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Lumbar Spine Joint Manipulation (High Velocity Thrust)
Lumbar Spine Joint Manipulation (High Velocity Thrust) is a manual therapy technique used to treat various musculoskeletal conditions. This technique is used to target the lumbar spine area (lower back) and involves a quick thrust of the spine in a specific direction using the hands. This movement aims to increase joint range of motion, reduce stiffness, and improve flexibility in the area. It also activates the muscles surrounding the area and increases circulation, which reduces pain and increases
Transcript
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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
