1

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POSITIONAL
RELEASE
&
JONES’ STRAIN
COUNTERSTRAIN

1
 Course Description
So many people suffer with painful muscle trigger points as the
result of stress, tension, and injury. Functional impairments
and participation restrictions result from the pain and motion
limitations associated with TPs.

In this program, learn to manage painful trigger points (TPs)

and muscle spasm, and the neurophysiological reflexes that
modulate muscle tension. The use of gentle positioning to relax
and release abnormal muscle tension is described. Specific
positions are demonstrated, based on the Strain-Counterstrain
principles described by Dr. Lawrence Jones, DO, to reduce
painful TPs and improve mobility and function. Research review
indicates the efficacy of using gentle positioning to improve
flexibility, strength, reduce pain and improve performance.
Imagine being able to reduce painful TPs in just 90 seconds!

AGENDA
 Hour 1
• History of strain counterstrain/positional release,
description, theory of neuromuscular reflex function, and
evidence-basis for positional release (PRT).
• Definition and assessment of trigger points (TPs) and their
relationship to neuromuscular reflexes, abnormal tension
and pain.
 Hour 2
• Illustration and description of specific positioning
interventions to reduce painful TPs, release abnormal
tension and improve function and pain.
• Research discussion of evidence for the positive outcomes
of positional release.

Learning Outcomes
1. Discuss the theoretical basis and evidence-based
research for positional release (PRT).
2. Identify trigger points (TPs) and their
relationship to neuromuscular tension and pain.
3. Apply specific positioning interventions to reduce
the painful sensitivity of TPs, release abnormal
neuromuscular tension and improve functional
mobility.
4. Discuss the research evidence for the positive
outcomes of positional release.

2
Welcome from Theresa A. Schmidt,
DPT,MS,OCS,LMT,CEAS,DD
Physical therapist specializing in
orthopedic rehab, muscle energy, joint
mobs, myofascial release,
craniosacral & visceral manipulation,
precision exercise, medical massage,
bioenergy, functional training and
evidence-based integrative therapy at
Flex Physical Therapy and Educise
Resources Inc, Northport, NY.
[Link]

CASE REPORT
Client presents with R sided pain and
spasm in her neck and shoulder after 3
hours of computer work.
You palpate a tight R upper trapezius
and she jumps due to the pain
What can you do to relieve her
discomfort to allow her to resume her
work?
What can she do to manage this
recurring problem? 8

OUCH! IT HURTS
People present with muscle
problems:
 pain

 stiffness,

 weakness,

3
 GOAL: TELL THE MUSCLES

It is safe to let go now!

10

MUSCLE BIOMECHANICS
 Remember the rules of
biomechanics: the length-tension
rule:
 Muscles contract with greatest force
at or near their resting length or
slightly longer
 Too long or too short: muscles will
be weak
11

WHAT DO YOU SEE?

12

4
 POSTURE
 Look around the room
 How do people hold their bodies?
 What about YOU?

13

POSTURAL ALIGNMENT
 Posture= the relative alignment of
body parts
 How we hold ourselves up (or down)
all day

 Does it matter?

14

POOR POSTURE ALTERS

MUSCLE LENGTH

15

5
 INJURIES ALTER MUSCLE
LENGTH

16

NEUROPHYSIOLOGY of
MUSCLE PAIN

 MUSCLE LENGTH influenced

by:
• Our security system:

• MONOSYNAPTIC REFLEXES
• PROPRIOCEPTIVE REFLEXES
17

MONOSYNAPTIC REFLEXES
 The muscle spindle:

 Sensory receptor in the muscle

bellies
 Detects change in length of muscle
during stretch and strain

18

6
 MUSCLE SPINDLE
components
 Extrafusal: Alpha motoneuron
monitors muscle length: CONTRACTION

 Intrafusal: Gamma motoneuron

monitors muscle length and speed:
causes CONTRACTION
 Spindle bias is the present sensitivity
to changes in length and speed of
change 19

Golgi Tendon Organ

 GTOs: sensory receptor located in
the muscle tendons
 Monitor tone
 when stretched, GTOs fire 1B,
results: inhibits alpha motoneuron
 Inhibits contraction
 If sensitized, may weaken muscle
20

ABNORMAL= “FACILITATED”
REFLEXES
 Stress overexcites nerves, lowers
threshold for stimulation, facilitates
afferents, overloads into adjacent
spinal cord segments

21

7
 TYPES OF FACILITATED
REFLEXES
 Local:
•at the myofascial level: Trigger
points (TPs), taut bands, tension
 Segmental:
•at spinal nerve level: spasm,
edema, ANS sympathetic
dysfunction in several spinal
levels 22

EXAMPLE
 RSD / Complex Regional Pain
Syndrome / Sudek’s Atrophy:

 A chronic pain syndrome characterized

by severe sensitivity and pain to touch,
shiny glossy dry skin, edema,
cyanosis, even osteopenia and
abnormal skin and hair

 Usually due to injury 23

CRPS/ RSD Interventions

 Requires many interventions,
including Positional Release PRT
 PRT resets the abnormal facilitated
segmental reflex that caused
sympathetic vasoconstriction,
 As circulation improves, more oxygen
reduces pain and helps healing

24

8
 CAUSES OF ABNORMAL
REFLEXES

25

HOW DO YOU KNOW THERE

ARE FACILITATED
REFLEXES?
A.R.T.
 Abnormal posture or joint position

 Range of motion is limited

 Tissue tension is elevated, Trigger

Points are present (TPs)

26

WHAT ARE TRIGGER POINTS?

 Dr. Janet Travell: Trigger
Points=
 “hyperirritable foci lying within
taut bands of muscle which are
painful on compression and
which refer pain or other
symptoms at a distal site”
(Chaitow, p.59)

27

9
 TRIGGER POINTS: on EMG
 Areas of persistent contraction
 Calcium buildup in t-tubules
 Oxygen deficit, can’t pump out
calcium
 Selective shortening of sarcomeres
 Must clear TPs to relax muscle

28

Trigger Point EMG Research

• Barbara Headley, PT showed trigger
points can also be areas of abnormal
electrical silence on EMG studies,
where the muscle has too little
activity, also causing a trigger point
• The muscle is too inhibited!

• (From: Headley, [Link] Exams and

Biofeedback: Can Emg Validate Trigger Points?
ISBN 0929538080) 29

POSITIONAL RELEASE OR
JONES’ STRAIN-COUNTERSTRAIN:
•Technique using trigger points
as diagnostic indicators of joint
problems and
•A position of comfort to release
abnormal muscle tension and
pain
30

10
31

32

33

11
 34

TYPES OF RELEASES FOR

JOINT DYSFUNCTION:
•Direct release

•Indirect release

35

DIRECT RELEASE

Direct techniques:
Practitioner moves the joint in the
direction of tension or stretch, known
as the direction of bind
The position the joint goes into a
stretch or strain
LENGTHENING- pulling

36

12
 INDIRECT RELEASE

Indirect techniques:
Practitioner moves the joint in the
direction of freedom, known as the
direction of ease
The position the joint goes into readily
in which it relaxes
SHORTENING- passively folding

37

38

JONES’ COUNTERSTRAIN
THEORY

Abnormal proprioceptive firing

results from strain/stress to the
system
Stress elevates muscle spindle
sensitivity
As spindles fire, muscles contract 39

13
 WHAT ARE YOU DOING?

• During positional release,

practitioners apply stretching to
muscles on one side of the joint while
folding or shortening muscles on the
opposite side of the joint

40

HOW DOES PRT WORK?

41

RECIPROCAL INHIBITION
More reflexes are at work:
• Muscle spindle reflexes are activated
by stretching, causing agonist
contraction to protect against tearing
-Agonist contracts
• By reciprocal inhibition, the antagonist is
inhibited by agonist activity, so
-Antagonist must relax

42

14
 SELF INHIBITION

• Practitioners “fold and hold” the

muscle in a maximally short position to
reduce the firing of the muscle spindles
that were causing the muscle to
contract, resulting in relaxation
• See text by Anderson: Muscle Pain
Relief in 90 Seconds, the Fold and
Hold Method

43

44

45

15
46

47

48

16
 Jones’ COUNTERSTRAIN=
“Mild strain (overstretching)
applied in a direction
opposite to that false and
continuing message of strain
from which the body is
suffering”
= SHORTENS THE TP
MUSCLE!
49

STRAIN/COUNTERSTRAIN
JONES’ RULES

Pain is position oriented

Joint dysfunction is due to
abrupt reaction to strain

50

• POC is held still for 90

seconds
• the rate of return to the
neutral position must be slow
for success

51

17
 Joint dysfunction behaves
as if it is constantly strained

52

Muscle spindle maintains

joint dysfunction

53

Dr. Jones said:

Position the tender point muscle
in its maximally shortened
position: actually this is NOT
necessary in practice

54

18
 SUMMARY OF PRT

PRT is done in slow motion

It takes at least 90 seconds of holding
to work
It takes longer in CNS lesions:
spasticity takes time (several minutes)
Temporary lowering tone
( Sharon Weiselfish PT)
55

OUTCOMES OF PRT:

Decreased
tissue tension
Decreased pain
Increased
strength
(Wong, 2004)

56

RESEARCH ON PRT: EFFECT

ON PAIN & STRENGTH
Wong and Schauer 2004, Touro College
Randomized 49 adult subjects with hip
muscle TPs and weakness
Outcomes:
Visual analog pain scale 0-10
Strength using hand held
dynamometer,Nicholas muscle tester
Pre and post counterstrain intervention
57

19
RESEARCH ON PRT: EFFECT
ON PAIN & STRENGTH
3 groups: counterstrain, (SCS) exercise
and combination
Intervention: counterstrain for 90 secs. to
hip abductor’s TPs 2x/wk for 2 wks
Result: Significant increase in strength in
SCS and SCS+EX group
All groups had TP pain reduced and
greater strength 2-4 wks post
intervention
(Wong & Schauer, Jnl Man Manip Ther 2004)
58

WHAT HAPPENED?

Reflect:
Pain is a neurogenic inhibitor of muscle
Relieve the pain,
Muscles are able to contract

59

TREATMENT PRINCIPLES:
Flex the flexors, extend the
extensors
Abduct the abductors
Place the muscle in its
passively short position
Takes about 90+ seconds
to hold to release TPs
Use all actions of the
muscle 60

20
 PRECAUTION WITH PRT
If you shorten muscles on
one side of the joint,
you stretch muscles on the
opposite side
Possibility of delayed onset
muscle soreness,
Let clients know!
61

PRT - INDICATIONS
Muscle guarding
Acute injury
Joint hypomobility
Fascial tension
Postural dysfunction
WHO IS WITHOUT ANY
TRIGGER POINTS! 62

RESULTS
Normalize muscle tone and
length
Normalize fascial tension
Improve joint mobility
Improve circulation
Reduce pain
Improve strength 63

21
CONTRAINDICATIONS TO PRT

Infection
Nonunited fracture
Open wound
Hematoma
Healing Sutures
Hypersensitivity (precaution)
When motion is contraindicated
64

PRECAUTION!
MEDICAL CLEARANCE must be
obtained prior to working on
clients with medical conditions!

65

ASSESSMENT OF TPs
Palpate and record TP
location and pain pattern
TPs: Areas of hard, dense,
tender spots that do not yield
easily to pressure
Client twitches, jumps or cries
out from pain when you push
on the TP
Use pain scale: 0-10 to grade
severity, 10 is worst pain 66

22
 ASSESSMENT OF TPs
Prioritize by severity,
treat the worst first
PRT is part of the Plan,
clients may need
strengthening and
stretching exercises
Teach home programs
with self-care
67

TECHNIQUES
After assessing areas of concern:
• Flexibility
• Pain
• Weakness
• Poor performance in specific activities
Discuss needs and set goals
Design a program to meet the goals

68

KEEP GOALS REASONABLE

69

23
 TRY POSITIONAL RELEASE
• If the client is stiff and in pain, use the
positional release prior to their exercise
program.
• If they are sore post-workout, they may
again apply the positional release on
their own to relieve the muscle tension.
• Even a single repetition of the position
of comfort will help.
• Use as needed.
70

PRT TECHNIQUE
Posterior Cervical (most TPs)
Extend neck
Sidebend toward TP, and rotate away
from or toward the TP
Ipsilateral rotators= erectors, splenius,
suboccipitals
Contralateral rotators= upper
trapezius, sternocleidomastoid origin
71

POSTERIOR CERVICALS

72

24
 PRT TECHNIQUE
Upper Trapezius
• Extend neck
• Sidebend toward TP
• Rotate away from the TP
• Elevate (shrug) the scapula
• Contralateral rotator
• Combine one or more motions
73

POSTERIOR CERVICALS
Spinalis cervicis Suboccipitals

74

UPPER TRAPEZIUS
muscle belly

75

25
 POSITIONING
• For upper traps:
• TP is in the supraspinous fossa over
the muscle belly or at posterior skull
attachment
• Be sure the muscles can relax
• Try sitting with pillow behind their
head, leaning on something for support
• Try supine or sidelying with pillow
• Can you try it in prone? May be difficult
76

UPPER TRAPEZIUS, LEVATOR

Upper trapezius Levator scapula

77

WRIST: COMMON EXTENSORS,

Lateral epicondyle

78

26
 POSITIONING
• For wrist/finger extensors: extensor
digitorum communis, extensor carpi
radialis, extensor carpi ulnaris,
supinator, brachioradialis

• TP is at lateral epicondyle or in the

muscle belly of specific muscle
• Extend the wrist and fingers and add
supination if it helps
79

WRIST, FINGER EXTENSORS

Extensor digitorum Extensor carpi radialis

80

WRIST, FINGER EXTENSORS

supinator extensor carpi ulnaris

81

27
SHOULDER: SUBSCAPULARIS
Anterior lateral scapula or anterior
medial border

82

POSITIONING
For subscapularis
• TP is found by elevating shoulder
above 90 deg., palpate the front
surface of scapula as it moves forward
on the thorax (not the ribs). Ask client
to internally rotate to make it easy to
feel
• Place arm behind back into extension
and internal rotation as they relax
• May also use scapula retraction with 83

shoulder extension for stiff clients

SUBSCAPULARIS

84

28
 ANTERIOR LUMBAR/ HIP:
Hip flexor iliopsoas

85

ILIOPSOAS

86

POSITIONING
For Iliopsoas:
• TP is in the combined tendon where it
passes just below and inside the hip
joint (ASIS) along the inguinal ligament
• Position the hip in flexion > 90 degrees
and slight external rotation and hold for
several minutes
• Do in sidelying with knee to chest and
pillow between legs, supine knee to
chest, or sitting bending forward, or
yoga kneeling child’s pose 87

29
 KNEE: HAMSTRINGS
behind the thigh and knee

88

POSITIONING
• For semimembranosus,
semitendinosus, and biceps femoris
• TP is between ischial tuberosity and
posterior knee, in muscle belly or tendon
• Position: flex the knee and extend the hip
• Opposite hip is flexed for comfort or lumbar
spine arches too much
• Use sidelying, holding ankle, or supine,
hang leg off table, or standing holding
above ankle or using a strap
89

HAMSTRINGS
semitendinosus biceps femoris shorthead

90

30
 HAMSTRINGS
semimembranosus biceps femoris longhead

91

CLINICAL CASE STUDY

Identify a TP on your partner

Test the ROM and muscle strength
Determine a position of comfort
and release the TP
Re-test for results!

92

CASE STUDY: TRY PRT

find TPs on your partner
Rhomboids
Gastrocnemius
Opponens pollicis
Right lumbar erector spinae
Scalenus anticus
Plantar fascia
Carpal tunnel syndrome
93

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EVIDENCE FOR POSITIONAL
RELEASE OR
STRAIN COUNTERSTRAIN

94

EFFECT ON LOCAL PAIN

UPPER TRAPEZIUS
Meseguer: RCT of 54 subjects with
upper trap TPs
3 groups: classic PRT, PRT with
stroking, and control
Outcomes: pain scale VAS with
4.5kg/cm2 pressure at 2 min after tx.
2 groups had significant pain reduction
but no difference between PRT alone
or PRT with stroking the TP
(Mesenguer et al., Clin Chiropractic 9/06) 95

EFFECT ON BACK PAIN TPS

Lewis & Khan: RCT of 28 with low back
pain & TPs
Outcomes: Low Back disability index,
pressure pain threshold, electrical
detection threshold EDT and electrical
pain threshold EPT
PRT reduced TP pain but not maintained
after 24-96 hrs., Control group had
increased EDT and EPT
(Lewis, Khan et al., Man Ther 12/10) 96

32
EFFECT ON CHRONIC ANKLE
INSTABILITY
Collins: RCT of 27 adults with instability
Outcomes: isokinetic strength, dynamic
balance (Ft Ank Ability Measure), Instability
(Star excursion balance test and global
rating of change)
PRT 1x/wk for 4 wks with home exercise for
all groups
2 groups: PRT+exercise & sham+exercise
No effect on strength/subjective ankle
function but dynamic stability improved (Nova
Univ., 2010)
97

EFFECT OF COMBINED WORK

Nagrale: RCT of 60 adults neck TPs
2 groups: 1) muscle energy/ischemic
compression and 2) muscle energy, ischemic
compression and PRT to TPs for 4 wks
Outcomes: pain, neck disability index, and
ROM cervical sidebending
Measured 2 and 4 wks post intervention
Most significant improvement in group with
combined PRT, muscle energy and
ischemic compression
(Nagrale, et al., Jnl Man Manip Ther 3/10)
98

INIT Effect on TPs in Upper Trap

RCT 30 adults 18-35, dx. Mech. Neck
pain, in 2 groups
1: HP, INIT, strength/stabiliz ex,
ergonomics, posture
2: all except no INIT
6 sessions x 2 wks
Results, VAS pain, Neck disability
index, tenderness improved significantly
with INIT added
(Aggarwal, 2018)
99

33
 MET/SCS for Acute LBP
RCT 50 pts. In 2 groups: MET or
MET+SCS
Tx: 2 sessions on 2 days
Results: Oswestry Index and Roland
Morris Q, VAS pain, lumbar ROM
Both groups showed significant
improvement with no diff. between groups
Addition of SCS did not alter results.
(Patel, 2018)

100

PRT vs. Taping or Control

RCT 45 people with myofascial neck
pain in 3 grps.
SCS, kinesiotape, and control. Tx 2 wks
3x/wk x 20 mins.
Measured VAS pain, NDI, PPT
Result:
SCS had greater effect on NDI, pain
and pressure pain threshold than
kinesio or control
(Abdelfattah, 2018)
101

SCS for Jaw Muscle TPs

RCT of 99 people 18-24 with TPs in

masseter, temporalis, int. pterygoid
muscles
2 groups: SCS vs control placebo.
Measured maximal opening of the jaw
and bite force 1 min pre and 5 mins
post tx.
Results: signif. improvement in jaw
opening, and stronger bite force (Blanco,
102
2019)

34
 PRT for Office Worker TPs

RCT of 38 office workers 26-61 y/o

with neck and shoulder pain.
Measured NDI, NPRS, and algometer
for pain.
Levator, SCM, traps, subocciptals.
Result: signif decrease in pain, and
increase in ROM
(Bockowski 2019)

103

104

RESEARCH
Aggarwal, S. and Bansal, G., Efficacy of Integrated Neuromuscular Inhibition
Technique in Improving Cervical Function by Reducing the Trigger Points on
Upper Trapezius Muscle: A Randomized Controlled Trial. Muller Jnl of Medical
Sciences and Research, 2018(9)1:1-6.
Amini, A., Goljaryan, S., Shakouri, S. K., & Mohammadimajd, E. (2017). The Effects
of Manual Passive Muscle Shortening and Positional Release Therapy on Latent
Myofascial Trigger Points of the Upper Trapezius: A Double-Blind Randomized
Clinical Trial. Iranian Red Crescent Medical Journal, 19(9).
Blanco, CR, Figallo, MA, et al, Short Term Application of the Muscular Inhibition
Method of Strain/Counterstrain in the Treatment of Latent Myofascial Trigger
Points of the Masticatory Musculature: A Randomized Controlled Trial. Clinical
Advances in Health Research. 2019(1)1: From:
[Link]
/9
Bockowski, r., and Gebska, M, Assessment of Trigger Points Therapy Effectiveness
with Positional Release Method among Office Workers, J Educ Health Sport.
2019(9)3:Collins CK. Physical therapy management of complex regional pain
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D’Ambrogio KJ, and Roth GB. Positional Release Therapy Assessment &
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DiGiovanna, Eileen, D.O., and Schiowitz, D.O., An Osteopathic Approach To
Diagnosis And Treatment. Philadelphia, Pennsylvania: J.B. Lippincott 105
Company, 1991.

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Falsiroli Maistrello, L., Geri, T., Gianola, S., Zaninetti, M., & Testa, M.
(2018). Effectiveness of Trigger Point Manual Treatment on the
Frequency, Intensity, and Duration of Attacks in Primary Headaches: A
Systematic Review and Meta-Analysis of Randomized Controlled
Trials. Frontiers in neurology, 9, 254. doi:10.3389/fneur.2018.00254
González-Ravé, JM, Sánchez-Gómez, A, and Santos-García, DJ. Efficacy
of 2 different stretch training programs (passive vs. proprioceptive
neuromuscular facilitation) on shoulder and hip range of motion in older
people. J Strength Cond Res 26(4): 1045-1051, 2012
Howell JN, Cabell KS, Chila AG, Eland DC. Stretch reflex and Hoffman
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Atienza-Meseguer A, Planella-Abella S, Fernández-de-Las Peñas C,
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Movement Therapies 2009; Jan: Vol. 13 (1), pp. 2-10
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Academy of Osteopathy, 1981.
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patients with low back pain. J Manual Manipulative Ther 2001;9:92-98.
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Lewis, C, Khan, A, Souvlis, T, Sterling, M, A randomized controlled study

examining the short-term effects of Strain-Counterstrain
treatment on quantitative sensory measures at digitally tender
points in the low back Man Ther 2010 Dec: 15(6):536-41
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Bianco, Gandia, JJB, Immediate effects or the
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controlled trial. J Man Manip Ther 2010;Mar;18(1):37-43
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energy technique with and without strain-counterstrain technique
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Wong CK, Schauer CS. Reliability, validity, and effectiveness of strain
counterstrain techniques. J Manual Manipulative Ther 2004;12:107-
112.

Wong KW, Schauer-Alvarez, C. Effect of strain counterstrain on pain

and strength in hip musculature. J Manual Manipulative Ther
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Wynne MM, Burns JM, Eland DC, Conatser RR, Howell JN. Effect of
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109

SPECIAL THANKS
Sam Barrow of Primal Pictures Ltd.
provided copyright permission to use
the anatomy pictures from the Primal
Pictures. Ltd. DVD: Interactive
Functional Anatomy, Second Edition
[Link]
Primal Pictures Ltd. 4th Floor, Tennyson
House, 159-165 Great Portland St.
London, W1W5PA, UK
110

[Link]
Get your FREE course on
chronic pain!

37
 Disclosure
To comply with professional
boards/associations standards, I declare
that I do not have any financial
relationship in any amount occurring
within the last 12 months with a
commercial interest whose products or
services are discussed in my
presentation.
Theresa A. Schmidt
EDUCISE RESOURCES INC. 112

LONG ISLAND SUNSET

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