00:00:0500:00:07
This is Brent of the Brookbush Institute, and in this video we're going to go over a joint
00:00:0700:00:11
based manual therapy technique, If you're watching this video I'm assuming you're
00:00:1100:00:14
watching it for educational purposes, and that you are a licensed professional
00:00:1400:00:20
with joint based techniques within your scope. That means osteopath's chiropractors,
00:00:2000:00:24
physical therapists, you're probably all in the clear. Physical therapy assistants,
00:00:2400:00:28
athletic trainers, massage therapists, you need to check with your governing body
00:00:2800:00:32
in your state or region to see whether this is within your scope of practice.
00:00:3200:00:36
Personal trainers this is definitely not within your scope of practice. Of course
00:00:3600:00:41
all professions could use this video for purely educational purposes to help with
00:00:4100:00:46
learning biomechanics, anatomy, and of course palpation. In this video we're
00:00:4600:00:51
going to go over posterior to anterior well as superior to inferior, clavicle on
00:00:5100:00:56
acromion mobilization. So this is our acromioclavicular joint mobilizations.
00:00:5600:00:58
I'm going to have my friend Melissa come out, she's going to help me demonstrate.
00:00:5800:01:03
Now these are great joint mobilizations I want you to keep in your back pocket, and
00:01:0300:01:08
I know a lot of individuals don't do these mobilizations on a regular basis,
00:01:0800:01:12
but they are great for putting the finishing touches on regaining optimal
00:01:1200:01:19
mobility, or optimizing the quality of motion of the shoulder girdle. And that
00:01:1900:01:24
we have some research to kind of back this up. Research on the shoulder,
00:01:2400:01:27
specifically shoulder dysfunction and things like impingement syndrome, kind of
00:01:2700:01:32
show this propensity of the scapula to adopt an excessively downwardly
00:01:3200:01:36
rotated and anteriorly tipped position. If we think about what that would do to
00:01:3600:01:44
the arthrokinematic of the AC joint, it would push the acromion shelf anterior
00:01:4400:01:51
and inferior to the clavicle. So now the question is is how do we get it back, and
00:01:5100:01:54
I know some of you guys are thinking well you just push the scapula up and
00:01:5400:01:58
you push the scapula back and that makes a lot of sense, and it does make a
00:01:5800:02:04
lot of sense if it wasn't for the fact that the scapula is kind of big, and this
00:02:0400:02:08
is what that mobilization would look like. If we had some crazy way of
00:02:0800:02:11
stabilizing the clavicle, which we just kind of don't have a good way to
00:02:1100:02:15
stabilize the clavicle. The easier way to do this from a technique standpoint is
00:02:1500:02:20
to actually move the clavicle on a scapular that's being stabilized by
00:02:2000:02:24
the table. The only thing we have to consider now is we have to reverse the
00:02:2400:02:29
direction of our mobilisation, so rather than going superior and posterior with
00:02:2900:02:36
our scapula, we're going to go inferior and anterior with our clavicle, So what
00:02:3600:02:39
would that look like? Well first things first
00:02:3900:02:43
with all of our joint mobilizations, knowing your anatomy and having some
00:02:4300:02:49
palpation skills are very very helpful. I had suggested in another video that
00:02:4900:02:55
maybe even outline the clavicle, and you just outlined the clavicle you know with
00:02:5500:02:59
your with your partner with your colleague in a class, you know grab grab
00:02:5900:03:03
some people to practice on. I'm not suggesting you do this with every
00:03:0300:03:07
patient, but I know you know where your collarbone is, but try to identify the
00:03:0700:03:13
entire flattened S shape of the clavicle, and get a good visual model of what that
00:03:1300:03:18
looks like. See if you can feel the ends of the clavicles right, you'll notice
00:03:1800:03:23
that usually the proximal side of the clavicle is a lot more prominent than
00:03:2300:03:26
the distal side, which I guess works against us for the acromioclavicular
00:03:2600:03:32
joint mobilizations. But if you feel the entire distal end you'll notice that
00:03:3200:03:36
it's usually a little easier to get your fingers posterior to the joint, than it is
00:03:3600:03:42
to try to get your fingers anterior to the the AC joint, or at least the
00:03:4200:03:49
anterior to the distal end of the acromion, or clavicle rather. So once you
00:03:4900:03:55
find this border, what I want you to do is keep tracing that border until you
00:03:5500:04:03
feel this line that seems to indent around the distal clavicle, that is your
00:04:0300:04:07
joint line. Once we find that joint line we're back in the same place we've been
00:04:0700:04:09
in with all of our joint mobilizations where now we just have to figure out
00:04:0900:04:15
which direction we want to go, and we have a good chance of actually feeling
00:04:1500:04:20
our first resistance barrier, our first point of motion of arthrokinematic
00:04:2000:04:25
motion. Now this is glide as well as the end of arthrokinematic motion or the
00:04:2500:04:31
end of glide, and if we start with our our superior to inferior glides here, and
00:04:3100:04:33
I'm just going to move kind of kind of off to the side
00:04:3300:04:40
here. I can even keep one thumb right on the joint line and the acromion shelf,
00:04:4000:04:45
and use the other thumb, try to get my hands in here, use the other thumb to
00:04:4500:04:51
push straight superior to inferior on that clavicle, and make sure you use your
00:04:5100:04:57
thumb pad guys here not your fingertip, we don't want to poke at a joint that's
00:04:5700:05:02
that's never a good idea. Think about always using the broadest surface area
00:05:0200:05:07
you can. Right i'm going to go this way, you okay Melissa. You guys just got to be
00:05:0700:05:10
careful on these techniques, when you straighten out your arms it's really
00:05:1000:05:16
easy just keep knocking people in the head, and nobody likes that. So I have my
00:05:1600:05:20
thumb on the joint line, I can feel first point at which it moves, which which
00:05:2000:05:23
comes on pretty fast in this little joint, there's not a lot of motion there;
00:05:2300:05:28
and then I push all the way down until I feel end range, there we go, back off to
00:05:2800:05:33
50% and I can do whatever graded mobilization I'd like. Let's say grade
00:05:3300:05:38
three here, I'm going to back off the where I first felt that resistance and
00:05:3800:05:47
then go all the way down 50%, back to the beginning, and go from the beginning to
00:05:4700:05:54
50%, and if I can I'm going to straighten out my arms and just use my trunk to do
00:05:5400:05:59
this mobilization. Now I'm going to warn you guys we've been real careful with
00:05:5900:06:05
our technique up to this mobilization, there are joint mobilizations that just
00:06:0500:06:11
don't lend themselves very well to great body mechanics and great posture, which
00:06:1100:06:16
is why you have to be perfect on all of your other mobilizations. So that when
00:06:1600:06:21
you get to a mobilization like this where it is really really hard to have
00:06:2100:06:26
great mechanics, if you wear yourself down a little bit on this technique
00:06:2600:06:32
you're okay because the rest of the day you have perfect posture, and you're not
00:06:3200:06:37
really using the strength of your hands you're just using your bodyweight. Now
00:06:3700:06:42
this one I can use a little bit better technique
00:06:4200:06:47
than posterior to anterior, this is where things get really really tricky, because
00:06:4700:06:52
obviously if I was going to go posterior to anterior and have a great body
00:06:5200:06:56
position I would somehow be able to get my arms straight down this way through
00:06:5600:07:02
the table, and I can't go through tables, I don't know anybody who can. So what we
00:07:0200:07:08
end up having to do is kind of this like flip up technique with our wrists,
00:07:0800:07:11
alright which is it's going to get tough if you had to do a bunch of these
00:07:1100:07:16
throughout a day. But granted that we don't use this technique all the time
00:07:1600:07:21
you should be able to to get away with it here and there, and all you're going
00:07:2100:07:28
to do is put your thumb behind the distal end of the clavicle just like we
00:07:2800:07:33
talked about you finding, when we were talking about palpation here, so find the
00:07:3300:07:38
joint line, you're going to have to scoot over quite a bit so that this arm ends
00:07:3800:07:42
up straight next to your patient's head, because if you try to get this arm
00:07:4200:07:46
straight once again you just end up banging them in the head, or you end up
00:07:4600:07:50
putting your arm down on their face, also not okay.
00:07:5000:07:56
Clients don't seem to like going back and forth over the top of their face,
00:07:5600:08:03
probably not great customer service. So get your dummy thumbs set up guys,
00:08:0300:08:07
alright so I'm going to use my inside thumb as my dummy thumb here, and then
00:08:0700:08:14
I'm going to try to like I said kind of use that flip-up technique. Now before I
00:08:1400:08:20
did this flip-up technique I should have found my first resistant barrier, find
00:08:2000:08:27
the end and then back off to 50%, this time we'll do a grade four, I'll stay
00:08:2700:08:33
right there and I'm just kind of flipping my thumbs up, right I'm just
00:08:3300:08:38
doing this, takes a little bit of practice. This one you might want to grab
00:08:3800:08:43
a couple extra colleagues when you're practicing this technique, make sure you
00:08:4300:08:48
do both of their shoulders and get as much practice as you possibly can,
00:08:4800:08:52
and of course if I'm doing my grade four mobilizations, I'm doing
00:08:5200:08:57
one two two two oscillations per second, and I'm going to keep going until
00:08:5700:09:02
I feel a reduction in arthrokinematic stiffness. As I mentioned in the
00:09:0200:09:08
beginning of this video if we're going to go back to like a more reliable
00:09:0800:09:13
objective measure, I would probably use something like end range shoulder
00:09:1300:09:17
flexion, and this is gross shoulder flexion not just glenohumeral shoulder
00:09:1700:09:20
flexion. But do they get a hundred and eighty degrees, can they get their arm
00:09:2000:09:25
all the way down to the table shoulder flexion. Or maybe I use external rotation
00:09:2500:09:30
and see and see to make sure that they've got all the way to 90-95 degrees,
00:09:3000:09:34
which is going to include not only glenohumeral motion but posterior
00:09:3400:09:39
tipping of the scapula as well, to see if I got some loosening up of the AC joint.
00:09:3900:09:44
So just real quick - to recap that mobilization before we're going to our
00:09:4400:09:49
close-up recap. You guys are going to have to get real good at finding the
00:09:4900:09:54
distal border of the clavicle. Pretty easy to do our superior to inferior
00:09:5400:10:00
mobilization but you're going to have to scoot over, and probably use one arm
00:10:0000:10:07
straight right parallel to their face, and probably one thumb is going to end
00:10:0700:10:13
up being like a dummy thumb and a feeler, and then the other hand you can pretty
00:10:1300:10:18
much use your trunk to get that superior to inferior mobilization. The posterior
00:10:1800:10:23
to anterior mobilization a little trickier, it is easy enough to get your
00:10:2300:10:28
thumb behind the clavicle, but then to get both thumbs and to create a
00:10:2800:10:34
posterior to anterior direction, you end up doing this flip-up technique which is
00:10:3400:10:41
going to take a little practice. Obviously is not great on our own body
00:10:4100:10:46
mechanics, so I wouldn't recommend doing this all day every day as your go-to
00:10:4600:10:53
technique for everybody, but it does work in a pinch. Guys try these techniques,
00:10:5300:10:59
stay tuned for the close-up recap. So for a close-up recap of the superior to
00:10:5900:11:04
inferior and posterior to anterior clavicle on acromion
00:11:0400:11:11
mobilisations. First just palpate your clavicle, find the end of your clavicle
00:11:1100:11:17
the distal end. Now the distal end is usually not quite as prominent as the
00:11:1700:11:21
proximal end if you've done the sternal sternoclavicular joint mobilization
00:11:2100:11:29
before, but it's usually prominent enough that if you take your time and
00:11:2900:11:37
investigate you'll notice that it drops off into the flat acromion, you can
00:11:3700:11:43
definitely feel a little bump when going from acromion shelf back onto the
00:11:4300:11:50
clavicle; and that of course is the somewhat spherical end of the clavicular
00:11:5000:11:55
bone there. It's definitely a little bit more spherical in the
00:11:5500:12:00
posterior aspect. If I'm doing my superior to inferior mobilization then I
00:12:0000:12:06
might use this hand as my my feeler, we talked about kind of placing any free
00:12:0600:12:12
fingers or hand that we have on the joint line so we can feel the amount of
00:12:1200:12:16
glide happening, and of course if I put this finger here I can I can just push
00:12:1600:12:22
like this and feel joint motion. Once I started doing the mobilization I want to
00:12:2200:12:27
use the the largest surface I can. So we're not going to poke at the joint, but
00:12:2700:12:33
we're going to use a thumb pad like this, I'm going to straighten up my arm, I
00:12:3300:12:37
could use thumb over thumb technique but I'm actually going to leave this thumb
00:12:3700:12:42
here so that I can feel that joint line, and then straighten out my arm find that
00:12:4200:12:48
first resistance barrier, find the end of athrokinematic range, back off to 50% and
00:12:4800:12:54
of course then I can just use my torso to get a nice oscillation here, one to
00:12:5400:12:58
two oscillations per second. Now the harder technique I kind of explained to
00:12:5800:13:02
you guys was the posterior to anterior, because you have to use this kind of
00:13:0200:13:10
flipping wrist technique. It is easier to get on the posterior aspect of the
00:13:1000:13:15
clavicular bone that's not too hard, and of course you could leave a finger on
00:13:1500:13:17
the joint line or you could end up using both
00:13:1700:13:23
fingers to do this flipping up technique, to get your posterior to anterior
00:13:2300:13:31
direction. Now with this technique it is very tough to kind of identify your
00:13:3100:13:37
first resistance barrier, your end range, back off the 50% and stay there, that's
00:13:3700:13:42
going to take some practice. With this particular technique I would definitely
00:13:4200:13:50
find more than a couple colleagues to practice getting the direction right on
00:13:5000:13:55
that mobilization, and of course with all of these mobilizations you can test
00:13:5500:14:00
which one is most effective. For example I could do this then test and range
00:14:0000:14:04
shoulder flexion, and then I could test this one and do end range shoulder
00:14:0400:14:07
flexion again and see which one works better. So there you have it
00:14:0700:14:12
assess, address, reassess. Make sure that every time you choose a joint based
00:14:1200:14:17
manual therapy technique it is based on an assessment, and that you return to
00:14:1700:14:21
that assessment after you finish the intervention, to see if it was effective
00:14:2100:14:26
for the individual, the patient or client that you had in front of you. Ensure that
00:14:2600:14:31
you continue to learn your Anatomy because your Anatomy is going to help
00:14:3100:14:36
you with your hand placement, with understanding what a joint can do, with
00:14:3600:14:41
understanding what you may gain from this particular technique. And of course
00:14:4100:14:46
practice, you have to practice these techniques hopefully not for the first
00:14:4600:14:51
time on a patient or client who just walked in the door. If you can, find a
00:14:5100:14:56
more senior instructor or mentor to give you some really good hands-on
00:14:5600:15:03
instruction. Use your peers for some good feedback, and of course always look for
00:15:0300:15:09
live education to help with your manual therapy techniques. I know these videos
00:15:0900:15:15
make education very convenient, but there is no substitute for learning manual
00:15:1500:15:19
therapy in a live setting. I look forward to talking to you guys again