0:04 This is Brent of the Brookbush Institute, 0:06 in this video we're bringing you another 0:07 manual technique. Now if you're watching 0:09 this video I'm assuming you're watching 0:10 it for educational purposes, and that you 0:12 are a licensed manual therapist 0:14 following the laws regarding scope of 0:16 practice in your state or region. That 0:18 means athletic trainers, chiropractors, 0:20 physical therapists, osteopaths, licensed 0:23 massage therapists, you are likely in the 0:25 clear to do these techniques. Personal 0:28 trainers this probably does not fall 0:29 within your scope of practice, although 0:31 you might be able to use the palpation 0:32 portion of this video to aid in learning 0:35 your functional anatomy in an 0:38 educational setting, supervised by a 0:40 licensed manual therapist. Now before we 0:42 place our hands on a patient or client, 0:44 it is important that we assess and have 0:47 a good rationale for doing so; and of 0:50 course if we're going to assess, then 0:52 we should be reassessing to ensure that 0:54 the manual technique we're using is 0:56 effective and we have a good rationale 0:58 for continuing to use that technique. In 1:00 this video we're going to go over static 1:02 manual release of the levator scapulae. 1:03 I'm going to have my friend Melissa come 1:04 out, she's going to help me demonstrate. 1:05 Now our manual release techniques 1:08 generally follow a very similar protocol 1:11 of differentiate between the target 1:15 tissue and other proximal structures, be 1:17 aware of any tissues that we do not want 1:20 to press on, those are sensitive 1:21 structures that could be insulted by 1:24 compression. We get some bonus points for 1:26 knowing where our trigger point trigger 1:28 points are, or our common trigger point 1:30 sites, as that's going to help us 1:32 increase the accuracy of our palpation. 1:34 And last we want to consider our 1:36 position and the patient's position. Now 1:39 Melissa here has her back to you guys so 1:42 that we can see some of the bony 1:43 landmarks that are going to help us 1:44 differentiate the levator scapulae from 1:46 some of the other proximal structures, 1:48 and she has her arm out of her sleeve so 1:51 that you guys can see her scapula. Now 1:54 under most conditions I would not ask 1:56 Melissa to take her arm out of the 1:59 sleeve of her gym shirt, gym clothing is 2:02 generally thin enough that I can palpate 2:04 through it to feel bone, and I can 2:07 perform the technique without any extra 2:09 strain on my hands. So if I put my hand 2:14 right down here guys you can see 2:15 that I come right up against the medial 2:19 border of the scapula. If I follow the 2:22 medial border of the scapula until it 2:24 starts turning around the top right, 2:28 where it started turning around the top 2:30 is the superior angle of the scapula. The 2:34 superior angle of the scapula is the 2:36 insertion of your levator scapulae, and 2:39 that is where we are going to start our 2:40 palpation. Now most of this that you 2:43 guys see is upper trapezius, your upper 2:47 trapezius is the most superficial muscle 2:49 of your posterior and lateral neck. We 2:53 want to palpate through it, and there is 2:55 a little trick to knowing the difference 2:57 between upper trapezius and levator 2:58 scapulae, and that has to do with the, I 3:01 guess direction and organization of the 3:05 muscle fibers themselves. The trapezius 3:08 is a fairly flat muscle whereas the 3:11 levator scapulae is a very ropey bundle 3:14 of muscle. In fact the levator scapula is 3:18 four ropes that twist as they go up the 3:23 neck, each rope attaching to one of the 3:26 transverse processes c1 through c4. You 3:30 can kind of feel the difference in 3:32 texture by simply falling off the 3:35 superior angle of the scapula, and then 3:38 you're going to strum across the length 3:42 of the fibers here until you feel those 3:47 ropey bundles. Alright so I know that 3:51 this is probably trapezius, but if I go a 3:54 little deeper and I do my strumming 3:57 strokes here, I can feel like this isn't 3:58 that right, I can feel those little ropes. 4:01 Now before we go any further let me 4:03 think to myself are there any tissues 4:06 that I could injure if I start pressing 4:10 in this area, the truth of the matter is 4:12 not really. I mean there's always tissues 4:15 we could injure, we press hard enough and 4:17 we're really careless. But for the most 4:20 part if we are posterior the transverse 4:22 processes, most of the sensitive 4:25 structures of the neck are anterior the 4:28 transverse processes. So as long as I 4:30 don't grossly miss this palpation and 4:32 end up here, chances are i'm not going to do 4:35 anything like compress the carotid 4:38 artery or stretch the brachial plexus. As 4:41 long as I stay around here, and even as I 4:43 track up the length of the tissues I 4:45 stay posterior to these transverse 4:47 processes, I'm probably okay. Now then the 4:50 question is is where do we get these 4:52 acute points of hyperactivity? Where did 4:54 we get these acute points of tenderness? 4:56 And I said you get bonus points for 4:57 knowing where your trigger points are. In 4:59 the case of the levator scapulae the 5:00 trigger points tend to be just 5:02 superficial and medial to the superior 5:06 angle of the scapula, or right at the 5:07 insertion and then about halfway up the 5:10 length of the levator scapulae, just 5:13 anterior to the angle of the upper 5:18 trapezius. Actually at this point guys 5:20 the levator scapulae becomes a 5:22 superficial muscle bordered by the 5:25 trapezius here, and then the middle 5:28 scalene in front of it. But going back to 5:32 where we were with our palpation if I do 5:35 my strumming strokes across those 5:37 bundles, find the densest bundle which 5:41 we're going to assume is the most active 5:43 bundle, and then I start going proximal 5:48 to distal, or actually distal to 5:50 proximal- proximal to distal, looking for 5:52 any tender nodules or any points of 5:55 increased density. We're going to assume 5:58 that those are the trigger points were 6:00 looking for. Right and i find one right 6:03 there, and if I held this pressure 6:05 chances are i could get a release. Now the 6:08 last thing we have to think about is 6:10 position, and this is obviously not the 6:12 position that i would normally do this 6:14 technique in guys. We have 6:16 Melissa's back to the camera so that you 6:18 guys can see what i'm working on with my 6:20 hands, but i'm essentially doing this 6:22 completely by feel without any visual 6:25 alignment here. So what I'm going to have 6:27 Melissa do is I'm going to have her put 6:29 her arm back in the sleeve of her 6:31 shirt, like i said i don't actually need 6:33 her to take her arm out of the sleeve of 6:34 her shirt, i can do this technique right 6:35 through her shirt. I'm going to have her 6:37 flip around. 6:41 Now I have seen this done in a seated 6:45 position, i'm going to show you guys how 6:46 to perform this technique in a seated 6:48 position, although it's not the way i 6:50 prefer to do this technique. What you 6:53 guys would do is you'd start off by 6:54 putting the levator scapulae in a 6:56 lengthened position, that lengthening 7:00 helps us pin down those points of 7:02 overactivity right. It gives us like a 7:04 little bit of tension on either side of 7:06 it, so we don't play that game where 7:08 we're trying to put our finger down on 7:09 top of the marble and it keeps spinning 7:11 out all over the place. The way we 7:13 stretch our levator scapulae, and some of 7:15 you guys already know this is by doing 7:17 the pocket stretch, which is having the 7:19 patient look in the opposite pocket. So 7:21 we're going to do a little contralateral 7:23 rotation, contralateral flexion and 7:27 flexion, and then I've seen two ways of 7:31 holding the head for a little bit of 7:33 control. I happen to have fairly large 7:35 hands, so I can kind of do something like 7:38 this and kind of palm the back of the 7:42 head, which some people are fine with. 7:45 If this doesn't make you very 7:46 comfortable, if you feel like you have to 7:48 put a lot of pressure into somebody 7:49 scalp that's not going to feel great; you 7:51 can use the other position commonly used 7:54 in like cervical manipulations, which is 7:57 kind of a forehead headlock, where you're 8:00 going to put the person's forehead right 8:02 inside the crease of your elbow here, and 8:05 then you can even place their head 8:07 against your your chest right so that 8:10 they're completely locked in. Now they're 8:12 completely stable and I can use this 8:14 hand to apply pressure. I'm still going to 8:17 use the same technique, I'm going to find 8:18 the superior angle of the scapula, I'm 8:20 going to do my stroking across the 8:24 length of the tissue this way. I'm going to 8:26 stroke this way looking for the tightest 8:28 nodules or the tightest fascicles, and 8:31 then I'm going to go from distal to 8:34 proximal looking for any increases in 8:39 tissue density, which we're going to 8:40 assume are a nodule or a trigger point. Now 8:43 if i press and I hold for 8:47 30 seconds to 2 minutes, I should notice 8:50 a reduction in tissue density, Melissa 8:53 should notice a reduction in tenderness, 8:55 and I'll have a successful release 8:57 technique. Now the problem with this 8:59 position is this hand. Essentially I 9:04 can't get my hand into a position where 9:06 i can actually get my forearm parallel 9:09 to the direction of force, and i'm having 9:12 to use essentially the strength of my 9:14 hand to do all of the work. Fine if 9:19 you're just trying to get something done 9:21 real quick, you're not doing this a lot 9:24 of times throughout the day it's fine. If 9:28 you happen to be doing a bunch of 9:29 techniques in seated position, and you 9:31 think that this might help you take that 9:33 next step. But I'm going to go ahead and 9:35 show you guys how I like to do this 9:36 technique, which is in the supine 9:38 position. So I'm going to have Melissa go 9:40 ahead and lay down, we're going to need 9:43 to bring the table up a little higher, 9:47 and I think you guys will see pretty 9:49 quick that this is a much much easier 9:51 technique for the clinician, and the 9:54 patient doesn't seem to mind the 9:55 technique. I'm going to use this hand 9:57 right underneath the occiput, you guys 10:02 can see I have total control of her head, 10:04 she's very relaxed right, so I can kind 10:07 of just have her flop her head over this 10:10 way. She's literally just rolling her 10:13 head over as if she just she just went 10:15 down for a nap, totally relaxed. You guys 10:18 can see that this is still the same 10:20 position, the same pocket stretch that we 10:22 were in before, and now I can get in here 10:27 most of my arm is rested which feels a 10:30 little better to me; and once I get in 10:34 position I can use a combination of her 10:38 bodyweight against my fingers as well 10:42 as friction on the table, to take off 10:45 some of the pressure that I would have 10:46 to put on with my hands. Alright so if i 10:50 strung tissue this way, 10:54 I can find the densest fascicles and 10:58 then I go from distal to proximal here, 11:00 in this case looking for that nodule and 11:03 boom. I got my tender point, i'm in a nice 11:07 relaxed position and I just wait for the 11:10 release to happen. If I want I can take 11:12 her into a little bit more rotation, I 11:14 can take her into a little bit more of a 11:16 lateral flexion, and again this arm 11:18 once I move it, I can set it down and 11:22 forget about it. Alright it doesn't 11:25 take a lot of energy on my part. If you 11:26 guys are doing a lot of neck treatments, 11:30 you're doing a lot of scapular dyskinesis 11:32 type treatments where the 11:34 levator scapulae would be something that 11:35 you would treat out, I definitely 11:37 recommend this technique. Guys stay tuned 11:41 for the close of recap. For a close-up 11:43 recap of levator scapulae release. You 11:45 guys can see I have the levator scapulae 11:48 trigger point marked off there, at least the 11:50 higher one that's about midway up the 11:52 length of levator scapulae. We can see 11:54 this muscle right here which is the 11:56 upper trapezius will help, that will help 11:59 us as a landmark. We're going to go ahead 12:01 and lengthen the levator scapulae, so we 12:03 can help pin down those hyperactive 12:06 points or those nodules of increased 12:09 tissue density. I'm just going to go 12:11 ahead and pull her into a levator 12:13 scapulae stretch, which is letting her 12:15 head fall into my opposite hand. We're 12:18 going to pull a little bit in the 12:19 contralateral flexion, a little bit 12:21 into flexion, and now I have all of this 12:24 area to start working through with my 12:26 palpation. If you guys remember the other 12:29 trigger point was just above the 12:31 superior angle of the scapula, that's 12:33 also where we started palpation of our 12:35 levator scapulae. So if Melissa gives me a bit 12:37 of a crunch here, you guys can notice 12:39 this trigger point right here, and the 12:42 the superior angle of her scapula is 12:45 right here, and I'm just going to go 12:47 ahead and put my thumb down there. So you 12:49 guys can see kind of what that looks 12:51 like when I have my hand between her and 12:55 the table, searching for those overactive 13:01 or tight fascicles. Alright so I'm 13:05 doing my strumming from 13:07 superior lateral to inferior medial. 13:10 Although unlike the trapezius angle that we 13:14 were using for strumming, this angle is 13:17 much more lateral to medial. It's just 13:19 slightly turned this way because the 13:23 levator scapulae it's so much more 13:24 vertical on the cervical spine. So 13:28 I'm moving across these fibers a little 13:30 bit this way, and then I can move from 13:32 distal to proximal to find the tightest 13:36 nodule, and then I can push in a little 13:40 bit, get the pressure that I need which 13:42 the pressure that I need is just pushing 13:45 in until I get a little kickback from 13:49 the tissue. So I'm going to go right up 13:51 to the point where I feel an increase in 13:54 tissue density and then I'm just going 13:57 to lay my arm down, and allow the table 14:00 to keep my arm there. So the friction 14:03 between my arm and the table is actually 14:06 whats keeping me in position. I'm going to 14:09 hold for 30 seconds to 2 minutes and 14:11 wait for a nice release. Melissa how's that 14:14 feeling? Ok. Starting to relax a little 14:17 bit. Good this other trigger point guys 14:22 is a little tricky, a little bit more of 14:24 an advanced palpation. It is just 14:27 anterior to the upper trapezius. So this 14:33 is the upper trapezius and I can 14:34 actually kind of pull this away, and then if 14:37 i push down in here I have to make sure 14:40 I stay just posterior to my transverse 14:44 processes, which you can feel is these 14:46 like bony tips right in here. Now these 14:50 are not something you want to press real 14:52 hard on. You press down on somebody's 14:53 transverse process you make them very 14:55 very uncomfortable. If I go right on top 14:59 of the transverse process I end up on 15:01 the scalenes. If I go too far back I end 15:04 up on the Splenii, but if I kind of 15:09 follow the levator scapula up. 15:13 Note how those taught bands feel 15:17 underneath my fingers, and then fall 15:19 right off the anterior border of the 15:24 upper trap and then do my same 15:27 strumming. This time I'm a little bit 15:30 more posterior to anterior, then I can 15:33 move distal to proximal and I can 15:37 do the same thing. So this is still 15:40 levator scapulae but oddly i'm actually 15:43 now not going through the trap, whereas 15:46 before i was pressing through the upper 15:48 trapezius to get the levator scapulae. 15:50 Your levator scapulae is actually a 15:52 superficial muscle here, the only thing 15:54 to note is this is also a different 15:56 trigger point than we were on before. So 16:01 just a quick recap guys with all these 16:04 levator scapulae releases. You are going 16:06 to pull or gently place the neck into 16:11 contralateral rotation, contralateral 16:14 flexion, a little bit of flexion. You're 16:16 going to find the superior angle of the 16:18 scapula, work your way up from there with 16:21 mostly lateral to medial stroking, until 16:26 you get just anterior to the upper trap. 16:30 And then you're using very short strokes 16:32 but more of a posterior to anterior 16:35 strumming. You're always going to be 16:37 looking for taut bands, and this is a 16:39 very ropey muscle when compared to the 16:41 upper trapezius. And then once you've found 16:45 the taut band you can look for dense 16:48 nodules within those taut bands to 16:51 hold some compression on, until you get a 16:54 release. So there you have it knowing 16:56 your functional Anatomy will definitely 16:58 help your manual technique. It'll help 17:00 you differentiate structure so that you 17:01 can place your hands where they need to 17:03 be. As well as make you aware of these 17:05 sensitive structures around the tissue 17:07 that you're trying to target; things like 17:09 nerves and lymph nodes, and arteries. Make 17:12 sure that if you're going to place your 17:13 hands on a patient, that you have done an 17:15 assessment and add a good rationale for 17:17 placing your hands on that patient. And 17:19 if you're going to assess, make sure you 17:21 reassess to ensure that your technique 17:23 was 17:23 effective, and you have a good rationale 17:25 for using that technique. Again now with 17:27 manual therapy, one-on-one live education 17:31 is incredibly important. Please be 17:34 looking for opportunities like workshops 17:37 and mentorships, and maybe even classes 17:40 at your local university, that can get 17:42 you some one on one individual 17:45 instruction; or at least a live classroom 17:47 instruction so you've had a chance to be 17:51 critiqued and mentored by somebody 17:54 senior to you, with some experience in 17:56 manual therapy techniques. And before you 18:00 bring this stuff back to your rehab 18:03 fitness or performance setting, please 18:06 practice on colleagues. There is no 18:08 substitute for practice, and it is going 18:11 to take a while to get accustomed to some 18:15 of the techniques that we show in these 18:17 manual technique videos. Don't expect to 18:19 learn them in two or three, or even five 18:22 minutes. You want to have hours of 18:25 experience under your belt working on 18:27 various different body sizes and shapes. 18:29 So that when you do get that first 18:32 paying client, first paying customer, and 18:34 you're really trying to make a good 18:36 positive impact, really trying to promote 18:39 better outcomes, you feel comfortable 18:42 with that technique. I look forward to 18:44 hearing about your outcomes and hearing 18:46 your questions in the comments section 18:48 of this video. I'll talk with you soon. 18:59
