0:05 This is Brent of the Brookbush Institute, and in this video we're going to go over a joint 0:07 based manual therapy technique. If you're watching this video I'm assuming you're 0:11 watching it for educational purposes, and that you are a licensed professional 0:14 with joint based techniques within your scope. That means osteopath's ,chiropractors, 0:20 physical therapists you're probably all in the clear. Physical therapy assistants, 0:24 athletic trainers, massage therapists, you need to check with your governing body 0:28 in your state or region to see whether this is within your scope of practice. 0:32 Personal trainers this is definitely not within your scope of practice. Of course 0:36 all professions could use this video for purely educational purposes, to help with 0:41 learning biomechanics anatomy and of course palpation. In this video we're 0:47 going to go over lateral hip mobilization, this is a great general 0:50 technique for reducing arthrokinematic stiffness of the hip joint. I'm going to 0:54 have my friend Melissa come out, she's going to help me demonstrate. Now if I'm 0:56 doing a joint mobilization for the hip there might be several indicators that 1:00 led me to believe that a mobilization may be effective, and first and foremost 1:04 we could use something like the overhead squat assessment; because the hip is so 1:08 involved in several of our functional tasks and motions, something like the 1:15 overhead squat is going to give me an indication with signs like knees bow in, 1:18 knees bow out, anterior pelvic tilt, posterior pelvic tilt, maybe an excessive 1:22 forward lean, or an asymmetrical weight shift all could be indicators that somethings 1:26 up with a hip. I could then go to goniometery, something like internal 1:32 and external rotation of the hip. If I have stiffness I may get a reduction in 1:37 rotation, whereas I can almost be guaranteed that if rotation is normal 1:42 hypomobility, arthrokinematic hypomobility is probably not an issue. The 1:49 last thing I personally rely on is passive accessory motion exams in this 1:54 case. I know that is the traditional method for determining whether we need a 1:59 joint mobilization, but with the hip we're dealing with so much soft tissue 2:03 and this is a very strong soft tissue, it makes it much harder to feel normal 2:10 versus abnormal joint play. Now we could go to convex on concave rules and start 2:15 talking about why this mobilization is traditionally 2:18 used, but in reality we're dealing with femoral spin and a lateral distraction- 2:25 our lateral mobilization is actually distraction. So convex on concave 2:30 rules don't apply real well here, although these are generally this 2:35 technique I'm showing you is generally used to increase flexion and internal 2:40 rotation. I've personally found that this is such a general mobilization probably 2:47 most affecting the posterior structures of the hip, which have a propensity 2:51 towards adaptive shortening like our posterior capsule, that I have seen 2:55 increases in external rotation, internal rotation, flexion. I've seen increases in 3:00 adduction range of motion all from doing this one technique. Again with all the 3:06 techniques we do we have to be careful getting too specific with our 3:11 biomechanics and we should always assess, or address and then reassess. So I'm 3:16 going to do whatever assessment I'm going to do -the overhead squat, goniometry, 3:19 I'm going to do my mobilization, and then I'm going to go to 3:22 my reassessment to see if that technique was effective. 3:25 Now Anatomy in this case, you guys can't feel the hip, I'm sorry like you're not 3:33 going to reach in and and palpate the hip joint. You'd have to get through 3:39 a lot of tissue and and that would be problematic and probably painful, so 3:45 let's not do that. A couple things you are going to want to be able to find 3:49 though is you're going to want to be able to find that inguinal line right, so 3:53 you got to find that crease because either the belt which we're going to 3:57 show that technique, or your hands are going to end up there. You probably want 4:01 to be able to find the ASIS right so that anterior superior iliac spine. I'm 4:06 going to show you guys how to kind of palpate joint motion, in the sense that 4:12 if you put your hand down on the ASIS and the greater trochanter, it makes it 4:17 somewhat easy to feel how much joint play you're getting. Other than that 4:23 we're going to find that this technique is more like hug the leg. 4:30 So I'll never forget my one of my clinical 4:34 instructors coming up in school and of course an instructor for the the 4:37 Maitland Institute Rob Flugel, telling me that manual therapy is a full-contact 4:43 sport, and I think the biggest mistake I see with with this particular 4:47 mobilization is people will use the strap and then stand about this far away, 4:52 and start trying to do the mobilization. You're not going to feel anything, you're 4:57 not going to get a real controlled motion that way, and we want to be as 5:02 specific as we possibly can. So I'm going to show with the strap 5:06 first because this is the technique I prefer, and then I'll show it again of 5:11 course using just my hands for those people who the strap is actually 5:14 uncomfortable on them, and or for those who just don't have a strap -for example 5:19 maybe you do home care and you forgot your strap at home that day. Alright so 5:25 I'm going to wrap this around my backside not my low back, alright we 5:32 want to make sure that I'm not putting myself at risk here, and then I'm going 5:37 to clip it around Melissa's side. Melissaf if you could 5:40 scoot a little closer to me that would be great. 5:42 Alright I'm going to have Melissa go ahead and position this strap all the 5:47 way down as far as she can, because we want to be as close to the joint line as 5:51 we possibly can. Now obviously the strap is close to some sensitive tissues, my 6:00 guys know this is the adjust and guard technique. You might have to ask people 6:05 to kind of use a hand to kind of move some stuff over and then they can block 6:10 if they need to, that's especially handy when you personally are using your hands 6:14 on this technique, you know that that way they they feel safe and comfortable and 6:19 trust me if you get any of your sensitive skin underneath this strap or 6:24 somebody's hands doing a lateral mobilization, you will have them talking 6:27 falsetto. We are going to use a fairly large amount of force the hip is a 6:32 fairly large joint. Now what I'll usually do is bring somebody into flexion, and 6:37 then I'm going to go ahead and hug Melissa's leg like this. Alright so you 6:42 guys can see here I kind of like like you were doing a headlock 6:45 around the knee, but I'm going to have her thigh against my chest have her leg 6:53 underneath my arm, and what this allows me to do is I can control not only how 6:58 much flexion but how much rotation as well, and I mentioned in one of the other 7:03 videos we seem to have a bit of research coming out that states that maybe we 7:07 should be doing mobilizations at the end of the range that we're trying to get. So 7:11 if I want more internal rotation maybe I shouldn't be doing it in open packed 7:16 position, but doing this mobilization at the end of their pain-free internal 7:22 rotation. Well I can do all that now right like I have her leg completely 7:27 locked up, I'm good I'm in control here. Now I'm going to apply all the force 7:32 with the strap by just sitting back here in a second, so that gives me an open 7:35 hand. What am I going to do with this hand, well just like I explained in the 7:40 knee mobilization video this is a great chance for you to try to be able to 7:46 palpate joint motion, which is going to make it easier to follow through with 7:50 those protocols that we talked about a couple times where you're trying to get at 7:54 about 50 percent, well 50 percent between initial resistance and end of arthro- 8:00 kinematic range. In this case what I usually do is I'll go thumb on ASIS -or 8:07 maybe I'll turn that around I'll go fingers on ASIS and then thumb on 8:11 greater trochanter, and I think if you guys kind of get them in to end range 8:16 here and this is just first resistance barrier I'm not pushing her too hard, 8:19 remember we want pain free alright first resistance barrier, and then if I sit 8:25 back into the strap I can actually feel the greater trochanter moving into my 8:32 finger while the ASIS stays in place right, so that's all arthrokinematic 8:37 range I'm getting. So now I can kind of pull back on the strap and go oh 8:43 there there it's started moving, and now it's stopped moving and it seems like no 8:49 matter how far I sit back now if I keep pulling her ASIS comes with me. I'm not 8:54 I'm not increasing the distance between greater trochanter 8:58 ASIS anymore. Alright so that that helps me feel beginning of resistance 9:04 and end of arthrokinematic range and now I can back off to 50%, and here's the 9:10 tough part guys, how do i do my oscillations? I don't want to be like 9:17 trying to manhandle her thigh and I have this strap here, but what I see people do 9:21 with the strap is they start like throwing their butt back like they're 9:26 twerking or something, like that that's not going to be good for your 9:30 back don't twerk for mobilizations. It does help if you have a mirror in your 9:36 office to watch yourself. What you want to do is get into a staggered stance and 9:41 you want to try to rock, and you want all of you to rock so as the the the straps 9:48 coming back you also want the knee to come back with you,, otherwise this isn't 9:52 completely a lateral distraction, it would end up being like a lateral 9:56 distraction with anterior rotation and adduction of the femur. We want pure 10:01 lateral distraction. So what I'm doing here is I'm pushing back with my front 10:07 leg onto my back leg right, and I'm just kind of going back and forth between my 10:14 two legs. So this isn't this isn't twerking, this isn't using my upper body. 10:19 You guys can see here like I'm just rocking back and forth and I could do 10:23 this all day, maybe not all day but I could do this 10:26 for quite a long time. I'm just using the strength in my legs in kind of this 10:30 quasi-lunge position or split-stance position to get all of my force. Alright 10:35 So now that I've got this rocking motion down let's go back to where I was, I'm 10:39 going to hug Melissa's leg, first resistance barrier, flexion and internal 10:42 rotation. I'm going to use this hand to feel ASIS and greater trochanter. I'm 10:47 going to sit back, alright so there's my first resistance barrier, there's arthro- 10:54 kinematic end range right there, back off to 50%, and now I can either do 11:00 my grade three or my grade four mobilization, lets do grade three at this 11:03 point. So I'm going to come back to first resistance barrier alright this is my 11:08 larger amplitude oscillation, and I'm going to keep doing that one to two 11:16 oscillations per second until I feel a decrease in joint stiffness. So notice 11:21 guys like I'm very relaxed, I can keep talking to you there's no problem okay 11:27 could do this all day. Now if you happen to use other protocols, you don't use the 11:33 1 to 2 oscillations per second like the the Maitland protocols that I use that's 11:38 okay, just make sure that you are looking for first resistance barrier, you know 11:43 where arthrokinematic end range is, your setup is good and that you follow 11:47 through with your protocols. As I've mentioned in several videos that's the 11:53 the biggest mistake I see, is people kind of start and then like halfway through a 11:58 protocol they just kind of go yeah, and then they move the leg around and they 12:03 go that's good. Right I'm going to assess, I'm going to pay close attention to my 12:08 technique, because I want to make sure that if I didn't get the result I was 12:12 looking for, that it was the wrong technique and I need to pick something 12:16 else, and not just bad form on my part. So let me review this technique one more 12:22 time, and I'm going to show you guys the hand version of this technique. So again 12:28 I took the leg up, wrapped around right I'm kind of hugging the leg with one arm, 12:32 I can get as much internal rotation I need, I could even get some extra 12:36 rotation if you guys thought you wanted that, and I can go into as much flexion 12:41 as I want. I'm going to get myself all straightened out, I'm going to palpate my 12:46 ASIS and my greater trochanter, and I'll show you guys that in the close-up recap, 12:51 and then find my first resistance barrier, my arthrokinematic end range, and 12:57 then I'm just going back and forth between my front and back legs in a 13:03 split stance position. Hand position for this if you don't have a strap, or let's 13:10 say every time I put that strap down Melissa was like that pinches right, and 13:14 we know we have like the obturator nerve in there, we have some cutaneous nerves 13:18 in here, maybe no matter what I do with the strap I keep pinching 13:21 down on that nerve, okay we need to figure something else out. Some people 13:26 just, like it pinches and digs into their skin and the straps not comfortable. So 13:30 Melissa can guard if she wants all right, so we can, go ahead and put your hands 13:34 down over yourself alright, and then I'm going to get my hands down as close 13:39 to that joint line as I possibly can. You guys can't be bashful on this, obviously 13:44 explain to your patient client what you're doing and why you're doing it, and 13:49 make sure that you're coming down from the thigh to get into position so that 13:53 you don't act, you know purposely brush up against anything, but you have to get 13:58 as close to the joint line as you possibly can, if you get up here you're 14:02 going to pull into horizontal abduction, adduction and not get your mobilization. 14:06 But once you're here, notice that my position is not that much different than 14:10 it was before, I'm still hugging the leg, now I don't have this extra hand 14:15 unfortunately, but I'm going to use my legs to pull back to arthro- 14:20 kinematic end range, you know find my first resistance barrier, kind of figure 14:25 out where I'm going, and then once I get there I can do my rock between my legs. 14:34 Notice I'm not hugging, this is the biggest mistake I see on the hands only 14:39 technique, is people just start hugging the thigh, 14:44 we're not hugging the thigh. Alright stay tuned for the close-up recap. 14:50 Alright guys showing you another view, notice that the the strap here is around 14:54 my backside, not my lumbar spine. I don't want to be giving myself a posterior to 14:59 anterior mobilization everytime I try to loosen up somebody's hip. The strap is 15:04 also down on Melissa's inguinal line here as close to her hip joint as I can 15:09 possibly get it. We're then going to take this hand wrap it around the thigh, 15:13 bringing the thigh close to the torso, so essentially we're given the thigh a hug 15:19 here. This allows us to control all of the weight of this limb just by rocking 15:25 back and forth and swaying back and forth, rather than trying to muscle it 15:30 with our arms. I know some of you guys treat individuals a lot 15:32 larger than yourselves, if any of you guys are working with professional 15:35 athletes it's not real easy to muscle a very large leg. So you guys are using 15:43 your body, you got the hugged in position here, you now have a free hand; you can 15:48 use this free hand as a barometer like we were talking about, fingers on the 15:53 ASIS thumb over the greater trochanter, that allows you to feel the greater 16:00 trochanter move into your thumb against the relatively stable ASIS. So as soon as 16:07 I sit back into the strap I can feel the greater trochanter move, even though the 16:12 ASIS is staying totally stable. So as I go into my protocol here I can feel 16:19 first resistance barrier, it's already starting to move a little bit right 16:22 there, and then I can pull all the way in to my arthrokinematic end range, and 16:30 then I can back off to 50% where I'm going to do my oscillations. If you guys 16:35 are using 25% or 75% that's fine, but you can use this hand to kind of guide how 16:44 much you're going to pull into that resistance. Now as I mentioned in the 16:50 other take you want to try to sway between your front leg and your back leg, 16:57 you're not doing rows, you're just front leg back leg, front leg back leg, front 17:06 leg back leg, allowing your whole body and their thigh to essentially move as 17:13 one as you shift your weight between your feet. Now if I was going to do this 17:18 technique at a normal tempo here, again first resistance barrier, 17:24 arthrokinematic end range, back off the 50% and then 1 to 2 oscillations per 17:29 second right about here, and I'm going to keep doing this probably for about 30 17:36 seconds, but essentially until I feel a decrease in arthrokinematic resistance. 17:43 Once I feel a decrease if I really wanted to keep working on internal 17:49 notation I could pull this way, if I was working on hip flexion I could come up a 17:55 little further this way, and then maybe do a second set. Now you don't want to 18:00 push too far before you reassess and see if you've regained normal range of 18:06 motion, but that does give you guys an idea that if you have good control of 18:10 this limb, you can kind of adjust as you go to try to get the most benefit from 18:18 this technique. Now I understand that a strap doesn't always work, like I said 18:22 some people feel pinching when they use a strap and sometimes you just don't 18:26 have a strap handy, so you can use your hands -you do lose your barometer here, 18:32 because what you're going to end up doing is taking this hand, lacing it 18:36 underneath the lower leg dropping that hand right down on the thigh as close to 18:41 the hip joint as you can possibly get, putting this hand over the top and now 18:47 you're using the same technique. Make sure you're trying to get your your 18:50 chest pretty close to vertical with your hands right, making sure that that the 18:56 leg itself is vertical; and once you're all kind of hugged in and that leg is 19:02 right up next to your torso, you're going to do the same front leg back leg, front 19:08 leg back leg, front leg back leg with your body wave. None of this, this will 19:12 wear out your arms. We want to make sure that we use our bodyweight so that we 19:18 can keep mobilizing for as long as we need to do this technique, to feel a 19:24 decrease in arthrokinematic resistance. So there you have it, 19:27 assess, address, reassess. Make sure that everytime you choose a joint based 19:32 manual therapy technique it is based on an assessment, and that you return to 19:36 that assessment after you've finished the intervention to see if it was 19:40 effective, for the individual, the patient or client that you had in front of you. 19:45 Ensure that you continue to learn your Anatomy, because your Anatomy is going to 19:50 help you with your hand placement, with understanding 19:53 what a joint can do, with understanding what you may gain from 19:58 this particular technique; and of course practice, you have to practice these 20:04 techniques. Hopefully not for the first time on a patient or client who just 20:08 walked in the door. If you can, find a more senior instructor or a mentor to 20:13 give you some really good hands-on instruction. Use your peers for some good 20:19 feedback, and of course always look for live education to help with your manual 20:27 therapy techniques. I know these videos make education very convenient, but there 20:32 is no substitute for learning manual therapy in a live setting. I look 20:37 forward to talking to you guys again soon. 20:47
