00:05 - 00:07This is Brent of the Brookbush Institute, and in this video we're going to go over a joint
00:07 - 00:11based manual therapy technique, If you're watching this video I'm assuming you're
00:11 - 00:14watching it for educational purposes, and that you are a licensed professional
00:14 - 00:20with joint based techniques within your scope. That means osteopath's chiropractors,
00:20 - 00:24physical therapists, you're probably all in the clear. Physical therapy assistants,
00:24 - 00:28athletic trainers, massage therapists, you need to check with your governing body
00:28 - 00:32in your state or region to see whether this is within your scope of practice.
00:32 - 00:36Personal trainers this is definitely not within your scope of practice. Of course
00:36 - 00:41all professions could use this video for purely educational purposes to help with
00:41 - 00:46learning biomechanics, anatomy, and of course palpation. In this video we're
00:46 - 00:51going to go over posterior to anterior well as superior to inferior, clavicle on
00:51 - 00:56acromion mobilization. So this is our acromioclavicular joint mobilizations.
00:56 - 00:58I'm going to have my friend Melissa come out, she's going to help me demonstrate.
00:58 - 01:03Now these are great joint mobilizations I want you to keep in your back pocket, and
01:03 - 01:08I know a lot of individuals don't do these mobilizations on a regular basis,
01:08 - 01:12but they are great for putting the finishing touches on regaining optimal
01:12 - 01:19mobility, or optimizing the quality of motion of the shoulder girdle. And that
01:19 - 01:24we have some research to kind of back this up. Research on the shoulder,
01:24 - 01:27specifically shoulder dysfunction and things like impingement syndrome, kind of
01:27 - 01:32show this propensity of the scapula to adopt an excessively downwardly
01:32 - 01:36rotated and anteriorly tipped position. If we think about what that would do to
01:36 - 01:44the arthrokinematic of the AC joint, it would push the acromion shelf anterior
01:44 - 01:51and inferior to the clavicle. So now the question is is how do we get it back, and
01:51 - 01:54I know some of you guys are thinking well you just push the scapula up and
01:54 - 01:58you push the scapula back and that makes a lot of sense, and it does make a
01:58 - 02:04lot of sense if it wasn't for the fact that the scapula is kind of big, and this
02:04 - 02:08is what that mobilization would look like. If we had some crazy way of
02:08 - 02:11stabilizing the clavicle, which we just kind of don't have a good way to
02:11 - 02:15stabilize the clavicle. The easier way to do this from a technique standpoint is
02:15 - 02:20to actually move the clavicle on a scapular that's being stabilized by
02:20 - 02:24the table. The only thing we have to consider now is we have to reverse the
02:24 - 02:29direction of our mobilisation, so rather than going superior and posterior with
02:29 - 02:36our scapula, we're going to go inferior and anterior with our clavicle, So what
02:36 - 02:39would that look like? Well first things first
02:39 - 02:43with all of our joint mobilizations, knowing your anatomy and having some
02:43 - 02:49palpation skills are very very helpful. I had suggested in another video that
02:49 - 02:55maybe even outline the clavicle, and you just outlined the clavicle you know with
02:55 - 02:59your with your partner with your colleague in a class, you know grab grab
02:59 - 03:03some people to practice on. I'm not suggesting you do this with every
03:03 - 03:07patient, but I know you know where your collarbone is, but try to identify the
03:07 - 03:13entire flattened S shape of the clavicle, and get a good visual model of what that
03:13 - 03:18looks like. See if you can feel the ends of the clavicles right, you'll notice
03:18 - 03:23that usually the proximal side of the clavicle is a lot more prominent than
03:23 - 03:26the distal side, which I guess works against us for the acromioclavicular
03:26 - 03:32joint mobilizations. But if you feel the entire distal end you'll notice that
03:32 - 03:36it's usually a little easier to get your fingers posterior to the joint, than it is
03:36 - 03:42to try to get your fingers anterior to the the AC joint, or at least the
03:42 - 03:49anterior to the distal end of the acromion, or clavicle rather. So once you
03:49 - 03:55find this border, what I want you to do is keep tracing that border until you
03:55 - 04:03feel this line that seems to indent around the distal clavicle, that is your
04:03 - 04:07joint line. Once we find that joint line we're back in the same place we've been
04:07 - 04:09in with all of our joint mobilizations where now we just have to figure out
04:09 - 04:15which direction we want to go, and we have a good chance of actually feeling
04:15 - 04:20our first resistance barrier, our first point of motion of arthrokinematic
04:20 - 04:25motion. Now this is glide as well as the end of arthrokinematic motion or the
04:25 - 04:31end of glide, and if we start with our our superior to inferior glides here, and
04:31 - 04:33I'm just going to move kind of kind of off to the side
04:33 - 04:40here. I can even keep one thumb right on the joint line and the acromion shelf,
04:40 - 04:45and use the other thumb, try to get my hands in here, use the other thumb to
04:45 - 04:51push straight superior to inferior on that clavicle, and make sure you use your
04:51 - 04:57thumb pad guys here not your fingertip, we don't want to poke at a joint that's
04:57 - 05:02that's never a good idea. Think about always using the broadest surface area
05:02 - 05:07you can. Right i'm going to go this way, you okay Melissa. You guys just got to be
05:07 - 05:10careful on these techniques, when you straighten out your arms it's really
05:10 - 05:16easy just keep knocking people in the head, and nobody likes that. So I have my
05:16 - 05:20thumb on the joint line, I can feel first point at which it moves, which which
05:20 - 05:23comes on pretty fast in this little joint, there's not a lot of motion there;
05:23 - 05:28and then I push all the way down until I feel end range, there we go, back off to
05:28 - 05:3350% and I can do whatever graded mobilization I'd like. Let's say grade
05:33 - 05:38three here, I'm going to back off the where I first felt that resistance and
05:38 - 05:47then go all the way down 50%, back to the beginning, and go from the beginning to
05:47 - 05:5450%, and if I can I'm going to straighten out my arms and just use my trunk to do
05:54 - 05:59this mobilization. Now I'm going to warn you guys we've been real careful with
05:59 - 06:05our technique up to this mobilization, there are joint mobilizations that just
06:05 - 06:11don't lend themselves very well to great body mechanics and great posture, which
06:11 - 06:16is why you have to be perfect on all of your other mobilizations. So that when
06:16 - 06:21you get to a mobilization like this where it is really really hard to have
06:21 - 06:26great mechanics, if you wear yourself down a little bit on this technique
06:26 - 06:32you're okay because the rest of the day you have perfect posture, and you're not
06:32 - 06:37really using the strength of your hands you're just using your bodyweight. Now
06:37 - 06:42this one I can use a little bit better technique
06:42 - 06:47than posterior to anterior, this is where things get really really tricky, because
06:47 - 06:52obviously if I was going to go posterior to anterior and have a great body
06:52 - 06:56position I would somehow be able to get my arms straight down this way through
06:56 - 07:02the table, and I can't go through tables, I don't know anybody who can. So what we
07:02 - 07:08end up having to do is kind of this like flip up technique with our wrists,
07:08 - 07:11alright which is it's going to get tough if you had to do a bunch of these
07:11 - 07:16throughout a day. But granted that we don't use this technique all the time
07:16 - 07:21you should be able to to get away with it here and there, and all you're going
07:21 - 07:28to do is put your thumb behind the distal end of the clavicle just like we
07:28 - 07:33talked about you finding, when we were talking about palpation here, so find the
07:33 - 07:38joint line, you're going to have to scoot over quite a bit so that this arm ends
07:38 - 07:42up straight next to your patient's head, because if you try to get this arm
07:42 - 07:46straight once again you just end up banging them in the head, or you end up
07:46 - 07:50putting your arm down on their face, also not okay.
07:50 - 07:56Clients don't seem to like going back and forth over the top of their face,
07:56 - 08:03probably not great customer service. So get your dummy thumbs set up guys,
08:03 - 08:07alright so I'm going to use my inside thumb as my dummy thumb here, and then
08:07 - 08:14I'm going to try to like I said kind of use that flip-up technique. Now before I
08:14 - 08:20did this flip-up technique I should have found my first resistant barrier, find
08:20 - 08:27the end and then back off to 50%, this time we'll do a grade four, I'll stay
08:27 - 08:33right there and I'm just kind of flipping my thumbs up, right I'm just
08:33 - 08:38doing this, takes a little bit of practice. This one you might want to grab
08:38 - 08:43a couple extra colleagues when you're practicing this technique, make sure you
08:43 - 08:48do both of their shoulders and get as much practice as you possibly can,
08:48 - 08:52and of course if I'm doing my grade four mobilizations, I'm doing
08:52 - 08:57one two two two oscillations per second, and I'm going to keep going until
08:57 - 09:02I feel a reduction in arthrokinematic stiffness. As I mentioned in the
09:02 - 09:08beginning of this video if we're going to go back to like a more reliable
09:08 - 09:13objective measure, I would probably use something like end range shoulder
09:13 - 09:17flexion, and this is gross shoulder flexion not just glenohumeral shoulder
09:17 - 09:20flexion. But do they get a hundred and eighty degrees, can they get their arm
09:20 - 09:25all the way down to the table shoulder flexion. Or maybe I use external rotation
09:25 - 09:30and see and see to make sure that they've got all the way to 90-95 degrees,
09:30 - 09:34which is going to include not only glenohumeral motion but posterior
09:34 - 09:39tipping of the scapula as well, to see if I got some loosening up of the AC joint.
09:39 - 09:44So just real quick - to recap that mobilization before we're going to our
09:44 - 09:49close-up recap. You guys are going to have to get real good at finding the
09:49 - 09:54distal border of the clavicle. Pretty easy to do our superior to inferior
09:54 - 10:00mobilization but you're going to have to scoot over, and probably use one arm
10:00 - 10:07straight right parallel to their face, and probably one thumb is going to end
10:07 - 10:13up being like a dummy thumb and a feeler, and then the other hand you can pretty
10:13 - 10:18much use your trunk to get that superior to inferior mobilization. The posterior
10:18 - 10:23to anterior mobilization a little trickier, it is easy enough to get your
10:23 - 10:28thumb behind the clavicle, but then to get both thumbs and to create a
10:28 - 10:34posterior to anterior direction, you end up doing this flip-up technique which is
10:34 - 10:41going to take a little practice. Obviously is not great on our own body
10:41 - 10:46mechanics, so I wouldn't recommend doing this all day every day as your go-to
10:46 - 10:53technique for everybody, but it does work in a pinch. Guys try these techniques,
10:53 - 10:59stay tuned for the close-up recap. So for a close-up recap of the superior to
10:59 - 11:04inferior and posterior to anterior clavicle on acromion
11:04 - 11:11mobilisations. First just palpate your clavicle, find the end of your clavicle
11:11 - 11:17the distal end. Now the distal end is usually not quite as prominent as the
11:17 - 11:21proximal end if you've done the sternal sternoclavicular joint mobilization
11:21 - 11:29before, but it's usually prominent enough that if you take your time and
11:29 - 11:37investigate you'll notice that it drops off into the flat acromion, you can
11:37 - 11:43definitely feel a little bump when going from acromion shelf back onto the
11:43 - 11:50clavicle; and that of course is the somewhat spherical end of the clavicular
11:50 - 11:55bone there. It's definitely a little bit more spherical in the
11:55 - 12:00posterior aspect. If I'm doing my superior to inferior mobilization then I
12:00 - 12:06might use this hand as my my feeler, we talked about kind of placing any free
12:06 - 12:12fingers or hand that we have on the joint line so we can feel the amount of
12:12 - 12:16glide happening, and of course if I put this finger here I can I can just push
12:16 - 12:22like this and feel joint motion. Once I started doing the mobilization I want to
12:22 - 12:27use the the largest surface I can. So we're not going to poke at the joint, but
12:27 - 12:33we're going to use a thumb pad like this, I'm going to straighten up my arm, I
12:33 - 12:37could use thumb over thumb technique but I'm actually going to leave this thumb
12:37 - 12:42here so that I can feel that joint line, and then straighten out my arm find that
12:42 - 12:48first resistance barrier, find the end of athrokinematic range, back off to 50% and
12:48 - 12:54of course then I can just use my torso to get a nice oscillation here, one to
12:54 - 12:58two oscillations per second. Now the harder technique I kind of explained to
12:58 - 13:02you guys was the posterior to anterior, because you have to use this kind of
13:02 - 13:10flipping wrist technique. It is easier to get on the posterior aspect of the
13:10 - 13:15clavicular bone that's not too hard, and of course you could leave a finger on
13:15 - 13:17the joint line or you could end up using both
13:17 - 13:23fingers to do this flipping up technique, to get your posterior to anterior
13:23 - 13:31direction. Now with this technique it is very tough to kind of identify your
13:31 - 13:37first resistance barrier, your end range, back off the 50% and stay there, that's
13:37 - 13:42going to take some practice. With this particular technique I would definitely
13:42 - 13:50find more than a couple colleagues to practice getting the direction right on
13:50 - 13:55that mobilization, and of course with all of these mobilizations you can test
13:55 - 14:00which one is most effective. For example I could do this then test and range
14:00 - 14:04shoulder flexion, and then I could test this one and do end range shoulder
14:04 - 14:07flexion again and see which one works better. So there you have it
14:07 - 14:12assess, address, reassess. Make sure that every time you choose a joint based
14:12 - 14:17manual therapy technique it is based on an assessment, and that you return to
14:17 - 14:21that assessment after you finish the intervention, to see if it was effective
14:21 - 14:26for the individual, the patient or client that you had in front of you. Ensure that
14:26 - 14:31you continue to learn your Anatomy because your Anatomy is going to help
14:31 - 14:36you with your hand placement, with understanding what a joint can do, with
14:36 - 14:41understanding what you may gain from this particular technique. And of course
14:41 - 14:46practice, you have to practice these techniques hopefully not for the first
14:46 - 14:51time on a patient or client who just walked in the door. If you can, find a
14:51 - 14:56more senior instructor or mentor to give you some really good hands-on
14:56 - 15:03instruction. Use your peers for some good feedback, and of course always look for
15:03 - 15:09live education to help with your manual therapy techniques. I know these videos
15:09 - 15:15make education very convenient, but there is no substitute for learning manual
15:15 - 15:19therapy in a live setting. I look forward to talking to you guys again
15:19 - 15:21soon.
15:27 - 15:29