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
00:00:1400:00:18
are a licensed professional with high velocity thrust or manipulation
00:00:1800:00:24
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 assessmen,t 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
00:01:0900:01:13
reason to continue using this technique. This video we're going to go over the
00:01:1300:01:17
cervical thoracic junction manipulation or upper thoracic manipulation, that area
00:01:1700:01:22
between C6 and we'll say T4. I'm going to have my friend a Yvette come out, she's
00:01:2200:01:25
going to help me demonstrate. Now keep in mind if you're doing manipulation
00:01:2500:01:28
techniques you're doing them to increase mobility, not just based on subjective
00:01:2800:01:33
symptoms but also based on objective signs. So in this case I would probably
00:01:3300:01:38
use something like cervical lateral flexion. Cervical lateral flexion
00:01:3800:01:43
goniometry is reliable although some of our other cervical goniometery
00:01:4300:01:47
assessments are not so reliable, and then i might try to find a thoracic rotation
00:01:4700:01:52
test that works well for reassessment. The last thing i would rely on is
00:01:5200:01:58
palpation, now i generally do two types of palpation with this particular area.
00:01:5800:02:03
I'll do my P-A's like I do when I'm doing mobilizations, and then I'll do this
00:02:0300:02:08
rotation palpation that I learned from the
00:02:0800:02:14
the Maitland workshops. So the P-A's here, you're going to go thumb over
00:02:1400:02:19
thumb or you can go your pisiform hamate grip, whichever you find more comfortable.
00:02:1900:02:24
Generally I find that I'm in this position when I'm working with neck and
00:02:2400:02:30
and upper back patients like this. So to go thumb over thumb is a little bit more
00:02:3000:02:34
convenient, and I'm just going to press all the way down to arthrokinematic
00:02:3400:02:39
end range and feel how these segments feel compared to one another,
00:02:3900:02:47
and compared to that internal model that I've built up over time with experience
00:02:4700:02:52
pressing on a lot of necks and upper-thoracic spines. I'm going to try to give
00:02:5200:02:59
myself a little bit of an indication of how stiff this area feels. Of course we
00:02:5900:03:06
could add another layer of this and go, hey Yvette how does that feel? Okay so
00:03:0600:03:11
that feels fine, that feels fine. We might get a little additional information like
00:03:1100:03:16
what if one of these segments is not only stiff it's actually part of the
00:03:1600:03:21
dysfunction that's causing her symptoms or complaints, and I can kind of go on
00:03:2100:03:26
through and do these P-A's. Now what I'm feeling with a Yvette is she definitely
00:03:2600:03:31
feels pretty good in her cervical spine as as far as motion goes, but then as I
00:03:3100:03:39
start moving down C6-C7, C7-T1 and then like C7 to T3, it's like really
00:03:3900:03:42
stif, it's actually really hard to get arthrokinematic motion. I don't think
00:03:4200:03:46
that's normal, I think that's an abnormal level of
00:03:4600:03:51
stiffness that maybe indicates I should do this manipulation technique. Now
00:03:5100:03:55
before I do this manipulation technique I've found that this rotation assessment
00:03:5500:03:59
that I learn from these workshops works really good and helping me determine
00:03:5900:04:04
which direction I should go, and all I'm going to do is I'm going to take my thumbs
00:04:0400:04:10
like so and put them each on a spinous process and rotate the spinous process
00:04:1000:04:16
in the opposite direction. So we'll go this way and then this way
00:04:1600:04:21
right. So I went this way and then this way. I rotated the upper segment
00:04:2100:04:31
to her right and then to her left, and then the same thing going on down, and
00:04:3100:04:36
what you'll start to notice a lot of times is people get stiff in one
00:04:3600:04:43
direction. So in a Yvette's case she actually moves better rotating to her
00:04:4300:04:50
left. Now I cannot explain what I'm about to tell you biomechanically, but it
00:04:5000:04:55
seems that this manipulation works better if rather than going into the
00:04:5500:05:01
resistance trying to manipulate to get more range of motion or decreased
00:05:0100:05:04
stiffness in the direction you're feeling in, it actually works better to
00:05:0400:05:12
go with the motion they already have. We could make an excuse and say well
00:05:1200:05:17
technically speaking if we're rotating in either direction the facets on
00:05:1700:05:22
both sides have to move. So at the very least we know if we get a good
00:05:2200:05:27
manipulation, everything's moving regardless. I really can't explain to you
00:05:2700:05:32
though why moving with the direction they already have motion tends
00:05:3200:05:36
to work better than moving them into the direction they have stiffness like every
00:05:3600:05:40
other manipulation. Experiment with this yourself, I think you will find the
00:05:4000:05:44
same thing. One thing about this technique is it's better to be right the
00:05:4400:05:47
first time because this is one of those techniques that if somebody is a little
00:05:4700:05:54
irritable, somebody is a little inflamed, flared up, you keep reaching back and
00:05:5400:05:58
trying to do the technique over and over again and you'll flare them up more. This
00:05:5800:06:03
is one of those techniques that you might get one, two, maybe three attempts
00:06:0300:06:09
at the most before you need to back off for the day and wait for them to come
00:06:0900:06:15
back in. So in Yvette's case I'm going go ahead and I'm going to rotate her this way,
00:06:1500:06:19
she moves better in this direction and like I said that tends to work better
00:06:1900:06:24
for this manipulation. Now I said she's stiff in all these
00:06:2400:06:31
segments going down here. There's two ways to block segments, and there's an
00:06:3100:06:34
easy way to set up the joint actions that we
00:06:3400:06:38
need to lock up the upper part of her cervical spine or the upper part of her
00:06:3800:06:42
thoracic spine as well. So what we're going to do is we can either use that
00:06:4200:06:47
thumb on a specific segment, or we can use our thenar eminence to block off
00:06:4700:06:54
several segments. This obviously is probably a little less specific and a
00:06:5400:07:00
little bit more aggressive. In Yvette's case I'd probably start here, being that
00:07:0000:07:03
she's not somebody who's accustomed to getting a lot of manipulations, she
00:07:0300:07:07
hasn't come in to see me before I probably want to start off a little bit
00:07:0700:07:15
more gentle and see how she responds. Now in order to get her all locked up I want
00:07:1500:07:20
to rotate her this way, side bend her towards me, so it's still that
00:07:2000:07:27
contralateral rotation, it's still the ipsilateral flexion and we're still
00:07:2700:07:30
needing a little bit of extension to get in the lock position just like we did
00:07:3000:07:35
with the cervical spine. The nice thing about this particular technique is if
00:07:3500:07:41
you just lift their head out of the head cradle and then rock their head
00:07:4100:07:47
on their chin just by turning their head, they do it automatically. So you
00:07:4700:07:51
can see if I just push her out of the head cradle, I'm there. Now I can
00:07:5100:07:57
tell in this case Yvette's guarding on me a little bit. One other thing I should
00:07:5700:08:01
probably bring up, that this table does naturally but some of you don't
00:08:0100:08:08
have tables with these arm thingies, is their arms need to be up, and the reason
00:08:0800:08:13
why is you want to take slack out of these muscles. If I was to try to rotate
00:08:1300:08:18
her this way with this arm down you can see I'm adding a lot of tension into her
00:08:1800:08:22
upper trap, and that's not going to be helpful for getting a manipulation, so
00:08:2200:08:25
you can bring both arms up. If we didn't have these arms cut out she could
00:08:2500:08:29
actually put her hands underneath her forehead like this, and we could just
00:08:2900:08:34
turn her forehead on her hands, it would still work the same way. All right so you
00:08:3400:08:39
can put your arms down, we're going to try not to guard. In the case of
00:08:3900:08:43
Yvette, if she is guarding and I feel like I keep getting pushed out of her spinous
00:08:4300:08:47
process and I can't hold it down with just my thumb, I might go back to my
00:08:4700:08:50
thenar eminence like this. So now I can really make sure
00:08:5000:08:56
I stabilize, I just have to try to be a little bit more careful to line up the
00:08:5600:09:02
end of my thenar eminence with whatever segment I'm trying to lock out from the
00:09:0200:09:07
bottom down. So in this case I want her about there, I can then bring
00:09:0700:09:13
her this way. You okay, no pain? Just relax, nice deep breath, try to just
00:09:1300:09:18
pretend like you're laying on your pillow on your belly. All right so I do
00:09:1800:09:21
find that that cue helps as I try to get them into like thinking about
00:09:2100:09:27
relaxing on a pillow. Okay now all we're going to do for the manipulation is
00:09:2700:09:31
add a little pressure this way. So I'm moving this hand this way to
00:09:3100:09:36
block out whether it's my thumb or my thenar eminence, and then I'm going to go
00:09:3600:09:40
this way with this hand because if I do that, I automatically push her into
00:09:4000:09:44
lateral flexion and rotation. So it ends up being a very easy for technique for
00:09:4400:09:49
us as long as you spend plenty of time getting your setup right, you make sure
00:09:4900:09:55
you get a really good lock out, get a nice deep breath, you okay? Deep
00:09:5500:10:02
breath, breathe out, and that's it. We actually got a pretty good cavitation on
00:10:0200:10:07
that one, I know Yvette felt it. You're seeing these manipulations
00:10:0700:10:11
done on somebody who does not get manipulations done. So I think
00:10:1100:10:15
that is important, that's a lot more realistic than some of the videos I see
00:10:1500:10:18
out there with people doing manipulations on people who get
00:10:1800:10:21
manipulations all the time. You do have to be careful, you do have to set
00:10:2100:10:25
somebody up well, you do have to help them with their expectations and be like
00:10:2500:10:30
hey this is this is not a big deal it's going to be over really quick, and you know
00:10:3000:10:34
take a nice deep breath and before you know it, click and then you just let them
00:10:3400:10:38
go, and a lot of times after I do manipulations like this I'll actually
00:10:3800:10:42
have somebody sit up take a second before I go ahead and do my next
00:10:4200:10:46
technique, so they don't feel like they're getting rapid-fire
00:10:4600:10:49
high-intensity manipulation one over the other.
00:10:4900:10:53
So I'm going to show you from this side, if I was going to manipulate
00:10:5300:10:58
her other side I would just block this way, I would put her head on this side
00:10:5800:11:02
and Yvette I'm not going to manipulate you this way okay. So I would go
00:11:0200:11:06
ahead and put either her chin up on the table or maybe like in this case on this
00:11:0600:11:12
head cradle, her maxilla is actually resting at the end of that headrest, and
00:11:1200:11:17
then I'd get her right here and then I make sure I'm locked. If I need to change
00:11:1700:11:23
her head position I can, and I want to make sure everything's right. Again
00:11:2300:11:30
I have said this in every one of our manipulation videos, setup is 90% of this.
00:11:3000:11:36
If you get somebody locked up right, if you've done your assessment and you're
00:11:3600:11:41
on the right segment, the manipulation, the high velocity thrust is like the
00:11:4100:11:45
icing on the cake. In fact I think you will find that if you really get
00:11:4500:11:51
good at the locked position, you'll get people to like move, manipulate, cavitate
00:11:5100:11:55
before you even get the thrust to happened a fair percentage of the time.
00:11:5500:11:58
It's kind of interesting, like you'll just be like okay and you'll get them
00:11:5800:12:03
here, and they'll be click, click, and you're like oh okay I didn't even need to do the thrust.
00:12:0300:12:10
So again I could do my little rotation stuff, find the segment in this
00:12:1000:12:14
case I'm going to go with the easier motion, block out that bottom segment,
00:12:1400:12:20
make sure that I apply a little pressure this way and then I'm going to rotate
00:12:2000:12:24
the head this way which is going to push her into rotation a lateral flexion,
00:12:2400:12:31
while I block out this way. Last thing, and I don't want to
00:12:3100:12:34
come across the sounding arrogant on this but I think it's something that
00:12:3400:12:39
needs to be said for whatever reason because I own this education company and
00:12:3900:12:44
I'm available online, and I get a lot of individuals who come and find me after
00:12:4400:12:50
other practitioners didn't work for them, and I would say nine times out of ten
00:12:5000:12:55
I'm able to help somebody because something was missed. That shouldn't
00:12:5500:13:01
happen, I think this is one of those things that is very often missed. I can't
00:13:0100:13:10
tell you how many cervical spine patients I've had that were manipulated up here in their cervical spine,
00:13:1100:13:16
nobody ever looked at their CT Junction and they were never given any sort of
00:13:1600:13:21
like activation or stabilization exercise. With these type of patients a
00:13:2100:13:26
lot of times I can come in and I manipulate their cervical thoracic junction using
00:13:2600:13:30
this technique. I give them some deep cervical flexor activation, maybe some
00:13:3000:13:34
serratus anterior activation, maybe we'll work on some other stuff for scapular
00:13:3400:13:38
mechanics, all that stuff that gets left behind because their last
00:13:3800:13:43
practitioner only looked at their cervical spine and sure enough within a
00:13:4300:13:46
couple sessions they're on a home exercise program and they're good to
00:13:4600:13:51
self-manage. Keep this technique, although it's a little difficult,
00:13:5100:13:55
although it does have a little higher tendency to flare people up than some of
00:13:5500:13:59
the other techniques I've shown you. Get good at it, because like I said
00:13:5900:14:04
it will make you a lot of money and it's making me more money than it should. Stay
00:14:0400:14:08
tuned for the close-up recap. All right for the close-up recap remember
00:14:0800:14:12
we're going to start with our subjective assessment and objective assessments, and
00:14:1200:14:16
of course the last assessment we're going to do is our palpation to try to
00:14:1600:14:21
give us an indication of where and which way we should manipulate, and what you're
00:14:2100:14:28
seeing me do here is that thumb to thumb on spinous process P-A, and I'm just going
00:14:2800:14:34
all the way to the end of arthrokinematic range, trying to feel the
00:14:3400:14:40
relative stiffness joint to joint and then of course my own internal model
00:14:4000:14:46
of stiffness at these joints based on my experience. To add another layer we could
00:14:4600:14:53
of course ask Yvette hey how does this feel? Sometimes what you'll get is the
00:14:5300:14:57
patient will complain about pain when you press on a particular segment which
00:14:5700:15:01
might help us get a little bit more dialed in with our manipulation
00:15:0100:15:05
techniques or soft tissue techniques. Then the other thing I'm going to do of
00:15:0500:15:09
course is that rotation, all right so you can see I'm on either side of spinous
00:15:0900:15:13
process and then I'm just zip zip, alright and then I'm going to
00:15:1300:15:16
switch my thumbs so that I rotate the other way. You
00:15:1600:15:20
see how that works, I think with a little bit of practice you will
00:15:2000:15:24
get pretty good at going all the way down the spine and starting to determine
00:15:2400:15:28
the direction here, and then we found that she
00:15:2800:15:36
moves, she gets stiffer as she goes down here so we might want to block like so,
00:15:3600:15:41
or we can block with a thumb like so on that spinous process just below the
00:15:4100:15:46
segment that we think is stuck, and then we're moving with the direction that she
00:15:4600:15:51
moved better. I know that's very odd and doesn't make a lot of sense but it does
00:15:5100:15:56
tend to work better based on assessment and outcomes, and then of course we're
00:15:5600:16:03
going to turn her head off the face hole here, or the face cut out of
00:16:0300:16:08
on this table which is immediately going to put us into extension, rotation and
00:16:0800:16:12
lateral flexion, and I'll spend a couple extra seconds trying to get a good
00:16:1200:16:15
lockout position, maybe a little bit more extension, maybe try a little bit more
00:16:1500:16:22
flexion, maybe try position a different part of her face, see if that helps. Try
00:16:2200:16:28
my thumb try my thenar eminence see which one gets the better lock. You do
00:16:2800:16:34
want to be quick in the sense that nobody likes to be in lockout position
00:16:3400:16:38
for long, but don't be in a hurry. Everything is set up 90-percent of this
00:16:3800:16:45
is finding that lockout position, and then once you find it all you have to do
00:16:4500:16:51
is one quick thrust and be done with it. So it's all set up, the thrust
00:16:5100:16:55
is just the icing on the top of the cake. If you have any questions on this
00:16:5500:16:59
whatsoever please feel free to leave them in the comments box below. A couple
00:16:5900:17:03
of points to recap, knowing your anatomy and knowing your biomechanics will
00:17:0300:17:07
certainly help you choose the right technique for the right patient. If
00:17:0700:17:11
you're unsure whether manipulations are appropriate due to their higher
00:17:1100:17:17
intensity it's okay to do mobilizations, most research points to manipulations
00:17:1700:17:21
being slightly more effective but mobilizations being very effective, and
00:17:2100:17:25
of course we have those videos for you if you want to start with those less
00:17:2500:17:30
intense techniques. Make sure that if you are doing any technique that is based on
00:17:3000:17:34
assessment, and of course that you're reassessing, ensuring that the technique
00:17:3400:17:38
is effective for the patient that you're working on, and when it comes to all
00:17:3800:17:43
techniques manipulations maybe more than any other look, for opportunities to
00:17:4300:17:49
get live education. Although I know videos are convenient and I'm happy to
00:17:4900:17:54
have these up for you to watch, it would be so much more helpful to use
00:17:5400:18:00
those videos as a recap of one-on-one attention with somebody who's
00:18:0000:18:07
experienced with manipulation techniques. At the very least grab a colleague, grab
00:18:0700:18:11
a friend and start practicing these before you bring them into clinic and
00:18:1100:18:16
start using them on patients and clients. I hope you enjoyed this video, if you