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This is Brent of the Brookbush Institute, and in this
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video we're going to go over a joint
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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 therapist's 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 anterior to posterior humerus on glenoid fossa mobilization,
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commonly known as a shoulder AP. I'm going to have my friend Melissa come out,
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she's going to help me demonstrate. Now if I'm doing this mobilization, chances
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are I've already done some sort of functional movement assessment like the
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overhead squat assessment, or I've seen that wall shoulder mobility test that
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kind of looks like our serratus anterior activation, that is also a great
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functional exam. We'll probably follow that up with
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goniometery, something like internal and external rotation of the humerus, and
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then last I'm going to want to check passive accessory motion to see if there
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is arthrokinematic stiffness. Now we do have to be careful using this technique
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with the shoulder, the shoulder has a propensity to become both hypermobile
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that is too flexible, and hypomobile that's stiff. Now we only want to mobilize those
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individuals who have stiffness, somebody who is too flexible who gets this
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mobilization done, we might actually exacerbate their symptoms or actually
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make them worse. The last thing we want to do is take somebody who's too
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flexible, and make them even more flexible.. So now you've done your
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assessment, you determined that there is arthrokinematic stiffness and you're
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ready to do this mobilization, how do I place my hands? Well that all requires a
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little bit of knowledge of anatomy and palpation. Alright so the first thing I
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would recommend finding is just the acromion shelf, so the acromion shelf is
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that big bony shelf that kind of sits right between
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all of the muscle of the deltoid. So if you make a little muscle for me there
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Melissa good job, alright you guys see this like dent right here, this dent
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between her anterior middle and posterior right, that makes like a little
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'U' this way, that dent that is the acromion shelf. So you can have somebody
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kind of do this, get your fingers down on that bone, now go ahead and explore the
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edges of that bone, explore the edges of the acromion shelf. You need the person
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to stay nice and relaxed, good there we go nice and relaxed, so make sure their
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arm is supported by the table. Once you've felt through the acromion shelf
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you can actually start to feel like a divot underneath it, you can almost get
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your fingers underneath it, and then if you keep going down the arm this way a
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little bit you'll start to be able to sink your fingers around the humeral
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head. Now the humeral head obviously is the most proximal portion of our humerus
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bone, and that's going to be where we want to get our hands so we can do this
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mobilization. Although we're going to place our hand on the interior portion
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of the humerus I do recommend having a good idea of
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where all of the humeral head lies, like being able to get your hands on the
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posterior humeral head, kind of feeling how it goes down into the the neck of
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the humerus as you sink past the deltoids, and keep moving distally. What
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you'll notice about the anterior portion of the humerus is it's a lot more bumpy,
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so you have the greater and lesser tubercle there, and then you also have
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this ropey thing, this really thick rope and what that is is the biceps tendon.
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The reason I bring this up is that it's something that we don't really want to
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press on. If you really gear into somebody's bicep tendon while you're
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doing this mobilization it's going to hurt, if they have impingement syndrome
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it might be because it's inflamed, even if they don't have shoulder problems
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you're just doing this on your your partner or your practice partner, or one
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of your colleagues, or perhaps a mentor or teacher that you're practicing on,
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you start gearing down on their their biceps tendon, it's going to hurt no
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matter what, so we want to kind of know where that is so we can stay away from
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it; and once you have the whole kind of idea of where the humerus is I'm going
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to ask you to try to put, or at least imagine putting the humeral head right
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in the palm of your hand like so. Now you can use these fingers to kind of wrap
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yourself around the rest of the humerus and the acromion shelf, which might come
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in handy when we start trying to find the beginning of arthrokinematic
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motion, and the end of arthrokinematic motion. Now what I usually do
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with this hand is I'm going to have Melissa who'll be inside of my bicep, I'm
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going to hold her elbow like this, and now I have good control of abduction
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adduction, and a little control over flexion and extension. I could probably
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even internally rotate and externally rotate a little bit, like I have good
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control over arm. I'm going to use this hand again, put my palm down right over
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the anterior portion of her humerus, and then notice that once I'm in position
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guys my trunk -my chest is over my hands. So again I'm not going to manhandle this
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right, this is not how we do a mobilization that would actually get really tiring if
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let's say Melissa was twice my size which would make her absolutely huge, but
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if she was a very large person or had a very large arm, let's say I'm working on
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like a professional football player or something, that would, this would be
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almost impossible. You need to get used to using your body mechanics and save
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your own body, perhaps even before you think about saving the body of your
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patient because you got to do this all day. Alright because if you're seeing eight, nine, ten,
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twelve, twenty patients a day, you need to have good mechanics and and save your
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joints. So again I just have my client or patient reach in grab the inside of my
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bicep, I grab underneath their elbow, I have to control this hand over the
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anterior portion of the humerus, I'm just thinking about putting the humeral head
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right in the palm of my hand. Since I'm using such a broad surface area I don't
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usually have that problem with the biceps tendon,
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if I do I try to put the biceps tendon between my thenar eminence, all right so most
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of my pressure is coming here and the biceps tendon is falling in this groove
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here. I'm now just going to use the weight of my trunk to kind of find okay
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there's the first resistance barrier, and that's going to come on real quick with
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the shoulder and then I'm going to find the end, alright you got to be careful
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with the shoulder. Shoulder like I said is a very mobile joint, so if you press
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too hard you're going to push right out of the glenoid fossa; not that you're
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just locating the shoulder, but you will push the humeral head onto the posterior
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lip of the glenoid fossa, and if you can do that really easily then this is probably
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not somebody who needs this mobilization. The people who need this mobilization are
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the ones you press into and you feel like you have something to press into,
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there seems to be a certain amount of stiffness almost like you're pushing
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into the back of a leather strap, like a like a leather belt.
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Alright so beginning, feel like if I go any further than this all right like I'm
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going to start pushing through. Now I'm going to back off to 50% and we've
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talked about there's a lot of different protocols out there guys, and I just
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asked you to follow through with whatever protocol that you learned. I use
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generally the Maitland protocols for grade three and grade four mobilizations,
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If we're talking about getting mobility here and this isn't like a pain dominant
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patient. So we'll go to 50%, and then I can either do back off to where was my
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first resistance barrier, to 50% and do my grade threes which is that higher
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amplitude mobilization, or I can find my 50% and do my small amplitude
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mobilizations right at that resistance barrier, making this a little higher
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intensity. Now I'm going to do this until I feel a reduction in joint stiffness,
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and then the most important thing as I've said throughout all these videos is
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I'm going to reassess. Alright so to go through that just one more time guys.
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Hand on inside of bicep, I got her elbow, I'm going to take her to where I need
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herin abduction, adduction, more flexion, more extension, wherever
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you guys feel like you need to be to work through that stiffness. The palm of
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my hand goes over the humeral head, the anterior surface of the humeral head, trying to put the biceps tendon
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between my thenar groove there, find the first resistance barrier, the end,
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back off to 50%, and then do whatever grade I think is appropriate. I have my
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hand around Melissa's elbow, and her hand is up around my arm, although I know you
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can't see that you saw that in the previous shot. You guys can see Melissa's
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acromion shelf here, and then you guys should be able to palpate around the
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acromion shelf to define the subacromial space which is going to feel like a
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depression, then as I mentioned before you should take some time to try to
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palpate through the relaxed deltoid, to kind of outline the humeral head as it
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goes down into the the neck of the humerus here, but once you find the
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humeral head now we can place our palm on top of the anterior face of the
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humeral head, and I kind of mentioned before if you kind of strum across this
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way you'll feel a big rope like tendon there, that's the biceps tendon. I would
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put that in your inner thenar groove so that you don't place undue pressure,
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and now I can kind of feel like there you go there's your first first little
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bit of motion of the humeral head, and I can push down until the end of her
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glenohumeral motion there, and then back off to 50%, and then I can either go
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from initial resistance to 50% for some grade threes or maybe I can stay at 50%
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for grade 4's, but notice I'm using a nice wide palm
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getting a lot of surface area, and trying to keep any direct pressure off that
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biceps tendon for this joint mobilization. I'm doing my one to two
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oscillations per second for 30 seconds plus until I feel a reduction in arthro-
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kinematic stiffness, and of course i'm going to reassess. If i did one set and
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got a little reduction, I could maybe pull further into flexion see if I run
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into more stiffness. I could pull further out into abduction do another set and
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see if I run into more stiffness, as I have a lot of control over Melissa's arm
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here. So guys make sure you take the time to palpate the humeral head through the
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deltoid, palm over anterior face, biceps tendon in thenar groove. Make sure you
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feel for initial movement or first resistance barrier, and end of arthro-
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kinematic range, and follow through with your protocols. 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've finished the intervention, to see if it was
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effective for the individual, the patient or client that you had in front of you.
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Ensure that you continue to learn your Anatomy because your Anatomy is going to
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help 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
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for learning manual therapy in a live setting. I look forward to talking to you