0:04 This is Brent of the Brookbush Institute, and in this video we're going to go over 0:07 manipulations or high-velocity thrust techniques. I assume that if you're 0:11 watching this video you're watching it for educational purposes, and that you 0:14 are a licensed professional with high velocity thrust or manipulation 0:19 techniques in your scope of practice. If you are not sure, check with your state 0:24 board. Most physical therapists, chiropractors and osteopaths you're in 0:28 the clear. I believe that ATC's you can't do manipulations in the United States, 0:33 although other countries again check your scope. Of course massage therapists 0:38 and personal trainers these are generally not within your scope. Of 0:41 course you could continue to watch these videos just for educational purposes, 0:47 learn a little Anatomy, learn a little biomechanics. If you're going to do these 0:51 techniques please make sure that you have a good rationale for putting your 0:56 hands on a patient. This should be based on assessment, and if you're going to 1:00 assess I'm hoping that you'll assess use these interventions and reassess, to 1:06 ensure that you're getting the result that you're looking for and have good 1:09 reason to continue using this technique. In this video we're going to go over 1:12 cervical manipulation, or at least mid to lower cervical manipulation. I'm going to 1:16 have my friend Yvette come out, she's going to help me demonstrate. Now if I'm 1:19 doing a cervical manipulation we do have to keep in mind that I'm basing this on 1:22 more than just subjective complaints of neck pain. We can have neck pain for 1:27 hypermobility of cervical segments, if we're doing manipulations it should be 1:32 for hypomobility, or some sort of restriction. So I'm going to base this on 1:36 some sort of assessment for range of motion, for example we could do our 1:40 visual exam of rotation, lateral-flexion, flexion and extension. I might try to add 1:44 goniometry, keep in mind the only reliable goniometric assessment for the 1:48 cervical spine is actually lateral flexion, and you can look that video 1:52 up. Now you might want to continue with some special tests, if you're going to do 1:57 this, the VBI and ligament tests are often brought up as necessary before 2:04 doing a cervical manipulation, that's probably more dependent on what your 2:08 liability insurance states or what insurance companies you're working with 2:13 state have to be done; and the reason why I say that is 2:17 there is very little evidence to suggest that those tests themselves are 2:22 particularly reliable, or that they would give us any indication of somebody who 2:28 could be hurt by a cervical manipulation. So I think cervical manipulation 2:32 injuries are rare, and that's possibly the most important thing to keep in mind. 2:38 If somebody does look like they need this technique due to a mobility 2:41 restriction you should probably move ahead and do so with care, and obviously 2:46 with practice, and we're going to try to show you some pretty conservative 2:49 techniques here. Now after I've gone through my assessments, whether that's 2:54 subjective, objective and special tests including VBI, or it's subjective and 3:00 objective alone, I'm going to go ahead and have Yvette back off the table here so 3:05 our heads hanging, so that now I have control of her head and cervical spine; 3:10 and the next thing I'm going to do is I'm going to use what's called a piano 3:14 finger grip, I like the Maitland school where I'm going to put my fingertips 3:18 between her spinous process. So you can think of her spinous process are 3:24 lined up this way and I'm trying to put my fingers just in between, and what I'm 3:28 going to try to feel for is, do the spinous process move sequentially, right almost 3:37 like dominoes falling they should go tic tic tic tic tic; rather than what 3:42 you'll feel with somebody who has restriction, is you'll get one that moves 3:46 and then maybe two or three that move together. Or you pulling the 3:50 lateral flexion and it's the same thing, where you get one that moves and then a 3:53 bunch that move together. Well you know those segments that are stuck together 3:56 are potentially something that could be helped by a cervical manipulation. So I 4:02 can do this with Yvette here a little lateral flexion, a little rotation and I 4:06 can do both ways, and I do feel a little restriction over what's probably between 4:17 C3 and C5, so those two segments. Now how am I going to manipulate those 4:25 segments, well this was a little confusing when I first got 4:28 taught it, but I think part of the reason why it was confusing is nobody really 4:34 helped me understand that the most important thing about a cervical 4:37 manipulation is finding the lock out position. Finding that position where you 4:42 have all of the joints locked, so that when you do the actual manipulation 4:47 motion the only thing that can move is the segment you're trying to move and 4:52 that comes down to two big things, well maybe more than two big things, but 4:58 two major things are going to be that you block out the lower segments and that 5:03 you get in locked position with the top segments. So what we're going to do is we're 5:08 going to use our second MCP on the spinous process just below the segment we feel 5:15 restriction. You don't even have to necessarily know which segment that is 5:19 to be quite honest. Some people get very detail-oriented about while I'm 5:24 manipulating C4 on C5, or you could just feel for the stiff segments and go after 5:32 that, your accuracy is probably pretty similar either way. So I'm going to put this 5:37 MCP on the spinous process of the lower segment and press it into the articular 5:44 pillar. So you can see I 5:46 start to take up some tissue slack by pushing my MCP in this direction, 5:52 I'm already stabilizing making sure that those lower segments when I rotate this, 5:58 side-bend or extend, I'm resisting all of those motions at anything lower than 6:05 this MCP. Once I have that stabilized I'm now going to use this hand, and you can 6:11 either use an open hand technique which I'm a little less comfortable with quite 6:15 honestly, or you can do head cradle position. So now I have her head 6:20 cradled in my elbow crease there, most of what she's feeling is like my bicep on 6:26 the top of her head. I can almost control all of it just by doing this. I'm 6:32 literally just cradling her head so she feels nice and comfortable and 6:37 stable, and then we're going to wrap our hand around her chin, but keep in mind 6:42 I'm not like yanking on her face. So I have just got her all wrapped 6:46 up so her heads nice and stable, and then once she's nice and relaxed. Now 6:52 I can move around a little bit, ninety percent of this is set up. So I 6:58 know some of you are waiting for me to do the manipulation, just show me the manipulation, 7:02 we got to get it to crack. That's literally the last 10%, and 7:08 potentially the least important point because if you lock somebody up perfect, 7:12 a lot of times they'll move on you, you'll get a cavitation without even 7:17 having to do a high-velocity thrust. So I'm blocking out those lower segments 7:21 here up this way. I'm then going to rotate away, I'm going to side-bend 7:28 towards me. I'm going to extend and flex and you can see now once 7:34 I rotate, side-bend and extend and flex then I search; and what I'm 7:40 searching for is if I push up here, or push sideways here or rotate sideways 7:45 here, I'm moving her head in this general direction. Get used to that 7:50 general direction, you don't even have to think joint actions. So I know you might 7:53 be like, well you've got a contralaterally rotate and ipsilaterally 7:57 flex and extend. That's all great, but if you just think about this 8:01 general motion, and this general motion here, and get all locked up which I am 8:09 right now. Now all I have to do is a little lateral flexion and rotation and 8:13 I guarantee she's going go. So nice deep breath Yvette, 8:22 and that's it. Sometimes it is a surprise to patients. Not everybody is used to 8:29 getting their cervical spine manipulated and I appreciate that Yvette is 8:32 letting me do this for the first time, because she is not somebody who gets 8:35 cervical manipulations done very often. But 8:37 that wasn't that bad, no pain. You can see I didn't 8:42 move that much, it was more of a startle response than it was any sort of like 8:46 pain response. We're definitely not doing big whips this way, or trying to 8:52 press in really hard, it's just getting that lock and then just a quick 8:56 twist; and I think you have seen chiropractors doing it with the open 9:00 hand technique which looks a little bit more impressive. but they just wrap, 9:05 it's a very quick little technique. So let's try that one more 9:11 time, I'll show you from the other side. I'm going to use this knuckle, I'm 9:18 going to get on the spinous process of the segment just below where I think she's 9:24 stuck. Now I could use an open hand technique, and I'll show you the 9:29 open hand technique this time. So I'm still blocking this way and I'm 9:32 still thinking about pushing up in this direction, because I want to 9:36 oppose the lateral flexion this way and I want to oppose the rotation I'm going 9:41 to do. So I'm trying to keep the spinous process below in position, which 9:46 means I kind of have to push up and in this way towards the articular pillar, 9:49 kind of in the direction of my thumb right now. Now I can use this hand kind 9:55 of wrapped around, you can see like I got my thumb up to her maxilla here and I'm 10:01 just wrapped around her head, and I have some some big hands. So it kind of 10:04 depends on your hand size too where you're going to end up 10:08 as far as your fingertips. So don't look at my hands and be like oh that's 10:12 how it's got to be look, you get your hands where they're comfortable. But 10:17 if I think about the same direction of motion, yes we can think about 10:20 it's the lateral flexion and contralateral rotation and all that 10:24 stuff, or you can think of, you're doing this with her head. You're doing 10:30 this general motion with her head and you can add a little bit of this to get 10:33 locked out. Once I'm locked out I'm here, and 10:39 then she takes a nice deep breath for me and all I'm going to do with my hands is 10:46 this sort of thing, because I'm going to push her into lateral flexion and 10:49 rotation this way, which means I'm going to slide my 10:52 hand this way to get that motion. How you feeling Yvette? Okay good, and that's it. 11:02 Sometimes you get a cavitation, sometimes you don't. Never forget 11:08 cavitation does not mean success. Success is performed better on reassessment, the 11:14 manipulation is the manipulation regardless of whether you got a 11:18 cavitation. It could be that I didn't get her locked up enough on that particular 11:22 try, or it could be that I got it. I would still reassess first before I gave this 11:27 one more try, be careful not trying to get a cavitation too many times because 11:33 you think you failed, because what you will do is you'll start to flare people 11:36 up. We do have to keep in mind that high- velocity also means high-intensity, and 11:40 if we keep doing a high-intensity technique to a tissue over and over 11:44 again that maybe is already a little irritable, 11:46 we could start increasing pain rather than reducing pain. How do you feel Yvette? 11:53 Why don't you sit up and take a minute and we'll go to the close-up recap. 11:57 Alright for a close-up recap I brought out the spine model, I wanted to 12:01 show you some of the stuff we were talking about so you have a little bit 12:04 better visualization. So if this is the back of the cervical spine that you 12:08 would be feeling, the first thing you're going to feel is those spinous process and 12:12 when I talked about that piano grip I was talking about putting my fingertips 12:16 between the spinous process, so I could feel them move sequentially like 12:21 one, two, three, four. They should just each move like little 12:25 dominoes falling, and when two spinous process move together that might be an 12:29 indication that I have a little bit of restriction between those segments, so I 12:33 use that piano grip for that. All right that's what it would look like from 12:37 the other side, and of course then I'm rotating and side-bending. When I talked 12:42 about putting my second MCP against the spinous process, realise 12:47 I'm trying to fit it in this laminar trough, almost trying to put it on these 12:53 articular pillars; and you can see here the articular pillar is called that 12:57 because when all these facets come together they kind of make this like 13:00 pillar shape. But somewhere between the articular pillar and what this would be 13:05 called would be the laminar trough, is kind of where I'm trying to fit my first 13:08 or my second MCP so that I stabilize the lower segments. Now if I have Yvette go 13:16 ahead and come back here, I'll try to demonstrate for you guys one more time 13:21 in a close-up here. So piano grip, what that would look like on her neck is 13:28 I would feel my spinous process, and then I would just slide my fingers over so I 13:32 was on the side of my spinous process, and then I can laterally flex and rotate 13:37 and see if any of those segments seem to want to move together rather than 13:44 sequentially; and then once I find some segments realize that I'm going to then 13:51 try to place my second MCP right up against that spinous process, or the 13:58 spinous process that's lower than the stuck segment. Once I have that set up 14:05 then I'm going to rotate away, laterally flex towards, but we're talking 14:11 about kind of bending her head or bending her neck over that second MCP; 14:18 and then once she's there and I'm nice and locked up, take a deep breath, I can 14:27 give her a quick little rotation and lateral flexion thrust. So this, and if 14:34 she's locked up properly and we hadn't just done a manipulation on the previous 14:38 take of this video which you just saw, 14:40 she probably would have got a cavitation on that one. But keep 14:44 in mind that cavitations don't mean success, changes on reassessment mean 14:48 success. I hope you found this video very helpful. Grab some friends in 14:53 practice, and if you have any questions leave them in the comments box below. A 14:56 couple of points to recap, knowing your anatomy and knowing your biomechanics 15:00 will certainly help you choose the right technique for the right patient. If 15:05 you're unsure whether manipulations are appropriate due to their higher 15:09 intensity, it's okay to do mobilizations. Most research points to manipulations 15:15 being slightly more effective but mobilizations being very effective, and 15:18 of course we have those videos for you if you want to start with those less 15:22 intense techniques. Make sure that if you are doing any technique that is based on 15:28 assessment, and of course that you're reassessing ensuring that the technique 15:32 is effective for the patient that you're working on, and when it comes to all 15:35 manual techniques, manipulations may be more than any other, look for 15:40 opportunities to get live education. Although I know videos are convenient 15:45 and I'm happy to have these up for you to watch, it would be so much more 15:50 helpful to use those videos as a recap of one-on-one attention with somebody 15:57 who's experienced with manipulation techniques. At the very least grab a 16:03 colleague, grab a friend and start practising these before you bring them 16:08 into clinic and start using them on patients and clients. I hope you enjoyed 16:12 this video, if you have any questions please leave them in the comments box 16:16 below.
