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This is Brent of the Brookbush Institute, and in this
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video we're going to go over a joint
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based manual therapy technique. If you're watching this video I'm assuming you're
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watching it for educational purposes, and that you are a licensed professional
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with joint based techniques within your scope. That means osteopath's, chiropractors,
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physical therapists, you're probably all in the clear. Physical therapy assistants,
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athletic trainers, massage therapist's, you need to check with your governing body
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in your state or region to see whether this is within your scope of practice.
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Personal trainers this is definitely not within your scope of practice. Of course
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all professions could use this video for purely educational purposes to help with
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learning biomechanics, anatomy and of course palpation. In this video we're
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going to do an anterior to posterior fibula tibia mobilization, that's the
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distal tibiofibular joint. I'm going to have my friend Melissa come out, she's
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going to help me demonstrate. Now this technique makes a great ancillary
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technique to a technique we did in a previous video, which was the anterior to
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posterior talus on tibia mobilization. The hypothesis being that the lateral
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malleolus or distal fibula, has to follow the talus posteriorly as we dorsiflex
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the ankle. So with that being said, although we want to do a passive
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accessory motion exam and make sure that we have arthrokinematic stiffness
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in the direction that we're trying to mobilize, you might also do this
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technique as a means of maintaining, or trying to gain optimal dorsiflexion. Now
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the position you're going to be in for this technique is going to be foot on
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thigh; and the reason being is I want to be able to control dorsiflexion with my
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thigh, and have both hands-free for this mobilization. I need one hand to
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stabilize the tibia, and the other one to actually mobilize the fibula. You guys
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can see here just by leaning forward I can actually push Melissa into a
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few degrees of dorsiflexion. I can even control eversion and inversion a little
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bit just by swaying, to make sure she's neutral. The palpation portion of this is
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not totally complicated, but it is important that you guys kind of look
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over your Anatomy, and you practice putting your hands down on the ankle and
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trying to identify that Anatomy, specifically the lateral malleolus. For
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this technique it's important that you not
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only can find the lateral malleolus, but that you know the contours and edges of
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the lateral malleolus. So find your lateral malleolus, find the bottom of the
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lateral malleolus. So make sure you can feel that, go ahead and go to the
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posterior part of the lateral malleolus, and you should feel a groove in the back
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of the lateral malleolus, where your fibularis tendon runs through, and you
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might be able to feel that a little bit. Go to the front of the lateral malleolus
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and you'll notice that you run into a couple of tendons, those are the tendons
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of your long toe extensors, but if you press into that soft tissue just a
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little bit, you might be able to feel the joint line. Now the joint line is a nice
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thing to feel for this technique, because what we want to see is does the fibula
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move a little bit on the tibia, that's all we're trying to feel, does the fibula
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wiggle. If we have no wiggle we need to mobilize, if we have lots of wiggle then
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we don't want to mobilize. This joint the research kind of shows has one of two
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propensities right, either gets stiff or it becomes hypermobile. It's important
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that if we feel hypermobility, you feel more than a millimeter of motion here,
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it's really easy to wiggle this joint, this is not a technique you're going to
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do. Now if you feel good about your palpation, and you try to move the fibula
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it doesn't seem to move, that's a good sign that you have stiffness and that
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you probably should mobilize. It's really that simple, we don't need to get into
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grades of stiffness or anything, it's just does it feel like it barely moves
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or does it wiggle a lot. If it wiggles a lot, don't do this. Now once you felt
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the motion of the fibula, and you guys can see here I'm just kind of lifting it
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with these fingers, pushing it down with these fingers trying to kind of get my
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hands like right up against the joint line, maybe put the rest of my hand on
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the tibia here so that I can feel the amount of motion I have. Now Melissa's a
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little stiff. I would not do the mobilization with that same hand
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position guys. It's a little hard to feel how much movement you have with the
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technique I'm going to show you, but using your fingertips to do
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mobilizations just leads to pain. Just pushing your thumb down into this bony
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prominence is going to make somebody cringe. You have to be careful alright,
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trying to do something like this, is not a great idea. What we're actually going
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to do is use our thenar eminence here, try to get as much surface area on the
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lateral malleolus as we possibly can. What that usually ends up leading to is
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we we do a little bit of mobilization, and then we check with our fingertips,
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and we do a little mobilization, and then we check with our fingertips. So
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again how are we going to do this technique? We're going to use our thenar
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eminence, we're going to come over the top of our lateral malleolus. Now my
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suggestion is, is as you do this you're going to pick up a little bit of skin,
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before you press down. Alright so you guys I'm kind of smooshing some skin up
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this way, before I push down this way. The reason being is if I grab a bunch of
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skin and then pull down this way I stretch the skin out, and then I go to
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push down and it stretches the skin even more, and that becomes really
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uncomfortable. We want this to be as comfortable as possible otherwise
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they're going to guard and this technique is going to be really really challenging.
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Now the other contraindication that you have to be aware of, is you can really
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send a nice little shock up somebody's leg, give somebody a nice little burn,
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give somebody a really intense pinch by getting on that peroneal nerve. Of course
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if you do that this nerve is not gigantic, it's it's very very narrow,
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we're talking like a millimeter wide so you should be able to move your hand
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around and get off it pretty easy. So I'm going to take my hand here, I'm going to
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wrap it around Melissa's calcaneus, I'm going to make
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sure that calcaneus is off the table so that I don't crunch my hand when I
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start pushing down. I'm then going to grab a little bit of skin, just kind of
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slide my hand up this way, then put my thenar eminence over the top of her
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lateral malleolus, I'm going to kind of push her into dorsiflexion, this hand I'm
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going to stabilize her tibia with, and then I'm going to use, you guys notice
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I'm leaned forward here again, I'm just going to use my bodyweight to rock into
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this mobilization. Now I mentioned in previous videos I'm a Maitland certified
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orthopedic manual therapist, the protocols I know are the grades 1, 2, 3 &
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4. Grade 3 & 4 being at 50% between the initial resistance and end of arthro-
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kinematic range. If you guys have a different protocol that's fine, just make sure that
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you are disciplined about using that protocol, that you assess, address and
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reassess. If I went through this with my protocol, I'm going to go through
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everything I just told you, grab the calcaneus, take up some skin, push down on
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that lateral malleolus, ask my client did you, in any pain? This comfortable? Okay
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I'm going to find that first resistance barrier, once I find that first
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resistance barrier I'm going to start testing down, watching my clients face
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making sure she doesn't cringe on me, until I find the end. Notice that as I'm
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pushing down I have Melissa in at least neutral dorsiflexion with my thigh, so I
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have good control of her foot and ankle, and then once I find first resistance
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barrier, I find the end, I back off to 50%, now I'm just going to do 1 to 2
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set, 1 to 2 pulses per second until I feel a change in arthrokinematic
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stiffness. Now I mentioned a little earlier in this video, that is tough to
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feel with my thenar eminence, chances are I'm going to go back and check with
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my fingertips to see if I got an increase in range of motion.
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That's arthrokinematic range-of-motion though. So we'll do this for 30 seconds, and then
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I'm just going to use my fingertips here, did I get more range? If I got more range
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great, if I didn't I might go back and do another set, or another two sets, and then
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of course I'm going to want to follow this up with something a little bit more
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reliable than passive accessory motion exam, maybe I do my dorsiflexion
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goniometery. Alright so to go through hand position one more time, or body
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position and hand position; foot on thigh, neutral or slightly dorsiflexed, this
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hand's going to cup the calcaneus, pick up just a little bit of skin just kind
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of sliding up the side of the ankle here, and then press down over the front of
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the lateral malleolus, this hand is going to stabilize the tibia, and then I'm just
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going to find 50% between initial resistance and end of arthrokinematic
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range, back off to 50. I'm going to do my, this is going to be a grade 3 here
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alright. So I'm going to take up almost back to zero in resistance and down into
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50%. See if I can get a change in stiffness, check with my fingers. If I feel
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like I've got a change in stiffness maybe I'd follow that up with a dorsiflexion
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range of motion for goniometery, or maybe more of like a functional
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assessment like the overhead squat assessment. So in our close-up recap
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you'll notice my thighs against Melissa's foot here so that I can
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control dorsiflexion as well as eversion and inversion, and you can see
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her lateral malleolus right here. Now of course to assess this joint I
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talked about just using the fingertips, getting your thumb kind of on the joint
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line here. So if I start on her lateral malleolus and then fall off pushing the
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tendons of her long toe extensors over, I can kind of feel the joint line and then
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I'll usually just take these few fingers and kind of push up while my thumb
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pushes down, see if there's any wiggle there; and then here's the really
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important point that I was trying to make in the the further away shot, is as
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you're going to mobilize this joint it's important that you kind of slide your
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hand up this way, and you can see how her skin kind of crunches up, so that when I
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press down her skin is back to its normal length, whereas if I pull down
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from here, you can see I stretch out her skin trying to get pressure over the
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anterior surface of her lateral malleolus. Now I'm going to come up like this, press
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down, ask Melissa if she feels any pain, if she feels any tingling burning right,
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we don't want to stretch that nerve. I can use the other hand to stabilize her
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tibia, and then I can kind of find my resistance point, so first resistance end
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of arthrokinematic range, and then of course all of our mobilization protocols
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end up somewhere in the middle. I'll go from zero to 50% and a little larger
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amplitude doing my grade three. I'll go for thirty seconds until I think I feel
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a change in stiffness, and then I can go back to my assessment position of
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feeling the joint line, seeing if I got any wiggle back. Alright guys so get
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familiar with your lateral malleolus, feel all of its surfaces, find the the
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inferior border, find the anterior border, try to feel that joint line, really try
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to grab ahold of it with your fingertips, gently of course, so you don't hurt your
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patient, client, or partner you're practicing on. Stabilize the tibia with
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one hand, pick up a little tissue, make sure you follow through on your
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protocols, and of course at the end of your technique make sure you assess. So
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there you have it; assess, address, reassess. Make sure that
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every time you choose a joint based manual therapy technique it is based on
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an assessment, and that you return to that assessment after you've finished
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the intervention to see if it was effective for the individual, the patient
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or clients that you had in front of you. Ensure that you continue to
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learn 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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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
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setting. I look forward to talking to you guys again soon.