0:04 This is Brent of the Brookbush Institute, and in this video we're bringing 0:07 you another manual technique. Now if you're watching this video I'm assuming 0:09 you're watching it for educational purposes, and that you are a licensed 0:13 manual therapist following the laws regarding scope of practice in your 0:17 state or region. That means athletic trainers, chiropractors, physical 0:20 therapists, osteopaths, licensed massage therapists you are likely in the clear 0:25 to do these techniques. Personal trainers this probably does not fall within your 0:30 scope of practice, although you might be able to use the palpation portion of 0:33 this video to aid in learning your functional anatomy in an educational 0:38 setting, supervised by a licensed manual therapist. Now before we place our hands 0:43 on a patient or client it is important that we assess, and have a good rationale 0:48 for doing so, and of course if we're going to assess then we should be 0:53 reassessing to ensure that the manual technique we're using is effective, and 0:57 we have a good rationale for continuing to use that technique. We're going to go 1:01 over static manual release of the pectoralis major and subclavius muscles. 1:05 My friend Melissa is going to help me demonstrate this technique. We're going 1:08 to use that same palpate and compress release technique we've used in all of 1:11 our static manual release videos. We are going to break it down a little bit 1:15 though, and use our four-step process of differentiate, know where our common 1:20 trigger points are, know what tissues we probably shouldn't be compressing are, 1:23 and of course patient client and professional positions so that we have 1:27 good technique and our patient and client is comfortable. Now let's start 1:30 off with how large the pectoralis major is because that's going to be the first 1:36 step in our palpation. I think individuals kind of underestimate how 1:42 big this muscle is. It essentially attaches its origin to all of the 1:49 clavicle that isn't covered by the deltoid, so the medial two-thirds of the 1:52 clavicle, and then this is the the really large part, it also goes from 1:57 sternoclavicular joint all the way down to the xiphoid process. So this is a very 2:04 broad muscle and all of these fibers converge into the lateral lip of the 2:11 occipital groove, which you guys can see kind of how all this tissue right here 2:14 converges into the shoulder, kind of passing 2:17 underneath the anterior deltoid here. We do need to think about a couple muscles 2:21 that run underneath the pectoralis major, we have the pectoralis minor underneath 2:27 the lateral side of the pectoralis major. The nice thing from a palpation 2:32 standpoint is the pectoralis minor runs nice and vertical, while most of the 2:37 pectoralis major fibers run horizontal. So if you happen to be releasing this 2:41 pectoralis major trigger point then all of a sudden start hitting fibers that go 2:45 this way, you know you're not on pec major. Now if you want to release the 2:50 pec minor that's fine, but be cognizant of what you're releasing and ensure that 2:55 it's going to contribute to your goal. The other muscle that is underneath your 2:59 pectoralis major, I've marked a trigger point off with an X here, I'm going to 3:03 show you guys how to get to it, but it's your subclavius. Your subclavius is 3:07 a funny little muscle which can restrict posterior rotation and upward rotation, 3:16 or what's actually called elevation of the clavicle. So it can affect elevation 3:21 of the arm. We're going to show where that trigger point is, but it's it's way 3:25 up here in the corner right next to your your sternoclavicular joint. You kind of 3:30 have to wrap your finger underneath some of the pec major fibers. Now the trigger 3:37 points for the most part, the majority of the trigger points are right in the 3:42 middle of the length of these fibers. So I don't know if you guys can see these 3:47 X's, of course we'll do a close-up so you guys can see these X's, but these X's run 3:51 right down the middle, right right down the middle of the pec here, that's where 3:57 the majority of our trigger points are. There's an additional trigger point out 4:02 on this little wing of the pec major here and then we have one other trigger 4:09 point which I just mentioned, which is way up in here and this is generally 4:14 speaking a subclavius trigger point. Now getting into step 3, are there tissues 4:20 that we probably don't want to compress. Well when we're here we probably want to 4:25 be aware that we're kind of close to the brachial plexus, and if we put 4:30 tension on the pec major and the pec minor we could compress the brachial 4:34 plexus, and that's going to give us some some weird nerve sensations, either 4:38 numbing or tingling in the fingers, or that sharp burning pain. Of course if you 4:42 press down and any of that happens just move a little bit, nerves are fairly thin 4:48 structures so you should be able to move a half centimeter in any direction and 4:53 not be on that nerve tissue anymore. The bigger issue with pec major is if 4:59 you happen to be a male therapist treating a female about half of the 5:05 pectoralis major is covered by breast tissue. 5:07 This creates not only a issue where we need to be sensitive and respectful, and 5:13 also it kind of hurts to just smash breast tissue like that, that doesn't feel good 5:18 for anybody. So when we talk about how we're going to lay our hands down that's 5:23 going to be the biggest challenge, how do we lay our hands down get to these 5:27 trigger points and not just compress and put our hands where they probably 5:34 shouldn't be. Now with that being said you probably want to do a little bit 5:40 extra work assessing, explaining to your client where you're going to place your 5:46 hands, what you expect your outcome to be and get a verbal confirmation that it is 5:52 okay for you to do this technique. Obviously we don't want to allow 5:58 embarrassment or any sort of fear of sexual misconduct, which I know is a 6:06 terrible thing. If you have to bring another female physical therapist in the 6:10 room, or another female professional in the room because you feel uncomfortable 6:12 great. We really don't want that stuff though to prevent us from being good 6:17 practitioners. So I hope with the techniques I show you in this video you 6:22 guys feel totally comfortable placing your hands where you need to place your 6:26 hands. So patient and client positioning, you guys will notice I'm standing at 6:32 about her shoulder height, and for most of the trigger points in the pec I'm 6:37 actually not going to do the side closest to me, I'm going to do the side 6:43 further from me, and the reason being is I can get my hands out straight this way. 6:48 And then if you guys kind of see how I even put my hands just from 6:54 practice, I kind of have that fingers tilted up position so I can put my hand 6:59 down, starting at sternum and move laterally, 7:03 keep my fingers up and I'm nowhere close to sensitive areas. Melissa doesn't feel 7:10 uncomfortable, I don't feel uncomfortable, we're all in the clear once we're there. 7:14 We can then use those same palpatory techniques we've been going through in 7:19 all of our videos. I know these fibers are horizontal, all 7:23 right so I'm going to use a perpendicular stroke to find the most 7:28 dense or overactive fibers. Now a little trick here guys so that you don't play 7:35 the finger on top of a wet marble game, where the marble keeps trying to shoot 7:40 out, you want to pin these tissues down a little bit so you can really get your 7:44 fingers on top of one of these hyperactive nodules. I'm going to go 7:48 ahead and have Melissa place her hands behind your head. Now that she has her 7:53 hands behind her head I'm going to go ahead and start my perpendicular strokes, 7:59 and I can feel some nice nice overactive fascicles right there, and once I find 8:06 those overactive fascicles I will then search the length of the fiber, I told 8:10 you it's usually closer to the middle. Once I get close to the middle of 8:15 these fibers I do in fact feel like a little nodule of hyperactivity, what I'm 8:21 going to do is I'm going to actually keep my hand with my fingers flared out 8:24 like this, and then rather than try to like grip or press down with this hand, 8:31 I'm going to leave this is my dummy thumb. So if I keep my hand off of breast 8:35 tissue, I'm going to use this hand to apply pressure with kind of that 8:39 pisiform hamate grip we'd use for mobilizations, just like so. And you 8:45 can see Melissas face turn, I think I got that trigger point. It is a little tough 8:50 to play with the tension on these because the the muscle becomes pretty 8:54 thin here, but do try to be careful to not press too hard. You're 8:59 just pressing enough to get a little tissue tension back. Once you feel a 9:05 little increase in tissue tension then you just want to hold real still. So in 9:10 this position with my arms long using my right arm to apply most of the pressure, 9:14 I can just kind of lean in a little bit and then wait for a release. Now if this 9:21 technique you're not comfortable with, you could use thumb over thumb. I have 9:26 seen that, I have seen this before right, that tends to work too. I think a lot of it is 9:32 going to depend for you guys on the size of your hands. I happen to have some 9:36 pretty large hands and some very long fingers so this works better for me. I 9:40 have seen people do it this way who don't have as large hands, and this 9:44 is comfortable for them, so they put down this way and they end up keeping their 9:49 hands out of any sensitive areas. You're going to want to practice on a partner 9:53 and figure out what techniques work best for you. 9:56 Alright so as I mentioned, perpendicular strokes, perpendicular strokes then go 10:02 the length of the tissue to find the tightest nodules, and you can see I have 10:05 common trigger points I found earlier already marked off here, but just to show 10:11 you guys can you use this, perfect, up, there, yup, yep, okay right. And 10:17 then once again I'm just going to put this part of my hand right 10:21 over this thumb, this becomes my dummy thumb. I can even lay this down on top of her 10:25 sternum, like my thenar eminence over my sternum 10:32 here, and then just apply a little pressure just like this, and go ahead and 10:37 release all those trigger points. Now there's two trigger points that require 10:43 slightly different technique. The nice thing is they're not nearly, they're not 10:47 in the same sensitive areas. We have the lateral, very lateral trigger point of 10:53 the pectoralis major, which is really close to the shoulder. You guys can see I 10:57 have it marked off here. This one I actually do on the same side. I think I 11:02 showed you guys a technique when we did pectoralis minor, the hand position I 11:06 like to use for this stuff is I actually just take this hand 11:09 the hand that's farthest from my patient I guess now, and I just cup their 11:13 shoulder. So I'm just going to go up and grab their shoulder just like so. If I 11:17 grab their shoulder that puts my thumb right over these lateral fibers, and then 11:22 I can do my perpendicular strokes because these fibers are now running 11:26 this way. I can do my perpendicular strokes like this and then use this hand 11:30 to apply pressure. How's that feel? Yeah that's tender right. So I just cup her 11:38 shoulder, use this thumb to palpate, use this thumb for pressure. The trickiest 11:43 one is subclavius, because if you just put your hand down right here on the 11:49 let's say just lateral and just inferior to the sternoclavicular joint, 11:55 you end up on some really thick pectoralis major fibers. This is not your 12:01 subclavius, your subclavius is a thin little muscle. So what you have to do is 12:06 you have to find a way to fall, either fall off the clavicle inferiorly 12:12 underneath these thick fibers that are the pec major, or you need to find a way 12:17 to fall superiorly off the thick fibers of the pectoralis major into the 12:23 depression that's created right between the clavicle and the bulk of the pec 12:29 major. And of course if you're very careful with your palpation, meaning you 12:34 don't over press too fast you really work to find the depth that allows you 12:41 to kind of scan that layer of tissues, you'll find a trigger point which I just 12:47 did, and then you can kind of press on in. All right, so this one up here guys 12:53 is the subclavius trigger point, and just keep in mind that it's not just 13:00 lateral and inferior to your sternoclavicular joint, it's off the 13:06 pectoralis major fibers, in fact you might have to kind of push the 13:11 pectoralis major fibers out of the way with like a scooping motion so that they 13:14 lay on the inferior aspect of your thumb there. So just a quick review because I 13:20 know I just went over a whole bunch of stuff. 13:23 Most of the pectoralis major trigger points fall right down the middle of the 13:28 pec major, which means you need to do some experimenting with hands position 13:34 on a partner that maybe is not a patient, to figure out what the best position for 13:42 your size hands are, and I mentioned a few different ways. For me it works best 13:46 to use this hand as a dummy thumb, all right so the the inferior hand here 13:54 compared to my patient, and then use this hand to apply pressure, and I kind of 13:58 keep this like up and flared out position for my hand. I think it would 14:03 probably be fine to go thumb over thumb too, especially if maybe you had slightly 14:09 smaller hands than I do. Somebody who has smaller hands than I do 14:14 might also find it's fine to curl under and go on the same side. All these 14:22 techniques are very acceptable providing you can get into a position that is 14:26 straight-armed, using your bodyweight not your hand strength, and you're trying to 14:32 keep your fingertips which of course makes this a little bit more 14:36 affectionate, off breast tissue right. Again we don't want to let embarrassment 14:43 or any sort of fear of sexual misconduct, keep us from doing techniques 14:49 that are going to be effective. So make sure you're communicating with your 14:51 client, make sure they understand what's going on, and if you have to if you 14:55 happen to be a male therapist with a female patient, bring another female 15:00 colleague into the room so everybody feels nice and comfortable. With the most 15:03 lateral trigger point remember my cupping the anterior deltoid trick. I think 15:08 it works great, you got your thumb here it gives you a lot of leverage and then 15:12 subclavius is going to be inferior to the clavicle, lateral to the 15:18 sternoclavicular joint, but off these thick superior pectoralis major fibers. 15:25 You kind of got to push them out of the way. Stay tuned for a close-up recap. In 15:30 this view you guys can see that the trigger points which I've marked off 15:33 with X's here, fall right in the middle of the length 15:37 of the pectoralis major fibers, and that's the middle of the pectoralis 15:41 major fibers running all the way from sternoclavicular joint to the xiphoid 15:46 process. So you can see here even these lower X's getting cut off would go all 15:50 the way down, having a trigger point at each of the bands of the pectoralis 15:56 major fibers. We talked about several hand positions. We're going to need to 16:00 not only address these trigger points, but our subclavius trigger point as well 16:05 as these trigger points on the lateral aspect of the pectoralis major fibers. 16:10 Let's talk about the majority of the trigger points first and the hand 16:15 position we used for that. We used a cross-body hand position in this one. I 16:21 find that it is most comfortable for me to reach across with my fingers turned 16:26 up, and this helps to keep my hands off of sensitive areas and to get my arms 16:33 straight so that I can use bodyweight and leaning, rather than hand strength to 16:37 try to release these trigger points. We talked about perpendicular strokes to 16:42 find the most dense fascicles, that would be fascicles we're going to presume that 16:48 are overactive. And then once we find a dense fascicle, we can then go along the 16:55 length of that fascicle to find any acute point of overactivity, a nodule, a 17:03 trigger point. Once we find that trigger point we can lay our thenar eminence 17:10 here, over the sternum so that our hands anchored and relaxed. This turns into our 17:17 dummy thumb and we can use our other hand, and I just use my pisiform hamate 17:22 here over my thumb to apply pressure, pushing just hard enough to get a little 17:30 give back from the tissue. So I feel like this give, give, give and then the tension 17:34 increases in a tissue and that's right where I'm going to hold it, 17:36 just at tension, 30 seconds to two minutes until I get a release. Of course 17:44 guys these are the hardest trigger points to release because 17:48 you end up having to do this turned up position with your fingers, to try to 17:51 keep your hands from laying down over sensitive tissues. The easier trigger 17:57 points to release are the lateral trigger points. The lateral trigger 18:02 points can be easily addressed by cupping the anterior deltoid, just put your 18:08 thumb in perfect position to do perpendicular strokes of these lateral 18:12 fibers. So you guys can see where I marked off the two common trigger points 18:20 here, find the densest fascicles. Once I find the densest fascicles I'm going to go 18:26 on the length of that fascicle for an acute point. Sometimes you're going to 18:32 want to pick up your finger there just so you don't take too much skin with you 18:36 and just get a skin short stretch, that wouldn't feel good, and once I find it, 18:40 again I can use this part of my hand right here over this palpating thumb now 18:47 becoming my dummy thumb, and just apply a little pressure until I get a release. 18:52 Now the trickiest palpation is the subclavius trigger point because if I 18:58 just push down right here, I'm actually not going to hit it. If I push down right 19:02 here I just get these thick, I don't know if you guys can see a little bit of 19:07 Melissa's hypertrophied pecs as she's obese, she works out hard, but this 19:14 is all really thick pectoralis major fibers. I need to find a way to get 19:18 around these. So you kind of have two options, you can either find these fibers 19:22 and then fall off them superiorly, pushing them down inferiorly as you do, 19:28 so you fall into the canyon between these fibers and your clavicle. Or what's 19:35 probably easier is put your thumb on the clavicle, and then fall 19:40 off the clavicle by pushing these pectoralis major fibers out of the way. 19:45 Once you're there, you're going to search that level of tissue for anything that 19:51 feels like a increase in tissue density, feels a little bit more tender to your 19:56 patient. You can watch their face in this position. Sometimes you find that first once 20:01 you're there, maybe thumb over thumb technique works here because we just 20:05 don't have as much room. I don't want to put my hand down over somebody's neck 20:10 that's going to be real uncomfortable. So I might just do a little thumb over 20:14 thumb here, maybe use a little bit more hand strength than I would on the other 20:18 techniques. So there you have it knowing your functional anatomy will definitely 20:22 help your manual technique. It'll help you differentiate structure so you can 20:26 place your hands where they need to be, as well as make you aware of these 20:29 sensitive structures around the tissue that you're trying to target. Things like 20:33 nerves and lymph nodes, and arteries. Make sure that if you're going to place your 20:38 hands on a patient that you have done an assessment and have a good rationale for 20:41 placing your hands on that patient, and if you're going to assess make sure you 20:45 reassess to ensure that your technique was effective, and you have a good 20:49 rationale for using that technique again. Now with manual therapy, one on one live 20:55 education is incredibly important. Please be looking for opportunities like 21:00 workshops and mentorships, and maybe even classes at your local university that 21:06 can get you some one-on-one individual instruction, or at least some live 21:11 classroom instruction, so you've had a chance to be critiqued and mentored by 21:18 somebody senior to you with some experience in manual therapy techniques. 21:22 And before you bring this stuff back to your rehab fitness or performance 21:29 setting, please practice on colleagues, there is no substitute for practice, and 21:35 it is going to take a while to get accustomed to some of the techniques 21:40 that we show in these manual technique videos, don't expect to learn them in two 21:45 or three, or even five minutes. You want to have hours of experience under your 21:50 belt working on various different body sizes and shapes, so that when you do get 21:56 that first paying client first paying customer and you're really trying to 21:59 make a good positive impact, really trying to promote better outcomes, you 22:06 feel comfortable with that technique. I look forward to hearing about your 22:09 outcomes and hearing your questions in the comment section of this 22:13 video. I'll talk with you soon. 22:23
