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strainWinter 2005 • www.amtamassage.org 73

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72 Massage Therapy Journal • Winter 2005

COUNTERSTRAINP

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This gentle new approach addresses protective muscle

spasm at its core.

Text and Illustrations by Lissa Wheeler

Technique

ADVANCED

01

Winter 2005 • www.amtamassage.org 75

Externalforces frominjuries andaccidents, or internal stressors

from toxicity and

inflammation,can initiate a

protectiveresponse.

Technique


For more than 30 years, Sharon Weiselfish-Giammatteo had been looking foranswers for chronic pain. Never satisfiedthat her training in traditional physicaltherapy was enough for clients, she con-

tinually sought out new techniques and modalities.In 1981, she discovered Lawrence Jones and hisremarkable modality, strain and counterstrain,which is a technique that eliminates protectivemuscle spasm through precise positioning of thebody. Weiselfish-Giammatteo was so impressedwith results from this technique, she had her entirestaff trained in strain and counterstrain, and eventu-ally began teaching the technique.

After working with strain and counterstrain tech-niques, Weiselfish-Giammatteo observed that somepatients responded beautifully,while others were get-ting only partial results and merely temporary relief.She realized that the more vital structures, such asvasculature and viscera, could go into states of pro-tective muscle spasm in the same way skeletal mus-cles do. In 1990, with Jones’s blessing, Weiselfish-Giammatteo began to research and develop a wholenew way to utilize his technique. She applied thesame principles to autonomically innervated smoothmuscles, and created advanced strain counterstrain.

A Quick OverviewAdvanced strain counterstrain is an organization ofpositional techniques for the vascular and visceralsystems. For each technique, the therapist passivelyplaces the client’s body in a precise position, main-taining it for one minute.These are “indirect” posi-

tions, meaning that the body is taken into the pat-tern where it wants to go, which can feel incrediblyrelaxing.The positions create a “long lever” release,so that the therapist doesn’t have to put handsdirectly on the structure that is being released—thedesign of the position does it.The positions appearquite simple, and because they are so precise, verylittle force or effort is required. The whole processrequires only 60 seconds, making it an easy addi-tion to any massage and bodywork session.

Why Address Blood Vessels And Organs? In the field of massage, we talk about the benefitsof massage for improving circulation. Betterblood flow helps injuries heal faster throughimproved cellular nutrition and reduction ofvenous and lymphatic congestion.This is great fora wide range of needs, from enhancing athleticperformance to promoting wound healing.

We also think about vascular problems in rela-tion to serious life-threatening situations, such ascardiac disease and stroke. We may believe thatthese problems are beyond the realm of massagetherapy. However, there is much that we can dofor our more fragile clients because these tech-niques are so gentle.

We are also taught to avoid massage workaround vascular structures because it is inappro-priate to apply pressure to a blood vessel, yet thevascular system has muscles and fascia just likeour deltoids and latissimus dorsi. These tissuescan greatly benefit from appropriate bodywork.

Lawrence Jones’s original idea of a positional tech-nique is an ideal approach for delicate structuresbecause the position does all the work for thetherapist. It isn’t necessary to touch blood vesselsand organs directly.

The Hierarchy Of ProtectionVasculature, nerves and viscera are at the top ofwhat we call the hierarchy of protection. For exam-ple, the aorta is the largest artery in the body andthe primary distributor of arterial blood to the restof the body. An irritation to the aorta would bemore significant to the body than an irritated cru-ciate ligament. Understanding this hierarchy ofprotection can give you a whole new understand-ing of body tension patterns. While someone canlive with a sprained ankle, cells will die withinminutes without the oxygen provided by an artery.The entire body will rally to protect the more vitalstructures and systems. Muscles will contract, liga-ments and fascia will tighten, joints will becomerigid and body posture will become distorted.Flexibility and movement are sacrificed to splintand immobilize a vulnerable artery, vein, nerve ororgan. The skeletal muscle and fascia are furtherdown on the list, as irritation in these systems isnot life-threatening. Utilizing this concept givesyou a key to unlocking chronic pain patterns forthose clients who return session after session withthe same tension patterns.While there can be manyreasons for tension patterns, protective musclespasm in the vasculature or viscera can be a pri-mary or contributing factor.

A Common Example Of The Hierarchy Of ProtectionA typical postural distortion is a forward head withprotracted shoulders, which is usually accompaniedby neck and back pain, and possibly temporo-mandibular joint (TMJ) dysfunction. What vascularstructure might this person be trying to protect?What runs along the front of your spine? The aorta.This forward head posture can be taking stress offthe aorta. Spinal flexion and extension are often verylimited, because the body’s protective mechanismwants to prevent any further stretch on the aorta.Therespiratory diaphragm will tighten around the pas-sageway of the aorta to immobilize the chest areaand give stability to this vital structure.

What Causes Arteries AndVeins To Go Into Spasm?When you hear the words spasm and artery, youmight think of heart attack and stroke. Protectivemuscle spasm also happens in much less dramaticways throughout daily life. External forces frominjuries and accidents, or internal stressors fromtoxicity and inflammation, can initiate a protec-tive response. The body can often repair theseproblems on its own.With enough chronic stress,a self-perpetuating cycle can occur, which willnot be able to resolve itself.

Why Does It Work? The explanation for why strain and counterstrainworks is conjecture at this point.The theory that bestexplains this self-perpetuating phenomenon is the

Hierarchy OfProtectionARTERYVEINNERVEVISCERALYMPHATIC TISSUEBONEMUSCLECONNECTIVE TISSUE

01 ARTERY LAYERS

The tunica media is the muscular layer (red layer) of

the artery that goes into protective muscle spasm.

02 MUSCLE SPINDLE CLOSEUP

03 MUSCLE SPINDLE

04ANATOMY OF PELVIC DIAPHRAGM

Muscle SpindleDorsal

Root

AlphaMotor

Neuron

DorsalRoot

Ganglion

VentralRoot

ExtrafusalMuscleFibers

ExtrafusalFibers

IntrafusalFibers

Gamma EfferentAfferent Fibers

Alpha Efferent

03

spindle.The spindle will stop its firing, and returnto a resting state.The muscle must never elongatepast its limit or else the spindle will start firing,and the whole cycle of afferent gain starts again.

What if we could reprogram the muscle spin-dle so that it would allow the muscle to lengthen?That is what strain and counterstrain achieves.

The Hyperactivity Of The Gamma Motor Nerve LoopThe gamma motor nerve is responsible for musclespindle sensitivity. Normal muscle resting tonecomes from the gamma bias, which maintains thealpha motor nerves in a moderately excited state. Inthat state, muscles do not have excess tension, norare they flaccid.They have a healthy tone.The gammamotor nerve’s job is to control the tension in the spin-dle via contraction or relaxation of the intrafusalfibers. If the gamma excitation increases (this is calledgamma gain), the spindle excitation also increases, andtherefore the muscle contraction increases.

Lawrence Jones discovered that by eliminatingany mechanical stimulation of the spindles, thegamma excitation would immediately cease,which would stop the pattern of hyperactivityand allow the muscle to lengthen.

Hypothetical ModelThis brings us to the theory of how strain and coun-terstrain technique works.When the muscle sends itshigh frequency discharge to the dorsal horn of itsspinal segment, this information is conveyed to allthe structures innervated by the segment.The exces-

02

concept of the myotatic reflex arc, or what’s oftencalled the stretch reflex reaction. This is a reflexo-genic response that we need to protect muscles,joints and other soft tissues from overstretching andbecoming injured. This becomes a problem if thereflex becomes chronically hyperactive and neverallows the muscle to lengthen. By removing allstretch stimulation to the affected muscle throughthe positioning techniques, the reflexogenic activityof the stretch reflex arc is stopped.This happens byrelaxing the muscle spindle proprioceptors withinthe skeletal muscle.This then eliminates the afferentgain, which then eliminates the gamma gain thatfinally eliminates the alpha gain.

Relaxing The Muscle SpindleThe concept of the stretch reflex arc is the samefor both autonomically innervated muscles andfor skeletal muscles. It starts with the reaction ofthe muscle spindles. The muscle spindles are thetiny proprioceptors within the muscle fibers,which are responsible for detecting changes inmuscle fiber length. They will initiate a musclespasm if the muscle is stretched too far. They aremade up of delicate intrafusal fibers that wrapthemselves around the large extrafusal fibers ofthe skeletal muscle (see illustration, page 86).These intrafusal fibers are set to a specific level oftension. If the skeletal muscle becomes longerthan what the muscle spindle can accommodate,the intrafusal fiber tension becomes too tight, andthe spindle immediately starts sending an alarmmessage to the central nervous system. This mes-


Technique


sage is called a high frequency discharge, whichsignals the skeletal muscle to tighten in order totake the tension off the intrafusal fibers.

Muscle spindles sustain this high frequencydischarge for as long as they are stimulated. Thismeans they never become fatigued and maintainmuscles in perpetual chronic states of contrac-tion. Attempts to stretch out the muscle furtheronly increase the high frequency discharge andthe subsequent muscle spasm.

The stretch reflex arc also relates to spasticity.Cerebral palsy and hemiplegia are good examples.Because the spasming muscle cannot be stretchedout, a typical solution for these people is to cut thetendons of the spastic muscle or inject botox into itto eliminate the spasm. Strain and counterstraintechniques can be a welcome noninvasive alterna-tive to help eliminate spasticity in these individuals.

The Cycle Of Afferent GainAfferent gain is what strain and counterstrainseeks to eliminate.The discharge from the musclespindle is conveyed up the sensory afferent nerveto the dorsal horn of that particular spinal seg-ment.This is called afferent gain. The afferent gain isinformation that is immediately relayed to thespine’s anterior horn to the alpha motor nerve.The alpha motor nerve innervates the skeletalmuscle fiber, making it contract. The goal of thealpha gamma nerve is to satisfy the muscle spin-dle requirement for shorter muscle fibers. If themuscle is now shortened enough, via the con-traction, all mechanical tension should be off the

sive discharge of the muscle spindle affects more thanthe muscle fibers in which it is invested. This dis-charge is communicated throughout the entire cen-tral nervous system. It directly affects all other mus-cles that are innervated by the same segment. Forexample, the C5 spinal segment innervates thesupraspinatus, subscapularis, deltoid and biceps.Dysfunction in any one of these muscles will increasegamma gain to all the muscles at this segment. If youstrained the supraspinatus muscle after lifting a heavymassage table, the rest of the muscles at this segmentwould also go into protective muscle spasm. All themuscles in your entire body would be affected, astheir dorsal roots will receive this discharge.

If this gamma/afferent/alpha gain is main-tained long enough, a self-perpetuating cycleoccurs where the spindles cannot relax and theycontinue to fire a high-frequency discharge.Thus,the muscles can never fully relax and elongate,causing chronic protective muscle spasm. Thisentire pattern is called the “facilitated segment.”

Smooth Muscle SpasmAn individual spinal segment innervates skeletalmuscle, smooth muscle and organs. For example,the same C5 that innervates the supraspinatus alsoinnervates contractile fibers of blood vessels thatsupply the neck and shoulder. C5 is also the inner-vation of the phrenic nerve, which contracts thediaphragm. An irritation at the diaphragm or anyof the neck vasculature would initiate this samehigh frequency discharge, creating the same pro-tective muscle spasm as the strained supraspinatus.

05ASCS PELVICDIAPHRAGM

If you strained

thesupraspinatusmuscle after

lifting aheavy

massagetable, the rest of the muscles at

this segmentwould also

go into protective

musclespasm.

06RESPIRATORYDIAPHRAGM

07ASCS RESPIRATORYDIAPHRAGM

08THORACIC INLETDIAPHRAGM

09ASCS THORACIC INLET DIAPHRAGM


Technique


Implementing The Method Each technique in advanced strain counterstrain hasbeen specifically designed to reduce pressure on themuscle spindles of that particular organ or vascularstructure.This eliminates the hyperexcitation of themuscle spindles, which instantly reduces spasm.

Applying these simple but profound tech-niques is easy to incorporate into a massage ses-sion.They can be performed prior to the massage,before the client undresses. They can also be per-formed during the session, with attention to drap-ing the client during positioning of the technique.

There are no contraindications with thesetechniques, as you are simply putting the bodyinto a position of comfort.The only contraindica-tion would be if the position weren’t comfortablefor the client.

Each position should be maintained for 60 sec-onds to eliminate the spasm of autonomically inner-vated structures. They can be used at any time dur-ing a bodywork session. Used before a massage, theywill create a more profound relaxation, because youhave removed a core source of tension.An entire ses-sion can be comprised of these techniques.

When To Use Advanced Strain CounterstrainThese gentle techniques can be used for manytypes of clients. They can be integrated within aregular massage and bodywork session or com-prise an entire session. An individual with achronic pain pattern that is not responding tomusculoskeletal modalities would benefit from

This case study is a good example of how releas-ing vascular spasm can reduce swelling. Thiswoman had three total knee replacements becauseof subsequent staph infections. When she wastold to have a fourth, she sought an alternativethrough massage and bodywork. She has beenreceiving integrative manual therapy as part ofher rehabilitation for more than a year.The goal ofthis particular session was to reduce swelling andpain in her left knee. Advanced strain counter-strain techniques were performed for all fourdiaphragms, lymphatic vessels, iliac and femoralarteries, and superficial veins of the left leg.

Following the session, she experienced a reduc-tion in pain and an increase of 20 degrees in kneeflexion. The photo on the far right shows thechanges in circumference of her left thigh. Beforeand after measurements of her leg were taken infour places with measuring tape.

The following case studies illustrate a wide range of application with these techniques. Standard range of motion testing was usedto show objective changes. Two of these individuals have histories of severe health issues or injuries. Small changes in range ofmotion are very significant for them.The remaining two individuals are in good health and responded to the techniques with moredramatic changes in range of motion.

This case study is a good example of how tensionin the vascular system can affect spinal range ofmotion.Techniques for the aorta and superior andinferior vena cava were performed on this client.

these techniques. A vascular problem, such asvascular insufficiency or high blood pressure,generally responds well to this modality.

Study the client’s anatomy and begin to questionwhether a postural deviation and loss of range ofmotion appears to be protecting a vascular structure.

The techniques may be repeated as often asdesired, but after the first time, the tension pat-tern will never be as severe.

A general philosophy with this approach isthat if the same tension pattern returns with thesame intensity, a different technique is needed.

The best place to begin is generally at the mostproximal aspect, and then work out to moreperipheral structures. The techniques presented inthis article for the aorta, superior vena cava andinferior vena cava are excellent places to start andwill benefit everyone. The four diaphragm tech-niques are included in this article as well. Theyshould be released first before any vascular tech-nique is performed. All the vasculature must travelthrough the diaphragms. You want to open thesepassageways to allow room for increased blood flow.

Seven TechniquesThese seven techniques offer a wonderful foun-dation for reducing tension in the autonomicnervous system. Release the four diaphragmsfirst. Position the body according to the instruc-tions. (Photos are included to demonstrate thepositions.) As you set up the positions, be awareof the structure you are affecting. Use justenough pressure to maintain the position.

10ANATOMY SHOT:CRANIAL BASE

11DEMO OF TECHNIQUE:ASCS CRANIAL BASE

FOUR CASE STUDIES

Case Study 1LEFT KNEE PAIN AND DYSFUNCTIONAFTER TOTAL KNEE REPLACEMENT

BEFORE AFTER

Case Study 2LIMITATION OF SPINAL FLEXION AND EXTENSION

SPINAL FLEXION BEFORE = 15 DEGREES

SPINAL FLEXION AFTER = 65 DEGREES

SPINAL EXTENSION BEFORE = 20 DEGREES

SPINAL EXTENSION AFTER = 45 DEGREES

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0807

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Technique


Reducing vascular spasm can be significant in therehabilitation of neurologically injured clients.This man sustained a traumatic brain injury,which affected all functions, including walking,bowel and bladder. Advanced strain counterstrainhas been part of his rehabilitation process. At thetime of this session, he was just beginning stand-ing and gait training. The technique for the rightiliac artery was performed to increase his abilityto abduct his hip as preparation for his gait train-ing session. Spasm of the iliac artery was prevent-ing his ability to abduct his right hip. After thistechnique was performed, he gained 20 degreesin right hip abduction.This improved his hip sta-bility, which increased his ability to stand andtake steps.

When the aorta is in a state of protective musclespasm, there can be considerable limitation inspinal motion and left shoulder range of motion.Typically, this includes limitation in spinal exten-sion and guarding of left shoulder movement inorder to protect the aorta from further stretching.Releasing the protective muscle spasm in theaorta allowed the client to have considerableincreases in her range of motion in these areas.

The pelvicsoft tissue is almostalways in a state

of spasm,especiallybecause

of the incidence

of sacroiliacbiomechanical

imbalance.

12AORTA

13ASCS AORTA

Case Study 3THE EFFECT OF THE AORTA TECHNIQUE ON SPINALMOTION AND LEFT SHOULDER EXTENSION BEINGDEMONSTRATED BY WEISELFISH-GIAMMATTEO

SPINAL EXTENSION BEFORE = 0 DEGREES

SPINAL EXTENSION AFTER = 45 DEGREES

ARM EXTENSION BEFORE = 25 DEGREES

ARM EXTENSION AFTER = 50 DEGREES

Case Study 4TRAUMATIC BRAIN INJURY

LEG ABDUCTION PRE-TECHNIQUE ROM

LEG ABDUCTION POST-TECHNIQUE

CASE STUDIES CONTINUED• Lift both feet towards ceiling six inches offthe table.

• Push on the illium, two inches below the iliac crest,mid-axillary line. Push with three pounds of force.

Respiratory Abdominal DiaphragmThis technique specifically improves breathingand is an excellent support for any pulmonary,cardiac or spinal problems.Follow these steps:• Flex hips to 50 degrees.• Flex knees to end of range.• Gently side bend the neck, as far it will go

comfortably.• Press on the lower lateral rib cage towards the floor.

Thoracic InletThis technique is good to use before performingany cranial techniques in order to open up venousdrainage. This will also improve lymphaticdrainage, as the lymph terminus is located in thethoracic inlet. Swelling and congestion of theentire body will be reduced.Follow these steps:• Use a pillow under the head and neck to keep

them in midline.• Abduct the ipsilateral shoulder to 70 degrees.• Gently press the ipsilateral shoulder girdle toward

the feet with three pounds of pressure.

Cranial DiaphragmThis technique will prepare the body for cranialwork, as it releases protective muscle spasm in the

Remember that the specificity of the positiondoes all the work for you.

It takes only 60 seconds to release the protec-tive muscle spasm. You can hold the positionlonger, for five to 20 minutes, to release the facialrestrictions related to the structure.

There are no precautions for these techniquesother than checking that the client is comfortablein the position.

Four Diaphragm TechniquesThese four techniques ideally should be per-formed within the same session because all thediaphragms work together as a system. The statusof one diaphragm will affect the status of all theothers.The goal is to release hypertonicity of eachdiaphragm, which will improve breathing, circu-lation and reduce congestion. All techniques areperformed with the client side-lying on theopposite side. For example, if the right diaphragmis being worked on, have the client lie on his orher left side.

Pelvic DiaphragmThe pelvic soft tissue is almost always in a state ofspasm, especially because of the incidence ofsacroiliac biomechanical imbalance. This tech-nique can be used during pregnancy, during laborto facilitate delivery and immediately after deliv-ery to promote healing of the pelvic floor.Follow these steps:• Flex both hips to 70 degrees.• Flex both knees to 70 degrees.

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toms, scars and other connective tissue problems.Cardiopulmonary and cardiovascular problemsare also helped with these techniques, and allbrain and spinal cord dysfunction whether mildor severe, chronic or acute.

Lissa Wheeler is certified in muscular therapy, shiatsu, Trager® Approach, neuromuscular therapyand integrative manual therapy. She is an instructorat the Connecticut School of Integrative ManualTherapy. Wheeler teaches courses nationally andinternationally for Dialogues in ContemporaryRehabilitation (DCR). She has a master’s degree inclinical psychology, and is currently completing aPh.D. in integrative manual therapy.

BibliographyGiammatteo, Thomas and Sharon Weiselfish-

Giammatteo. Utilizing Advanced Strain and

Counterstrain Technique. Integrative Manual Therapy For

The Autonomic Nervous System And Related Disorders.

Berkeley, California: North Atlantic Books, 1997.

Jones, Lawrence. Strain And Counterstrain.

Indianapolis, Indiana: American Academy of

Osteopathy, 1981.

Marieb, Elaine. Human Anatomy and Physiology.

Boston, Massachusetts: Addison Wesley Longman

Inc., 1998.

Netter, Frank. Atlas of Human Anatomy. Summit,

New Jersey: Ciba-Geigy Corp., 1989.

Weiselfish-Giammatteo, Sharon. Integrative Manual

Therapy For The Upper and Lower Extremities.

Berkeley, California: North Atlantic Books, 1998.

Both thesuperior and

inferior vena cava techniques

are excellentfor reducing

edema, lymphedema,lipedema, allfibromyialgia-

like symptoms,scars and

other connective

tissue problems.

14ANATOMY SHOT:SUPVC

15ASCS SUPVC

16ANATOMY SHOT: IVC

17DEMO OF TECHNIQUE:ASCS IVC

tentorium. There may be a change in visionbecause the tentorium is no longer compressingthe cranial nerves, which innervate the ocularmuscles that must pass through this structure. Earpain, tinnitus, hearing and equilibrium may alsoimprove from pressure being released from thesecranial nerves and the ear canal. Seizure disordersmay occasionally improve from release of pres-sure in the temporal lobe. All head, face and neckpain clients can benefit from this technique.Follow these steps:• Place the palm of your hand over the ear (meatus),

with fingers also covering the temporal bonesuperior to the meatus.

• Press the medial toward the floor.• Place the other hand in the axilla of the ipsilat-

eral side and push the axilla up toward themeatus of the ear.

Vascular TechniquesPlease release all four diaphragms before per-forming these techniques. These structures travelthrough the diaphragms, and if the diaphragm isin spasm, the vessel will not be able to relax fully.Ideally, all three techniques are performed. Thereis a circular flow of arterial to venous to arterialand so on.You don’t want to increase one system’sflow without balancing the others.

AortaWhen the aorta is hypertonic, there will be limi-tations, especially in the left shoulder, to preventmore tension on the aorta. Measure pulse and

blood pressure, as with pre- and post-testing forall cardiac and pulmonary problems.There will beimmediate changes in ranges of motion, especial-ly in the left shoulder and spine. There can be achange in total body edema, secondary to extra-cellular edema from tension surrounding theaorta. Heartburn may be occasionally affectedfrom releasing pressure on the esophagus, whichsits between the heart and aorta. Thoracic outletsyndrome and reflex sympathetic dystrophyclients will also benefit.Follow these steps:• Have the client sit on a table or on a chair without

a back.• Rotate the trunk to the right 10 degrees.• Side bend the trunk to the right 10 to 15 degrees.• Rotate the head and neck to the right 10 degrees.• Side bend the head and neck to the right five degrees.• Move the spinous processes of T2,T3 or T4. Pick

the most rigid segment and gently flex this seg-ment toward the front of the body.The aorta sitsright in front of the spine. Think of taking thepressure off the top of the aorta.

• Press L3 up toward the other hand.Think of tak-ing the pressure off the bottom of the aorta.

Superior Vena CavaFollow these steps:• Sit to the right of the client. Place one hand under

the spine at the level of T5 and compress bothtransverse processes toward each other. Think ofgently taking pressure off the back of the heart,where the superior vena cava enters the heart.

• Bend the right knee and rest the left ankle on theright knee.

• Side bend the trunk to the right 10 to 15 degrees.• Flex the neck 30 degrees.• Rotate the head and neck to the right 10 degrees.• Side bend the head and neck five degrees.• Gently compress the right anterior eighth rib, one-

inch lateral to the intercostal cartilage in a posterior,superior, lateral direction. Use 5 to 10 grams ofpressure.Think about taking tension off the superi-or vena cava by holding up the inferior vena cava.

Inferior Vena CavaFollow these steps:• Sit to the right of the client.• Place one hand under the spine at the level of

T8, and compress both transverse processestoward each other. Think of gently taking pres-sure off the back of the heart, where the inferi-or vena cava enters the heart.

• Bend the left knee and rest the right ankle on theleft knee.

• Gently compress the right anterior eighth rib,one-inch lateral to the intercostal cartilage in aposterior, superior, lateral direction. Use a verylight pressure, about 5 to 10 grams, which is alittle more than the weight of a nickel. Thinkabout taking tension off the path of the inferiorvena cave as it travels up to the heart.

Both the superior and inferior vena cava tech-niques are excellent for reducing edema, lym-phedema, lipedema, all fibromyialgia-like symp-

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