0:04 This is Brent of the Brookbush Institute, in this video we're going to go over 0:07 manipulations or high-velocity thrust techniques. I assume that if you're 0:11 watching this video you're watching it for educational purposes, and that you 0:14 are a licensed professional with high- velocity thrust or manipulation 0:19 techniques in your scope of practice. If you are not sure check with your state 0:24 board. Most physical therapists, chiropractors and osteopaths you're in 0:28 the clear. I believe that ATC's you can't do manipulations in the United States, 0:33 although other countries again check your scope. Of course massage therapists 0:38 and personal trainers these are generally not within your scope. Of 0:41 course you could continue to watch these videos just for educational purposes, 0:47 learn a little Anatomy, learn a little biomechanics. If you're going to do these 0:51 techniques please make sure that you have a good rationale for putting your 0:56 hands on a patient, this should be based on assessment, and if you're going to 1:00 assess I'm hoping that you'll assess, use these interventions and reassess to 1:06 ensure that you're getting the result that you're looking for and have good 1:09 reason to continue using this technique. In this video we're going to do a cuboid 1:13 manipulation. I'm gonna have my friend Yvette come out, she's going to help me 1:15 demonstrate. Remember if I'm doing manipulations, I'm using more than 1:17 passive accessory motion and more than just subjective complaints. We want to 1:21 make sure that we have some sort of movement or postural exam like the 1:26 overhead squat assessment, to see what compensation pattern were actually 1:29 trying to correct, and I like to use continuous interval measures to track 1:33 progress, that's something we can measure objectively. In this case I'd probably 1:37 use the navicular drop test with like a ruler, so I can see how many centimeters 1:41 of height we have between the navicular tubercle and the floor. Now the 1:46 last thing I'm going to go to is of course my passive accessory motion exams, to 1:50 indicate whether this particular joint is stiff, and it's actually several 1:54 joints here. We are manipulating the cuboid bone but we have to keep in mind 1:58 that the cuboid has joints with the calcaneus, the lateral cuneiform and the 2:04 navicular a little bit; and what we're trying to to do is see if it'll tilt 2:11 this way on the combination of those three joints. Now the first thing 2:16 we have to do is be able to palpate the cuboid which is not terribly hard. If 2:20 you just think about the fact that the cuboid is on the lateral 2:23 side of the foot, and essentially on the lateral side of the foot you can palpate 2:28 the calcaneus, the fifth metatarsal or the cuboid. Now what I'll usually do just 2:36 kind of instinctively, is I'll start grabbing at the side of the foot until I 2:40 feel something that feels wedge-shaped. All right like right here 2:45 it feels a little wedge-shaped, but it's not the round long bone of the fifth 2:53 metatarsal. So I got this wedge-shaped bone in it, it'll actually 2:56 wiggle for me. So this will wiggle, this is definitely skin there's no bone here. 3:00 This is a bone that'll wiggle, and then this one you can 3:04 feel the whole lever move. So now that you have the cuboid, 3:09 really kind of take a second to palpate around. You'll notice it's a pretty 3:13 sizable bone, it feels like almost half the width of the foot. So it 3:17 takes, not this way right, it's only about, maybe on Yvette's little foot here 3:22 maybe an inch and a half long, but it it's almost as wide as like half 3:28 the foot there. So I'll feel around there, 3:31 you kind of feel like, you get this feeling like it has like a little 3:34 curvature to it, so like it's shaped a little like if I turned my hand 3:40 this way, right so I can kind of put my thumb in this little divot and the 3:46 cuboid, or at least it feels that way. So now what I want to check is 3:50 this when I do my passive accessory motion. Of course I can just 3:54 wiggle back and forth, dorsal to plantar. But what I think you are going to find 4:00 is that's not what gets stuck. What gets stuck is the ability to move this way, 4:08 almost like a rotation, and I guess we could call that external rotation of the 4:15 of the cuboid bone, but it's probably more like inversion, e-version 4:20 of the cuboid bone, and I think you'll get this sense that the medial edge 4:27 doesn't want to move the same. So the outside edge will wiggle on you a 4:32 little bit, and then you get to the medial edge and your like that does feel a little 4:35 stuck. So now how do we manipulate this joint? So keep in mind manipulations are 4:43 always about setup first, just because we know where this bone is we don't just 4:46 want to go snap, it's not going to work. Remember we're trying to get range of 4:50 motion back, so we want to lock out all the range of motion she has in a 4:54 particular direction, and then push past the resistance barrier; and the way that 4:58 looks with this this particular joint is I'm going to put the cuboid right here in 5:02 my hand on the outside. I actually like to use my thumb on the inside, so 5:11 I'm just like this and I'll show you this closer on the close-up recap, 5:14 and what I'm going to try to do is twist the cuboid this way. But before I do that, 5:22 I have to lock the cuboid out. So I'm going to take all of the inversion that I 5:28 have up. All right I'm going to take her all the way as far into inversion as I 5:32 possibly can. I'm going to plantar flex the foot as well, not plantar flex the ankle 5:38 plantar flex here, her metatarsals, her transverse tarsal joint. I want to 5:45 take up all the slack in the top of her foot. So I get here and then what you 5:52 want to do is not this right, which is instinctively like plantar to dorsal 5:58 you'd be like yeah that's the manipulation right. But with this particular 6:02 manipulation there's so much leg involved that if I did this, you can 6:05 see it's just got knee extension, that's not what I was trying to do. I want to 6:10 get more inversion at the cuboid so I'm going to take up all the slack on the foot 6:16 here and then this is cool. All you really need to do is just go like that, 6:22 it's a whip. I don't know if you guys heard that, that was actually a pretty a 6:26 pretty loud cavitation for the cuboid. Usually this is one of those ones that 6:29 you'll feel the cavitation and you won't hear it, but I just took up all the slack 6:33 and then I just whipped her foot. Wow. So again, find the cuboid, 6:42 the outside of the cuboid on this part of your hand, so this is going to help 6:47 us turn into inversion from the top side. This side you're going to press the medial 6:52 portion of the bone down this way. I've even seen some people with really great 6:58 technique here use their pisiform hamate like this. My problem is my hands are 7:04 kind of stupidly big, and I can't get that part of my hand into that part of 7:08 this little foot. I just happened to be a lot bigger than Yvette. For some 7:12 of you with less difference between the size of your patient and 7:16 yourself that might work out better, and then you can get to the end range here 7:19 and that would look a little bit more like a PA. You would do a whip but it would be 7:24 more like a PA you do on the spine. So that might be more comfortable for some 7:30 of you, but again you're going to outside, wraps up the outside of the cuboid, here 7:36 I'm going to end up using my thumb on the medial portion, plantar flex all the way. 7:42 Not the ankle necessarily, the foot, invert as far as you can. Again, 7:49 forefoot not necessarily the ankle. Get all the way to end range where you feel 7:54 that lock position, and play with it if you have to for a second like really 7:57 feel like you have the cuboid to a point that it doesn't want to move anymore, and 8:00 then once you're there just give it a little whip. 8:03 Alright stay tuned for the close-up recap. For a close-up recap you 8:07 can see here like if you grab here you got the calcaneus then you got some 8:12 skin, and then right as I get down to about here like I feel bone again, this 8:16 is her fifth metatarsal, this is her cuboid. So I'm going to put my thumb on the 8:22 medial aspect of her cuboid, then I'm going to take this part of my hand, put it 8:28 on the outside of her cuboid, and my goal here is to push this way with this 8:34 finger and then pull up this way with my hand, so that I'm tilting the cuboid this 8:40 way. So we get all set up and then I mentioned before remember we want 8:46 inversion and plantarflexion of the foot, and you can see the difference 8:50 between inversion and plantar flexion of the ankle where you get all this 8:54 calcaneal motion, as opposed to inversion and plantar 8:59 flexion of the foot. You can see the calcaneus stays basically in place. 9:04 So once I get her all locked up I can pull all the way down into end- 9:11 range, and then of course this time the manipulation is not just like a thrust 9:16 PA, we're just going to give the the foot a little whip, and that's it, that was the 9:23 entire manipulation. So take your time getting set up, get your hand over the 9:29 cuboid, get your thumb or you can use pisiform hamate in here if you got 9:33 smaller hands, or at least hands that are smaller compared to the person's foot. 9:37 You're gonna plantarflex and invert the forefoot as far as you possibly can, 9:42 and then just a little whip, and of course you could use something like 9:47 the navicular drop test to go ahead and measure pretest, post-test. A couple of 9:52 points to recap, knowing your Anatomy and knowing your biomechanics will certainly 9:56 help you choose the right technique for the right patient. If you're unsure 10:00 whether manipulations are appropriate due to their higher intensity it's okay 10:06 to do mobilizations. Most research points to manipulations being slightly more 10:10 effective, but mobilizations being very effective, and of course we have those 10:15 videos for you if you want to start with those less-intense techniques. Make sure 10:20 that if you are doing any technique that is based on assessment, and of course 10:24 that you're reassessing ensuring that the technique is effective for the 10:28 patient that you're working on, and when it comes to all manual techniques, 10:32 manipulations maybe more than any other, look for opportunities to get live 10:37 education. Although I know videos are convenient and I'm happy to have these 10:42 up for you to watch, it would be so much more helpful to use those videos as 10:48 a recap of one-on-one attention with somebody who's experienced with 10:54 manipulation techniques. At the very least grab a colleague, grab a friend and 11:00 start practising these before you bring them into clinic and start using them on 11:05 patients and clients. I hope you enjoyed this video, if you have any questions 11:10 please leave them in the comments box below.
