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Acromioclavicular (AC) Joint Posterior to Anterior Manual Mobilization

Acromioclavicular (AC) Joint Posterior to Anterior Manual Mobilization is a technique used to help improve motion at the AC joint. During this mobilization, the acromion—the outermost bony point of the shoulder blade—is moved posteriorly and then anteriorly in order to improve both joint range of motion and the quality of movement. Goal of this technique is to help decrease pain associated with dysfunction at the AC joint as well as to restore impaired joint mechanics

Transcript

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