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 do posterior to anterior tibia on femur, or rather let's do 0:51 anterior to posterior femur on tibia mobilization since they're the same 0:54 relative arthrokinematic motion, but the latter allows us to get in good 1:00 body position making it easy for us to perform the technique. I'm going to have 1:04 my friend Melissa come out, she's going to help me demonstrate this technique. 1:07 Now if I'm doing this technique on Melissa I've already done some sort of 1:10 passory excessive motion exam on her knee, and I've assessed her as having artho- 1:15 kinematic stiffness right. We don't want to be using mobilizations on 1:20 hypermobile joints, that's not going to make anybody feel better. The other joint 1:24 action we need to check for because of the way this technique is set up, is if 1:28 Melissa had beyond normal extension of the knee that's beyond five degrees of 1:34 hyperextension, I also wouldn't use this technique because of the way I'm pushing 1:38 down this way, I could end up making hyperextension, 1:42 hypermobility worse, which is also not going to make anybody feel any better. 1:47 Now traditionally this technique is used to increase extension of the knee so 1:54 somebody who lacks full range of extension, and this is all based on 1:59 concave on convex rules that's glide same as roll. However I think research is 2:06 kind of pointed to the fact that those rules are not completely reliable when 2:10 it comes to the knee. Now what does that mean, it probably means that mobilization 2:14 in the either direction could potentially be effective for 2:18 either extension or flexion, which I know creates some grey area but here's what 2:24 you're going to do. This is the technique I fall back on most often because I find 2:29 it most effective, most often. But if you wanted to try mobilization in the other 2:35 direction the only thing I would ask is that you assess, do your intervention, and 2:40 reassess; and then if you're going to try the other technique, do that and reassess 2:46 again. You want to try to determine which technique, which direction of glide is 2:50 most effective, write that down and continue to use that with your patient 2:54 or client. Now I'm going to have Melissa go ahead and put her leg down so that 2:58 you guys can see what I'm doing to Melissa's knee here, what my hand position 3:03 is, what I'm palpating, and how I set this up. So we wanted to do a posterior to 3:09 anterior glide on the tibia, or the tibia on the femur, and rather we turned it 3:15 around. So we're going to do anterior to posterior on the femur so that we can 3:18 push, because pushing is a lot easier than pulling. I don't want to manhandle 3:23 and wear my hands out, or wear my body out trying to do this mobilization. In 3:27 order to get myself a little space anterior to posterior I had to elevate 3:33 Melissa's leg just a little bit, so that's where this half foam roll comes 3:36 in, and guys I find half foam rolls to be the best thing for this technique; and 3:41 notice this isn't one of those super hard like premium foam rolls, this is 3:45 kind of a soft dish foam roll. So it's firm, but not so firm that it's 3:52 mean on Melissa's calf. Alright you could use a pillow, like one of these round pillows 3:58 that's under Melissa's head, just realize that if you use one of those round 4:01 pillows you're going to have to push all the way through the pillow softness, 4:05 before you're going to be palpating any sort of arthrokinematic motion. Now like 4:12 all of our techniques for mobilizations and soft tissue techniques and sometimes 4:18 even exercise, the more Anatomy you know the better. With the knee maybe you want 4:24 to start by finding the patella, the kneecaps kind of easy to find. 4:28 So I can start outlining the borders of her patella, I can find her patellar 4:33 tendon or patellar ligament depending on what you want to particularly call it. 4:37 I'll find her tibial tuberosity right here, I can find the top of her patella 4:43 and then maybe I want to let my hand sink down medial and lateral, so that I 4:49 can feel through her soft tissue and find those femoral condyles, which should 4:54 feel like roundish bumps kind of on the superior half of where her patella was 5:01 right -so the end of the femur. If I go lower than that I should be able to feel 5:06 the tibia which is going to feel a little bit more ridgey, alright so your 5:10 femoral condyles are nice and round, your tibia kind of comes up and then hits a 5:14 plateau. Now if you visualize that you should be able to come to the end of 5:19 those round bumps and the end of all those ridges, and find a depression 5:26 that's a line, that's the joint line, this is going to be an important part of this 5:32 technique, the thing that we really want to try to to palpate. So see if you can 5:37 feel through that soft tissue in here nicely, don't jab your fingers into your 5:43 your partner's clients or patients knee, that's not going to feel good, but gently 5:48 kind of try to find that joint line. If you want you could have your patient 5:51 like flex their knee a little bit and then straighten it, flex it and straighten it, 5:55 flex it and straighten it, so that you can kind of find where that joint line 5:57 is, there we go got it. Alright once I found her joint line I'm just going to 6:02 set my hands down around her patella, because the last thing I want to do is 6:06 this, if you guys know Clark's sign or Clark's test, or the patellar compression 6:10 test, if you've ever done it, it just kind of hurts everybody, it's not a real great 6:15 test. It's supposed to be a test for knee pain, but you push down on somebody's 6:19 patella to have them extended it just freaking hurts so don't do that. Instead 6:23 take your web spaces and just kind of put it around the patella, put your index 6:27 fingers and your thumbs down over the joint line. Now you're going to apply 6:32 pressure using the arm that's over the femur with the palm of your hand, and you 6:40 really want to use a lot of the surface of your hand. I've 6:44 explained this in some of your other in in some of our other videos you don't 6:47 want to use fingertips to do mobilizations if you don't have to, 6:50 because they're going to feel really pointy and even your webspace with it's 6:56 very narrow surface area, can feel like a chisel into somebody's knee, it just 7:02 doesn't feel good. Alright so hands down right around the 7:07 patella just like so, we're going to put index fingers on the joint line, thumbs on 7:11 the joint line, and I'm getting ready to push down here. Now is where we start 7:18 thinking about okay do I have any contraindications to think about. Well 7:23 obviously if I started pressing in, if I started in like this and Melissa 7:28 immediately starts complaining of pain, that would be a bad thing. We might want 7:33 to back off and find another technique, and of course if you have somebody who's 7:37 come in after acute knee injury you got to start thinking about did they 7:41 potentially tear any of the ligaments of the knee, even like just mild mild tears 7:48 can cause a pretty significant amount of pain, and maybe you have to go back and 7:52 do your special tests. Of course you could press down and impinge on 7:57 nerves or impinge on some trigger points, generally those are easy to get around 8:01 by just moving your hands a tiny bit. Remember trigger points aren't generally 8:08 very large things and nerves are definitely not very large things right, 8:14 they're very narrow, we're talking like millimeters. So usually you can just kind 8:17 of reposition your hands and somebody like ahh, 8:20 and I'm like well what happened, you're like right above my knee it hurt, okay 8:25 let me let me move my hand around a little bit. 8:28 Notice that the table is low enough so that I can get my chest over this 8:35 technique, because once again I don't want to muscle this technique. Melissa 8:38 has super strong legs and the knee is a nice big joint, so I want to be able to 8:44 use my upper body mass to create the force, and now I'm just going to go back 8:50 to whatever protocol it is that I use. Now I've mentioned in other videos I 8:54 happen to be in certified orthopedic manual 8:57 therapists through through Maitland, so I use the 50% grade three and four right. 9:04 So grade three's would be larger amplitude at fifty percent, grade four 9:09 would be smaller amplitude at fifty percent -now that's fifty percent between 9:12 first resistance barrier and end of arthrokinematic range, and you're going 9:16 to keep oscillating at one to two oscillations per second until you feel a 9:20 decrease in joint stiffness. Now if you use another protocol that's fine, I think 9:26 there's a lot of protocols out there, the thing they all have in common is finding 9:32 first resistance barrier, so that's first resistance barrier for Melissa, and I'm 9:36 palpating the joint line right now. So I should be able to really easily find 9:40 where the end of arthokinematic range is, that is no matter how much 9:45 harder I push right now, I'm not getting any more motion in glide, that's femur on 9:52 tibia glide, no matter how much harder I push I'm not getting any more motion. So 9:57 I know where the beginning is, I know where the end is. Most protocols have you 10:02 mobilized somewhere in between whatever protocol you use, just make sure you go 10:09 through with it. Alright make sure you do it from 10:11 beginning to end, that you don't half-ass it per se right, that you actually do the 10:18 protocol, give the technique a fair chance, so that when you go to reassess 10:24 you know whether it was an effective technique, and it wasn't just bad form on 10:30 your part that didn't get you the result that you were looking for. How does that 10:35 feel? A little weird, it does feel a little weird to be pushed pushed into 10:41 this direction right, like this is this is end range knee extension. Melissa does 10:47 have a little bit of stiffness here though, so I'm going to see how it makes 10:51 you feel upon reassessment. I'm thinking she'll feel a little bit better. Alright 10:57 guys so I want to set that up for you one more time before we go to the close 11:00 up recap. Notice that the table is low enough that when I palpate her knee I 11:05 have to lean over just a little bit, that its 11:08 purposeful so that I can use my upper body mass to create the force, and I'm 11:13 not manhandling and using my upper body strength or the strength of my hand to 11:18 get this mobilization done, that's not going to work. 11:21 I then am going to find her patella, and I'm going to put my hands down around 11:25 her patella, no Clark sign or Clark's test, like it's a bad idea it 11:30 hurt so bad. Alright once I have my hands down around her patella I think 11:36 it's good practice to find the joint line. It's going to make it so much 11:41 easier to find your first resistance barrier and end arthrokinematic 11:46 range. I'm not sure why it's not more common to teach palpation of the joint 11:51 line for this technique when your hands are right here. You're then going to 11:55 apply force through the arm on the femur right, this hand you can use to kind of 12:00 make sure that the tibia doesn't rotate if you'd like, or to stabilize the tibia 12:04 or you know, you could even adjust as you're going the foam roll in case like 12:10 I press down and I press the foam roll right into a gastroc or a soleus trigger 12:15 point, obviously I would move that. This hand essentially though it's just going 12:19 to be there to stabilize, while this one applies the force. I'm going to find my 12:24 first resistance barrier, find the end of arthrokinmatic range, back off to 50%, and 12:30 if I was doing a grade 4 it would be a very small amplitude oscillation, one to 12:38 two oscillations per second, and notice I'm just rocking my upper body, you guys 12:42 don't see me doing this with my arms right, no pumping, not pumping her knee, I'm 12:46 just rocking with my arms putting weight this way right so it's all coming down 12:51 through this arm, with a nice large surface area created by the entirety of 12:58 my palm, not my web space. Stay tuned for the close-up recap. So for a close-up 13:03 recap guys once again it always helps to know your Anatomy. So we have Melissa's 13:08 patella here, and then if I just kind of sink my hands down I can start feeling 13:15 well there's the fibular head right there. If I follow the fibular head this 13:19 nice rounded bony landmark here, I actually 13:24 feel like a little guitar string right here, that's actually her LCL which leads 13:31 right into her joint line which is exactly where I want my thumbs to be. Now 13:36 notice how I've positioned my hands here guys I got both my thumb's over the 13:39 joint line so that I can feel glide, but my hands themselves are around her 13:46 patella; again we don't want to mimic Clark sign and give her patellar pain 13:50 for no reason. Now as soon as I kind of get myself in good position, I got her 13:57 leg nice and stable with my left hand here, with my right hand I'm just going 14:02 to go ahead and apply a little bit of force until I start to feel some glide, 14:07 and then I'm going to keep applying force until I feel the end of arthro- 14:12 kinematic range of motion, I then can back off 50% and I can start doing my 14:18 oscillations. Remember guys to keep your bodyweight over your hands, you're using 14:24 the weight of your upper body mass, your torso to create these oscillations. 14:29 You're not muscling it with your hands, or even trying to muscle it with your 14:34 arms, it should be a nice sway that's applying all this force; and of course 14:40 once I finished my mobilizations I could then go ahead and reassess. So there you 14:44 have it assess, address, reassess. Make sure that 14:47 every time you choose a joint based manual therapy technique it is based on 14:52 an assessment, and that you return to that assessment after you've finished 14:55 the intervention to see if it was effective for the individual, the patient 15:00 or clients that you had in front of you. Ensure that you continue to learn your 15:04 Anatomy because your Anatomy is going to help you with your hand placement, with 15:09 understanding what a joint can do, with understanding what you may gain from 15:15 this particular technique. And of course practice, you have to practice these 15:21 techniques, hopefully not for the first time on a patient or client who just 15:25 walked in the door. If you can, find a more senior instructor or a mentor to 15:30 give you some really good hands-on instruction. Use your peers for some good 15:36 feedback, and of course always look for live education to help with your manual 15:44 therapy techniques. I know these videos make education very convenient, but there 15:49 is no substitute for learning manual therapy in a live setting. I look 15:54 forward to talking to you guys again soon. 16:04
