0:05 This is Brent of the Brookbush Institute, and in this video we're going to go over a joint 0:07 based manual therapy technique, If you're watching this video I'm assuming you're 0:11 watching it for educational purposes, and that you are a licensed professional 0:14 with joint based techniques within your scope. That means osteopath's chiropractors, 0:20 physical therapists, you're probably all in the clear. Physical therapy assistants, 0:24 athletic trainers, massage therapists, you need to check with your governing body 0:28 in your state or region to see whether this is within your scope of practice. 0:32 Personal trainers this is definitely not within your scope of practice. Of course 0:36 all professions could use this video for purely educational purposes to help with 0:41 learning biomechanics, anatomy, and of course palpation. In this video we're 0:46 going to go over posterior to anterior well as superior to inferior, clavicle on 0:51 acromion mobilization. So this is our acromioclavicular joint mobilizations. 0:56 I'm going to have my friend Melissa come out, she's going to help me demonstrate. 0:58 Now these are great joint mobilizations I want you to keep in your back pocket, and 1:03 I know a lot of individuals don't do these mobilizations on a regular basis, 1:08 but they are great for putting the finishing touches on regaining optimal 1:12 mobility, or optimizing the quality of motion of the shoulder girdle. And that 1:19 we have some research to kind of back this up. Research on the shoulder, 1:24 specifically shoulder dysfunction and things like impingement syndrome, kind of 1:27 show this propensity of the scapula to adopt an excessively downwardly 1:32 rotated and anteriorly tipped position. If we think about what that would do to 1:36 the arthrokinematic of the AC joint, it would push the acromion shelf anterior 1:44 and inferior to the clavicle. So now the question is is how do we get it back, and 1:51 I know some of you guys are thinking well you just push the scapula up and 1:54 you push the scapula back and that makes a lot of sense, and it does make a 1:58 lot of sense if it wasn't for the fact that the scapula is kind of big, and this 2:04 is what that mobilization would look like. If we had some crazy way of 2:08 stabilizing the clavicle, which we just kind of don't have a good way to 2:11 stabilize the clavicle. The easier way to do this from a technique standpoint is 2:15 to actually move the clavicle on a scapular that's being stabilized by 2:20 the table. The only thing we have to consider now is we have to reverse the 2:24 direction of our mobilisation, so rather than going superior and posterior with 2:29 our scapula, we're going to go inferior and anterior with our clavicle, So what 2:36 would that look like? Well first things first 2:39 with all of our joint mobilizations, knowing your anatomy and having some 2:43 palpation skills are very very helpful. I had suggested in another video that 2:49 maybe even outline the clavicle, and you just outlined the clavicle you know with 2:55 your with your partner with your colleague in a class, you know grab grab 2:59 some people to practice on. I'm not suggesting you do this with every 3:03 patient, but I know you know where your collarbone is, but try to identify the 3:07 entire flattened S shape of the clavicle, and get a good visual model of what that 3:13 looks like. See if you can feel the ends of the clavicles right, you'll notice 3:18 that usually the proximal side of the clavicle is a lot more prominent than 3:23 the distal side, which I guess works against us for the acromioclavicular 3:26 joint mobilizations. But if you feel the entire distal end you'll notice that 3:32 it's usually a little easier to get your fingers posterior to the joint, than it is 3:36 to try to get your fingers anterior to the the AC joint, or at least the 3:42 anterior to the distal end of the acromion, or clavicle rather. So once you 3:49 find this border, what I want you to do is keep tracing that border until you 3:55 feel this line that seems to indent around the distal clavicle, that is your 4:03 joint line. Once we find that joint line we're back in the same place we've been 4:07 in with all of our joint mobilizations where now we just have to figure out 4:09 which direction we want to go, and we have a good chance of actually feeling 4:15 our first resistance barrier, our first point of motion of arthrokinematic 4:20 motion. Now this is glide as well as the end of arthrokinematic motion or the 4:25 end of glide, and if we start with our our superior to inferior glides here, and 4:31 I'm just going to move kind of kind of off to the side 4:33 here. I can even keep one thumb right on the joint line and the acromion shelf, 4:40 and use the other thumb, try to get my hands in here, use the other thumb to 4:45 push straight superior to inferior on that clavicle, and make sure you use your 4:51 thumb pad guys here not your fingertip, we don't want to poke at a joint that's 4:57 that's never a good idea. Think about always using the broadest surface area 5:02 you can. Right i'm going to go this way, you okay Melissa. You guys just got to be 5:07 careful on these techniques, when you straighten out your arms it's really 5:10 easy just keep knocking people in the head, and nobody likes that. So I have my 5:16 thumb on the joint line, I can feel first point at which it moves, which which 5:20 comes on pretty fast in this little joint, there's not a lot of motion there; 5:23 and then I push all the way down until I feel end range, there we go, back off to 5:28 50% and I can do whatever graded mobilization I'd like. Let's say grade 5:33 three here, I'm going to back off the where I first felt that resistance and 5:38 then go all the way down 50%, back to the beginning, and go from the beginning to 5:47 50%, and if I can I'm going to straighten out my arms and just use my trunk to do 5:54 this mobilization. Now I'm going to warn you guys we've been real careful with 5:59 our technique up to this mobilization, there are joint mobilizations that just 6:05 don't lend themselves very well to great body mechanics and great posture, which 6:11 is why you have to be perfect on all of your other mobilizations. So that when 6:16 you get to a mobilization like this where it is really really hard to have 6:21 great mechanics, if you wear yourself down a little bit on this technique 6:26 you're okay because the rest of the day you have perfect posture, and you're not 6:32 really using the strength of your hands you're just using your bodyweight. Now 6:37 this one I can use a little bit better technique 6:42 than posterior to anterior, this is where things get really really tricky, because 6:47 obviously if I was going to go posterior to anterior and have a great body 6:52 position I would somehow be able to get my arms straight down this way through 6:56 the table, and I can't go through tables, I don't know anybody who can. So what we 7:02 end up having to do is kind of this like flip up technique with our wrists, 7:08 alright which is it's going to get tough if you had to do a bunch of these 7:11 throughout a day. But granted that we don't use this technique all the time 7:16 you should be able to to get away with it here and there, and all you're going 7:21 to do is put your thumb behind the distal end of the clavicle just like we 7:28 talked about you finding, when we were talking about palpation here, so find the 7:33 joint line, you're going to have to scoot over quite a bit so that this arm ends 7:38 up straight next to your patient's head, because if you try to get this arm 7:42 straight once again you just end up banging them in the head, or you end up 7:46 putting your arm down on their face, also not okay. 7:50 Clients don't seem to like going back and forth over the top of their face, 7:56 probably not great customer service. So get your dummy thumbs set up guys, 8:03 alright so I'm going to use my inside thumb as my dummy thumb here, and then 8:07 I'm going to try to like I said kind of use that flip-up technique. Now before I 8:14 did this flip-up technique I should have found my first resistant barrier, find 8:20 the end and then back off to 50%, this time we'll do a grade four, I'll stay 8:27 right there and I'm just kind of flipping my thumbs up, right I'm just 8:33 doing this, takes a little bit of practice. This one you might want to grab 8:38 a couple extra colleagues when you're practicing this technique, make sure you 8:43 do both of their shoulders and get as much practice as you possibly can, 8:48 and of course if I'm doing my grade four mobilizations, I'm doing 8:52 one two two two oscillations per second, and I'm going to keep going until 8:57 I feel a reduction in arthrokinematic stiffness. As I mentioned in the 9:02 beginning of this video if we're going to go back to like a more reliable 9:08 objective measure, I would probably use something like end range shoulder 9:13 flexion, and this is gross shoulder flexion not just glenohumeral shoulder 9:17 flexion. But do they get a hundred and eighty degrees, can they get their arm 9:20 all the way down to the table shoulder flexion. Or maybe I use external rotation 9:25 and see and see to make sure that they've got all the way to 90-95 degrees, 9:30 which is going to include not only glenohumeral motion but posterior 9:34 tipping of the scapula as well, to see if I got some loosening up of the AC joint. 9:39 So just real quick - to recap that mobilization before we're going to our 9:44 close-up recap. You guys are going to have to get real good at finding the 9:49 distal border of the clavicle. Pretty easy to do our superior to inferior 9:54 mobilization but you're going to have to scoot over, and probably use one arm 10:00 straight right parallel to their face, and probably one thumb is going to end 10:07 up being like a dummy thumb and a feeler, and then the other hand you can pretty 10:13 much use your trunk to get that superior to inferior mobilization. The posterior 10:18 to anterior mobilization a little trickier, it is easy enough to get your 10:23 thumb behind the clavicle, but then to get both thumbs and to create a 10:28 posterior to anterior direction, you end up doing this flip-up technique which is 10:34 going to take a little practice. Obviously is not great on our own body 10:41 mechanics, so I wouldn't recommend doing this all day every day as your go-to 10:46 technique for everybody, but it does work in a pinch. Guys try these techniques, 10:53 stay tuned for the close-up recap. So for a close-up recap of the superior to 10:59 inferior and posterior to anterior clavicle on acromion 11:04 mobilisations. First just palpate your clavicle, find the end of your clavicle 11:11 the distal end. Now the distal end is usually not quite as prominent as the 11:17 proximal end if you've done the sternal sternoclavicular joint mobilization 11:21 before, but it's usually prominent enough that if you take your time and 11:29 investigate you'll notice that it drops off into the flat acromion, you can 11:37 definitely feel a little bump when going from acromion shelf back onto the 11:43 clavicle; and that of course is the somewhat spherical end of the clavicular 11:50 bone there. It's definitely a little bit more spherical in the 11:55 posterior aspect. If I'm doing my superior to inferior mobilization then I 12:00 might use this hand as my my feeler, we talked about kind of placing any free 12:06 fingers or hand that we have on the joint line so we can feel the amount of 12:12 glide happening, and of course if I put this finger here I can I can just push 12:16 like this and feel joint motion. Once I started doing the mobilization I want to 12:22 use the the largest surface I can. So we're not going to poke at the joint, but 12:27 we're going to use a thumb pad like this, I'm going to straighten up my arm, I 12:33 could use thumb over thumb technique but I'm actually going to leave this thumb 12:37 here so that I can feel that joint line, and then straighten out my arm find that 12:42 first resistance barrier, find the end of athrokinematic range, back off to 50% and 12:48 of course then I can just use my torso to get a nice oscillation here, one to 12:54 two oscillations per second. Now the harder technique I kind of explained to 12:58 you guys was the posterior to anterior, because you have to use this kind of 13:02 flipping wrist technique. It is easier to get on the posterior aspect of the 13:10 clavicular bone that's not too hard, and of course you could leave a finger on 13:15 the joint line or you could end up using both 13:17 fingers to do this flipping up technique, to get your posterior to anterior 13:23 direction. Now with this technique it is very tough to kind of identify your 13:31 first resistance barrier, your end range, back off the 50% and stay there, that's 13:37 going to take some practice. With this particular technique I would definitely 13:42 find more than a couple colleagues to practice getting the direction right on 13:50 that mobilization, and of course with all of these mobilizations you can test 13:55 which one is most effective. For example I could do this then test and range 14:00 shoulder flexion, and then I could test this one and do end range shoulder 14:04 flexion again and see which one works better. So there you have it 14:07 assess, address, reassess. Make sure that every time you choose a joint based 14:12 manual therapy technique it is based on an assessment, and that you return to 14:17 that assessment after you finish the intervention, to see if it was effective 14:21 for the individual, the patient or client that you had in front of you. Ensure that 14:26 you continue to learn your Anatomy because your Anatomy is going to help 14:31 you with your hand placement, with understanding what a joint can do, with 14:36 understanding what you may gain from this particular technique. And of course 14:41 practice, you have to practice these techniques hopefully not for the first 14:46 time on a patient or client who just walked in the door. If you can, find a 14:51 more senior instructor or mentor to give you some really good hands-on 14:56 instruction. Use your peers for some good feedback, and of course always look for 15:03 live education to help with your manual therapy techniques. I know these videos 15:09 make education very convenient, but there is no substitute for learning manual 15:15 therapy in a live setting. I look forward to talking to you guys again 15:19 soon. 15:27
