Name: Lumbar Spine Joint Manipulation (High Velocity Thrust)
Uploaded: 2023-04-26T00:59:12.000Z
Duration: 15 min 17 s
Description: Learn the proper technique for Lumbar Spine Joint Manipulation (high velocity thrust) in this step-by-step tutorial. This video demonstrates correct clinician posture, patient positioning, and the precise force and direction needed to restore mobility, reduce feelings of tension, and improve function.

English captions

https://stream.mux.com/9xC1EpF9Ml00Gnsm7WhAt696Q1ClacEIbknutX00Xj01Mw.m3u8

Learn the proper technique for Lumbar Spine Joint Manipulation (high velocity thrust) in this step-by-step tutorial. This video demonstrates correct clinician posture, patient positioning, and the precise force and direction needed to restore mobility, reduce feelings of tension, and improve function.

Introduction to High-Velocity Thrust Techniques

Assessment and Preparation for Lumbar Spine Manipulation

Rotational Manipulation Technique

Ensuring Proper Patient Setup and Execution

Reviewing Key Steps and Techniques

Importance of Assessment and Ongoing Education

Lumbar Spine Joint Manipulation (High Velocity Thrust)

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

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Joint manipulations for the lumbar spine, sacroiliac joint, and pubic symphysis. Types of manipulations, manipulations vs. mobilizations of the spine, lumbar spine, SI joint, and pubic symphysis. Optimal intervention for anterior pelvic tilt, low back pain, inadequate forward lean, asymmetrical weight shift, sacroiliac joint dysfunction, knee bow in, knee bow out, and hip symmetry. The risk of adverse events, accuracy vs sensitivity, screening, reliability, and validity of lumbar spine, SIJ, and pubic symphysis manips.

Joint Manipulation: Lumbar Spine, Sacroiliac Joint and Pubic Symphysis

The patient should be side-lying, facing the practitioner, with shoulders stacked, top leg flexed and bottom leg straight.

The table should be low enough for the practitioner to comfortably reach over the patient and palpate the spinous process, as well as be able to lay their trunk over the trunk of the patient during the manipulation. The ability to use the weight of your trunk during this manipulation is almost mandatory, especially if the patient is considerably larger than you are.

Motion can be assessed using central or unilateral posterior to anterior lumbar mobilizations.

Note: this usually happens with the patient in prone prior to this technique

During the set-up of this technique, the therapist may also notice that the spinous processes of two vertebrae move together during flexion, extension, or rotation, indicating stiffness of the facets between those segments.

Place the fingertips of the hand closest to the patient's head over the spinous processes of the segment you wish to target with the manipulation.

Place the knee of the patient's top leg in the crease under your anterior superior iliac spine (ASIS).

Use your other hand and your ASIS, to move the patient's leg into hip flexion, to posteriorly tilt the pelvis, and flex the lumbar spine from the bottom up.

Continue to flex the hip, until the lower vertebrae of the segment you are targeting starts to move. This indicates that you have "locked-up" all of the joints below that segment (ligamentous lock).

Adjust the patient's bottom leg, top foot, and hip as needed to ensure you maintain ligamentous lock as you set the top knee on the table, turn slightly to face top half of the body and reset your ASIS to pin the top knee to the table and in position.

Switching hands while successfully completing step 5 may be the trickiest step in this technique; carefully replace the fingers that were monitoring motion of the spinous process with the fingertips of the hand closest to the patient's feet.

Using the hand closest to the patient's head, gently pull the bottom arm up and behind you to slowly rotate the patient's torso away from you. It may be helpful to cue the patient to allow their top shoulder to roll back as you pull the bottom arm forward and up.

Continue to rotate the patient's torso until you feel the top vertebrae of the segment you are targeting start to move. This indicates "facet lock" of all the joints above this segment.

Adjust the forearm of the arm closest to the patient's feet so that they are aligned over the patient's pelvis, and you feel you could use the friction between your forearm and the patient's pelvis to forcefully rotate it toward you.

Place your other forearm over the patient's lateral 

 , slip your hand under their top arm, and hold your opposite wrist.

Place your torso over your arms and adjust as needed to feel as though you are pressing and holding the patient in their end-range, i.e lock-out position.

Important Note: 90% of the manipulation technique is set-up. If you have not achieved lock-out in the previous steps, having great "thrust technique" will be rendered useless.

The motion is primarily toward the table, with the intent of rotating the spine. Most of the force is coming from the practitioner's body weight.

Visualize the small, rapid motion (maybe 4 - 6"".). You are trying to force "one segment" to rotate.

Tip: have the patient take a deep breath or wiggle their toes. Your goal is to distract them so that they allow you to passively control their trunk with as little muscle activity as possible.

Quickly, thrust the patient into the new position by allowing a large portion of your body weight to depress into their torso while pulling back with the forearm on the pelvis, and pushing a bit forward and toward the table with forearm over the lateral 

 . Again, you are depressing into the table with some intent to rotate. This generally takes a little practice before it can be performed at "high velocity"

Slowly and gently release pressure, by standing up, tipping the patient back into side-lying, or gently performing physiological rotational mobilizations in side-lying to allow the patient a moment to "catch their breath".

Lumbar Spine Joint Manipulation (High Velocity Thrust)

Cuboid Manipulation

Sacroiliac Joint Chicago Technique

Thoracic Pistol Manipulation

Upper Cervical Manipulation

Radial Head Manipulation

Shotgun (Pubic Symphysis) Manipulation

Wrist Manipulation

Talocalcaneal Manipulation

Talonavicular and Cuneonavicular Joint Manipulations

Proximal Tibiofibular Joint Manipulation

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