0:05 This is Brent of the Brookbush Institute and in this video we're going to go over a 0:07 joint based manual therapy technique. If you're watching this video I'm assuming 0:11 you're watching it for educational purposes and that you are a licensed 0:14 professional with joint based techniques within your scope. That means osteopaths, 0:19 chiropractors, physical therapists you're probably all in the clear. Physical 0:23 therapy assistants, athletic trainers, massage therapist you need this check 0:27 with your governing body in your state or region to see whether this is within 0:30 your scope of practice. Personal trainers this is definitely not within your scope 0:35 of practice, of course all professions could use this video for purely 0:39 educational purposes to help with learning biomechanics, anatomy and of 0:45 course palpation. In this video we're going to go over posterior to anterior 0:48 sacroiliac joint mobilization. I'm going to have my friend Melissa come out she's 0:51 going to help me demonstrate. Now Melissa is going to lie prone, you'll notice that I 0:55 have the table fairly low because I want to be able to get my chest over her 0:58 sacrum with arms straight, so that I can use my torso and not my hands or my 1:05 arm strength to try to manhandle this technique, that's going to wear me out very 1:09 fast. Now before we start this mobilization we need to have good palpatory 1:14 skills and palpatory skills basically comes down to practice and 1:19 anatomy, like you have to know your Anatomy. 1:21 If you haven't looked at the sacroiliac joint in a little while it's good to 1:24 review maybe an Anatomy textbook, look at those illustrations start identifying 1:29 various landmarks and how they relate to one another, and if you can get a hold of 1:35 one of these plaster cast models, I know they're not perfect and the 1:39 standard plaster cast model is of a fairly small person I would have to 1:43 guess, maybe somebody who is like 5 foot 4, or 5 foot 3 and Melissa here's like 1:48 almost 5 foot 8 so it's not quite perfect, but it'll do and it'll 1:53 definitely teach us quite a bit. I'll give you a couple landmarks that you 1:56 probably should be aware of. Every time I'm looking to do the sacroiliac joint 2:01 posterior to anterior mobilization realizing that I'm going to be pressing 2:05 on the sacral base, what I'm going to try to find is my PSIS. And I know that if I 2:12 fall immediately medially and I had to practice that now, immediately 2:17 medially off the PSIS, the posterior superior 2:21 iliac spine, I end up roughly on the S2 S3 segment of my sacroiliac joint. Well 2:29 okay maybe you're not great at finding the PSIS how would I do that? Well maybe 2:34 you start with the iliac crest, and the iliac crest is fairly easy to palpate 2:38 right that's the top of your pelvis, the top of what people call their 2:41 hips where they wear their pants. So you could follow your iliac crest to your PSIS 2:46 and I personally like to find the under that corner, hook underneath the 2:50 PSIS, so I hit the same point every time and I don't end up on this. Alright so I 2:55 want to be able to hook underneath the PSIS, maybe I have to start at the iliac 2:58 crest. Maybe you want to take it a step further, 3:01 what does your iliac crest line up with as far as what spinous process of the 3:06 lumbar spine? Well it lines up with roughly L3-L4 spinous process so I 3:11 should be able to find those spinous process, work my way down, know that L5 is 3:15 going to feel a little hidden and then I'm going to have a divot all right like a 3:18 little fold there and then I'm going to go on to the alligator back of the sacrum. 3:23 And sure enough if you tried to find that I think you guys would find that it 3:29 feels a lot like I'm describing to you right, like I can feel like this little 3:34 divot in here right which is like this part represented right here. Another 3:39 thing you might want to be able to identify is you know where the ischial 3:43 tuberosity relative to the iliac crest. Where are the where's the coccyx 3:47 relative to the rest of the sacrum relative to the iliac crest? You kind of 3:52 want to have a good visual model in your head of where all these landmarks are, 3:56 where your hands are, and how to get back to what you're trying to palpate, which 4:01 in this case is the sacral base. I would definitely recommend practicing on one 4:06 of these plaster cast models by closing your eyes, choosing a landmark, laying 4:11 your hands down and forcing yourself to work through those landmarks until you 4:15 end up on whatever you chose. Let's say I said sacroiliac joint here 4:23 and then when I open my eyes am I on the sacral base, and I'm sure enough I am. You 4:28 might want to even test yourself by choosing some of those other points. 4:32 Can I find my coccyx right, and sure enough I found the tip of my coccyx. The 4:39 reason being is people are not all shaped the same, you're going to be 4:43 working through various techniques so you want to be able to go from one 4:46 technique to the other as smoothly as possible. 4:49 And when you lay your hands down you have no way of knowing boom there's my 4:53 PSIS, you might get lucky, and the better you get the closer you'll 4:58 get over time. But it is always helpful to kind of have a step by step 5:02 process here. Let's use the simplest of these processes I'm going to 5:06 find the iliac crest, I'm going to follow my iliac crest to my boney notches being 5:12 my PSIS. I'm going to hook my thumb's underneath the PSIS so I find those 5:17 corners, that corner will lead me right to the S2-S3 segment of the sacral base 5:27 which is exactly where my thumb's need to be to do this mobilization. So 5:32 there you have it, we have all of our palpation leading to the landmark we 5:37 need. Now notice I kept saying S2-S3 segments of the sacral base, it's kind of 5:43 odd and I can't totally explain why from a biomechanics standpoint. Despite the 5:49 fact that the sacrum is fused segments of the spine right they don't move 5:54 separate from each other, it is helpful to mobilize the segments like they 6:02 aren't fused, if you're with me. Maybe it just has to do with the breadth of the 6:07 joint, like our thumbs aren't wide enough to mobilize the whole thing at once. 6:11 Maybe it has to do with the way the bumps are right, like those joints 6:16 aren't two smooth surfaces together, they're kind of bumpy, right they fit 6:19 together like with bumps and grooves. Maybe so maybe we're mobilizing 6:24 different bumps and different grooves as we move through the segment, but kind of 6:28 keep in mind that if you find the S2 to S3 segment you're probably going to have to 6:33 move up at least one segment, and you are probably going to have to move down at 6:37 least one segment maybe two. So you could start your mobilizations however if 6:42 you want you can start on the S2 segment, work up one 6:46 and then go back down two's to your S3-S4 segment and maybe go down one more. Or 6:51 you could find S2-S3 segment and try to start at the top of the sacral base and 6:55 work your way down. Whatever you want to do just understand that you're probably 6:58 going to have to mobilize a few segments before you feel like you've got good 7:03 mobility back into what was an assessed stiff SI joint if you're doing this 7:08 mobilization. Now let's talk about hand position, this is one of those techniques 7:13 that works best with your thumbs which is really unfortunate, because this is a 7:19 very stiff joint which means it's going to take a lot of strength, it's going to 7:24 take a lot of force to get a little bit of motion and that's all you're really 7:28 looking for, is a little bit of motion. So again if I find her PSIS I fall off, my 7:34 go-to technique is going to be just like this thumb touching thumb. I'm going to try 7:44 to find my first resistance barrier which is right there, and then my end 7:47 which is right there. These are very close alright the first resistance 7:52 barrier and the end, there's not a whole lot of motion. So trying to determine the 7:57 difference between a grade three and a grade four immobilization for example is 8:00 going to be very hard if not impossible. Generally speaking I try to find the end 8:05 range, I back off and then I mobilize. I think if I'm doing grade three it's a 8:13 little less intense and more mobility, grade four I'm really kind of digging in 8:17 and doing small oscillations at end range and I just kind of leave it at 8:21 that. Trying to find the 50% mark or 75% mark for a joint that has very little 8:26 motion to begin with is going to be very challenging. 8:30 Now just to kind of go back over the same techniques we've been doing through 8:35 all these mobilizations; first resistance barrier, end resistance, barrier back off, 8:39 do my one to two oscillations a second kind of going from that first resistance 8:46 barrier into roughly 50% until I get an increase in mobility, and then as I 8:53 mentioned I'm going to have to move segments. So I actually started on the S2-S3 8:58 segment here, I might want to move up one and then move down a couple. Try to 9:03 get all that mobility back that I possibly can, but this is just one hand 9:08 position. Now I'm going to show you another hand position that I've been 9:12 working on that I have a hard time with, and I think you might have a hard time 9:17 with it too but I'm challenging both of us to try this technique, and that's to 9:22 use pisiform hamate on the sacral base. The reason I think this is a challenge 9:28 is because the PSIS actually hangs over the sacral base a 9:33 little bit, and it's actually kind of challenging to get your hand, the thicker 9:39 part of your hand on to the sacral base. Now maybe it's just me and I've 9:44 mentioned before I do have bigger than normal hands right, and Melissa's well 9:49 Melissa is kind of an average-sized individual with average dimensions. Maybe 9:53 my hands are just too big to to get in there and you guys will have an 9:57 easier time, maybe it's a feel thing like I don't feel things as well here 10:01 as I do the tips of my fingers. Either way it's worth trying because of how 10:06 hard this joint is to mobilize, how delicate our thumbs are, and of course if 10:11 we're trying to extend our careers I've mentioned several times that if you can 10:14 find a way not to use your thumbs don't use your thumbs. There's too many 10:19 techniques already that are totally dependent on us being able to use our 10:23 thumbs. The other big tip for this technique or I guess the big tip for 10:29 this technique is don't try to go on the same side, this probably won't work. If 10:36 you go to the other side it'll work better. Now this happens to be Melissa 10:41 stiff side, and just as a pointer more often than not, in fact almost 10:46 always you only have one stiff SI joint they usually both don't get stiff. 10:51 This happens to be her stiff side if I was going to keep working on her with this 10:54 pisiform hamate grip I'd walk around the table, for you I'm just going to show 10:59 you on her opposite side. I want to try to get underneath her PSIS 11:03 and push down on her sacral base. So I'm going to find the PSIS, use my fingers to 11:09 find where I want to be, put my pisiform hamate 11:13 over my fingers and then go this way. And you can already see this would be a lot 11:19 less pressure on me physically. I think this feels okay. I'm not sure I have got 11:26 the same outcomes from it as I do with my thumbs, but I'm going to keep practicing. 11:31 I want you to keep practicing because I think this could be a career 11:36 saver long term. How's that feel Melissa, this probably feels a lot better than me 11:42 pushing on your other side huh? Yeah so her stiff side is this side which is why 11:46 it's a little a little bit more tender for her. So just a quick repeat of what I 11:51 showed you. This posterior to anterior mobilization for the sacroiliac joint is 11:56 definitely my go-to for sacroiliac joint dysfunction. Look for the stiff side, do 12:01 my PA's, see if I can increase mobility, tends to have a pretty big effect on my 12:06 outcomes. I did this mobilization by finding iliac crest, using my iliac crest 12:12 to find my PSIS, hooking my fingers underneath my PSIS, dropping off 12:17 immediately medially all right onto my sacral base, that's S2-S3 great. I can do 12:25 this thumb technique, or I can challenge myself walk around the table and use my 12:31 pisiform hamate because I know that'll be better for my career long term, and 12:34 then of course I have to remember that I probably should move up and down 12:39 segments, and treat the SI joint like it has several segments similar to how I 12:46 would like the lumbar spine as a whole. Alright I have the plaster cast 12:50 model set up here so you can see where we're trying to get our hands when 12:54 we do these two different techniques, the the thumb over thumb technique for the 12:58 same side, or we're trying to do that pisiform hamate on the opposite side. So 13:03 here's the PSIS on the plaster cast model, we would fall right off immediately 13:07 medially onto the sacral base and do our PAs goin segment by segment. Or we would 13:15 try to get our pisiform hamate down into this space here on the opposite side, 13:22 that would be the other way to do this technique. Now I've had Melissa 13:27 roll down her belt line here just a little bit so that that we're palpating 13:33 directly on skin. So you can see here if I follow the ilium down 13:39 I find her PSIS right about here, so right just above her backside there and 13:49 then if I fall off immediately medially I'm now on sacral base. So now 13:55 I can get my hands in position and I can find the first resistance barrier, last 14:01 resistance barrier just quite a bit of force, and then I can back off a little 14:05 bit and do my one to two oscillations per second. Now don't forget you're not 14:12 just going to do one segment quote-on-quote of the sacral base here, you're going to 14:18 have to move up a little bit, make sure that you don't have stiffness higher, 14:23 you're going have to move down a little bit and almost treat the sacroiliac 14:29 joint like it's multi segmented like the lumbar spine. 14:33 Now what I've challenged all of us to do is to not just use our thumbs which is 14:38 kind of the easy way out although very hard on our thumbs, and try to teach 14:42 ourselves to feel with this part of our hand, go to the opposite sacral base by 14:48 falling off immediately medialy once again, onto that sacral base, and then 14:54 trying to use that point of our pisiform portion of our hand to try to get some 15:03 some good mobilization of the sacrum here on the ilium. Alright so you got 15:08 your thumb over thumb technique which of course you need to learn. Of course it's 15:13 a lot easier to palpate but once you get that down don't forget to keep working 15:18 on this one, just to save your thumbs and add a little longevity to your career. So 15:24 there you have it assess, address, reassess. Make sure that every time you 15:29 choose a joint based manual therapy technique it is based on an assessment, 15:33 and that you return to that assessment after you've finished the intervention 15:37 to see if it was effective for the individual, 15:40 the patient or client that you have in front of you. 15:43 Ensure that you continue to learn your Anatomy because your Anatomy is going to 15:48 help you with your hand placement, with understanding what a joint can do, with 15:53 understanding what you may gain from this particular technique. And of course 15:59 practice, you have to practice these techniques hopefully not for the first 16:04 time on a patient or client who just walked in the door. If you can find a 16:09 more senior instructor or a mentor to give you some really good hands-on 16:13 instruction, use your peers for some good feedback and of course always look for 16:21 live education to help with your manual therapy techniques. I know these videos 16:27 make education very convenient but there is no substitute for learning manual 16:33 therapy in a live setting, I look forward to talking to you guys again 16:36 soon.
