positional release handout - allied health education
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POSITIONAL
RELEASE
&
JONES’ STRAIN COUNTERSTRAIN
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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!
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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.
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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.
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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.
www.educise.com
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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,
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GOAL: TELL THE MUSCLES
It is safe to let go now!
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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
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WHAT DO YOU SEE?
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POSTURE
Look around the room
How do people hold their bodies?
What about YOU?
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POSTURAL ALIGNMENT
Posture= the relative alignment of body parts
How we hold ourselves up (or down)
all day
Does it matter?
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POOR POSTURE ALTERS
MUSCLE LENGTH
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INJURIES ALTER MUSCLE
LENGTH
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NEUROPHYSIOLOGY of MUSCLE PAIN
MUSCLE LENGTH influenced by:• Our security system:
•MONOSYNAPTIC REFLEXES
•PROPRIOCEPTIVE REFLEXES
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MONOSYNAPTIC REFLEXES
The muscle spindle:
Sensory receptor in the muscle
bellies
Detects change in length of muscle during stretch and strain
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MUSCLE SPINDLEcomponents
Extrafusal: Alpha motoneuronmonitors muscle length: CONTRACTION
Intrafusal: Gamma motoneuron
monitors muscle length and speed: causes CONTRACTION
Spindle bias is the present sensitivityto 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
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ABNORMAL= “FACILITATED” REFLEXES
Stress overexcites nerves, lowers threshold for stimulation, facilitates
afferents, overloads into adjacent spinal cord segments
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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 injury23
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
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CAUSES OF ABNORMAL
REFLEXES
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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)
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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)
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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
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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, Barbara.Myofascial 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
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TYPES OF RELEASES FOR JOINT DYSFUNCTION:
•Direct release
•Indirect release
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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
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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
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JONES’ COUNTERSTRAIN THEORY
Abnormal proprioceptive firing
results from strain/stress to the
system
Stress elevates muscle spindle
sensitivity
As spindles fire, muscles contract39
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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
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HOW DOES PRT WORK?
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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
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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
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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!
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STRAIN/COUNTERSTRAIN
JONES’ RULES
Pain is position oriented
Joint dysfunction is due to abrupt reaction to strain
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• POC is held still for 90
seconds
• the rate of return to the neutral position must be slow
for success
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Joint dysfunction behaves
as if it is constantly strained
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Muscle spindle maintains
joint dysfunction
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Dr. Jones said:
Position the tender point muscle in its maximally shortened
position: actually this is NOT necessary in practice
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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)
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OUTCOMES OF PRT:
Decreased
tissue tension
Decreased pain
Increased strength
(Wong, 2004)
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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 intervention57
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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 wksResult: 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)
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WHAT HAPPENED?
Reflect:
Pain is a neurogenic inhibitor of muscle
Relieve the pain,
Muscles are able to contract
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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
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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!
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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 strength63
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CONTRAINDICATIONS TO PRT
Infection
Nonunited fracture
Open wound
Hematoma
Healing Sutures
Hypersensitivity (precaution)
When motion is contraindicated
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PRECAUTION!
MEDICAL CLEARANCE must be obtained prior to working on
clients with medical conditions!
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ASSESSMENT OF TPsPalpate 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
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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
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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
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KEEP GOALS REASONABLE
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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 origin71
POSTERIOR CERVICALS
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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
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POSTERIOR CERVICALS
Spinalis cervicis Suboccipitals
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UPPER TRAPEZIUS muscle belly
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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 difficult76
UPPER TRAPEZIUS, LEVATORUpper trapezius Levator scapula
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WRIST: COMMON EXTENSORS,
Lateral epicondyle
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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
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WRIST, FINGER EXTENSORSExtensor digitorum Extensor carpi radialis
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WRIST, FINGER EXTENSORSsupinator extensor carpi ulnaris
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SHOULDER: SUBSCAPULARISAnterior lateral scapula or anterior
medial border
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POSITIONINGFor 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 shoulder extension for stiff clients
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SUBSCAPULARIS
84
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ANTERIOR LUMBAR/ HIP: Hip flexor iliopsoas
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ILIOPSOAS
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POSITIONINGFor 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
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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
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HAMSTRINGSsemitendinosus biceps femoris shorthead
90
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HAMSTRINGS
semimembranosus biceps femoris longhead
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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!
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CASE STUDY: TRY PRT
find TPs on your partner
Rhomboids
Gastrocnemius
Opponens pollicis
Right lumbar erector spinae
Scalenus anticus
Plantar fascia
Carpal tunnel syndrome93
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EVIDENCE FOR POSITIONAL RELEASE OR
STRAIN COUNTERSTRAIN
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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
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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)
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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)
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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)
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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)
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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,
2019)102
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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)
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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:
http://clinicaladvancesinhealthresearch.com/index.php/clinadvheares/article/view
/9
Bockowski, r., and Gebska, M, Assessment of Trigger Points Therapy Effectiveness
with Positional Release Method among Office Workers, J Educ Health Sport.
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Manual Manipulative Ther 2007;15:25-41.
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
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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
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Howell JN, Cabell KS, Chila AG, Eland DC. Stretch reflex and Hoffman reflex responses to osteopathic manipulative treatment in subjects with
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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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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
113