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This is Brent of the Brookbush Institute,
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in this video we're bringing you another
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manual technique. Now if you're watching
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this video I'm assuming you're watching
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it for educational purposes, and that you
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are a licensed manual therapist
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following the laws regarding scope of
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practice in your state or region. That
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means athletic trainers, chiropractors,
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physical therapists, osteopaths, licensed
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massage therapists, you are likely in the
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clear to do these techniques. Personal
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trainers this probably does not fall
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within your scope of practice, although
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you might be able to use the palpation
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portion of this video to aid in learning
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your functional anatomy in an
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educational setting, supervised by a
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licensed manual therapist. Now before we
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place our hands on a patient or client,
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it is important that we assess and have
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a good rationale for doing so; and of
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course if we're going to assess, then
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we should be reassessing to ensure that
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the manual technique we're using is
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effective and we have a good rationale
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for continuing to use that technique. In
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this video we're going to go over static
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manual release of the levator scapulae.
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I'm going to have my friend Melissa come
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out, she's going to help me demonstrate.
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Now our manual release techniques
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generally follow a very similar protocol
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of differentiate between the target
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tissue and other proximal structures, be
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aware of any tissues that we do not want
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to press on, those are sensitive
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structures that could be insulted by
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compression. We get some bonus points for
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knowing where our trigger point trigger
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points are, or our common trigger point
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sites, as that's going to help us
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increase the accuracy of our palpation.
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And last we want to consider our
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position and the patient's position. Now
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Melissa here has her back to you guys so
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that we can see some of the bony
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landmarks that are going to help us
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differentiate the levator scapulae from
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some of the other proximal structures,
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and she has her arm out of her sleeve so
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that you guys can see her scapula. Now
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under most conditions I would not ask
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Melissa to take her arm out of the
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sleeve of her gym shirt, gym clothing is
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generally thin enough that I can palpate
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through it to feel bone, and I can
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perform the technique without any extra
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strain on my hands. So if I put my hand
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right down here guys you can see
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that I come right up against the medial
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border of the scapula. If I follow the
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medial border of the scapula until it
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starts turning around the top right,
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where it started turning around the top
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is the superior angle of the scapula. The
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superior angle of the scapula is the
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insertion of your levator scapulae, and
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that is where we are going to start our
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palpation. Now most of this that you
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guys see is upper trapezius, your upper
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trapezius is the most superficial muscle
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of your posterior and lateral neck. We
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want to palpate through it, and there is
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a little trick to knowing the difference
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between upper trapezius and levator
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scapulae, and that has to do with the, I
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guess direction and organization of the
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muscle fibers themselves. The trapezius
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is a fairly flat muscle whereas the
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levator scapulae is a very ropey bundle
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of muscle. In fact the levator scapula is
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four ropes that twist as they go up the
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neck, each rope attaching to one of the
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transverse processes c1 through c4. You
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can kind of feel the difference in
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texture by simply falling off the
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superior angle of the scapula, and then
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you're going to strum across the length
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of the fibers here until you feel those
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ropey bundles. Alright so I know that
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this is probably trapezius, but if I go a
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little deeper and I do my strumming
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strokes here, I can feel like this isn't
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that right, I can feel those little ropes.
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Now before we go any further let me
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think to myself are there any tissues
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that I could injure if I start pressing
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in this area, the truth of the matter is
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not really. I mean there's always tissues
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we could injure, we press hard enough and
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we're really careless. But for the most
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part if we are posterior the transverse
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processes, most of the sensitive
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structures of the neck are anterior the
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transverse processes. So as long as I
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don't grossly miss this palpation and
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end up here, chances are i'm not going to do
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anything like compress the carotid
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artery or stretch the brachial plexus. As
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long as I stay around here, and even as I
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track up the length of the tissues I
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stay posterior to these transverse
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processes, I'm probably okay. Now then the
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question is is where do we get these
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acute points of hyperactivity? Where did
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we get these acute points of tenderness?
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And I said you get bonus points for
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knowing where your trigger points are. In
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the case of the levator scapulae the
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trigger points tend to be just
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superficial and medial to the superior
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angle of the scapula, or right at the
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insertion and then about halfway up the
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length of the levator scapulae, just
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anterior to the angle of the upper
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trapezius. Actually at this point guys
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the levator scapulae becomes a
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superficial muscle bordered by the
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trapezius here, and then the middle
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scalene in front of it. But going back to
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where we were with our palpation if I do
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my strumming strokes across those
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bundles, find the densest bundle which
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we're going to assume is the most active
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bundle, and then I start going proximal
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to distal, or actually distal to
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proximal- proximal to distal, looking for
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any tender nodules or any points of
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increased density. We're going to assume
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that those are the trigger points were
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looking for. Right and i find one right
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there, and if I held this pressure
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chances are i could get a release. Now the
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last thing we have to think about is
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position, and this is obviously not the
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position that i would normally do this
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technique in guys. We have
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Melissa's back to the camera so that you
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guys can see what i'm working on with my
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hands, but i'm essentially doing this
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completely by feel without any visual
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alignment here. So what I'm going to have
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Melissa do is I'm going to have her put
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her arm back in the sleeve of her
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shirt, like i said i don't actually need
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her to take her arm out of the sleeve of
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her shirt, i can do this technique right
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through her shirt. I'm going to have her
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flip around.
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Now I have seen this done in a seated
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position, i'm going to show you guys how
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to perform this technique in a seated
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position, although it's not the way i
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prefer to do this technique. What you
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guys would do is you'd start off by
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putting the levator scapulae in a
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lengthened position, that lengthening
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helps us pin down those points of
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overactivity right. It gives us like a
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little bit of tension on either side of
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it, so we don't play that game where
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we're trying to put our finger down on
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top of the marble and it keeps spinning
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out all over the place. The way we
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stretch our levator scapulae, and some of
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you guys already know this is by doing
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the pocket stretch, which is having the
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patient look in the opposite pocket. So
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we're going to do a little contralateral
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rotation, contralateral flexion and
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flexion, and then I've seen two ways of
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holding the head for a little bit of
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control. I happen to have fairly large
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hands, so I can kind of do something like
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this and kind of palm the back of the
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head, which some people are fine with.
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If this doesn't make you very
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comfortable, if you feel like you have to
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put a lot of pressure into somebody
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scalp that's not going to feel great; you
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can use the other position commonly used
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in like cervical manipulations, which is
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kind of a forehead headlock, where you're
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going to put the person's forehead right
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inside the crease of your elbow here, and
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then you can even place their head
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against your your chest right so that
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they're completely locked in. Now they're
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completely stable and I can use this
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hand to apply pressure. I'm still going to
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use the same technique, I'm going to find
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the superior angle of the scapula, I'm
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going to do my stroking across the
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length of the tissue this way. I'm going to
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stroke this way looking for the tightest
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nodules or the tightest fascicles, and
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then I'm going to go from distal to
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proximal looking for any increases in
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tissue density, which we're going to
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assume are a nodule or a trigger point. Now
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if i press and I hold for
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30 seconds to 2 minutes, I should notice
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a reduction in tissue density, Melissa
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should notice a reduction in tenderness,
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and I'll have a successful release
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technique. Now the problem with this
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position is this hand. Essentially I
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can't get my hand into a position where
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i can actually get my forearm parallel
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to the direction of force, and i'm having
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to use essentially the strength of my
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hand to do all of the work. Fine if
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you're just trying to get something done
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real quick, you're not doing this a lot
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of times throughout the day it's fine. If
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you happen to be doing a bunch of
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techniques in seated position, and you
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think that this might help you take that
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next step. But I'm going to go ahead and
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show you guys how I like to do this
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technique, which is in the supine
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position. So I'm going to have Melissa go
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ahead and lay down, we're going to need
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to bring the table up a little higher,
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and I think you guys will see pretty
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quick that this is a much much easier
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technique for the clinician, and the
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patient doesn't seem to mind the
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technique. I'm going to use this hand
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right underneath the occiput, you guys
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can see I have total control of her head,
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she's very relaxed right, so I can kind
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of just have her flop her head over this
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way. She's literally just rolling her
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head over as if she just she just went
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down for a nap, totally relaxed. You guys
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can see that this is still the same
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position, the same pocket stretch that we
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were in before, and now I can get in here
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most of my arm is rested which feels a
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little better to me; and once I get in
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position I can use a combination of her
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bodyweight against my fingers as well
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as friction on the table, to take off
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some of the pressure that I would have
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to put on with my hands. Alright so if i
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strung tissue this way,
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I can find the densest fascicles and
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then I go from distal to proximal here,
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in this case looking for that nodule and
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boom. I got my tender point, i'm in a nice
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relaxed position and I just wait for the
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release to happen. If I want I can take
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her into a little bit more rotation, I
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can take her into a little bit more of a
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lateral flexion, and again this arm
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once I move it, I can set it down and
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forget about it. Alright it doesn't
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take a lot of energy on my part. If you
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guys are doing a lot of neck treatments,
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you're doing a lot of scapular dyskinesis
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type treatments where the
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levator scapulae would be something that
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you would treat out, I definitely
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recommend this technique. Guys stay tuned
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for the close of recap. For a close-up
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recap of levator scapulae release. You
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guys can see I have the levator scapulae
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trigger point marked off there, at least the
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higher one that's about midway up the
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length of levator scapulae. We can see
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this muscle right here which is the
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upper trapezius will help, that will help
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us as a landmark. We're going to go ahead
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and lengthen the levator scapulae, so we
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can help pin down those hyperactive
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points or those nodules of increased
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tissue density. I'm just going to go
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ahead and pull her into a levator
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scapulae stretch, which is letting her
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head fall into my opposite hand. We're
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going to pull a little bit in the
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contralateral flexion, a little bit
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into flexion, and now I have all of this
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area to start working through with my
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palpation. If you guys remember the other
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trigger point was just above the
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superior angle of the scapula, that's
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also where we started palpation of our
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levator scapulae. So if Melissa gives me a bit
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of a crunch here, you guys can notice
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this trigger point right here, and the
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the superior angle of her scapula is
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right here, and I'm just going to go
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ahead and put my thumb down there. So you
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guys can see kind of what that looks
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like when I have my hand between her and
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the table, searching for those overactive
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or tight fascicles. Alright so I'm
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doing my strumming from
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superior lateral to inferior medial.
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Although unlike the trapezius angle that we
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were using for strumming, this angle is
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much more lateral to medial. It's just
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slightly turned this way because the
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levator scapulae it's so much more
00:13:2400:13:28
vertical on the cervical spine. So
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I'm moving across these fibers a little
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bit this way, and then I can move from
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distal to proximal to find the tightest
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nodule, and then I can push in a little
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bit, get the pressure that I need which
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the pressure that I need is just pushing
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in until I get a little kickback from
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the tissue. So I'm going to go right up
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to the point where I feel an increase in
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tissue density and then I'm just going
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to lay my arm down, and allow the table
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to keep my arm there. So the friction
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between my arm and the table is actually
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whats keeping me in position. I'm going to
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hold for 30 seconds to 2 minutes and
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wait for a nice release. Melissa how's that
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feeling? Ok. Starting to relax a little
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bit. Good this other trigger point guys
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is a little tricky, a little bit more of
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an advanced palpation. It is just
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anterior to the upper trapezius. So this
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is the upper trapezius and I can
00:14:3400:14:37
actually kind of pull this away, and then if
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i push down in here I have to make sure
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I stay just posterior to my transverse
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processes, which you can feel is these
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like bony tips right in here. Now these
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are not something you want to press real
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hard on. You press down on somebody's
00:14:5300:14:55
transverse process you make them very
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very uncomfortable. If I go right on top
00:14:5900:15:01
of the transverse process I end up on
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the scalenes. If I go too far back I end
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up on the Splenii, but if I kind of
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follow the levator scapula up.
00:15:1300:15:17
Note how those taught bands feel
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underneath my fingers, and then fall
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right off the anterior border of the
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upper trap and then do my same
00:15:2700:15:30
strumming. This time I'm a little bit
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more posterior to anterior, then I can
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move distal to proximal and I can
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do the same thing. So this is still
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levator scapulae but oddly i'm actually
00:15:4300:15:46
now not going through the trap, whereas
00:15:4600:15:48
before i was pressing through the upper
00:15:4800:15:50
trapezius to get the levator scapulae.
00:15:5000:15:52
Your levator scapulae is actually a
00:15:5200:15:54
superficial muscle here, the only thing
00:15:5400:15:56
to note is this is also a different
00:15:5600:16:01
trigger point than we were on before. So
00:16:0100:16:04
just a quick recap guys with all these
00:16:0400:16:06
levator scapulae releases. You are going
00:16:0600:16:11
to pull or gently place the neck into
00:16:1100:16:14
contralateral rotation, contralateral
00:16:1400:16:16
flexion, a little bit of flexion. You're
00:16:1600:16:18
going to find the superior angle of the
00:16:1800:16:21
scapula, work your way up from there with
00:16:2100:16:26
mostly lateral to medial stroking, until
00:16:2600:16:30
you get just anterior to the upper trap.
00:16:3000:16:32
And then you're using very short strokes
00:16:3200:16:35
but more of a posterior to anterior
00:16:3500:16:37
strumming. You're always going to be
00:16:3700:16:39
looking for taut bands, and this is a
00:16:3900:16:41
very ropey muscle when compared to the
00:16:4100:16:45
upper trapezius. And then once you've found
00:16:4500:16:48
the taut band you can look for dense
00:16:4800:16:51
nodules within those taut bands to
00:16:5100:16:54
hold some compression on, until you get a
00:16:5400:16:56
release. So there you have it knowing
00:16:5600:16:58
your functional Anatomy will definitely
00:16:5800:17:00
help your manual technique. It'll help
00:17:0000:17:01
you differentiate structure so that you
00:17:0100:17:03
can place your hands where they need to
00:17:0300:17:05
be. As well as make you aware of these
00:17:0500:17:07
sensitive structures around the tissue
00:17:0700:17:09
that you're trying to target; things like
00:17:0900:17:12
nerves and lymph nodes, and arteries. Make
00:17:1200:17:13
sure that if you're going to place your
00:17:1300:17:15
hands on a patient, that you have done an
00:17:1500:17:17
assessment and add a good rationale for
00:17:1700:17:19
placing your hands on that patient. And
00:17:1900:17:21
if you're going to assess, make sure you
00:17:2100:17:23
reassess to ensure that your technique
00:17:2300:17:25
effective, and you have a good rationale
00:17:2500:17:27
for using that technique. Again now with
00:17:2700:17:31
manual therapy, one-on-one live education
00:17:3100:17:34
is incredibly important. Please be
00:17:3400:17:37
looking for opportunities like workshops
00:17:3700:17:40
and mentorships, and maybe even classes
00:17:4000:17:42
at your local university, that can get
00:17:4200:17:45
you some one on one individual
00:17:4500:17:47
instruction; or at least a live classroom
00:17:4700:17:51
instruction so you've had a chance to be
00:17:5100:17:54
critiqued and mentored by somebody
00:17:5400:17:56
senior to you, with some experience in
00:17:5600:18:00
manual therapy techniques. And before you
00:18:0000:18:03
bring this stuff back to your rehab
00:18:0300:18:06
fitness or performance setting, please
00:18:0600:18:08
practice on colleagues. There is no
00:18:0800:18:11
substitute for practice, and it is going
00:18:1100:18:15
to take a while to get accustomed to some
00:18:1500:18:17
of the techniques that we show in these
00:18:1700:18:19
manual technique videos. Don't expect to
00:18:1900:18:22
learn them in two or three, or even five
00:18:2200:18:25
minutes. You want to have hours of
00:18:2500:18:27
experience under your belt working on
00:18:2700:18:29
various different body sizes and shapes.
00:18:2900:18:32
So that when you do get that first
00:18:3200:18:34
paying client, first paying customer, and
00:18:3400:18:36
you're really trying to make a good
00:18:3600:18:39
positive impact, really trying to promote
00:18:3900:18:42
better outcomes, you feel comfortable
00:18:4200:18:44
with that technique. I look forward to
00:18:4400:18:46
hearing about your outcomes and hearing
00:18:4600:18:48
your questions in the comments section
00:18:4800:18:53
of this video. I'll talk with you soon.