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Nociceptive Considerations in Treating with Counterstrain

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Nociceptive Considerations in Treating with Counterstrain • Nociceptive considerations in treating with counterstrain MARK BAILEY, PhD LORANE DICK, DO The proprioceptive mechanis- nism by which counterstrain techniques ame- tic model of somatic dysfunction proposed liorate somatic dysfunction has not been ex- by Korr is accepted as the neurophysiolo- plained conclusively. (Somatic dysfunction is gic basis of counterstrain by the developer defined3 as "Impaired or altered function of re- of that manipulative technique. We sug- lated components of the somatic [body frame- gest that the physician should also take work] system: skeletal, arthrodial, and myofas- into account the physical damage, if any, cial structures, and related vascular, lym- that the original trauma produced. We pro- phatic, and neural elements." Korr o has de- pose that with tissue injury, nociceptive scribed a proprioceptive mechanism of somatic reflexes could produce patterns of motion dysfunction that Jones2 accepts as underlying restriction opposite that predicted by a counterstrain. This explanation is compatible solely proprioceptive model. A nociceptive with personal clinical impressions of changes component is suggested as an explanation observed during counterstrain treatment. for the origin and maintenance of somatic However, it seems unlikely that propriocep- dysfunction and its response to the coun- tive reflexes represent the sole element in- terstrain technique. In actuality, both pro- volved in how counterstrain works, a position prioceptive and nociceptive responses with which Korr agrees (conversation, May may occur in dysfunctional states. Other 1989). Advances in physiologic knowledge of physiologic responses also may be in- the proprioceptive functions have not changed volved. These views are consistent with Korrs concepts. These advances, in fact, have clinical experience. clarified the theoretical basis for somatic dys- (Key words: Counterstrain, osteo- function and explanations for response to ma- pathic manipulative treatment, nocicep- nipulative treatments. In this paper, we (1) sug- tive reflexes, somatic dysfunction.) gest an updated theoretical basis for somatic dysfunction involving nociceptive stimuli, and Counterstrain is a passive, positional-re- (2) examine the responses to counterstrain treat- lease manipulative technique, developed by ment. Our proposed theoretical role of nocicep- Lawrence Jones. 1,2 Counterstrain techniques tive mechanisms in initiating or maintaining place somatic systemic elements into the posi- somatic dysfunction (or both) and proposed ba- tion of greatest perceived ease, or comfort, by sis for effects of counterstrain treatment ex- passively approximating the attached surfaces tend the concepts related to proprioceptive func- of those elements. Osteopathic physicians have tions. demonstrated time and again that counter- strain is a clinically valid and useful entity. Basic reflexes However, the theoretical physiologic mecha- First, let us apply Korrs proprioceptive model to a simple hinge-type joint, the elbow. To fa- Dr Bailey, currently a senior student at the College of cilitate the discussion, let us concern ourselves Osteopathic Medicine of the Pacific, Pomona, Calif, will with only two antagonistic muscles that act be starting a neurology residency at the University of Alabama at Birmingham. Dr Dick, past chairman of the across the elbow joint: the lateral head of the Department of Osteopathic Principles and Practice, Col- triceps brachii muscle, an extensor of the fore- lege of Osteopathic Medicine of the Pacific, is currently arm, and the brachialis muscle, a forearm in private practice in San Dimas, Calif. Reprint requests to Mark Bailey, PhD, 2128 South- flexor (Figure 1). Now let us assume that while wood Rd, Jackson, MS 39211. the elbow is semiflexed, a weight is placed in (continued on page 337) 334 • JAOA • Vol 92 • No 3 • March 1992 Brief report • Bailey and Dick the hand. To lift the load, the brachialis mus- of the central nervous system, that is, from cle shortens (contracts), and the triceps mus- the brain rather than the spinal cord. 2 Col- cle is concurrently stretched. Both brachialis lectively, the muscle spindles provide proprio- and triceps muscles contain specialized encap- ceptive information, and the reflexes they me- sulated receptors called muscle spindles 6 that diate are called proprioceptive reflexes. are responsive to stretch. When the muscle is stretched, the spindles are activated. The in- Proprioceptive reflexes and somatic nervated muscle is reflexively induced to con- dysfunction tract, and the contraction is accompanied by What does this elementary neurophysiology the reciprocal inhibition of its functional an- have to do with somatic dysfunction and, more tagonists. 7 This simple reflex arc is the famil- specifically, its treatment by counterstrain? To iar myotactic or stretch reflex. When the mus- answer this question, let us return to our pre- cle shortens, the spindles are "unloaded" and, vious example in which a weight was placed as a result, their responses are quieted or even on the semiflexed upper extremity (Figure 2A). silenced.8 Thus, in our example, the spindles Furthermore, assume that the weight is ap- in the triceps muscle increase their response plied suddenly. The upper extremity is rates as the muscle is stretched. Similarly, the abruptly "loaded," and the forearm is forced spindles in the brachialis muscle decrease immediately toward extension. The brachialis their rate of firing momentarily as the muscle muscle is suddenly stretched (the strain part shortens. of Jones original strain/counterstrain), and the In simple terms, we have now defined the triceps muscle is shortened (Figure 2B). primary muscle-spindle afferent response. Mus- Subsequent reflexive reactions establish cle spindles, however, are complex receptors, and maintain the somatic dysfunction. Propri- and the primary afferent response is only one oceptive reflexes come into play (Figure 2C), constituent of an entire informational spec- and the brachialis muscle is contracted, such trum. In addition to primary spindle informa- contraction applying physiologic "brakes" to tion, there is another component provided by the runaway movement of the forearm. Accord- their gamma-efferents. 9 The functioning of the ing to Korrs4,6 explanation, this sudden shorten- gamma-efferent system and its interactions ing and concurrent silencing of the spindles with the spindle primaries is both subtle and in the triceps muscle (Figure 2E) causes both complex. For the purpose of this discussion, the gamma "gain" in the triceps muscle to be it is sufficient to state that the gamma-effer- reflexively turned up, and the muscle itself to ents augment and fine-tune the activity of the be reflexively contracted (the counterstrain of primary afferent system. 19 In our example, the strain/counterstrain) (Figure 2F). The central primary afferent spindle response of the brachi- nervous system regains its all-important spin- alis muscle is quieted, so that the central nerv- dle information but at the expense of a short- ous system is provided with little information ened triceps muscle. This muscle now reports regarding the degree of brachialis stretch. to the central nervous system that it is being The gamma efferent system subserving the stretched, even before it attains its neutral brachialis muscle would "turn up" the sensi- length. On recovery from the sudden exten- tivity of its primary afferents and restore some sion movement, flexion is resisted by a triceps level of spindle activity and information in- muscle that is now tonically shortened by its flow to the central nervous system. The pri- inappropriately high gamma gain. mary spindle afferent stretch reflex functions Clinical findings associated with this exam- largely at a segmental level." This means that ple include the forearms moving easily into the specific segment of the spinal cord respon- extension (the direction of ease), but resistance sible for the innervation of the muscle is also to movement into flexion (the direction of bind) responsible for its myotactic reflexes. In con- and pain. Thus, normal symmetry of motion trast to the primary afferents, the gamma sys- about the elbow joint is disrupted. There are tem is controlled from suprasegmental levels tender points, or painful foci, located on the Brief report • Bailey and Dick JAOA • Vol 92 • No 3 • March 1992 • 337 posterior aspect of the upper arm/forearm, with from the influence of the primary afferent spin- associated changes in tissue texture. Jones2 dle stimuli, the inappropriately exaggerated pointed out that the pathologic alteration in gamma gain can be reset by the central nerv- this type of somatic dysfunction involves tis- ous system. The forearm would be held by the sues with an essentially atraumatic history; physician in this position for a short time (typi- for example, the only external events to which cally, about 1 minute). Accompanying the nerv- the triceps muscle (the counterstrained ele- ous system–mediated release are palpable tis- ment) was exposed was that it was suddenly sue texture changes and a resolution of the allowed to shorten. Only the brachialis mus- tender points. The upper extremity is then cle (the strained element) was suddenly slowly returned to a more neutral semiflexed stretched. position. All movements of the forearm must The proprioceptive model of somatic dysfunc- be accomplished by the physician without ac- tion as applied to our example may be sum- tive assistance from the patient. 13 On
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