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 go over thoracic 1:13 manipulations, these are the thoracic manipulations that are P to A high 1:18 velocity thrust, also sometimes referred to as the screw manipulation. I'm going to 1:22 have my friend a Yvette come out, she's going to help me demonstrate. Now remember 1:25 if we're doing manipulations we're doing manipulations because we need to 1:30 increase mobility in a segment that we think is stiff, and that's going to be based 1:34 on not just subjective information but objective information as well. For 1:39 example, maybe we've seen some signs of upper-body dysfunction during like a 1:43 postural exam,maybe arms fall forward or shoulders elevate during one of our 1:46 movement patterns, and then maybe since we don't have great goniometric 1:51 assessments for our thoracic spine we could use something like a rotation test 1:56 for thoracic mobility, that we could at least use as an assessment and 2:00 reassessment as we're going through our interventions. 2:03 Now the screw technique is probably the one that everybody is most familiar with 2:08 and tends to be the most detailed as far as its explanation, and that's the one 2:14 where we find transverse processes right and we go the transverse process 2:21 above and below on opposite sides, and then this is called the screw 2:26 manipulation because we press down on both sides which is supposed to do this 2:30 with our thoracic spine which causes the manipulation. That's great and I think 2:36 it's a good technique to start with to get some detail in, but I've also seen 2:40 people just come and press, I've seen people come and press this way. I think 2:45 all of these techniques generally work, and the reason being is it's very hard 2:50 to be specific to a particular joint in the thoracic spine especially when you 2:56 consider not only the number of facets but the number of costovertebral facets. So you have 3:03 two costovertebral joints on every transverse process, plus your facet 3:08 joints. I think when people do these manipulations a lot of times we're 3:11 getting multiple cavitations because we're manipulating a lot of joints 3:17 in it's segmented area. So with that being said let's 3:23 start with the detailed screw P-A thrust. So the first thing I need to 3:31 do is maybe start with some palpation, in this position I'd probably do my P-A's 3:36 using my pisiform hamate grip this way. So we'll say I've already done 3:41 cervical, I've already done my upper thoracic spine as part of my cervical 3:44 exam and now I'm kind of in through here. I'm just going to feel for some stiffness 3:50 here, maybe I asked Yvette, hey Yvette is any of this painful, or just a lot of 3:56 pressure? Just a lot of pressure right, and you do have to put quite a bit of 4:01 pressure just to get to the end of arhrokinematic motion in the 4:07 thoracic spine, there is definitely some movement this way that can happen, 4:12 and I think what we're finding here is I feel Yvette's a little stiff right here. 4:18 This is kind of common actually with women, you'll find that right about where 4:23 the bra strap would end up they'd either end up really stiff or hypermobile, it 4:29 seems like they either end up stiff because 4:31 of all of the, maybe pressure and maybe that's a compensatory pattern. Or they 4:37 end up hinging over that point and then of course we wouldn't want to do a 4:40 manipulation there, but she is definitely stiff a little bit right here. All right so I can 4:47 keep doing my P-A's, you just saw me cheat there with a little bit of like 4:52 general spring testing. You will see like P-A's would be specific, sometimes you'll 4:57 see people just do this thing right this is just kind of a spring test 5:01 to see if they can feel any of resistance. Another thing that you might 5:07 be able to feel is like tissue density, so maybe some overactivity around the 5:15 segments, and we definitely have some stuff going on here. So what I'm 5:20 going to do is I'm going to find my transverse process, now if I go out 5:28 just a about an inch from either spinous process I can feel the transverse 5:36 process, and then I can actually feel a bump right here about two inches from 5:41 the spinous process, that's where the ribs start, alright there's that little 5:45 bump there at the the beginning of the ribs. But let's say I find these two 5:53 transverse process and I'm going to switch my fingers this way a couple 5:59 times so that I rotate in both directions, figure out which one's 6:03 stiffest. Alright so she tends to be more stiff this way so what I'm 6:12 going to do is get my pisiform hamate on either of those transverse process. I'm 6:19 going to take up all the tissue slack so that my hands don't move around 6:23 and there's a couple ways to do that, you guys can twist your hands, you 6:26 can move up into position so you take up tissue slack this way, but you 6:30 definitely want to do something to take up a little tissue slack because 6:32 otherwise you'll go on press and your your hands will move off those 6:35 transverse process. Then I'm going to ask a Yvette to take a nice deep breath, 6:43 and when she breathes out at the bottom I'm just going to do a little quick, and 6:49 that's it. I think you have seen Yvette in some earlier videos, Yvette's not 6:53 used to getting manipulations which I actually like for these videos 6:57 because I feel like she's very similar to a new patient which I think you 7:03 need to be aware of, that not everybody loves to get manipulated. Some of you 7:08 might like to get manipulated, other people hate to get manipulated, but it's what they 7:11 need. Manipulations are are very effective for increasing mobility, 7:17 they're very effective for decreasing pain for a lot of different pathologies. 7:22 So again going through that, all I did was find two of these 7:28 transverse process where she was tight and I just kind of set my body up right 7:35 over the top, and then just gave a quick P-A down. Now since my hands are set up on 7:41 on the caddy corner transverse 7:47 processes here, when I press down it did this to the two vertebrae. Now could I 7:53 have just laid my hands down like this? The chances are yes. I think people get a 7:59 little too caught up in the details, if I have somebody who's coming in for 8:03 general thoracic stiffness, and I'm not dealing with somebody who's like has a 8:09 very specific pain. For example if Yvette had come in with very specific pain 8:15 right underneath where her bra strap was, I thought there was a chance that there 8:19 was a hypermobile segment surrounded by stiff segments, that's a good reason for 8:23 me to be very specific on where I'm going to apply these techniques. But if 8:26 Yvette's coming in because she's been suffering from thoracic spine tightness, 8:31 maybe you know we started hearing about things like she's got desk work followed 8:36 by these group classes that she teaches, and we think she's probably sitting in 8:40 really bad posture and then reinforcing it with workouts because she doesn't 8:44 really get a chance to do any sort of movement prep before she goes into this 8:47 group class, like I just want to loosen this up. I probably can just put my hands 8:52 down, I take up my tissue slack, big deep breath for me, 8:58 breathe all the way out for me, there you go, 9:01 relax and there you go. Alright you saw I just set my hands down and 9:06 I got multiple cavitations. Do I know whether it was thoracic facets or 9:12 costovertebral facets? No, and honestly it might not matter in a case of general 9:20 stiffness. In the case of general stiffness all we want to do is see 9:23 improvement on a reassessment, and if that was for example upper-body for 9:28 example, maybe she didn't get her arms all the way back during an overhead 9:31 squat assessment, or she was performing poorly on a thoracic spine assessment 9:36 now I would just reassess and see if that got better. If it did good, then 9:40 that was the right technique to use. I've seen people do this thing as well and 9:45 sometimes that works really well, that's not a technique I'm particularly 9:49 comfortable with, but you could just do hand over hand and push down, and now 9:55 you're doing a central P-A high-velocity thrust. I think with all 10:00 these techniques you need to practice, the ability to feel where the stiffness 10:08 is probably is the most important thing because the techniques themselves aren't 10:13 hard. The only part that you as a practitioner you need to get real 10:19 comfortable with, is setting your body up in a way that you're using your 10:23 biomechanics and not your arm strength, because if we were to flip places and 10:28 Yvette was to try to do this on me, granted I probably outweigh Yvette by about 10:33 a hundred pounds, I'm almost twice her size. She's 10:37 going to have to have really good mechanics to be able to move my thoracic spine in 10:42 a way that's going to get a good manipulation, and the way to do that of 10:46 course is to get the table low enough to get your arms straight so that you can 10:52 then use the weight of your torso in a quick fashion. You're almost 10:57 thinking about I'm just going to drop my weight in and try to straighten my arms 11:02 out at the same time, and kind of like a a little bit of a, I don't want to say 11:08 like punching motion, but like you're just kind of doing one of, 11:11 alright I'm all set up and then I'm just going to drop in. So I'm going to 11:16 straighten my arms, let my bodyweight all fall at the same time very quickly. You 11:21 are going to have to move a little more than you expect. If you have 11:25 ever done like the CPR training think about how far a sternum is willing to 11:30 move, you know you have to push the thoracic spine a good couple of 11:34 centimeters before you're going to get any of these cavitations to happen. Last, 11:39 you could potentially, I wouldn't suggest this for everybody, but you might be able 11:45 to get some of the upper thoracic spine by doing a technique up here. Notice that 11:52 if I'm going to do this I'm going to tilt her head down a little bit into flexion, that 11:57 seems to help. I might go cross hand,or this way. I'm 12:01 pushing in this direction. Alright nice deep breaths, and then I 12:10 would push down hard here. The one problem with that particular technique, 12:14 where you want to be careful is you do have to use quite a bit of force, and 12:18 it does tend to push people's clavicle very hard into a tablem and for some 12:23 people that's enough to be uncomfortable enough that they don't want to do it 12:28 again. For individuals like that I would go back to my mobilization techniques 12:32 remembering that most of the research points to manipulations being a little 12:38 more effective than mobilizations, but mobilizations being generally very 12:42 effective unto themselves. Stay tuned for the close-up recap. All right 12:47 for your close-up recap I wanted to give you a little different view here. Of 12:50 course we would go through and do our palpation, take up all that 12:56 arthrokinematic range, ask Yvette here, hey does that cause you any pain? No, so we might 13:03 get a little extra information on top of palpating stiffness on whether that 13:08 particular segment seemed to be the one that was causing some of her symptoms, 13:12 especially if that pain is related to our concordance sign. Now other things we 13:18 might be able to tell is do we have increases in tissue density, 13:23 overactivity and any of the muscles 13:26 around a particular segment, and I mentioned sometimes 13:30 it's coming through and just doing a general spring test, you'll feel where 13:36 the spine is generally tighter. We found with Yvette this seemed to be your 13:43 tighter area. Now if we wanted to get real specific with our screw technique 13:47 and we had found a couple of spinous process that we're really stiff, 13:52 remember that your spinous process actually are quite long in the 13:57 thoracic spine. So the transverse process that is related to it, a little 14:01 trickier, if you fall off that spinous process to the side and start 14:05 rotating. I'm probably going to have to go about two spinous process up, but you can 14:12 lay a thumb down and feel where that transverse process related to that 14:20 spinous process is. So right here would be that particular segment I could 14:27 put one hand here, I could then go one below it or one above it with 14:32 the other hand, and then have Yvette take a nice deep breath, breathe all the way out, 14:38 follow her down and then of course my chest is right over my hand so I can 14:42 just drop in and give a quick thrust, and just like that we got a nice little 14:48 cavitation via our screw technique which is called screw technique because it 14:53 basically does this with the two vertebrae that we're pressing. Now I did 14:59 mention that just general hand placement like as long as you're on either side of 15:04 the spine, chances are a PA thrusts will get you some good manipulations. The 15:10 problem with that technique is it's not specific, the advantage of that technique 15:14 is it's not specific. You're probably getting a lot of stiff joints involved, 15:19 maybe some costovertebral joints as well as facet joints. Of course I've even 15:24 seen this work where the spinous process is put in between the thenar eminence. Essentially that's just 15:30 a central P-A thrust. I don't tend to use that one very often. I think it;s 15:37 a little bit more uncomfortable for the patient and not as effective as the 15:42 other techniques I just showed you for the thoracic spine. Give these a try, 15:47 really start doing some palpation before you try the thoracic 15:53 manipulation if you haven't been successful. I think just determining 15:56 where on the spine is stiff will be the biggest to jump in your ability to make 16:03 this technique successful, as as opposed to continuing to just work on smashing 16:09 the thoracic spine which I think with a little practice anybody can get pretty 16:13 good at by itself. A couple of points to recap, knowing your Anatomy and knowing 16:18 your biomechanics will certainly help you choose the right technique for the 16:22 right patient. If you're unsure whether manipulations are appropriate due to 16:27 their higher intensity, it's okay to do mobilizations. Most research points to 16:32 manipulations being slightly more effective, but mobilizations being very 16:36 effective and of course we have those videos for you if you want to start with 16:40 those less intense techniques. Make sure that if you are doing any technique that 16:46 is based on assessment, and of course that you're reassessing ensuring that 16:50 the technique is effective for the patient that you're working on, and when 16:53 it comes to all manual techniques, manipulations maybe more than any other, 16:57 look for opportunities to get live education. Although I know videos are 17:03 convenient and I'm happy to have these up for you to watch, it would be so 17:09 much more helpful to use those videos as a recap of one-on-one attention with 17:15 somebody who's experienced with manipulation techniques. At the very 17:20 least grab a colleague and grab a friend and start practising these before you 17:26 bring them into clinic and start using them on patients and clients. I hope you 17:31 enjoyed this video, if you have any questions please leave them in the 17:34 comments box below.
