0:04 This is Brent of the Brookbush Institute and in this video we're going to go over 0:07 manipulations, or high-velocity thrust techniques. I assume that if you're 0:11 watching this video you're watching it for educational purposes, and that you 0:14 are a licensed professional with high velocity thrust or manipulation 0:19 techniques in your scope of practice. If you are not sure, check with your state 0:24 board. Most physical therapists, chiropractors and osteopaths you're in 0:28 the clear. I believe that ATC's you can't do manipulations in the United States, 0:33 although other countries again check your scope. Of course massage therapists 0:38 and personal trainers these are generally not within your scope, of 0:41 course you could continue to watch these videos just for educational purposes, 0:47 learn a little Anatomy, learn a little biomechanics. If you're going to do these 0:51 techniques please make sure that you have a good rationale for putting your 0:56 hands on a patient, this should be based on assessment, and if you're going to 1:00 assess I'm hoping that you'll assess, use these interventions and reassess to 1:06 ensure that you're getting the result that you're looking for, and have good 1:09 reason to continue using this technique. In this video we're going to go over a 1:13 lumbar spine manipulation. I'm going to have my friend a Yvette come out, she's going to 1:15 help me demonstrate. Now of course if I'm doing lumbar spine manipulation I've 1:19 done not only passive accessory motion, I've probably done something like a 1:23 subjective exam as well as a movement exam like the overhead squat assessment, 1:28 and I have some reason to believe that there's lumbo-pelvic hip complex 1:31 dysfunction issues, and then I'd like to use continuous interval measures to 1:34 measure progress, something like goniometry. Unfortunately in the lumbar 1:38 spine goniometry isn't very reliable, so maybe you could work on some of 1:41 those rotation tests to at least get some sort of visual indicator to see if 1:45 you are actually making progress with this particular technique. Now once we 1:50 get through that and we're doing our passive accessory motion exam to try to 1:54 figure out which segment is stiff, you can go back to the lumbar mobilizations 1:59 video because one of the first things I'm going to do is just a central PA; 2:03 where I'm going to go ahead and press all the way down to end range, see 2:08 if it feels normal to me which of course is where the reliability of passive 2:12 accessory motion exams comes into play. Obviously you have to feel a lot of 2:16 different lower-backs to get a good idea of what a lower- 2:20 back should feel like, but I also want to take into account what a Yvette feels. So 2:24 does that feel like pressure or pain? Obviously pressure is normal and as long 2:30 as I don't feel stiffness then fine. How about there? All right and I'm just 2:34 pushing all the way down to end range arthrokinematics, and I do feel a 2:39 little bit of stiffness in her mid-lumbar spine. So we even have some 2:45 research to back this up, L5-S1 tends to get a little hypermobile, 2:48 L4-L5 might get a little hypermobile, L2-L4 we tend to get quite a bit of 2:53 stiffness. So for this particular technique I'm actually going to have a Yvette 2:57 rolling or side facing me. Now some of you have probably seen this technique 3:04 before, this of course is the rotational manipulation, and I think a lot of people have a 3:08 very hard time with this technique; and it's because they get bound up in the 3:13 details of what the legs are supposed to be doing and what the arms are supposed 3:18 to be doing, and what the hands are supposed to be doing, and they forget one 3:21 simple thing, you have to find the lockout position. So if we're going 3:29 for L2-L4 I'm going to get my hands set up with that piano grip, where 3:36 I have my fingertips on those spinous process or in between those spinous 3:40 process, and once I find that stiff segment I'm going to now lock up from the 3:48 bottom using ligamentous lock. The way I do that is by posteriorly pelvic tilt, 3:53 right I'm creating a posterior pelvic tilt and creating some lumbar flexion 3:57 which will pull all of those posterior spine ligament's tight, that's why we 4:04 move this leg. So what I'm going to do is I'm actually just putting my knee right 4:09 in the crease of my hip there, so I don't even have to hold her entire weight of 4:13 her leg, and I'm going to move up until I feel that segment that I'm trying to 4:18 manipulate, move on me. Now I know that's locked I'm going to go ahead and set this 4:23 leg down, double-check now that I have it down to make sure it stayed locked. One 4:28 thing you will find is it's real easy for people to get 4:35 them locked up and then you move, and they unwind on you. So make sure 4:40 that once you find your ligament lock from the bottom you tell your patient, 4:46 hey don't move your lower-body once they get you there. You can see 4:49 you can move this bottom leg, the reason the bottom leg is straight is 4:53 to give you something to rotate over. It really doesn't have much to do with the 4:57 manipulation itself. I mean I guess technically we could probably bring both 5:00 legs up and still make this manipulation happen, but with this bottom leg here I 5:05 have something to pivot on, and then I can actually bend it a little bit and 5:10 get her foot hooked up so that once I find that lockout position, 5:14 Yvette has some pretty good hip mobility here so I had to go up a little further 5:18 to get that locked out position. Now I get her set, cool I'm now going to switch 5:24 hands. Now I have to figure out how to lock out from the top, and the way 5:28 to do that is to rotate and extend a little bit this way, not huge amounts of 5:33 extension just a little bit of extension, and what I'm going to do is I'm going to 5:38 grab a Yvette's whole arm and I'm going to pull up and back, sliding her arm to 5:48 the point that I feel that joint lock out. So I'm rotating all the way up 5:54 to where my fingers are, so you can even try to get a little bit more, good 6:02 there we go. Now she's wound nice and tight. Now what 6:05 I like to do is come back here I have my thigh where her knee 6:11 is at, that's going to help me keep her nice and stable, I'm then going to take 6:17 this hand, and this hand is going to go between her greater trochanter and 6:22 her ilium, and this hand I'm going to slide right between her arm. 6:27 Now the reason I'm going to do that is because I'm going to use this forearm 6:33 on as much surface area as I can, like over her PEC. So not over her 6:39 chest but over her PEC, try to stay off the shoulder you don't want to give like 6:43 a really hard anterior to posterior force 6:46 to the shoulder that's not going to feel very good either, and once I get 6:50 set-up, get my hands back in place; now just like I did with like the cervical 6:55 spine or like I was doing with some of the joints of the foot, you want to 7:00 kind of mess around just a little bit, a little bit more flexion from the bottom, 7:06 a little bit more extension from the top. Get really nice and tight so you 7:12 can feel that all it's going to move is those two segments. I'm not saying take all 7:18 the time in the world, but make sure that your setup is just like any other 7:23 manipulation -setup is everything. All right then I'm going to have a Yvette take a 7:27 nice deep breath and my manipulation is going to be pulling down this way, well 7:33 going down this way with this side and that's it. 7:38 How did that feel? Yeah not too bad right. This is one of those ones 7:44 where I told you to take all the time you need for setup, except don't take all the 7:49 time you need for setup because your patients hate it; with that being said 7:53 how do we how do we bridge those two contradictory statements is 7:58 yes take all the time you need to set-up, but you need to practice this. 8:03 I would grab some friends, grab some colleagues and make sure that before you 8:07 do this on a patient you've had a couple times, to go okay wait how am i adjusting 8:12 the leg like what am i doing, where are my hands supposed to be. Okay this is locked 8:17 up now how do I get this to stay, okay good adjust this leg, alright good now 8:23 that's like that. You know you're going through all this stuff well before 8:27 you see your first patient, you don't want this to be a 10-minute setup for 8:33 your patient. But if you can get it down to - all right let's let's start all the 8:36 way over, right and we'll show them what like a normal setup would look like, so 8:40 let's start on your back. Alright so if I'm doing this let's say I have my 8:46 patient, all right Yvette we're going to try a little 8:48 manipulation, all right so it's going to be one of those quick thrust techniques 8:52 that I know you love so much. As you know from some of our other videos 8:55 Yvette's not somebody who gets manipulation, she volunteered to model 8:59 for these videos and we thank her for that but she's very much a new kind of 9:03 patient to this stuff. All right so you did know the cervical spine one though, 9:06 right like you've you've seen a couple of them, let's have you lay on your side. 9:10 Okay you're going to face me, now sometimes you end up like this with your 9:16 patients, just make sure you straighten out their leg, all right and then what I 9:20 do is I go ahead and set my left hand up and I get my piano grip to figure 9:26 out where I'm at, all right there's our sacrum, L5, L4, L3. Okay I'm going to 9:34 try to go L4-L3. Now am I necessarily specific or 9:40 surgical in my approach enough to ensure that it's L4-L3 no, but you 9:46 know I'm pretty sure I'm going to be able to get a manipulation from a hypomobile 9:50 segment. I'm going to go ahead and pull up from the bottom. 9:54 All right that's locked out there, good and I want to make sure I follow that 9:59 down so you notice here like her foot isn't really hooked in, so this is where 10:04 I'll usually pull this leg so I can get their foot hooked in, 10:08 because when their foot isn't hooked in that's where they tend to like start 10:11 sliding and then you lose your ligamentous lock from the 10:14 bottom. So we're all nice there, now I'm going to switch my hand put it 10:19 right where my other fingers were. I'm going to grab your arm, thank you, pull up a 10:26 little bit this way. If I feel like I need a little bit more extension and rotation I 10:29 can come up this way a little bit, go ahead and no no don't help, let 10:34 your shoulder roll back, and your patients will try to help, don't let them 10:38 help you. All right good, go ahead and one hand like that, so 10:43 your hands are kind of one hand over your other wrist. So I'm now going to 10:47 put my forearm in this slot, boom, boom. Alright once I get her locked 10:54 up, I feel like I got good position here, I'm just going to adjust a little bit more, 11:02 there we go, there we g,o that feels nice locked up. 11:07 Remember it's down this way, like I'm trying to put my elbow on my back pocket, 11:12 or going down this way. 11:16 Nice and locked up, big deep breath, alright and that's it. I just wanted to show you 11:23 one more view, I'm going to quickly go through this technique but give you a 11:27 little bit more of a view of what I see from my side. So Yvette go ahead and roll 11:32 towards me, alright you can back up a little bit towards the middle of the 11:35 table, and I'm going to have her back up or move forward so that when she gets 11:40 locked up I can still set this knee down, but it'll still pass the table if I need 11:46 it. Alright so you have to feel 11:48 for that adjustment, but if you remember I feel for the segment that I 11:53 want to move, I'm going to pull her into a posterior pelvic tilt until I feel the 11:59 bottom segment move just a little bit so I know that all of the segments below 12:05 are locked up. Alright we have pretty good hip mobility here from Yvette so it 12:10 takes a little bit more hip flexion than you will see on some other people, 12:13 and then of course I kind of mentioned to you I've been moving the bottom 12:16 leg to get that foot hooked up. I mean you noticed I 12:21 used my thigh to move her leg, I don't use all my upper-body strength to try to do 12:26 that, it's just a little energy saver there. Now I switched my hand 12:30 over I'm going to use my other hand to rotate and extend from the top. Alright 12:37 so I can go this way if I have to, I can pull up a little bit this way, good get 12:43 her all nice and locked up there. Alright and then this hand goes on this wrist, 12:48 and then you are going to snake this hand through this way, push down this way. 12:54 Now this is where adjustment time comes in, right so I'm going to use this 13:00 forearm in between her iliac crest and her greater trochanter to rotate 13:05 towards me. I can even laterally flex a little bit, I can move her into flexion 13:12 with my thigh a little bit using that knee that's on my thigh, 13:15 and once they get her all locked up, nice deep breath and then down this way, push 13:24 down this way, I'm just going to drop in all at once. Sorry one more deep 13:28 breath Yvette, and just like so. Alright so there you have it, hopefully with 13:38 these few times through you can rewatch this video and get this 13:42 technique down. I think you'll find it's very helpful for individuals with a hypo- 13:46 mobile lumbar spine. A couple of points to recap, knowing your Anatomy and 13:50 knowing your biomechanics will certainly help you choose the right technique for 13:54 the right patient. If you're unsure whether manipulations are appropriate 13:58 due to their higher intensity, it's okay to do mobilizations. Most research points 14:04 to manipulations being slightly more effective, but mobilizations being very 14:08 effective, and of course we have those videos for you if you want to start with 14:12 those less intense techniques. Make sure that if you are doing any technique that it 14:18 is based on assessment, and of course that you're reassessing ensuring that 14:22 the technique is effective for the patient that you're working on, and when 14:25 it comes to all manual techniques, manipulations maybe more than any other, 14:30 look for opportunities to get live education. Although I know videos are 14:35 convenient and I'm happy to have these up for you to watch, it would be so 14:41 much more helpful to use those videos as a recap of one-on-one attention with 14:47 somebody who's experienced with manipulation techniques. At the very 14:52 least grab a colleague, grab a friend and start practising these before you bring 14:59 them into clinic and start using them on patients and clients. I hope you enjoyed 15:03 this video. If you have any questions please leave them in the comments box 15:06 below.
