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This is Brent of the Brookbush Institute,
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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 assessment, 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. In this video we're going to do a cuboid
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manipulation. I'm gonna have my friend Yvette come out, she's going to help me
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demonstrate. Remember if I'm doing manipulations, I'm using more than
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passive accessory motion and more than just subjective complaints. We want to
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make sure that we have some sort of movement or postural exam like the
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overhead squat assessment, to see what compensation pattern were actually
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trying to correct, and I like to use continuous interval measures to track
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progress, that's something we can measure objectively. In this case I'd probably
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use the navicular drop test with like a ruler, so I can see how many centimeters
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of height we have between the navicular tubercle and the floor. Now the
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last thing I'm going to go to is of course my passive accessory motion exams, to
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indicate whether this particular joint is stiff, and it's actually several
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joints here. We are manipulating the cuboid bone but we have to keep in mind
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that the cuboid has joints with the calcaneus, the lateral cuneiform and the
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navicular a little bit; and what we're trying to to do is see if it'll tilt
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this way on the combination of those three joints. Now the first thing
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we have to do is be able to palpate the cuboid which is not terribly hard. If
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you just think about the fact that the cuboid is on the lateral
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side of the foot, and essentially on the lateral side of the foot you can palpate
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the calcaneus, the fifth metatarsal or the cuboid. Now what I'll usually do just
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kind of instinctively, is I'll start grabbing at the side of the foot until I
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feel something that feels wedge-shaped. All right like right here
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it feels a little wedge-shaped, but it's not the round long bone of the fifth
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metatarsal. So I got this wedge-shaped bone in it, it'll actually
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wiggle for me. So this will wiggle, this is definitely skin there's no bone here.
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This is a bone that'll wiggle, and then this one you can
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feel the whole lever move. So now that you have the cuboid,
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really kind of take a second to palpate around. You'll notice it's a pretty
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sizable bone, it feels like almost half the width of the foot. So it
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takes, not this way right, it's only about, maybe on Yvette's little foot here
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maybe an inch and a half long, but it it's almost as wide as like half
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the foot there. So I'll feel around there,
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you kind of feel like, you get this feeling like it has like a little
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curvature to it, so like it's shaped a little like if I turned my hand
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this way, right so I can kind of put my thumb in this little divot and the
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cuboid, or at least it feels that way. So now what I want to check is
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this when I do my passive accessory motion. Of course I can just
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wiggle back and forth, dorsal to plantar. But what I think you are going to find
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is that's not what gets stuck. What gets stuck is the ability to move this way,
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almost like a rotation, and I guess we could call that external rotation of the
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of the cuboid bone, but it's probably more like inversion, e-version
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of the cuboid bone, and I think you'll get this sense that the medial edge
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doesn't want to move the same. So the outside edge will wiggle on you a
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little bit, and then you get to the medial edge and your like that does feel a little
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stuck. So now how do we manipulate this joint? So keep in mind manipulations are
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always about setup first, just because we know where this bone is we don't just
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want to go snap, it's not going to work. Remember we're trying to get range of
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motion back, so we want to lock out all the range of motion she has in a
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particular direction, and then push past the resistance barrier; and the way that
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looks with this this particular joint is I'm going to put the cuboid right here in
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my hand on the outside. I actually like to use my thumb on the inside, so
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I'm just like this and I'll show you this closer on the close-up recap,
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and what I'm going to try to do is twist the cuboid this way. But before I do that,
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I have to lock the cuboid out. So I'm going to take all of the inversion that I
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have up. All right I'm going to take her all the way as far into inversion as I
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possibly can. I'm going to plantar flex the foot as well, not plantar flex the ankle
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plantar flex here, her metatarsals, her transverse tarsal joint. I want to
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take up all the slack in the top of her foot. So I get here and then what you
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want to do is not this right, which is instinctively like plantar to dorsal
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you'd be like yeah that's the manipulation right. But with this particular
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manipulation there's so much leg involved that if I did this, you can
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see it's just got knee extension, that's not what I was trying to do. I want to
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get more inversion at the cuboid so I'm going to take up all the slack on the foot
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here and then this is cool. All you really need to do is just go like that,
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it's a whip. I don't know if you guys heard that, that was actually a pretty a
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pretty loud cavitation for the cuboid. Usually this is one of those ones that
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you'll feel the cavitation and you won't hear it, but I just took up all the slack
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and then I just whipped her foot. Wow. So again, find the cuboid,
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the outside of the cuboid on this part of your hand, so this is going to help
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us turn into inversion from the top side. This side you're going to press the medial
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portion of the bone down this way. I've even seen some people with really great
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technique here use their pisiform hamate like this. My problem is my hands are
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kind of stupidly big, and I can't get that part of my hand into that part of
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this little foot. I just happened to be a lot bigger than Yvette. For some
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of you with less difference between the size of your patient and
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yourself that might work out better, and then you can get to the end range here
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and that would look a little bit more like a PA. You would do a whip but it would be
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more like a PA you do on the spine. So that might be more comfortable for some
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of you, but again you're going to outside, wraps up the outside of the cuboid, here
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I'm going to end up using my thumb on the medial portion, plantar flex all the way.
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Not the ankle necessarily, the foot, invert as far as you can. Again,
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forefoot not necessarily the ankle. Get all the way to end range where you feel
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that lock position, and play with it if you have to for a second like really
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feel like you have the cuboid to a point that it doesn't want to move anymore, and
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then once you're there just give it a little whip.
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Alright stay tuned for the close-up recap. For a close-up recap you
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can see here like if you grab here you got the calcaneus then you got some
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skin, and then right as I get down to about here like I feel bone again, this
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is her fifth metatarsal, this is her cuboid. So I'm going to put my thumb on the
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medial aspect of her cuboid, then I'm going to take this part of my hand, put it
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on the outside of her cuboid, and my goal here is to push this way with this
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finger and then pull up this way with my hand, so that I'm tilting the cuboid this
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way. So we get all set up and then I mentioned before remember we want
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inversion and plantarflexion of the foot, and you can see the difference
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between inversion and plantar flexion of the ankle where you get all this
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calcaneal motion, as opposed to inversion and plantar
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flexion of the foot. You can see the calcaneus stays basically in place.
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So once I get her all locked up I can pull all the way down into end-
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range, and then of course this time the manipulation is not just like a thrust
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PA, we're just going to give the the foot a little whip, and that's it, that was the
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entire manipulation. So take your time getting set up, get your hand over the
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cuboid, get your thumb or you can use pisiform hamate in here if you got
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smaller hands, or at least hands that are smaller compared to the person's foot.
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You're gonna plantarflex and invert the forefoot as far as you possibly can,
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and then just a little whip, and of course you could use something like
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the navicular drop test to go ahead and measure pretest, post-test. A couple of
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points to recap, knowing your Anatomy and knowing your biomechanics will certainly
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help you choose the right technique for the right patient. If you're unsure
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whether manipulations are appropriate due to their higher intensity it's okay
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to do mobilizations. Most research points to manipulations being slightly more
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effective, but mobilizations being very effective, and of course we have those
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videos for you if you want to start with those less-intense techniques. Make sure
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that if you are doing any technique that is based on assessment, and of course
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that you're reassessing ensuring that the technique is effective for the
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patient that you're working on, and when it comes to all manual techniques,
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manipulations maybe more than any other, look for opportunities to get live
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education. Although I know videos are convenient and I'm happy to have these
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up for you to watch, it would be so much more helpful to use those videos as
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a recap of one-on-one attention with somebody who's experienced with
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manipulation techniques. At the very least grab a colleague, grab a friend and
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start practising these before you bring them into clinic and start using them on
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patients and clients. I hope you enjoyed this video, if you have any questions