Osteopathic Manipulative Treatment: Counterstrain Procedure - Cervical Vertebrae

Anatomy and Physiology

The cervical spine can be divided into the atlas (C1), the axis (C2), and the typical cervical vertebrae (C2-C7). C1 has no spinous process or vertebral body. C2 has the dens that projects superiorly from its body and articulates with C1. As the union between the head and the atlas, the atlantooccipital (AO) joint's primary motion involves flexion and extension (nodding motion). The atlantoaxial (AA) joint's primary motion involves rotation. The vertebral bodies of the typical cervical segments are separated by intervertebral discs.[7] The upper typical cervicals (approximately C2-C4) have a primary motion of rotation. The lower typical cervicals (approximately C5-C7) have a primary motion of side-bending. The facet joints are synovial joints that display unique orientation along the cervical spine that aid in movement. Studies have determined that particular facet orientation has been correlated with clinical conditions.[8]

The pathophysiology of tenderpoints (TPs) could be explained through the interplay of muscle strain and the resulting perception of pain. A sudden muscle strain—from the overstretching of myofascial tissues—is detected by muscle spindle receptors due to the change in length of the muscle fibers that have been affected. Increased firing of the muscle spindle receptors triggers increased gamma motor neuron activity and subsequent contraction of the muscle and affiliated pain. The explanation for the effects of strain-counterstrain (SCS) in the treatment of TPs is not entirely clear, but the most common theory proposes that the positioning of the patient minimizes the tension of the tissue of interest and reduces the nociceptive input, thus preventing the pathological neural reflex arc.[5]

TPs are most commonly located near bony attachments of tendons, ligaments, or muscle bellies. TPs should not be confused with trigger points, which are normally found within taut musculotendinous tissue bands.[9] TPs can be palpated as tense, small, edematous regions in the soft tissue. TPs only refer to local areas of tenderness; no pain referral should be experienced. To date, there have been over 200 anatomical TPs identified by osteopathic physicians.[9] Interestingly, cervical radiculopathy is associated with TPs located on the same side of the apparent radiculopathy.[10] In this review, we will focus on the most common cervical TPs found in the clinical setting. 

Location of Anterior Cervical (AC) TPs:

• Anterior cervical C1 (AC1) TPs are located near the transverse processes of C1, on the posterior edge of the ramus of the mandible.
• AC2-AC6 TPs are located on the anterolateral tips of the corresponding transverse processes.
• AC7 TPs are located on the superior surface of the clavicle at the clavicular attachment of the sternocleidomastoid (SCM).
• AC8 TPs are located at the medial end of the clavicle at the sternal attachment of the SCM.

Location of Posterior Cervical (PC) TPs:

• Posterior cervical C1 (PC1) midline TP is located around the inion.
• PC1 lateral TPs are located on the occiput, midway between the inion and mastoid process.
• PC2 midline TP is located on the superior aspect of the spinous process.
• PC2 lateral TPs are located on the occiput, midway between the inion and PC1 lateral TPs on the occiput.
• PC3 midline TP is located on the inferolateral aspect of the C2 spinous process.
• PC3-PC7 lateral TPs are located on the posterolateral surface of the corresponding articular processes. 
• PC4-PC8 midline TPs are located on the inferior aspect of the spinous process of the vertebra directly above the corresponding cervical level.

Indications

• Acute or chronic somatic dysfunctions
• Hypertonic muscles
• Somatic dysfunctions with a neural component (e.g., hypertonic muscle)
• As primary treatment or in conjunction with any other treatment options

Contraindications

Strain-counterstrain (SCS) is widely regarded as one of the safest osteopathic manipulative treatment options. However, like any physical procedure, contraindications still exist. Contraindications for counterstrain could be divided into absolute (do not perform the procedure) and relative (may perform the procedure with caution, depending on the circumstance).

Absolute Contraindications

• Absence of somatic dysfunction
• Lack of patient consent or cooperation
• Fracture or torn ligament in the area

Relative Contraindications

• Cervical vertebral artery disease
• Severe osteoporosis
• Any rheumatologic conditions such as rheumatoid arthritis
• Ligamentous instability
• Severe illness
• Patient unable to voluntarily relax muscles

Equipment

The following equipment is needed:

• Osteopathic manipulative treatment table
• Stool

Preparation

The principles of diagnosis through the use of strain-counterstrain (SCS) involve a holistic evaluation of the patient's history and a thorough observation of body habitus. Before beginning the technique, the provider must assess the patient for any possible contraindications. After a potential dysfunction is determined, the tissue area is evaluated for tenderness and tissue texture abnormalities. It is recommended that the amount of pressure applied to diagnose a TP should typically not exceed the pressure required to blanch the nail-bed of the diagnosing finger. Applying more pressure than what is recommended could elicit pain that may inadvertently be perceived by the patient as a TP.

Notable tips to keep in mind while utilizing SCS:

• Anterior TPs typically require flexion.
• Posterior TPs typically require an extension.
• Midline points typically require primarily flexion or extension.
• Lateral points typically require more side-bending and rotation.
• It is best to use both tissue texture changes and tenderness to find the most suitable treatment position.
• Adequate myofascial relaxation is typically achieved by the presence of a "release" or "ease" of tension.

Technique or Treatment

Strain-Counterstrain (SCS) Technique for Anterior Cervical C1-C8 (AC1-8) TPs

1. With the provider at the head of the table, have the patient lay supine on the treatment table.
2. The provider locates the TP.
3. The provider establishes a pain scale with the patient at 10 out of 10.
4. The provider gently and passively wraps the patient around the TP, taking them to a position-of-comfort by flexing, side-bending, and rotating the head away (FSARA) from the TP until the TP pain has reduced to at least a 3 out of 10 (70% tenderness reduction) or better (with the goal of 100% tenderness reduction).
5. The provider reduces his/her palpating pressure at the TP and continues to monitor, maintaining the patient's position for 90 seconds (do not remove contact with the TP until the technique is complete).
6. After 90 seconds has elapsed, the patient's head should be slowly and passively returned to a neutral position.
7. Re-test for tenderness at the TP.

Strain-Counterstrain (SCS) Technique for Posterior Cervical C1-C8 (PC1-8) TPs

1. With the provider at the head of the table, have the patient lay supine on the treatment table.
2. The provider locates the TP.
3. The provider establishes a pain scale with the patient at 10 out of 10.
4. The provider gently and passively wraps the patient around the TP, taking them to a position-of-comfort by extending, side-bending, and rotating the head away (ESARA) from the TP until the TP pain has reduced to at least a 3 out of 10 (70% tenderness reduction) or better (with the goal of 100% tenderness reduction).
5. The provider reduces his/her palpating pressure at the TP and continues to monitor, maintaining the patient's position for 90 seconds (do not remove contact with the TP until the technique is complete).
6. After 90 seconds has elapsed, the patient's head should be slowly and passively returned to a neutral position.
7. Re-test for tenderness at the TP.

*The exceptions to treating PC1-C8 TPs with "ESARA" are for PC1 midline and PC3 midline TPs, which are treated with cervical flexion only (no side-bending or rotation).

Complications

Significant complications are rarely associated with cervical strain-counterstrain (SCS). Any complications may be associated with the position of the patient during the technique. It is recommended to avoid positions that cause discomfort, dizziness, panic, or neurogenic pain (such as rapid rotation and extension of the upper cervicals). A minor side effect may include pain in the antagonistic muscles. However, this is usually self-limiting and well-tolerated by patients.

Clinical Significance

The clinical use of cervical strain-counterstrain (SCS) on patients with neck pain is an effective and conservative alternative or adjunct to other treatment modalities.

Enhancing Healthcare Team Outcomes

A patient with persistent cervical pain may present with a variety of symptoms and complaints. Without direct knowledge of the existence of osteopathic manipulative treatment (OMT), these patients often turn to unnecessary and aggressive management options. While cervical strain-counterstrain (SCS) may be a popular technique utilized among several osteopathic physicians, it is rarely used elsewhere. Therefore, osteopaths should educate allopathic physicians and healthcare providers as a whole on the benefits of OMT, so they feel more inclined to refer patients to a specialist when necessary. Through the use of interprofessional communication, osteopathic clinicians can prevent unsatisfied outcomes and enhance the care of their patients.