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 0:18 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 do the 1:12 proximal tibiofibula joint manipulation. I'm going to have my friend Yvette come out, 1:16 she's going to help me demonstrate. Now if I'm doing the proximal tibiofibula 1:20 joint manipulation chances are I'm basing it on a lot more 1:24 than just subjective symptoms. I want to follow that up with objective tests like 1:28 maybe my overhead squat assessment, maybe Yvette here had knees bow in, knees bow 1:34 out or feet turnout on the overhead squat. Something that would lead me to 1:38 believe that there's some sort of dysfunctional motion happening at the 1:42 knee joint itself, and then maybe I'd follow up with something as simple as 1:46 like that hamstring length goniometry so that i had some sort of 1:49 continuous interval measure to actually address a progress and see some progress 1:54 over time. So the next and last thing we would do is then palpation, we know 1:59 palpation is our least reliable assessment but it is really important in 2:02 the case of this joint. This joint has a tendency to both become stiff in some 2:06 individuals and hypermobile in other individuals. In fact dislocation of this 2:13 joint is not a totally uncommon diagnosis, so we have to make sure that 2:17 we're not doing this technique on individuals that 2:20 already have a very mobile proximal tibiofibula joint. So the first thing 2:25 I'm going to show you how to do here is palpate the fibular head, and it's 2:30 pretty easy. Usually I'll set somebody up at 90-degrees just like I was doing like 2:34 an anterior or posterior drawer test. I'm going to go ahead and just 2:39 use a pincer grip, if I go just below the joint line here of the knee you can 2:44 feel the the fibular head right here. Now if I just grab on either side of my 2:50 fibular head and give it a wiggle, that's actually pretty stiff right. So if 2:56 you feel no motion, no wiggle or it's very hard to get it to wiggle 3:00 that's probably a good indication to do this technique. Now if you grab it and 3:07 it's pretty easy to wiggle and it's only going to be two or three millimeters, 3:10 we're not talking about huge motion but that two or three millimeters happens 3:14 really easy, don't do this technique. There's no need and obviously we don't 3:19 want to promote hypermobility, that could potentially lead to 3:22 dislocation which is going to be a whole another set of symptoms that we would 3:25 have to try to address if that happened. Now the technique itself is pretty quick, 3:31 and easy once you get the hang of it we're going to use our second MCP which 3:37 this is a knuckle you need to get very used to using if you're doing 3:42 manipulations, we're going to put this knuckle right over the fibular head. Now 3:48 I'm going to show you this again in a close-up recap so don't worry if you 3:51 can't totally see where I'm putting my hand, but I'm going to put that MCP over the 3:56 fibular head and then what I'm going to do is I'm going to smash my hand in between 4:03 Yvette's thigh and her calf. So rather than trying to create a manipulation 4:08 force this way which is just it's awkward and hard to do that, we can 4:13 literally just whip her lower leg, use this as kind of like a 4:19 spacer on her fibula so that we get the rest of her leg moving, and hold 4:25 her fibula back while we do this thing. You ready to see what that looks 4:30 like? So for 4:32 MCP I'm going to get nice and locked up, I want to make sure that I press in and 4:37 I'm feeling her fibular head right up against that knuckle when I'm in that 4:44 end range position. Once I know it's going to be there and a little trick, a 4:48 little clinical gem for you, sometimes it helps to turn the tibia and 4:52 external rotation. So I'm even further pressing the fibular head into 4:56 my hand, I get right there, okay I know I'm going to lock out right there. 5:00 I tell Yvette to give me a nice deep breath, and I mentioned before 5:04 unless we're doing like spine manipulation, breath doesn't totally matter, but it's a 5:10 great way to distract your patient so they don't guard on you. So 5:14 take a deep breath, she takes a deep breath I get all locked out and then, and 5:18 that's it. It's almost like I'm trying to get her to kick her own butt. 5:22 Did you see how that worked? It's just that simple, boom. Sometimes you get 5:27 a cavitation, sometimes you won't. Keep in mind cavitations aren't necessarily the 5:32 indicator of a successful manipulation, the manipulation and reassessment right, 5:40 what happened on your reassessment is indication of a successful manipulation. 5:44 Now there is one other way to do this, right we could have a Yvette go ahead and 5:50 turn over, and she's going to lie facedown. 5:54 Now in this case we're going to get a little weird, we're going to use this 5:59 knuckle against the fibular head, we're going to do the same thing, kind of lock up 6:05 right, and then we can push down this way and we got a nice little pop there. 6:11 So we did notice that that side was stiff, I did notice earlier that this 6:14 side was not. The big problem with this technique and probably why I don't use 6:19 it very often, is if somebody has any rectus femoris tightness, like you have a 6:25 very hard time getting their leg far enough that you can actually smash their 6:31 leg together enough for you to apply enough force to the fibular head. Does 6:37 that make sense? So if we get here, like you can imagine if she was super tight 6:42 I'd get here, and then I'd go to do my manipulation 6:45 and I just don't have, I'm not actually squeezing anything together. So you 6:50 can try this if somebody's fairly mobile, other than this one particular joint you 6:55 might be able to get away with that. Otherwise go ahead and flip over back on 6:58 your back, this tends to be the better technique. So one more time, 7:06 second MCP over the top of fibular head, you can externally rotate a little bit 7:11 to feel that fibular head push into that MCP. We're going to get all locked up so we 7:18 know that when we do our final whip that we're getting pressure where we need it, 7:23 and then of course once we get there take a nice deep breath and we just do a 7:28 little, and that's it. All right so we're just swinging the leg a few centimeters 7:33 to get basically a posterior to anterior force against the fibular head. Stay 7:39 tuned for your close-up recap. All right for your close-up recap, starting 7:43 with palpation if we have the knee joint line kind of like right here and this is 7:47 where you would expect it to be, if we go down a little bit you can 7:51 feel this bump right about here, that's the fibular head and if you pincer grip 7:57 it you should be able to move it back and forth. Now of course we're going to base 8:00 it on additional assessments, but if you were to feel stiffness that might be an 8:04 indication to do this particular manipulation. What I'm going to try to do is 8:08 if you see where this finger is right behind the fibular head, I'm now going to 8:12 try to put my second MCP right there, so I'm going to just put my 8:22 hand right up in there and getting through all of the soft tissue, and then 8:26 I might even turn her tibia out. You can see I just kind of turned her foot 8:32 out there and what I should feel is I turn that out like it presses the 8:36 fibular head right into my MCP, and then I want to double check to make sure that 8:42 if I press down is that going to increase tension or increase the amount 8:47 of force on my MCP, and if I get that check then I'm going to go ahead and 8:52 tell Yvette to take a deep breath, and I'm going to go ahead and just a real 8:58 quick, and that's it. Just like she's trying to kick her own butt. 9:02 I just have to remember to go a few centimeters, again one of the common 9:08 mistakes that's made on manipulations is probably not moving enough. Although low 9:13 amplitude means less motion and we're not doing high amplitude manipulations like we 9:18 would move the whole leg. You still do need to move a good few centimeters to 9:23 make sure you take up all tissue slack, to make sure that you're moving through 9:27 all the soft tissue, maybe somebody's clothing and actually getting to the 9:32 point where all that's left is motion at the bone to force it. So again for second 9:39 MCP right behind the fibular head, I can even twist the tibia so that I press the 9:44 fibular head into my MCP and then I'm going to press it up against her thigh 9:48 make sure I got a good lock position once I'm set up, pop. A couple of points 9:53 to recap, knowing your Anatomy and knowing your biomechanics will certainly 9:57 help you choose the right technique for the right patient. If you're unsure 10:01 whether manipulations are appropriate due to their higher intensity, it's okay 10:07 to do mobilizations. Most research points to manipulations being slightly more 10:11 effective, but mobilizations being very effective, and of course we have those 10:16 videos for you if you want to start with those less intense techniques. Make sure 10:21 that if you are doing any technique that it's based on assessment, and of course 10:25 that you're reassessing ensuring that the technique is effective for the 10:29 patient that you're working on, and when it comes to all manual techniques, 10:33 manipulations maybe more than any other, look for opportunities to get live 10:38 education. Although I know videos are convenient and I'm happy to have these 10:43 up for you to watch, it would be so much more helpful to use those videos as 10:49 a recap of one-on-one attention with somebody who's experienced with 10:55 manipulation techniques. At the very least grab a colleague, grab a friend and 11:01 start practicing these before you bring them into clinic and start using them on 11:06 patients and clients. I hope you enjoyed this video, if you have any questions 11:10 please leave them in the comment box below.
