Short-Term Effects of Strain Counterstrain in
Reducing Pain in Upper Trapezius Tender Points
A Pilot Study
Adam Perreault, MEd, ATC; Brent Kelln, PhD, MPT, OCS; Jay Hertel, PhD, ATC, FNATA, FACSM;
Kelli Pugh, MS, ATC, CMT; and Susan Saliba, PhD, ATC, PT
ABSTRACT
Tender points are common in the upper trapezius muscles and
can cause persistent pain and muscle spasm. The purpose of
this pilot study was to evaluate short-term effects of a single in-
tervention of strain counterstrain (SCS) as a treatment for tender
points in the upper trapezius for the reduction of resting pain,
pressure threshold, and provoked pain compared with a sham
treatment. Twenty participants with self-reported upper trape-
zius pain volunteered for treatment with a single 90-second ap-
plication of SCS or 90-second sham treatment. Pain measures
were taken before, after, and 24 hours after treatment. Three
separate 2x3 ANOVAs showed a significant main effect for time
(P = .003), but not treatment for resting pain. No significant dif-
ferences were found for the provoked pain or pain threshold.
Statistical evidence showed no superiority of a single treatment
of strain counterstrain over a sham treatment for upper trape-
zius tender point pain.
A
pproximately 23 million people (close to 10%
of the U.S. population) suffer from chronic
musculoskeletal disorders.1 Myofascial pain is
estimated to account for 85% of muscular pain due to
Mr Perreault is Head Athletic Trainer, U.S. Mens Alpine Ski Team, United States
Ski and Snowboard Association, Park City, Utah, Dr Kelln is from the Naval Health
Clinic Hawaii, Pearl Harbor, Hawaii, Dr Hertel, Ms Pugh, and Dr Saliba are from the
University of Virginia, Charlottesville, Va.
Originally submitted March 2, 2009.
Accepted for publication May 21, 2009.
The authors have no financial or proprietary interest in the materials presented
herein.
The views expressed in this article are those of the authors and do not reflect
the official policy of the Department of the Navy, the Department of Defense, nor
the United States Government.
Address correspondence to Susan Saliba, PhD, ATC, PT, Human Services,
University of Virginia, PO Box 400407, Charlottesville, VA 22904; e-mail saf8u@
virginia.edu.
doi:10.3928/19425864-20090826-05
214
injury and 90% of patients treated in pain clinics at a cost
of $47 billion U.S. dollars per year.2 Manual therapy is
often sought as an appealing intervention, but few data
substantiate its short- or long-term use. Many individu-
als prefer massage and alternative treatments over phar-
macological intervention for chronic pain, especially
when the discomfort is less severe.3 Furthermore, many
healthy people experience occasional muscle tightness
and pain that may be treated with manual therapy. Strain
counterstrain (SCS) is a manual therapy intervention
used for the treatment of myofascial pain and has been
proposed to interrupt muscle spasm.
Strain counterstrain attempts to place the pain-
ful area in a position of comfort to alleviate tension
and pain. The mechanism of relief is thought to oc-
cur from the involvement of a combination of neu-
rological and circulatory changes in the distressed
area when placed in its most comfortable position.4,5
The physiological mechanism for SCS is unknown
but has been hypothesized to occur from a change
in the muscle spindle activity. For example, a strain
occurs from the muscle spindle activity, or gamma
gain, and is produced by the rate of firing from the
annulospiral nerve endings when the muscle is over-
stretched.6 The muscle spindle sensitivity increases as
a protective measure by increasing the gamma gain in
the overstretched position. Other muscles that sup-
port the joint are in a shortened position and have
less spindle activity at rest. However, once the joint is
moved, the muscle spindles react to the new position
by increasing tension. The shortened muscle creates
resistance to movement and ultimately results in so-
matic dysfunction or pathology to the musculoskel-
etal system.7 The aberrant gamma gain is likely due to
local reflexogenic activity.8
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Jones6 explained that the somatic dysfunction is not
caused from the strain, but from the body’s reaction to
the strain. The reaction is termed the counterstrain and
results in a shortening of intrafusal fibers, leading to an
oversensitized muscle spindle.8 If the counterstrain is
slow and deliberate, the somatic dysfunction is avoided.
If the reaction is rapid, as in a functional movement, a
reflex muscle spasm occurs, creating the dysfunction.6,9,10
The muscle position must be reset to rectify the sensi-
tized muscle spindle. The position is held to reprogram
the muscle spindle and allow the afferent activity to nor-
malize. Once the muscle spindle has accommodated to
the new position, the shortened muscle no longer resists
movement and function is restored.
In the current literature, there are surprisingly few ar-
ticles that address the efficacy of manual therapies and
fewer that discuss SCS as a treatment. In 1994, a review
of treatments for myofascial pain syndrome treatments
revealed that no reported treatment was more effective
than the control intervention.11 In 2005, a second review
of myofascial trigger point treatments concluded that
previous findings could neither be confirmed nor refuted
due to the lack of research in this area and a lack of reli-
able and valid outcome measures.12 Investigations on the
effects of SCS specifically use a variety of treatment posi-
tions13,14 and patient diagnoses,14-17 making comparisons
difficult.
Tender points are defined as small zones of localized
tenderness in muscle, the muscle tendon junction, fat pad,
or bursal region.14,18-21 Tender points are described as focal
areas of tightness, pain, or hypersensitivity and are con-
sidered to be the pathological condition that can be treat-
ed with SCS.6 Tender points, as described by Jones,6,10 are
considered more segmental than trigger points. Tender
points located along the vertebral column designate seg-
mental dysfunction at the corresponding vertebral level
and can be a sensory manifestation of a neuromuscular
or musculoskeletal dysfunction.6 However, from a clini-
cal perspective, it is difficult to distinguish tender points
from myofascial trigger points. Studies that examine the
ability to reliably categorize the points have been incon-
clusive, even with experienced clinicians.21,22
There are many treatments aimed to release muscle
tension, tightness, and tender or trigger point pain. Cur-
rent trends include the use of tricyclic antidepressants,
muscle relaxants, trigger point injections, mild analgesics,
and nonsteroidal anti-inflammatory drugs.23 There are
several manual therapies used to trigger tender points, in-
Athletic Training & Sports Health Care | Vol. 1 No. 5 2009
Short-Term Effects of SCS
cluding ischemic compression, spray and stretch, muscle
energy techniques, trigger point pressure release, trans-
verse friction massage, and SCS.12 Because there is a lack
of evidence supporting many treatment options, the goal
of this study was to evaluate the use of SCS on upper tra-
pezius discomfort in a convenience sample of otherwise
healthy individuals. Our purpose was to compare the ef-
fectiveness of a single intervention of SCS to a sham treat-
ment both immediately following the treatment and 24
hours later. We hypothesized that the SCS group would
have superior pain relief compared to the sham treatment.
A secondary goal was to establish a methodology that
could translate into future studies so that manual thera-
py outcomes could be compared. This pilot data would
be used to develop a more extensive research plan that
would involve SCS as part of a comprehensive treatment
program for the management of upper trapezius pain.
METHOD
Design
The study was a double-blinded, randomized control trial
of participants with self-reported complaints of upper tra-
pezius stiffness, pain, or tightness. Participants were ran-
domly assigned to either an experimental group receiving
a SCS treatment or a control group receiving a sham treat-
ment. To test the effects of the treatment over time, pain
measurement was conducted pretreatment, immediately
posttreatment, and 24 hours posttreatment. The depen-
dent variables were resting pain measured using a visual
analogue scale, pain threshold, and provoked pain.
Participants
Twenty participants (11 men, 9 women, mean age,
22.462.6 years; mean height, 172.469.75 cm; mean
mass, 74.99614.33 kg) with self-reported upper tra-
pezius tightness and pain volunteered to participate in
this study. This convenience sample was recruited from
the general student body and faculty of a military col-
lege. Participants were otherwise healthy and had no
previous knowledge of SCS. The university’s board for
health sciences approved the study methods. All partic-
ipants read and signed an informed consent agreement
prior to participating in the study.
Instruments
A pressure algometer (Model PTH, Pain Diagnostics
and Treatment, Inc., Great Neck, NY) was used in this
215
Perreault et al
study to measure the amount of pressure applied to
an area 1 cm2 in surface area. The algometer measured
pressures ranging from 0-10 kg/cm2 in 0.1-kg/cm2 in-
crements. After measuring resting pain, we used the al-
gometer to measure the pressure that would evoke a pain
response (pain threshold). We then used the algometer to
apply a constant pressure to measure the sensitivity of
the tender point. For this measurement, the algometer
was applied to the upper trapezius tender point to pro-
voke the pain response that was measured using a visual
analogue scale (provoked pain). Several studies have re-
ported this type of algometer to be reliable when mea-
suring the sensitivity of a variety of trigger points.24-28
Nussbaum and Downes28 reported excellent same-day
intratester reliability (intraclass correlation coefficient
([ICC]2,1 = 0.93-0.98) and excellent day-to-day intra-
tester reliability (ICC2,1 = 0.88-0.90) when used on upper
trapezius trigger points.24 The algometer has been used as
an important assessment tool in past research evaluating
the effectiveness of trigger point therapy.23,28
The visual analogue scale (VAS) was used as a tool to
measure pain. The VAS has been reported to be a valid
and reliable measurement of pain intensity.29,30 We used
the VAS to measure resting pain and pain during the
provocation maneuver with a predetermined pressure
application from the algometer.
Testing Procedures
Participants responded to flyers posted around campus
to recruit individuals with chronic muscle pain or tight-
ness in the upper trapezius region. Potential participants
were prescreened over the phone for injuries and other
exclusion criteria. A certified athletic trainer confirmed
the presence of palpable tenderness or focal tightness in
the upper trapezius musculature associated with either a
trigger or tender point and administered a health histo-
ry questionnaire. The pain had to be present for at least
1 week and could not be alleviated with stretching. We
avoided rigorous palpation of the treatment area dur-
ing the evaluation because manipulation of the area, in-
cluding inducing a twitch response, might influence the
outcome.31 Participants were excluded from the study
if they reported that they had recent acute cervical or
shoulder trauma, facet joint pathologies in the cervical
spine, and a history of thoracic outlet syndrome, fibro-
myalgia, or myofascial pain syndrome. Specific details
of each type of pathology were described in the ques-
tionnaire and over the phone so participants would un-
216
derstand and be able to report if they had one of these
conditions. Furthermore, participants were asked to
report whether they were receiving any other medical
care for any existing condition that would affect their
continuation in the study. All 20 participants met the
inclusion criteria and were enrolled in the study.
Participants were placed in a treatment group (SCS
or sham) using random allocations enclosed in sealed en-
velopes. The group assignment was blinded to both the
participant and the assessing clinician; only the treating
clinician was aware of the group assignment. The treat-
ing clinician placed the algometer over the most sensitive
point and marked the participant’s skin around the rod of
the algometer with a black felt-tipped permanent marker
so that the location could be correctly identified by the
assessing clinician and would remain marked the follow-
ing day.
The assessing clinician performed all measurements
and was unaware of the treatment condition. He in-
structed the participant to record a quiet VAS to assess
resting pain. Participants were shown a 10-cm nonde-
marcated line and were asked to mark a vertical line along
the line corresponding with the level of pain they were
experiencing in the tender point at that moment. Next,
the examiner measured pain threshold. He applied pres-
sure over the marked area with the algometer at a rate of
1 kg/sec until the participant reported the first onset of
pain. At that time, the examiner released the pressure and
read and recorded the value as the baseline pain threshold
score. Finally, a provoked VAS was taken by applying a
predetermined force that was slightly more than what has
been found in the literature as the normal values for pain
threshold of the upper trapezius. Fischer et al32 found
the normal pain thresholds of the upper trapezius to be
4.8 kg/cm2 of pressure for men and 3.3 kg/cm2 of pres-
sure for women. We added 0.7 kg of force to each value
to provoke enough pain to minimize the possibility of
a floor effect (ie, when the pain scores are already low,
making it potentially impossible to go lower with any
kind of treatment) during our analysis. Male participants
received a force of 5.5 kg/cm2, and female participants
received 4.0 kg/cm2. Depending on group assignment,
the participant then received the experimental or sham
treatment, performed by the treating clinician when the
assessing clinician was out of the room.
The SCS group received the SCS intervention as de-
scribed by Jones9,10 and was applied by a clinician who
was trained in the Jones technique. Strain counterstrain is
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1 2
Figure 1. The position of the strain counterstrain treatment for the
right upper trapezius. The head is laterally flexed to the ipsilateral side
and rotated away while the tender point is palpated. The shoulder is
passively moved into flexion and relative external rotation according
to feedback from the subject.
a very individualized treatment and all participants were
placed in a position that alleviated most of their pain. The
upper trapezius was placed in a position of comfortable
shortening, while the participant noted a subjective de-
crease in tenderness with palpation over the tender point
(Figure 1). The head was passively laterally flexed to the
ipsilateral side and rotated away. Then the shoulder was
flexed to approximately 150 to 170 degrees and the rela-
tive position of internal or external rotation was adjusted
to comfort. None of the motions were at the end range,
and adjustments were made according to participant
feedback. This position was held for 90 seconds, and then
the participant was slowly and passively returned to a
normal resting position.
The sham treatment consisted of the clinician placing
his hands on the upper trapezius and on the head, con-
tralateral to the side of the tender point and, holding this
position for 90 seconds (Figure 2). The head was turned
slightly, and there was minimal pressure applied to the
tender point with an open palm to prevent a treatment ef-
fect with the sham condition. After either treatment, the
same measurements were taken by the assessing clinician,
as described earlier. The participant was dismissed for the
day and asked to refrain from any strenuous activities,
drinking alcohol in excess, and taking analgesics or non-
steroidal anti-inflammatory drugs.
Participants reported for a follow-up assessment 24
hours after the treatment. The examiner repeated the
steps taken after the treatment on the first day, measur-
ing the resting pain, pain threshold, and provoked pain.
All participants completed all components of the study.
Athletic Training & Sports Health Care | Vol. 1 No. 5 2009
Short-Term Effects of SCS
Figure 2. The position of the sham treatment for the upper trapezius.
The head is gently positioned without reaching any restriction in the
tissues. There is a laying of the hands in a broad manner on the upper
trapezius and on the head.
Statistical analysis
General linear model analyses of variance (ANOVAs)
were used to compare group by time interactions with re-
peated measures for the three dependent variables (resting
pain, pain threshold, and provoked pain). For each mea-
sure, a 2x3 repeated measures ANOVA was used to com-
pare group (SCS, sham) and time (baseline, immediate
posttreatment, 24 hours posttreatment). The alpha level
was set a priori at P < 0.05 and SPSS version 13.0 software
(SPSS Inc, Chicago, Ill) was used for all analyses. Sample
size was estimated using an effect size of 0.80, which was
obtained from means and standard deviations from a pre-
vious study examining the effect of SCS on tender point
pain.13 Based on these calculations, it was estimated that
10 participants per group would be necessary to have an
80% chance (ß) of detecting a significant change in muscle
activation with an a priori alpha level of P < .05.
RESULTs
Means and standard deviations for measurements are re-
ported in the Table. For resting pain, there was a signifi-
cant time main effect (F18,1 = 7.04, P = .003) (Figure 3),
with both treatments associated with decreased pain
from baseline to the 24-hour assessment. There was
no significance for the group by time interaction
(F18,1 = 0.281, P = .757), or group main effect (F18,1 = .895,
P = .357) for the resting pain (1-ß = 0.091). Effect sizes
were calculated with Cohen’s d, and there was a large
effect size for the SCS (0.71), moderate for sham treat-
ments (0.4) for immediate resting pain, and large effect
sizes for SCS (0.85) and sham (0.97) for resting pain at
24 hours posttreatment.
217
Perreault et al

For the pain threshold measure, there was no signifi-

Postassessment
cant time main effect (F18,1 = 1.929, P = .16) (1- ß = 0.374)

4.1 (2.7)

5.5 (1.8)
(Figure 4), group by time interaction (F18,1 = .269, P = .766)

24-Hour
(1- ß = 0.089), or group main effect (F18,1 = .767, P = .393)
Provoked Pain (1-ß = 0.132). There were negligible effect sizes for all
pain threshold measurements.
PostTreatment Similarly for provoked pain, there was no significant
4.7 (2.4) time main effect (F18,1 = 2.286, P = .116) (1-ß = 0.434)

5.8 (2.0)
(Figure 5), group by time interaction (F18,1 = 1.214,
P = .309) (1-ß = 0.248), or group main effect (F18,1 = 1.26,
P = .276) (1-ß = 0.186). The effect sizes for the provoked
pain were small to negligible for the SCS (0.17) and sham
Baseline
5.1 (1.8)

5.9 (1.5)

(0.05) immediately after the treatment and small 24 hours

later for both SCS (0.24) and control (0.30).
Means and Standard Deviations of Measurements

Postassessment

DISCUSSION
There were no significant differences found between
3.8 (1.1)

3.5 (1.8)

the single 90-second SCS treatment and the sham treat-

24-Hour

ment for pain at rest, pain threshold, or provoked pain

in this pilot study. Although a main effect was found for
Pain Threshold

resting pain over time, there was not a significant interac-

PostTreatment

tion between the groups. These results indicate that the

3.7 (1.3)

3.2 (1.2)

participants experienced a perceived treatment effect for

Tab l e

resting pain measures regardless of group assignment.

We hypothesized that the SCS treatment would result
in a significant reduction in pain. Although our results
Baseline

offer no support for the use of SCS over a placebo treat-

3.5 (1.2)

2.6 (1.6)

ment, we offer several explanations for our results. Our

participants self-reported the presence of upper trape-
zius pain and tightness, but they were not seeking medi-
PostAssessment

cal treatments for their pain. The mean (±SD) baseline

0.2 (0.4)a

resting pain values were low and potentially subclinical

0.3 (0.5)

(1.2±1.4; mean ± SD). These values are in contrast to Lee

24-Hour

et al33 who reported resting VAS scores of 5.3±1.95 in

patients with upper trapezius trigger points who were
Resting Pain

recruited from physician referrals. We believe this may

There was a significant main effect for time for resting pain scores.
PostTreatment

have had a floor effect on our data given that it would

0.3 (0.5)

0.8 (1.3)

have been unlikely to improve the pain value from a clini-

cal perspective. Clearly, patient referrals should be used
for participant recruitment. However, both treatment
groups reported a significant reduction in resting pain
over time.
Baseline
1.0 (1.3)

1.4 (1.5)

Another potential explanation of our results is that the

SCS treatment group received only one treatment appli-
cation at the single tender point. This method was to en-
mean (SD)

sure consistency from one participant to another; how-

SCS mean

ever, a full SCS treatment may require up to three or four

Sham
(SD)

repeated applications during one treatment. The effect

a

218 atshc.com

3 4
Figure 3. Resting pain scores. Results for pain at rest on the VAS scale.
There was a significant main effect (*) for time (P = .003) indicating
that both groups improved after intervention. There was not a signifi-
cant group main effect or group by time interaction.
sizes indicate that participants reported improvements in
both resting pain and provoked pain immediately and at
24 hours after either the SCS or sham treatment. Perhaps
the attention to the pain and “laying of hands” involved
in both the treatment and sham conditions contributed to
these results, indicating that SCS was as effective as a pla-
cebo. However, other studies found positive treatment
effects using a single exposure to SCS.14,15
To evaluate the sensitivity of the tender points, we
applied pressure to them. In a previous study assessing
the reliability of the algometer, Reeves et al27 noted that
repeated application of pressure above the pain thresh-
old altered the sensitivity of the tissue, confounding the
measurement process. The assessment of our outcome
measures had the potential for altering the sensitivity of
the tender points in our participants. Although we took
care in the pressures that we applied to the participants
during the assessment, the predetermined force could
have affected the tender point sensitivity to confound
our results.
Using methods of pain threshold and pain provo-
cation strengthened our study by including measures
that could be altered by the treatment, especially be-
cause the resting pain values were so low. However, the
pain provocation test may have had a therapeutic effect
similar to shiatsu massage. Furthermore, by minimiz-
ing the manipulation of the tissues, it was more difficult
to distinguish trigger from tender points in this other-
wise healthy population. Therefore, we considered this
study to be a pilot test to establish the feasibility of us-
ing a single 90-second SCS treatment in a convenience
sample. Future studies should include a true control
Athletic Training & Sports Health Care | Vol. 1 No. 5 2009
Short-Term Effects of SCS
Figure 4. Pain threshold scores. There were no significant findings for
the pain threshold measures.
5
Figure 5. Provoked pain scores. There were no significant findings for
the provoked pain measures.
Abbreviations: VAS, visual analogue scale; SCS, strain counterstrain.
with no treatment given that the manipulation of the
area in the evaluation may have influenced a treatment
effect.31
Strain counterstrain is a passive positional procedure
that places the body in a position of greatest comfort.
Pain and dysfunction are hypothesized to be reduced by
decreasing inappropriate proprioceptor activity that has
created the somatic dysfunction.10 The muscle spindles
are reset during the passive positioning so the aberrant
signals become diminished. The treating clinician in our
study was trained in the proper technique of SCS and had
clinical experience in manual therapy.
The technique we used for SCS was developed by
Jones and Ontario34 and other clinicians8 who have used
passive position to elicit their results. Meseguer et al13 used
SCS to effectively decrease tender point pain in the upper
trapezius, but his technique used a sitting position with
the noninvolved arm abducted while downward pressure
was exerted over the upper trapezius. This technique is
219
Perreault et al
also described by D’Ambrogio and Roth16, but is often
recommended when the tender point is caused by an el-
evated rib.The complexity of the treatment and the poten-
tial for confounding techniques remains a problem with
all research on manual therapy. We chose the procedure
in which the participant was supine, the neck was later-
ally flexed and rotated, with the involved arm placed in
flexion and rotation, assuming that we would be able to
consistently place the upper trapezius in a relaxed posi-
tion. There are many positions that can be used for similar
etiologies, and the choice of position and election to treat
all participants similarly may have affected our results.
Future research should be directed at more accu-
rately evaluating the theory behind SCS and should
perhaps include activation measures such as electromy-
ography to support the effects on the muscle spindle.
Both the SCS and sham treatments resulted in a main
effect for time, indicating there was no superior treat-
ment effect.
Our study presents a design to evaluate the effective-
ness of a single treatment both immediately and 24 hours
later. Manual therapy is rarely used in isolation and its
effects should be examined in conjunction with a typical
therapeutic regimen. Clinically, we would use a treatment
such as SCS to evoke pain relief so that rehabilitative ef-
forts could address muscle strength and performance
deficits during functional movement. Outcome data that
captures the entire therapeutic process would be valu-
able, but unlikely to account for the variation in treat-
ment approaches.
Conclusion
Pain at rest, provoked pain, and pain threshold did not
significantly differ between the SCS treatment and the
sham treatment. Our results showed no evidence to sup-
port the use of SCS over the sham treatment. Additional
research on SCS is necessary to address the effectiveness
of SCS as part of a comprehensive treatment program. n
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