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 the upper 1:13 cervical spine manipulations. I'm going to have my friend a Yvette come out, she's 1:16 going to help me demonstrate. Now keep in mind if I'm doing a manipulation I'm 1:20 doing it as part of an integrated intervention routine that's going to 1:23 include things like soft tissue techniques and exercise, and of course 1:26 follow up with a whole exercise program and I'm basing this on more than just 1:30 subjective assessment. Although upper cervical spine manipulation we might be 1:35 able to think symptoms would be cervical spine or maybe cervicogenic related, we 1:41 still want to have movement assessment to be able to reassess if we had any 1:45 effectiveness. We're still going after stiffness in these joints so don't 1:48 forget about your visual range of motion exams with like rotation, flexion- 1:53 extension, lateral-flexion, maybe lateral-flexion goniometry. 1:57 I know your upper cervical segments don't laterally flex much, that doesn't mean that 2:03 stiffness in the upper cervical spine won't change muscle activity enough to 2:08 affect lateral flexion goniometry, and then two ranges of motion to think about 2:14 a little bit are jut, or forward head, and nod or chin tuck. If 2:21 somebody can't get to the ends of range of motion for these right, 2:25 the very extreme end range of motion, they're restricted, that's a good sign 2:30 that some upper cervical stuff is going on, because it's your upper cervical 2:35 spine that allows you to extend your head as your lower cervical spine is 2:41 flexing, and then as your lower cervical spine is extending it's also your upper 2:46 cervical spine that allows you to tuck your chin. So these two ranges of 2:51 motion can be very indicative of upper cervical spine restriction outside of 2:57 just like maybe rotation. Now before we go into this technique, a teaching tip if 3:04 you're new to manipulations, don't start here. Go ahead and go back to our 3:09 cervical manipulation video, in that video I go over mid and lower cervical 3:14 manipulations. Those techniques are much easier for several reasons, including 3:21 blocking out the lower segments is easier because you have more to grab on 3:25 to, finding the lock out position is easier because there's more motion to 3:30 work with, and then actually getting the manipulation is a little easier because what 3:35 your palpating during that is not so small. I think if you started here you're 3:41 going to have a hard time palpitating what you need to palpate, moving in the tiny 3:47 ranges of motion that you need to move, and feeling that walkout position is not 3:51 the easiest thing in the world on this particular technique. Now to get into 3:56 this particular technique I can tell you that if you're familiar with the 4:02 cervical manipulation video we're still using this basic motion. So that's 4:08 lateral flexion away, rotation toward with a little extension. Some differences 4:15 we're going to do a little bit more of a forward head jut, we're also going to do 4:23 a little bit more of a side glide than just pure lateral flexion. So 4:30 before we get into the extension thing we need to come 4:34 into this forward head position. Before we just laterally flex we want to side 4:38 glide as much as we can. Now other weirdnesses, rather than being 4:44 able to use, yeah I made up a word weirdnesses, all right 4:48 second MCP, rather than being able to use my second MCP to lock out the spinous 4:53 process and then bend over it to find locked position. I could only do that if 4:59 I'm C2 and up, right because C2 has a spinous process but C1 doesn't. So 5:08 maybe you want to try second MCP, find the highest spinous process, you can try 5:17 to get your MCP there, jut, side bend and then you know I use cradle grip on 5:23 my cervical manipulations. You could use open hand if you want to, but since I use 5:27 cradle grip on my other manipulations I tend to like to use it here. Once I get 5:31 side glide, jut, blocked out for C2 then I could side-bend then rotate a little 5:39 bit, maybe a little traction I find helps, get her all locked up and then I can do 5:45 my manipulation. But here's the tricky part what if I need to do C1, what if I want 5:52 to do C1 on the occiput, right the atlanto-occipital joint, the a/o joint. I 5:58 don't have a spinous process to use my second MCP on. I need something else, and 6:03 the way to go is to block the transverse process of C1. Now if you've never 6:10 palpated the transverse process of C1 it is just underneath the mastoid process. 6:17 So here's what I'm going to recommend you do, find your earlobe, find your mastoid 6:22 process, go just underneath your mastoid process if you don't feel a bump like a 6:29 peg coming at you into your finger side bend away, and that transverse process 6:35 should pop right into your finger. Once you do that on yourself try 6:41 that little trick on hopefully your friend or colleague 6:45 when you start, not a flared up patient I do not recommend practising these on 6:50 flared up patients. So there's her transverse process of C1 right there, 6:56 transverse process of C1 right there, right underneath each mastoid process. 7:00 Great, so now I know what they are what do I do with them? Well what I'm going to 7:05 do is if I'm trying to do a manipulation on this side, I'm actually going to wrap my hand around 7:08 so i can use a comfortable hand position, because I'm usually using that second 7:12 MCP. But this time I'm going to use my middle finger, and I'm going to push it into 7:16 the back of the transverse process of C1, and push up this way to block out that 7:22 vertebra. So that when I go to do my manipulation, this is blocked and I'm twisting 7:28 on this blocked out vertebra. So the way that would look is here, 7:35 find my transverse process, I can use both hands 7:38 you got it locked in. Now I can use this palm to help control her head a 7:44 little bit. Alright I can get into my quasi-cradle grip here, jut, side-bend, 7:52 good. Now I can laterally flex, rotate, extend or flex, and I find a little 7:59 traction helps a lot, and once I get her all locked up right if I feel like she's 8:05 tense I'll have her do the breath thing. 8:08 Breathe in, breathe out and then rotation is my primary movement, just like that. 8:18 You notice I just tip. Alright so I tipped here, I did keep pressure with my 8:22 forearm against her head right so that I got a little bit of lateral flexion too. 8:26 At the very least when I rotated I don't want her coming out of lateral flexion. 8:29 I'll show you what that looks like on the other side. All right so I'm going to 8:36 find her transverse process, and remember you can use both hands. It's okay, take 8:40 your time. Setup is 99% of this. I keep saying 90 in 8:45 the other videos, I think 99% is where it's at, because even when I'm watching the 8:49 videos I'm like I spent 15 minutes talking about setup, and the actual manipulation 8:53 was nothing. So there's her transverse process, I'm 8:57 going to make sure my fingers there right I can use this palm still to help control 9:02 her head a little bit. I'm going to use this kind of quasi-cradle grip here. I'm 9:07 going to jut a little bit, side glide this way, all right so I'm kind of, you 9:13 can think of like kind of opening up the joint that you're trying to manipulate, side 9:17 glide, rotate this way, lateral-flexion some extension on this side, I'm just 9:25 kidding we're going to save that one for the close-up recap. So there you 9:29 have it C1, fingertip via transverse process, C2 you can use your second 9:38 MCP just like you did on the mid-cervical techniques. The only difference 9:42 is it's harder to get on that spinous process because it's so close to the 9:45 occiput, and you have to jut and side glide first to really make this technique 9:50 work for you. Stay tuned for our close-up recap. For the close-up recap 9:54 I'm going to show you the atlanto-occipital joint manipulation. I think you 9:57 have the blocking of C2 with your second MCP down pretty good, but 10:03 this ability to block out the C1 transverse process with the middle 10:08 finger is a little complicated. So my suggestion is use both hands to find 10:13 first the mastoid process and then the transverse process of C1, and you 10:19 can use a little lateral flexion away to have that poke you right in the 10:24 finger, and then I'm going to use this finger to get underneath that transverse 10:29 process so that I can really get underneath it and like block it. Like 10:34 right now I can, not that this would be great technique for a mobilization, but I 10:39 can literally mobilize C1 on her occiput. Alright so if I feel like I got 10:45 that type of purchase, that's when I'm ready to do this manipulation. So now I would 10:49 jut, alright so pull her into a little bit of this forward head position, and 10:55 I've removed the pillow this time just to make it a little easier for you 10:58 to see. I'm now going to side glide towards the camera, 11:02 alright so towards you and I'm going to try to use open hand technique 11:07 here so you can the motions that I'm doing, because if I 11:10 do cradle grip this close to the camera I'm going to block everything. But I'm going to 11:15 keep my finger there, forward, side-glide, lateral flexion, rotation, get 11:28 her all locked up; and then once I know I have her locked up maybe a little 11:35 traction, and I can just rotate, and that's the manipulation. All right so I'm not 11:44 quite as good as that open hand technique, for me and be a little bit 11:48 more comfortable to get in here. Remember you're only going to go ahead and do your 12:00 high-velocity thrust when you feel lock, and deep breath, and just like so. All 12:11 right so a little scary for Yvette there, but no pain right. All right 12:15 so practice that, remember you have your fingertips here, that you have to 12:21 block the joint out with. A little bit of forward, a little bit of side glide, and a 12:26 little bit of traction really helps with this technique, which then you can do 12:32 your normal cervical manipulation motions; and then I would 12:36 say the other big difference with this manipulation is it's almost totally a 12:41 rotation for the actual manipulation. If you have any questions leave them in the 12:45 comments box below. A couple of points to recap, knowing your Anatomy and knowing 12:50 your biomechanics will certainly help you choose the right technique for the 12:54 right patient. If you're unsure whether manipulations are appropriate due to 12:59 their higher intensity, it's okay to do mobilizations. Nost research points to 13:04 manipulations being slightly more effective but mobilizations being very 13:08 effective, and of course we have those videos for you if you want to start with 13:12 those less intense techniques. Make sure that if you are doing any technique that it 13:18 is based on assessment, and then of course that you're 13:20 reassessing, ensuring that the technique is effective for the patient that you're 13:24 working on; and when it comes to all manual techniques, manipulations 13:28 maybe more than any other, look for opportunities to get live education. 13:33 Although I know videos are convenient and I'm happy to have these up for you 13:38 to watch, it would be so much more helpful to use those videos as a recap 13:44 of one-on-one attention with somebody who's experienced with manipulation 13:51 techniques. At the very least grab a colleague and grab a friend, and start 13:57 practising these before you bring them into clinic and start using them on 14:01 patients and clients. I hope you enjoyed this video, if you have any questions 14:05 please leave them in the comments box below.
