00:00:0400:00:07
This is Brent of the Brookbush Institute, and
00:00:0400:00:07
in this video we're going to go over
00:00:0700:00:11
manipulations or high-velocity thrust techniques. I assume that if you're
00:00:1100:00:14
watching this video you're watching it for educational purposes, and that you
00:00:1400:00:19
are a licensed professional with high velocity thrust or manipulation
00:00:1900:00:24
techniques in your scope of practice. If you are not sure, check with your state
00:00:2400:00:28
board. Most physical therapists, chiropractors and osteopaths you're in
00:00:2800:00:33
the clear. I believe that ATC's you can't do manipulations in the United States,
00:00:3300:00:38
although other countries again check your scope. Of course massage therapists
00:00:3800:00:41
and personal trainers these are generally not within your scope. Of
00:00:4100:00:47
course you could continue to watch these videos just for educational purposes,
00:00:4700:00:51
learn a little Anatomy, learn a little biomechanics. If you're going to do these
00:00:5100:00:56
techniques please make sure that you have a good rationale for putting your
00:00:5600:01:00
hands on a patient. This should be based on assessment, and if you're going to
00:01:0000:01:06
assess I'm hoping that you'll assess use these interventions and reassess, to
00:01:0600:01:09
ensure that you're getting the result that you're looking for and have good
00:01:0900:01:12
reason to continue using this technique. In this video we're going to go over
00:01:1200:01:16
cervical manipulation, or at least mid to lower cervical manipulation. I'm going to
00:01:1600:01:19
have my friend Yvette come out, she's going to help me demonstrate. Now if I'm
00:01:1900:01:22
doing a cervical manipulation we do have to keep in mind that I'm basing this on
00:01:2200:01:27
more than just subjective complaints of neck pain. We can have neck pain for
00:01:2700:01:32
hypermobility of cervical segments, if we're doing manipulations it should be
00:01:3200:01:36
for hypomobility, or some sort of restriction. So I'm going to base this on
00:01:3600:01:40
some sort of assessment for range of motion, for example we could do our
00:01:4000:01:44
visual exam of rotation, lateral-flexion, flexion and extension. I might try to add
00:01:4400:01:48
goniometry, keep in mind the only reliable goniometric assessment for the
00:01:4800:01:52
cervical spine is actually lateral flexion, and you can look that video
00:01:5200:01:57
up. Now you might want to continue with some special tests, if you're going to do
00:01:5700:02:04
this, the VBI and ligament tests are often brought up as necessary before
00:02:0400:02:08
doing a cervical manipulation, that's probably more dependent on what your
00:02:0800:02:13
liability insurance states or what insurance companies you're working with
00:02:1300:02:17
state have to be done; and the reason why I say that is
00:02:1700:02:22
there is very little evidence to suggest that those tests themselves are
00:02:2200:02:28
particularly reliable, or that they would give us any indication of somebody who
00:02:2800:02:32
could be hurt by a cervical manipulation. So I think cervical manipulation
00:02:3200:02:38
injuries are rare, and that's possibly the most important thing to keep in mind.
00:02:3800:02:41
If somebody does look like they need this technique due to a mobility
00:02:4100:02:46
restriction you should probably move ahead and do so with care, and obviously
00:02:4600:02:49
with practice, and we're going to try to show you some pretty conservative
00:02:4900:02:54
techniques here. Now after I've gone through my assessments, whether that's
00:02:5400:03:00
subjective, objective and special tests including VBI, or it's subjective and
00:03:0000:03:05
objective alone, I'm going to go ahead and have Yvette back off the table here so
00:03:0500:03:10
our heads hanging, so that now I have control of her head and cervical spine;
00:03:1000:03:14
and the next thing I'm going to do is I'm going to use what's called a piano
00:03:1400:03:18
finger grip, I like the Maitland school where I'm going to put my fingertips
00:03:1800:03:24
between her spinous process. So you can think of her spinous process are
00:03:2400:03:28
lined up this way and I'm trying to put my fingers just in between, and what I'm
00:03:2800:03:37
going to try to feel for is, do the spinous process move sequentially, right almost
00:03:3700:03:42
like dominoes falling they should go tic tic tic tic tic; rather than what
00:03:4200:03:46
you'll feel with somebody who has restriction, is you'll get one that moves
00:03:4600:03:50
and then maybe two or three that move together. Or you pulling the
00:03:5000:03:53
lateral flexion and it's the same thing, where you get one that moves and then a
00:03:5300:03:56
bunch that move together. Well you know those segments that are stuck together
00:03:5600:04:02
are potentially something that could be helped by a cervical manipulation. So I
00:04:0200:04:06
can do this with Yvette here a little lateral flexion, a little rotation and I
00:04:0600:04:17
can do both ways, and I do feel a little restriction over what's probably between
00:04:1700:04:25
C3 and C5, so those two segments. Now how am I going to manipulate those
00:04:2500:04:28
segments, well this was a little confusing when I first got
00:04:2800:04:34
taught it, but I think part of the reason why it was confusing is nobody really
00:04:3400:04:37
helped me understand that the most important thing about a cervical
00:04:3700:04:42
manipulation is finding the lock out position. Finding that position where you
00:04:4200:04:47
have all of the joints locked, so that when you do the actual manipulation
00:04:4700:04:52
motion the only thing that can move is the segment you're trying to move and
00:04:5200:04:58
that comes down to two big things, well maybe more than two big things, but
00:04:5800:05:03
two major things are going to be that you block out the lower segments and that
00:05:0300:05:08
you get in locked position with the top segments. So what we're going to do is we're
00:05:0800:05:15
going to use our second MCP on the spinous process just below the segment we feel
00:05:1500:05:19
restriction. You don't even have to necessarily know which segment that is
00:05:1900:05:24
to be quite honest. Some people get very detail-oriented about while I'm
00:05:2400:05:32
manipulating C4 on C5, or you could just feel for the stiff segments and go after
00:05:3200:05:37
that, your accuracy is probably pretty similar either way. So I'm going to put this
00:05:3700:05:44
MCP on the spinous process of the lower segment and press it into the articular
00:05:4400:05:46
pillar. So you can see I
00:05:4600:05:52
start to take up some tissue slack by pushing my MCP in this direction,
00:05:5200:05:58
I'm already stabilizing making sure that those lower segments when I rotate this,
00:05:5800:06:05
side-bend or extend, I'm resisting all of those motions at anything lower than
00:06:0500:06:11
this MCP. Once I have that stabilized I'm now going to use this hand, and you can
00:06:1100:06:15
either use an open hand technique which I'm a little less comfortable with quite
00:06:1500:06:20
honestly, or you can do head cradle position. So now I have her head
00:06:2000:06:26
cradled in my elbow crease there, most of what she's feeling is like my bicep on
00:06:2600:06:32
the top of her head. I can almost control all of it just by doing this. I'm
00:06:3200:06:37
literally just cradling her head so she feels nice and comfortable and
00:06:3700:06:42
stable, and then we're going to wrap our hand around her chin, but keep in mind
00:06:4200:06:46
I'm not like yanking on her face. So I have just got her all wrapped
00:06:4600:06:52
up so her heads nice and stable, and then once she's nice and relaxed. Now
00:06:5200:06:58
I can move around a little bit, ninety percent of this is set up. So I
00:06:5800:07:02
know some of you are waiting for me to do the manipulation, just show me the manipulation,
00:07:0200:07:08
we got to get it to crack. That's literally the last 10%, and
00:07:0800:07:12
potentially the least important point because if you lock somebody up perfect,
00:07:1200:07:17
a lot of times they'll move on you, you'll get a cavitation without even
00:07:1700:07:21
having to do a high-velocity thrust. So I'm blocking out those lower segments
00:07:2100:07:28
here up this way. I'm then going to rotate away, I'm going to side-bend
00:07:2800:07:34
towards me. I'm going to extend and flex and you can see now once
00:07:3400:07:40
I rotate, side-bend and extend and flex then I search; and what I'm
00:07:4000:07:45
searching for is if I push up here, or push sideways here or rotate sideways
00:07:4500:07:50
here, I'm moving her head in this general direction. Get used to that
00:07:5000:07:53
general direction, you don't even have to think joint actions. So I know you might
00:07:5300:07:57
be like, well you've got a contralaterally rotate and ipsilaterally
00:07:5700:08:01
flex and extend. That's all great, but if you just think about this
00:08:0100:08:09
general motion, and this general motion here, and get all locked up which I am
00:08:0900:08:13
right now. Now all I have to do is a little lateral flexion and rotation and
00:08:1300:08:21
I guarantee she's going go. So nice deep breath Yvette,
00:08:2200:08:29
and that's it. Sometimes it is a surprise to patients. Not everybody is used to
00:08:2900:08:32
getting their cervical spine manipulated and I appreciate that Yvette is
00:08:3200:08:35
letting me do this for the first time, because she is not somebody who gets
00:08:3500:08:37
cervical manipulations done very often. But
00:08:3700:08:42
that wasn't that bad, no pain. You can see I didn't
00:08:4200:08:46
move that much, it was more of a startle response than it was any sort of like
00:08:4600:08:52
pain response. We're definitely not doing big whips this way, or trying to
00:08:5200:08:56
press in really hard, it's just getting that lock and then just a quick
00:08:5600:09:00
twist; and I think you have seen chiropractors doing it with the open
00:09:0000:09:05
hand technique which looks a little bit more impressive. but they just wrap,
00:09:0500:09:11
it's a very quick little technique. So let's try that one more
00:09:1100:09:18
time, I'll show you from the other side. I'm going to use this knuckle, I'm
00:09:1800:09:24
going to get on the spinous process of the segment just below where I think she's
00:09:2400:09:29
stuck. Now I could use an open hand technique, and I'll show you the
00:09:2900:09:32
open hand technique this time. So I'm still blocking this way and I'm
00:09:3200:09:36
still thinking about pushing up in this direction, because I want to
00:09:3600:09:41
oppose the lateral flexion this way and I want to oppose the rotation I'm going
00:09:4100:09:46
to do. So I'm trying to keep the spinous process below in position, which
00:09:4600:09:49
means I kind of have to push up and in this way towards the articular pillar,
00:09:4900:09:55
kind of in the direction of my thumb right now. Now I can use this hand kind
00:09:5500:10:01
of wrapped around, you can see like I got my thumb up to her maxilla here and I'm
00:10:0100:10:04
just wrapped around her head, and I have some some big hands. So it kind of
00:10:0400:10:08
depends on your hand size too where you're going to end up
00:10:0800:10:12
as far as your fingertips. So don't look at my hands and be like oh that's
00:10:1200:10:17
how it's got to be look, you get your hands where they're comfortable. But
00:10:1700:10:20
if I think about the same direction of motion, yes we can think about
00:10:2000:10:24
it's the lateral flexion and contralateral rotation and all that
00:10:2400:10:30
stuff, or you can think of, you're doing this with her head. You're doing
00:10:3000:10:33
this general motion with her head and you can add a little bit of this to get
00:10:3300:10:39
locked out. Once I'm locked out I'm here, and
00:10:3900:10:46
then she takes a nice deep breath for me and all I'm going to do with my hands is
00:10:4600:10:49
this sort of thing, because I'm going to push her into lateral flexion and
00:10:4900:10:52
rotation this way, which means I'm going to slide my
00:10:5200:11:02
hand this way to get that motion. How you feeling Yvette? Okay good, and that's it.
00:11:0200:11:08
Sometimes you get a cavitation, sometimes you don't. Never forget
00:11:0800:11:14
cavitation does not mean success. Success is performed better on reassessment, the
00:11:1400:11:18
manipulation is the manipulation regardless of whether you got a
00:11:1800:11:22
cavitation. It could be that I didn't get her locked up enough on that particular
00:11:2200:11:27
try, or it could be that I got it. I would still reassess first before I gave this
00:11:2700:11:33
one more try, be careful not trying to get a cavitation too many times because
00:11:3300:11:36
you think you failed, because what you will do is you'll start to flare people
00:11:3600:11:40
up. We do have to keep in mind that high- velocity also means high-intensity, and
00:11:4000:11:44
if we keep doing a high-intensity technique to a tissue over and over
00:11:4400:11:46
again that maybe is already a little irritable,
00:11:4600:11:53
we could start increasing pain rather than reducing pain. How do you feel Yvette?
00:11:5300:11:57
Why don't you sit up and take a minute and we'll go to the close-up recap.
00:11:5700:12:01
Alright for a close-up recap I brought out the spine model, I wanted to
00:12:0100:12:04
show you some of the stuff we were talking about so you have a little bit
00:12:0400:12:08
better visualization. So if this is the back of the cervical spine that you
00:12:0800:12:12
would be feeling, the first thing you're going to feel is those spinous process and
00:12:1200:12:16
when I talked about that piano grip I was talking about putting my fingertips
00:12:1600:12:21
between the spinous process, so I could feel them move sequentially like
00:12:2100:12:25
one, two, three, four. They should just each move like little
00:12:2500:12:29
dominoes falling, and when two spinous process move together that might be an
00:12:2900:12:33
indication that I have a little bit of restriction between those segments, so I
00:12:3300:12:37
use that piano grip for that. All right that's what it would look like from
00:12:3700:12:42
the other side, and of course then I'm rotating and side-bending. When I talked
00:12:4200:12:47
about putting my second MCP against the spinous process, realise
00:12:4700:12:53
I'm trying to fit it in this laminar trough, almost trying to put it on these
00:12:5300:12:57
articular pillars; and you can see here the articular pillar is called that
00:12:5700:13:00
because when all these facets come together they kind of make this like
00:13:0000:13:05
pillar shape. But somewhere between the articular pillar and what this would be
00:13:0500:13:08
called would be the laminar trough, is kind of where I'm trying to fit my first
00:13:0800:13:16
or my second MCP so that I stabilize the lower segments. Now if I have Yvette go
00:13:1600:13:21
ahead and come back here, I'll try to demonstrate for you guys one more time
00:13:2100:13:28
in a close-up here. So piano grip, what that would look like on her neck is
00:13:2800:13:32
I would feel my spinous process, and then I would just slide my fingers over so I
00:13:3200:13:37
was on the side of my spinous process, and then I can laterally flex and rotate
00:13:3700:13:44
and see if any of those segments seem to want to move together rather than
00:13:4400:13:51
sequentially; and then once I find some segments realize that I'm going to then
00:13:5100:13:58
try to place my second MCP right up against that spinous process, or the
00:13:5800:14:05
spinous process that's lower than the stuck segment. Once I have that set up
00:14:0500:14:11
then I'm going to rotate away, laterally flex towards, but we're talking
00:14:1100:14:18
about kind of bending her head or bending her neck over that second MCP;
00:14:1800:14:27
and then once she's there and I'm nice and locked up, take a deep breath, I can
00:14:2700:14:34
give her a quick little rotation and lateral flexion thrust. So this, and if
00:14:3400:14:38
she's locked up properly and we hadn't just done a manipulation on the previous
00:14:3800:14:40
take of this video which you just saw,
00:14:4000:14:44
she probably would have got a cavitation on that one. But keep
00:14:4400:14:48
in mind that cavitations don't mean success, changes on reassessment mean
00:14:4800:14:53
success. I hope you found this video very helpful. Grab some friends in
00:14:5300:14:56
practice, and if you have any questions leave them in the comments box below. A
00:14:5600:15:00
couple of points to recap, knowing your anatomy and knowing your biomechanics
00:15:0000:15:05
will certainly help you choose the right technique for the right patient. If
00:15:0500:15:09
you're unsure whether manipulations are appropriate due to their higher
00:15:0900:15:15
intensity, it's okay to do mobilizations. Most research points to manipulations
00:15:1500:15:18
being slightly more effective but mobilizations being very effective, and
00:15:1800:15:22
of course we have those videos for you if you want to start with those less
00:15:2200:15:28
intense techniques. Make sure that if you are doing any technique that is based on
00:15:2800:15:32
assessment, and of course that you're reassessing ensuring that the technique
00:15:3200:15:35
is effective for the patient that you're working on, and when it comes to all
00:15:3500:15:40
manual techniques, manipulations may be more than any other, look for
00:15:4000:15:45
opportunities to get live education. Although I know videos are convenient
00:15:4500:15:50
and I'm happy to have these up for you to watch, it would be so much more
00:15:5000:15:57
helpful to use those videos as a recap of one-on-one attention with somebody
00:15:5700:16:03
who's experienced with manipulation techniques. At the very least grab a
00:16:0300:16:08
colleague, grab a friend and start practising these before you bring them
00:16:0800:16:12
into clinic and start using them on patients and clients. I hope you enjoyed
00:16:1200:16:16
this video, if you have any questions please leave them in the comments box