Positional release technique

1. Assessment &
Treament Procedures
In Positional Release
Technique (PRT)
Dr. Venus Pagare (PT)
MPT, KMC Mangalore,
SEHA Emirates Hospital,
Abu Dhabi, UAE

2. Assessment &
Treament Procedures
In Positional Release
Technique (PRT)
Presented By: Venus Pagare
Moderated By: Mr Zulfeequer

3. ❶ Introduction ❽ When to use PRT
❷ History ❾ Principles
❸ Assessment Procedures ❿ General Rules
❹ Scanning Evaluation ⓫ Contraindications
❺ PRT in Somatic Dysfunction ⓬ PRT Variations
❻ Effects of PRT ⓭ Studies on PRT
❼ Ideal settings & Indications ⓮ References
Contents

4. • Osteopathic Treatment technique
• Founder – Dr Lawrence Jones in 1964
• Method of total body evaluation
• Treatment using a Position of Comfort (POC)
INTRODUCTION TO PRT

5. • Indirect & Passive
• Visceral and musculoskeletal dysfunction
• All 3 planes of movement are used
• Positions body to enhance function and release tension
• Puts certain parts of body under stretch while others in a
position of relaxation
• PRT :‘invites change, rather than forcing change’
• Allows a spontaneous change to take place

6. • Tissues are painful, in spasm, inflamed or have recently
been traumatized or if manual method induces discomfort
• Indirect treatment technique is needed
• Application of force away from a resistance barrier, in
direction of greater ease; more shortened state
• Harold V. Hoover uses term ‘Dynamic Neutral’:
- what is achieved as tissues relating to a structurally
disturbed joint or area were positioned into a state of
‘ease’

7. Charles Bowles:
‘state in which tissues find themselves when motion of
structure they serve is free, unrestricted and within
range of normal physiological limits… it is state and
condition to be restored to dysfunctional area.’

8. • Lawrence H. Jones, an osteopath found that specific
positions were able to reduce the sensitivity of tender
point (Tep)
• Was called on by patient who had been suffering with low
back pain since 2 months that was unresponsive to
treatment
• Patient displayed psoas spasm
• Jones attempted to find a comfortable position for patient
to help him in sleeping
HISTORY

9. • After trial and error, a comfortable position was achieved
• It was maintained for some time
• Patient could come out of the posture and stand erect
• This discovery emphasized the value of position of comfort.
• Jones found that by maintaining these positions for varying
periods of time, lasting improvement would often be the
result.
• This application was referred as Counterstrain

10. • Aim : To relieve musculoskeletal pain and somatic
dysfunction through indirect manual manipulation
• Treatment begins by identifying areas of musculoskeletal
dysfunction
• Skillful palpation allows discrimination between various
states and stages of dysfunction
ASSESSMENT PROCEDURES

11. Osteopathic assessment of somatic dysfunction
• The basis of osteopathic palpation when assessing for
somatic dysfunction is (using the acronym ARTT):
A – Asymmetry
• linked to positional focus; 'position of vertebra or other
bone is asymmetrical'
• Greenman (1996) broadens concept by including functional
in addition to structural asymmetry

12. R - Range of motion.
• ROM ( Restriction/ Increase), Quality of movement and end feel
• Altered ROM of single joint, several joints or a region
T – Texture changes.
• Palpable changes may be noted in superficial, and deep tissues
T - Tissue tenderness.
• Pain provocation and reproduction of familiar symptoms are
used to localize somatic dysfunction

13. Assessment using Functional Technique
• While evaluating joint / muscle by listening hand, motive
hand makes a series (any order) of motion demands (within
normal range), which includes all possible variations.
• Following results might occur:
a. Response is ease in all directions: tissues are functioning
normally
b. In some directions movement produce bind, tissues are
responding dysfunctionally.
• This region demands for treatment with PRT

14. Using Tender Points (TeP) as a guide to dysfunction
• All somatic dysfunctions have associated areas of palpable
tenderness
• Tender Point (TeP) is a clinically recognized expression of
somatic dysfunction
• Used in PRT as a diagnostic indicator
• Accurate palpation of diagnostic tender-points is central to
PRT
• TeP: tender upon palpation, small (<1 cm), round, tense,
edematous regions located deep in muscle, tendon,
ligament, or fascial tissues

15. • Localized areas of distressed and dysfunctional tissues
• Ischemia, sensitized (Usually 4 times as sensitive as normal
tissue)
• Associated with biomechanical, biochemical, neurological,
circulatory and psychological changes
• Evolve from sensitivity to discomfort, and eventually pain
• Primarily show sudomotor changes
• ↑ or ↓ temperature
• Blanching, erythema and sweating of skin overlying TeP
help in identification

16. Where to look for tender points?
• Use of Jones's maps' (or D' Ambrogio & Roth 1997)
• If patient can identify a movement in which tissues were
strained, concept of 'replicating the position of strain' may
be used, with tender point likely to be located in tissues
short at time of strain
• Obvious distortion, or marked imbalance of 'loose-tight'
tissues, TePs most likely to be found in tight (i.e. short)
tissues

17. • Patient demonstrates a movement that is painful, or
restricted, Goodheart suggests TeP most useful for
monitoring will be located in muscles that would perform
opposite movement to that which is painful or restricted,
- i.e. seek tender points in antagonists to muscles active
when pain or restriction is reported or observed.

18. How hard should tender point be palpated?
• Palpate such that minimum pressure is used to elicit jump /
jerk sign.
• Characterized by responses, such as a sudden jerking
motion, grabbing of the therapist’s hand, a facial grimace.
• Depth of tissue being palpated
• Firm, but tissue must be entered gently, and only necessary
pressure must be used to palpate through layers of tissue

19. How is the severity of tenderness graded?
• Grade 1: Patient complains of pain
• Grade 2: Patient complains of pain and winces
• Grade 3: Patient winces and withdraws the joint
• Grade 4: patient will not allow palpation
Another method of grading is:
• Extremely sensitive; visual jump sign is present and the
patient expresses extreme sensitivity to touch
• Very sensitive; very tender but no jump sign

20. • Moderately sensitive; patient states that the point is tender
to touch but does not flinch or jump away.
• No tenderness
Also assess individual joints for ranges of motion, and
individual muscles and groups of muscles, for strength,
flexibility, endurance etc., as well as for presence of
myofascial trigger points within them.
General screening tools:
Indicate current levels of functionality and to evaluate
progress

21. Clinically useful indicators of function / dysfunction are:
• Postural alignment – particularly crossed syndrome
patterns described by Janda
• Specific functional evaluations and movement pattern tests
such as hip extension test, hip abduction test,
scapulohumeral rhythm test.
• Assessment of balance, core stability
• Standard functional examination, palpatory findings along
with information gained from a thorough history will direct
towards possible somatic dysfunction.

22. The purpose is to:
• Evaluate entire body for tender points (TePs)
• Prioritize them according to severity
• Helps in determining dominant tender point (DTP), and
treatment plan can then be implemented
• Provides clear, visual representation of location of
dysfunctions
SCANNING EVALUATION (SE)

23. • If a point is palpated and there is an observable jump sign,
point is labeled extremely sensitive and the whole circle is
filled ( )
• If patient feels that point is very tender but does not have
jump sign, then top part is filled in ( )
• If patient feels only moderate amount of tenderness, point
is only moderately sensitive and bottom part of the circle is
filled in ( )
• If patient experiences no tenderness, point is left blank ( )

24. • After sensitivity, location of TeP is noted
• If found on either side of body, following keys are used to
label:
Right / Left + Most sensitive ο Treatment
Eg. MK stands for medial knee.
• MK : Extremely sensitive tender point is found on
medial aspect of left knee
• MK : Extremely sensitive tender point is found on medial
aspect of the right knee

25. • Extremely sensitive tender points, equally on both points,
circle is filled and no lines are put underneath ( )
• Extremely sensitive tender points on both sides, but right
side appears more tender, slashing lines are drawn to left
and right and place a crossing line through one on right.
MK
• Point treated during a session, place a small dot over filled-
in circle ( )
• Once DTP has been identified, appropriate position of
treatment should be given

26. 1. Proprioceptors : Neuromuscular Feedback
• Based on the work of Irvin Korr:
Proposed a neural basis for joint dysfunction incriminating
the muscle spindle
Korr’s Revelations:
• Dysfunction that characterizes the osteopathic lesion does
not arise in joint, but are imposed by muscles that traverse
the joint
RATIONALE FOR PRT

27. • Increased gamma discharge exaggerates afferent discharge
from spindle causing reflex spasm which fixates joint in
certain position
Jone’s Postulates:
• Muscle spindle apparatus plays predominant role in
development of somatic dysfunction
• Not a lesion but an on-going neuromuscular noxious
stimulus
• Hyper-stimulated muscle must return to neutral length
slowly
• POC “arrests inappropriate proprioceptive activity”

28. Jones Neuromuscular Model
• Effect of a strain on a pair of antagonistic muscles (A and B)
on a joint
Figure A : a joint at rest with
approximately an equal state of
tone within both muscles.

29. • Muscle A is overstretched - increased rate of neural
impulses to be generated within the gamma system.
• Muscle B is in hypershortened state - decreased rate of
impulses.
• Sudden stretch in muscle A - myotatic reflex contraction =
rapid rebound from initial direction of strain
Figure B : a condition of
joint strain

30. • Sudden stretch of muscle B.
• Annulospiral endings respond to rate of change of length,
are hyperstimulated as muscle B is suddenly stretched,
resulting in the generation of a massive neural discharge in
relation to this muscle.
Figure 3 represents the joint
subsequent to the injury

31. • Joint is unable to return to neutral due to hypershortened
state of muscle B.
• Muscle B - primary source of dysfunction.
• At this level, PRT may exert a major influence
• POC, by moving away from restriction barrier and in
direction of greatest ease, reduces tension on affected
tissues and minimizes stimulation of affected
proprioceptors
• Neutralizes reflex arc, which is responsible for the
continuing hypertonicity

32. 2. Nociceptors : Pain Pathways
• Free nerve endings receptors are stimulated by
neuropeptides produced by noxious influences, including
trauma
• Impulses generated spread centrally and peripherally along
numerous branches of each neuron.
• At terminus of axons, peptide neurotransmitters such as
substance P are released
• Response of musculoskeletal system to these painful
stimuli may play a central role in development and
maintenance of somatic dysfunction

33. • PRT exerts its action on nociceptive system through
relaxation of surrounding tissues and resulting
improvement in vascular and interstitial circulation.
• Indirect effect on removing chemical mediators of
inflammation.
• Subsequent resolution of guarding reflexes in myofascial
structures may also contribute to a reduction in release of
further nociceptive substances

34. 3. The Facilitated Segment: Neural Crossroads
• “Lesion of spinal cord, maintained in that state by impulses
of endogenous origin entering corresponding dorsal root”
• All structures receiving efferent nerve fibers from that
segment are, therefore, potentially exposed to excessive
excitation or inhibition.
• When impulses extend beyond their normal sensory-
motor pathways, CNS begins to misinterpret information
due to an overflow of neurotransmitter substance within
involved segment

35. This FS is exemplified by following:
• Hypersensitivity : Minimal impulses may produce excessive
response
• Overflow: Impulses may become nonspecific and “spill
over” to adjacent pathways. Referred pain may be
produced.
• Autonomic dystrophy: sympathetic ganglia become
excessively activated; reduced healing and repair of target
cells, reduced immune function, impaired circulation,
accelerated aging, and deterioration of peripheral tissues.

36. • PRT has damping influence on excitability within facilitated
segment, giving opportunity for CNS to normalize level of
activity
4. Fascial Dysfunction:
Connective Tissue Connections
• According to Tensegrity model:
all organic tissue are composed of a type of truss and
essential building block of all tissue is tension icosohedron

37. • Accounts for concept of kinetic chain; lesions transmit
tensions throughout body
• Through hydrostatic pressure and connective tissue
framework- in conjunction with active muscles
• Allows symptoms to be traced back to their source and
treated indirectly by aligning fascial lines of force in relation
to primary focus of restriction.

38. • Tensegrity model delineates following properties of somatic
tissue:
 Forces maintaining structure of body are tension and
compression and have no bending moments
 Structural integrity of body is gravity independent and is
stable with flexible joints
 Body is a functional unit; forces applied at any one point
are transmitted uniformly and instantaneously throughout
entire body

39. • Condition in one area of body may have its origin in
another area
• Therapeutic action at source of dysfunction will have an
immediate, corrective effect on all secondary areas,
including site of symptom manifestation.
• Restriction in one area result in a reduced ROM in a distal
structure.
• TePs - areas of relative fixation, are splinted

40. • Area of perception of pain by patient, especially in chronic
cases, may often be remote from area of most sensitive
TePs
• Body attempts to create full range of gross motion by
compensating for areas of relative fixation
• Results in excessive motion in regions of body that extend
from focus of dysfunction
• PRT, reduces tension on myofascial system, and engages
fascial components of dysfunction

41. • This fascial component of release during the POC appears
to require a maintenance of positioning for several minutes
and 90 second interval addresses only neuromuscular
aspect of dysfunction
• Resulting reduction in tension at level of primary lesion
would , in accordance with tensegrity model, create an
equilibrium of tension throughout body

42. 5. Circulatory Concepts
• In stressed soft tissues, localized areas of relative ischaemia
– lack of oxygenated blood
• Key factor in production of pain
• Cadaveric studies have shown that when a radiopaque dye
is injected into muscles, this is more likely to spread into
vessels of muscle when a 'counterstrain' position of ease is
adopted than when muscle is in a neutral position.

43.  Normalization of Muscle hypertonicity
- During 1st / neuromuscular phase
- Normalize tone , set normal length- tension relationship in
muscle
- Elongation of involved muscle fibers to their normal state
 Normalization of fascial tension
- During 2nd /fascial phase
- “Unwinding” action in the myofascial tissue
- Significant release response may be palpated
EFFECTS OF PRT

44.  Reduction of joint hypomobility
- Muscles crossing joints become hypertonic or tight: joint
hypomobility.
- PRT relaxes affected muscles and fascial tissues
- Eases tension around joint, allowing it to move more freely
 Increased circulation and decreased swelling
• Structures are relaxed, pressure is relieved on structures
such as blood and lymph vessels.
• Increased circulation, aids in healing of damaged tissues.

45. • Improved lymphatic drainage - reabsorption of tissue fluids,
reducing swelling
Decreased pain
• Pain from joint dysfunction is position oriented
• Severe pain in one position to almost complete comfort in
opposite position.
• PRT alleviates muscle spasm and restore proper pain-free
movement and tissue flexibility.

46. • Patient may have some remaining discomfort because of
residual inflammation, but sharp pain is often significantly
reduced.
Increased strength
• Normalizing proprioceptors and neutral balance within
muscle tissue and removing inhibition caused by pain
• PRT help restore normal tone and function of involved
muscles.

47. INDICATIONS:
• Any patient with distinct physical mechanism of injury
The various conditions that can benefit from PRT are:
INDICATIONS FOR UPPER LIMB/ SPINE/ LOWER LIMB
WHY OR WHY NOT

48. 48
Intervertebral disc
prolapse
Spondylolisthesis
Degenerative disc
diseases
Myofascial pain
Spinal canal
stenosis Scoliosis
SI Joint Pain
Arthritis
Coccydynia
Facet
impingement
Lumbosacral Pain
Post surgical :
Laminectomy,
Diskectomy
Lumbar strain

49. • Does not repair pathologic or surgical conditions.
• Treats dysfunction by decreasing muscle hypertonicity,
reducing fascial tension and restoring joint mobility.
• In cases of restriction of ROM, apply PRT only within
available range

50. 50
Bursitis
Tennis elbow /
Golfer’s elbow
Thoracic outlet
syndrome
Acromioclavicular
/ Sternoclavicular
sprain
Adhesive
capsulitis
Post fracture
Rotator cuff
tendinitis
Impingement
syndrome

51. • Upper limb is linked to cervicothoracic spine and rib cage in
relation to nerve supply, circulatory supply, muscular and
fascial extensions.
• Disorders of the shoulder, elbow, wrist and hand may often
arise from primary dysfunctions of axial skeleton
• Significant tender points are present in cervical spine,
thoracic spine or rib cage, that, when treated may help
resolve many of conditions that cause primary symptoms in
upper limb

52. 52
Tendinitis
Plantar fasciitis
Capsulitis
Ligament sprain
Meniscal tears
Total Hip
Replacement
Chondromalacia
Hip Bursitis

53. 4. Motor vehicle accident
• Where there is a clear mechanism of injury, respond well to
PRT
• Early post-injury intervention reduces incidence of
secondary complications and tender points.
• Simplify treatment and speed recovery.

54. 5. Geriatric Patients
• Good acceptance as gentle and effective.
• Can release several chronic dysfunctions that have been
preventing patient from achieving a normal functional
range of motion.
6. Pediatrics Patients
• Infants and young children with torticollis, brachial plexus
injuries (Erb’s or mixed palsy)
• More reliance on observation and palpation skills

55. 7. Sports injuries
• Common injuries such as sprained ankles, hamstring or calf
strains, knee ligament sprains, pelvic or sacroiliac strains,
and rotator cuff and elbow injuries can be treated
effectively using PRT in conjunction with other treatment
methods.
8. Respiratory patients
• Restricted ribs, spine, pelvis, and hypertonic muscles
prevent patients from achieving full functional benefit.

56. • Treating restrictions in spine, pelvis, ribs, and hypertonic
muscles ( i.e diaphragm, psoas, quadratus lumborum and
intercostal muscles)
• Allows expand rib cage more fully and with greater ease
and may be able to perform breathing exercises to a
greater potential and with more comfort.
• PRT does not treat respiratory disease but improves
breathing mechanics

57. 9. Neurologic Patients
• Treating hypertonicity
• Traumatic brain injury, cerebral vascular accident, multiple
sclerosis, cerebral palsy and spinal cord injuries.
• Patients with hypotonia or atonia are not appropriate for
PRT
10. Amputees
• When pelvis, sacrum, spine and non-affected leg are
treated, it may result in better alignment and comfort when
sitting in a wheelchair

58. • Realigns patients body, decrease pain, and reduce excessive
pressure or discomfort.
11. In Hospitalized setting
• As an adjunctive treatment for patients with congestive
heart failure, respiratory failure, pneumonia, bronchitis and
asthma.
• Acquired positional pain, especially after spinal anesthesia,
or after the return to a normal position following a
lithotomy position, after perineal surgery.

59. • PRT can be used in differential diagnosis in acute pain
situations.
e.g. acute abdominal pain below and to the right of
umbilicus. flexion strain of a lower thoracic or upper
lumbar vertebrae, as well as acute appendicitis.
If pain returns rapidly after an SCS application to the point,
appendicitis is strongly indicated.
• Differential assessment of myocardial infarction and acute
costochondritis.

60. Contraindications / Precautions:
• Malignancy
• Aneurysm
• Acute rheumatoid arthritis
• Open wounds
• Sutures
• Healing fractures
• Hematoma
• Systemic or localized infection
• Hypersensitivity of the skin
• Acute MI - Precaution

61. 1. Treat most severe tender point first
2. Treat more proximal or medial tender point before those
that are more distal or lateral.
• Required if there are equally sensitive tender points
proximally and distally. Example: If there is a tender point in
neck and shoulder, are equally sensitive, neck is treated
first.
PRINCIPLES OF PRT

62. 3. Several areas of extremely sensitive tender points, area
with greatest number of TePs is treated first
4. Several equally sensitive tender points in a row (example,
on anterior aspect of sternum), treat one in middle first.
• 2 equally tender points, side by side, monitor together.
• Key is to pick one point in middle to represent group, and in
general it will be found that they all will shut off with same
treatment position.

63. • Jones : Fold body part over tender point
Shorten, relax affected muscles and other
soft tissues
1. Anterior tender points treated in flexion
GENERAL RULES
Treatment position for Iliacus

64. 2. Posterior tendor points are treated in Extension
Treatment position
for gluteus medius

65. 3. TeP on or near midline,treated with more pure flexion for
anterior points and with more pure extension for posterior
points.
• Example. Treatment of 1st,2nd and 3rd Thoracic spine

66. 4. TeP lateral to midline, is treated with addition of side
bending, rotation or both.
Example: anterior 3rd through 10th ribs

67. • Optimal position of ease = comfort zone (CZ)
What is Comfort Zone (CZ) ??
Relationship of the CZ to
the position of the body
(long head of the biceps)

68. • CZ is specific and different for each treatment positions
• Use of fine movements is necessary as CZ is approached
• Signals indicating that optimal CZ has been attained:
dramatic reduction in tenderness
palpable softening of tissues in area of TeP
• Maintain contact with TeP being treated
• Gentle touch, not applying additional pressure
Achieving optimal POC

69. • As CZ is approached, increased pressure must be applied
periodically to monitor its progress
• As soon as CZ is reached, contact should be maintained but
no additional pressure applied.
• Position is the treatment, not pressure; primarily a monitor
to help locate the position of ease
• Pressure may be added intermittently to confirm that ideal
position is being properly maintained.

70. • Pain free. Any pain experienced, is not correct position.
• Use of either traction or compression in small amounts may
help
• Once position is close to comfort zone, small movements to
fine tune
• Point should be fully eliminated or at least 70% improved.

71. • Jones: 90 seconds for release of tension in muscle tissue.
• Weiselfish and D’Ambrogio: 2 phases:
a. The 1st phase : Length-tension change in muscle, takes
approximately 90 seconds for orthopaedic and 3 minutes
with neurologic patients
b. The 2nd phase : Fascial release component and may take
anywhere from 5 to 20 minutes to resolve.
How long is POC maintained ??

72. • Return to neutral position slowly specially for first 15°
of motion
• Ballistic proprioceptors can get reengaged
• Reestablishment of protective muscle spasm
• Recheck TeP after returning to neutral
• After treatment, patient will feel a sense of relaxation
in that area and will often find more ease and less
discomfort during motion
Immediate Post-Treatment Response

73. • In next 24 to 48 hrs, approximately 40% of patients feel
some increased soreness.
• Found not only in region treated but also in areas remote
from treatment area.
• Important to explain all patients that it is a part of body’s
healing process and soft tissue reorganization taking place
• Post treatment soreness can be relieved by gentle exercises
and consuming water to assist body in elimination of
accumulated metabolites such as histamines.

74. • Hydrotherapy, relaxation, breathing exercises, ultrasound,
interferential current, diathermy and microcurrent may be
useful
• Cessation of strenuous activity for next 24 to 48 hours
• Protective muscle spasm can easily return
• Tissues may also be connected to a facilitated segment that
may be vulnerable to reactivation

75. • Perform manual therapy once a week
• Other days: exercise, modalities, and education
• Allows body to adapt to changes made during manual
therapy session.
• Next manual therapy session in one week to 10 days
• Re-evaluation be performed using general rules and
principles to find next most dominant lesion and treat if
necessary
Frequency, Duration & Scheduling

76. 1. Exaggeration of distortion
• Eg. individual bent forward in psoas spasm/ lumbago
• Postural distortion - bent forward into flexion, with rotation
and side-bending
• Attempt to straighten towards normal posture - increased
pain and resistance.
• Movement toward, or engagement of, resistance barrier
would therefore not be an ideal first option
PRT Variations

77. • Moving away from restriction barrier is usually easier.
• Position of 'ease' normally involves painlessly increasing
degree of distortion
• Placing person (in example given) into variation based on
forward bending (supine or side-lying) until pain is found to
reduce or resolve
2. Replication of position of strain
• Ex: Someone is bending to lift a strain,spasm occurs
• Patient would be locked into 'lumbago-like' antalgic
distortion

78. • Position of ease = position of strain: patient needs to go
back into flexion -in slow motion -until tenderness vanishes
and/or a sense of ease is perceived in previously hypertonic
shortened tissues
• Position is held for 60 to 90 seconds before slowly
returning patient to neutral
• Position of strain, is an exact duplication of position of
exaggeration of distortion

79. 3. Using Jones's tender points as monitors
(Jones 1981)
• Jones has compiled charts and lists of specific tender point
areas, involving most of the joints and muscles.
• TeP are usually found in tissues that were in a shortened
state at time of strain, rather than those that were
stretched, and in tissues that have become chronically
shortened over time
• Position of ease usually involves 'folding' or crowding of
tissues in which tender point lies

80. • E.g.: person with acute low back pain locked in flexion, TeP
usually located on anterior surface of abdomen, in
structures that were short at time of strain
• Position of ease will require flexion and probably some
fine-tuning involving rotation and/ or side-bending
4. Goodheart's approach
(Goodheart 1984, Walther 1988)
• Relies more on individual features displayed by patient

81. Goodheart suggests that :
a. TeP be sought in tissues antagonistic to those active when
pain or restriction is noted
b. If pain or restriction is reported, or is apparent on any
given movement, antagonist muscles to those operating
at time of pain is noted will be those that house TeP
c. TePs will usually be found in tissues that have shortened
• Applied to muscles which initially test as being of 'normal'
strength, and then test as weak following short -3-second
-isometric contraction

82. • Indicate a neuromuscular imbalance, possibly involving
neuromuscular spindle cell function
Reducing time the POC is held to 30 seconds
This can be achieved by following two means:
a. ‘Respiration assist'
• If TeP lies on anterior surface, inhalation is used
• If on the posterior aspect, exhalation is used
 Mechanical effect of respiration on resting myofascial
tissue

83. Lewit (1999): 'breathing in enhances effort' and 'breathing
out enhances movement
b. Stretching of tissues being palpated by spreading fingers
over tissues
• Thumbs press into tissues which are 'pulled' apart
• ‘Strengthens' a hypotonic or inhibited muscle

84. 5. Functional technique
(Bowles 1981, Hoover 1969)
• Involves a subjective appreciation of tissue rather than
relying on a report by patient as to reduction in pain
• 'stacking' sequence
• 'listening' hand palpates affected tissues
• motive hand’, contact hand (or fingers, or thumb or even
verbal commands) that directs or guides the patient toward
‘normal motion demand’

85. Example :
Functional treatment of the atlanto-occipital joint
• Patient is supine.
• Practitioner sits at head end of table
• One hand cradles occiput
• Index finger and thumb palpate soft tissues adjacent to
atlas.
• Other hand placed on patient's forehead or crown of head
• Flexion and extension are first movement

86. • Following directions of motion are tested, seeking always
position of head and neck which elicits greatest degree of
ease in the tissues
• ‘Stack' onto the previously identified positions of ease

87. • Side-bending to left and right
• Rotation left and right

88. • Antero-posterior translation
(shunt, shift)
• Side-to-side translation

89. • Compression/traction
• Final combined position of ease is held for 90 seconds
before slowly returning to neutral

90. 6. Facilitated positional release (FPR)
(Schiowitz 1990)
• Elements of both SCS and functional technique
• Positioning of distressed area into direction of its greatest
freedom of movement
• Modification of sagittal posture to take body or part (neck
for example) into a more 'neutral' position
• ‘Facilitating' elements/force:
compression or torsion,combination of both (usually a
crowding of the tissues)

91. • Final 'crowding' of tissues, encourage 'slackening' of local
tension, facilitating aspect
• Length of time position of ease is held is around 5 seconds.
• Can be directed towards local, palpable soft-tissue changes,
or be used as a means of modifying deeper muscles that
might be involved in joint restriction.

92. Similarities and Differences between SCS and FPR
SCS FPR
Indirect Approach Yes Yes
Monitoring Contact Pain Point Tissue Tension
Find position of
ease
Yes Yes
Holding Time 30 – 90 seconds 3 – 4 seconds
Use of facilitating
crowding
No Yes

93. 7. Integrated Neuromuscular Inhibition Technique
(Chaitow 1994)
• Multifaceted approach for deactivation of Trigger Points (TPs)
• Combined methods of direct inhibition (ischaemic compression)
+ PRT and MET
• Specific targeting of dysfunctional soft tissues.
• Tissues receive: - compression
- local positional release
- local contraction
- local stretch
- whole muscle contraction + stretch

94. 1. Kelencz et al. ( 2011) performed a study to evaluate
effectiveness of PRT in 6 patients with cervicobrachialagia
• Electromyographic analysis was used to demonstrate tension
in upper fibers of trapezius
• All patients were submitted to 10 session of 30 minutes each
• EMG collected on 1st and 10th day of treatment
• All patients had gradual decrease in pain after each session
• Decrease in state of tension in upper fibers of trapezius during
application of PRT
Studies on PRT

95. 2. Nagrale et al. (2010), conducted a randomized controlled
trial to find out efficacy of INIT on upper trapezius TrPs.
• 60 subjects were randomized to receive either METs or
INIT.
• At end of 2nd and 4th week significant improvement was
seen in pain, functioning, and lateral flexion in group
receiving INIT.
• However, study does not recognize isolated benefits of PRT

96. 3. Lewis, Sterling & Souvlis (2010) conducted RCT to examine
short-term effects of Strain - Counterstrain on quantitative
sensory measures at digitally TePs in low back region.
• 28 subjects were included : SCS intervention, sham-SCS and
control.
• Results showed immediate increase in PPT at DTPs but this
increase is not significantly greater than that following sham-
SCS intervention.
• Some of the increase in PPT at DTPs is likely to be due to the
manual-contact component of the procedures
• No evidence was found for maintained reduction in tenderness
at DPTs at follow-up sessions

98. 1. Ambrogio KJD, Roth GB. Positional Release Therapy:
Assessment & Treatment of Musculoskeletal
Dysfunction. United States of America: Mosby; 1999
2. Chaitow L. Positional Release Techniques. 3rd ed. China:
Elsevier; 2007
3. Lewis C, Khan A, Souvlis T, Sterling M. A randomised
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; 15: 536-541
REFERENCES

99. 4. Kelencz CA, Tarini VAF, Amorim CF. Trapezius upper
portion trigger points treatment purpose in positional
release therapy with electromyographic analysis. N Am
J Med Sci. 2011 Oct; 3 (10): 451-455
5. Hutchinson JR. An investigation into the efficacy of
strain-counterstrain technique to produce immediate
changes in pressure pain thresholds in symptomatic
subjects. (degree of Master of Osteopathy). Available
from:
http://unitec.researchbank.ac.nz/bitstream/handle/10
652/1355/fulltext.pdf?sequence=1
6. Wong KC. Strain counterstrain: Current concepts and
clinical evidence. Man Ther. 2011; 1-7

100. 7. Nagrale AV, Glynn P, Joshi A, Ramtaka G. The efficacy of
an integrated neuromuscular inhibition technique on
upper trapezius trigger points in subjects with non-
specific neck pain: a randomized controlled trial. J Man
Manip Ther. 2010; 18 (1): 37-43
8. Blanco, C. R., Fernández-de-las-Peñas, C., Xumet, J. E.
H., Algaba, C. P., Fernández-Rabadán, M., & Lillo-de-la-
Quintana, M. C. (2006). Changes in active mouth
opening following a single treatment of latent
myofascial trigger points in the masseter muscle
involving post-isometric relaxation or
strain/counterstrain. J Bodywork Mov Ther, 10(3), 197-
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