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. This is Brent of the Brookbush Institute in this video 0:48 we're going over thoracic spine mobilizations, that's posterior to 0:51 anterior mobilizations also known as PAs, and transverse mobilizations. I'm going 0:56 have my friend Melissa step out she's going to help me demonstrate. Now the first 1:00 thing you'll notice is that she's going to lie prone and that I have the table 1:02 fairly low. The table is low for these posterior to anterior mobilizations. I 1:07 want to be able to get my chest over her thoracic spine with my arms straight, so 1:12 that I can use the weight of my torso and not my hand strength to try to do 1:16 these mobilizations which would wear out my hands pretty quickly I think. Now before 1:21 we get into the techniques themselves it is important that we cover anatomy and 1:26 palpation, and of course your knowledge of anatomy is going to determine how 1:30 good you are at your palpations. For those of you just starting out 1:35 I would have you start on bare skin, remember that clothing is just one more 1:40 layer of stuff to feel through. For those of you who've done mobilizations 1:44 before you have a good idea of your palpations, you've been doing some 1:48 release work, I don't think a gym shirt like this is much of an issue. So I would 1:53 actually do therapy right through this fairly thin shirt I wouldn't want to do 1:57 it through a sweater, but a thin workout shirt like this should not be a problem. 2:01 Going back to our Anatomy now, remember that your thoracic spine by definition 2:06 is all of the vertebrae that your ribs attach to. So you can think this 2:12 huge stable rib cage, that alone is going to add a lot of stability to the 2:17 thoracic spine which to us as manual therapists is going to feel 2:20 like stiffness, right the thoracic spine tends to feel fairly stiff even when 2:25 compared to like unilateral PAs of the lumbar spine and of course when compared 2:30 to the more flexible cervical spine. Now finding the thoracic vertebrae if we 2:35 wanted to create our borders we could find the spinous prominence of C7 that 2:39 big bump right at the bottom of the neck, so I know if that's C7 and T1 is 2:44 right here. Then of course we could find rib number 12 and hopefully Melissa 2:48 isn't too ticklish here, but if I follow 2:55 rib 12 on up to T12 I can find my last thoracic vertebrae, so there we go 3:00 there's my thoracic spine. Now I would recommend looking at an anatomy book 3:06 maybe one of these plaster cast models, and start trying to think about how the 3:13 thoracic vertebrae differ from the other vertebrae that I've put my hands on. So 3:18 maybe you've already watched our lumbar spine and cervical spine posterior to 3:22 anterior mobilization videos, you'll notice that the cervical spine and the 3:27 lumbar spine for that matter the spinous process goes fairly straight out. It's 3:32 almost in line with the facet joint. And then you look here to the thoracic 3:38 spine and you notice they all look bent down, aright so they're very very angled. 3:45 So some things that that does its a little different. 3:47 Whereas this feels very pointy up here when you go through the spinous process, and we 3:52 talked about the lumbar spinous process they feel like flat and then divot, flat 3:56 and then divot, flat and then divot. The thoracic spine feels much more like this 4:01 under your fingers if you like just palpate down. Alright it just kind of 4:06 feels like this curve like this like you've seen pictures of sine 4:11 sinusoidal curves or like sound waves, alright so you got those type of bumps. 4:18 The other thing you're going to notice real quick is if you feel the end of a 4:23 spinous process it doesn't match up to the facet of the same segment right. 4:30 So if I wanted to let's say do a transverse mobilization 4:34 and a unilateral posterior-anterior mobilization on the same segment, I'd 4:39 have to go from here to here right, So it's going to feel like one and a half 4:44 almost two segments away from the end of that spinous process, and I'm going to show 4:50 you a way to feel that out so you don't necessarily have to 4:53 remember that it's two away. That's a good thing to 4:58 remember I guess, but the the better thing to do would be able to be tested 5:02 with your fingers so that whether it's one and a half, two, or one away it 5:07 doesn't really matter because you can palpate it. Now the other thing 5:11 to think about and although it's not really clear on this particular model is 5:16 that the transverse process of the thoracic spine feel much shorter this 5:22 way. It's probably partly because they're angled up a little bit, right the ribs 5:28 kind of come up underneath them, alright so that might be part of why their angle 5:33 is a little different. But the ends of those definitely 5:36 feel closer to the spinous process. So already we're starting to see our 5:42 palpations are going to be a little different, this is going to be smoother 5:45 bumps, these bumps aren't going to match up to the facets. The end of our 5:50 transverse processes are going to feel much closer to our spinous process, 5:54 and our facets actually are going to be between those two points, so you're 6:00 literally going to fall right off the spinous process and then look for your 6:03 bumps to do your mobilizations to get over those facets. Alright of course your 6:10 rib cage you can actually feel this, comes this way and you have your 6:14 transverse costal joints and you have your costovertebral joints here right 6:21 they come in this way, you can actually feel the ribs dive underneath the 6:27 transverse processes. So that might be a good place for you to start your 6:31 palpation, there for us to start your palpation. So what we just looked through 6:35 on that let's let's go through real quick and I'll show you guys that again 6:38 on the close-up recap. If I just feel Melissa's rib cage right, I'm 6:42 just using broad hands here right and feel all those 6:46 bumps, and I just I just feel one of the ribs and I just slowly palpate up, and I 6:52 make sure that I'm palpating through the soft tissue I'm keeping on those bones 6:56 all right, I can actually feel right here I run into bone and I know you guys 7:02 can't see this yet but will again see this on the close-up recap, I run 7:06 right into her transverse process. So I can actually even take this hand now and 7:12 put it over the rib and press down and feel like a ledge like this that's the 7:19 transverse process, and the rib kind of do this underneath it. Alright so now I 7:24 got rib, I got transverse process, I got a little bit of a valley and then I got a 7:31 spinous process right in the middle. So that gives me some good 7:35 landmarks; I got rib, transverse process, valley, spinous process and I can feel 7:42 that if I go down them it's smooth bumps like this. So now we get into what am I 7:51 going to mobilize? Well I want to be able to feel stiff segments, and sometimes the 7:56 easiest way to feel through what segments are stiff is using something 8:01 called a central PA. Now for a central PA we want to push down on the spinous 8:07 process posterior to anterior. What I'm going to use generally is I'm going to use my 8:15 pisiform hamate grip, so I'm going to put her spinous process right here, right 8:21 in this meaty portion here right around my pisiform. I'm then going to saddle my 8:26 fingers around the top of them, and I can press down until I run out of 8:32 motion and I can ask Melissa is that pain or pressure, lots of pressure no 8:42 pain. And as well as I'm going down the various spinous process here and notice 8:48 I'm kind of going a little bit in this direction too, we got to think about 8:51 how those facet joints are shaped right they kind of do this thing and they're 8:56 pretty flat this way, and how does that feel? That feels okay. I 9:03 can also take mental note of does part of her thoracic spine feel stiffer, so 9:11 the thoracic spine as a whole is going to feel stiffer than maybe our lumbar or 9:14 cervical spine, but is there a segment or segments in her thoracic spine that 9:19 feels stiffer than others, like maybe she's really stiff up in here and the 9:23 only way you're going to get a good idea of what that feels like, is one comparing it 9:28 to other parts of the spine, and two you're going to have to palpate a lot of 9:32 people. You're going to have to do this on a lot of people and start creating your 9:35 internal frame of reference of what normal is, based on your techniques that 9:40 you use consistently. So Melissa to me feels a little stiff up in here, so now 9:48 what can I do, well I could use my central PA as a technique. So I could 9:56 drop right back into this position, arms straight use this grip, notice 10:02 that my chest is over my hands and now I'm going to find my first resistance 10:08 barrier, I'm going to find my end range, now that's arthrokinematic end range you 10:14 got to push them all the way to the end of their joint it's not going to be 10:16 necessarily very comfortable for them, and I'm going to back off to 50%, and then 10:23 from there I can start with my first end range to just around 50% of resistance 10:29 grade three mobilizations. One to two oscillations per second if you're using 10:35 a Maitland-Cyriax approach like I do, and of course I'm going to keep 10:40 doing this until I feel a change in the amount of stiffness. Usually that's 10:45 around thirty seconds, so make sure you follow through and do as many 10:49 mobilizations as it takes. It could take up to two minutes, you know one minute to 10:54 two minutes of mobilizations like this to really get some significant change 10:58 depending on how stiff they are. If you feel like they might be irritable of 11:02 course you could start with a few seconds like let's say five seconds 11:08 of mobilization, let off and go hey how do you feel, and if they're still feeling 11:13 pain then you know this might be a person that you have to start off 11:17 gently with, just do a little bit of mobilizing and go ahead and let them sit 11:22 up and retest. So that's central PAs and all I'm doing is finding the end of 11:28 the spinous process hooking my pisiform portion of my hand in there right this 11:34 nice meaty part right here. I'm going to hook it in and then do my mobilizations. 11:41 I could do the entire thoracic spine if I thought the whole 11:44 thoracic spine was stiff, I'm just going to go ahead palpate, move down one put my 11:49 pisiform over it. Palpate again and all I'm doing is 11:54 taking these two fingers and putting the spinous process right between it moving 11:57 down one, and boom do it again. What other options do I have? Well I could try to 12:04 get down to the facet joints, realizing that the facet joint if I'm trying to do 12:10 the same segment I have to move up, all right so the spinous process this 12:14 spinous process is actually attached to this facet. I don't know if you can 12:21 see how far my fingers are apart but that's that's a fair distance, that's 12:25 that's for me a good two fingers width. There's actually almost two spinous 12:32 process between, so I can go, if that's one spinous process I can 12:37 go here's my next one, here's my next one. If I drop off laterally and inferiorly, 12:43 so I drop down just a little bit like that, that's where the facet connected 12:47 to this spinous process is. Alright so what could I do there, well I can do a 12:51 bilateral PA. So a bilateral PA you're going to put two fingers over those facets 13:00 like this, these become dummy fingers. They don't do anything but hold your 13:06 place and feel. You're going to use this hand and go over the top and that's 13:13 going to create your pressure, same thing first resistance barrier, last resistance 13:18 barrier, back off and you maybe this time I want to do 13:21 grade four, so I'm going to do small oscillations at 50% plus of resistance. 13:29 Okay so that's one way to do bilateral PAs. The other way I could do bilateral 13:33 PAs is the crossed thumb technique, right so I could do this. Now I've mentioned 13:41 this in other videos, for me if I can get away with not using my thumbs 13:46 I don't use my thumbs because there's way too many techniques that are 13:51 completely dependent on your thumbs like there's just no other ways to do it. So 13:55 you want to save your fingers as much as you can. If you were in a difficult 13:59 situation though and you felt like you were having a hard time just palpating 14:03 what you were supposed to feel, maybe you're having a hard time sticking to 14:07 the facet that you know is stiff, alright maybe somebody has some weird 14:12 anatomy like you don't feel like things are matching up and you feel like your 14:17 thumbs are your best tool alright. So you can do something like this, we could we 14:23 could go this way if we had to. We can go this way, or you saw what I was just 14:29 doing was this, this is a little bit more difficult but could be done. 14:36 What else could I do well we could go back to our workhorse 14:40 of spine mobilizations which is UPA's, and i've talked about this a lot. These 14:46 are the unilateral posterior to anterior mobilizations where you're focusing on 14:50 one facet joint at a time, and again all I'm going to do is find that stiff segment 14:56 alright think about okay well if I want to affect that facet maybe I have to 15:01 find the right facet. So I was just on that spinous process, if I keep 15:09 pushing on that spinous process and then move my thumb around until I feel that 15:12 facet move under my other thumb, so that's right about there. I can then 15:19 use my thumb over thumb technique just like so, I could use kind of 15:27 a dummy thumb pisiform grip, so here's something that I see a lot of people do 15:34 although I don't see it textbooks as often is I'll use my thumb 15:37 as my dummy thumb, and then put my thumb in this pisiform point like I was doing 15:43 with the spinous process and go right over the top just like so. I use 15:48 that really commonly in the thoracic spine because there's so much muscle to 15:51 get through, and Melissa is so jacked because of all the weight training she 15:56 does. So I can go right in there and could I use other fingers? 16:00 Potentially, like I could use maybe you know if my thumb was getting beaten up, 16:05 maybe I go back and look like I'm setting up for that bilateral PA but 16:11 only putting my hand over one finger. That's not very comfortable for me but 16:16 it is a possibility. Alright thumb over thumb, and then the 16:22 question is what else, what else could you do? Well you could do 16:27 transverse mobilizations so hopefully you guys are following me here, we went 16:31 from CPAs which is on the spinous process to bilateral PAs which was this 16:35 like so, or double thumb technique which I'm not actually necessarily 16:41 recommending because we don't want to wear out the thumbs. You could then do 16:44 UPA's which are probably the workhorse and the thing I go back to most often. 16:48 But another thing that's helpful in the thoracic spine and I almost use it 16:52 exclusively in the thoracic spine, it's actually very rare that I would even try 16:56 this in the lumbar spine because of how stiff the lumbar spine is, it's very rare 17:00 that I tried it the cervical spine because I just don't need it, but these 17:02 transverse mobilizations come in real handy for the thoracic spine and 17:07 especially the upper thoracic spine for whatever reason. So if you're going to do a 17:12 transverse mobilization let's think about this for a second, you'll notice 17:15 I'm raising the table way up, because what I'm going to try to do is I'm going to 17:19 try to push the spinous process this way. By pushing the spinous process this way 17:25 I rotate the whole segment, and hopefully you guys can kind of see how that would 17:31 work. Now the problem with transverse mobilizations is they also can be very 17:35 hard on your hands, it's very hard to get a grip on one of these vertebrae. I'm 17:43 actually going to drop Melissa's head down a little bit so I have access to these 17:46 upper thoracic segments, but I'm going to find my 17:52 spinous process and then I need to do a couple things that are kind of 17:55 interesting here. I'm going to use my dummy thumb and I'm going to grab a little bit of 17:59 skin, all right I'm going to actually pull, pull just like this all right like I'm 18:04 going to gather up some of her skin and press it into her spinous process like 18:10 so. So if this was her, the bone that I'm feeling like I want to gather up 18:14 some skin and then push it up against like this, because if you don't and you start 18:18 pressing into a transverse mobilization you're going to stretch the skin on one 18:22 side and it's going to feel really uncomfortable. So let's let's say we're 18:27 doing C7 and T1 which is right there. So I'm going to go on T1 here grab a 18:37 little bit extra, and then I'm going to take this hand I'm going to go like this. Now my 18:42 force needs to go that way so I actually might have to drop down a little bit 18:46 like so, and then you can see I actually have my my hand on Melissa's head so I 18:50 don't push her head to, alright I can kind of stabilize her head put the rest 18:55 of my hand down here on her back and then I'm just going to go this way 18:59 feeling for where's my first resistance barrier, where's my end range and I'm 19:05 telling you guys right now this is not an easy thing to feel, this is going to take 19:08 some practice. But once I find it, back off to my 50% mark and again I can do my 19:14 grade fours or my larger oscillation grade threes just like so, until I get 19:21 some good increase in mobility and I can keep going right on down the spine again, 19:27 feel my next spinous process and like so. Just remember you don't want to do 19:36 this, so this isn't a transverse mobilization, this is like an oblique PA. 19:43 You got to be very careful what your intention is, like if you're trying to do 19:47 transverse mobilizations and you want more motion out of your facets, but then 19:53 all the sudden you're doing an oblique PA you might actually just be closing 19:57 down on facets. You might be doing like some sort of smashing, 20:02 and so we got to kind of keep these angles in mind, and I don't want to go 20:06 too far down the the biomechanic thing because I know research has shown that 20:11 our biomechanics aren't as consistent as we might hope they were as physical 20:15 therapists, but do be aware of the angles that you're using if for no other reason 20:20 than reliability. Alright if I did it this way this time and then I had the 20:25 table lower next time, so it was way up pushing down like this and calling it a 20:28 transverse and then the next time the table was high and I was doing this as a 20:32 transverse, those three things are not the same. So let's let's run through 20:38 those techniques one more time because I just I just threw a bunch of stuff at 20:41 you. So remember your thoracic anatomy, try to keep this stuff 20:48 in mind as you're doing all of these various techniques, your thoracic spine 20:55 is attached to your ribcage that's going to make it a little stiffer. One thing you 20:59 might also want to think about with the thoracic spine it being attached to the 21:03 ribs, is you probably want to keep somebody's hands down because if they 21:06 put their hands up, can you put your hands up real quick, they put their hands 21:10 up like this it's going to posteriorly tilt their scapula which is then going 21:14 to press down into the rib cage which then could extend their spine further, 21:18 and none of this is going to feel the same anymore. 21:20 So from a reliability standpoint you need to be thinking about that, like you 21:26 might be able to get used to somebody's hands being up all the time but that 21:29 means every patient that walks in is going to have to start with their hands up. 21:32 Whereas if you start with their hands down then you don't have the posterior 21:37 tipping of their scapula, you don't have that change to their rib cage, you don't 21:40 have the change to their thoracic spine, and this becomes your norm. So be aware 21:45 of little things like that, right know where your thoracic spine starts so 21:50 right under spinous prominence C7, and know where to find T1 and then of 21:56 course where's the spinous process? Right down the middle, make sure you can feel 22:01 all those, make sure you're very aware that the facet and the end of the 22:06 spinous process don't match. So you're facet is almost 2 spinous, 22:11 tip of 2 spinous process away. All right we talked about this was one 22:15 spinous process, and you had this one, this one and then I actually fell off this way 22:19 and found her facet for this spinous process. And then your transverse process 22:24 are actually a little shorter this way, so if you are palpating and you feel 22:30 like you're going to feel a canyon and then a big bump, you know you don't want to go 22:34 beyond that bump because if you go beyond that bump you're just mobilizing 22:38 your ribs, which is fine if your intention is to mobilize the ribs but if 22:41 your intention is to mobilize her thoracic spine then that's not going to 22:45 work very well. Now I showed you a bunch of techniques we did central PAs which I 22:50 used this grip, could you use a two thumb technique? Of course, you could do this 22:55 thing. Again you know that personally my feeling is if you can get 23:00 away with not using your thumbs for any technique don't use your thumbs 23:06 because there are techniques like I said where you pretty much are stuck only 23:10 with being able to use your thumbs, for example unilateral PAs you are kind 23:15 of stuck on this technique. You could try to do the unilateral over a different 23:20 finger but it doesn't feel very comfortable. Alright so we tried central 23:24 PAs with the pisiform hamate grip right which i said was like this, and that 23:31 worked out pretty well, Then we did bilateral PAs which would have a very 23:34 similar effect to a central PA but we did that with two fingers, those two 23:40 fingers of course would end up higher if we were trying to do the same 23:43 segment, and then I used this hand over those two fingers and that can come in 23:48 handy, that can definitely come in handy. You feel like you're just not getting it, 23:53 maybe the the angle of the spinous process on this person is just messing 23:57 you up, or they're really really thick or maybe they're really really tiny and 24:01 this just isn't comfortable, okay let's try this technique. Then we talked about 24:06 unilateral PAs all right and then we just did our thumb over thumb oh that's 24:12 a that's a nice stiff facet right there. Okay and then of course with all 24:17 these techniques we found our resistance barriers 50% all the way down at end 24:22 range, our first resistance barrier I should say end range 24:27 of arthrokinematic motion, I can't press this joint any further and then 24:30 back off the 50%. Then I can either go zero to 50/50 plus, or I can stay at 24:37 50/50 plus for a grade four, so that's my unilateral PA. We did talk 24:43 about doing like a dummy thumb and pisiform for that, you could do that. Just 24:48 be careful not to beat up on your thumbs too much 24:50 all right this can be a little uncomfortable too. Then the last 24:53 technique we talked about was transverse mobilizations which do tend to come in 24:57 handy for the thoracic spine, especially the upper thoracic spine, right and with 25:03 that you'll notice I'll get the table as high as I can because I really want to 25:07 be consistent and try to create or a horizontal force this way. So that 25:11 hopefully all I'm doing is tipping essentially the vertebral body there. We 25:17 don't want to be inconsistent and start creating oblique angles that are going to 25:21 be this quasi turn, quasi PA, quasi frontal plane smash into the other facet 25:29 joint. Although that can be a great technique right, there are things 25:34 called super close techniques right for facet joint mobilizations. The big thing 25:39 is whatever you're going to do you got to be consistent. So if we're going to do 25:42 transverse mobilizations let's truly be transverse. You're going to pick up all the 25:47 slack on the skin around it you're going to use that dummy thumb, and then with your 25:52 other thumb you're going to push straight this way. Like I said guys you can see 25:56 that I'm up in her upper thoracic spine or cervical thoracic junction, this is 26:00 where I find I use these particular techniques most. Part of that might 26:05 just be because I can then come around this way, and what I'll do is I'll go 26:10 here's one spinous process let's say C7, here's another spinous process T1, and I 26:15 can do this thing to them, and I can actually check how mobile they are. 26:22 So let's see, I feel stiff, that feels a little stiff. Alright let me get set up, 26:26 do my mobilizations and then I can retest. 26:32 I know palpation may be my least reliable assessment, but while I'm doing 26:37 my manual work here for a few minutes I can kind of keep retesting and working 26:41 different facets, and then I can have her sit up and do whatever my more 26:46 reliable assessment, in this case maybe goniometry for lateral flexion, 26:51 or whatever I found to be her concordance sign, whatever test provoked 26:56 her symptoms I could go back to that. Alright guys so there you have it, 27:00 work on your palpations, know your thoracic anatomy and then start slowly 27:04 working through central PA, bilateral PA, unilateral PA, and transverse 27:11 mobilizations. Stay tuned for the close-up recap. Now close-up recap guys 27:15 here I have Melissa's thoracic spine down this way. We talked about finding 27:20 the first thoracic vertebrae by finding spinous prominence at C7 which is right 27:25 here, and then this is T1. So you can tell if move this way 27:31 hopefully you guys can see my finger kind of bump up and down, and you can see 27:36 that if I depress my fingers I can go right around a spinous process just like 27:40 so. So that's how I'm going to identify these spinous process. I can 27:45 move out a little bit and I find another big bump right here this would be the 27:49 edge of a transverse process, and if I fall off that I would get into the 27:53 ribcage. So spinous process, transverse process, ribcage. Between my 28:00 spinous process and transverse process are those facet joints I'm going to want 28:04 to be able to get into. Now let's talk about our hand positions here again. So 28:09 we did central PAs, and what I did there is I found a spinous process I put my 28:15 pisiform hamate part of my hand over that spinous process, I saddled with the 28:21 other hand, got my arms straight, my chest over and then of course found first 28:26 resistance barrier and range backed off to 50%, and I could do my grade 3s which 28:32 are my larger amplitude, or I can go a little more intense and do my grade 28:37 fours which are small amplitude. And we talked about bilateral PAs which is 28:43 where I'm going to get my fingers over two facets. Now if I wanted to mobilize 28:48 the same segment I have to realize that the facet for this spinous process is 28:53 actually probably closer to like up here, and the way I'm going to find that is 28:57 I can go up two spinous process and then fall lateral and inferior, or I can do a 29:04 little transverse mobilization with this hand 29:07 alright you guys see that, and I can wait to see, move my thumb around, until I feel 29:13 the facet joint under that thumb move a little bit. I got right there 29:17 right there I feel if I push on this spinous process this moves. So 29:24 that's a little check for you guys. Now I can do my bilateral PAs first and we 29:29 talked about this hand position right like this and then putting this hand 29:32 over like this, once again straightening out my arms, 29:35 torso over the place I'm trying to, or chest over the segment I'm trying to 29:41 mobilize, and then I can do my oscillations. We did unilateral PAs which 29:47 is thumb over thumb all right same thing, and then of course we did transverse 29:55 mobilizations here and these are the special ones right, so this one is where 29:59 I would normally raise up the table and then I would try to get my arms 30:03 horizontal, and I'm actually pushing that way. So I have to take up a little 30:10 tissue slack, you see how I did that I took a little tissue slack I just 30:13 kind of ran my finger over the top of the spinous process and then 30:18 this becomes my dummy thumb. I'm going to push with the other hand transverse just 30:24 like so. Alright guys have fun practicing. So there you have it 30:28 assess, address, reassess. Make sure that every time you choose a joint based 30:33 manual therapy technique it is based on an assessment, and that you return to 30:38 that assessment after you've finished the intervention to see if it was 30:41 effective for the individual, the patient, or client that you have in front of you. 30:46 Ensure that you continue to learn your Anatomy because your Anatomy is going to 30:51 help you with your hand placement, with understanding what a joint can do, with 30:56 understanding what you may gain from this particular technique, and of course 31:02 practice. You have to practice these techniques hopefully not for the first 31:07 time on a patient, client who just walked in the door. If 31:11 you can find a more senior instructor or a mentor to give you some really good 31:15 hands-on instruction, use your peers for some good feedback, and of course always 31:22 look for live education to help with your manual therapy techniques. I know 31:29 these videos make education very convenient but there is no substitute 31:34 for learning manual therapy in a live setting. I look forward to talking to you 31:39 guys again soon.
