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Cervical Spine Posterior to Anterior Mobilization

Cervical Spine Posterior to Anterior Mobilization is a technique used to help reduce neck pain, stiffness, and tension. It is a type of manual therapy which involves the clinician to place their hands below the patient’s neck and use controlled pressure to move the patient’s cervical vertebrae in a posterior to anterior (back to front) direction. This technique can be used to relieve muscle tightness and improve range of motion as well as helping to alleviate

Transcript

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This is Brent of the Brookbush Institute, and in this video we're going to go over a
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...blank
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joint based manual therapy technique. If you're watching this video I'm assuming
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you're watching it for educational purposes, and that you are a licensed
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professional with joint based techniques within your scope. That means osteopaths,
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chiropractors, physical therapists you're probably all in the clear. Physical
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therapy assistants, athletic trainers, massage therapist you need to check
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with your governing body in your state or region, to see whether this is within
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your scope of practice. Personal trainers this is definitely not within your scope
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of practice. Of course all professions could use this video for purely
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educational purposes to help with learning biomechanics, anatomy and of
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course palpation. In this video we're going to go over posterior to anterior
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mobilizations for the cervical spine. Now that's unilateral posterior to anterior
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mobilizations, which i think you guys will find is the workhorse of all of the
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mobilization techniques we use for the entire spine. I'm going to have my friend
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Melissa come out, she's gonna help me demonstrate these techniques. The first
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thing I'm going to talk about is set up a little bit. We're going to have Melissa
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face down in the face cut out here, and just so that we save her more
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sensitive cheek bones, remember we're going to be pressing down on her neck, which
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means we're going to be pressing her down into the table a little bit. I'm going to go
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ahead and have her use a towel so that her forehead takes most of the force.
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We're not going to be pressing that hard, but this area tends to get easily
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aggravated, especially if we have multiple segments or multiple facet
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joints we have to mobilize. Now the next thing is we want the arms in a
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comfortable relaxed position, that could be by their sides, that could be hanging
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off the table. Or if you're lucky enough to be here at Flex in New York where I
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treat, like we have the arm cutouts that depress. So you can see Melissa can just
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kind of hang out in this position, which tends to be very comfortable for
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cervical patients. The thing you're trying to avoid is we don't want
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increased tension here, right the muscles that go from the scapula to the cervical
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spine, namely her levator scapulae and upper trap. Lastly you will notice
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that the table is pretty low, and the reason the table is low is I want to be
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able to get my chest over Melissa's neck, and then put my arms straight and have
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my thumbs right where they need to be; because once we start doing the mobilization all
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I want to have to do is rock my torso. I don't want to be in a position where I
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have to either use my hands or my elbows, right like extension using my triceps
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because number one if I have a lot of very large patients I'm going to wear
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myself out really quick, and even if I don't have a lot of large patients I
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think you guys will find that this is just not a consistent amount of force.
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It's hard to be really really consistent when you're doing this. Or you're doing
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this compared to okay I get here, and now I just rock. It's really easy to keep a
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very consistent amount of force this way. Next thing we need to consider is
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anatomy, and if you haven't spent some time going over cervical spine
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anatomy I suggest doing a little review before you start practicing these
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techniques. And I do suggest you purchase or find one of these to practice on. I
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know they're a little expensive for what they are. I think they run between 80 and
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150 bucks right. I bought one of the flexible ones, and let me explain why. I
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know this and this aren't exactly the same, but this is a close facsimile to
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the bones and joints of the cervical spine, and there's something to being
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able to touch, feel all the different bumps. Challenge yourself to go okay I'm
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going to find the transverse process of C1. All right and then be able to look down
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and go oh I'm on the transverse process of C1. Or I go I'm going find spinous
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process of C3. All right I did it, I did it, I remembered that C1 doesn't really
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have a spinous process. So as I'm doing this what I'm doing is building a
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visual model up here of what the bones of the neck look like, and I can't tell
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you how helpful that is when you get your hands here, which is basically that
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with a bunch of mush on top of it. It's not exactly the same. I'm not saying it's
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exactly the same, but I think it's going to help you guys as a learning tool
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that once you get your hands in here and you can get through the soft tissue, you
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get better at feeling through the soft tissue,
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you'll start being able to match up your visual model with what's actually going
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on here a lot quicker. Now we are going to start with the most complicated
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joints of the neck to actually palpate and mobilize, but that's just because
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we're going start from the top and work our way down. So let me show you guys how
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to palpate C1, and then how we're going to mobilize C1-CO, or the atlanto-
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occipital joint. So if you guys feel the back of the skull and then take the back
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of the skull towards the ears, and find that little point known as the mastoid
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process right that's like right here,
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and some of you have felt your mastoid processes before, they can be a
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little tender to poke on. And you guys go what does that have to do with the
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cervical spine? Well if you go just inferior to your mastoid process, you can
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actually feel it on yourself, you run into like two hard things sticking
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out this way. That's actually the transverse process of C1 all right. So
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find that on your patient and then look down, and I want you to draw an imaginary
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line between your two fingers. The little horizontal line between your two
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fingers and think C1's right under that. Alright so I know C1 is right under
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that line, and then if you can remember that the atlanto-occipital joint tilts
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towards the person's eyes. You can think okay if that's C1 I need to go just
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above C1 so that I can get on that AO joint, and I need to push in this
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direction. So what I'm going to have you guys do is trade your index fingers
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which you were probably palpating the transverse process with, with your
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pinkies. Lay your fingers over right where you think C1 is, and then think
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okay which side am I going to do. I want you to put your thumbs where these two
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fingers were. So if I had just laid down my fingers like this over C1, I'm now
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going to put my thumbs right over where my middle and fourth finger were on one
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side, and then I'm going to try to push up towards the eyeball. And I think you guys
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will find that as you gently push in and kind of
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give a couple test presses, you'll feel that joint move a little bit.
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Now I actually find this position a little uncomfortable for me so I tend to
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put my thumb down on this side if I'm going to mobilize this joint, and then I use
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this arm over that thumb. Once again I have kind of big hands right, so for me
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to do thumb thumb next to thumb is really tough, and then I'm just going to
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mobilize in the direction of her eye here just like so. All right so that's
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how I find that that occipital and Atlas joint, right that AO joint or CO-C1 joint.
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Now notice guys I went thumb over thumb. All of the techniques for the cervical
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spine are either thumb next to thumb or thumb over thumb, and be careful don't
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let yourself get into extension too much in your thumbs like that can ruin
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careers if you keep doing it. You end up with hypermobility there and then it
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becomes really hard to do these techniques, and try to use both hands
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whenever possible so that you gain the benefit of the strength of both your
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thumbs, rather than wearing down one. Like I'm sure I could get in here and I have
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enough hand strength to do it just like this, but that's going to wear me down over
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time. This is a much safer technique for my hands. So we have CO-C1 let's go C2-C3.
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If I look for the spinous process that's just underneath Melissa's skull, that
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spinous process is C2. So C1 doesn't have a spinous process. If I then drop
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slightly lateral and inferior, I end up on the facet joint of C2-C3. Now you'd
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think well that's easy enough and then I can just press down, and I know some of
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you guys have already figured out that I skipped C1-C2, and there's this little
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trick. So if I find the spinous process and drop off that's C2-C3
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and I can do my normal PA if C2-C3 and I can either do it this way getting over
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the top, or I can do it this way getting over the top, and again I'm thumb over
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thumb because my thumb's are fairly large. If you feel more comfortable this
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way that's fine. I'm going to find my first resistance barrier and then push through
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to the end. Find the end point, you guys are going to find that there's not a lot of
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range of motion there. I back off to 50%, then I can do either my grade 3's or
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my grade 4's. For C1-2 you got to remember what joint that is, so
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that's the atlanto-axial joint, the the AA joint. That joint wants to rotate
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and if you just press down on C1-C2 like I'm pressing down on C2 here,
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there's too much left because of rotation for that mobilization to be
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effective. So what we need to do is get to end range of motion and then start
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mobilizing, and the way we do that is just turn
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Melissa's head about 30 degrees. So she's just going to lay on one side like
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she'd lay on a pillow, and I'm going to go back to that same facet, that same
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bump; because I was basically over the top of C2. So just right here and
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then I'm going to push straight down, and then of course retest rotation.
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So quick recap here, and once again these are the hardest joints and the
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cervical spine to figure out. So if you can get these you're in good shape. For
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C1 and the occiput you're going to go towards her eyeball just
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underneath the occiput. So you can go over the top this way or you can
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come around to the side, and then I end up using this arm, because this arms now
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facing eyeball, this is my dummy thumb and I can go this way. If I then find the
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spinous process of C2 and drop off laterally, you end up naturally wanting
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to drop off laterally and inferiorly a little bit, that bump was over the top of
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the articular pillar of C2. If I press straight down that's actually mobilizing
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C2-C3 which is fine if that's what you want to mobilize. If you were looking for
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upper cervical rotation though and you think that C1-C2 is stuck, then you're
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going to need to rotate towards and press down because I needed to take up that
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end range rotation, like basically turn C1 all the way like this and then press
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down on C2 to get more range. Guys that was the hard part, that was the hard part.
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If you got that rewind this video watch that a couple times. If you got that the
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rest is easy breezy. So C3 now we're starting to get into mid
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cervical spine, fall-off just lateral and inferior. I like to come around this
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side, it's just straight down, and then c4 is just one segment down again, C5 one
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segment down again, C6 one segment down again. Now you guys know C7 and spinous
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prominence, so that's that's right here for her, right and then I can go right there. So I can
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mobilize all of those joints, there's nothing special about them. It's just, you
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just kind of go lateral and you end up dropping off just a little tiny bit, and
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I can go straight through all of these. Now let's talk a little bit about
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what I'm feeling for as I'm doing these mobilizations. I already mentioned it a
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little bit, don't forget your protocols. So every time I get over the top of the
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joint before I mobilize I'm going okay, there's my first resistance barrier,
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there's the end of articular arthrokinematic motion, before I would just
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start pushing her into a further extension. So my end range of
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this motion, so first resistance barrier and usually if I'm going to do
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this I'm not going to go argh end. I'm going to kind of do some
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test pulses my way down until I get to the end, see if the patient depending on
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how sensitive they are can take it. I'm going to back off the 50%
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and now I have my choice, I can either do larger amplitude grade 3's
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going from first resistance barrier down to 50%, or maybe just a little beyond 50%.
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Or I can do my grade fours which are a little bit more intense, because I'm
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going to start at 50% and do small amplitude, or go even deeper as I need to.
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So get here 1-2 oscillations per second, and I'm going to keep going
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probably for 30 seconds or more until I feel a change in tissue sensitivity.
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Or not tissue sensitivity I guess is the wrong word, maybe malleability tissue
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density. I'll feel like it's easier to move the joint. How does that feel
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Melissa? Feels good. Now we do have to be very careful. With the cervical spine we
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are as likely to end up with a hyper mobile segment as we are to end up with
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a hypomobile segment, and I think we get into the unfortunate habit of going
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diagnosis modality, right that's how we treat right. Cervical pain,
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mobilizations is what fixes it, and we have to keep in mind that that's not
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very good logic. Mobilizations are to increase mobility, and if somebody has
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pain because they're hypermobile then we could be making the problem worse.
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And the unfortunate thing is a hypermobile person sometimes feels very tight,
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because they end up with a lot of spasming an increase in tonicity in
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those extensor muscles. So it is very important that as you're doing these
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mobilizations, unless you've been with this patient for a long time and try
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this before, I would do one facet joint have him sit up and redo my tests.
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See if that reduced their pain, increase their range of motion. If it increased
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their pain, I'm heading in the wrong direction.
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It could mean that I chose the wrong facet, but I mobilized the hypermobile
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facet rather than a hypomobile facet. It could also mean that
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mobilizations maybe aren't the most appropriate thing to start with, and
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maybe we should back off and start thinking about maybe this person needs
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more of like exercise first, stability exercises first. Or maybe I need to leave
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the neck alone and maybe treat out the upper thoracic spine, and I see
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if I can get some good progress that way, let their neck calm down before
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I come back to these more aggressive techniques that directly affect where
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they're having pain. All right so just to review here real quick, CO,
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C2-C3 is just off that first
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spinous process you feel. If I rotate 30 degrees C1-C2, all of the other cervical
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facets feel like little bumps, you're getting it right over what the, it's
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called the articular pillar and when you look at the spine the cervical spine all
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they're talking about with the articular pillar is the facet joints
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stack up in such a way that they feel like pillars on either side of the
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spinous process. So for the rest of the cervical spine joints you're just
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getting right lateral and slightly inferior and pressing down, and we're
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probably mobilizing the upper on the lower segment, and you guys can just
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think about that as you go through and feel each one of these bumps right
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that's that's connected to the spinous process. As you try to loosen up all of
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those cervical facets. Stay tuned for your close-up recap. Now for the
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close-up recap all of the palpations and the various ways to do these UPA
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mobilizations for the cervical spine which is a little complicated, we're
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going to go ahead and start from the top and work our way down again.
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You're going to find the mastoid process which is this little bump I think you
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can see sticking out right here, right behind Melissa's earlobe, and then
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if you go just below that on either side of her spine, you'll feel these two
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things sticking out like so, and those are her transverse process;
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and then if I put my pinkies on those transverse process and just lay my
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fingers down horizontally just underneath her occiput, my fingers are
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right over C1. Now if I want to do this side over here and I just replace my
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third and fourth finger with my thumbs, I'll be over that CO-C1 joint, and
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then I can push down find my first resistance barrier. Remember that
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I'm pushing down towards her eyeball, so this one's not straight on, this isn't
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not a straight on PA this way, it's this way a little bit. So I have to kind of
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push back in towards her head and I'll find my first resistance barrier, my end
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range, back off to 50%, and then do either my grade 3's or my grade 4's. Now the
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next one we're going to find is actually C2-C3, and if I drop off laterally and
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inferiorly from C2 spinous process, remember the C2 spinous processes the
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first spinous process we feel underneath the occiput; because C1 essentially
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doesn't have a spinous process. So if I go right over C2-C3 I can go ahead and
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do my normal straight up and down PA over that little bump I feel, essentially
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between C2 and cC3 spinous processes just lateral to it, and so that bump.
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Where is my first resistance barrier, where's my end, back off to half. Now just
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like in the video you guys will notice I went CO-C1, C2-C3 because to get to C1-C2
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I need to turn Melissa towards me or towards the side that I'm mobilizing,
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because I need to take up all that slack in the atlanto-axial joint which wants
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to rotate. So if we're going to improve range of motion we need to get pretty
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close to end range, but then once they get her in this position I'm just going to
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go back to C2 spinous process, fall off and do a PA, same thing.
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So it's not a more complicated technique you just have to remember the
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little trick of taking up all of the upper cervical rotation you can, and then
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for the rest of the spinous process it's just fall off, a little lateral, a little
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medial unto what feels like an articulatar pillar, a column, our
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articular pillar, you can feel those little bumps. That little bump this
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way, and there's even a little bumpiness this way that each facet joint you just
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do your PA's, go to the next spinous process, do your PA, next one. As long as
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it feels stiff you can keep going, or you can do one and then retest. Or you
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could do one and then do the other side if you think it's more of like a
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bilateral restriction. These PA's will work all the way into the upper thoracic
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spine for sure, even coming over the top of somebody as I am here. You could be on
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the side of somebody if you think something is unilateral do all one side
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and then retest. So the rest of these segments are real easy, just fall off
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this way find your first resistance barrier, your end resistance barrier, back
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off to 50%. Of course zero to fifty for a grade three or stay closer to fifty be a
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little bit more intense, and this would be our grade four mobilizations. As per
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all our techniques assess, address and reassess. I hope this helped make sense
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of these palpations for you. So there you have it assess, address, reassess. Make
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sure that every time you choose a joint based manual therapy technique it is
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based on an assessment, and that you return to that assessment after you've
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finished the intervention to see if it was effective for the individual ,the
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patient or client that you have in front of you. Ensure that you continue to learn
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your Anatomy because your Anatomy is going to help you with your hand
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placement, with understanding what a joint can do, with understanding what you
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may gain from this particular technique, and of course practice. You have to
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practice these techniques hopefully not for the first time on a patient or
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client who just walked in the door. If you can find a more senior instructor or
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a mentor to give you some really good hands-on instruction, use your peers for
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some good feedback, and of course always look for live education to help with
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your manual therapy techniques. I know these videos make education very
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convenient, but there is no substitute for learning manual therapy in a live