Background: Strain counterstrain (SCS) is an indirect osteopathic manipulative technique that uses passive positioning to relieve tender point (TP) palpation pain and associated dysfunction.

Objective: The purposes of this systematic review with meta-analysis were to 1) determine the pooled effect of SCS on TP palpation pain compared to a control condition and 2) assess the quality of the overall evidence.

Data source: A search conducted using the MEDLINE with AMED, PUBMED, CINAHL, and SCOPUS databases for publications from January 2002 and April 2012 yielded 29 articles for eligibility screening.

Study selection: Included studies were limited to randomized control trials comparing TP palpation pain after isolated SCS treatment compared to control conditions assessed with a visual analog scale. Other study designs or manipulative treatments were excluded.

Data extraction: Two reviewers adhered to a predetermined study protocol following current Cochrane Collaboration recommendations to independently extract the data with standardized extraction forms and assess studies for methodological quality and determine risks of bias.

Results: Five randomized control trials were included for qualitative and quantitative analysis. The pooled effect of SCS was a reduction of TP palpation pain (p < 0.001, 95% CI -0.291 to -0.825). The overall evidence quality was low: while all studies met at least 8 of 12 methodological quality criteria, most were low quality.

Conclusions: This systematic review and meta-analysis found low quality evidence suggesting that SCS may reduce TP palpation pain. Future studies with larger samples of better quality studies with patient populations that assess long-term pain, impairment, and dysfunction outcomes could enrich the literature.