0:02 This is Brent of the Brookbush Institute, and in this video we're going to go over a 0:07 joint based manual therapy technique. If you're watching this video I'm assuming 0:11 you're watching it for educational purposes, and that you are a licensed 0:14 professional with joint based techniques within your scope. That means osteopaths, 0:19 chiropractors, physical therapists you're probably all in the clear. Physical 0:23 therapy assistants, athletic trainers, massage therapist you need to check 0:27 with your governing body in your state or region, to see whether this is within 0:30 your scope of practice. Personal trainers this is definitely not within your scope 0:35 of practice. Of course all professions could use this video for purely 0:39 educational purposes to help with learning biomechanics, anatomy and of 0:45 course palpation. In this video we're going to go over posterior to anterior 0:48 mobilizations for the cervical spine. Now that's unilateral posterior to anterior 0:52 mobilizations, which i think you guys will find is the workhorse of all of the 0:56 mobilization techniques we use for the entire spine. I'm going to have my friend 1:00 Melissa come out, she's gonna help me demonstrate these techniques. The first 1:03 thing I'm going to talk about is set up a little bit. We're going to have Melissa 1:05 face down in the face cut out here, and just so that we save her more 1:11 sensitive cheek bones, remember we're going to be pressing down on her neck, which 1:15 means we're going to be pressing her down into the table a little bit. I'm going to go 1:19 ahead and have her use a towel so that her forehead takes most of the force. 1:23 We're not going to be pressing that hard, but this area tends to get easily 1:27 aggravated, especially if we have multiple segments or multiple facet 1:31 joints we have to mobilize. Now the next thing is we want the arms in a 1:34 comfortable relaxed position, that could be by their sides, that could be hanging 1:39 off the table. Or if you're lucky enough to be here at Flex in New York where I 1:43 treat, like we have the arm cutouts that depress. So you can see Melissa can just 1:48 kind of hang out in this position, which tends to be very comfortable for 1:51 cervical patients. The thing you're trying to avoid is we don't want 1:55 increased tension here, right the muscles that go from the scapula to the cervical 1:59 spine, namely her levator scapulae and upper trap. Lastly you will notice 2:04 that the table is pretty low, and the reason the table is low is I want to be 2:09 able to get my chest over Melissa's neck, and then put my arms straight and have 2:16 my thumbs right where they need to be; because once we start doing the mobilization all 2:21 I want to have to do is rock my torso. I don't want to be in a position where I 2:26 have to either use my hands or my elbows, right like extension using my triceps 2:33 because number one if I have a lot of very large patients I'm going to wear 2:37 myself out really quick, and even if I don't have a lot of large patients I 2:41 think you guys will find that this is just not a consistent amount of force. 2:44 It's hard to be really really consistent when you're doing this. Or you're doing 2:48 this compared to okay I get here, and now I just rock. It's really easy to keep a 2:55 very consistent amount of force this way. Next thing we need to consider is 3:02 anatomy, and if you haven't spent some time going over cervical spine 3:07 anatomy I suggest doing a little review before you start practicing these 3:10 techniques. And I do suggest you purchase or find one of these to practice on. I 3:16 know they're a little expensive for what they are. I think they run between 80 and 3:20 150 bucks right. I bought one of the flexible ones, and let me explain why. I 3:25 know this and this aren't exactly the same, but this is a close facsimile to 3:32 the bones and joints of the cervical spine, and there's something to being 3:37 able to touch, feel all the different bumps. Challenge yourself to go okay I'm 3:45 going to find the transverse process of C1. All right and then be able to look down 3:49 and go oh I'm on the transverse process of C1. Or I go I'm going find spinous 3:56 process of C3. All right I did it, I did it, I remembered that C1 doesn't really 4:05 have a spinous process. So as I'm doing this what I'm doing is building a 4:11 visual model up here of what the bones of the neck look like, and I can't tell 4:16 you how helpful that is when you get your hands here, which is basically that 4:22 with a bunch of mush on top of it. It's not exactly the same. I'm not saying it's 4:27 exactly the same, but I think it's going to help you guys as a learning tool 4:32 that once you get your hands in here and you can get through the soft tissue, you 4:36 get better at feeling through the soft tissue, 4:38 you'll start being able to match up your visual model with what's actually going 4:43 on here a lot quicker. Now we are going to start with the most complicated 4:47 joints of the neck to actually palpate and mobilize, but that's just because 4:51 we're going start from the top and work our way down. So let me show you guys how 4:55 to palpate C1, and then how we're going to mobilize C1-CO, or the atlanto- 5:02 occipital joint. So if you guys feel the back of the skull and then take the back 5:10 of the skull towards the ears, and find that little point known as the mastoid 5:14 process right that's like right here, 5:16 and some of you have felt your mastoid processes before, they can be a 5:19 little tender to poke on. And you guys go what does that have to do with the 5:23 cervical spine? Well if you go just inferior to your mastoid process, you can 5:27 actually feel it on yourself, you run into like two hard things sticking 5:32 out this way. That's actually the transverse process of C1 all right. So 5:38 find that on your patient and then look down, and I want you to draw an imaginary 5:41 line between your two fingers. The little horizontal line between your two 5:46 fingers and think C1's right under that. Alright so I know C1 is right under 5:51 that line, and then if you can remember that the atlanto-occipital joint tilts 5:57 towards the person's eyes. You can think okay if that's C1 I need to go just 6:04 above C1 so that I can get on that AO joint, and I need to push in this 6:10 direction. So what I'm going to have you guys do is trade your index fingers 6:16 which you were probably palpating the transverse process with, with your 6:18 pinkies. Lay your fingers over right where you think C1 is, and then think 6:25 okay which side am I going to do. I want you to put your thumbs where these two 6:30 fingers were. So if I had just laid down my fingers like this over C1, I'm now 6:36 going to put my thumbs right over where my middle and fourth finger were on one 6:40 side, and then I'm going to try to push up towards the eyeball. And I think you guys 6:45 will find that as you gently push in and kind of 6:49 give a couple test presses, you'll feel that joint move a little bit. 6:53 Now I actually find this position a little uncomfortable for me so I tend to 6:59 put my thumb down on this side if I'm going to mobilize this joint, and then I use 7:04 this arm over that thumb. Once again I have kind of big hands right, so for me 7:09 to do thumb thumb next to thumb is really tough, and then I'm just going to 7:14 mobilize in the direction of her eye here just like so. All right so that's 7:23 how I find that that occipital and Atlas joint, right that AO joint or CO-C1 joint. 7:32 Now notice guys I went thumb over thumb. All of the techniques for the cervical 7:37 spine are either thumb next to thumb or thumb over thumb, and be careful don't 7:41 let yourself get into extension too much in your thumbs like that can ruin 7:46 careers if you keep doing it. You end up with hypermobility there and then it 7:49 becomes really hard to do these techniques, and try to use both hands 7:53 whenever possible so that you gain the benefit of the strength of both your 7:58 thumbs, rather than wearing down one. Like I'm sure I could get in here and I have 8:01 enough hand strength to do it just like this, but that's going to wear me down over 8:05 time. This is a much safer technique for my hands. So we have CO-C1 let's go C2-C3. 8:15 If I look for the spinous process that's just underneath Melissa's skull, that 8:23 spinous process is C2. So C1 doesn't have a spinous process. If I then drop 8:29 slightly lateral and inferior, I end up on the facet joint of C2-C3. Now you'd 8:42 think well that's easy enough and then I can just press down, and I know some of 8:49 you guys have already figured out that I skipped C1-C2, and there's this little 8:53 trick. So if I find the spinous process and drop off that's C2-C3 8:59 and I can do my normal PA if C2-C3 and I can either do it this way getting over 9:05 the top, or I can do it this way getting over the top, and again I'm thumb over 9:11 thumb because my thumb's are fairly large. If you feel more comfortable this 9:14 way that's fine. I'm going to find my first resistance barrier and then push through 9:19 to the end. Find the end point, you guys are going to find that there's not a lot of 9:24 range of motion there. I back off to 50%, then I can do either my grade 3's or 9:28 my grade 4's. For C1-2 you got to remember what joint that is, so 9:35 that's the atlanto-axial joint, the the AA joint. That joint wants to rotate 9:42 and if you just press down on C1-C2 like I'm pressing down on C2 here, 9:48 there's too much left because of rotation for that mobilization to be 9:54 effective. So what we need to do is get to end range of motion and then start 10:00 mobilizing, and the way we do that is just turn 10:03 Melissa's head about 30 degrees. So she's just going to lay on one side like 10:06 she'd lay on a pillow, and I'm going to go back to that same facet, that same 10:11 bump; because I was basically over the top of C2. So just right here and 10:17 then I'm going to push straight down, and then of course retest rotation. 10:25 So quick recap here, and once again these are the hardest joints and the 10:31 cervical spine to figure out. So if you can get these you're in good shape. For 10:37 C1 and the occiput you're going to go towards her eyeball just 10:46 underneath the occiput. So you can go over the top this way or you can 10:52 come around to the side, and then I end up using this arm, because this arms now 10:56 facing eyeball, this is my dummy thumb and I can go this way. If I then find the 11:02 spinous process of C2 and drop off laterally, you end up naturally wanting 11:06 to drop off laterally and inferiorly a little bit, that bump was over the top of 11:12 the articular pillar of C2. If I press straight down that's actually mobilizing 11:18 C2-C3 which is fine if that's what you want to mobilize. If you were looking for 11:23 upper cervical rotation though and you think that C1-C2 is stuck, then you're 11:29 going to need to rotate towards and press down because I needed to take up that 11:35 end range rotation, like basically turn C1 all the way like this and then press 11:42 down on C2 to get more range. Guys that was the hard part, that was the hard part. 11:48 If you got that rewind this video watch that a couple times. If you got that the 11:53 rest is easy breezy. So C3 now we're starting to get into mid 11:59 cervical spine, fall-off just lateral and inferior. I like to come around this 12:05 side, it's just straight down, and then c4 is just one segment down again, C5 one 12:13 segment down again, C6 one segment down again. Now you guys know C7 and spinous 12:19 prominence, so that's that's right here for her, right and then I can go right there. So I can 12:27 mobilize all of those joints, there's nothing special about them. It's just, you 12:31 just kind of go lateral and you end up dropping off just a little tiny bit, and 12:36 I can go straight through all of these. Now let's talk a little bit about 12:42 what I'm feeling for as I'm doing these mobilizations. I already mentioned it a 12:45 little bit, don't forget your protocols. So every time I get over the top of the 12:51 joint before I mobilize I'm going okay, there's my first resistance barrier, 12:58 there's the end of articular arthrokinematic motion, before I would just 13:03 start pushing her into a further extension. So my end range of 13:07 this motion, so first resistance barrier and usually if I'm going to do 13:14 this I'm not going to go argh end. I'm going to kind of do some 13:19 test pulses my way down until I get to the end, see if the patient depending on 13:23 how sensitive they are can take it. I'm going to back off the 50% 13:27 and now I have my choice, I can either do larger amplitude grade 3's 13:33 going from first resistance barrier down to 50%, or maybe just a little beyond 50%. 13:38 Or I can do my grade fours which are a little bit more intense, because I'm 13:41 going to start at 50% and do small amplitude, or go even deeper as I need to. 13:47 So get here 1-2 oscillations per second, and I'm going to keep going 13:55 probably for 30 seconds or more until I feel a change in tissue sensitivity. 14:03 Or not tissue sensitivity I guess is the wrong word, maybe malleability tissue 14:09 density. I'll feel like it's easier to move the joint. How does that feel 14:18 Melissa? Feels good. Now we do have to be very careful. With the cervical spine we 14:25 are as likely to end up with a hyper mobile segment as we are to end up with 14:30 a hypomobile segment, and I think we get into the unfortunate habit of going 14:34 diagnosis modality, right that's how we treat right. Cervical pain, 14:41 mobilizations is what fixes it, and we have to keep in mind that that's not 14:45 very good logic. Mobilizations are to increase mobility, and if somebody has 14:51 pain because they're hypermobile then we could be making the problem worse. 14:57 And the unfortunate thing is a hypermobile person sometimes feels very tight, 15:01 because they end up with a lot of spasming an increase in tonicity in 15:06 those extensor muscles. So it is very important that as you're doing these 15:10 mobilizations, unless you've been with this patient for a long time and try 15:13 this before, I would do one facet joint have him sit up and redo my tests. 15:21 See if that reduced their pain, increase their range of motion. If it increased 15:25 their pain, I'm heading in the wrong direction. 15:28 It could mean that I chose the wrong facet, but I mobilized the hypermobile 15:33 facet rather than a hypomobile facet. It could also mean that 15:36 mobilizations maybe aren't the most appropriate thing to start with, and 15:40 maybe we should back off and start thinking about maybe this person needs 15:43 more of like exercise first, stability exercises first. Or maybe I need to leave 15:48 the neck alone and maybe treat out the upper thoracic spine, and I see 15:53 if I can get some good progress that way, let their neck calm down before 15:58 I come back to these more aggressive techniques that directly affect where 16:03 they're having pain. All right so just to review here real quick, CO, 16:11 C2-C3 is just off that first 16:16 spinous process you feel. If I rotate 30 degrees C1-C2, all of the other cervical 16:24 facets feel like little bumps, you're getting it right over what the, it's 16:30 called the articular pillar and when you look at the spine the cervical spine all 16:34 they're talking about with the articular pillar is the facet joints 16:37 stack up in such a way that they feel like pillars on either side of the 16:41 spinous process. So for the rest of the cervical spine joints you're just 16:46 getting right lateral and slightly inferior and pressing down, and we're 16:51 probably mobilizing the upper on the lower segment, and you guys can just 16:59 think about that as you go through and feel each one of these bumps right 17:05 that's that's connected to the spinous process. As you try to loosen up all of 17:13 those cervical facets. Stay tuned for your close-up recap. Now for the 17:18 close-up recap all of the palpations and the various ways to do these UPA 17:23 mobilizations for the cervical spine which is a little complicated, we're 17:27 going to go ahead and start from the top and work our way down again. 17:31 You're going to find the mastoid process which is this little bump I think you 17:35 can see sticking out right here, right behind Melissa's earlobe, and then 17:39 if you go just below that on either side of her spine, you'll feel these two 17:46 things sticking out like so, and those are her transverse process; 17:50 and then if I put my pinkies on those transverse process and just lay my 17:56 fingers down horizontally just underneath her occiput, my fingers are 18:01 right over C1. Now if I want to do this side over here and I just replace my 18:10 third and fourth finger with my thumbs, I'll be over that CO-C1 joint, and 18:17 then I can push down find my first resistance barrier. Remember that 18:23 I'm pushing down towards her eyeball, so this one's not straight on, this isn't 18:27 not a straight on PA this way, it's this way a little bit. So I have to kind of 18:33 push back in towards her head and I'll find my first resistance barrier, my end 18:39 range, back off to 50%, and then do either my grade 3's or my grade 4's. Now the 18:46 next one we're going to find is actually C2-C3, and if I drop off laterally and 18:54 inferiorly from C2 spinous process, remember the C2 spinous processes the 18:59 first spinous process we feel underneath the occiput; because C1 essentially 19:04 doesn't have a spinous process. So if I go right over C2-C3 I can go ahead and 19:10 do my normal straight up and down PA over that little bump I feel, essentially 19:17 between C2 and cC3 spinous processes just lateral to it, and so that bump. 19:24 Where is my first resistance barrier, where's my end, back off to half. Now just 19:29 like in the video you guys will notice I went CO-C1, C2-C3 because to get to C1-C2 19:35 I need to turn Melissa towards me or towards the side that I'm mobilizing, 19:41 because I need to take up all that slack in the atlanto-axial joint which wants 19:48 to rotate. So if we're going to improve range of motion we need to get pretty 19:51 close to end range, but then once they get her in this position I'm just going to 19:56 go back to C2 spinous process, fall off and do a PA, same thing. 20:03 So it's not a more complicated technique you just have to remember the 20:07 little trick of taking up all of the upper cervical rotation you can, and then 20:14 for the rest of the spinous process it's just fall off, a little lateral, a little 20:19 medial unto what feels like an articulatar pillar, a column, our 20:26 articular pillar, you can feel those little bumps. That little bump this 20:32 way, and there's even a little bumpiness this way that each facet joint you just 20:36 do your PA's, go to the next spinous process, do your PA, next one. As long as 20:43 it feels stiff you can keep going, or you can do one and then retest. Or you 20:49 could do one and then do the other side if you think it's more of like a 20:52 bilateral restriction. These PA's will work all the way into the upper thoracic 20:58 spine for sure, even coming over the top of somebody as I am here. You could be on 21:03 the side of somebody if you think something is unilateral do all one side 21:08 and then retest. So the rest of these segments are real easy, just fall off 21:14 this way find your first resistance barrier, your end resistance barrier, back 21:20 off to 50%. Of course zero to fifty for a grade three or stay closer to fifty be a 21:26 little bit more intense, and this would be our grade four mobilizations. As per 21:33 all our techniques assess, address and reassess. I hope this helped make sense 21:40 of these palpations for you. So there you have it assess, address, reassess. Make 21:45 sure that every time you choose a joint based manual therapy technique it is 21:49 based on an assessment, and that you return to that assessment after you've 21:53 finished the intervention to see if it was effective for the individual ,the 21:58 patient or client that you have in front of you. Ensure that you continue to learn 22:02 your Anatomy because your Anatomy is going to help you with your hand 22:07 placement, with understanding what a joint can do, with understanding what you 22:12 may gain from this particular technique, and of course practice. You have to 22:18 practice these techniques hopefully not for the first time on a patient or 22:23 client who just walked in the door. If you can find a more senior instructor or 22:27 a mentor to give you some really good hands-on instruction, use your peers for 22:33 some good feedback, and of course always look for live education to help with 22:41 your manual therapy techniques. I know these videos make education very 22:45 convenient, but there is no substitute for learning manual therapy in a live 22:51 setting. I look forward to talking to you guys again soon.
