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This is Brent of the Brookbush Institute, and
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in this video we're going to go over a
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joint based manual therapy technique. 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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professional with joint based techniques within your scope. That means osteopaths,
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chiropractors, physical therapists you're probably all in the clear. Physical
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therapy assistants, athletic trainers, massage therapist you need to check
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with your governing body in your state or region to see whether this is within
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your scope of practice. Personal trainers this is definitely not within your scope
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of practice. Of course all professions could use this video for purely
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educational purposes, to help with learning biomechanics, anatomy and of
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course palpation. In this video we're going to do posterior to anterior
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mobilizations for the lumbar spine. That's both unilateral and central PA's.
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I think you are going to find for all of the spine that unilateral PA's or
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UPA's, are the workhorse for our mobilizations of the spine. You're going to
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use those possibly the most frequently. I'm going to have my friend Melissa come
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out, she's going to help me demonstrate. The first thing we're going to talk about of
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course is position. So I'm going to have Melissa lie prone. If Melissa had pain
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in extension I could put a bolster underneath her
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hips, just to give us a little bit of flexion and me a little bit more room to
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be able to do these PA's, without pushing her into a painful range. You guys will
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notice her arms are in a relaxed position, and we have these really nice
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tables at Flex here in New York, and they have the arm drop downs. But if you
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didn't have those, this position is probably fine as long as somebody
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doesn't have a really tight shoulder girdle. Or you can have their arms by
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their sides. The thing you want to keep away from is somebody putting their arms
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up, creating a lot of tension through the latissimus dorsi because their latissimus
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dorsi does cross their lumbar spine. So tension here could
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make your mobilizations a little tougher. You can go ahead and put
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your arms down, arm cradle. The other thing you want to consider is that
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Melissa needs to be low enough on this table, that I can get my chest over her
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spine. So that when my arms are straight, all I have to do is rock my torso to get
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my mobilizations. So in essence I'm using my bodyweight, the weight of
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my torso to do my joint mobilizations and not my hands, like trying to do
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something like this. Alright I see people do that every once in a while, oh
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my gosh you're going to wear out your hands. Or they start trying to tricep
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press down their mobilizations, I think you're going to find it not only
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wears you out, it's almost impossible on bigger patients for the lumbar spine
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because the lumbar spine is pretty strong and stiff to begin with, and I
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think you also find that your forces aren't very consistent. So if you're
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trying to do these nice consistent oscillations at the same depth, with the
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same resistance so that you're consistent and reliable, you're going to
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have a hard time doing this, as opposed to just rocking with your
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bodyweight. So the table is nice and low, Melissa's in a good relaxed position. The
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next thing you probably want to do as a newer manual therapists, new
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to mobilizations which I'm assuming you are for these videos, you
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probably don't want to start by trying to palpate through clothing. Now
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obviously we don't want to move clothing that people are uncomfortable with, but I
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can tell you adding a layer of clothing is just one more layer of stuff that we
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have to try to feel through, and if we're talking about pants, right like if you
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have to try to feel through denim pants forget it. Especially the L4-L5, L5-S1.
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If you're doing SI joint mobilizations, trying to do those joints
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which are already very strong through denim, is going to wear your hands out real
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quick. So what I'm going to do is have Melissa lift her shirt up just above the
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bottom of her rib cage, because by definition her lumbar spine would be
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below her rib cage right. So the 12th rib, our last rib, hooks into our last
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thoracic vertebrae and everything below that is lumbar spine. And then I'm going to
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have her flip the top of her waistband down. So she doesn't have to like pull
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down her pants, she just needs to flip her waistband down a little bit.
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If you have people come in workout clothes, sometimes these yoga pants do
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come up high on females so be aware of that and don't let that
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mess with your palpation. Make sure that you find the top of their iliac crests,
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and that you can kind of get your thumbs down to the sacral base, even if it's
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just tucking under the lip of their pants, that's okay. But you
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definitely need them to be enough out of the way that you can get to the lumbar
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spine without having to push through clothing. So the next thing we should
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probably think about is anatomy. Now if you haven't looked at the lumbar spine in a
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little while, you don't remember how the spinous process and transverse process,
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and where the facet joint is located, and what muscles to work around, I definitely
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suggest a little review. You could start with some of those soft tissue videos we
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did, the static release videos we did. Maybe look at some of the anatomy of
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some of the muscles around the lumbar spine, and I've mentioned in our other
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spine videos buying one of these plaster cast spines is really an invaluable tool.
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I understand that this spine is not the same as Melissa's spine and that the
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proportions are not identical, but you take a huge step forward in testing
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yourself with a plaster cast spine. For example, I am going to find
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my sacral base, and then being able to look down and see if you're on the sacral
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base. Then you can test yourself, for example I want to get on to L4-L5, so I'm going to go
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L5 spinous process, L4 spinous process, fall off just lateral
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and inferior, and sure enough I'm on L4-L5, and I can look down. What you're
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doing when you do that is you're starting to create a visual model up
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here, which is going to help you match to what's underneath the soft tissue here.
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If you don't do that it just takes a little bit more time, because this is
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essentially that with mush on top. Mush being all the soft tissues right,
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and all these lumbar extensors and multifidi, and you got things
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like your quadratus lumborum which are off to the side. If you're
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not really familiar and you haven't been doing a lot of manual
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techniques, it's nice to have that thing just to check things out. Now
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let's talk about some of our first palpations. If I find the bottom of
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my rib cage, and follow those ribs up and just follow that, they kind of come
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at an angle like this, and so I'm going to follow that angle up to that spinous
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process, and then I go down one, that's L1, so L1, L2.
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The spinous process have very flat tops, so what you're going to feel is like
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flat and then there's a little divot, and then that's the next spinous process and
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then a little divot, the next spinous process. So once you find L1 you can
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go L2, L3, L4 and hopefully what you'll do is
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if you test yourself, you'll get to the sacrum which starts to feel like a
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crocodile's back. It has two ridges essentially and it's bumpier,
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it's not so flat with a divot, flat with a divot, it's not that consistent anymore,
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it's just bumpier down here right that's that's sacrum. Hopefully you get to L5
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and then sacrum and you're not like L6, L7, there's there's no L6 on most people.
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Every once in a while you meet somebody with an L6, but that's a pretty rare
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thing to come across. So count your lumbar vertebra, and then maybe the next
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thing you want to try doing is finding the transverse process. Believe it or not
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the lumbar vertebrae are wide, they're like really wide. The transverse
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process are as wide as your fist. So you can get in here like this and I can feel
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like that's bone out there, all the way out there, and I'll show you
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this in the close-up recap. They're wide, they're really wide and
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feel it, you can get L3, after L3 transverse process now that we're on, you
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run into the iliac crest here, and then they start getting hidden.
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So find the transverse process, find the spinous process, and then the next
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challenge would be to try to get your fingers on the facets.
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The facets are going to feel like bumps, a little more than a finger
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width from the spinous process. So if this is my spinous process, I want to go
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a finger width over, and then if we're going this way
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the facet joint that's related to the spinous process that you were just on is
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actually lateral and inferior just a little bit, just a tiny tiny
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bit. Once I am over the top of them, then what I want you to do is
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gently start trying to feel through all the soft tissue and see if
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you can get that joint to move a little bit. It does take a bit of force, it does
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take quite a bit of force. This is one of those things where having a mentor who's
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done this before is a really good thing, because I think people get scared
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pushing on the spine and there's reason to be scared. Obviously we don't want to
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damage anything, we don't want to hurt anybody, but to give you an idea if
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I'm doing a central PA I have to push Melissa pretty hard into the table.
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I'm using quite a bit of my bodyweight to get to the end range of those facets
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that are associated with the L1 segment. How does that feel? Yeah it's a
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significant amount of pressure. So let's let's talk about central PA's now that we
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know transverse process, we know spinous process and we know
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where those facet joints are. Let's start moving down and start talking about
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these different mobilizations. So you could do your central
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PA on the spinous process with two thumbs. You just come
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to either side and do it this way. I don't like to do that and I'll
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tell you why, anytime I can find a technique that doesn't require my thumbs I use
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that technique, because there are techniques where your thumbs are your
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only option and your thumbs will wear out if that's all you ever use. So a lot
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of therapists get themselves into trouble because their IP's of
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their thumb, they start ending up with hyperextension, they can't really get
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stable and it starts causing them a lot of pain in that joint. So for this one I
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like what's called a pisiform hamate or cradle, I think it's called a cradle saddle, a
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saddle grip maybe is the right term. What I do is I put this part of my
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hand right about where your pisiform is, over the spinous process. Now
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that's pretty comfortable for the patient too because I'm pretty much
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just pushing them into the soft tissue of my hypothenar eminence there,
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the mush underneath my pinky finger, and then to use both of my hands,
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I'm going to take this hand and it's going to saddle over the top of my hand like so,
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and now when I get into position I can just use my bodyweight. So you can
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see that, this is what I'm pushing with, but this is where my force
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is coming from, straighten out both my arms and now I can do my central PA's. Now
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I have to admit usually central PA's I don't use unless somebody is super
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stiff. I use these more as a part of my passive accessory motion exams where
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I go, okay please tell me the difference between pressure and pain, and I'll
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push down and what's that, pressure or your symptoms? That's symptoms,
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okay so that's symptoms and then I start moving down. Pressure or symptoms?
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Pressure, pressure, pressure, pressure. Good so we know in her case, or at least we're
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going to take a guess in her case, that most of her pain is coming through that
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thoracolumbar junction, somewhere like the L1 segment.
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So I'm going to want to start thinking about what dysfunction happens there.
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Unfortunately hypermobility is actually a more common at that segment, but the
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next thing to do would be to think do I feel like that segment was hypermobile or
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hypo-mobile. The only way you're going to know that is from experience, and you do
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have to keep in mind that palpation is probably our least reliable assessment.
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So this is one of those situations where I may do mobilizations and then
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immediately retest. Just mobilize that one segment for 30-60 seconds,
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have them get up and see if I can reproduce their pain. If they got better
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than we're on the right track, if they didn't then maybe the segment is hyper-
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mobile we need to start thinking more towards stabilization exercise. So again
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in central PA's just thenar eminence over like this, and then I use this like
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this, and then I'm going to push down to end range if I'm doing an exam, and see where
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pain comes from. But if I was doing mobilizations you know that it's
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50 percent. Alright so first resistance barrier, end of arthrokinematic range which
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is there for her, back off to 50 percent, and then I can either do my grade 3 by
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backing off to the first resistance bearing and pushing down to 50 percent, so
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that's my larger amplitude, but less intense mobilization because I'm backing
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all the way off to essentially no resistance. Or I can get a little bit
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more intense by going right up to 50% or maybe even a little deeper, and staying
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there with small amplitude mobilizations. Alright and then see how that feels, and
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she actually does feel kind of stiff. So I might try this and then see how she
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does, and you can follow this technique all the way down. So what I'll
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do is if I'm trying to do more segments in the spine and test.
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So my pisiform hamate is under the spinous process, I
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just take my two fingers, find the next one down, move, and go, two fingers down, go
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two fingers down, go and you can see I can address the whole spine real quick
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there. Now let's go back to the workhorse technique of UPA's. A lot of
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lumbar spine issues tend to be asymmetrical. You have restriction on
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rotation to one side, or at least one side is more restricted than the other, or
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lateral flexion is more restricted to one side than the other, we start looking
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towards these unilateral posterior to anterior mobilizations, this is why I'm
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going to have to use a thumb over thumb technique. So I'm going to find
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spinous process, now we know in her case her symptoms seem to be coming from
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somewhere around the L1 segment. So maybe I start with L1-L2 facet. Push down,
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find the first resistance barrier, find the end. How are you feeling? m-hmm mm-hmm,
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yep that's that's a little bit of her symptoms. Then maybe I start
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my grade three mobilizations, assuming that it's hypomobility, despite
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the fact that she has pain there it's not pain. I don't run into pain before I
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run into her mobility issues, it's like as I get to the end of her range she
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starts having pain, which tends to be stiffness dominance if you're talking
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about like a Maitland approach. So what I might do is do 10-15 seconds worth of
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this, and then ask Melissa does that feel like it's getting better or getting
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worse? Okay so if it's getting better then I'll keep doing it and then of
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course retest. I could go up, the mobilization technique here is
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the same for T11-T12, T10-T11, it's the same unilateral PA so I could
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go up a couple segments, I could go down a couple segments, I could try the other
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side. Of course I would walk to the other side of the table, but again notice that
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all I had to keep in mind was my anatomy which is this facet is just lateral
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and inferior, if I'm talking L1-L2. If I wanted to go T12-L1 then I have to go
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lateral and up just a tiny bit. I'm keeping thumb over thumb so that I'm
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using both thumbs and I have as much strength in my hands as I possibly can.
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My arms are practically straight and I'm just using the weight of my torso to do
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the mobilization for me, keeping my protocols in mind. Notice I'm not doing
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this, I'm not doing this, that's all really bad technique. In fact for some
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individuals if you wanted to try this, you could use the hand position we
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used on the static release videos, which is dummy thumb in between our inner
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thenar groove applying the force. On some individuals you might be able to get
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your hands into the right position, to not have to use thumbs at all in
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a straight up-and-down position, you're essentially using this as a
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little point that you're then pressing into with this, and sometimes that's a
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little bit more comfortable for individuals. You could try maybe a
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little less specific going off to the side and pressing on the transverse
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process with the pisiform hamate grip, that we just talked about with the
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saddle grip. Keep all this stuff in mind, although it's not as specific as this,
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and I know some of you are thinking well why wouldn't I just use the best
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technique. The truth of the matter is, is you're going to get tired and if your
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thumb's hurt, and it's the end of a long day, and you've had a lot of big
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individuals on your table, or a lot of stiff patients. Or maybe it's the end of
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a long week. Maybe you happen to be the athletic trainer or physical therapist
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for like a football team, and everybody you treat is just a really large human
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being. Keep these other techniques in mind,
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a good technique is better than nothing. Even if it's not, don't let perfect
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be the enemy of the good is essentially what I'm trying to say. Let
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me show you guys just a couple more things here, just some special palpations
00:19:3100:19:40
to keep in mind. If you find at the top of the iliac crest right, and you keep
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following down you'll eventually run into the PSIS. If you find the space
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that's between the top of the posterior iliac spine, the PSIS and
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then these spinous process here. What we're on, this is L4
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and L5. You will be able to feel this a lot better than I'm
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showing it to you, but there's a little place in between all of this bone
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mass that you start running into here, and in there is your L4-L5 facet. It
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is definitely worth testing that facet. People forget about that facet.
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People will do all of this stuff because it's easy to access, and then they'll
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forget that they need to get in there and really search for that facet
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specifically. How does that feel? That feels really stiff to me. So she
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doesn't have pain, but maybe she's getting hyper-mobile here because this
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is super stiff, I would check on it. Now the same thing with L5-S1. So find that
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triangular space, that's between PSIS, the top of the posterior iliac
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crest, and the spinous process that's just lateral to it. Find that space and
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then what I want you to do is find the sacral base, and I want you to keep
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feeling up the sacral base until you fall off it and that's L5-S1. And now I
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realize L5-S1 you might have to go a little bit this way, to get that to
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move the way you want it to move. Again these are worth checking. They are the
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two segments most likely to be hypermobile, but they also have a
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propensity to become hypomobile. It just depends on the condition, it's a 50-50
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shot. So if you feel like you have normal or more motion than normal when you
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press into them, then leave them alone because you can definitely make somebody
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worse by making them more hypermobile. But I don't know that I would ever rely
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completely on central PA's without at least checking L5-S1, L4-L5 facet, just
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to make sure everything is in good working order. Alright so stay tuned
00:22:2400:22:29
for the close-up recap. Okay for our close-up recap we have the lumbar
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spine, you can see how it's nice and visible here. The first thing that we
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talked about finding was maybe L1 right. We did that by following the last rib up
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to the spinous process of T12, because the last rib would hook into our
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last thoracic vertebrae and the next spinous process we feel. Alright so kind
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of flattish spinous process divot. Spinous process would be our first
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lumbar spinous process, and then we started by talking about central PA's
00:23:0300:23:07
which you know I told you that you could use your thumbs like so. I put one on
00:23:0700:23:11
either side, don't press down on a spinous process like that, that's
00:23:1100:23:16
very pokey. But if you go this way on just either side of the spinous
00:23:1600:23:18
process, you can notice there's a little bit of skin there in the middle.
00:23:1800:23:21
You could do it that way although that's tougher on your thumbs than you need to
00:23:2100:23:33
be. I would go ahead and put your pisiform hamate spot, right this mush of
00:23:3300:23:38
hyperthenar meat right here, right over the top of the spinous process and then
00:23:3800:23:44
you can saddle it up like this, and then you get just that nice lean with your
00:23:4400:23:51
chest over the top of where you're trying to mobilize, and you can just use your bodyweight,
00:23:5100:23:55
real easy. Of course once we found one spinous process it's real easy
00:23:5500:24:01
to go spinous process divot, next spinous process, spinous process divot
00:24:0100:24:06
next spinous process, spinous process divot next spinous process. Keep in
00:24:0600:24:11
mind the spinous process takes up a lot more space than the tiny
00:24:1100:24:16
little divot in between spinous processes. Now the next thing we talked
00:24:1600:24:23
about finding was your transverse process, which believe it or not come out
00:24:2300:24:31
about this wide, they're really wide. This is me rocking Melissa's lumbar
00:24:3100:24:35
vertebra here, and you can see my hands are, they're
00:24:3500:24:39
a fair amount apart like they're her fist width, not quite my fist width but
00:24:3900:24:45
her fist width apart. Nice big lumbar vertebra with nice wide
00:24:4500:24:50
transverse process, and we can use transverse process to do UPA'S. That is
00:24:5000:24:52
something that you're going to want to consider, especially if your thumbs start
00:24:5200:24:57
getting tired and you need to switch to something like this position, this tends
00:24:5700:25:00
to work a little bit better using a transverse process than trying to
00:25:0000:25:05
get into a facet joint, because once you are looking for a facet joints,
00:25:0500:25:11
and you're falling off that spinous process about a fingers width
00:25:1100:25:17
away you'll feel that bump, you can go this way a little bit and feel a bump.
00:25:1700:25:25
You pretty much have to use your thumbs to fit in there, otherwise this becomes
00:25:2500:25:29
tough. You end up getting multiple segments, not that that's a bad thing
00:25:2900:25:35
providing they're stiff at all those segments, but this is a bit more specific.
00:25:3500:25:41
So we have spinous process, we have transverse process that come all
00:25:4100:25:47
the way out here, and then we could go to facets in here and I'm going to show you
00:25:4700:25:50
this on the other side, although I'm on the opposite side of this individual
00:25:5000:25:56
wouldn't do these mobilizations this way. So spinous process, transverse process is
00:25:5600:26:05
all the way out here, and then the facet is about right there. Alright so I
00:26:0500:26:08
hope that helps you with your proportions a little bit. Now I did show
00:26:0800:26:13
you a couple of special techniques, we have the top of the iliac crest here.
00:26:1300:26:20
In line with the top of the iliac crest is the spinous process of L3-L4. If
00:26:2000:26:25
you go just below the spinous process of L4, so you draw a triangle
00:26:2500:26:33
between that spinous process, the top of the back of the iliac crest
00:26:3300:26:37
here there's this little triangle section that's leading
00:26:3700:26:45
into the bony sacroiliac joint, and the bony PSIS. This little
00:26:4500:26:49
spot of still soft tissue, at the bottom of that is the facet of L4-L5.
00:26:4900:26:54
I would keep that in mind because that's one of those segments that people forget
00:26:5400:26:59
to palpate. They're palpating down, palpating down, palpating down, and then
00:26:5900:27:06
they stop because they either accidentally hit the iliac crest, maybe
00:27:0600:27:09
they were too wide to begin with and they were pressing on transverse process
00:27:0900:27:13
instead of facets. So they get to the iliac crest and they
00:27:1300:27:18
stop. Keep that L4-L5 facet in mind, and then the other thing I want you
00:27:1800:27:22
to do is make sure that you find the sacral base, which you know you're going to
00:27:2200:27:29
come off the flat sacrum, and then just fall off the top of it so that you
00:27:2900:27:35
find L5-S1. Now those are the two joints most likely to become hypermobile,
00:27:3500:27:41
but in a lot of individuals with a chronic history of lumbar pathology they
00:27:4100:27:47
can also get stiff. So knowing how to palpate and then mobilize L4-L5, and L5
00:27:4700:27:52
and S1 are important techniques to have in your arsenal. Of
00:27:5200:27:59
course the technique that we use is the same as all of the other vertebral
00:27:5900:28:04
UPA's that we've done. Once you find that facet, find the first resistance barrier
00:28:0400:28:09
and then find the end of arthrokinematic range, and you're going to have to press
00:28:0900:28:12
down pretty good in the lumbar spine. This is one of those techniques that
00:28:1200:28:17
having a good mentor will definitely give you the confidence to push this to
00:28:1700:28:22
end range, and you'll back off to 50% between, and then you can do your grade
00:28:2200:28:26
fours right there at 50%, or you can back off to zero resistance and go to 50%
00:28:2600:28:33
like a grade three. And of course make sure you follow through your protocols
00:28:3300:28:40
getting a increase in joint mobility before you stop, probably 30 seconds or
00:28:4000:28:44
more. So there you have it assess, address, reassess. Make sure that
00:28:4400:28:49
every time you choose a joint based manual therapy technique it is based on
00:28:4900:28:52
an assessment, and that you return to that assessment after you've finished
00:28:5200:28:57
the intervention to see if it was effective for the individual, the
00:28:5700:29:01
patient or client that you have in front of you. Ensure that you continue to learn
00:29:0100:29:06
your Anatomy because your Anatomy is going to help you with your hand
00:29:0600:29:11
placement, with understanding what a joint can do, with understanding what you
00:29:1100:29:17
may gain from this particular technique; and of course practice, you have to
00:29:1700:29:22
practice these techniques hopefully not for the first time on a patient or
00:29:2200:29:27
client who just walked in the door. If you can find a more senior instructor or
00:29:2700:29:32
a mentor to give you some really good hands-on instruction, use your peers for
00:29:3200:29:40
some good feedback, and of course always look for live education to help with
00:29:4000:29:44
your manual therapy techniques. I know these videos make education very
00:29:4400:29:50
convenient but there is no substitute for learning manual therapy in a live