Omm 11-8-2007 Still Technique

Front 1

The Still Technique: Objectives

Back 1

To be able to define the three basic terms required for the current description of the method of the Still Technique
To be able to apply the method of the Still Technique to treatment of Somatic Dysfunctions of the Cervical, Thoracic, and Lumbar Spine, Ribs, Pelvis, and selected muscles of the upper and lower extremities

Front 2

Force Vector

Back 2

a line of force that runs from the point of external compression or traction through the restricted tissue. The force vector can be conceived as a lever used to move the tissue through its range of motion.

Front 3

Sensing hand or finger

Back 3

The physician's sensing hand or finger stabilizes the tissues around the area of somatic dysfunction, monitors the response of the tissue, and acts as a guiding focus for the force vector.

Front 4

Operating hand

Back 4

The physician’s operating hand introduces the force vector moving the tissue through its range of motion and into release of the “barrier.”

Front 5

The Still Technique: Current Formulation

Back 5

1.First, determine where the joint or tissue moves most easily. Typically this corresponds to the position in which it is found. The tissues in the area will relax in this position and any tenderness from the somatic dysfunction will be relieved.
2. Next, passively move the affected tissue into its position of ease. It may be useful to slightly exaggerate this position in order to maximally relax the tissues.
3. Now introduce a force vector of five pounds (2 kilos) or less to the tissue using the operating hand. The force can involve compression or traction. The force vector is typically along the long axis of the spine for spinal segmental dysfunctions. The force vector can be introduced from any part of the body having a potential mechanical linkage with the affected tissue.
4. Use the force vector as if it were a lever or stirring rod to carry the tissue through its range of motion toward and through the initial restriction. Use a low to moderate velocity. The movement will be typically a composite utilizing all of the tissue’s normal planes of motion. Ideally the movement will be made in a smooth arc.
5. As the coupled force vector and tissue motion carries the tissue past its previous restriction there is often a palpable release, sometimes accompanied by an audible click such as is commonly heard in HVLA treatments. The click is not necessary to achieve complete resolution of the somatic dysfunction.
6. Now release the force vector. Return the tissue passively to neutral. Retest the tissue for presence or absence of signs of somatic dysfunction. If adequate release has not been achieved, there is no harm in repeating the treatment.

Front 6

Normal spinal segmental axes of motion include the _______, _______ and ______ axis.

Back 6

transverse, anterior-posterior and longitudinal

Front 7

Normal range of motion of a spinal segment includes _______-_______, _______, and _______ about the ________ axis of the spine. Coupled together this range can be described as a three dimensional sheet.

Back 7

Flexion-extension, sidebending and rotation.
longitudinal axis

Front 8

force vector

Back 8

The still technique applies a ____ _____ through the affected tissue at the tissue's position of ease. It carries the tissue through its potential range of motion and through the original restriction.

Front 9

Fryette Type II

Back 9

When a spinal segment extends (or flexes) on the one below it and sidebending is introduced, the segment rotates toward the same side. This interlocking of flexion or extension with sidebending and rotation toward the same side is obligatory and is termed______ ____ __ . It applies to both normal segmental motion and the somatic dysfunction.

Front 10

Segmental Motion Coupling Type I

Fryette's Type I

Back 10

-Group curve or single segment
-Applies to both normal segmental motion and somatic dysfunction
-Neutral: no flexion or extension
-Sidebent towards one side & rotated toward the opposite side
-Single segment often has traumatic origin

Front 11

Naming the Somatic Dysfunction

Back 11

In the common nomenclature we name a segmental somatic dysfunction by its position of ease, not for the restriction. Naming by position of ease defines the starting position for treatment using the Still Technique.

Front 12

For ribs & limbs the dysfunction is named for the _________ ______ to the spine.

Back 12

attachment closest

Front 13

Muscles, tendons & ligaments are given their anatomical names. Their position of ease corresponds to _______ ________.

Back 13

maximal shortening

Front 14

The _____ __ is a ring structure. A facet joint on the posterior surface of the anterior atlas, termed the anterior tubercle, articulates with the dens of __.

Back 14

atlas (C1); C2

Front 15

The _____ ___ is more similar to a typical vertebra except that the body is extended superiorly as the dens

Back 15

axis (C2)

Front 16

The _____ ___ is more similar to a typical vertebra except that the body is extended superiorly as the dens

Back 16

axis (C2)

Front 17

The _____ ___ is more similar to a typical vertebra except that the body is extended superiorly as the dens

Back 17

axis (C2)

Front 18

The anterior part of the ring of the atlas encircles the dens of the axis. The dens is held in place by a ______ _____ . Matching horizontally oriented facet joints are found between the anterior lateral surfaces of the atlas and the axis.

Back 18

transverse ligament

Front 19

Muscles attaching to the atlas include ______ _______ _______ ______, ________, ______ ______ ______ attaching to the posterior transverse processes, and anteriorly ______ _____ _____ and ___________ ______.

Back 19

Posterior attachments to the atlas
-Rectus capitus posterior superior
-Trapezius
-Obliquus capitus superior

Anterior attachments
-Rectus capitus anterior
-Longissimus capitus

Front 20

___________ _____ bridges between the basiocciput and C2 and below, as does ______ ______.

Back 20

Semispinalis capitus; Splenius capitus

Front 21

________ ______ _____, _____ _____ _______ _____, and _________ _______ connect posterior C2 to the lower cervical vertebrae.

Back 21

-Obliquus capitus inferior
-Rectus capitus posterior major
-Semispinalis cervicis

Front 22

Diagnosis: The principle motion of AA is rotation. Diagnose by palpating C1 transverse process behind the jaw angle. Tender fullness is seen most often on the side towards which it is rotated.

Back 22

Still Technique: Atlas-axis

Front 23

Additionally, _________ of the posterior-lateral ring of C1 just below and posterior to the mastoid body indicates an atlas-axis dysfunction. Restriction of OA on one side causes prominence toward the side of ease.

Back 23

prominence

Front 24

Still Technique: Atlas-axisq

Back 24

1. The patient can be seated or supine.
2. The physician places the sensing hand behind the head with the pad of the sensing finger on the transverse process of the affected side (right in the case of AARR).
3. Place the operating hand on the dorsum of the head.
4. The operating hand rotates the head toward the side of ease (right in this case).
5. The operating hand introduces compression toward the AA.
6. Rotate the head through neutral to and through the former restriction (left).
7. Once release is felt (typically about 45 degrees beyond midline), remove compression and return the head to neutral.
8. Now retest.

Front 25

Cervical spine segmental mechanics below the atlas (C2 through C7) generally involves coupling of side bending and rotation toward the ____ side in flexion or extension. Classically this type of coupling was thought due to the presence of four facet-type joints between cervical vertebrae rather than two as seen in the thoracic & lumbar spine. The cervical joints consist of two facet joints on the posterior-lateral aspect of the neural arch and two additional Joints of Luschka on the anterior-lateral aspect of the vertebral bodies

Back 25

same

Front 26

Still Technique: Typical Cervical Spine

Quick diagnosis:
Evaluate the posterior-lateral prominence of the ________ ______ for each segment. Prominence and tenderness indicates the segment is rotated toward that side. Most likely the segment is sidebent & rotated to that side.

Back 26

articular pillar

Front 27

Still Technique: Typical Cervical Spine

Quick Diagnosis, continued:

Next evaluate the segment’s behavior when the spine is flexed and extended down to the segment. of ________ the segment’s unilateral articular pillar prominence in flexion or extension indicates the segment’s position of ease.

Back 27

Disappearance

Front 28

Typical cervical spine, seated treatment

Back 28

1. The physician stands in front of the seated patient.
2. The physician’s sensing finger (left hand in the case of ERSR) contacts the articular pillar of the affected segment.
3. The physicians operating hand (right in this case) is placed on the top of the patent’s head.
4. Extend, sidebend, and rotate the patient’s head and neck toward the right until the tissues and affected segment palpably relax.
5. Using the operating hand, introduce a force vector toward the affected segment.
6. The operating hand rotates the patient’s head and neck through neutral into left sidebending, rotation, and flexion.
7. As the cervical segment passes through the original barrier a palpable release may be felt.
8.Release compression from the head.
9.Return the head and neck to neutral and retest the segment.

Front 29

The head of the first rib articulates posteriorly via ________ _____ on the body and transverse process of T1. Anteriorly the rib attaches to the via a costal cartilage. The first rib articulates with the _______ inferior and lateral to the anterior articulation of the clavicle.

Back 29

articular facets;
manubrium

Front 30

Muscular attachments to the first rib include _______ , _____, and ______ _______, ____________ , and , ________,_________ , and _________. Intercostal muscles attach between ribs one and two.

Back 30

-Anterior, Medius, and Posterior scalenes
-Sternocleidomastoid
-Sternothyroid
-Sternohyoid
-Subclavius.

Front 31

Still Technique: First Rib

Diagnosis: First rib diagnosis is based on _____ of the rib head. First check the relative positions of the first rib heads approximately where they articulate with the thoracic spine. Note which rib head is relatively superior, if either.

Now check the first rib heads for compliance and tenderness. A first rib is probably involved in a somatic dysfunction if it:
-does not move during part of the respiratory cycle.
-is relatively immobile to external pressure.
-is tender to palpation.

Back 31

position

Front 32

Diagnosis, continued: If a dysfunctional first rib head is superior relative to the other side it will be termed a _______ _____ ____.
Its anterior attachment to the manubrium and clavicle will be relatively inferior and tender.
To use the respiratory terminology, it will be caught in exhalation and will not readily move during inhalation.

Back 32

superior first rib

Front 33

Superior first rib, seated

Back 33

1, The patient is seated.
2. The physician stands in front of the patient.
3. The physician’s places the sensing finger on the rib head of the superior first rib.
4. Place the operating hand on the top of the patient’s head.
5. The patient’s neck is flexed and sidebent away from the affected rib, “exaggerating the dysfunction” and bringing it into ease.
6. Introduce the force vector from the patient’s head to the affected rib head.
7. Using the force vector as a lever, move the patient’s head and neck into extension and sidebending toward the side of the affected rib.
8. Now release the compression on the patient’s head, and return the head and neck to neutral.
9. Retest.

Front 34

There are __ thoracic vertebrae. Like the lower cervical and lumbar vertebrae the thoracic vertebrae consist of an ____ body, resting on a ____ and a _______ _____ ___ with __________ ___________, superior and inferior ________ ______ and a posterior _______ _______.

Back 34

12; anterior; disc; posterior neural arch; transverse processes ; articular processes (facets); spinous process

Front 35

The _____ form true joints between vertebrae that are generally oriented in a vertical plane. The body and transverse processes of the thoracic vertebrae also feature articular surfaces for the ribs.

Back 35

facets

Front 36

What type of segmental motion coupling?

-Group or single segment
-Neutral
-Sidebent towards one side & rotated toward the opposite side
-Single segment may have traumatic origin

Back 36

Fryette's Type I

Front 37

What type of segmental motion coupling?

-Single segment
-Flexed or extended
-Sidebent and rotated towards the same side
-May be primary or compensatory

Back 37

Fryette's Type II

Front 38

Quick diagnosis: Evaluate the relative position of the transverse processes.
If a transverse process is rotated posterior relative to its neighbors, the overlying tissues are prominent, boggy & tender. The segment is _______ & _______ toward this side.
Induce flexion & extension from above. This will cause the segment to lose its prominence in flexion or extension. Where it loses its prominence is its position of ease. This defines its_______ __________ .

Back 38

rotated & sidebent;
somatic dysfunction

Front 39

Still Technique: Flexed upper thoracic from front.

Back 39

1. The patient sits.
2. The physician stands in front of the patient with an arm over each of the patient's shoulders.
3. The index finger of the physician’s sensing hand is on the patient’s right thoracic vertebral transverse process for an FRSR.
4. Pressure from the physician's arms through the patient's shoulders produces flexion and rotation toward the right until the tissues under the sensing finger are palpably softened and the transverse process is no longer prominent.
5. The physician’s arms introduce 1 kg (2 pounds) or less of compression in vectors to the affected segment from each shoulder. This “V” vector is equivalent to a single direct vector from the head.
6. Passively rotate the patient to the left while reducing flexion. The coupling of rotation and decreasing flexion (extension) occurs naturally.
7. Carry the patient past neutral and into left rotation and sidebending with mild extension.
8. Release compression and return the patient passively to neutral.
9. Retest.

Front 40

Still Technique: Upper thoracic from behind

Back 40

1. The patient is seated. The physician stands behind.
2. The sensing hand is the same side as the somatic dysfunction (the physician's right in the case of T3FRSR). Place a sensing finger over the affected segment’s transverse process.
3. The physician's operating arm (left in this case) is passed over the patient's left shoulder and around the superior chest wall. Place the operating hand on the patient’s right shoulder.
4. This position gives the physician adequate leverage to introduce the necessary flexion or extension, sidebending, rotation, and compression.
5. Flex (in this case) the patient's thorax and spine and rotate toward the side of the somatic dysfunction (right) producing palpable relaxation.
6. Introduce compression through the patient’s shoulders toward the right transverse process.
7. Simultaneously the operating arm reduces flexion (or extension when the somatic dysfunction is extended) and rotates the spine through neutral into the previously restricted range (left extension, sidebending, and rotation).
8. Once release is noted remove compression. Passively return the patient to neutral.
9. Retest

Front 41

Review of Method of the Still Technique

Back 41

-Place the affected tissue in its position of ease.
-Introduce a force vector from a connected part of the body through the affected tissue.
-Using the force vector as a ”stirring rod,” move the affected tissue in a smooth path from its position of ease toward and through the position of its restriction.
-As the tissue moves through its restriction a “bump” and/or a click may be felt or heard. Neither is necessary for correction of the somatic dysfunction.
-Passively move the patient back to neutral and retest.