Name: Thoracic Pistol Manipulation
Uploaded: 2023-04-26T01:01:54.000Z
Duration: 16 min 40 s
Description: Learn the proper technique for Thoracic Pistol Manipulation in this instructional video designed for clinicians and movement professionals. As part of a comprehensive manual therapy program, this high-velocity, low-amplitude mobilization may aid in reducing thoracic spine pain, improving mobility, enhancing posture, and optimizing overall spinal function.

English captions

https://stream.mux.com/DJTnBrVfCwXeB01XnGKkwww018MEIDp3imr01F02K00T01XP4.m3u8

Learn the proper technique for Thoracic Pistol Manipulation in this instructional video designed for clinicians and movement professionals. As part of a comprehensive manual therapy program, this high-velocity, low-amplitude mobilization may aid in reducing thoracic spine pain, improving mobility, enhancing posture, and optimizing overall spinal function.

Introduction to High Velocity Thrust Techniques

Clinical Rationale for Manipulation Techniques

Demonstrating the Thoracic Pistol Manipulation

Techniques for Effective Manipulation Setup

Variations of Pistol Manipulation Techniques

Recap and Best Practices for Manipulation

Thoracic Pistol Manipulation

This is Brenda. The Brooke Bush Institute in this video. We're gonna go over manipulations or High Velocity thrust techniques. I assume that if you're watching this video you're watching it for educational purposes and that you are a licensed professional with high velocity thrust or manipulation techniques in your scope of practice. If you're not sure check with your state board most physical therapists chiropractors and osteopaths, you're in the clear. I believe that atc's you can't do manipulations in the United States, although other countries again, check your scope, of course massage therapists and personal trainers. These are generally not within your scope. Of course, you could continue to watch these videos just for educational purposes. Learn a little Anatomy learn a little biomechanics. If you're going to do these techniques, please make sure that you have a good rationale for putting your hands on a patient. This should be based on assessment and if you're going to assess I'm hoping that you'll assess use these interventions. And reassess to ensure that you're getting the result that you're looking for and have good reason to continue using this technique in this video. We're going to go over the thoracic pistol manipulation. I'm going to have my friend a vet come out. She's gonna help me demonstrate. Now. Keep in mind if I'm doing a thoracic manipulation. I'm basing on a more than passive accessory motion. I have subjective complaints maybe a vet has shoulder pain. I've followed that up with some sort of movement exam like the overhead squat assessment maybe on the overhead squat assessment. I saw arms fall and scapular elevation. I like to have a continuous interval measure so that I can measure progress. Unfortunately with the thoracic spine goniometry doesn't work very well. It's not very reliable. So maybe you guys could look into some of those rotation tests and at least have some sort of visual indicator of pre and post intervention. And then the last thing we're going to rely on is actually our patient skills. So the things that might want to palpate for here, of course, I could do my PAs with my peace of form handmade grip like a Central PA on the spinous process. to look for any stiff segments or painful segments painful segments might be a reason not to do manipulation. Keep that in mind, but If I find some stiff segments. That might be a reason to do manipulation and you know as I'm doing these all I'm doing guys is I'm taking a PA and you can look up these mobilization videos. This is just a thoracic PA taking it all the way to end range. Does it feel stiff to me? I can talk to that. Hey, how does that feel of it? Pressure right a lot of pressure generally the thoracic spine you have to push pretty hard. There's probably a lot of inherent stiffness and thoracic spine just because of all the rib joints too. Right? So there's a lot of connective tissue and a lot of joints throughout this segment of the Torso. Any pain there? What I start to notice is I'm going through the spine here guys, and I'll keep I won't waste your time going through the whole thing. But as I go through this I noticed that she is real real stiff in this area. So I'm gonna want to take a mental note of this is where I feel increased stiffness. I could also check for Like increased tissue density, right? That might be an indication of overactivity. And of course I could do some like General spring type testing rather than like a PA just to see if I feel like anything in the ribs. Do I feel like once again this segment definitely feels different than like when I press down here. You okay? All right. Now the pistol manipulation itself is face up. So we're going to go ahead and have a vet roll over. And then I'm going to show you guys how to set this up the best way I can this is definitely one of those techniques where people get caught up in the minutiae and then they get all freaked out and then they stop thinking about just doing the technique right? So scoot down a little bit more. One thing you guys want to watch out for for your own hands, right? Because what we're gonna do is make a fist underneath of that's back is you don't want to be on seams. Right or or creases in your table. So I want to make sure that the portion I'm going to manipulate is on a nice flat seamless surface. The next thing I'm going to ask a vet to do is I'm going to have her interlock her fingers like this. And then put them at the base of her neck. because what I'm going to use her arms for Is controlling our torso? Now I guarantee this is gonna happen. Everybody is gonna do this. So go ahead and show them and then they're gonna you're gonna go put it on your neck and they're gonna go like this the bottom of their head and then they're gonna lay down and you're gonna try to put their elbows together and squish their face. We don't want to squish faces besides. This is just not as easy to control. Sorry, but I see it all the time. So again right here, right? So you guys all I'm doing is interlocking like my fingers go down to the edge of my other fingers not Crossing like this and then go all the way down to the base of your neck. And now when I bring your elbows together, you miss your face. And of course, I have good control over your torso notice her head comes with us. I can rotate away which when I do this technique I tend to do this way. I will show you guys the other method as well. now From here. What I want to do is I'm going to wrap one hand around forearm like this and then you notice my wrist and my other forearm kind of keep her elbows together. pull away and then going to take my fist. And place it right over that stiff part of her spine. Now the goal. is to put the segment that I want to manipulate just above my last. knuckle The reason this is called the pistol manip is you can do it this way. Right like you're making a pistol with your hand. Right. I like to do it this way and it doesn't matter all that matters is is this is the last segment that you're bracing? And this segment right here? Is the one that gets man nipped we're in essence shearing. one vertebrae over another so yeah, go ahead. She stiff up in this area I can feel for her. Her spinous process. I'm gonna put the spinous process right here. Right between my theme or eminence. And my IPS, I'm then gonna. Just bring her over the top of my hand now. I have had many a patient with a nice setup like this who as soon as I drop them back I get a cavitation. Right again set up is everything so be comfortable. Make sure you have spinous process right here stiff segment of the spine here. make sure you're both comfortable. And what you're going to do? Is azure lay in your hand down it helps to push a little in this direction. I'm going to lay my chest kind of over my forearm here. Oh my God, sorry. I'm gonna lay my my chest over and then all I'm gonna do is have a vet. Take a nice deep breath. I'm gonna and as she breathes out all the way to the end. I'm gonna give a nice quick push and that was it in that particular case. I actually felt the vertebrae move, but there was no cavitation. big thing to remember guys that is a successful manipulation cavitation does not mean success. Increase range of motion on assessment is success and whether you get a cavitation or not, it doesn't really seem to matter. So now let me give you guys a couple tips going back through that. I have no problem with my hands creating this type of fist. Putting her spine like this or spinous process like this and pushing down. Some people don't like how that feels on their knuckles. So they do this thing. They either grab a pencil. Or a vet here was nice enough to lend me her lipstick something. I don't particularly carry on a regular basis, but I've seen people use chapstick. I'm only gonna give you one bit of advice once you find something that works for you. Keep it on you. Because if you get used to this and switch to this, I guarantee you're going to have a problem with your setup. If you get used to this and switch to this same thing if you get used to having something in your hands. Going without anything in your hand is gonna feel a little weird. The setup would be the same. Let's go ahead and have you right. The setup would be the same. It's still put her spinous process between but now I can feel like I can't Crush my own knuckles. I do think in general this overcomplicates things. I don't think it's necessary for most individuals. I think people just get hooked on it in the beginning when they're learning this technique because they're not real comfortable with their setup. So they tend to spend a lot of time over the top of their Knuckles. And then since they're spending a lot of time with us talking their Knuckles, it gets really uncomfortable. Now if you're not. Larger than the person that you happen to be working on there is another way to do this. Which is hand from the same side under now every all of the same stuff would still apply. So let's go here. And then all I would do is turn her this way. Right. So turn her away from me. I would take this hand. Put it under her spine. and then flip her back and the same technique applies right now for me. This is a little uncomfortable because this is not the way I actually do this technique personally, but once you get set up you can see how my fist is still in the same position. And now I'm going to do is push down this way kind of in that direction again. It's a nice little clinical gem guys. It's not straight down. It's go that way with your Force right? It'll work the same way. Last variation you guys might want to try is I have seen this done. this way Okay. I find it a little harder to control the Torso this way. But if I was going to do this, I could still grab her elbow. Set myself up. and now I'm kind of like. Trying to figure out how to position my torso and end up with a little bit more of like her. This part kind of like here on my ribcage. But again the setups the same this is just not as intense on the client's shoulders. I think all of this once again guys is really dependent on whatever setup you get good at do I think it's great to experiment in the beginning? but then once you have a technique that you go to I would just keep going to it because I think a lot of the little Again, my new show of this hurts my knuckles. I can't reach my arm around this hurts. The patient's shoulders what that's really a complaint of is it takes you a really long time to set up because you're not as well practiced as you should. Like if I do the pistol man up, let's go ahead and do the pistol minute one more time to review here. Here my clients get used to it. Great. I'm here. I know I want to be. really nice deep breath Good, and that was it? right, so that took it took a few seconds. I'm not suggesting you. Do things in a hurry? What I'm suggesting is you practice enough that you can kind of go into a flow with this particular technique guys. Stay tuned for your close-up recap. All right guys for the close-up recap. I'm gonna go ahead and have a vet change from this arm position. Although this arm position for some people is very comfortable. When have you go ahead and do the little interlaced fingers at the back of the neck right? Remember we go to the base of the neck so that I'm not squishing her face and then from here I can use my hand over one forearm and then I actually use my wrist on the other side of the other forearm so that I have control and I'm gonna pull of that a little further away than I normally would now you could go the other way. Don't forget guys like whatever is your comfort zone like whether you're gonna wrap around you're gonna come from the same side. You're gonna do this arm position or the other arm position. Just make sure you get comfortable. The technique is still the same. We're still going to use our fist. To go on either side of the spinous process. And then Shear the top vertebrae. Over the vertebrae we have stabilized. Right. So what I'm going to try to do is I'm going to feel her spinous process and try to put them right there. You know, this IP is gonna be on one side. My feet are Eminence on the other. I'm going to try to set this up if you guys prefer this technique and it would be to set this up. As just below the segment that I want to manip. And then I'm going to pull her into as much flexion as I can lock her out by going into flexion with cranial Force at that segment. So you get this kind of combination of flexion with extension against your hand. Pull up this way. feel those spinous process there they are. And we'll check. All right, maybe those little farther be careful. It's really easy when you're not looking I just I caught the end of the ribs there. Thought I was on the spinous process double checked and now I'm on the spinous process. So I'm gonna get my hand wrapped around. Now my hand is there now keep in mind. The direction of my force is more or less going to be in the direction that her forearms are currently in. Right. So if I just kind of follow the direction of her forearms. So I need to reset. all the direction of our forearms big deep breath and that's it guys. Take your time to get set up make sure you practice this often and then whichever elbow setup you want hand set up you want whether you want to put a pencil or or ChapStick in there? Whether you're gonna wrap around or same side just get used to it practice it if you have any questions leave them below a couple of points to recap knowing you're anatomy and knowing your biomechanics will certainly help you choose the right technique for the right patient. If you're unsure whether manipulations are appropriate due to their higher intensity. It's okay to do mobilizations most research points to manipulations being slightly more effective, but mobilizations being very effective. And of course, we have those videos for you. If you want to start with those less intense techniques make sure that if you are doing any technique that is based on assessment and of course that you're reassessing and sharing that the technique is effective for the patient that you're working on and when it comes to all manual techniques guys manipulations, maybe more than any other Look for opportunities to get live education. Although I know videos are convenient and I'm happy to have these up for you guys to watch it would be so much more helpful to use those videos as a recap. Of one-on-one attention with somebody who's experienced with manipulation techniques at the very least grab a collie grab a friend and start practicing these before you bring them into clinic and start using them on patience and clients. I hope you enjoyed this video. If you have any questions, please leave them in the comments box below.

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Joint manipulations for the thoracic spine. Types of manipulations, manipulations vs. mobilizations of the spine and thoracic spine. Optimal intervention for cervical pain, CTJ, shoulder pain, TMJ, elbow pain, thoracic spine pain, forward head, arms fall, scapula elevates, and epicondylitis (epicondylalgia). The risk of adverse events, accuracy vs sensitivity, screening, reliability, and validity of thoracic spine manips. 

Joint Manipulation: Thoracic Spine

The patient should be supine, with upper-back on a flat part of the table (no seams or creases).

The table should be low so the practitioner can get their trunk over the trunk of the patient.

The patient is asked to cross their arms or interlace fingers behind the base of their neck.

Note, if the patient chooses to interlace fingers, they should be fingertips to opposite hand web space, and not web space to web space. If the fingers are interlaced too far it will be impossible to touch one elbow to the other without squeezing the patient's face with their own arms.

unilateral posterior-to-anterior thoracic mobilization

Note: this usually happens with the patient in prone prior to this technique

During set-up of this technique, the therapist may also feel increased tissue density of the 

Use the patient's elbow to tip the thorax, allowing the clinician to slide a fist under the stiff segment of the thoracic spine.

The clinician can use tissue density as a general indicator of stiff segment location.

The fist should be positioned so the patient's spinous processes lay in the groove between the distal interphalangeal joints (IP), and the thenar eminence.

The lowest segment the clinician is attempting to block should be at the level of the 2nd finger, with the segment to be mobilized hanging just past the second finger.

The clinician then lowers the patient's body weight on to their fist.

Lock position is created by maintaining some thoracic flexion, with some anterior to posterior force, and caudal to cranial force. (As if you were trying to "retract" the thoracic spine like you "retract" a cervical spine).

With a little practice, it is not uncommon to get a manipulation and cavitation from the patient's body weight alone.

Important Note: 90% of manipulation technique is set-up. If you have not achieved lock-out in the previous steps, having great "thrust technique" will be rendered useless.

The motion is a posterior to anterior force, with force coming primarily from the practitioner's body weight.

Visualize the small, rapid motion (maybe 2 - 3".). You are trying to force the "one joint" to extend just over your 2nd distal IP.

Tip: have the patient take a deep breath or wiggle their toes. Your goal is to distract them so that they allow you to passively control their trunk with as little muscle activity as possible.

Quickly, thrust the patient into the new position.

Without letting go of the patient's elbows, gently tip the patient show that you can slide your hand to the next stiff segment, or out from under the patient's trunk.

Thoracic Pistol Manipulation

Cuboid Manipulation

Sacroiliac Joint Chicago Technique

Upper Cervical Manipulation

Radial Head Manipulation

Shotgun (Pubic Symphysis) Manipulation

Lumbar Spine Joint Manipulation (High Velocity Thrust)

Wrist Manipulation

Talocalcaneal Manipulation

Talonavicular and Cuneonavicular Joint Manipulations

Proximal Tibiofibular Joint Manipulation

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