0:01 This is Brent of the Brookbush Institute, and in this video we're going to go over a 0:07 joint based manual therapy technique. If you're watching this video I'm assuming 0:11 you're watching it for educational purposes, and that you are a licensed 0:14 professional with joint based techniques within your scope. That means osteopaths, 0:19 chiropractors, physical therapists you're probably all in the clear. Physical 0:23 therapy assistants, athletic trainers, massage therapist you need to check 0:27 with your governing body in your state or region to see whether this is within 0:30 your scope of practice. Personal trainers this is definitely not within your scope 0:35 of practice. Of course all professions could use this video for purely 0:39 educational purposes, to help with learning biomechanics, anatomy and of 0:45 course palpation. In this video we're going to do posterior to anterior 0:48 mobilizations for the lumbar spine. That's both unilateral and central PA's. 0:53 I think you are going to find for all of the spine that unilateral PA's or 0:58 UPA's, are the workhorse for our mobilizations of the spine. You're going to 1:02 use those possibly the most frequently. I'm going to have my friend Melissa come 1:06 out, she's going to help me demonstrate. The first thing we're going to talk about of 1:08 course is position. So I'm going to have Melissa lie prone. If Melissa had pain 1:13 in extension I could put a bolster underneath her 1:16 hips, just to give us a little bit of flexion and me a little bit more room to 1:22 be able to do these PA's, without pushing her into a painful range. You guys will 1:27 notice her arms are in a relaxed position, and we have these really nice 1:29 tables at Flex here in New York, and they have the arm drop downs. But if you 1:34 didn't have those, this position is probably fine as long as somebody 1:38 doesn't have a really tight shoulder girdle. Or you can have their arms by 1:41 their sides. The thing you want to keep away from is somebody putting their arms 1:45 up, creating a lot of tension through the latissimus dorsi because their latissimus 1:49 dorsi does cross their lumbar spine. So tension here could 1:53 make your mobilizations a little tougher. You can go ahead and put 1:57 your arms down, arm cradle. The other thing you want to consider is that 2:01 Melissa needs to be low enough on this table, that I can get my chest over her 2:07 spine. So that when my arms are straight, all I have to do is rock my torso to get 2:14 my mobilizations. So in essence I'm using my bodyweight, the weight of 2:18 my torso to do my joint mobilizations and not my hands, like trying to do 2:23 something like this. Alright I see people do that every once in a while, oh 2:26 my gosh you're going to wear out your hands. Or they start trying to tricep 2:31 press down their mobilizations, I think you're going to find it not only 2:35 wears you out, it's almost impossible on bigger patients for the lumbar spine 2:39 because the lumbar spine is pretty strong and stiff to begin with, and I 2:42 think you also find that your forces aren't very consistent. So if you're 2:46 trying to do these nice consistent oscillations at the same depth, with the 2:49 same resistance so that you're consistent and reliable, you're going to 2:54 have a hard time doing this, as opposed to just rocking with your 2:58 bodyweight. So the table is nice and low, Melissa's in a good relaxed position. The 3:04 next thing you probably want to do as a newer manual therapists, new 3:10 to mobilizations which I'm assuming you are for these videos, you 3:14 probably don't want to start by trying to palpate through clothing. Now 3:17 obviously we don't want to move clothing that people are uncomfortable with, but I 3:21 can tell you adding a layer of clothing is just one more layer of stuff that we 3:27 have to try to feel through, and if we're talking about pants, right like if you 3:31 have to try to feel through denim pants forget it. Especially the L4-L5, L5-S1. 3:36 If you're doing SI joint mobilizations, trying to do those joints 3:42 which are already very strong through denim, is going to wear your hands out real 3:47 quick. So what I'm going to do is have Melissa lift her shirt up just above the 3:50 bottom of her rib cage, because by definition her lumbar spine would be 3:53 below her rib cage right. So the 12th rib, our last rib, hooks into our last 3:59 thoracic vertebrae and everything below that is lumbar spine. And then I'm going to 4:03 have her flip the top of her waistband down. So she doesn't have to like pull 4:07 down her pants, she just needs to flip her waistband down a little bit. 4:11 If you have people come in workout clothes, sometimes these yoga pants do 4:15 come up high on females so be aware of that and don't let that 4:20 mess with your palpation. Make sure that you find the top of their iliac crests, 4:25 and that you can kind of get your thumbs down to the sacral base, even if it's 4:30 just tucking under the lip of their pants, that's okay. But you 4:34 definitely need them to be enough out of the way that you can get to the lumbar 4:38 spine without having to push through clothing. So the next thing we should 4:42 probably think about is anatomy. Now if you haven't looked at the lumbar spine in a 4:46 little while, you don't remember how the spinous process and transverse process, 4:51 and where the facet joint is located, and what muscles to work around, I definitely 4:54 suggest a little review. You could start with some of those soft tissue videos we 4:58 did, the static release videos we did. Maybe look at some of the anatomy of 5:02 some of the muscles around the lumbar spine, and I've mentioned in our other 5:05 spine videos buying one of these plaster cast spines is really an invaluable tool. 5:11 I understand that this spine is not the same as Melissa's spine and that the 5:19 proportions are not identical, but you take a huge step forward in testing 5:26 yourself with a plaster cast spine. For example, I am going to find 5:32 my sacral base, and then being able to look down and see if you're on the sacral 5:36 base. Then you can test yourself, for example I want to get on to L4-L5, so I'm going to go 5:43 L5 spinous process, L4 spinous process, fall off just lateral 5:47 and inferior, and sure enough I'm on L4-L5, and I can look down. What you're 5:52 doing when you do that is you're starting to create a visual model up 5:56 here, which is going to help you match to what's underneath the soft tissue here. 6:06 If you don't do that it just takes a little bit more time, because this is 6:12 essentially that with mush on top. Mush being all the soft tissues right, 6:18 and all these lumbar extensors and multifidi, and you got things 6:23 like your quadratus lumborum which are off to the side. If you're 6:28 not really familiar and you haven't been doing a lot of manual 6:31 techniques, it's nice to have that thing just to check things out. Now 6:37 let's talk about some of our first palpations. If I find the bottom of 6:42 my rib cage, and follow those ribs up and just follow that, they kind of come 6:49 at an angle like this, and so I'm going to follow that angle up to that spinous 6:54 process, and then I go down one, that's L1, so L1, L2. 7:06 The spinous process have very flat tops, so what you're going to feel is like 7:11 flat and then there's a little divot, and then that's the next spinous process and 7:16 then a little divot, the next spinous process. So once you find L1 you can 7:21 go L2, L3, L4 and hopefully what you'll do is 7:28 if you test yourself, you'll get to the sacrum which starts to feel like a 7:39 crocodile's back. It has two ridges essentially and it's bumpier, 7:45 it's not so flat with a divot, flat with a divot, it's not that consistent anymore, 7:50 it's just bumpier down here right that's that's sacrum. Hopefully you get to L5 7:57 and then sacrum and you're not like L6, L7, there's there's no L6 on most people. 8:03 Every once in a while you meet somebody with an L6, but that's a pretty rare 8:08 thing to come across. So count your lumbar vertebra, and then maybe the next 8:13 thing you want to try doing is finding the transverse process. Believe it or not 8:19 the lumbar vertebrae are wide, they're like really wide. The transverse 8:25 process are as wide as your fist. So you can get in here like this and I can feel 8:32 like that's bone out there, all the way out there, and I'll show you 8:36 this in the close-up recap. They're wide, they're really wide and 8:41 feel it, you can get L3, after L3 transverse process now that we're on, you 8:48 run into the iliac crest here, and then they start getting hidden. 8:54 So find the transverse process, find the spinous process, and then the next 8:58 challenge would be to try to get your fingers on the facets. 9:01 The facets are going to feel like bumps, a little more than a finger 9:10 width from the spinous process. So if this is my spinous process, I want to go 9:16 a finger width over, and then if we're going this way 9:24 the facet joint that's related to the spinous process that you were just on is 9:30 actually lateral and inferior just a little bit, just a tiny tiny 9:34 bit. Once I am over the top of them, then what I want you to do is 9:42 gently start trying to feel through all the soft tissue and see if 9:48 you can get that joint to move a little bit. It does take a bit of force, it does 9:54 take quite a bit of force. This is one of those things where having a mentor who's 9:59 done this before is a really good thing, because I think people get scared 10:06 pushing on the spine and there's reason to be scared. Obviously we don't want to 10:10 damage anything, we don't want to hurt anybody, but to give you an idea if 10:15 I'm doing a central PA I have to push Melissa pretty hard into the table. 10:25 I'm using quite a bit of my bodyweight to get to the end range of those facets 10:30 that are associated with the L1 segment. How does that feel? Yeah it's a 10:38 significant amount of pressure. So let's let's talk about central PA's now that we 10:44 know transverse process, we know spinous process and we know 10:47 where those facet joints are. Let's start moving down and start talking about 10:52 these different mobilizations. So you could do your central 11:00 PA on the spinous process with two thumbs. You just come 11:05 to either side and do it this way. I don't like to do that and I'll 11:10 tell you why, anytime I can find a technique that doesn't require my thumbs I use 11:16 that technique, because there are techniques where your thumbs are your 11:19 only option and your thumbs will wear out if that's all you ever use. So a lot 11:27 of therapists get themselves into trouble because their IP's of 11:31 their thumb, they start ending up with hyperextension, they can't really get 11:34 stable and it starts causing them a lot of pain in that joint. So for this one I 11:39 like what's called a pisiform hamate or cradle, I think it's called a cradle saddle, a 11:44 saddle grip maybe is the right term. What I do is I put this part of my 11:49 hand right about where your pisiform is, over the spinous process. Now 11:55 that's pretty comfortable for the patient too because I'm pretty much 12:01 just pushing them into the soft tissue of my hypothenar eminence there, 12:05 the mush underneath my pinky finger, and then to use both of my hands, 12:11 I'm going to take this hand and it's going to saddle over the top of my hand like so, 12:16 and now when I get into position I can just use my bodyweight. So you can 12:22 see that, this is what I'm pushing with, but this is where my force 12:27 is coming from, straighten out both my arms and now I can do my central PA's. Now 12:34 I have to admit usually central PA's I don't use unless somebody is super 12:39 stiff. I use these more as a part of my passive accessory motion exams where 12:45 I go, okay please tell me the difference between pressure and pain, and I'll 12:50 push down and what's that, pressure or your symptoms? That's symptoms, 12:57 okay so that's symptoms and then I start moving down. Pressure or symptoms? 13:04 Pressure, pressure, pressure, pressure. Good so we know in her case, or at least we're 13:18 going to take a guess in her case, that most of her pain is coming through that 13:23 thoracolumbar junction, somewhere like the L1 segment. 13:26 So I'm going to want to start thinking about what dysfunction happens there. 13:31 Unfortunately hypermobility is actually a more common at that segment, but the 13:36 next thing to do would be to think do I feel like that segment was hypermobile or 13:40 hypo-mobile. The only way you're going to know that is from experience, and you do 13:46 have to keep in mind that palpation is probably our least reliable assessment. 13:50 So this is one of those situations where I may do mobilizations and then 13:55 immediately retest. Just mobilize that one segment for 30-60 seconds, 14:00 have them get up and see if I can reproduce their pain. If they got better 14:04 than we're on the right track, if they didn't then maybe the segment is hyper- 14:07 mobile we need to start thinking more towards stabilization exercise. So again 14:12 in central PA's just thenar eminence over like this, and then I use this like 14:17 this, and then I'm going to push down to end range if I'm doing an exam, and see where 14:23 pain comes from. But if I was doing mobilizations you know that it's 14:29 50 percent. Alright so first resistance barrier, end of arthrokinematic range which 14:37 is there for her, back off to 50 percent, and then I can either do my grade 3 by 14:42 backing off to the first resistance bearing and pushing down to 50 percent, so 14:46 that's my larger amplitude, but less intense mobilization because I'm backing 14:49 all the way off to essentially no resistance. Or I can get a little bit 14:54 more intense by going right up to 50% or maybe even a little deeper, and staying 14:59 there with small amplitude mobilizations. Alright and then see how that feels, and 15:04 she actually does feel kind of stiff. So I might try this and then see how she 15:08 does, and you can follow this technique all the way down. So what I'll 15:14 do is if I'm trying to do more segments in the spine and test. 15:18 So my pisiform hamate is under the spinous process, I 15:23 just take my two fingers, find the next one down, move, and go, two fingers down, go 15:31 two fingers down, go and you can see I can address the whole spine real quick 15:36 there. Now let's go back to the workhorse technique of UPA's. A lot of 15:42 lumbar spine issues tend to be asymmetrical. You have restriction on 15:47 rotation to one side, or at least one side is more restricted than the other, or 15:51 lateral flexion is more restricted to one side than the other, we start looking 15:55 towards these unilateral posterior to anterior mobilizations, this is why I'm 16:00 going to have to use a thumb over thumb technique. So I'm going to find 16:05 spinous process, now we know in her case her symptoms seem to be coming from 16:11 somewhere around the L1 segment. So maybe I start with L1-L2 facet. Push down, 16:20 find the first resistance barrier, find the end. How are you feeling? m-hmm mm-hmm, 16:27 yep that's that's a little bit of her symptoms. Then maybe I start 16:32 my grade three mobilizations, assuming that it's hypomobility, despite 16:38 the fact that she has pain there it's not pain. I don't run into pain before I 16:42 run into her mobility issues, it's like as I get to the end of her range she 16:46 starts having pain, which tends to be stiffness dominance if you're talking 16:50 about like a Maitland approach. So what I might do is do 10-15 seconds worth of 16:55 this, and then ask Melissa does that feel like it's getting better or getting 16:58 worse? Okay so if it's getting better then I'll keep doing it and then of 17:02 course retest. I could go up, the mobilization technique here is 17:07 the same for T11-T12, T10-T11, it's the same unilateral PA so I could 17:13 go up a couple segments, I could go down a couple segments, I could try the other 17:17 side. Of course I would walk to the other side of the table, but again notice that 17:22 all I had to keep in mind was my anatomy which is this facet is just lateral 17:27 and inferior, if I'm talking L1-L2. If I wanted to go T12-L1 then I have to go 17:33 lateral and up just a tiny bit. I'm keeping thumb over thumb so that I'm 17:39 using both thumbs and I have as much strength in my hands as I possibly can. 17:42 My arms are practically straight and I'm just using the weight of my torso to do 17:49 the mobilization for me, keeping my protocols in mind. Notice I'm not doing 17:53 this, I'm not doing this, that's all really bad technique. In fact for some 17:58 individuals if you wanted to try this, you could use the hand position we 18:04 used on the static release videos, which is dummy thumb in between our inner 18:10 thenar groove applying the force. On some individuals you might be able to get 18:16 your hands into the right position, to not have to use thumbs at all in 18:24 a straight up-and-down position, you're essentially using this as a 18:27 little point that you're then pressing into with this, and sometimes that's a 18:35 little bit more comfortable for individuals. You could try maybe a 18:43 little less specific going off to the side and pressing on the transverse 18:46 process with the pisiform hamate grip, that we just talked about with the 18:49 saddle grip. Keep all this stuff in mind, although it's not as specific as this, 18:54 and I know some of you are thinking well why wouldn't I just use the best 18:57 technique. The truth of the matter is, is you're going to get tired and if your 19:01 thumb's hurt, and it's the end of a long day, and you've had a lot of big 19:04 individuals on your table, or a lot of stiff patients. Or maybe it's the end of 19:07 a long week. Maybe you happen to be the athletic trainer or physical therapist 19:11 for like a football team, and everybody you treat is just a really large human 19:16 being. Keep these other techniques in mind, 19:19 a good technique is better than nothing. Even if it's not, don't let perfect 19:24 be the enemy of the good is essentially what I'm trying to say. Let 19:27 me show you guys just a couple more things here, just some special palpations 19:31 to keep in mind. If you find at the top of the iliac crest right, and you keep 19:40 following down you'll eventually run into the PSIS. If you find the space 19:50 that's between the top of the posterior iliac spine, the PSIS and 19:59 then these spinous process here. What we're on, this is L4 20:06 and L5. You will be able to feel this a lot better than I'm 20:10 showing it to you, but there's a little place in between all of this bone 20:15 mass that you start running into here, and in there is your L4-L5 facet. It 20:22 is definitely worth testing that facet. People forget about that facet. 20:28 People will do all of this stuff because it's easy to access, and then they'll 20:33 forget that they need to get in there and really search for that facet 20:39 specifically. How does that feel? That feels really stiff to me. So she 20:47 doesn't have pain, but maybe she's getting hyper-mobile here because this 20:52 is super stiff, I would check on it. Now the same thing with L5-S1. So find that 20:58 triangular space, that's between PSIS, the top of the posterior iliac 21:07 crest, and the spinous process that's just lateral to it. Find that space and 21:15 then what I want you to do is find the sacral base, and I want you to keep 21:19 feeling up the sacral base until you fall off it and that's L5-S1. And now I 21:28 realize L5-S1 you might have to go a little bit this way, to get that to 21:35 move the way you want it to move. Again these are worth checking. They are the 21:42 two segments most likely to be hypermobile, but they also have a 21:48 propensity to become hypomobile. It just depends on the condition, it's a 50-50 21:53 shot. So if you feel like you have normal or more motion than normal when you 21:59 press into them, then leave them alone because you can definitely make somebody 22:03 worse by making them more hypermobile. But I don't know that I would ever rely 22:08 completely on central PA's without at least checking L5-S1, L4-L5 facet, just 22:19 to make sure everything is in good working order. Alright so stay tuned 22:24 for the close-up recap. Okay for our close-up recap we have the lumbar 22:29 spine, you can see how it's nice and visible here. The first thing that we 22:33 talked about finding was maybe L1 right. We did that by following the last rib up 22:40 to the spinous process of T12, because the last rib would hook into our 22:45 last thoracic vertebrae and the next spinous process we feel. Alright so kind 22:50 of flattish spinous process divot. Spinous process would be our first 22:58 lumbar spinous process, and then we started by talking about central PA's 23:03 which you know I told you that you could use your thumbs like so. I put one on 23:07 either side, don't press down on a spinous process like that, that's 23:11 very pokey. But if you go this way on just either side of the spinous 23:16 process, you can notice there's a little bit of skin there in the middle. 23:18 You could do it that way although that's tougher on your thumbs than you need to 23:21 be. I would go ahead and put your pisiform hamate spot, right this mush of 23:33 hyperthenar meat right here, right over the top of the spinous process and then 23:38 you can saddle it up like this, and then you get just that nice lean with your 23:44 chest over the top of where you're trying to mobilize, and you can just use your bodyweight, 23:51 real easy. Of course once we found one spinous process it's real easy 23:55 to go spinous process divot, next spinous process, spinous process divot 24:01 next spinous process, spinous process divot next spinous process. Keep in 24:06 mind the spinous process takes up a lot more space than the tiny 24:11 little divot in between spinous processes. Now the next thing we talked 24:16 about finding was your transverse process, which believe it or not come out 24:23 about this wide, they're really wide. This is me rocking Melissa's lumbar 24:31 vertebra here, and you can see my hands are, they're 24:35 a fair amount apart like they're her fist width, not quite my fist width but 24:39 her fist width apart. Nice big lumbar vertebra with nice wide 24:45 transverse process, and we can use transverse process to do UPA'S. That is 24:50 something that you're going to want to consider, especially if your thumbs start 24:52 getting tired and you need to switch to something like this position, this tends 24:57 to work a little bit better using a transverse process than trying to 25:00 get into a facet joint, because once you are looking for a facet joints, 25:05 and you're falling off that spinous process about a fingers width 25:11 away you'll feel that bump, you can go this way a little bit and feel a bump. 25:17 You pretty much have to use your thumbs to fit in there, otherwise this becomes 25:25 tough. You end up getting multiple segments, not that that's a bad thing 25:29 providing they're stiff at all those segments, but this is a bit more specific. 25:35 So we have spinous process, we have transverse process that come all 25:41 the way out here, and then we could go to facets in here and I'm going to show you 25:47 this on the other side, although I'm on the opposite side of this individual 25:50 wouldn't do these mobilizations this way. So spinous process, transverse process is 25:56 all the way out here, and then the facet is about right there. Alright so I 26:05 hope that helps you with your proportions a little bit. Now I did show 26:08 you a couple of special techniques, we have the top of the iliac crest here. 26:13 In line with the top of the iliac crest is the spinous process of L3-L4. If 26:20 you go just below the spinous process of L4, so you draw a triangle 26:25 between that spinous process, the top of the back of the iliac crest 26:33 here there's this little triangle section that's leading 26:37 into the bony sacroiliac joint, and the bony PSIS. This little 26:45 spot of still soft tissue, at the bottom of that is the facet of L4-L5. 26:49 I would keep that in mind because that's one of those segments that people forget 26:54 to palpate. They're palpating down, palpating down, palpating down, and then 26:59 they stop because they either accidentally hit the iliac crest, maybe 27:06 they were too wide to begin with and they were pressing on transverse process 27:09 instead of facets. So they get to the iliac crest and they 27:13 stop. Keep that L4-L5 facet in mind, and then the other thing I want you 27:18 to do is make sure that you find the sacral base, which you know you're going to 27:22 come off the flat sacrum, and then just fall off the top of it so that you 27:29 find L5-S1. Now those are the two joints most likely to become hypermobile, 27:35 but in a lot of individuals with a chronic history of lumbar pathology they 27:41 can also get stiff. So knowing how to palpate and then mobilize L4-L5, and L5 27:47 and S1 are important techniques to have in your arsenal. Of 27:52 course the technique that we use is the same as all of the other vertebral 27:59 UPA's that we've done. Once you find that facet, find the first resistance barrier 28:04 and then find the end of arthrokinematic range, and you're going to have to press 28:09 down pretty good in the lumbar spine. This is one of those techniques that 28:12 having a good mentor will definitely give you the confidence to push this to 28:17 end range, and you'll back off to 50% between, and then you can do your grade 28:22 fours right there at 50%, or you can back off to zero resistance and go to 50% 28:26 like a grade three. And of course make sure you follow through your protocols 28:33 getting a increase in joint mobility before you stop, probably 30 seconds or 28:40 more. So there you have it assess, address, reassess. Make sure that 28:44 every time you choose a joint based manual therapy technique it is based on 28:49 an assessment, and that you return to that assessment after you've finished 28:52 the intervention to see if it was effective for the individual, the 28:57 patient or client that you have in front of you. Ensure that you continue to learn 29:01 your Anatomy because your Anatomy is going to help you with your hand 29:06 placement, with understanding what a joint can do, with understanding what you 29:11 may gain from this particular technique; and of course practice, you have to 29:17 practice these techniques hopefully not for the first time on a patient or 29:22 client who just walked in the door. If you can find a more senior instructor or 29:27 a mentor to give you some really good hands-on instruction, use your peers for 29:32 some good feedback, and of course always look for live education to help with 29:40 your manual therapy techniques. I know these videos make education very 29:44 convenient but there is no substitute for learning manual therapy in a live 29:50 setting. I look forward to talking to you guys again soon.
