Title: Bone Wizardry / OMM Mastery / 14.Counterstrain and FPR
Tags: #BW_OMM::Technique::Counterstrain #BW_OMM::Technique::FPR #BW_OMM::Type::Cloze BoneWizardry bonewizardry-free omm omt
On every note of this deck, unless a note says otherwise:
Topic: Counterstrain and FPR
Review Links: - Bone Wizardry counterstrain pelvis and lumbar
- Practice: Counterstrain and FPR QBank
Show outside sources
- StatPearls counterstrain and FPR
- StatPearls MET and counterstrain
- StatPearls OMT topic index

Q: Counterstrain is a [...], [...] technique. The physician moves the dysfunctional tissue into ease, positioning it at its most comfortable point rather than engaging the barrier.
A: passive; indirect
Comment: Lawrence Jones developed counterstrain in 1955.
Bone Wizardry Lock: Passive and indirect go together here. The physician never pushes against restriction. Counterstrain always moves toward comfort, not the barrier.

Q: [...] are localized, edematous, exquisitely tender spots about the size of a fingertip.
A: Tenderpoints
Q: Remind me...
what's the difference between a trigger point and a tenderpoint?
[...]
A: Trigger points radiate pain to specific areas when compressed. Tenderpoints do not radiate pain.
Comment: You will find them near where tendons and ligaments attach to bone, or in the belly of certain muscles.
Comment 2: Thanks boo boo, I knew you knew knew.
Bone Wizardry Lock: Key distinction: tenderpoints are purely local. Trigger points radiate to a distant site on compression. Counterstrain tenderpoints never do.

Q: If there are multiple areas of tenderness, treat the [...] tender area first.
A: most
Comment: If all areas are equal in tenderness, treat the middle point first.
Bone Wizardry Lock: Start with the worst tenderpoint. If they are all equally tender, pick the middle one. Same priority rule applies regardless of region.

Basic counterstrain treatment steps:
1. Locate a significant tenderpoint
2. Palpate the tenderpoint
3. Place the patient in the position of optimal comfort
4. Maintain the position for 90 seconds
5. Slow return to neutral
6. Recheck the tenderpoint
Bone Wizardry Lock: Six steps: locate, palpate, position for comfort, hold 90 seconds, return slowly to neutral, recheck. The slow return is mandatory. Snapping back to neutral undoes the treatment.

Q: After positioning for comfort, dial in with small movements until the tenderpoint tenderness has dropped by at least [...].
A: 70%
Bone Wizardry Lock: 70% drop in tenderness is the minimum before you hold. Less than that means the position is off. Keep adjusting before starting the 90-second timer.

Q: AC7 and 8 are the attachments of the [...] muscle.
A: sternocleidomastoid
Q: Counterstrain points:
Posterior aspect of the ascending ramus of mandible = [...]
A: AC1
Q: Counterstrain treatment for AC1 = Neck [...]
A: RA (rotated away)
Q: Counterstrain treatment for AC7 = Neck [...]
A: F STRA (Flexed Sidebent Towards and Rotated Away)
Q: Counterstrain treatment for AC8 = Neck [...]
A: F SARA (Flexed Sidbent Away Rotated Away)
Q: Counterstrain points:
On the inferior nuchal line, just lateral to the inion = [...]
A: PC1 inion
Q: Counterstrain treatment for PC1 inion = Pure [...]
A: flexion
Q: Counterstrain point:
On the inferior/infero-lateral aspect/tip of the spinous process of C2 = [...]
A: PC3
Q: Counterstrain treatment for PC3 = Neck [...]
A: F SaRa
Comment 2: Tenderpoints/counterstrain are a bitch to remember but they are frequently tested on level 2 and the comat.
Comment 5: If you have to guess on a neck counterstrain guess F SARA.
Comment 7: Not sure if these pics will help, but I'm pretty visual so I included them anyways:/
Comment 8: This one can be confusing/ a curveball. Watch out for it.
Comment 9: This one is confusing because all of the other posterior cervical points are treated with E SARA.
Bone Wizardry Lock: AC7 and AC8 mark the SCM attachments. Most anterior cervicals default to F SARA if you have to guess. PC3 at C2 is the odd one out: F SaRa rather than E SARA like the rest of the posterior cervicals.

Q: Counterstrain point:
Below clavicle at first chondrosternal articulation = [...]
A: AR1
Q: Counterstrain point:
Superior aspect of 2nd rib at midclavicular line = [...]
A: AR 2
Q: Counterstrain point:
ribs at the anterior axillary line = [...]
A: AR 3-6
Q: Counterstrain treatment:
AR1-6 = [...]
A: F StRt
Comment 4: AR 1-2 you have the patient in supine
AR 3-6 you have them seated in the mermaid's position
Bone Wizardry Lock: All anterior rib points go F StRt. The position differs by group: supine for AR1-2, seated mermaid for AR3-6.

Q: Counterstrain tender points:
posterior superior aspect angle of the corresponding rib = [...]
A: PR 1-10
Bone Wizardry Lock: PR points 1 through 10 share the same landmark: posterior superior angle of the matching rib. Same spot, numbered rib by rib.

Q: Counterstrain treatment:
PR 2-6 = [...]
A: F SARA
Q: Counterstrain treatment:
PR 1 = [...]
A: E SART
Q: Counterstrain tender points:
Medial to ASIS = [...]
A: AL 1
Q: Counterstrain treatment:
AL 1 = Hip [...]
A: F STRA
Q: Counterstrain tender points:
Medial to AIIS = [...]
A: AL 2
Q: Counterstrain treatment:
AL 2 = Hip [...]
A: F SART
Q: Counterstrain tender point:
Lateral to AIIS = [...]
A: AL 3
Q: Counterstrain treatment:
AL3 = Hip [...]
A: F SART
Q: Counterstrain tender point:
Inferior to AIIS = [...]
A: AL4
Bone Wizardry Lock: PR1 breaks from the group: it goes E SART while PR2-6 go F SARA. Anterior lumbar points AL1-4 are all F SART. AL5 at the pubic ramus flips to F SARA.

Q: Counterstrain treatment:
AL4 = Hip [...]
A: F SART
Q: Counterstrain tender point:
Anterior superior aspect of pubic ramus = [...]
A: AL 5
Q: Counterstrain treatment:
AL 5 = Hip [...]
A: F SARA
Bone Wizardry Lock: AL4 and AL5 are both near the pubic area but treat differently. AL4 is F SART. AL5 switches to F SARA. That one-letter flip is a board trap.

Q: Counterstrain tender point:
1/3 distance from ASIS to midline = [...]
A: Iliacus
Q: Counterstrain treatment:
Iliacus = Hip [...]
A: F ER
Q: Counterstrain tenderpoint:
2/3 distance from ASIS to midline = [...]
A: Psoas
Q: Counterstrain treatment:
Psoas = Hip [...]
A: F ST
Comment 2: External rotation; good side over bad side
Bone Wizardry Lock: ASIS-to-midline distance tells you which muscle. One-third of the way in is iliacus, treat with hip F ER. Two-thirds in is psoas, treat with hip F ST. Iliacus gets the good-side-over-bad external rotation cross.

Q: Counterstrain tenderpoint:
Inferior aspect of 12th rib, lateral tips of lumbar transverse processes and superior aspect of iliac crest = [...]
A: Quadratus Lumborum
Q: Counterstrain treatment:
Quadratus lumborum = Hip [...]
A: E Abd ER
Comment: So it basically has 6 different spots that extend from the 12th rib down to the iliac crest. That makes it unique and somewhat easier to remember. It correlates with the lumbars as well. P.s. I hate counterstrain too.
Bone Wizardry Lock: QL tenderpoints span six spots from the 12th rib tip along the lumbar transverse processes down to the iliac crest. Treatment is hip E Abd ER, the one posterior lumbar point going into extension and abduction rather than flexion.

Q: Anterior rib tenderpoints are associated with [...] ribs.
A: exhalation
Q: Posterior rib tenderpoints are associated with [...] ribs.
A: inhalation
Bone Wizardry Lock: Anterior tenderpoint means the rib got stuck in exhalation. Posterior means inhalation. The front-versus-back location tells you which phase of breathing failed to release.

Q: Counterstrain tenderpoints:
Midpoint between ILA and greater trochanter = [...]
A: Piriformis
Q: Counterstrain treatment:
Piriformis = Hip [...]
A: F Abd IR/ER
Q: Counterstrain tenderpoints:
Superior medial aspect of PSIS = [...]
A: UPL5
Q: Counterstrain treatment:
UPL5 = Hip [...]
A: E add IR/ER
Comment 2: Can be either internally rotated or externally rotated.
Comment 4: Can either be internally or externally rotated.
Bone Wizardry Lock: Piriformis point: halfway between ILA and greater trochanter, treat with hip flexion plus abduction and either IR or ER. UPL5 point: superior medial PSIS, treat with hip extension plus adduction and either IR or ER.

Q: Counterstrain tenderpoints:
Inferior and medial to the coracoid process = [...]
A: Pec minor
Q: Counterstrain treatment:
Pec minor = [...]
A: F Add
Q: Counterstrain tenderpoint:
in the belly of the supraspinatus = [...]
A: supraspinatus
Q: Counterstrain treatment:
Supraspinatus = Shoulder [...]
A: F Abd ER
Comment 2: Some text say to only adduct the arm.
Comment 3: Hmmm... I wonder what it could be...
Bone Wizardry Lock: Pec minor tenderpoint is medial to the coracoid, treat with flexion and adduction. Supraspinatus point sits in the muscle belly itself, treat with flexion, abduction, and external rotation.

Q: Counterstrain tenderpoint:
Anterolateral border of scapula = [...]
A: Subscapularis
Q: Counterstrain treatment:
Subscapularis = Shoulder [...]
A: E IR
Bone Wizardry Lock: Subscapularis tenderpoint is at the anterolateral scapula. Treat with shoulder extension and internal rotation, the position that shortens the subscapularis.

Q: Counterstrain tenderpoints:
Superior medial border of the scapula = [...]
A: Levator scapulae
Q: Counterstrain treatment:
Levator scapulae = shoulder [...]
A: IR traction/Abd
Bone Wizardry Lock: Levator scapulae tenderpoint is at the superior medial scapular border. Treat with shoulder internal rotation plus traction or abduction to unload the muscle.

Q: Counterstrain tenderpoints:
Bicipital groove = [...]
A: Long head of biceps
Q: Counterstrain treatment:
Long head of biceps = [...]
A: F Abd IR
Comment 2: "Bruh what are you doing"
Bone Wizardry Lock: Long head of biceps tenderpoint is in the bicipital groove. Treat with shoulder flexion, abduction, and internal rotation.

Q: Counterstrain tenderpoints:
Inferolateral aspect of coracoid = [...]
A: Short head of biceps
Q: Counterstrain treatment:
Short head of biceps = [...]
A: F Add IR
Bone Wizardry Lock: Short head of biceps tenderpoint is inferolateral to the coracoid, near the short head's origin. Treat with flexion, adduction, and internal rotation.

In facilitated positional release, the affected region is placed in a neutral position, then either compression or torsion is applied as the activating force.
Q: How long does it take for facilitated positional release to induce a release?
[...]
A: 3-4 seconds
Q: FPR technique can be used to treat:
1. [...] muscles
2. Deep [...] muscles
A: Superficial; intervertebral
Bone Wizardry Lock: FPR: neutral position first, then add compression or torsion as the activating force. Release happens in 3-4 seconds. Works on both superficial muscles and deep intervertebral muscles.

Q: A [...] is a tenderpoint that does not respond to the standard ease position, so the clinician positions the patient in the opposite direction instead.
A: maverick point
Comment: Approximately 5% of tenderpoints will not improve with the expected treatment even with careful fine tuning.
Bone Wizardry Lock: About 5% of tenderpoints won't respond even with careful fine-tuning of the expected position. When that happens, flip to the opposite direction instead.

Q: What region is associated with the greatest number of "maverick" tenderpoints?
[...]
A: Cervical spine
Bone Wizardry Lock: The cervical spine has the highest concentration of maverick tenderpoints. If cervical counterstrain is not working, try the opposite position before moving on.

Q: What is the first action performed when utilizing FPR to a superficial muscle?
[...]
A: Straightening of the AP spinal curves
Bone Wizardry Lock: For superficial muscles with FPR, the first step is flattening the AP spinal curves to reach neutral. Only then do you add the activating force.

Q: Counterstrain Tenderpoints:
AT1 = [...]
A: Episternal notch
Q: Counterstrain Treatments:
AT1 = Trunk [...]
A: F
Bone Wizardry Lock: AT1 tenderpoint is at the episternal notch. Treat with trunk flexion, bringing the sternum toward the chin.