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This is Brent of the Brookbush
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Institute, and in this video we're bringing
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you another manual technique. Now if you're watching this video I'm assuming
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you're watching it for educational purposes, and that you are a licensed
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manual therapist following the laws regarding scope of practice in your
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state or region. That means athletic trainers, chiropractors, physical
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therapists, osteopaths, licensed massage therapists you are likely in the clear
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to do these techniques. Personal trainers this probably does not fall within your
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scope of practice, although you might be able to use the palpation portion of
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this video to aid in learning your functional anatomy in an educational
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setting, supervised by a licensed manual therapist. Now before we place our hands
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on a patient or client it is important that we assess and have a good rationale
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for doing so, and of course if we're going to assess then we should be
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reassessing to ensure that the manual technique we're using is effective, and
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we have a good rationale for continuing to use that technique. In this video were
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going to go over static manual release of the erector spinae muscle. I'm going
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to have my friend Melissa come out, she's going to help me demonstrate. We're going
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to use the same palpate and compress technique we've been using for all of
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our static manual release videos, using that that four-step process of
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differentiating, knowing where our common trigger points are, knowing what not to
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press on, and of course getting our patient inclined in good position and us
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in good position so that we have good technique. Starting with a
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differentiation of tissues your erector spinae are fairly superficial, and
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providing we're not talking about trying to differentiate the various erector
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spinae muscles, they're actually not that hard to palpate. The three muscles
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combined create a column of tissue on either side of the spine. I think you
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guys instinctually knew this right. this this valley is created by the skin and
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underlying fascia being tacked down to the spinous process, and then the
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thoracolumbar fascia and fascia along the spine here, all the way
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into like our cervical thoracic fascia create these columns wrapping around the
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erector spinae muscles that create hills on either side for our palpation. The
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only thing we have to consider outside of knowing where these hills are, is what
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direction of a diagonal these fibers go in, because we're going to want to go
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back to that stroke perpendicularly to find the densest fascicles, and then go
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parallel along the dense fiber to find the nodule hyperactive point,
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trigger point. Alright so here's how the diagonals work. most of the erector
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spinae, in fact all of the erector spinae have a diagonal that goes from lumbar
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spine essentially to shoulder. If you think in that direction from inferior
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medial to superior lateral, and then you just drew parallel lines in your head,
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that's the direction of the erector spinae. The only muscles that are a
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little different being erectors of the spine that can
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also develop trigger points is our multifidi, our trigger points for our
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multifidi are usually in our lumbar spine here is what we're talking about, and
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they go in the other direction. They go from inferior lateral to superior medial.
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If I'm going to palpate tissues that run this way again so we're back to a erector
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spinae, I'm going to set up my hips so they're even with Melissa's hips and
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then my hands are going to be going in the direction of Melissa's head, and that
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would be my perpendicular stroke. So that's not too bad. When I do my erector
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spinae I'm facing this way, and then I can just survey the length of my erector
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spinae. I'm just kind of picking up my hand,
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strumming over the tissues. Now it helps to know where your trigger points are.
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Your two common trigger points that we're usually releasing in the erector
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spinae are right in the middle of the lumbar spine, like in line with somewhere
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between l2 and l4, and then just above the thoracolumbar junction there tends
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to be another trigger point. So if I know that I might go right to those points
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first just to see if I can narrow this this search down a little
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bit, and when I find really dense fascicles again, I'm then going to go in
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line with a fiber, search the whole fiber here for a nodule and acute point of
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density and acute point of overactivity, And then you guys can use one of your
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various comfortable hand grips either thumb over thumb just again leaning in,
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you can use the technique I like to use as you guys know which is kind of
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having that dummy thumb underneath, or putting my pisiform hamate over my thumb,
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or putting my thumb in my thenar groove here. So in this case what I'm
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going to do is pisiform hamate, and I'm just going to hold 30 seconds to two minutes
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to kind of pin down the tissue. Notice I am I'm not pushing straight
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down, I'm kind of pushing this way, that does help to keep me from playing that
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game of like put your finger on top of a marble just and it just like keeps
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shooting out this way. I tend to not only push down but push a little bit so
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that I'm kind of like bowing this tissue this way, which holds that trigger point
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underneath my thumb. Now if I want to switch around and do the multifidus,
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maybe I have done all of my erector spinae,
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I'm then going to put my hips level with Melissa's shoulders, and I'm now facing
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her opposite hip. I can then go through, and guys these are going to be
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lumbar spine right, otherwise as we get up in the thoracic spine the multifidus
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are not well developed in the thoracic spine, and of course when we we do the neck that's a
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whole different set of techniques which we talked about in different video. So if
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we're doing multifidus it is going to be lumbar spine. We're going to go this way,
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this direction, a little closer to our spinous process until we find an acute
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point of overactivity or density. It does help to kind of bring the pants down a
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little bit, so that you don't have to feel through another
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layer of clothing right. You already have the skin to feel through, you already
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have some adipose tissue fascia, there's a lot going on back here that we
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got to feel through to just feel these small increases in tissue density. And in
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fact, the common trigger point here is actually somewhere between, in that
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little divot between our PSIS and then the spinous process of l4 l5. Like right
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in here there's like a very common trigger point, all right so if I push in
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there, how does that feel Melissa? Yeah a little a little tender. This is
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definitely a common trigger point. As far as is there anything in this area that
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maybe we shouldn't put our hands on, well no if providing that we're staying close
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to the vertebral column, our transverse processes for the most part protect us
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from being able to do damage to things that would be deeper and more sensitive.
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It would be pretty hard for example for me to push down so hard that I damaged a
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nerve or damaged an internal organ. Like you'd have to be way out here to
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get to some of your internal organs, and I know people worry about that, but the
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transverse processes protect us pretty well. Of course if somebody was or had
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acute lumbar pathology like a nerve root adhesion that was kind of new. Or they
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were experiencing some pretty significant sciatic symptoms, or you had
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like a lumbar herniation, obviously be careful. Don't go in and push
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down as hard as you possibly can. It's not so much that this is one of those
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things that you need to watch where you put your hands, but maybe how you put
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your hands. If I knew somebody was very sensitive to posterior to anterior
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pressure I might even bring the table up a little
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higher, so that I can get a little bit more of a horizontal pressure
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so that I'm not getting so much of this. We can still pin tissues pretty good by
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pushing them towards the spinous process. how does that feel Melissa? It's still very tender, of
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course she has no lumbar pathology that we need to worry about, but you guys can
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kind of imagine how this would be helpful. Back to client position,
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notice when I wanted a more horizontal direction I raised the table, when I want
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a more vertical direction of course I'm going to lower the table. What you don't
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want to do and this is just if you think about it some common sense, you don't
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want a high table and trying to be pushing down,
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we don't want arms like this. We want arms straight. We want to use our fingers
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maybe to palpate just because we need that sensitivity, but then when we
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palpated the tissue that we need and we're just applying pressure, we
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really want to apply pressure not with hand strength and arm strength, but just
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by weaning our body and using body weight. I'm actually not using any
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strength at all here. My elbows are just shy of lock, my arms are nice and
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straight, and I push down, I can tell you guys this is where having mirrors in
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your office comes in handy. I know not everybody has that, but if you have
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mirrors in your office check your own posture every once in a while. I know we
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put mirrors and offices for assessments of our patients, but I think sometimes we
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need as much assessment on our technique and posture while we work. Alright so
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just a real quick recap guys, common trigger points just above the
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thoracolumbar junction right in the middle of the lumbar spine, and then in
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that little soft area between the PSIS and spinous process of l4 l5 usually a
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multifidus trigger point, Eerector spinae perpendicular strokes are this way,
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because those fibers run this way multifidus run this way, so we set up
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this way. Stay tuned for a close-up recap. You guys
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can see the trigger points I've marked out, here are the most common trigger
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points in the erector spinae and the multifidus. One just above the
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thoracolumbar junction the other right in the middle of the lumbar spine, and
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then of course that multifidus trigger point often occurs right between the
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PSIS and the spinous process of l4 l5 and that soft tissue divot there. Now if
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we're going to palpate and release the erector spinae, because they had a
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inferior medial to superior lateral diagonal, I want to line my hips up with
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Melissa's hips, and then my hands are kind of going in the direction towards
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her opposite shoulder. I'm going to do my perpendicular strokes, strumming these
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fibers just like guitar strings, looking for the densest or tensest guitar
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strings. Once I find the densest tissues, I then go along the length of that
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tissue to see if there's any sort of nodule or acute point of hyperactivity, a
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trigger point, once I find that point then I can go -the palpating thumb
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becomes my dummy thumb, and I can just place either my thenar groove
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over that thumb, or my pisiform hamate over that thumb. Straighten out my arms,
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lean in, apply pressure for thirty seconds to two minutes. Once I get a
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release there, then maybe I keep palpating, keep strumming all these
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fibers looking for any other shorter points. You have to remember that your
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erector spinae is made up of tons of fascicles
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right that all run in parallel this way. So it is possible to have multiple
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trigger points in multiple different levels these are simply the most common
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trigger points. Now for the multifidus remember that instead of going this way,
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since the multifidus go superior medial to inferior lateral, I have to go this way,
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that I have to turn myself around, so now my hips are in line with Melissa's
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shoulders, my hands going towards her opposite
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hip, and it's a little different palpation, it's a little different feel than these
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big erector spinae muscles. The multifidus are usually a little flatter. But
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you're going to look for the densest fascicles. Once you find them, once again we'll go along that
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fascicle to find any tender nodule, and then once I find it, I can either do my
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thumb over thumb, pisiform hamate over thumb, or a my I can even do thenar
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groove over thumb like this, holding for 30 seconds to two minutes, until I get a
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release. So there you have it, knowing your functional Anatomy will definitely
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help your manual technique. It'll help you differentiate structures so that you
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can place your hands where they need to be, as well as make you aware of these
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sensitive structures around the tissue that you're trying to target. Things like
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nerves and lymph nodes, and arteries. Make sure that if you're going to place your
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hands on a patient that you have done an assessment and have a good rationale for
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placing your hands on that patient, and if you're going to assess make sure you
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reassess to ensure that your technique was effective, and you have a good
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rationale for using that technique again. Now with manual therapy, one on one live
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education is incredibly important, please be looking for opportunities like
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workshops and mentorships, and maybe even classes at your local university, that
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can get you some one-on-one individual instruction or at least some live
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classroom instruction, so you've had a chance to be critiqued and mentored by
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somebody senior to you with some experience in manual therapy techniques.
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And before you bring this stuff back to your rehab, fitness or performance
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setting, please practice on colleagues. There is no substitute for practice and
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it is going to take a while to get accustomed to some of the techniques
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that we show in these manual technique videos, don't expect to learn them in two
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or three, or even five minutes. You want to have hours of experience under your
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belt, working on various different body sizes and shapes, so
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that when you do get that first paying client, first paying customer then you're
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really trying to make a good positive impact, really trying to promote better
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outcomes, you feel comfortable with that technique. I look forward to hearing
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about your outcomes and hearing your questions in the comments section of
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this video. I'll talk with you soon.