask? About as much as a sugar pill, facilitated communication. Difference is, MD's don't CHARGE for sugar pills, and the parents sent to JAIL on the basis of the sexual assault charges of their "facilitated" children have been set free . . . but not before the lifetime of damage was done. I'm not arguing that there is not an effect with SCS, just that the effect doesn't have ANYTHING to do with the theories of Jones or Weezelfish. Also, we should measure the effect before we charge patients for it. To do otherwise is unethical and unprofessional don't you think?

I’m proud to see that the increasingly evidence-based forum at RehabEdge has challenged your comments. That paradigm shift slowly occurring within the profession, not sham treatments, is what our profession "cannot put a price on.”

Respectfully,
Andrew M. Ball, MS, MBA, PT
PhD Candidate


[This message has been edited by Andrew M. Ball, MS, PT (edited September 26, 2000).]

[This message has been edited by Andrew M. Ball, MS, PT (edited October 02, 2000).]



Andrew M. Ball, MS, PT -> Re: Strain-Counterstrain Techniques (October 2, 2000 6:17:00 AM)

Metapod,

I find it quite telling that you're responded to other threads on RehabEdge, but to my last posting, you remain silent and unable to defend your claims.

I ask you, I ask the RehabEdge community . . . Why is this? Is this because my last posting was so offensive and inappropriate, and therefore, in your mind no response is necessary . . . or is it that the truth hurts? (e.g. that your apparent metaphysical approach to the practice of physical therapy is potentially, unethical, indefensible and damaging to the profession?)

I'll quote (as directly as I can remember) a comment made by Jules Rothstien to John Barns:

"I believe in metaphysics John, I just don't bill for it." I'd take that a step farther. Until we're sure how some of these metaphysical techniques work, until we have some social science research on how they affect outcomes, and until we abandon techniques based on faulty theory (e.g. SCS and Strain-Counterstrain) we have no business bringing the technique into the clinic . . . unless as part of a clincal trial CLEARLY DEFINED to the patient as an UNPROVEN EXPERIMENTAL TECHNIQUE.

Of course, some patients may choose to pay out of pocket for such quackery, but I'd reject that approach too (unless of course the non-scientific nature of the technique was FULLY disclosed, which never happens).

I wonder how many patients would elect SCS or CSR if their therapist told them quite honestly. "The validity of the technique has not been established through research. The very neurophysiologic theories that most of my colleagues will tell you the patient has to how this stuff works is CLEARLY wrong. Nevertheless, I think it works and I've seen results with many of my patients . . . that will be $90 per session 2 times a week for 4 weeks please."

It's WHOLLY INAPPROPRIATE to bill for this crap (to insurance OR to the patient willing to pay out of pocket) without fully disclosing the facts. It rapes the patient, a vulnerable person in pain, of making an informed, autonomous decision because you've biased the patient by filtering them the facts as you see fit.

Not to fully disclose the lack of evidence for a technique ROBBS the patient of autonomy. Not respecting autonomy is a very clear case of ethical violation.

Respectfully,
Andrew M. Ball, MS, MBA, PT

I eagerly await your response, but won't hold my breath.


[This message has been edited by Andrew M. Ball, MS, PT (edited October 02, 2000).]



SPT 2009 -> RE: Re: Strain-Counterstrain Techniques (November 28, 2008 9:18:29 PM)

I don't know if this thread is dead or not, but I'm interested in adding!  I'm a student about to do an inservice on strain counterstrain, at a clinic that is divided about practicing CS.  I have found some evidence, and it's not half bad. 

1.       Wynne, M., Burns, J., Eland, D., Conaster, R., Howell, J., Effect of Counterstrain on Stretch Reflexes, Hoffmann Reflexes, and Clinical Outcomes in Subjects with Plantar Fasciitis, JAOA Vol 106 No 9, Sept 2006, pp 547-556.  (*free full text on PubMed)
2.      Howell, J., Cabell, K., Chila, A., Eland, D., Stretch Reflex and Hoffmann Reflex Response to Osteopathic Manipulative Treatment in Subjects with Achilles Tendinitis.  JAOA Vol 106 No 9, Sept 2006, pp537p545  (*free full text on PubMed)
3.       Licciardione, J. et al, A Randomized Controlled Trial of Osteopathic Manipulative Treatment Following Knee or Hip Arthroplasty, JAOA Vol 104 No 5 May 2004 pp193-202
4.       Hayes, N., Bezilla, T., Incidence of Iatrogenesis Associated with Osteopathic Manipulative Treatment of Pediatric Patients, JAOA, 2006, 106:605-608.
5.       Noll, D, et al, Effectivenes of a Sham Protocol and Adverse Effects in a Clinical Trial of Osteopathic Manipulative Treatment in Nursing Home Patients, JAOA, March 2004, Vol 104, No 3
6.       Maltzer, K., Standley, P., Modeled Repetitive Motion Strain and Indirect Osteopathic Manipulative Techniques in Regulation of Human Fibroblast Proliferation and Interleukin Secretion, JAOA, Dec 2007, Vol 107, No 12.
http://www.jiscs.com/PDFs/AbstractSCS.TreatmentofPatients.LowBackPain.Lewis.pdf
http://www.jiscs.com/PDFs/AbstractIntertesterReliability.Tatom.Laman.pdf

A lot of the evidence reports what you all have stated, that there are clinical improvements but the mechanism is still difficult to test.  It seems like the osteopathic physicians are doing much of the research in this area. 




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