0:04 This is Brent of the Brookbush 0:05 Institute, and in this video we're bringing 0:07 you another manual technique. Now if 0:08 you're watching this video I'm assuming 0:09 you're watching it for educational 0:11 purposes, and that you are a licensed 0:13 manual therapist following the laws 0:15 regarding scope of practice in your 0:17 state or region. That means athletic 0:19 trainers, chiropractors, physical 0:20 therapists, osteopaths, licensed massage 0:23 therapists, you are likely in the clear 0:25 to do these techniques, personal trainers 0:28 this probably does not fall within your 0:30 scope of practice; although you might be 0:31 able to use the palpation portion of 0:33 this video to aid in learning your 0:35 functional anatomy, in an educational 0:38 setting supervised by a licensed manual 0:41 therapist. Now before we place our hands 0:43 on a patient or client it is important 0:45 that we assess and have a good rationale 0:48 for doing so, and of course if we're 0:50 going to assess then we should be 0:53 reassessing to ensure that the manual 0:55 technique we're using is effective, and 0:57 we have a good rationale for continuing 0:59 to use that technique. In this video 1:01 we're going to go over static manual 1:02 release of the rhomboids. I'm going to 1:03 have my friend Melissa step out and help 1:04 me demonstrate. Now this technique uses 1:07 the same protocol we've used for all of 1:08 our static manual release techniques, 1:10 that basically comes down to palpate and 1:11 compress, although we are going to get a 1:13 little bit more detailed, talk about how 1:15 to differentiate the rhomboids from the 1:17 other tissues in the area. We're going to 1:18 talk about where our common trigger 1:20 points are, we're going to talk about 1:22 what other tissues in the area maybe 1:24 are contraindicated to press on, and then 1:27 of course the last thing we're going to 1:28 talk about is patient and client 1:30 position and your position, so that you 1:33 have great technique. 1:34 Now the rhomboids are deceptively 1:37 difficult to get a good release on. iIt's 1:40 a fairly thin muscle, we don't have those 1:42 big thick fibrous bands to find, that gives 1:45 us really good indication of like a 1:47 fiber direction; and there are a couple 1:50 of other muscles in the area, not to 1:51 mention the rib cage right underneath it. 1:53 So let's talk about how to differentiate 1:55 this tissue. The thing to start with 1:57 would be your origins and insertions to 1:59 set up some borders for the area that 2:02 you should be in. The origin of your 2:04 rhomboids major and minor goes from C7 2:07 to T5, and then the insertion is the 2:11 vertebral border of your scapula which 2:13 is fairly easy to palpate there. So if 2:15 you find these things 2:17 roughly C7 to T5 to the vertebral border, 2:22 and you draw a little box around that 2:26 you get this little twisted square, also 2:30 known as a rhomboid, which is where the 2:33 rhomboid muscle gets its name from. 2:35 We know that this is the area we 2:37 should be palpating in, so what other 2:39 tissues are there that maybe we need to 2:41 differentiate? Well, I happen to know that 2:43 our traps lie on top of our rhomboids, so 2:47 our lower trap and middle traps 2:49 specifically, we need to kind of figure 2:51 out how are we going to differentiate 2:52 between lower trap and rhomboid. Well 2:55 being that my rhomboid goes in this 2:57 direction we would expect more of a 2:58 horizontal fiber direction. My lower trap 3:01 goes from the spine of the scapula, the 3:04 medial portion of the spine of my 3:05 scapula, all the way down to T12. So we 3:08 get this somewhat oblique but mostly 3:11 vertical fiber direction, and what the 3:14 lower traps actually feel like is a 3:15 somewhat triangular shaped vertical 3:19 column of muscle, being that those fibers 3:22 are vertical it makes it very easy to 3:24 differentiate that from what would be 3:26 horizontal fibers of the rhomboids. Now 3:30 the middle traps do have that horizontal 3:32 fiber direction, but if we follow them 3:35 they don't go into the vertebral border 3:38 of the scapula they continue on to the 3:41 spine of the scapula, not to mention the 3:44 middle traps are much much thicker than 3:46 the rhomboids. So after you've done this 3:48 a few times you've learned how to 3:49 identify the rhomboids, you know how to 3:51 identify the mid traps, you're going to 3:53 know when you're on the trapezius muscle 3:55 in general just because it's a much much 3:56 thicker muscle. Now the only other muscle 3:59 that's in that area is the serratus 4:02 posterior superior which is deep to the 4:04 rhomboids, very thin, not generally 4:08 something we think about palpating, 4:10 something we think about having trigger 4:12 points. I would imagine if we were trying 4:14 to go after it, it would have something 4:15 to do with CT junction dysfunction, maybe 4:18 breathing dysfunction, maybe some 4:20 sort of assessed dysfunction of the upper 4:22 ribs. If we're trying to palpate the 4:26 rhomboids, my guess is we had more of the 4:29 thoracic or scapular dyskinesis 4:32 that we're worried about. I think it's 4:33 actually fairly uncommon for us to go 4:39 after the rhomboids, when the serratus 4:40 posterior superior was involved, or vice 4:42 versa. 4:43 I think that muscle for the most part is 4:45 not something that we're going to have 4:46 to worry about, and when we talk about 4:47 step 2 - where are the common trigger points, 4:49 we're going to find out that our hands 4:50 are actually going to be even further 4:52 from the serratus posterior superior. So 4:55 the trigger points here, that's getting 4:58 into step 2, are all along the vertebral 5:01 border of the rhomboids. This is a really 5:04 important fact because this is what's 5:06 going to save us when we try to locate 5:09 these hypertonic fascicles within the 5:13 rhomboids, because if you try to 5:15 feel here, like let's say you just start 5:18 trying to feel in that rhomboid area for 5:21 horizontal fibers, I don't think you're 5:23 going to find much. There's like there's 5:25 not these differentiated fascicles in 5:28 here and unfortunately we have the 5:29 ribcage which has these little bumps in 5:32 it, which make it a little hard to figure 5:36 out whether you're just feeling bumps on 5:38 the ribcage, or you're actually feeling 5:40 some fascicles on the rhomboid. You can 5:42 even end up just feeling this flat mush 5:44 over the ribcage until you get down into 5:49 the vertebral border here, and at the 5:51 vertebral border you can feel a little 5:54 bit of thickness as the rhomboid turns 5:58 into these tendinous fibers 6:02 that invest into that vertebral border. 6:05 In fact we're going to make this even 6:07 easier for ourselves, we're going to go 6:08 ahead and ask Melissa to put her hands 6:10 up over her head. If she didn't have a 6:13 face cut out in this table we could 6:15 actually have her put her hands 6:16 underneath her forehead which sometimes 6:18 it's just more comfortable, now I've 6:20 lengthened out these rhomboid fibers 6:22 even further. That's going to add a 6:24 little tension, maybe make it easier for 6:28 me to feel the horizontally oriented 6:30 fibers. It's also going to help me with 6:33 that finger on a marble game right, we 6:36 don't want to play that, we don't want to 6:37 play that game where we keep trying to 6:39 hit trigger points but they keep sliding 6:41 out from underneath our fingers. We can 6:42 use 6:42 this increase in length, increase in 6:44 tension on the rhomboids to help 6:45 stabilize that trigger point. I think 6:48 once you get somebody in this position 6:49 and you start strumming perpendicular to 6:52 those fibers right up against the 6:54 vertebral border, now you start feeling 6:57 some fascicles. But it's really not until 7:00 we get into this position and feel very 7:03 specific to about where these trigger 7:05 points are along the vertebral border 7:08 that we can feel anything, and I want you 7:10 guys to experiment with this, experiment 7:12 with hand down and then hand up and I 7:15 think you'll see what I'm talking about. 7:16 Now before we take this to the actual 7:19 technique and getting a good release 7:22 here, is there anything contraindicated, 7:24 is there anything that I shouldn't put 7:26 pressure on, is there anything that's 7:27 sensitive in this area -the answer is no 7:30 not really. You always run the risk of, or 7:33 the chance of over stretching like a 7:35 sensory nerve or something, like 7:37 something that gives us some 7:39 sensation in the skin and that would 7:43 give us some sort of like sharp twinge 7:47 of pain, like it's that burning searing 7:49 pain I know we've all felt when somebody 7:50 like stretches our skin the wrong way 7:52 and you like it that little that little 7:54 zap, but even that's fairly uncommon in 7:57 this area. I don't think it's something 7:58 that you're going to have to worry about. 7:59 So this is probably the best position 8:02 for the patient, before I go through this 8:05 technique also notice that I am working 8:09 on the rhomboid that's farthest from me, 8:11 and they're the reason for that has to 8:13 do with how we're going to pin the 8:15 tissues. If I were to try to do the 8:16 rhomboid closest to me I end up kind of 8:19 like this trying to push down towards my 8:21 thigh, which this type of force just 8:24 isn't a real easy force to apply. I'd 8:26 much rather be pushing across my body be 8:29 able to walk out my arms and just lean. 8:31 So this is the patient position I know 8:34 it was a long explanation to try to get 8:36 to where we're going to be, and the 8:37 technique isn't that difficult. All I'm 8:40 going to do is take a thumb, strum 8:43 perpendicular to what would be the 8:46 direction of the fibers at this point, 8:47 which is going to be parallel to the 8:51 vertebral border of my scapula. Once I 8:54 find something that feels like an 8:56 increase in tissue density, I'm then 8:58 going to go a little bit along the 9:01 length of the fiber and see if I can 9:04 identify a nodule of tightness. Once 9:08 again those nodules are going to be 9:09 pretty close to the vertebral border. I 9:12 don't know if you guys can see the X's 9:14 where I actually marked off the trigger 9:15 point parts, but when we get into the 9:16 close-up recap I know you will. 9:18 Once I've not only identified the tight 9:21 fascicles but I've done my palpation 9:23 along the length of those fascicles to 9:25 find the tight nodule, now what I'm going 9:27 to try to do to pin it -is actually push 9:29 into the vertebral border of the scapula. 9:33 I find that that is easiest and what 9:36 I'll usually do is since I was just 9:37 strumming this way, I'll use my thumb to 9:39 kind of block this way and then I'll put 9:42 my thumb right in between my thenar eminence 9:46 there, just like so walk out my arms, and 9:50 press in. How does that feel? Okay a 9:54 little tender I'm sure, I'm sure this is 9:57 just a little bit of tenderness here, and 10:01 of course after I get one release let's 10:03 say after 30 seconds to two minutes of 10:05 holding, that's not a tremendous amount 10:07 of pressure. I just have to press up to 10:10 the point of the tissue giving me some 10:13 resistance back, I don't have to like try 10:16 to push my thumb all the way down 10:18 underneath her scapula per se. I just 10:22 wait for a release then I can do the 10:24 same thing, perpendicular strums try to 10:28 feel for an increase in tissue density, 10:32 increase in tissue tightness, right about 10:37 there I'm feeling some tight fascicles, 10:39 and then I can move along the length of 10:41 the fascicles 10:42 to find a tight nodule, and then again 10:46 I'm going to make sure I can get some 10:48 pressure on that nodule and I find that 10:50 going in kind of this direction rather 10:53 than like let's say straight down, if 10:54 you did go straight down it just hurts a 10:56 little bit, you just end up pushing into 10:57 the rib cage. So if I go this way a 10:59 little bit -this direction, I can hold, 11:03 get a good release, 11:05 and on my bottom hand as soon as this 11:08 hand puts pressure becomes the dummy 11:09 thumb, I'm not using my hand strength I'm 11:12 just using my bodyweight to get a good 11:14 release. Now the only tricky point is 11:19 this rhomboid minor trigger point in 11:23 this position doesn't quite work, because 11:25 unfortunately when we 11:26 upwardly rotated the scapula 11:28 the superior angle ends up 11:31 retracting a little bit. So we need to 11:34 lengthen out these rhomboid minor 11:35 trigger points. I think the easiest way 11:37 to do that is to actually have Melissa 11:39 put her hands underneath her ASIS, 11:42 alright so I know you guys have seen 11:44 this position before and then I might 11:47 even try to protract her a little bit 11:50 further, abduct her scapula as far as I 11:53 possibly can and then I'm just going to 11:56 go ahead and palpate that superior 11:59 portion of her rhomboids right up 12:02 against the superior third of the 12:05 vertebral border of her scapula. 12:09 Doing my perpendicular strokes, now I'm 12:12 doing my along the fiber to find the 12:15 nodule, found it -make sure I can apply 12:20 some pressure right without losing it, 12:22 it's not trying to shoot out from under 12:24 my finger. I'm going to use my hand 12:27 here putting my thumb right in the 12:29 middle of my palm and just leaning, and 12:32 that's it. This is a real easy technique 12:34 for me, for Melissa it might not 12:37 feel that easy up front, we're going to 12:39 get a little bit of tenderness at first, 12:41 but then it's going to let go and of 12:43 course for example if she had something 12:45 like downwardly rotated scapula as part 12:49 of like some upper-body dysfunction and 12:51 shoulder impingement syndrome, hopefully 12:53 this would give her better outcomes 12:55 after we finished this technique. Stay 12:57 tuned for the close-up recap. The 12:59 close-up recap, step one we have to be 13:01 able to palpate, differentiate this 13:04 muscle from the other muscles in the 13:05 area. I already have Melissa's arms up so 13:08 we pulled the vertebral border of the 13:10 scapula away from the other tissues we 13:12 would be concerned about confusing 13:16 ourselves with, being like the lower trap 13:18 column over here, you know we have the 13:21 mid traps that they're way up here, 13:23 and then our serratus posterior superior 13:25 would be somewhere in here. The vertebral 13:28 border of the scapula is, I'm trying to 13:30 palpate this for you guys and kind of 13:32 show you, you see that crease I just 13:34 created in our skin, that crease is the 13:37 vertebral border of our scapula, and 13:40 you'll notice that these are the common 13:43 trigger point sites for the rhomboids 13:45 which are all along that vertebral 13:48 border. So well now all we have to do is 13:50 do our strokes perpendicular to the 13:54 fiber direction, all right so we're going 13:57 to come through here like this, and not 14:01 surprisingly as I do these perpendicular 14:05 strokes, I'm finding that I have these 14:07 dense fascicles, this increase in tissue 14:10 density, this tightness occurring right 14:13 around these X's, especially this X on 14:15 her, maybe a little bit here too. So once 14:20 I find that increase in tissue density 14:23 then I'm going to search it this way 14:25 right, make sure that I'm right on the 14:29 tightest nodule and then I'm going to 14:32 try to make sure I have that trigger 14:35 point anchored, so that it's not moving 14:38 out from under my thumb, and then once I 14:40 have it nice and anchored I'm going to 14:42 go ahead and put my palm over the top of 14:44 that thumb, and I can do this with each 14:49 of the dense fascicles, or each of the 14:52 tight nodules in the rhomboids here, hold 14:56 for 30 seconds to two minutes. The only 14:59 one that's a little different is the 15:00 rhomboid minor, i'm going to have 15:01 Melissa move her arm down so she has 15:04 her hands underneath her ASIS, and then 15:08 I'm going to make sure she's abducted, 15:09 her scapula is abducted as far as 15:11 possible, she's protracted as far as 15:13 possible, 15:13 and then I'll look at the upper rhomboid 15:18 fibers, and once again doing my 15:20 perpendicular strokes once I find the 15:22 tight fascicles, 15:23 going along the length of the fiber and 15:26 then anchoring that dense nodule, and 15:30 putting my palm over the top of it; 15:32 to apply that static pressure for 30 15:36 seconds to two minutes. So there you have 15:39 it, knowing your functional anatomy will 15:41 definitely help your manual technique. 15:43 It'll help you differentiate structure 15:45 so that you can place your hands where 15:46 they need to be, as well as make you 15:48 aware of these sensitive structures 15:50 around the tissue that you're trying to 15:52 target. Things like nerves and lymph 15:54 nodes, and arteries. Make sure that if 15:57 you're going to place your hands on a 15:58 patient that you have done an assessment 15:59 and have a good rationale for placing 16:02 your hands on that patient, and if you're 16:03 going to assess, make sure you reassess 16:05 to ensure that your technique was 16:07 effective and you have a good rationale 16:09 for using that technique again. Now with 16:11 manual therapy, one-on-one live education 16:15 is incredibly important. Please be 16:18 looking for opportunities like workshops 16:21 and mentorships, and maybe even classes 16:24 at your local university that can get 16:26 you some one-on-one individual 16:29 instruction, or at least some live 16:31 classroom instruction so you've had a 16:33 chance to be critiqued and mentored by 16:38 somebody senior to you with some 16:40 experience in manual therapy techniques, 16:42 and before you bring this stuff back to 16:45 your rehab, fitness, or performance 16:48 setting, please practice on colleagues. 16:52 There is no substitute for practice and 16:55 it is going to take a while to get 16:57 accustomed to some of the techniques 17:00 that we show in these manual technique 17:02 videos. Don't expect to learn them in two 17:04 or three or even five minutes. You want 17:07 to have hours of experience under your 17:10 belt working on various different body 17:12 sizes and shapes. So that when you do get 17:15 that first paying client, first paying 17:17 customer, then you're really trying to 17:19 make a good positive impact, really 17:22 trying to promote better outcomes, you 17:26 feel comfortable with that technique. I 17:28 look forward to hearing about your 17:29 outcomes and hearing your questions in 17:32 the comments section of this video. I'll 17:34 talk with you soon. 17:43 you
