Active vs Passive
Active = Patient exerts force (ME); Passive = Physician exerts force alone (HVLA, CS)
Muscle Energy Rule
Post-isometric relaxation activates Golgi Tendon Organs (Ib fibers) to relax agonist
Counterstrain Rule
Positions tissue into point of ease / shortening for 90 seconds (120s for ribs)
Still Technique
Starts INDIRECT in ease → adds compressive force → sweeps DIRECT into barrier
Master Modality Classification Matrix
Every OMT technique is classified along two axes: Active vs. Passive and Direct vs. Indirect:
| Technique | Active or Passive | Direct or Indirect | Primary Physiologic Mechanism |
|---|---|---|---|
| Muscle Energy (ME) | Active (patient contracts) | Direct (moved to barrier) | Golgi tendon organ (post-isometric) or muscle spindle (reciprocal) |
| High-Velocity Low-Amplitude (HVLA) | Passive | Direct (moved to barrier) | Rapid thrust overcomes pathologic barrier; resets joint mechanoreceptors |
| Counterstrain (CS) | Passive | Indirect (moved to ease) | Silences hyperactive gamma motor neuron loop / muscle spindle output |
| Myofascial Release (MFR) | Passive or Active | Direct OR Indirect | Creep, stress relaxation, fascial glide |
| Facilitated Positional Release (FPR) | Passive | Indirect | Neutral position + axial activating force (compression/torsion) for 3–5 seconds |
| Still Technique | Passive | Indirect to Direct | Position of ease + vector force + continuous arc through restrictive barrier |
| Cranial Osteopathy (OCF) | Passive | Direct OR Indirect | Balances reciprocal tension membrane; augments CSF fluctuation |
Muscle Energy: Post-Isometric Relaxation vs. Reciprocal Inhibition
Muscle Energy utilizes voluntary patient isometric contractions to lengthen hypertonic muscles:
Post-Isometric Relaxation (PIR)
The physician engages the restrictive barrier. The patient contracts the dysfunctional (agonist) muscle against an equal unyielding counterforce for 3 to 5 seconds. The patient relaxes for 2 seconds (latent period), during which Golgi tendon organs (Ib afferents) induce autogenic inhibition. The physician gently takes up the slack into the new restrictive barrier.
Reciprocal Inhibition (RI)
The physician engages the restrictive barrier. The patient contracts the ANTAGONIST muscle against resistance. When an antagonist contracts, Ia inhibitory interneurons in the spinal cord reflexively relax the agonist. Ideal for acute, exquisitely painful spasms where contracting the injured muscle directly is intolerable.
Counterstrain: High-Yield Positioning & Treatment Protocol
Developed by Lawrence Jones, DO, Counterstrain is an indirect, passive technique:
Step-by-Step Protocol
1. Locate tenderpoint and assign a baseline tenderness of 10/10.
2. Position the patient into ease until tenderness decreases by at least 70% (score ≤ 3/10).
3. Maintain position for 90 seconds while palpating the tenderpoint (rib tenderpoints require 120 seconds).
4. SLOWLY and passively return the patient to neutral without patient assistance.
5. Re-evaluate tenderpoint.
2. Position the patient into ease until tenderness decreases by at least 70% (score ≤ 3/10).
3. Maintain position for 90 seconds while palpating the tenderpoint (rib tenderpoints require 120 seconds).
4. SLOWLY and passively return the patient to neutral without patient assistance.
5. Re-evaluate tenderpoint.
Anterior vs Posterior Tenderpoint Rules
Most anterior tenderpoints require FLEXION (F SxRx or F SxRy). Most posterior tenderpoints require EXTENSION (E SxRx or E SxRy).
COMLEX / OMM Integration
NBOME High-Yield Correlate
Absolute Contraindications to HVLA
- Local bone pathology: Metastatic bone cancer, osteomyelitis, bone tuberculosis.
- Fractures, acute dislocations, or joint instability.
- Severe osteoporosis or osteopenia.
- Dens subluxation risk: Rheumatoid Arthritis and Down Syndrome at C1–C2.
- Vascular compromise: Vertebral basilar insufficiency, aortic aneurysm, carotid dissection.
- Patient refusal or lack of informed consent.
- Fractures, acute dislocations, or joint instability.
- Severe osteoporosis or osteopenia.
- Dens subluxation risk: Rheumatoid Arthritis and Down Syndrome at C1–C2.
- Vascular compromise: Vertebral basilar insufficiency, aortic aneurysm, carotid dissection.
- Patient refusal or lack of informed consent.
Board Traps & Common Distractors
- Trap: Returning the patient actively or quickly after Counterstrain. Active patient contraction re-engages the hyperactive muscle spindle loop and invalidates the entire treatment!
- Trap: Applying HVLA in a patient on anticoagulation with active radicular signs without screening for epidural hematoma risk.