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 0:18 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 assessmen,t 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. This video we're going to go over the 1:13 cervical thoracic junction manipulation or upper thoracic manipulation, that area 1:17 between C6 and we'll say T4. I'm going to have my friend a Yvette come out, she's 1:22 going to help me demonstrate. Now keep in mind if you're doing manipulation 1:25 techniques you're doing them to increase mobility, not just based on subjective 1:28 symptoms but also based on objective signs. So in this case I would probably 1:33 use something like cervical lateral flexion. Cervical lateral flexion 1:38 goniometry is reliable although some of our other cervical goniometery 1:43 assessments are not so reliable, and then i might try to find a thoracic rotation 1:47 test that works well for reassessment. The last thing i would rely on is 1:52 palpation, now i generally do two types of palpation with this particular area. 1:58 I'll do my P-A's like I do when I'm doing mobilizations, and then I'll do this 2:03 rotation palpation that I learned from the 2:08 the Maitland workshops. So the P-A's here, you're going to go thumb over 2:14 thumb or you can go your pisiform hamate grip, whichever you find more comfortable. 2:19 Generally I find that I'm in this position when I'm working with neck and 2:24 and upper back patients like this. So to go thumb over thumb is a little bit more 2:30 convenient, and I'm just going to press all the way down to arthrokinematic 2:34 end range and feel how these segments feel compared to one another, 2:39 and compared to that internal model that I've built up over time with experience 2:47 pressing on a lot of necks and upper-thoracic spines. I'm going to try to give 2:52 myself a little bit of an indication of how stiff this area feels. Of course we 2:59 could add another layer of this and go, hey Yvette how does that feel? Okay so 3:06 that feels fine, that feels fine. We might get a little additional information like 3:11 what if one of these segments is not only stiff it's actually part of the 3:16 dysfunction that's causing her symptoms or complaints, and I can kind of go on 3:21 through and do these P-A's. Now what I'm feeling with a Yvette is she definitely 3:26 feels pretty good in her cervical spine as as far as motion goes, but then as I 3:31 start moving down C6-C7, C7-T1 and then like C7 to T3, it's like really 3:39 stif, it's actually really hard to get arthrokinematic motion. I don't think 3:42 that's normal, I think that's an abnormal level of 3:46 stiffness that maybe indicates I should do this manipulation technique. Now 3:51 before I do this manipulation technique I've found that this rotation assessment 3:55 that I learn from these workshops works really good and helping me determine 3:59 which direction I should go, and all I'm going to do is I'm going to take my thumbs 4:04 like so and put them each on a spinous process and rotate the spinous process 4:10 in the opposite direction. So we'll go this way and then this way 4:16 right. So I went this way and then this way. I rotated the upper segment 4:21 to her right and then to her left, and then the same thing going on down, and 4:31 what you'll start to notice a lot of times is people get stiff in one 4:36 direction. So in a Yvette's case she actually moves better rotating to her 4:43 left. Now I cannot explain what I'm about to tell you biomechanically, but it 4:50 seems that this manipulation works better if rather than going into the 4:55 resistance trying to manipulate to get more range of motion or decreased 5:01 stiffness in the direction you're feeling in, it actually works better to 5:04 go with the motion they already have. We could make an excuse and say well 5:12 technically speaking if we're rotating in either direction the facets on 5:17 both sides have to move. So at the very least we know if we get a good 5:22 manipulation, everything's moving regardless. I really can't explain to you 5:27 though why moving with the direction they already have motion tends 5:32 to work better than moving them into the direction they have stiffness like every 5:36 other manipulation. Experiment with this yourself, I think you will find the 5:40 same thing. One thing about this technique is it's better to be right the 5:44 first time because this is one of those techniques that if somebody is a little 5:47 irritable, somebody is a little inflamed, flared up, you keep reaching back and 5:54 trying to do the technique over and over again and you'll flare them up more. This 5:58 is one of those techniques that you might get one, two, maybe three attempts 6:03 at the most before you need to back off for the day and wait for them to come 6:09 back in. So in Yvette's case I'm going go ahead and I'm going to rotate her this way, 6:15 she moves better in this direction and like I said that tends to work better 6:19 for this manipulation. Now I said she's stiff in all these 6:24 segments going down here. There's two ways to block segments, and there's an 6:31 easy way to set up the joint actions that we 6:34 need to lock up the upper part of her cervical spine or the upper part of her 6:38 thoracic spine as well. So what we're going to do is we can either use that 6:42 thumb on a specific segment, or we can use our thenar eminence to block off 6:47 several segments. This obviously is probably a little less specific and a 6:54 little bit more aggressive. In Yvette's case I'd probably start here, being that 7:00 she's not somebody who's accustomed to getting a lot of manipulations, she 7:03 hasn't come in to see me before I probably want to start off a little bit 7:07 more gentle and see how she responds. Now in order to get her all locked up I want 7:15 to rotate her this way, side bend her towards me, so it's still that 7:20 contralateral rotation, it's still the ipsilateral flexion and we're still 7:27 needing a little bit of extension to get in the lock position just like we did 7:30 with the cervical spine. The nice thing about this particular technique is if 7:35 you just lift their head out of the head cradle and then rock their head 7:41 on their chin just by turning their head, they do it automatically. So you 7:47 can see if I just push her out of the head cradle, I'm there. Now I can 7:51 tell in this case Yvette's guarding on me a little bit. One other thing I should 7:57 probably bring up, that this table does naturally but some of you don't 8:01 have tables with these arm thingies, is their arms need to be up, and the reason 8:08 why is you want to take slack out of these muscles. If I was to try to rotate 8:13 her this way with this arm down you can see I'm adding a lot of tension into her 8:18 upper trap, and that's not going to be helpful for getting a manipulation, so 8:22 you can bring both arms up. If we didn't have these arms cut out she could 8:25 actually put her hands underneath her forehead like this, and we could just 8:29 turn her forehead on her hands, it would still work the same way. All right so you 8:34 can put your arms down, we're going to try not to guard. In the case of 8:39 Yvette, if she is guarding and I feel like I keep getting pushed out of her spinous 8:43 process and I can't hold it down with just my thumb, I might go back to my 8:47 thenar eminence like this. So now I can really make sure 8:50 I stabilize, I just have to try to be a little bit more careful to line up the 8:56 end of my thenar eminence with whatever segment I'm trying to lock out from the 9:02 bottom down. So in this case I want her about there, I can then bring 9:07 her this way. You okay, no pain? Just relax, nice deep breath, try to just 9:13 pretend like you're laying on your pillow on your belly. All right so I do 9:18 find that that cue helps as I try to get them into like thinking about 9:21 relaxing on a pillow. Okay now all we're going to do for the manipulation is 9:27 add a little pressure this way. So I'm moving this hand this way to 9:31 block out whether it's my thumb or my thenar eminence, and then I'm going to go 9:36 this way with this hand because if I do that, I automatically push her into 9:40 lateral flexion and rotation. So it ends up being a very easy for technique for 9:44 us as long as you spend plenty of time getting your setup right, you make sure 9:49 you get a really good lock out, get a nice deep breath, you okay? Deep 9:55 breath, breathe out, and that's it. We actually got a pretty good cavitation on 10:02 that one, I know Yvette felt it. You're seeing these manipulations 10:07 done on somebody who does not get manipulations done. So I think 10:11 that is important, that's a lot more realistic than some of the videos I see 10:15 out there with people doing manipulations on people who get 10:18 manipulations all the time. You do have to be careful, you do have to set 10:21 somebody up well, you do have to help them with their expectations and be like 10:25 hey this is this is not a big deal it's going to be over really quick, and you know 10:30 take a nice deep breath and before you know it, click and then you just let them 10:34 go, and a lot of times after I do manipulations like this I'll actually 10:38 have somebody sit up take a second before I go ahead and do my next 10:42 technique, so they don't feel like they're getting rapid-fire 10:46 high-intensity manipulation one over the other. 10:49 So I'm going to show you from this side, if I was going to manipulate 10:53 her other side I would just block this way, I would put her head on this side 10:58 and Yvette I'm not going to manipulate you this way okay. So I would go 11:02 ahead and put either her chin up on the table or maybe like in this case on this 11:06 head cradle, her maxilla is actually resting at the end of that headrest, and 11:12 then I'd get her right here and then I make sure I'm locked. If I need to change 11:17 her head position I can, and I want to make sure everything's right. Again 11:23 I have said this in every one of our manipulation videos, setup is 90% of this. 11:30 If you get somebody locked up right, if you've done your assessment and you're 11:36 on the right segment, the manipulation, the high velocity thrust is like the 11:41 icing on the cake. In fact I think you will find that if you really get 11:45 good at the locked position, you'll get people to like move, manipulate, cavitate 11:51 before you even get the thrust to happened a fair percentage of the time. 11:55 It's kind of interesting, like you'll just be like okay and you'll get them 11:58 here, and they'll be click, click, and you're like oh okay I didn't even need to do the thrust. 12:03 So again I could do my little rotation stuff, find the segment in this 12:10 case I'm going to go with the easier motion, block out that bottom segment, 12:14 make sure that I apply a little pressure this way and then I'm going to rotate 12:20 the head this way which is going to push her into rotation a lateral flexion, 12:24 while I block out this way. Last thing, and I don't want to 12:31 come across the sounding arrogant on this but I think it's something that 12:34 needs to be said for whatever reason because I own this education company and 12:39 I'm available online, and I get a lot of individuals who come and find me after 12:44 other practitioners didn't work for them, and I would say nine times out of ten 12:50 I'm able to help somebody because something was missed. That shouldn't 12:55 happen, I think this is one of those things that is very often missed. I can't 13:01 tell you how many cervical spine patients I've had that were manipulated up here in their cervical spine, 13:11 nobody ever looked at their CT Junction and they were never given any sort of 13:16 like activation or stabilization exercise. With these type of patients a 13:21 lot of times I can come in and I manipulate their cervical thoracic junction using 13:26 this technique. I give them some deep cervical flexor activation, maybe some 13:30 serratus anterior activation, maybe we'll work on some other stuff for scapular 13:34 mechanics, all that stuff that gets left behind because their last 13:38 practitioner only looked at their cervical spine and sure enough within a 13:43 couple sessions they're on a home exercise program and they're good to 13:46 self-manage. Keep this technique, although it's a little difficult, 13:51 although it does have a little higher tendency to flare people up than some of 13:55 the other techniques I've shown you. Get good at it, because like I said 13:59 it will make you a lot of money and it's making me more money than it should. Stay 14:04 tuned for the close-up recap. All right for the close-up recap remember 14:08 we're going to start with our subjective assessment and objective assessments, and 14:12 of course the last assessment we're going to do is our palpation to try to 14:16 give us an indication of where and which way we should manipulate, and what you're 14:21 seeing me do here is that thumb to thumb on spinous process P-A, and I'm just going 14:28 all the way to the end of arthrokinematic range, trying to feel the 14:34 relative stiffness joint to joint and then of course my own internal model 14:40 of stiffness at these joints based on my experience. To add another layer we could 14:46 of course ask Yvette hey how does this feel? Sometimes what you'll get is the 14:53 patient will complain about pain when you press on a particular segment which 14:57 might help us get a little bit more dialed in with our manipulation 15:01 techniques or soft tissue techniques. Then the other thing I'm going to do of 15:05 course is that rotation, all right so you can see I'm on either side of spinous 15:09 process and then I'm just zip zip, alright and then I'm going to 15:13 switch my thumbs so that I rotate the other way. You 15:16 see how that works, I think with a little bit of practice you will 15:20 get pretty good at going all the way down the spine and starting to determine 15:24 the direction here, and then we found that she 15:28 moves, she gets stiffer as she goes down here so we might want to block like so, 15:36 or we can block with a thumb like so on that spinous process just below the 15:41 segment that we think is stuck, and then we're moving with the direction that she 15:46 moved better. I know that's very odd and doesn't make a lot of sense but it does 15:51 tend to work better based on assessment and outcomes, and then of course we're 15:56 going to turn her head off the face hole here, or the face cut out of 16:03 on this table which is immediately going to put us into extension, rotation and 16:08 lateral flexion, and I'll spend a couple extra seconds trying to get a good 16:12 lockout position, maybe a little bit more extension, maybe try a little bit more 16:15 flexion, maybe try position a different part of her face, see if that helps. Try 16:22 my thumb try my thenar eminence see which one gets the better lock. You do 16:28 want to be quick in the sense that nobody likes to be in lockout position 16:34 for long, but don't be in a hurry. Everything is set up 90-percent of this 16:38 is finding that lockout position, and then once you find it all you have to do 16:45 is one quick thrust and be done with it. So it's all set up, the thrust 16:51 is just the icing on the top of the cake. If you have any questions on this 16:55 whatsoever please feel free to leave them in the comments box below. A couple 16:59 of points to recap, knowing your anatomy and knowing your biomechanics will 17:03 certainly help you choose the right technique for the right patient. If 17:07 you're unsure whether manipulations are appropriate due to their higher 17:11 intensity it's okay to do mobilizations, most research points to manipulations 17:17 being slightly more effective but mobilizations being very effective, and 17:21 of course we have those videos for you if you want to start with those less 17:25 intense techniques. Make sure that if you are doing any technique that is based on 17:30 assessment, and of course that you're reassessing, ensuring that the technique 17:34 is effective for the patient that you're working on, and when it comes to all 17:38 techniques manipulations maybe more than any other look, for opportunities to 17:43 get live education. Although I know videos are convenient and I'm happy to 17:49 have these up for you to watch, it would be so much more helpful to use 17:54 those videos as a recap of one-on-one attention with somebody who's 18:00 experienced with manipulation techniques. At the very least grab a colleague, grab 18:07 a friend and start practicing these before you bring them into clinic and 18:11 start using them on patients and clients. I hope you enjoyed this video, if you 18:16 have any questions please leave them in the comments box below.
