0:04 This is Brenda. The Brooke Bush Institute in this video. We're gonna 0:07 go over manipulations or High Velocity thrust techniques. I 0:10 assume that if you're watching this video you're watching it for educational purposes 0:13 and that you are a licensed professional with 0:16 high velocity thrust or manipulation techniques in 0:19 your scope of practice. If you're not sure check 0:22 with your state board most physical 0:25 therapists chiropractors and osteopaths, you're 0:28 in the clear. I believe that atc's you 0:31 can't do manipulations in the United States, although other 0:34 countries again, check your scope, of course massage 0:37 therapists and personal trainers. These are generally not 0:40 within your scope. Of course, you could continue 0:43 to watch these videos just for educational purposes. 0:46 Learn a little Anatomy learn a little 0:49 biomechanics. 0:50 If you're going to do these techniques, please make sure 0:53 that you have a good rationale for putting your hands 0:56 on a patient. This should be based on assessment. And if 0:59 you're going to assess I'm hoping that you'll 1:02 assess use these interventions and reassess 1:05 to ensure that you're getting the result that you're 1:08 looking for and have good reason to continue using this 1:11 technique this video. We're gonna go over Taylor and avicular and 1:14 Cuneo navicular manipulation. I'm 1:17 gonna have my friend a vet come out. She's gonna help me demonstrate. Now, we're 1:20 gonna assume that a vet came in we've already done our assessment. 1:23 So if I'm doing manipulations, I'm not 1:26 just basing them off of passive accessory motion, which a lot of people 1:29 uses indicators four manipulation techniques. Unfortunately 1:32 research points to palpation being our least reliable assessment. 1:36 Now I'm not saying don't use palpation. But also maybe have 1:39 an overhead squat assessment some sort of postural or 1:42 transitional movement assessment in there. And then maybe 1:45 I would follow up with something like goniometry that I can use as my continuous 1:48 interval measure so that I can reassess and 1:51 figure out how much progress I'm getting and then 1:54 last I rely on my passive accessory 1:57 Motion in just my palpation skills. 2:00 So let's say you had feet turn 2:03 out knees bow in some flatness. 2:08 on her overhead squat 2:10 and then I did goniometry and her dorsiflexion was limited 2:13 and that all seems to meant to match her 2:16 symptomology because she's been complaining about some pretty classic plantar 2:19 fasciitis symptoms. 2:22 Right, so I'm gonna come over here and I'm gonna go. Okay last thing I want 2:25 to do last assessment. I'm gonna do before I do this technique is I need 2:28 to be able to palpate and do passive accessory motion exam 2:31 on these joints well to find my Taylor's I'm 2:34 gonna wrap my 2:36 My index finger and my thumb right underneath her 2:39 malleoli, and this bone right here that 2:42 I'm on. 2:43 Providing especially if I stay up on the anterior portion 2:46 here. I'm actually on the Taylor neck. 2:48 Right. So not only am I on my Taylor list, but I'm on my Taylor 2:51 neck, which is gonna help because that's the portion of 2:54 my tailless that if I go a little further, right? So 2:57 you guys here's just underneath the medial 3:00 malleoli. If I go a little further towards the 3:03 planter surface of her foot and a little anterior. There's 3:06 this bump right here. That's the navicular 3:09 bone, right? That's actually the navicular tubercle. It's a landmark 3:12 that we can use to help our palpation skills. So now 3:15 I know where her tailles is and I know her navicular joint 3:18 is now I just need to figure out how I'm gonna do a 3:21 passive accessory emotion exam on those two 3:24 bones coming together, which is actually pretty easy. 3:27 I'm just gonna kind of grab the Taylor like this. I'm going to 3:30 use a pinch or grit pincer grip around the navicular 3:33 bone. All right. So if I found my navicular tubercle there, I just 3:36 have to go above and below it and grab some bone and 3:39 then I'm just gonna wiggle 3:41 Kind of in this anterior posterior direction or I 3:44 guess technically that's dorsal to planter Direction. Whichever one you 3:47 want to call it is fine. And I feel a little bit of motion there. 3:50 She's not particularly stiff at our 3:53 tailonevicular joint. Now I could also check her Cuneo 3:56 navicular joints, so might as 3:59 well while I'm here the technique from nipping those joints is exactly 4:02 the same my hand position is just a little different. Right. 4:05 So all I'm going to do is now slide this hand 4:08 where my other hand was for my 4:11 navicular and then I'm just going to slide my hand down a little 4:14 bit and you guys will feel like a bump. 4:17 Right where the cuneiform joints start, but basically you 4:20 can slide down as much as you need just to 4:23 feel like the next thing that Wiggles. 4:25 Right. So the next two bones that you can wiggle in opposite 4:28 directions, of course if I win any further 4:31 I'd be on my metatarsal my first metatarsal 4:34 and my medial cuneiform. Of course, 4:37 if you want to have fun with your anatomy and palpation skills. 4:40 You can try to feel your 4:42 Your middle cuneiform and your lateral cuneiform right? And 4:45 you kind of get used to all the joints in there now. 4:48 I know what my joints are now in this particular case. 4:51 I don't feel a whole lot of stiffness at the 4:54 tailor navicular joint. I feel like there might be a little bit more stiffness at 4:57 her navicular cuneiform joints. 5:00 So, how am I going to manipulate this joint? 5:04 Well, there's two techniques. I'm going to show you and keep in mind guys. I'm showing 5:07 you this technique so you can see my body position and events body 5:10 position and then we'll do a close-up recap so you can see my hands close 5:13 up. 5:14 I'm going to go ahead and use. 5:17 This hand to do my manipulation. I'm going 5:20 to use this hand to stabilize our foot and I'm going to use the table 5:23 to stabilize for taylis by kind 5:26 of compressing her calcaneus and Taos together on 5:29 the table. You guys kind of got what I'm saying. So we're gonna 5:32 stabilize either end and put either the taylis 5:35 or the quneiform right in between what we're stabilizing. 5:39 And then apply our dorsal to planter 5:42 or anterior to posterior Force. However, you want to look at it with a 5:45 nice High Velocity thrust. 5:47 Alright, so we got that much. 5:49 Now the key to all manipulations and this does 5:52 not get talked about enough. 5:54 80 maybe 90% of manipulation techniques is 5:57 finding the lockout position. 6:01 Right. So if you can get that joint locked all the way to its tightest 6:04 point so that the very next motion. 6:08 Is essentially the motion you're looking for in the 6:11 manipulation. You know that thing that maybe would give you an audible or 6:14 give you the crack or give you the the Glide that 6:17 you're looking for. If you can get all the way 6:20 to locked up man. It's it's a lot easier the lock position 6:23 for this technique. 6:25 You're gonna use this hand. 6:28 to bend either 6:31 the qnea form and metatarsals 6:34 if you're trying to manipulate the navicular bone 6:37 or just the metatarsals if 6:40 you're trying to manipulate the Q Nail. 6:43 Navicular joint you guys with me there. So just based 6:46 on hand position. I'm either gonna wrap this index finger 6:49 around my cuneiforms or around my 6:52 metatarsals. And then this hand Will Go On which bone I'm 6:55 trying to manipulate. 6:57 But the motion is the same either way. 7:00 I'm just going to bend. 7:02 the metatarsals into dorsiflexion 7:05 and then externally rotate them. 7:09 All right. So the lock position in this case is to stabilize 7:12 the bone you're trying to manipulate and then 7:15 bend the bones below it up and 7:18 out. 7:21 All right. So let me show you guys what that looks like. I know that was a lot to take in. 7:25 We got this stable. I'm going to grab our foot and I'm 7:28 gonna show you guys this one. I'm gonna do 7:31 qnaio navicular joint and then we'll do the one that she actually 7:34 needs. All right. So Canadian navicular joint. 7:38 I found my navicular bone. I found my cuneiform. I'm 7:41 actually gonna wrap my hands around her cuneiform and 7:44 metatarsals. I'm gonna dorsiflex by pulling. 7:48 Up with this side of the my hand and then using this part 7:51 of my hand to press down. 7:55 I'm gonna turn against me that's gonna feel a 7:58 lot easier. Once you put your piece of form hamate portion 8:01 of your hand down on the navicular bone. 8:05 Right, so I'm kind of kind of Bend. 8:07 And rotate out against the stabilization force 8:10 of this hand. 8:12 And then once I'm all locked out and stabilized. 8:15 I'm going to get right over the top. 8:18 Take a nice deep breath. Although really guys breath 8:21 doesn't change the ability to manipulate somebody 8:24 what you're really doing to get somebody to breathe is distracting them 8:27 a little bit from what you're about to do and trying to get them 8:30 to relax so they don't guard on you but hey a vet 8:33 take a nice deep breath. 8:35 And that's it. 8:36 Right. So while she's breathing I don't even care if 8:39 she's breathing in or breathing out. That's what I'm gonna do my high 8:42 velocity thrust. 8:43 And if you guys noticed it was a 8:46 good couple centimeters of motion the mistake 8:49 everybody makes besides not really spending the time on setup really 8:52 spending the time on lockout. 8:56 Is their thrust is usually high 8:59 speed because people know like it's supposed to be high speed 9:02 but then they do this thing they go. Oh and you're like, I don't 9:05 think you actually moved your hands. It's not supposed to be the 9:08 one millimeter punch. Right? Like you're not supposed to 9:11 like get that little motion. Yes. It is low amplitude, but little 9:14 amplitude still means you have a good couple of centimeters to 9:17 go. 9:18 Because think about it guys you still have to get through all of the tissue Slack. 9:22 You still probably have to get through some softness on the table itself. Let's 9:25 talk practically here. You're gonna have to move a little 9:28 bit to get this thing. 9:31 To actually move. 9:33 now I showed you guys the 9:36 Table navicular joint, how would I do the navicular cuneiform 9:39 joints or maybe even 9:42 a little bit of the metatarsal caneiform joints? 9:45 I just moved my hand down. 9:47 Right. So if I was piezoform handmade on 9:50 the navicular 9:51 now I can go ahead and palpate again. 9:54 There's my cuneiform right there. I'm gonna go ahead and put my hand down 9:57 on my cuneiform. I'm gonna grab her metatarsal. 10:00 I'm gonna go ahead and lock out. 10:02 nice deep breath 10:05 that's it, right you just 10:08 And you're done. 10:10 now 10:11 This is one technique. I think it's a good technique to start 10:14 with it. Definitely is much more 10:17 similar to the way we would like to a joint mobilization for this which is 10:20 why I tend to teach it first is because people are often 10:23 a little bit more familiar with this body position, but I'll 10:26 show you the one I really like it tends to work a little 10:29 bit better for me is a longitudinal distraction 10:32 manip for this now big 10:35 big contraindication. You 10:38 have to think about here. If there is any structural issue 10:41 that you could make worse with a high velocity 10:44 thrust for example, ligament damage, right or 10:47 we have some sort of irritable labral 10:50 issue, or maybe we have even some low back stuff and 10:53 we don't want to tug on somebody. This is not 10:56 the right technique go back to the technique. I just showed 10:59 now that's not the issue and we have somebody more like a 11:02 vet who's just complaining about some very classic plantar fasciitis 11:05 type stuff. 11:07 This like this works really 11:10 really well. 11:12 It's pretty much the same technique, although instead of the piezoform 11:15 handmade on the top 11:18 of the navicular bone. 11:20 What you're going to do is wrap your pinkies 11:23 around the navicular or the quneiform 11:26 bones depending on which ones you want to manipulate and then 11:29 you're gonna use your feet in 11:32 our Eminence and thumb. 11:34 To dorsiflex and externally rotate the metatarsals. 11:39 And then your manip. 11:41 deep breath 11:44 It's just like that. 11:46 right A lot of people get exactly 11:49 like a better way all 11:51 but you guys notice I moved like a good two or three 11:54 centimeters. It was just nice and quick. 11:56 Right. I spent a lot of time on setup. 11:59 And I think that's the key to take away from this. So if I 12:02 was gonna go back and do like her navicular kineiform joint don't think 12:05 I'm gonna be like, hey watch this. Bye right like 12:08 that's not the goal is not speed. It's not the 12:11 fastest gun in the it's like the fastest gun in the west syndrome is what 12:14 we should start calling that take all the time. You need to set up if I 12:17 need to come back here and palpate. 12:19 Palpate your patients don't know your patients 12:22 don't know what you're supposed to do and what you're not supposed to do so, I know 12:25 her cuneiform is right there now. 12:28 And so I'm gonna try to do this a little higher on her foot. Can you back your 12:31 butt up a little bit? So I'll pull you off the table. There we go. Good. Have 12:34 her take a nice deep breath. 12:37 Good, make sure I'm locked up. 12:40 And I give that nice quick pull. 12:42 But notice all of the time. 12:44 was spent on 12:46 pal pain lockout. I'm comfortable. I'm 12:49 ready to go now. Boom. 12:52 Right that little last part the part that everybody focuses on the 12:55 high velocity thrust is just the 12:58 icing on the cake. 13:00 Steak stay tuned for the close-up recap. All right for your 13:03 close-up recap guys. Here's your your first Ray. 13:06 And of course what we're trying to manipulate is that 13:09 joint between your tailless and 13:12 your navicular or you're anvicular and 13:15 your canea forms, and of course all of those joints have the capacity to 13:18 get stiff and the manipulation technique is the same. 13:21 It's just going to be a change in hand position. So you guys 13:24 can palpate the Taylor by going just under the 13:27 malleoli and this navicular tubercle right here, 13:30 which is just inferior and a little bit more 13:33 anterior. The male lie is a 13:36 good Landmark to get used to define your navicular 13:39 bone, right? So there's the navicular tubercle now I 13:42 can grab either side. I can kind of see okay. Does 13:45 this joint move a little bit? 13:47 All right. What? 13:49 Is does it feel stiff to me? Right do those passive accessory motions 13:52 and then I can go down a little further. 13:54 And go okay. Well, what about the navicular and 13:57 the first cuneiform? 13:59 And a vet here actually feels like she's moving pretty good 14:02 at the first navicular and cuneiform. She doesn't feel like she's 14:05 moving very good between her navicular and her Talus. 14:08 So if that were the case, I would then want to make 14:11 sure that I'm trying to move the navicular from 14:14 a dorsal to a plantar Direction during my minute. 14:17 Make sure that when I place this this hand 14:20 my my piece of 14:23 form handmade or or some portion of the hypotherminance 14:27 is down over the top of it like so 14:30 so now I got to figure out how to put this joint 14:33 and lock position. 14:36 And the way to do that is you're going to grab the first Ray in this 14:39 case all the way up to just underneath the navicular with 14:42 this finger. You're going to pull. 14:45 Up into dorsiflexion, right? So you're gonna pull the 14:48 first Ray into dorsiflexion at the transverse tarsal 14:51 joint. So not this type of dorsiflexion. 14:54 This type of dorsiflexion is if we're trying to bend the 14:57 foot this way. 15:00 And then once I've done the dorsiflexion part, I also want to 15:03 do a little turning out this way. 15:06 Right, that'll get that joint to completely locked out 15:09 position. So now when I thrust the only 15:12 place for this joint to go is past 15:15 its resistance barrier. 15:17 All right. So dorsiflex locked out. 15:20 I got my Force right over the top of my navicular. 15:23 Take a deep breath of it. 15:25 and as she breathes out, I'm just gonna 15:28 and there we go. We got a nice little little cavitation 15:31 there. I know you guys can't hear that but I definitely felt it. 15:34 Of course. There is another way to do this 15:37 manipulation. 15:39 All right, we can go kind of like a longitudinal distraction 15:42 technique. Although it still is just a a plantar 15:46 dorsal force on the navicular the 15:49 difference this time is I'm going to use my pinkies over 15:52 the top of the bone. I'm trying to manip whether it's 15:55 my navicular my canea forms. 15:57 I'm gonna put both hands like this. I'm going to pull into a 16:00 little bit of dorsiflexion. 16:02 To get her back to neutral at the ankle. But then I'm 16:05 gonna do the same lockout position of transverse tarsal 16:08 dorsiflexion. So you notice like I moved 16:11 my hands this way to again bend your foot here. 16:16 Bender foot there 16:18 Then turn this out. 16:20 Turn the first Ray out not foot into invert even inversion 16:23 rather, but turn the first Ray out. 16:27 Pull up all the tissue slack and then nice deep 16:30 breath. 16:31 and a little pull 16:35 Right, and that's it. That's it. So guys again, please spend 16:38 as much time as you need. 16:41 Palpating understanding how this joint feels stabilizing 16:44 the bones. You need to stabilize getting 16:47 your hands a good position. And of course getting those 16:50 lock out positions so that the thrust 16:53 is just the icing on the cake a couple of points to 16:56 recap knowing your anatomy and knowing your biomechanics will 16:59 certainly help you choose the right technique for 17:02 the right patient. If you're unsure whether 17:05 manipulations are appropriate due to their higher intensity. 17:08 It's okay to do mobilizations most 17:11 research points to manipulations being slightly 17:14 more effective, but mobilizations being very effective. 17:17 And of course, we have those videos for you. If you 17:20 want to start with those less intense techniques make 17:23 sure that if you are doing any technique that 17:26 is based on assessment and of course that you're reassessing and 17:30 sharing that the technique is effective for the patient that you're working on 17:33 and when it comes to all manual techniques guys manipulations, maybe 17:36 more than any other look for opportunities 17:39 to get 17:41 Live education, although I know videos are convenient 17:44 and I'm happy to have these up for you 17:47 guys to watch it would be so much more helpful to 17:50 use those videos as a recap. 17:53 Of one-on-one attention with somebody 17:56 who's experienced with manipulation techniques 17:59 at the very least grab a 18:02 colleague grab a friend and start 18:05 practicing these before you bring them into clinic and 18:08 start using them on patience and clients. I hope 18:11 you enjoyed this video. If you have any questions, please leave 18:14 them in the comments box below.
