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