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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 do the
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proximal tibiofibula joint manipulation. I'm going to have my friend Yvette come out,
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she's going to help me demonstrate. Now if I'm doing the proximal tibiofibula
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joint manipulation chances are I'm basing it on a lot more
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than just subjective symptoms. I want to follow that up with objective tests like
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maybe my overhead squat assessment, maybe Yvette here had knees bow in, knees bow
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out or feet turnout on the overhead squat. Something that would lead me to
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believe that there's some sort of dysfunctional motion happening at the
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knee joint itself, and then maybe I'd follow up with something as simple as
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like that hamstring length goniometry so that i had some sort of
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continuous interval measure to actually address a progress and see some progress
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over time. So the next and last thing we would do is then palpation, we know
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palpation is our least reliable assessment but it is really important in
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the case of this joint. This joint has a tendency to both become stiff in some
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individuals and hypermobile in other individuals. In fact dislocation of this
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joint is not a totally uncommon diagnosis, so we have to make sure that
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we're not doing this technique on individuals that
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already have a very mobile proximal tibiofibula joint. So the first thing
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I'm going to show you how to do here is palpate the fibular head, and it's
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pretty easy. Usually I'll set somebody up at 90-degrees just like I was doing like
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an anterior or posterior drawer test. I'm going to go ahead and just
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use a pincer grip, if I go just below the joint line here of the knee you can
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feel the the fibular head right here. Now if I just grab on either side of my
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fibular head and give it a wiggle, that's actually pretty stiff right. So if
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you feel no motion, no wiggle or it's very hard to get it to wiggle
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that's probably a good indication to do this technique. Now if you grab it and
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it's pretty easy to wiggle and it's only going to be two or three millimeters,
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we're not talking about huge motion but that two or three millimeters happens
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really easy, don't do this technique. There's no need and obviously we don't
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want to promote hypermobility, that could potentially lead to
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dislocation which is going to be a whole another set of symptoms that we would
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have to try to address if that happened. Now the technique itself is pretty quick,
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and easy once you get the hang of it we're going to use our second MCP which
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this is a knuckle you need to get very used to using if you're doing
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manipulations, we're going to put this knuckle right over the fibular head. Now
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I'm going to show you this again in a close-up recap so don't worry if you
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can't totally see where I'm putting my hand, but I'm going to put that MCP over the
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fibular head and then what I'm going to do is I'm going to smash my hand in between
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Yvette's thigh and her calf. So rather than trying to create a manipulation
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force this way which is just it's awkward and hard to do that, we can
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literally just whip her lower leg, use this as kind of like a
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spacer on her fibula so that we get the rest of her leg moving, and hold
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her fibula back while we do this thing. You ready to see what that looks
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like? So for
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MCP I'm going to get nice and locked up, I want to make sure that I press in and
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I'm feeling her fibular head right up against that knuckle when I'm in that
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end range position. Once I know it's going to be there and a little trick, a
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little clinical gem for you, sometimes it helps to turn the tibia and
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external rotation. So I'm even further pressing the fibular head into
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my hand, I get right there, okay I know I'm going to lock out right there.
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I tell Yvette to give me a nice deep breath, and I mentioned before
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unless we're doing like spine manipulation, breath doesn't totally matter, but it's a
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great way to distract your patient so they don't guard on you. So
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take a deep breath, she takes a deep breath I get all locked out and then, and
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that's it. It's almost like I'm trying to get her to kick her own butt.
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Did you see how that worked? It's just that simple, boom. Sometimes you get
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a cavitation, sometimes you won't. Keep in mind cavitations aren't necessarily the
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indicator of a successful manipulation, the manipulation and reassessment right,
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what happened on your reassessment is indication of a successful manipulation.
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Now there is one other way to do this, right we could have a Yvette go ahead and
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turn over, and she's going to lie facedown.
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Now in this case we're going to get a little weird, we're going to use this
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knuckle against the fibular head, we're going to do the same thing, kind of lock up
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right, and then we can push down this way and we got a nice little pop there.
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So we did notice that that side was stiff, I did notice earlier that this
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side was not. The big problem with this technique and probably why I don't use
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it very often, is if somebody has any rectus femoris tightness, like you have a
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very hard time getting their leg far enough that you can actually smash their
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leg together enough for you to apply enough force to the fibular head. Does
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that make sense? So if we get here, like you can imagine if she was super tight
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I'd get here, and then I'd go to do my manipulation
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and I just don't have, I'm not actually squeezing anything together. So you
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can try this if somebody's fairly mobile, other than this one particular joint you
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might be able to get away with that. Otherwise go ahead and flip over back on
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your back, this tends to be the better technique. So one more time,
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second MCP over the top of fibular head, you can externally rotate a little bit
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to feel that fibular head push into that MCP. We're going to get all locked up so we
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know that when we do our final whip that we're getting pressure where we need it,
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and then of course once we get there take a nice deep breath and we just do a
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little, and that's it. All right so we're just swinging the leg a few centimeters
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to get basically a posterior to anterior force against the fibular head. Stay
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tuned for your close-up recap. All right for your close-up recap, starting
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with palpation if we have the knee joint line kind of like right here and this is
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where you would expect it to be, if we go down a little bit you can
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feel this bump right about here, that's the fibular head and if you pincer grip
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it you should be able to move it back and forth. Now of course we're going to base
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it on additional assessments, but if you were to feel stiffness that might be an
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indication to do this particular manipulation. What I'm going to try to do is
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if you see where this finger is right behind the fibular head, I'm now going to
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try to put my second MCP right there, so I'm going to just put my
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hand right up in there and getting through all of the soft tissue, and then
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I might even turn her tibia out. You can see I just kind of turned her foot
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out there and what I should feel is I turn that out like it presses the
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fibular head right into my MCP, and then I want to double check to make sure that
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if I press down is that going to increase tension or increase the amount
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of force on my MCP, and if I get that check then I'm going to go ahead and
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tell Yvette to take a deep breath, and I'm going to go ahead and just a real
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quick, and that's it. Just like she's trying to kick her own butt.
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I just have to remember to go a few centimeters, again one of the common
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mistakes that's made on manipulations is probably not moving enough. Although low
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amplitude means less motion and we're not doing high amplitude manipulations like we
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would move the whole leg. You still do need to move a good few centimeters to
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make sure you take up all tissue slack, to make sure that you're moving through
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all the soft tissue, maybe somebody's clothing and actually getting to the
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point where all that's left is motion at the bone to force it. So again for second
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MCP right behind the fibular head, I can even twist the tibia so that I press the
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fibular head into my MCP and then I'm going to press it up against her thigh
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make sure I got a good lock position once I'm set up, pop. A couple of points
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to recap, knowing your Anatomy and knowing your biomechanics will certainly
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help you choose the right technique for the right patient. If you're unsure
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whether manipulations are appropriate due to their higher intensity, it's okay
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to do mobilizations. Most research points to manipulations being slightly more
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effective, but mobilizations being very effective, and of course we have those
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videos for you if you want to start with those less intense techniques. Make sure
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that if you are doing any technique that it's based on assessment, and of course
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that you're reassessing ensuring that the technique is effective for the
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patient that you're working on, and when it comes to all manual techniques,
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manipulations maybe more than any other, look for opportunities to get live
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education. Although I know videos are convenient and I'm happy to have these
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up for you to watch, it would be so much more helpful to use those videos as
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a recap of one-on-one attention with somebody who's experienced with
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manipulation techniques. At the very least grab a colleague, grab a friend and
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start practicing these before you bring them into clinic and start using them on
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patients and clients. I hope you enjoyed this video, if you have any questions