The following techniques are the key approaches used in the integrative manual therapy series:
STRAIN COUNTERSTRAIN TECHNIQUE (SCS)
Strain counterstrain technique was first proposed by osteopath Dr Lawrence Jones in 1955 and is based on the palpation of tender points (TeP) used to both diagnose and treat pain throughout the body. The tender points are defined as small zones of tense, tender, edematous muscle and fascial tissue about a centimeter in diameter and about 4 times more tender to palpation than normal tissue. The formation of TePs is thought to be caused by a precipitating musculoskeletal injury leading to a persistent neuromuscular reflex loop and somatic pain.
Jones defined his technique as “a passive positional procedure that places the body in a position of greatest comfort, thereby relieving pain by reduction and arrest of inappropriate proprioceptor activity that maintains somatic dysfunction”. This hypothesis implies that an aberrant muscle spindle reflex creates an increased tone in one of the muscles surrounding a joint, fixating the joint in a certain position. Using the TeP as a monitor, the operator seeks a position of at least two thirds reduction in the TeP tenderness (usually a position that shortens the tissue containing the tenderpoint) and holds this position for 90 seconds. The operator then returns from this position slowly to neutral. If the treatment is effective, the TeP diminishes in tenderness ( by 70% or more) and there is a reduction in tissue tension and oedema contributing to myofascial pain patterns and somatic joint dysfunction.
Perhaps the most well known visceral method was developed in the 1980s by French physiotherapist and osteopath Jean-Pierre Barral who views the organs from a mechanical perspective. Organs form visceral “joints” with other organs or a part of the locomotor system, similar to the joints in the locomotor system moving against each other in fixed directions and ranges. In the locomotor system, joints have smooth surfaces and a synovial lining which produces small amounts of fluid to minimize friction during movement. Similarly in the visceral system, organs have a smooth surface formed by the subserous fascia of the peritoneum, pleura or endocardium which also produces a small amount of fluid within the serous cavities to allow frictionless motion. In the locomotor system, joints have myofascia and ligaments that permit and limit the direction and extent of movements and similarly the organs have mesentries, omenta and ligaments that constrain and direct their motion. This movement occurs along a defined axis with a defined amplitude similar to the joints of the locomotor system. Barral also constructs his theory of visceral treatment parallel to locomotor joint treatment where the organs are tested for their ability to move and treated to increase mobility until a normal range of motion is restored. Disturbed mobility may result from myofascial or muscular contraction (viscerospasms), inflammation or trauma creating adhesions or loss of ligamentary elasticity (ptosis).
American physical therapist Brian Tuckey has recently progressed Lawrence Jones’s SCS concept to treat the viscera. Similar to SCS taught for the musculoskeletal system, each dysfunctional organ creates a corresponding tender point within the deep or superficial fascia. Positioning is used to decrease tender point tenderness and thereby treat subserous fascial contraction and functional disturbance of the organ.
The founder of modern cranial treatment concepts is considered to be American osteopath William Garner Sutherland. In 1899, while a student at the American School of Osteopathy, Sutherlands attention was directed at the disarticulated skulls beveled surfaces between the greater wing of sphenoid and the squamous portions of the temporal bones. The inspirational thought came to him that “ it was beveled like the gills of a fish and indicating articular mobility for a respiratory mechanism”. The more he studied the cranial bones, the more logical his premise seemed as he found a rich variety of articular surfaces suggesting different types of motion of including gliding, rack and pinion, ball and socket and expansion joints that when put together, resulted in a pattern of motion for the entire skull.
In the absence of musculature with the correct location, origin and insertion to produce the movements he predicted, Sutherland coined the term ‘reciprocal tension membrane’ for the intracranial dura mater and its reflections which he believed acted to transmit motion from the cerebrospinal fluid (CSF) to the cranial bones and sacrum. When later reading of the physiological centres in the floor of the fourth ventricle, Sutherland reasoned that this was the region of the primary respiratory mechanism. Sutherland hypothesised that a fluctuation of the CSF resulted from the involuntary rhythmical motion of contraction and dilation of the cerebral ventricles.
Sutherland devised a technique to compress his own fourth ventricle and a mechanical hat that could direct pressure to different cranial bones of his own head. He discovered that he could create varied sensory, endocrine or neurological symptoms in his body and relieve the symptoms with treatment techniques. He deduced that distortions of the cranial bones and intracranial membranes could be a source of pathology. Sutherland created specific techniques for treating the ‘membranous articular strains’ of the cranial mechanism using low velocity / low amplitude pressures, tractions and torques on the cranial bones and sacrum and using CSF as the activating treating force and had considerable success with these techniques on his patients.
Others practitioners have built upon Sutherlands legacy. American osteopath John Upledger proposed a hydraulic-type system of CSF production and reabsorption as the mechanism responsible for the motion of the cranial bones and sacrum. Upledgers Craniosacral therapy focussed emphasis on treating the intracranial membranes and their attachments particularly with fluid dynamic techniques. Upledger proposed that the entire continuum of the connective tissue through the body connecting into the intracranial and intra-spinal dura was also part of the primary respiratory mechanism, the ebb and flow of fluid aiding the exchange of nutrients and metabolites. Treating restrictions in fluid exchange could therefore be done from any part of the body. Dr Jones and his colleague, American physical therapist Randall Kusunose also adapted the strain counterstrain method to treat cranial based dysfunction.