Counterstrain Manual Therapy Reduces Muscle Spasticity and Neuropathic Pain in Individual with Chronic Spinal Cord Injury: Case Report by David R. Dolbow in Journal of Clinical Case Reports Medical Images and Health Sciences

Counterstrain Manual Therapy Reduces Muscle Spasticity and Neuropathic Pain in Individual with Chronic Spinal Cord Injury: Case Report by David R. Dolbow in Journal of Clinical Case Reports Medical Images and Health Sciences

ABSTRACT

Introduction: Muscle spasticity and neuropathic pain are common comorbidities after spinal cord injury (SCI) that can lead to further disability and the reduction in quality of life. Pharmacologic treatments are used as a standard of care for muscle spasticity and neuropathic pain. A possible adjunct therapy is osteopathic manual manipulation therapy.

Case Report: In this case report counterstrain manual therapy was provided as a novel approach to help provide additional temporary relief of muscle spasticity and neuropathic pain. The 60-year-old African American patient with a C5 motor complete SCI completed six sessions over six months as an adjunct treatment to the standard pharmacologic care of Baclofen and Neurontin. Counterstrain manual therapy was provided to the anterior lumbar region and bilateral legs in the patient’s home. 

Discussion: The treatments produced additional temporary relief from spasticity and pain. In both cases the spasticity and pain decreased to greater levels as the number of treatment sessions increased, despite the length of time between treatments. Muscle spasticity decreased in a more consistent and uniform manner than pain although pain decreased significantly during later sessions with the sixth session resulting in the temporary elimination of pain. The patient also reported a significant reduction in interference in the participation of life activities.

Conclusion: The results of this case report cannot be generalized to the overall spinal cord population, but it does indicate the potential benefit of counterstrain manual therapy as an adjunct treatment to decrease muscle spasticity and neuropathic pain after SCI.   

Introduction 

Individuals with spinal cord injuries (SCI) often experience muscle spasticity and neuropathic pain, which can increase disability and reduce their quality of life. Spasticity affects around 70% of people with SCI, while neuropathic pain affects about 60% [1,2]. Spasticity is characterized by involuntary muscle contractions due to disorganized sensorimotor systems caused by damage to upper motor neurons [3]. Neuropathic pain is caused by disruption of the somatosensory system and can present itself as burning, squeezing, shooting, or pricking pain [4]. 

There are various pharmacological treatments, such as gabapentin, pregabalin, diazepam, and baclofen, that can help alleviate both spasticity and neuropathic pain [2,5,6]. Additionally, osteopathic manipulation therapy treatments including counterstrain manual therapy can be effective in reducing pain in people with chronic SCI [7]. Counterstrain manual therapy, also known as positional release therapy, may be uniquely suited to counter the effects of muscle spasticity and reduce neuropathic pain after SCI by allowing normal muscle spindle activity to return in those with neuromuscular imbalance due to aberrant neuromuscular activity and sympathetic nervous dysfunction [8].

We provide a case report in which counterstrain manual therapy was used as a novel adjunct treatment to pharmacological treatments to decrease spasticity and pain during six separate treatments.

Case Presentation 

A 60-year-old African American woman with chronic C5 SCI, American Spinal Injury Association Impairment Scale B as per International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) presented with lower back and leg pain, bilateral leg spasticity, and difficulty in performing daily activities. The patient was injured in a motor vehicle accident ten years ago. The patient received spinal fusions at C5 and T5. The patient was 162cm in height and 95kg in weight and required assistance with dressing and bathing and could transfer from the bed to her powerchair with the help of an overhead trapeze bar (modified independence). However, the process was slow and fatiguing due to the muscle spasticity in her legs. The patient had been prescribed Baclofen and Neurontin for muscle spasticity and neuropathic pain. The initial evaluation measured the patient's pain level and interference in life activities using numerical rating scales from 0-10, along with the Spinal Cord Injury Spasticity Tool [9]. The same measures were taken after the six sessions of counterstrain manual therapy. The Modified Ashworth Test [10] for muscle spasticity, numerical pain rating scale, and identification of tender points on palpation were performed prior to and after each treatment session. The Modified Ashworth Test was conducted by a licensed physical therapist or students trained by the physical therapist, while tender point identification and counterstrain manual therapy were provided by an osteopathic physician or students trained by the osteopathic physician. Onsite observation or internet connection was used for supervision by a licensed physical therapist and an osteopathic physician. The patient had long-term use of pharmacological treatments to decrease spasticity and pain but had no history of receiving counterstrain manual therapy.

Muscle spasticity was assessed for bilateral hip and knee flexion and extension. To test hip flexion tone, the joint was moved from maximum flexion to full hip extension as quickly as possible. Likewise, for hip extension tone, the joint was moved from maximum hip extension to full flexion as quickly as possible. The same procedure was followed to measure knee flexion and extension tone. The muscle tone was graded from 0 to 4 based on the resistance encountered during the movement (0 = no resistance, 4 = rigid in flexion or extension) [10]. Tender point palpation and counterstrain treatment were performed as described by Bazzi et al.[11].

The areas treated depended on the pain or muscle tone determined with palpation of the tender points in the anterior lumbar (AL) region of the body [11]. Once a tender point was verbalized by the patient or due to tightness determined through palpation by the treatment provider, those regions were treated as described below. Once the patient was repositioned to produce decreased pain and tightness, the position was held for 90 seconds allowing the muscle spindle to relax decreasing tone in the muscle group [11].

AL1 (Medial to Anterior Superior Iliac Spine) – Treatment position was marked hip flexion to L1 level, knees toward the trainer rotating the knees, pelvis and ankles toward the tender point. This rotates the torso away from the side of the tender point.

AL2 (Medial to Anterior Inferior Iliac Spine) – Treatment position was flexion of the knees and hips to the level of the L2 vertebrae, ankles toward the trainer, rotation of the hips 60 degrees toward the trainer to level L2.

AL3 (Lateral to Anterior Inferior Iliac Spine) – Flexion of the knees and hips to L3, ankles and knees toward the trainer, minimal rotation with knees. 

AL4 (Inferior to Anterior Inferior Iliac Spine) – Same as AL3 except more flexion than L3.

Discussion

Based on the Modified Ashworth Test scores before and after each session (Table 1), the degree of spasticity was reduced temporarily with greater degrees of reduction as the number of sessions increased. Throughout the initial three sessions, 14 out of 24 muscle group measures demonstrated decreased spasticity after the counterstrain manual therapy. During the last three sessions, all 24 muscle groups decreased in spasticity scores after the counterstrain manual therapy, with 21 of 24 muscle group measures recorded as level one on the Modified Ashworth Scale, which indicates only slight muscle tone. Additionally, the overall pre and post sessions spasticity scores decreased with the greater number of sessions. One possible reason that the counterstrain manual therapy sessions produced greater results as the number of sessions increased is that the patient may have become more relaxed with each session allowing greater benefits. It appears unlikely that the improvements were due to an accumulation effect of treatments because the six sessions were spread over a period of six months.

Spasticity levels as reported by the patient using the numeric rating scales for spasticity and interference in life activities prior to the first counterstarin manual therapy session and after the last manual therapy session demonstrated improvements over the length of the six sessions. The numeric scale regarding the level of interference in life activities by spasticity showed improvement in all categories except relationships. The patient reported scores on the 0-10 scale with 0 = Does not interfere and 10 = Completely interferes, demonstrating that the patient perceived important benefits. Regarding general activity, the patient reported a level 10 indicating maximal interference prior to the sessions but a 50% reduction to level 5 after the six sessions.

 According to the participant, mood improved from 5 to 2, a 60% improvement and spasticity interference in work decreased significantly from 8 to 3 (62.5% reduction). Spasticity’s interference with sleep decreased slightly from 10 to 8 which is a 20% improvement. Overall, the patient indicated a noteworthy improvement in quality of life due to a reduction in interference of spasticity from 8 to 5 (37.5%). When asked to provide an overall percentage that the counterstrain manual therapy sessions decreased her spasticity, the patient stated that the treatments reduced spasticity approximately 70-80%, which lasted a few hours to 24 hours allowing her to attend church and other activities more easily. There was a reduction in muscle fatigue level from -3 to -2 as demonstrated by the pre and post Spinal Cord Injury Spasticity Evaluation Tool.

The LANSS pain scale verified the presence of neuropathic pain both prior to and after the counterstrain manual therapy sessions [12]. The overall effect of the counterstrain sessions on the patient’s numeric rating of pain also improved as the number of sessions increased. There were no decreases in pain during the first session with a rating of 9 on the 0-10 point numeric rating scale and a slight increase with the second session moving from an 8 to level 9. Through sessions three and four there was a slight decrease in pain (9 to 8) and then a dramatic decrease in overall pain for the final session 9 to 0. There was a greater decrease in the tender point pain ratings as the number of sessions increased with the greatest decreases coming after sessions 4-6 (Table 2). This was especially true after session 6 as all tender point regions decreased to zero pain. The decrease in pain over the six sessions may be due to the reduced spasticity over the same time period, although the reduction in spasticity was greater than that of pain. It is possible the patient was able to become more relaxed with repeated sessions which may have allowed improved benefits. Because the six sessions were spread over six months it is doubtful that the improvements demonstrate a cumulative effect of the treatments. There were no adverse events associated with the six counterstrain manual therapy treatments during the six month program. 

Conclusion

This case report demonstrated that the use of counterstrain manual therapy may be an effective adjunct treatment to standard pharmacological treatments for spasticity and neuropathic pain after SCI. The results were temporary, lasting from a few hours to 24 hours. The reductions in muscle spasticity and neuropathic pain improved with the increased number of sessions regardless of time periods between the sessions. The counterstrain manual therapy demonstrated greater benefits with reduction of spasticity than pain except for the final session which resulted in the elimination of pain entirely. The patient also reported a reduction in the interference of spasticity in daily activities. Because these results reflect changes in a single patient, they cannot be generalized to the overall SCI population. However, it does show what is possible.

Data Availability Statement: Data is available in Tables 1 and 2 and can be received from the corresponding author upon reasonable request. Study protocols listed in ClinicalTrials. gov ID number: NCT05559255. 

Authors Contributions: All authors provided substantial contributions to conception and design, acquisition, and interpretation of data. All authors either revised or edited the manuscript and provided approval of the version of the article being submitted for publication. The authors agree to be accountable for all aspects of the work including its accuracy and integrity. 

Disclosure of Interests: The authors have no conflicts of interest to report. 

Funding: This case report was funded by the American Osteopathic Association G2211485

Acknowledgements: The authors would like to thank Sarosh Din OMSIII and Mary Grimmett PMSIII for developing the initial research question, Aakash Anandjiwala OMSII for his assistance with administering the counterstrain treatment with this participant and Evan Williamson, DO, Faculty.

Statement of Ethics: This study protocol was reviewed and approved by the Institutional Review Board at William Carey University, approval number IRB# 2020-018. The patient reviewed and signed an informed consent form regarding risks and benefits and the non-use of personal identifiers or images. The ethics guidelines from the Helsinki Declaration were observed.

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