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 therapist's 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 0:47 going to go over anterior to posterior humerus on glenoid fossa mobilization, 0:51 commonly known as a shoulder AP. I'm going to have my friend Melissa come out, 0:54 she's going to help me demonstrate. Now if I'm doing this mobilization, chances 0:57 are I've already done some sort of functional movement assessment like the 1:00 overhead squat assessment, or I've seen that wall shoulder mobility test that 1:04 kind of looks like our serratus anterior activation, that is also a great 1:08 functional exam. We'll probably follow that up with 1:11 goniometery, something like internal and external rotation of the humerus, and 1:16 then last I'm going to want to check passive accessory motion to see if there 1:21 is arthrokinematic stiffness. Now we do have to be careful using this technique 1:25 with the shoulder, the shoulder has a propensity to become both hypermobile 1:30 that is too flexible, and hypomobile that's stiff. Now we only want to mobilize those 1:36 individuals who have stiffness, somebody who is too flexible who gets this 1:43 mobilization done, we might actually exacerbate their symptoms or actually 1:46 make them worse. The last thing we want to do is take somebody who's too 1:49 flexible, and make them even more flexible.. So now you've done your 1:54 assessment, you determined that there is arthrokinematic stiffness and you're 1:59 ready to do this mobilization, how do I place my hands? Well that all requires a 2:04 little bit of knowledge of anatomy and palpation. Alright so the first thing I 2:09 would recommend finding is just the acromion shelf, so the acromion shelf is 2:13 that big bony shelf that kind of sits right between 2:18 all of the muscle of the deltoid. So if you make a little muscle for me there 2:22 Melissa good job, alright you guys see this like dent right here, this dent 2:27 between her anterior middle and posterior right, that makes like a little 2:30 'U' this way, that dent that is the acromion shelf. So you can have somebody 2:34 kind of do this, get your fingers down on that bone, now go ahead and explore the 2:39 edges of that bone, explore the edges of the acromion shelf. You need the person 2:45 to stay nice and relaxed, good there we go nice and relaxed, so make sure their 2:51 arm is supported by the table. Once you've felt through the acromion shelf 2:54 you can actually start to feel like a divot underneath it, you can almost get 3:00 your fingers underneath it, and then if you keep going down the arm this way a 3:06 little bit you'll start to be able to sink your fingers around the humeral 3:13 head. Now the humeral head obviously is the most proximal portion of our humerus 3:18 bone, and that's going to be where we want to get our hands so we can do this 3:23 mobilization. Although we're going to place our hand on the interior portion 3:28 of the humerus I do recommend having a good idea of 3:34 where all of the humeral head lies, like being able to get your hands on the 3:39 posterior humeral head, kind of feeling how it goes down into the the neck of 3:44 the humerus as you sink past the deltoids, and keep moving distally. What 3:50 you'll notice about the anterior portion of the humerus is it's a lot more bumpy, 3:55 so you have the greater and lesser tubercle there, and then you also have 3:59 this ropey thing, this really thick rope and what that is is the biceps tendon. 4:04 The reason I bring this up is that it's something that we don't really want to 4:08 press on. If you really gear into somebody's bicep tendon while you're 4:13 doing this mobilization it's going to hurt, if they have impingement syndrome 4:17 it might be because it's inflamed, even if they don't have shoulder problems 4:21 you're just doing this on your your partner or your practice partner, or one 4:25 of your colleagues, or perhaps a mentor or teacher that you're practicing on, 4:30 you start gearing down on their their biceps tendon, it's going to hurt no 4:33 matter what, so we want to kind of know where that is so we can stay away from 4:37 it; and once you have the whole kind of idea of where the humerus is I'm going 4:43 to ask you to try to put, or at least imagine putting the humeral head right 4:47 in the palm of your hand like so. Now you can use these fingers to kind of wrap 4:54 yourself around the rest of the humerus and the acromion shelf, which might come 4:59 in handy when we start trying to find the beginning of arthrokinematic 5:03 motion, and the end of arthrokinematic motion. Now what I usually do 5:07 with this hand is I'm going to have Melissa who'll be inside of my bicep, I'm 5:12 going to hold her elbow like this, and now I have good control of abduction 5:18 adduction, and a little control over flexion and extension. I could probably 5:24 even internally rotate and externally rotate a little bit, like I have good 5:27 control over arm. I'm going to use this hand again, put my palm down right over 5:31 the anterior portion of her humerus, and then notice that once I'm in position 5:36 guys my trunk -my chest is over my hands. So again I'm not going to manhandle this 5:47 right, this is not how we do a mobilization that would actually get really tiring if 5:51 let's say Melissa was twice my size which would make her absolutely huge, but 5:55 if she was a very large person or had a very large arm, let's say I'm working on 6:00 like a professional football player or something, that would, this would be 6:05 almost impossible. You need to get used to using your body mechanics and save 6:10 your own body, perhaps even before you think about saving the body of your 6:14 patient because you got to do this all day. Alright because if you're seeing eight, nine, ten, 6:18 twelve, twenty patients a day, you need to have good mechanics and and save your 6:23 joints. So again I just have my client or patient reach in grab the inside of my 6:31 bicep, I grab underneath their elbow, I have to control this hand over the 6:37 anterior portion of the humerus, I'm just thinking about putting the humeral head 6:37 right in the palm of my hand. Since I'm using such a broad surface area I don't 6:41 usually have that problem with the biceps tendon, 6:44 if I do I try to put the biceps tendon between my thenar eminence, all right so most 6:49 of my pressure is coming here and the biceps tendon is falling in this groove 6:53 here. I'm now just going to use the weight of my trunk to kind of find okay 7:01 there's the first resistance barrier, and that's going to come on real quick with 7:04 the shoulder and then I'm going to find the end, alright you got to be careful 7:10 with the shoulder. Shoulder like I said is a very mobile joint, so if you press 7:14 too hard you're going to push right out of the glenoid fossa; not that you're 7:19 just locating the shoulder, but you will push the humeral head onto the posterior 7:24 lip of the glenoid fossa, and if you can do that really easily then this is probably 7:32 not somebody who needs this mobilization. The people who need this mobilization are 7:36 the ones you press into and you feel like you have something to press into, 7:39 there seems to be a certain amount of stiffness almost like you're pushing 7:43 into the back of a leather strap, like a like a leather belt. 7:47 Alright so beginning, feel like if I go any further than this all right like I'm 7:55 going to start pushing through. Now I'm going to back off to 50% and we've 8:01 talked about there's a lot of different protocols out there guys, and I just 8:04 asked you to follow through with whatever protocol that you learned. I use 8:08 generally the Maitland protocols for grade three and grade four mobilizations, 8:12 If we're talking about getting mobility here and this isn't like a pain dominant 8:15 patient. So we'll go to 50%, and then I can either do back off to where was my 8:24 first resistance barrier, to 50% and do my grade threes which is that higher 8:28 amplitude mobilization, or I can find my 50% and do my small amplitude 8:39 mobilizations right at that resistance barrier, making this a little higher 8:44 intensity. Now I'm going to do this until I feel a reduction in joint stiffness, 8:50 and then the most important thing as I've said throughout all these videos is 8:56 I'm going to reassess. Alright so to go through that just one more time guys. 9:03 Hand on inside of bicep, I got her elbow, I'm going to take her to where I need 9:08 herin abduction, adduction, more flexion, more extension, wherever 9:12 you guys feel like you need to be to work through that stiffness. The palm of 9:18 my hand goes over the humeral head, the anterior surface of the humeral head, trying to put the biceps tendon 9:23 between my thenar groove there, find the first resistance barrier, the end, 9:33 back off to 50%, and then do whatever grade I think is appropriate. I have my 9:40 hand around Melissa's elbow, and her hand is up around my arm, although I know you 9:44 can't see that you saw that in the previous shot. You guys can see Melissa's 9:48 acromion shelf here, and then you guys should be able to palpate around the 9:53 acromion shelf to define the subacromial space which is going to feel like a 9:58 depression, then as I mentioned before you should take some time to try to 10:05 palpate through the relaxed deltoid, to kind of outline the humeral head as it 10:14 goes down into the the neck of the humerus here, but once you find the 10:21 humeral head now we can place our palm on top of the anterior face of the 10:27 humeral head, and I kind of mentioned before if you kind of strum across this 10:32 way you'll feel a big rope like tendon there, that's the biceps tendon. I would 10:38 put that in your inner thenar groove so that you don't place undue pressure, 10:45 and now I can kind of feel like there you go there's your first first little 10:50 bit of motion of the humeral head, and I can push down until the end of her 10:57 glenohumeral motion there, and then back off to 50%, and then I can either go 11:02 from initial resistance to 50% for some grade threes or maybe I can stay at 50% 11:08 for grade 4's, but notice I'm using a nice wide palm 11:14 getting a lot of surface area, and trying to keep any direct pressure off that 11:19 biceps tendon for this joint mobilization. I'm doing my one to two 11:25 oscillations per second for 30 seconds plus until I feel a reduction in arthro- 11:32 kinematic stiffness, and of course i'm going to reassess. If i did one set and 11:37 got a little reduction, I could maybe pull further into flexion see if I run 11:42 into more stiffness. I could pull further out into abduction do another set and 11:47 see if I run into more stiffness, as I have a lot of control over Melissa's arm 11:52 here. So guys make sure you take the time to palpate the humeral head through the 11:57 deltoid, palm over anterior face, biceps tendon in thenar groove. Make sure you 12:05 feel for initial movement or first resistance barrier, and end of arthro- 12:11 kinematic range, and follow through with your protocols. So there you have it 12:16 assess, address, reassess. Make sure that every time you choose a joint based 12:21 manual therapy technique it is based on an assessment, and that you return to 12:26 that assessment after you've finished the intervention, to see if it was 12:29 effective for the individual, the patient or client that you had in front of you. 12:34 Ensure that you continue to learn your Anatomy because your Anatomy is going to 12:39 help you with your hand placement, with understanding what a joint can do, with 12:45 understanding what you may gain from this particular technique. And of course 12:50 practice, you have to practice these techniques, hopefully not for the first 12:55 time on a patient or client who just walked in the door. If you can, find a 13:00 more senior instructor or mentor to give you some really good hands-on 13:05 instruction, use your peers for some good feedback, and of course always look for 13:12 live education to help with your manual therapy techniques. I know these videos 13:18 make education very convenient, but there is no substitute 13:23 for learning manual therapy in a live setting. I look forward to talking to you 13:27 guys again soon,
