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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 therapists, 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 go over lateral hip mobilization, this is a great general
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technique for reducing arthrokinematic stiffness of the hip joint. I'm going to
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have my friend Melissa come out, she's going to help me demonstrate. Now if I'm
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doing a joint mobilization for the hip there might be several indicators that
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led me to believe that a mobilization may be effective, and first and foremost
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we could use something like the overhead squat assessment; because the hip is so
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involved in several of our functional tasks and motions, something like the
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overhead squat is going to give me an indication with signs like knees bow in,
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knees bow out, anterior pelvic tilt, posterior pelvic tilt, maybe an excessive
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forward lean, or an asymmetrical weight shift all could be indicators that somethings
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up with a hip. I could then go to goniometery, something like internal
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and external rotation of the hip. If I have stiffness I may get a reduction in
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rotation, whereas I can almost be guaranteed that if rotation is normal
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hypomobility, arthrokinematic hypomobility is probably not an issue. The
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last thing I personally rely on is passive accessory motion exams in this
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case. I know that is the traditional method for determining whether we need a
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joint mobilization, but with the hip we're dealing with so much soft tissue
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and this is a very strong soft tissue, it makes it much harder to feel normal
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versus abnormal joint play. Now we could go to convex on concave rules and start
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talking about why this mobilization is traditionally
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used, but in reality we're dealing with femoral spin and a lateral distraction-
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our lateral mobilization is actually distraction. So convex on concave
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rules don't apply real well here, although these are generally this
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technique I'm showing you is generally used to increase flexion and internal
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rotation. I've personally found that this is such a general mobilization probably
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most affecting the posterior structures of the hip, which have a propensity
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towards adaptive shortening like our posterior capsule, that I have seen
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increases in external rotation, internal rotation, flexion. I've seen increases in
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adduction range of motion all from doing this one technique. Again with all the
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techniques we do we have to be careful getting too specific with our
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biomechanics and we should always assess, or address and then reassess. So I'm
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going to do whatever assessment I'm going to do -the overhead squat, goniometry,
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I'm going to do my mobilization, and then I'm going to go to
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my reassessment to see if that technique was effective.
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Now Anatomy in this case, you guys can't feel the hip, I'm sorry like you're not
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going to reach in and and palpate the hip joint. You'd have to get through
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a lot of tissue and and that would be problematic and probably painful, so
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let's not do that. A couple things you are going to want to be able to find
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though is you're going to want to be able to find that inguinal line right, so
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you got to find that crease because either the belt which we're going to
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show that technique, or your hands are going to end up there. You probably want
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to be able to find the ASIS right so that anterior superior iliac spine. I'm
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going to show you guys how to kind of palpate joint motion, in the sense that
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if you put your hand down on the ASIS and the greater trochanter, it makes it
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somewhat easy to feel how much joint play you're getting. Other than that
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we're going to find that this technique is more like hug the leg.
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So I'll never forget my one of my clinical
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instructors coming up in school and of course an instructor for the the
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Maitland Institute Rob Flugel, telling me that manual therapy is a full-contact
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sport, and I think the biggest mistake I see with with this particular
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mobilization is people will use the strap and then stand about this far away,
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and start trying to do the mobilization. You're not going to feel anything, you're
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not going to get a real controlled motion that way, and we want to be as
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specific as we possibly can. So I'm going to show with the strap
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first because this is the technique I prefer, and then I'll show it again of
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course using just my hands for those people who the strap is actually
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uncomfortable on them, and or for those who just don't have a strap -for example
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maybe you do home care and you forgot your strap at home that day. Alright so
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I'm going to wrap this around my backside not my low back, alright we
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want to make sure that I'm not putting myself at risk here, and then I'm going
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to clip it around Melissa's side. Melissaf if you could
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scoot a little closer to me that would be great.
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Alright I'm going to have Melissa go ahead and position this strap all the
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way down as far as she can, because we want to be as close to the joint line as
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we possibly can. Now obviously the strap is close to some sensitive tissues, my
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guys know this is the adjust and guard technique. You might have to ask people
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to kind of use a hand to kind of move some stuff over and then they can block
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if they need to, that's especially handy when you personally are using your hands
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on this technique, you know that that way they they feel safe and comfortable and
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trust me if you get any of your sensitive skin underneath this strap or
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somebody's hands doing a lateral mobilization, you will have them talking
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falsetto. We are going to use a fairly large amount of force the hip is a
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fairly large joint. Now what I'll usually do is bring somebody into flexion, and
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then I'm going to go ahead and hug Melissa's leg like this. Alright so you
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guys can see here I kind of like like you were doing a headlock
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around the knee, but I'm going to have her thigh against my chest have her leg
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underneath my arm, and what this allows me to do is I can control not only how
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much flexion but how much rotation as well, and I mentioned in one of the other
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videos we seem to have a bit of research coming out that states that maybe we
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should be doing mobilizations at the end of the range that we're trying to get. So
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if I want more internal rotation maybe I shouldn't be doing it in open packed
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position, but doing this mobilization at the end of their pain-free internal
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rotation. Well I can do all that now right like I have her leg completely
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locked up, I'm good I'm in control here. Now I'm going to apply all the force
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with the strap by just sitting back here in a second, so that gives me an open
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hand. What am I going to do with this hand, well just like I explained in the
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knee mobilization video this is a great chance for you to try to be able to
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palpate joint motion, which is going to make it easier to follow through with
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those protocols that we talked about a couple times where you're trying to get at
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about 50 percent, well 50 percent between initial resistance and end of arthro-
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kinematic range. In this case what I usually do is I'll go thumb on ASIS -or
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maybe I'll turn that around I'll go fingers on ASIS and then thumb on
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greater trochanter, and I think if you guys kind of get them in to end range
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here and this is just first resistance barrier I'm not pushing her too hard,
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remember we want pain free alright first resistance barrier, and then if I sit
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back into the strap I can actually feel the greater trochanter moving into my
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finger while the ASIS stays in place right, so that's all arthrokinematic
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range I'm getting. So now I can kind of pull back on the strap and go oh
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there there it's started moving, and now it's stopped moving and it seems like no
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matter how far I sit back now if I keep pulling her ASIS comes with me. I'm not
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I'm not increasing the distance between greater trochanter
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ASIS anymore. Alright so that that helps me feel beginning of resistance
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and end of arthrokinematic range and now I can back off to 50%, and here's the
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tough part guys, how do i do my oscillations? I don't want to be like
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trying to manhandle her thigh and I have this strap here, but what I see people do
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with the strap is they start like throwing their butt back like they're
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twerking or something, like that that's not going to be good for your
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back don't twerk for mobilizations. It does help if you have a mirror in your
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office to watch yourself. What you want to do is get into a staggered stance and
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you want to try to rock, and you want all of you to rock so as the the the straps
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coming back you also want the knee to come back with you,, otherwise this isn't
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completely a lateral distraction, it would end up being like a lateral
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distraction with anterior rotation and adduction of the femur. We want pure
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lateral distraction. So what I'm doing here is I'm pushing back with my front
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leg onto my back leg right, and I'm just kind of going back and forth between my
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two legs. So this isn't this isn't twerking, this isn't using my upper body.
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You guys can see here like I'm just rocking back and forth and I could do
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this all day, maybe not all day but I could do this
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for quite a long time. I'm just using the strength in my legs in kind of this
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quasi-lunge position or split-stance position to get all of my force. Alright
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So now that I've got this rocking motion down let's go back to where I was, I'm
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going to hug Melissa's leg, first resistance barrier, flexion and internal
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rotation. I'm going to use this hand to feel ASIS and greater trochanter. I'm
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going to sit back, alright so there's my first resistance barrier, there's arthro-
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kinematic end range right there, back off to 50%, and now I can either do
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my grade three or my grade four mobilization, lets do grade three at this
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point. So I'm going to come back to first resistance barrier alright this is my
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larger amplitude oscillation, and I'm going to keep doing that one to two
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oscillations per second until I feel a decrease in joint stiffness. So notice
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guys like I'm very relaxed, I can keep talking to you there's no problem okay
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could do this all day. Now if you happen to use other protocols, you don't use the
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1 to 2 oscillations per second like the the Maitland protocols that I use that's
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okay, just make sure that you are looking for first resistance barrier, you know
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where arthrokinematic end range is, your setup is good and that you follow
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through with your protocols. As I've mentioned in several videos that's the
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the biggest mistake I see, is people kind of start and then like halfway through a
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protocol they just kind of go yeah, and then they move the leg around and they
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go that's good. Right I'm going to assess, I'm going to pay close attention to my
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technique, because I want to make sure that if I didn't get the result I was
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looking for, that it was the wrong technique and I need to pick something
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else, and not just bad form on my part. So let me review this technique one more
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time, and I'm going to show you guys the hand version of this technique. So again
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I took the leg up, wrapped around right I'm kind of hugging the leg with one arm,
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I can get as much internal rotation I need, I could even get some extra
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rotation if you guys thought you wanted that, and I can go into as much flexion
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as I want. I'm going to get myself all straightened out, I'm going to palpate my
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ASIS and my greater trochanter, and I'll show you guys that in the close-up recap,
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and then find my first resistance barrier, my arthrokinematic end range, and
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then I'm just going back and forth between my front and back legs in a
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split stance position. Hand position for this if you don't have a strap, or let's
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say every time I put that strap down Melissa was like that pinches right, and
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we know we have like the obturator nerve in there, we have some cutaneous nerves
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in here, maybe no matter what I do with the strap I keep pinching
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down on that nerve, okay we need to figure something else out. Some people
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just, like it pinches and digs into their skin and the straps not comfortable. So
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Melissa can guard if she wants all right, so we can, go ahead and put your hands
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down over yourself alright, and then I'm going to get my hands down as close
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to that joint line as I possibly can. You guys can't be bashful on this, obviously
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explain to your patient client what you're doing and why you're doing it, and
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make sure that you're coming down from the thigh to get into position so that
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you don't act, you know purposely brush up against anything, but you have to get
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as close to the joint line as you possibly can, if you get up here you're
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going to pull into horizontal abduction, adduction and not get your mobilization.
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But once you're here, notice that my position is not that much different than
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it was before, I'm still hugging the leg, now I don't have this extra hand
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unfortunately, but I'm going to use my legs to pull back to arthro-
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kinematic end range, you know find my first resistance barrier, kind of figure
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out where I'm going, and then once I get there I can do my rock between my legs.
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Notice I'm not hugging, this is the biggest mistake I see on the hands only
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technique, is people just start hugging the thigh,
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we're not hugging the thigh. Alright stay tuned for the close-up recap.
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Alright guys showing you another view, notice that the the strap here is around
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my backside, not my lumbar spine. I don't want to be giving myself a posterior to
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anterior mobilization everytime I try to loosen up somebody's hip. The strap is
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also down on Melissa's inguinal line here as close to her hip joint as I can
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possibly get it. We're then going to take this hand wrap it around the thigh,
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bringing the thigh close to the torso, so essentially we're given the thigh a hug
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here. This allows us to control all of the weight of this limb just by rocking
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back and forth and swaying back and forth, rather than trying to muscle it
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with our arms. I know some of you guys treat individuals a lot
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larger than yourselves, if any of you guys are working with professional
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athletes it's not real easy to muscle a very large leg. So you guys are using
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your body, you got the hugged in position here, you now have a free hand; you can
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use this free hand as a barometer like we were talking about, fingers on the
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ASIS thumb over the greater trochanter, that allows you to feel the greater
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trochanter move into your thumb against the relatively stable ASIS. So as soon as
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I sit back into the strap I can feel the greater trochanter move, even though the
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ASIS is staying totally stable. So as I go into my protocol here I can feel
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first resistance barrier, it's already starting to move a little bit right
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there, and then I can pull all the way in to my arthrokinematic end range, and
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then I can back off to 50% where I'm going to do my oscillations. If you guys
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are using 25% or 75% that's fine, but you can use this hand to kind of guide how
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much you're going to pull into that resistance. Now as I mentioned in the
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other take you want to try to sway between your front leg and your back leg,
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you're not doing rows, you're just front leg back leg, front leg back leg, front
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leg back leg, allowing your whole body and their thigh to essentially move as
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one as you shift your weight between your feet. Now if I was going to do this
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technique at a normal tempo here, again first resistance barrier,
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arthrokinematic end range, back off the 50% and then 1 to 2 oscillations per
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second right about here, and I'm going to keep doing this probably for about 30
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seconds, but essentially until I feel a decrease in arthrokinematic resistance.
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Once I feel a decrease if I really wanted to keep working on internal
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notation I could pull this way, if I was working on hip flexion I could come up a
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little further this way, and then maybe do a second set. Now you don't want to
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push too far before you reassess and see if you've regained normal range of
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motion, but that does give you guys an idea that if you have good control of
00:18:1000:18:18
this limb, you can kind of adjust as you go to try to get the most benefit from
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this technique. Now I understand that a strap doesn't always work, like I said
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some people feel pinching when they use a strap and sometimes you just don't
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have a strap handy, so you can use your hands -you do lose your barometer here,
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because what you're going to end up doing is taking this hand, lacing it
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underneath the lower leg dropping that hand right down on the thigh as close to
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the hip joint as you can possibly get, putting this hand over the top and now
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you're using the same technique. Make sure you're trying to get your your
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chest pretty close to vertical with your hands right, making sure that that the
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leg itself is vertical; and once you're all kind of hugged in and that leg is
00:19:0200:19:08
right up next to your torso, you're going to do the same front leg back leg, front
00:19:0800:19:12
leg back leg, front leg back leg with your body wave. None of this, this will
00:19:1200:19:18
wear out your arms. We want to make sure that we use our bodyweight so that we
00:19:1800:19:24
can keep mobilizing for as long as we need to do this technique, to feel a
00:19:2400:19:27
decrease in arthrokinematic resistance. So there you have it,
00:19:2700:19:32
assess, address, reassess. Make sure that everytime you choose a joint based
00:19:3200:19:36
manual therapy technique it is based on an assessment, and that you return to
00:19:3600:19:40
that assessment after you've finished the intervention to see if it was
00:19:4000:19:45
effective, for the individual, the patient or client that you had in front of you.
00:19:4500:19:50
Ensure that you continue to learn your Anatomy, because your Anatomy is going to
00:19:5000:19:53
help you with your hand placement, with understanding
00:19:5300:19:58
what a joint can do, with understanding what you may gain from
00:19:5800:20:04
this particular technique; and of course practice, you have to practice these
00:20:0400:20:08
techniques. Hopefully not for the first time on a patient or client who just
00:20:0800:20:13
walked in the door. If you can, find a more senior instructor or a mentor to
00:20:1300:20:19
give you some really good hands-on instruction. Use your peers for some good
00:20:1900:20:27
feedback, and of course always look for live education to help with your manual
00:20:2700:20:32
therapy techniques. I know these videos make education very convenient, but there
00:20:3200:20:37
is no substitute for learning manual therapy in a live setting. I look
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forward to talking to you guys again soon.