Stiles - American Academy of Osteopathy

Richard L. Van Buskirk, DO, PhD, FAAO

� The grounding principles derived from Dr.
Still’s methods are:
� Start with a restricted tissue at its position of ease;
� Introduce a force vector from another but connected
body part focused on the restricted tissue;
� Use the force vector as a mechanical connector to
carry the tissue from its ease through the restriction.

� The redeveloped Still
Technique is focused on the
treatment of each tissue
restriction.
� It uses the methodology Dr.
Still developed and used from
the time of the founding of
osteopathy.
� It is gentle, fast and effective.

� Used to treat the whole body Still Technique
can require as many as 60 individual
treatments. Needless to say, this is not very
efficient.
� Treating each individual somatic dysfunction
as it is found, but treating throughout the body
is successful in producing a decrease in
musculoskeletal load and concomitant decrease
in pain.
� This has been the strategy for most of my years
of practice.

� By the end of his life Dr. Andrew
Taylor Still appears to have been
using a new variation of his method
that provides a single whole-body
treatment.
� Dr. Ed Stiles reintroduced this Still-
Laughlin method. He learned it from
Dr. George A. Laughlin, A.T. Still’s
grandson. According to Dr. Stiles, Dr.
Laughlin used HVLA and soft tissue
techniques exclusively until he came
back from Dr. W.G. Sutherland’s first
Cranial course. After that he only
used this new method of treatment.

� Although there is no formal evidence Dr.
Sutherland was in a course taught by Dr. Still,
he was a student at the ASO at the beginning of
the twentieth century when the old doctor was
still very active on campus. Dr. Still
presumably developed this newer version of
his method during that period.
� Dr. Sutherland discussed using Dr. Still’s
methodology throughout his writings.

“The principle used and taught by Dr.
Still, namely exaggeration of the
lesion to the degree of release and
then allowing the ligaments to
draw the articulations back into
normal relation.”
W.G. Sutherland, Contributions of Thought, p
133
“In all spinal technique it is my
custom to have the patient exercise
his own natural forces rather than
the application of mine. There are
no thrusts, no jerks ….”
W.G. Sutherland, Contributions of Thought, p 133

� The Still-Laughlin Technique uses the same
methodology as Still Technique, employing the
force vector to move tissue from ease through
restriction.
� It focuses on treating only dysfunctions that
have been variously called “key lesions,”
“areas of greatest restriction,” or “primary
dysfunctions”
� I am going to use the term Key Dysfunction for
reasons that will become apparent.

� Over the years the idea of a “key lesion” has
reappeared many times in the osteopathic
literature.
� Essentially these are tissue restrictions that go
beyond simple asymmetry of presentation and
motion tissue texture changes and tenderness.
� The idea is that when treated these significant
dysfunctions will resolve much more than the
specific tissue treated.

� Details of how to identify a Key Lesion tend to
be somewhat vague.
� One of the most common has the physician
scan down the spine in the paravertebral
gutters until one sensing finger is “drawn” to
one somatic dysfunction more than others. This
is obviously quite subjective, but does seem to
work in the hands of experienced physicians.

� Speece and Crow identify four more methods for
identifying the Key Lesion which may have origin in
Sutherland’s work. These include:
� Systematically working one’s way through the myriad of
somatic dysfunctions until one releases whatever remains.
Obviously this would not work in the case of the Still-Laughlin
Technique.
� Observing the patient walking and visually identifying
immobile axes around which the rest of the body moves.
� Introducing traction through the leg of a supine patient and
palpably identifying the anchoring point(s) in the fascia.
� Observing the patient changing position, such as getting on or
off of a table. Areas of obvious restriction, such as a tight psoas,
would show themselves in an abnormal transfer.

� Dr. Ed Stiles has developed an extensive
operational technology to identify key
dysfunctions, which he terms the “Area of
Greatest Restriction.”
� In its most basic form Dr. Stiles’ methods
involve a series of screening operations starting
with the spine and paraspinal structures and
eventually extending to the extremities. The
following discussion is derived from Dr. Stiles’
presentations at the American Academy of
Osteopathy Convocation, March 2004.

� Stiles’ AGR for CERVICAL:
� Start with the patient standing. The physician is behind. Place a
sensing hand on the patient’s posterior neck. Your other hand is on
the top of the patient’s head.
� Capture the mid cervical spine between the thumb and forefinger.
This will be your sensing hand.
� Using the hand on the top of the head move the head and neck into
flexion. Now introduce right sidebending and then left
sidebending. Using the sensing hand determine if there is
restriction in either direction. If there is restriction in sidebending
to one side then introduce rotation toward that side.
� Now try to introduce motion from the posterior neck on the side of
restriction toward the anterior neck on the opposite side with the
sensing hand. Test each segment in turn.
� Some segments will move easily and have a “soft end-feel.” At
least one segment may be unyielding and immobile to this
diagonal challenge. The segment with a hard end-feel will be the
AGR (key dysfunction).

� Stiles’ AGR for THORACIC AND UPPER BODY:
� The operating hand is on the patient’s shoulder.
� Fingers of the sensing hand are on the thoracic paraspinal tissues.
� Introduce sidebending with the operating hand. Listen for ease and restriction.
Transfer the operating hand to the other shoulder. Again compress to produce
sidebending and listen for ease or restriction.
� Now on the relatively restricted side reintroduce sidebending. Next introduce
flexion and anterior rotation and then extension and posterior rotation.
Determine which position feels more restricted.
� Maintaining the position of restriction, press each thoracic segment anteriorly
and diagonally toward the side of ease with the sensing hand listening for the
“hard end-feel.” Test each segment in turn. The segment with a “hard end-feel”
will be an AGR (key dysfunction).
� If there is no single segment that possesses this hard end-feel but instead the
whole paraspinal area medial to the scapula has a relative restriction, the AGR
is likely to be in the arm on that side. Screen the arm for dysfunction at its
joints.
� Move the sensing hand laterally over the area of the mid-thoracic rib angles on
the side of restriction. Again use the operating hand to introduce sidebending.
Is the sense of restriction greater than or less than the sense of restriction along
the spine? If worse, screen the ribs in the same fashion as the paraspinals.

� Stiles’ AGR for LOWER HALF OF THE BODY:
� For the lower half of the body start with a standing flexion test. Are the lumbar
paravertebral muscles symmetrical? Does one PSIS ride superior?
� Next perform a seated flexion test. Does the lumbar spine show asymmetry of
motion and/or muscle volume? Does one PSIS ride superior? Is the PSIS shift
stronger for seated than standing flexion? If so look to the lumbar spine,
innominates, and/or sacrum for the SGR.
� If the lumbar paravertebral muscles demonstrate asymmetry in both standing
and seated flexion use the same test as that performed for the thoracic spine
(sidebending from the shoulder). Is one side of the lumbar spine restricted? Can
you localize a segment that has a diagonal hard end-feel when the regional
restriction is maximized?
� Now use the same sidebending to test the sacrum. Is sacrum restricted? Did one
PSIS ride superior in the seated flexion test? Evaluate sacral mechanics.
� If the PSIS rides superiorly on the same side in both standing and seated
flexion, it suggests that the pelvis may be the area of greatest restriction.
Likewise compression from the shoulder may lateralize restriction to the pelvis.
Evaluate for the nature of the restriction.
� If the standing flexion PSIS shift is stronger than the seated, look to the leg on
that side. An additional clue that it might be the leg: diffuse unilateral
paravertebral muscle tightness.

� Dr. Van Buskirk’s method of determining spinal key
dysfunction:
� For spinal segments starting with the cervical spine check each
restricted segment in turn.
� Starting with each segment in neutral, introduce flexion and
extension from above (passive process on the patient’s part, active
on yours) but prevent sidebending or rotation. If the palpable
tissue texture changes do NOT disappear the segment is a key
dysfunction. If they do disappear in either flexion or extension the
segment is NOT a key dysfunction.
� For ribs the same principal applies except you use sidebending.
Again if the tissue texture changes fail to disappear the rib
dysfunction is a key dysfunction.
� Pelvic dysfunctions are rarely key dysfunctions but again if the
signs of a dysfunction (ASIS or PSIS displacement) disappear with
induced sidebending the dysfunction is not a key lesion.
� Key dysfunctions are likewise rare in the extremities but seem to
be made visible with axial rotation.

� Regardless of the method used to determine a
key dysfunction bear in mind the following:
� Key dysfunctions are dependent on the state of
the whole body. Change the parameters by
treating any somatic dysfunction and the key
dysfunction may move elsewhere.
� The corollary is that key dysfunctions are
unpredictable and rarely in the same place for
one patient over time, much less across the
population.

� The recommendation is that you do a complete
whole body analysis and documentation for
somatic dysfunction. Even though you will end
up focusing your actual treatment on a limited
subset of dysfunctions, documentation will
allow you to substantiate your claim for having
treated 7-10 areas.
� You will need to know the exact presenting
and ease position for each key dysfunction
along with its restriction.

� Treatment involves stacking
each key dysfunction at its
position of ease, one on top of
another, and then using a
force vector unwind each
through its restriction. The
force vector transfers over the
course of treatment from one
key dysfunction to the next.
� Typically Still-Laughlin will
successfully treat the whole
body by treating only two or
three key dysfunctions.

� For instance, suppose a patient presents with the following list
of somatic dysfunctions:
� OAEr
� C1 Rr
� C3FSrRr
� C4ESlRl
� C5FSrRr
� C7FSrRr
� T1ESrRr
� T3ESrRr
� T4FSlRl
� T5ESrRr
� T7ESrRr
� T8FSlRl
� T11ESrRr
� Rib 1 superior left
� Ribs 3,7 anterior right
� Ribs 4,6 posterior left
� L2FSrRr
� L3ESlRl
� L4FSrRr
� Sacrum unilateral R
� Right upslipped innominate
� Numerous cervical, gluteal, and leg muscles with tension

� Key dysfunctions are found at
� C3FSrRr
� T7ESrRr
� L3ESlRl
� Starting with most inferior key dysfunction: L3, position
it in its ease (ESlRl).
� Stack the thoracic T7 vertebra in its ease (ESrRr).
� Now stack the cervical segment C3 in its position of ease
(FSrRr).
� Introduce compression (force vector) from the top of the
head toward the cervical Key and unwind it through its
restriction.
� Without stopping, shift the focus of the force vector to
the thoracic Key and unwind it until you have passed
through its restriction (FSlRl).
� Finally, shift the focus of your force vector to the lumbar
Key and unwind it.
� Recheck the key dysfunctions and any other significant
dysfunctions that might be of concern, such as the
upslipped innominate.

� Unwinding may be direct from ease through
restriction (Van Buskirk’s version) or it can
follow the fascia as it unwinds (Stiles’ version).
� The first few times I tried this I was invariably
surprised that all of the somatic dysfunctions I
had previously diagnosed had resolved.

� The Still-Laughlin Technique treats all somatic
dysfunctions and their concomitant neural and
vascular restrictions in a single rapid but
complex dance.
� Still-Laughlin is very efficient, but still treats
everything the more focused methods like
HVLA, Muscle Energy, Counterstrain, and Still
Technique do.

� Still-Laughlin is not limited as to the type of
tissue treated although its focus is through the
musculoskeletal system.
� Accepting that most disease processes are due
to body-wide dysfunctions, an integrated
whole body treatment such as Still-Laughlin
should be incredibly efficient in removing or
reducing the musculoskeletal load contributing
to disease and preventing the body from
efficiently healing.

� That being said, the Still-Laughlin Technique
requires great skill, extensive anatomical and
physiological knowledge, extreme accuracy in
diagnosis, and ferocious concentration.

Still-Laughlin Integrative treatment
Richard L Van Buskirk, DO, PhD, FAAO
Lab presented at AAO Convocation, March 2012
1. Method of Still Technique
a. Determine exact tissue restriction.
b. Determine nature of restriction and position of ease
c. Set tissue in ease
d. Introduce compression (force vector) from another site toward the tissue
e. Using the compression as lever carry tissue from ease thru restriction
2. Basic method of Still-Laughlin taught today:
a. Diagnose whole body for medical problems and detailed somatic dysfunction
b. Evaluate for the key lesions or areas of greatest restriction
c. Evaluate key lesions for exact nature of restrictions and exact positions of ease
d. Set body into position of ease for lowest key lesion
e. Stack each additional key lesion in its position of ease on top of all lower
one(s)
f. Introduce compression from site above the top key lesion. Focus the
compression on the top key lesion.
g. Use this force vector to carry the top key lesion from its ease through its
restriction
h. Without removing the compressive force shift its focus to the next inferior key
lesion
i. Carry each successive key lesion from its ease through restriction
j. Re-evaluate the whole body for somatic dysfunctions. Typically all will have
been successfully treated.
3. Diagnose whole body for medical problems and detailed somatic dysfunction
a. Evaluate all primary systems for evidence of dysfunction
b. Look for each instance of somatic dysfunction
i. In the spine define each segmental restriction as so flexion/extension,
sidebending, and rotation
ii. For pelvis and sacrum determine restriction
iii. For arms and legs determine nature of restriction and ease
iv. For muscles and tendons determine ease and restriction
v. For each tissue document findings in a detailed fashion.
1. This will demonstrate for medical-legal-insurance purposes all
that you have treated
2. It will also allow you to have a clear picture of your success
and failures in treating the somatic dysfunction and its
concomitant medical problems.
4. Evaluate for the key lesions or areas of greatest restriction
a. You can use Dr. Stiles’ methods of determining the AGR’s
b. Alternatively you can use the following:
i. For spinal segments starting with the cervical spine take each restricted
segment in turn

ii. Holding each segment in neutral, introduce flexion and extension from
above (passive process on the patient’s part, active on yours). If the
palpable tissue texture changes do NOT disappear the segment is a key
lesion. If they do disappear in either flexion or extension the segment
is NOT a key lesion.
iii. For ribs the same principal applies except you use sidebending. Again
if the tissue texture changes fail to disappear the rib dysfunction is a
key lesion.
iv. Pelvic dysfunctions are rarely key lesions but again if the signs of a
dysfunction (ASIS or PSIS displacement) disappear with induced
sidebending the dysfunction is not a key lesion.
v. Key lesions are likewise rare in the extremities but seem to be made
visible with axial rotation.
5. Evaluate key lesions for exact nature of restrictions and exact positions of ease
a. This is very important. However you should have already determined these
factors when you first performed you somatic dysfunction list.
6. Set body into position of ease for lowest key lesion
7. Stack each additional key lesion in its position of ease on top of all lower one(s)
8. Introduce compression from site above the top key lesion. Focus the compression on
the top key lesion.
9. Use this force vector to carry the top key lesion from its ease through its restriction
10. Without removing the compressive force shift its focus to the next inferior key lesion
a. Carry each successive key lesion from its ease through restriction
11. Re-evaluate the whole body for somatic dysfunctions. Typically all will have been
successfully treated.
12. Alternatively you can try Dr. Stiles’ version and use a force vector myofascial release
focused on the AGR. Both versions produce comparable results.
a. Both treat all somatic dysfunctions and their concomitant neural and vascular
restrictions in a single rapid but complex dance.
b. Still-Laughlin is very efficient, but treats everything the more fractionated
methods like HVLA, Muscle Energy, Counterstrain, and Still Technique do.
c. Still-Laughlin is not limited as to the type of tissue treated although its focus
is on the musculoskeletal system.
d. Accepting that most disease processes are due to body-wide dysfunctions, an
integrated whole body treatment such as Still-Laughlin should be incredibly
efficient in removing or reducing the musculoskeletal load contributing to
disease and prevent the body from efficiently healing.