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Cervicothoracic Junction Manipulation

Cervicothoracic Junction Manipulation is a gentle, hands-on treatment technique used to help relieve neck and shoulder pain. This technique focuses on the areas between the neck and shoulder, including the muscles, ligaments, joints, and fascia. It can be used to improve mobility of the spine and related areas, decrease pain, improve posture, and promote relaxation. Cervicothoracic Junction Manipulation employs a combination of stretching, ligamentous and soft

Transcript

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