PRT
Positional Release Therapy
by Dr. George B. Roth, B.Sc., D.C., N.D.
Positional Release Therapy (PRT) is based on Counterstrain, developed by Lawrence Jones (DO) and several innovations developed by George Roth, co-author, Kerry D’Ambrogio (PT), and numerous pioneers on the cutting edge of advanced musculoskeletal assessment and treatment systems.
PRT liberates the practitioner from the tyranny of the symptoms and is directed to the dysfunction. This is akin to directing the fire hose at the base of the flames rather than at the flying sparks. The result is a comprehensive system which is objective, consistent, efficient, effective and extremely gentle. This technique is applicable to a wide range of conditions and to almost any category of patient.
Origins of PRT
Several of the characteristics of PRT, which may be shared with other therapeutic models, can be identified. These include the use of body positioning, the use of tender points to identify the lesion and to monitor the therapeutic intervention and an indirect approach with respect to tissue resistance. The origins of these three characteristics will be explored in order to place the evolution of PRT within its proper context.
Body Positioning
Body posture and the relative position of body parts has been a subject of intense speculation and research throughout history. From yoga to the martial arts to the study of body language, the arrangement of the parts of the human body has been deemed to have a certain mental, physical and spiritual significance. Several forms of yoga, a discipline with over 5000 years of history, include the physical practice of positioning the body to enhance function and release tension.16 These positions put certain parts of the body under stretch while other parts are placed in a position of relaxation (Fig. 1-1). The benefits of this form of exercise to relieve musculoskeletal pain are widely accepted and they are utilized successfully by a substantial number of people.9, 20 Modern derivations of this ancient art may be seen in the practices of Feldenkrais, Bio-energetic Therapy, Sotai, Core Stabilization, Functional Technic and Counterstrain (Fig. 1-2).1, 7, 9, 10, 14, 16 These practices share a commonalty in that they recognize the relationship of body movement and posture with the general condition of the body. Several authors, both modern and ancient elaborate on the ‘energetic’ properties of postures and body positions.28, 29, 33 Some of these phenomena have been noted regularly by practitioners of PRT as part of the release process, which is discussed in later chapters. The mechanism responsible for these effects is unknown.
Tender Points
Acupuncture points have been used therapeutically for at least 5000 years. These points correlate closely with many of those ‘discovered’ by subsequent investigators34. (Figure 1-3) References, in the western literature, to the presence of palpable tender points (TP’s) within muscle dates back to 1843. Froriep described his so-called “Muskelschwiele”, or muscle callous, which referred to the tender points in muscle which were found associated with rheumatic conditions. In 1876, the Swedish investigator, Helleday described tender points and nodules in cases of chronic myositis. In 1904, W. R. Gowers introduced the term ‘fibrositis’ to describe the palpable nodule, which he felt was associated with the fibrous elements of the musculoskeletal system. Post-mortem studies by Schade, which were reported in Germany in 1919, demonstrated thickened nodules in muscle, which served to confirm that these histological changes evolved into lesions which were independent of ongoing proximal neurological excitation.31 In the 1930’s, Frank Chapman, D.O. developed a system of reflexes which he associated with the functioning of the lymphatic system. (Figure 1-4) He found that direct treatment of these reflex tender areas resulted in improved circulation and lymphatic drainage. Resolution of the underlying condition, whether visceral or musculoskeletal would reduce the tenderness of these areas. These reflexes have been described as ‘gangliform’ contractions within the deep fascia and about the size of pea.5 More recently, Simons and Travell have systematized the mapping and direct treatment of TP’s in their two-volume series, Myofascial Pain and Dysfunction.31 Jones reported on his discovery of tender points associated with musculoskeletal dysfunction in his writings as early as 1964.13 The recognition of the tender point or trigger point as an important pathophysiological indicator of musculoskeletal dysfunction has also been elaborated by noted researchers such as Rosomoff and Fishbain.21,22
Bosey states that acupuncture points are situated in palpable depressions – cupules under which lie a fibrous cone containing a neurovascular formation associated with a concentration of free nerve endings, Golgi endings and Pacini corpuscles.2 Melzack and associates contend that there are no major differences between tender points, trigger points, acupuncture points or other reflex tender areas which have been described by different investigators.17 The varying effects reported with the use of different tender points may lie in their relative location with respect to underlying tissues. Chaitow points out that so-called ‘spontaneous sensitive points’ arise as the result of trauma or musculoskeletal dysfunction.3 The Chinese refer to these points as Ah Shi points in their writings dating back to the Tang Dynasty (618-907 AD). Chaitow insists that these are identical to the points which Jones used in his work.4
In summary, tender points have been recognized for thousands of years as having diagnostic and therapeutic significance. Various investigators have ‘rediscovered’ these points and have applied a range of therapeutic interventions in order to influence them. In general, any therapy which is able to reduce the tenderness of these tissues, appears to have a beneficial effect on the health of the individual. Jones was the first clinician to associate body position with a reduction in sensitivity of these tender points.13
Indirect Technique
The history of therapeutic intervention to affect somatic structures can be broadly divided into direct and indirect techniques. Direct techniques involve force being applied against a resistance barrier, such as stretching, joint mobilization, muscle energy, etc.8, 18 Indirect techniques employ the application of force away from a resistance barrier, i.e. into the direction of greatest ease. Indirect therapies, including PRT, have evolved in various forms and share certain common characteristics and underlying principles.
In 1943 William Sutherland introduced his concepts regarding manipulation of cranial structures. His technique to treat cranial lesions was to follow the motion of the skull in the direction in which it moved most freely.30 By placing pressure on the bones of the head into the direction of greatest ease, he found that the tissues spontaneously relaxed and allowed for a normalization of structural alignment and function.
In the late 1940’s Harold Hoover, D.O. introduced Functional Technic. He found that when a body part or joint was placed in a position of dynamic reciprocal balance, where all tensions were equal, the body would spontaneously release the restrictions associated with the lesion. During that period, the prevailing view of musculoskeletal assessment stressed the position and morphology of body parts. Dr. Hoover emphasized the importance of listening to the tissues. ‘Listening’ refers to the process of carefully observing, through palpation, the patterns of tension within the tissues and paying attention to their functional characteristics as well as their structure. He introduced the concept of functional diagnosis which takes into account the range-of-motion and tissue play within the structures being assessed.
Hoover advocated a treatment protocol which was respectful of the wisdom of the tissues and the inherent interaction of the neuromuscular, myofascial and articular components. The technique involves the movement towards the least resistance and greatest comfort and relies on the response of tissues under the palpating hand of the practitioner. This dynamic neutral position attempts to reproduce a balance of tensions, which is near the anatomical neutral position for the joint, within its traumatically induced range. A series of tissue changes may occur during the positioning which are perceived by the practitioner. The practitioner attempts to follow this evolving pattern until the body spontaneously achieves a state of resolution and the treatment is complete.10
Jones found that specific positions were able to reduce the sensitivity of tender points (See History of Counterstrain below). Once located, the tender point is maintained with the palpating finger at a subthreshold pressure. The patient is then passively placed in a position which reduces the tension under the palpating finger and causes a subjective reduction in tenderness as reported by the patient.14 This ‘specific’ position is, nevertheless, fine-tuned throughout the treatment period (90 seconds), much in the way that Hoover follows the lesion in his technique. Chaitow also alludes to the possibility that maintaining contact with the tender point exerts a therapeutic effect.4
Ira C. Rumney, D.O. of the Kirksville College of Osteopathy, in a paper presented a year or so before the publication of Jones’ discoveries, described the basis for re-establishing normal spinal motion as follows:
“Inherent corrective forces of the body – if the patient is properly positioned,his own natural forces may restore normal motion to an area.”25
Other clinicians have utilized an indirect method to treat musculoskeletal dysfunction by having the patient actively position themselves through various ranges-of-motion under the guidance of the practitioner and while being monitored for maximal ease by palpation.8
History of Counterstrain
In 1954, Dr. Lawrence H. Jones, D.O., an osteopath with almost 20 years experience was called on by a patient who had been suffering with low back pain of 2 month’s duration and which had not responded to chiropractic care. The patient displayed an apparent psoas spasm with resultant antalgic posture. Dr. Jones was going to “show him what a real osteopath could do”! However, after several sessions with no improvement, he was ready to admit defeat in the face of this resistant case. The patient was in so much pain that sleep for more than a few minutes was impossible. Jones decided that perhaps, finding a comfortable position which would allow him to sleep, would at least provide him with some temporary relief and some much-needed rest. After much trial and error, they did indeed find a position which apparently the patient found quite comfortable. Jones propped the patient in this unusual-looking folded position with several pillows and left him to rest. Upon his return, some time later, Jones suggested that the patient memorize the position in order to reproduce it when going to bed that night. The patient was then slowly taken out of the position and instructed to stand up. Much to the amazement of the patient, and Dr. Jones, the patient stood up erect and with drastically reduced pain. In the words of Dr. Jones: “…the patient was delighted and I was dumbfounded!”13,14
This first discovery emphasized the value of the position of comfort. He found that by holding these positions for varying periods of time, lasting improvement would often be the result. He initially held the position for 20 minutes and gradually found that 90 seconds was the minimal threshold for optimal correction of the lesion.
As Jones pursued the possible applications of this new discovery, which he referred to as Counterstrain, he noted that many of the painful conditions which he was able to alleviate were found to be associated with the presence of acutely painful tender points. The traditional approach to lesions of the spine was to assess and treat on the basis of tender areas in the paraspinal tissues. These points, upon positioning of the patient, became decidedly reduced in tenderness and remained so even after the treatment was concluded. Thus, an important diagnostic dimension was added to this form of therapy.
In many instances of back and neck pain, however, no tender point could be found in the area of the pain within the paraspinal tissues. Fate was to once again answer the need! A patient, who had been seeing Dr. Jones for low back pain, was working in the garden when he was struck in the groin with a rake handle. In pain and fearing that he may have induced a hernia, he called on Dr. Jones. Jones, upon examination, assured him that no hernia was present and decided that, since he was already in the office, he may as well stay and receive a treatment which was scheduled for later in the week. After the patient had been placed in the position for treatment of his low back, in which he was supine and flexed maximally at the hips, Jones decided to recheck the previously tender area in the groin. Much to his amazement, the tenderness was gone! This discovery answered the mystery of the missing tender points and shortly thereafter, Dr. Jones was able to uncover an array of anteriorly located tender points which were associated with pain throughout the spine.12 He noted that approximately 30 – [50]% of back pain was associated with these anterior tender points. With this latter discovery, much of the guesswork and trial and error in the application of therapy was eliminated. The use of the tender points became a reliable indicator of the type of lesion being encountered and therapeutic intervention could thus be instituted with increased confidence and reproducibility. Dr. Jones spent the better part of thirty years developing and documenting his discoveries which he first published in 196413 and later produced a book entitled Strain and Counterstrain.14
Recent Advances
Positional Release Therapy owes its recent evolution to a number of clinicians and researchers: Harold Schwartz, D.O. adapted several techniques to reduce practitioner strain.27 Stanley Shiowitz, D.O. and Arthur Pauls, D.O. introduced the use of a facilitating force (compression, torsion, etc.) to enhance the effect of the positioning26 Maurice Ramirez, D.O. discovered a group of tender points on the posterior aspect of the sacrum which have significant connections to the pelvic mechanism.19 Sharon Weiselfish, P.T., Ph.D. outlined the specific application of positional release techniques for use with the neurological patient. She found that the initial phase of release (neuromuscular) required a minimum of 3 minutes and she also outlined protocols to locate key areas of involvement with this patient population. She, along with D’Ambrogio outlined the two phases of release: 1. neuromuscular, 2. myofascial.32 Courtney W. Brown, M.D. developed a system of exercise for the spine in which a pain-free range-of-motion is maintained.1 Kerry D’Ambrogio, P.T. developed the Scanning Evaluation procedure to facilitate the efficiency and thoroughness of patient assessment.6 George Roth, D.C., N.D. has developed improved practitioner body mechanics to reduce strain and has correlated lesions with specific anatomical structures.23 Roth and D’Ambrogio have helped to simplify the terminology used to describe lesions and systematized the educational program to help make the development of PRT skills more efficient.
We owe much to the inspiration and perseverance of those who came before us. It has been said that ‘there is nothing new under the sun’. Positional Release Therapy had its origins in antiquity and continues to evolve through the discoveries of the current generation of clinicians and researchers.
Summary
Positional Release Therapy has historical roots in antiquity. The three major characteristics: body positioning, the use of tender points and the indirect nature of the therapy can be individually traced to practices established over the past 5000 years. Connections can be made with the ancient disciplines of yoga and acupuncture as well as with the work of investigators over the course of the past two centuries. The correlation of different systems which utilize tender points suggests a common mechanism for the development of these lesions. Significant contributions to the development of this art and science have been made by Dr. Lawrence Jones and several of his contemporaries. PRT is being continually advanced and developed through the contributions of many clinicians and researchers.
References:
1. Brown CW: The natural history of thoracic disc degeneration, Spine (suppl), June 1992.
2. Bosey J: The morphology of acupuncture points, Acupuncture and Electotherapeutic Research, 2:79, 1984.
3. Chaitow L: Soft Tissue Manipulation, Rochester, Vermont, Healing Arts Press, 1988.
4. Chaitow L: The Acupuncture Treatment of Pain, Thorsons Publishers Ltd., Wellingborough, 1976.
5. Chapman F, Owens C: Introduction to and Endocrine Interpretation of Chapman’s Reflexes, (Self-Published)
6. D’Ambrogio K: Strain/Counterstrain (Course Syllabus), Palm Beach Gardens, Upledger Institute, 1992.
7. Feldenkrais M: Awareness Through Movement: Health Exercises for Personal Growth, New York, Harper & Row Publishers, 1972.
8. Greenman PE: Principles of Manual Medicine, Baltimore, Williams & Wilkins, 1989.
9. Hashimoto K: Sotai Natural Exercise, Oroville, CA, George Ohsawa Macrobiotic Foundation, 1981.
9. Hewitt J: The Complete Yoga Book, New York, Random House, Pantheon Books, 1977.
10. Hoover HV: Functional Technic, AAO Year Book 47-51, 1958.
11. Jones LH: Foot treatment without hand trauma, JAOA 72:481, 1973.
12. Jones LH: Missed anterior spinal lesions: a preliminary report, The DO 6:75, 1966.
13. Jones LH: Spontaneous release by positioning, The DO 4:109, 1964.
14. Jones LH: Strain and Counterstrain, Newark, OH, American Academy of Osteopathy, 1981.
15. Jones LH: Strain and Counterstrain Lectures, 1992-1993.
16. Lowen A, Lowen L: The Way to Vibrant Health: A Manual of Bioenergetic Exercises, Harper & Row Publishers.
17. Melzack R, Stillwell, Fex EJ: Trigger points and acupuncture points for pain, correlations and implications, Pain 3:3, 1977.
18. Mitchell FL, Moran PS, Pruzzo HA: An Evaluation and Treatment Manual of Osteopathic Muscle Energy Procedures,Valley Park, MO, Mitchell, Moran and Pruzzo, Associates, 1979.
19. Ramirez MA, Haman J, Worth L: Low back pain: Diagnosis by six newly discovered sacral tender points and treatmentwith counterstrain, JAOA 89:7, 1989.
20. Ramnurti M: Fundamentals of Yoga, Doubleday
21. Rosomoff HL: Do herniated discs cause pain?, Clin J Pain 1:91, 1985.
22. Rosomoff HL, Fishbain DA, Goldberg M, Steele-Rosomoff R: Physical findings in patients with chronic intractable benign pain of the neck and/or back, Pain 37:279, 1989.
23. Roth GB: Counterstrain: Positional Release Therapy (Study Guide), Toronto, Wellness Institute (self-published), 1992.
24. Roth GB: Towards a unified model of musculoskeletal dysfunction, Can Chiro Assoc (presentation), June 1995.
25. Rumney IC: Structural diagnosis and manipulative therapy, J Osteopathy 70:21, Jan. 1963.
26. Schiowitz S: Facilitated positional release, JAOA 2:145, 1990.
27. Schwartz HR: The use of counterstrain in an acutely ill in-hospital population, JAOA, 86:433, 1986.
28. Schwartz JS: Human Energy Systems, New York, E.P. Dutton, 1980.
29. Smith FF: Inner Bridges, A Guide to Energy Movement and Body Structure, Atlanta, Humanics New Age, 1986.
30. Sutherland WG: The cranial bowl, JAOA 2:348, 1944.
31. Travell JG, Simons DG: Myofascial Pain and Dysfunction: The Trigger Point Manual, Baltimore, Williams & Wilkins, 1983.
32. Weiselfish S: Manual Therapy for the Orthopedic and Neurologic Patient Emphasizing Strain and Counterstrain Technique,Hartford, CT, Regional Physical Therapy (self-published), 1993.
33. Woodroffe J: The Serpent Power, Madras, India, Ganesh & Co., 1918.
34. Woolerton H, McLean CJ: Acupuncture Energy in Health and Disease: A Practical Guide for Advanced Students,Northamptonshire, England, Thorsons Publishers Ltd., 1979.
Dr. George Roth, D.C., N.D. is a practitioner with over 25 years experience in the field of energy medicine. He has developed a number of leading-edge technologies to assist individuals in the achievement of optimal wellness. He lectures extensively to various groups and educational institutions and is a published author.
For more information, or to make an appointment, please contact
Dr. George B. Roth,Matrix Wellness Solutions,67 Prospect St., Newmarket, Ontario, Canada, L4G 1R1Phone: 905 836-WELL (9355)1-877-905-7684Fax: 905 726-8575Email: info@matrixrepatterning.comWeb site: www.MatrixRepatterning.com
For Positional Release Therapy seminar information, please contact:
Kerry D’Ambrogio, PT at:Phone: 941-358-1033 or email: kdambrogio@aol.com
