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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
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manipulations, or high-velocity thrust techniques. I assume that if you're
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watching this video you're watching it for educational purposes, and that you
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are a licensed professional with high velocity thrust or manipulation
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techniques in your scope of practice. If you are not sure, check with your state
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board. Most physical therapists, chiropractors and osteopaths you're in
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the clear. I believe that ATC's you can't do manipulations in the United States,
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although other countries again check your scope. Of course massage therapists
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and personal trainers these are generally not within your scope, of
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course you could continue to watch these videos just for educational purposes,
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learn a little Anatomy, learn a little biomechanics. If you're going to do these
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techniques please make sure that you have a good rationale for putting your
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hands on a patient, this should be based on assessment, and if you're going to
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assess I'm hoping that you'll assess, use these interventions and reassess to
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ensure that you're getting the result that you're looking for, and have good
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reason to continue using this technique. In this video we're going to go over a
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lumbar spine manipulation. I'm going to have my friend a Yvette come out, she's going to
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help me demonstrate. Now of course if I'm doing lumbar spine manipulation I've
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done not only passive accessory motion, I've probably done something like a
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subjective exam as well as a movement exam like the overhead squat assessment,
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and I have some reason to believe that there's lumbo-pelvic hip complex
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dysfunction issues, and then I'd like to use continuous interval measures to
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measure progress, something like goniometry. Unfortunately in the lumbar
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spine goniometry isn't very reliable, so maybe you could work on some of
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those rotation tests to at least get some sort of visual indicator to see if
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you are actually making progress with this particular technique. Now once we
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get through that and we're doing our passive accessory motion exam to try to
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figure out which segment is stiff, you can go back to the lumbar mobilizations
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video because one of the first things I'm going to do is just a central PA;
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where I'm going to go ahead and press all the way down to end range, see
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if it feels normal to me which of course is where the reliability of passive
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accessory motion exams comes into play. Obviously you have to feel a lot of
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different lower-backs to get a good idea of what a lower-
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back should feel like, but I also want to take into account what a Yvette feels. So
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does that feel like pressure or pain? Obviously pressure is normal and as long
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as I don't feel stiffness then fine. How about there? All right and I'm just
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pushing all the way down to end range arthrokinematics, and I do feel a
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little bit of stiffness in her mid-lumbar spine. So we even have some
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research to back this up, L5-S1 tends to get a little hypermobile,
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L4-L5 might get a little hypermobile, L2-L4 we tend to get quite a bit of
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stiffness. So for this particular technique I'm actually going to have a Yvette
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rolling or side facing me. Now some of you have probably seen this technique
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before, this of course is the rotational manipulation, and I think a lot of people have a
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very hard time with this technique; and it's because they get bound up in the
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details of what the legs are supposed to be doing and what the arms are supposed
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to be doing, and what the hands are supposed to be doing, and they forget one
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simple thing, you have to find the lockout position. So if we're going
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for L2-L4 I'm going to get my hands set up with that piano grip, where
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I have my fingertips on those spinous process or in between those spinous
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process, and once I find that stiff segment I'm going to now lock up from the
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bottom using ligamentous lock. The way I do that is by posteriorly pelvic tilt,
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right I'm creating a posterior pelvic tilt and creating some lumbar flexion
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which will pull all of those posterior spine ligament's tight, that's why we
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move this leg. So what I'm going to do is I'm actually just putting my knee right
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in the crease of my hip there, so I don't even have to hold her entire weight of
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her leg, and I'm going to move up until I feel that segment that I'm trying to
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manipulate, move on me. Now I know that's locked I'm going to go ahead and set this
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leg down, double-check now that I have it down to make sure it stayed locked. One
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thing you will find is it's real easy for people to get
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them locked up and then you move, and they unwind on you. So make sure
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that once you find your ligament lock from the bottom you tell your patient,
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hey don't move your lower-body once they get you there. You can see
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you can move this bottom leg, the reason the bottom leg is straight is
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to give you something to rotate over. It really doesn't have much to do with the
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manipulation itself. I mean I guess technically we could probably bring both
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legs up and still make this manipulation happen, but with this bottom leg here I
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have something to pivot on, and then I can actually bend it a little bit and
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get her foot hooked up so that once I find that lockout position,
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Yvette has some pretty good hip mobility here so I had to go up a little further
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to get that locked out position. Now I get her set, cool I'm now going to switch
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hands. Now I have to figure out how to lock out from the top, and the way
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to do that is to rotate and extend a little bit this way, not huge amounts of
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extension just a little bit of extension, and what I'm going to do is I'm going to
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grab a Yvette's whole arm and I'm going to pull up and back, sliding her arm to
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the point that I feel that joint lock out. So I'm rotating all the way up
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to where my fingers are, so you can even try to get a little bit more, good
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there we go. Now she's wound nice and tight. Now what
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I like to do is come back here I have my thigh where her knee
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is at, that's going to help me keep her nice and stable, I'm then going to take
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this hand, and this hand is going to go between her greater trochanter and
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her ilium, and this hand I'm going to slide right between her arm.
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Now the reason I'm going to do that is because I'm going to use this forearm
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on as much surface area as I can, like over her PEC. So not over her
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chest but over her PEC, try to stay off the shoulder you don't want to give like
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a really hard anterior to posterior force
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to the shoulder that's not going to feel very good either, and once I get
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set-up, get my hands back in place; now just like I did with like the cervical
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spine or like I was doing with some of the joints of the foot, you want to
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kind of mess around just a little bit, a little bit more flexion from the bottom,
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a little bit more extension from the top. Get really nice and tight so you
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can feel that all it's going to move is those two segments. I'm not saying take all
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the time in the world, but make sure that your setup is just like any other
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manipulation -setup is everything. All right then I'm going to have a Yvette take a
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nice deep breath and my manipulation is going to be pulling down this way, well
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going down this way with this side and that's it.
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How did that feel? Yeah not too bad right. This is one of those ones
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where I told you to take all the time you need for setup, except don't take all the
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time you need for setup because your patients hate it; with that being said
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how do we how do we bridge those two contradictory statements is
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yes take all the time you need to set-up, but you need to practice this.
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I would grab some friends, grab some colleagues and make sure that before you
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do this on a patient you've had a couple times, to go okay wait how am i adjusting
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the leg like what am i doing, where are my hands supposed to be. Okay this is locked
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up now how do I get this to stay, okay good adjust this leg, alright good now
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that's like that. You know you're going through all this stuff well before
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you see your first patient, you don't want this to be a 10-minute setup for
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your patient. But if you can get it down to - all right let's let's start all the
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way over, right and we'll show them what like a normal setup would look like, so
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let's start on your back. Alright so if I'm doing this let's say I have my
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patient, all right Yvette we're going to try a little
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manipulation, all right so it's going to be one of those quick thrust techniques
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that I know you love so much. As you know from some of our other videos
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Yvette's not somebody who gets manipulation, she volunteered to model
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for these videos and we thank her for that but she's very much a new kind of
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patient to this stuff. All right so you did know the cervical spine one though,
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right like you've you've seen a couple of them, let's have you lay on your side.
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Okay you're going to face me, now sometimes you end up like this with your
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patients, just make sure you straighten out their leg, all right and then what I
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do is I go ahead and set my left hand up and I get my piano grip to figure
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out where I'm at, all right there's our sacrum, L5, L4, L3. Okay I'm going to
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try to go L4-L3. Now am I necessarily specific or
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surgical in my approach enough to ensure that it's L4-L3 no, but you
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know I'm pretty sure I'm going to be able to get a manipulation from a hypomobile
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segment. I'm going to go ahead and pull up from the bottom.
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All right that's locked out there, good and I want to make sure I follow that
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down so you notice here like her foot isn't really hooked in, so this is where
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I'll usually pull this leg so I can get their foot hooked in,
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because when their foot isn't hooked in that's where they tend to like start
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sliding and then you lose your ligamentous lock from the
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bottom. So we're all nice there, now I'm going to switch my hand put it
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right where my other fingers were. I'm going to grab your arm, thank you, pull up a
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little bit this way. If I feel like I need a little bit more extension and rotation I
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can come up this way a little bit, go ahead and no no don't help, let
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your shoulder roll back, and your patients will try to help, don't let them
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help you. All right good, go ahead and one hand like that, so
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your hands are kind of one hand over your other wrist. So I'm now going to
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put my forearm in this slot, boom, boom. Alright once I get her locked
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up, I feel like I got good position here, I'm just going to adjust a little bit more,
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there we go, there we g,o that feels nice locked up.
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Remember it's down this way, like I'm trying to put my elbow on my back pocket,
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or going down this way.
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Nice and locked up, big deep breath, alright and that's it. I just wanted to show you
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one more view, I'm going to quickly go through this technique but give you a
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little bit more of a view of what I see from my side. So Yvette go ahead and roll
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towards me, alright you can back up a little bit towards the middle of the
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table, and I'm going to have her back up or move forward so that when she gets
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locked up I can still set this knee down, but it'll still pass the table if I need
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it. Alright so you have to feel
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for that adjustment, but if you remember I feel for the segment that I
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want to move, I'm going to pull her into a posterior pelvic tilt until I feel the
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bottom segment move just a little bit so I know that all of the segments below
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are locked up. Alright we have pretty good hip mobility here from Yvette so it
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takes a little bit more hip flexion than you will see on some other people,
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and then of course I kind of mentioned to you I've been moving the bottom
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leg to get that foot hooked up. I mean you noticed I
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used my thigh to move her leg, I don't use all my upper-body strength to try to do
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that, it's just a little energy saver there. Now I switched my hand
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over I'm going to use my other hand to rotate and extend from the top. Alright
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so I can go this way if I have to, I can pull up a little bit this way, good get
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her all nice and locked up there. Alright and then this hand goes on this wrist,
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and then you are going to snake this hand through this way, push down this way.
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Now this is where adjustment time comes in, right so I'm going to use this
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forearm in between her iliac crest and her greater trochanter to rotate
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towards me. I can even laterally flex a little bit, I can move her into flexion
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with my thigh a little bit using that knee that's on my thigh,
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and once they get her all locked up, nice deep breath and then down this way, push
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down this way, I'm just going to drop in all at once. Sorry one more deep
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breath Yvette, and just like so. Alright so there you have it, hopefully with
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these few times through you can rewatch this video and get this
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technique down. I think you'll find it's very helpful for individuals with a hypo-
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mobile lumbar spine. A couple of points to recap, knowing your Anatomy and
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knowing your biomechanics will certainly help you choose the right technique for
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the right patient. If you're unsure whether manipulations are appropriate
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due to their higher intensity, it's okay to do mobilizations. Most research points
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to manipulations being slightly more effective, but mobilizations being very
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effective, and of course we have those videos for you if you want to start with
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those less intense techniques. Make sure that if you are doing any technique that it
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is based on assessment, and of course that you're reassessing ensuring that
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the technique is effective for the patient that you're working on, and when
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it comes to all manual techniques, manipulations maybe more than any other,
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look for opportunities to get live education. Although I know videos are
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convenient and I'm happy to have these up for you to watch, it would be so
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much more helpful to use those videos as a recap of one-on-one attention with
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somebody who's experienced with manipulation techniques. At the very
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least grab a colleague, grab a friend and start practising these before you bring
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them into clinic and start using them on patients and clients. I hope you enjoyed
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this video. If you have any questions please leave them in the comments box