0:04 This is Brent of the Brookbush Institute, and in this video we're bringing 0:07 you another manual technique. Now if you're watching this video I'm assuming 0:09 you're watching it for educational purposes, and that you are a licensed 0:13 manual therapist following the laws regarding scope of practice in your 0:17 state or region. That means athletic trainers, chiropractors, physical 0:20 therapists, osteopaths, licensed massage therapists you are likely in the clear 0:25 to do these techniques. Personal trainers this probably does not fall within your 0:30 scope of practice, although you might be able to use the palpation portion of 0:33 this video to aid in learning your functional anatomy in an educational 0:38 setting, supervised by a licensed manual therapist. Now before we place our hands 0:43 on a patient or client it is important that we assess and have a good rationale 0:48 for doing so, and of course if we're going to assess then we should be 0:53 reassessing to ensure that the manual technique we're using is effective, and 0:57 we have a good rationale for continuing to use that technique. In this video were 1:01 going to go over static manual release of the erector spinae muscle. I'm going 1:04 to have my friend Melissa come out, she's going to help me demonstrate. We're going 1:06 to use the same palpate and compress technique we've been using for all of 1:10 our static manual release videos, using that that four-step process of 1:14 differentiating, knowing where our common trigger points are, knowing what not to 1:18 press on, and of course getting our patient inclined in good position and us 1:21 in good position so that we have good technique. Starting with a 1:25 differentiation of tissues your erector spinae are fairly superficial, and 1:30 providing we're not talking about trying to differentiate the various erector 1:34 spinae muscles, they're actually not that hard to palpate. The three muscles 1:40 combined create a column of tissue on either side of the spine. I think you 1:47 guys instinctually knew this right. this this valley is created by the skin and 1:51 underlying fascia being tacked down to the spinous process, and then the 1:56 thoracolumbar fascia and fascia along the spine here, all the way 2:02 into like our cervical thoracic fascia create these columns wrapping around the 2:08 erector spinae muscles that create hills on either side for our palpation. The 2:15 only thing we have to consider outside of knowing where these hills are, is what 2:20 direction of a diagonal these fibers go in, because we're going to want to go 2:25 back to that stroke perpendicularly to find the densest fascicles, and then go 2:31 parallel along the dense fiber to find the nodule hyperactive point, 2:37 trigger point. Alright so here's how the diagonals work. most of the erector 2:43 spinae, in fact all of the erector spinae have a diagonal that goes from lumbar 2:49 spine essentially to shoulder. If you think in that direction from inferior 2:55 medial to superior lateral, and then you just drew parallel lines in your head, 3:00 that's the direction of the erector spinae. The only muscles that are a 3:05 little different being erectors of the spine that can 3:08 also develop trigger points is our multifidi, our trigger points for our 3:14 multifidi are usually in our lumbar spine here is what we're talking about, and 3:18 they go in the other direction. They go from inferior lateral to superior medial. 3:25 If I'm going to palpate tissues that run this way again so we're back to a erector 3:33 spinae, I'm going to set up my hips so they're even with Melissa's hips and 3:38 then my hands are going to be going in the direction of Melissa's head, and that 3:44 would be my perpendicular stroke. So that's not too bad. When I do my erector 3:49 spinae I'm facing this way, and then I can just survey the length of my erector 3:59 spinae. I'm just kind of picking up my hand, 4:01 strumming over the tissues. Now it helps to know where your trigger points are. 4:05 Your two common trigger points that we're usually releasing in the erector 4:10 spinae are right in the middle of the lumbar spine, like in line with somewhere 4:15 between l2 and l4, and then just above the thoracolumbar junction there tends 4:20 to be another trigger point. So if I know that I might go right to those points 4:26 first just to see if I can narrow this this search down a little 4:33 bit, and when I find really dense fascicles again, I'm then going to go in 4:38 line with a fiber, search the whole fiber here for a nodule and acute point of 4:48 density and acute point of overactivity, And then you guys can use one of your 4:52 various comfortable hand grips either thumb over thumb just again leaning in, 4:57 you can use the technique I like to use as you guys know which is kind of 5:03 having that dummy thumb underneath, or putting my pisiform hamate over my thumb, 5:07 or putting my thumb in my thenar groove here. So in this case what I'm 5:13 going to do is pisiform hamate, and I'm just going to hold 30 seconds to two minutes 5:21 to kind of pin down the tissue. Notice I am I'm not pushing straight 5:27 down, I'm kind of pushing this way, that does help to keep me from playing that 5:31 game of like put your finger on top of a marble just and it just like keeps 5:35 shooting out this way. I tend to not only push down but push a little bit so 5:41 that I'm kind of like bowing this tissue this way, which holds that trigger point 5:46 underneath my thumb. Now if I want to switch around and do the multifidus, 5:54 maybe I have done all of my erector spinae, 5:57 I'm then going to put my hips level with Melissa's shoulders, and I'm now facing 6:02 her opposite hip. I can then go through, and guys these are going to be 6:07 lumbar spine right, otherwise as we get up in the thoracic spine the multifidus 6:12 are not well developed in the thoracic spine, and of course when we we do the neck that's a 6:17 whole different set of techniques which we talked about in different video. So if 6:20 we're doing multifidus it is going to be lumbar spine. We're going to go this way, 6:26 this direction, a little closer to our spinous process until we find an acute 6:35 point of overactivity or density. It does help to kind of bring the pants down a 6:40 little bit, so that you don't have to feel through another 6:43 layer of clothing right. You already have the skin to feel through, you already 6:47 have some adipose tissue fascia, there's a lot going on back here that we 6:52 got to feel through to just feel these small increases in tissue density. And in 6:57 fact, the common trigger point here is actually somewhere between, in that 7:03 little divot between our PSIS and then the spinous process of l4 l5. Like right 7:11 in here there's like a very common trigger point, all right so if I push in 7:18 there, how does that feel Melissa? Yeah a little a little tender. This is 7:24 definitely a common trigger point. As far as is there anything in this area that 7:34 maybe we shouldn't put our hands on, well no if providing that we're staying close 7:40 to the vertebral column, our transverse processes for the most part protect us 7:46 from being able to do damage to things that would be deeper and more sensitive. 7:49 It would be pretty hard for example for me to push down so hard that I damaged a 7:56 nerve or damaged an internal organ. Like you'd have to be way out here to 8:02 get to some of your internal organs, and I know people worry about that, but the 8:06 transverse processes protect us pretty well. Of course if somebody was or had 8:10 acute lumbar pathology like a nerve root adhesion that was kind of new. Or they 8:15 were experiencing some pretty significant sciatic symptoms, or you had 8:19 like a lumbar herniation, obviously be careful. Don't go in and push 8:26 down as hard as you possibly can. It's not so much that this is one of those 8:32 things that you need to watch where you put your hands, but maybe how you put 8:36 your hands. If I knew somebody was very sensitive to posterior to anterior 8:40 pressure I might even bring the table up a little 8:44 higher, so that I can get a little bit more of a horizontal pressure 8:55 so that I'm not getting so much of this. We can still pin tissues pretty good by 9:02 pushing them towards the spinous process. how does that feel Melissa? It's still very tender, of 9:09 course she has no lumbar pathology that we need to worry about, but you guys can 9:13 kind of imagine how this would be helpful. Back to client position, 9:19 notice when I wanted a more horizontal direction I raised the table, when I want 9:26 a more vertical direction of course I'm going to lower the table. What you don't 9:30 want to do and this is just if you think about it some common sense, you don't 9:35 want a high table and trying to be pushing down, 9:37 we don't want arms like this. We want arms straight. We want to use our fingers 9:43 maybe to palpate just because we need that sensitivity, but then when we 9:48 palpated the tissue that we need and we're just applying pressure, we 9:52 really want to apply pressure not with hand strength and arm strength, but just 9:56 by weaning our body and using body weight. I'm actually not using any 10:02 strength at all here. My elbows are just shy of lock, my arms are nice and 10:07 straight, and I push down, I can tell you guys this is where having mirrors in 10:14 your office comes in handy. I know not everybody has that, but if you have 10:19 mirrors in your office check your own posture every once in a while. I know we 10:22 put mirrors and offices for assessments of our patients, but I think sometimes we 10:26 need as much assessment on our technique and posture while we work. Alright so 10:33 just a real quick recap guys, common trigger points just above the 10:38 thoracolumbar junction right in the middle of the lumbar spine, and then in 10:43 that little soft area between the PSIS and spinous process of l4 l5 usually a 10:50 multifidus trigger point, Eerector spinae perpendicular strokes are this way, 10:55 because those fibers run this way multifidus run this way, so we set up 11:02 this way. Stay tuned for a close-up recap. You guys 11:06 can see the trigger points I've marked out, here are the most common trigger 11:09 points in the erector spinae and the multifidus. One just above the 11:13 thoracolumbar junction the other right in the middle of the lumbar spine, and 11:17 then of course that multifidus trigger point often occurs right between the 11:21 PSIS and the spinous process of l4 l5 and that soft tissue divot there. Now if 11:28 we're going to palpate and release the erector spinae, because they had a 11:33 inferior medial to superior lateral diagonal, I want to line my hips up with 11:39 Melissa's hips, and then my hands are kind of going in the direction towards 11:44 her opposite shoulder. I'm going to do my perpendicular strokes, strumming these 11:53 fibers just like guitar strings, looking for the densest or tensest guitar 11:58 strings. Once I find the densest tissues, I then go along the length of that 12:05 tissue to see if there's any sort of nodule or acute point of hyperactivity, a 12:10 trigger point, once I find that point then I can go -the palpating thumb 12:16 becomes my dummy thumb, and I can just place either my thenar groove 12:21 over that thumb, or my pisiform hamate over that thumb. Straighten out my arms, 12:26 lean in, apply pressure for thirty seconds to two minutes. Once I get a 12:32 release there, then maybe I keep palpating, keep strumming all these 12:36 fibers looking for any other shorter points. You have to remember that your 12:40 erector spinae is made up of tons of fascicles 12:44 right that all run in parallel this way. So it is possible to have multiple 12:49 trigger points in multiple different levels these are simply the most common 12:53 trigger points. Now for the multifidus remember that instead of going this way, 12:58 since the multifidus go superior medial to inferior lateral, I have to go this way, 13:05 that I have to turn myself around, so now my hips are in line with Melissa's 13:11 shoulders, my hands going towards her opposite 13:15 hip, and it's a little different palpation, it's a little different feel than these 13:21 big erector spinae muscles. The multifidus are usually a little flatter. But 13:27 you're going to look for the densest fascicles. Once you find them, once again we'll go along that 13:34 fascicle to find any tender nodule, and then once I find it, I can either do my 13:41 thumb over thumb, pisiform hamate over thumb, or a my I can even do thenar 13:49 groove over thumb like this, holding for 30 seconds to two minutes, until I get a 13:54 release. So there you have it, knowing your functional Anatomy will definitely 13:58 help your manual technique. It'll help you differentiate structures so that you 14:01 can place your hands where they need to be, as well as make you aware of these 14:05 sensitive structures around the tissue that you're trying to target. Things like 14:09 nerves and lymph nodes, and arteries. Make sure that if you're going to place your 14:13 hands on a patient that you have done an assessment and have a good rationale for 14:17 placing your hands on that patient, and if you're going to assess make sure you 14:21 reassess to ensure that your technique was effective, and you have a good 14:25 rationale for using that technique again. Now with manual therapy, one on one live 14:31 education is incredibly important, please be looking for opportunities like 14:36 workshops and mentorships, and maybe even classes at your local university, that 14:42 can get you some one-on-one individual instruction or at least some live 14:47 classroom instruction, so you've had a chance to be critiqued and mentored by 14:54 somebody senior to you with some experience in manual therapy techniques. 14:58 And before you bring this stuff back to your rehab, fitness or performance 15:04 setting, please practice on colleagues. There is no substitute for practice and 15:11 it is going to take a while to get accustomed to some of the techniques 15:16 that we show in these manual technique videos, don't expect to learn them in two 15:20 or three, or even five minutes. You want to have hours of experience under your 15:26 belt, working on various different body sizes and shapes, so 15:30 that when you do get that first paying client, first paying customer then you're 15:34 really trying to make a good positive impact, really trying to promote better 15:40 outcomes, you feel comfortable with that technique. I look forward to hearing 15:45 about your outcomes and hearing your questions in the comments section of 15:49 this video. I'll talk with you soon. 15:59
