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This is Brent of the Brookbush
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Institute, and in this video we're bringing
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you another manual technique. Now if
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you're watching this video I'm assuming
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you're watching it for educational
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purposes, and that you are a licensed
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manual therapist following the laws
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regarding scope of practice in your
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state or region. That means athletic
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trainers, chiropractors, physical
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therapists, osteopaths, licensed massage
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therapists, you are likely in the clear
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to do these techniques, personal trainers
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this probably does not fall within your
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scope of practice; although you might be
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able to use the palpation portion of
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this video to aid in learning your
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functional anatomy, in an educational
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setting supervised by a licensed manual
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therapist. Now before we place our hands
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on a patient or client it is important
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that we assess and have a good rationale
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for doing so, and of course if we're
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going to assess then we should be
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reassessing to ensure that the manual
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technique we're using is effective, and
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we have a good rationale for continuing
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to use that technique. In this video
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we're going to go over static manual
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release of the rhomboids. I'm going to
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have my friend Melissa step out and help
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me demonstrate. Now this technique uses
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the same protocol we've used for all of
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our static manual release techniques,
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that basically comes down to palpate and
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compress, although we are going to get a
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little bit more detailed, talk about how
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to differentiate the rhomboids from the
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other tissues in the area. We're going to
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talk about where our common trigger
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points are, we're going to talk about
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what other tissues in the area maybe
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are contraindicated to press on, and then
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of course the last thing we're going to
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talk about is patient and client
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position and your position, so that you
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have great technique.
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Now the rhomboids are deceptively
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difficult to get a good release on. iIt's
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a fairly thin muscle, we don't have those
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big thick fibrous bands to find, that gives
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us really good indication of like a
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fiber direction; and there are a couple
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of other muscles in the area, not to
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mention the rib cage right underneath it.
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So let's talk about how to differentiate
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this tissue. The thing to start with
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would be your origins and insertions to
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set up some borders for the area that
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you should be in. The origin of your
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rhomboids major and minor goes from C7
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to T5, and then the insertion is the
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vertebral border of your scapula which
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is fairly easy to palpate there. So if
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you find these things
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roughly C7 to T5 to the vertebral border,
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and you draw a little box around that
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you get this little twisted square, also
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known as a rhomboid, which is where the
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rhomboid muscle gets its name from.
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We know that this is the area we
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should be palpating in, so what other
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tissues are there that maybe we need to
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differentiate? Well, I happen to know that
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our traps lie on top of our rhomboids, so
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our lower trap and middle traps
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specifically, we need to kind of figure
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out how are we going to differentiate
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between lower trap and rhomboid. Well
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being that my rhomboid goes in this
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direction we would expect more of a
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horizontal fiber direction. My lower trap
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goes from the spine of the scapula, the
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medial portion of the spine of my
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scapula, all the way down to T12. So we
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get this somewhat oblique but mostly
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vertical fiber direction, and what the
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lower traps actually feel like is a
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somewhat triangular shaped vertical
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column of muscle, being that those fibers
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are vertical it makes it very easy to
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differentiate that from what would be
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horizontal fibers of the rhomboids. Now
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the middle traps do have that horizontal
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fiber direction, but if we follow them
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they don't go into the vertebral border
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of the scapula they continue on to the
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spine of the scapula, not to mention the
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middle traps are much much thicker than
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the rhomboids. So after you've done this
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a few times you've learned how to
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identify the rhomboids, you know how to
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identify the mid traps, you're going to
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know when you're on the trapezius muscle
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in general just because it's a much much
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thicker muscle. Now the only other muscle
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that's in that area is the serratus
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posterior superior which is deep to the
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rhomboids, very thin, not generally
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something we think about palpating,
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something we think about having trigger
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points. I would imagine if we were trying
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to go after it, it would have something
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to do with CT junction dysfunction, maybe
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breathing dysfunction, maybe some
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sort of assessed dysfunction of the upper
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ribs. If we're trying to palpate the
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rhomboids, my guess is we had more of the
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thoracic or scapular dyskinesis
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that we're worried about. I think it's
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actually fairly uncommon for us to go
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after the rhomboids, when the serratus
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posterior superior was involved, or vice
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I think that muscle for the most part is
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not something that we're going to have
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to worry about, and when we talk about
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step 2 - where are the common trigger points,
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we're going to find out that our hands
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are actually going to be even further
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from the serratus posterior superior. So
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the trigger points here, that's getting
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into step 2, are all along the vertebral
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border of the rhomboids. This is a really
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important fact because this is what's
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going to save us when we try to locate
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these hypertonic fascicles within the
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rhomboids, because if you try to
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feel here, like let's say you just start
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trying to feel in that rhomboid area for
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horizontal fibers, I don't think you're
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going to find much. There's like there's
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not these differentiated fascicles in
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here and unfortunately we have the
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ribcage which has these little bumps in
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it, which make it a little hard to figure
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out whether you're just feeling bumps on
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the ribcage, or you're actually feeling
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some fascicles on the rhomboid. You can
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even end up just feeling this flat mush
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over the ribcage until you get down into
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the vertebral border here, and at the
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vertebral border you can feel a little
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bit of thickness as the rhomboid turns
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into these tendinous fibers
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that invest into that vertebral border.
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In fact we're going to make this even
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easier for ourselves, we're going to go
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ahead and ask Melissa to put her hands
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up over her head. If she didn't have a
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face cut out in this table we could
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actually have her put her hands
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underneath her forehead which sometimes
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it's just more comfortable, now I've
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lengthened out these rhomboid fibers
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even further. That's going to add a
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little tension, maybe make it easier for
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me to feel the horizontally oriented
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fibers. It's also going to help me with
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that finger on a marble game right, we
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don't want to play that, we don't want to
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play that game where we keep trying to
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hit trigger points but they keep sliding
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out from underneath our fingers. We can
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this increase in length, increase in
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tension on the rhomboids to help
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stabilize that trigger point. I think
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once you get somebody in this position
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and you start strumming perpendicular to
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those fibers right up against the
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vertebral border, now you start feeling
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some fascicles. But it's really not until
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we get into this position and feel very
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specific to about where these trigger
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points are along the vertebral border
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that we can feel anything, and I want you
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guys to experiment with this, experiment
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with hand down and then hand up and I
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think you'll see what I'm talking about.
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Now before we take this to the actual
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technique and getting a good release
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here, is there anything contraindicated,
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is there anything that I shouldn't put
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pressure on, is there anything that's
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sensitive in this area -the answer is no
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not really. You always run the risk of, or
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the chance of over stretching like a
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sensory nerve or something, like
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something that gives us some
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sensation in the skin and that would
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give us some sort of like sharp twinge
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of pain, like it's that burning searing
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pain I know we've all felt when somebody
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like stretches our skin the wrong way
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and you like it that little that little
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zap, but even that's fairly uncommon in
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this area. I don't think it's something
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that you're going to have to worry about.
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So this is probably the best position
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for the patient, before I go through this
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technique also notice that I am working
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on the rhomboid that's farthest from me,
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and they're the reason for that has to
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do with how we're going to pin the
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tissues. If I were to try to do the
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rhomboid closest to me I end up kind of
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like this trying to push down towards my
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thigh, which this type of force just
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isn't a real easy force to apply. I'd
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much rather be pushing across my body be
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able to walk out my arms and just lean.
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So this is the patient position I know
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it was a long explanation to try to get
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to where we're going to be, and the
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technique isn't that difficult. All I'm
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going to do is take a thumb, strum
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perpendicular to what would be the
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direction of the fibers at this point,
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which is going to be parallel to the
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vertebral border of my scapula. Once I
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find something that feels like an
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increase in tissue density, I'm then
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going to go a little bit along the
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length of the fiber and see if I can
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identify a nodule of tightness. Once
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again those nodules are going to be
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pretty close to the vertebral border. I
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don't know if you guys can see the X's
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where I actually marked off the trigger
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point parts, but when we get into the
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close-up recap I know you will.
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Once I've not only identified the tight
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fascicles but I've done my palpation
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along the length of those fascicles to
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find the tight nodule, now what I'm going
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to try to do to pin it -is actually push
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into the vertebral border of the scapula.
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I find that that is easiest and what
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I'll usually do is since I was just
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strumming this way, I'll use my thumb to
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kind of block this way and then I'll put
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my thumb right in between my thenar eminence
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there, just like so walk out my arms, and
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press in. How does that feel? Okay a
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little tender I'm sure, I'm sure this is
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just a little bit of tenderness here, and
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of course after I get one release let's
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say after 30 seconds to two minutes of
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holding, that's not a tremendous amount
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of pressure. I just have to press up to
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the point of the tissue giving me some
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resistance back, I don't have to like try
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to push my thumb all the way down
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underneath her scapula per se. I just
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wait for a release then I can do the
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same thing, perpendicular strums try to
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feel for an increase in tissue density,
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increase in tissue tightness, right about
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there I'm feeling some tight fascicles,
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and then I can move along the length of
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the fascicles
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to find a tight nodule, and then again
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I'm going to make sure I can get some
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pressure on that nodule and I find that
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going in kind of this direction rather
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than like let's say straight down, if
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you did go straight down it just hurts a
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little bit, you just end up pushing into
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the rib cage. So if I go this way a
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little bit -this direction, I can hold,
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get a good release,
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and on my bottom hand as soon as this
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hand puts pressure becomes the dummy
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thumb, I'm not using my hand strength I'm
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just using my bodyweight to get a good
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release. Now the only tricky point is
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this rhomboid minor trigger point in
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this position doesn't quite work, because
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unfortunately when we
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upwardly rotated the scapula
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the superior angle ends up
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retracting a little bit. So we need to
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lengthen out these rhomboid minor
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trigger points. I think the easiest way
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to do that is to actually have Melissa
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put her hands underneath her ASIS,
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alright so I know you guys have seen
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this position before and then I might
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even try to protract her a little bit
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further, abduct her scapula as far as I
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possibly can and then I'm just going to
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go ahead and palpate that superior
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portion of her rhomboids right up
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against the superior third of the
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vertebral border of her scapula.
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Doing my perpendicular strokes, now I'm
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doing my along the fiber to find the
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nodule, found it -make sure I can apply
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some pressure right without losing it,
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it's not trying to shoot out from under
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my finger. I'm going to use my hand
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here putting my thumb right in the
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middle of my palm and just leaning, and
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that's it. This is a real easy technique
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for me, for Melissa it might not
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feel that easy up front, we're going to
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get a little bit of tenderness at first,
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but then it's going to let go and of
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course for example if she had something
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like downwardly rotated scapula as part
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of like some upper-body dysfunction and
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shoulder impingement syndrome, hopefully
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this would give her better outcomes
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after we finished this technique. Stay
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tuned for the close-up recap. The
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close-up recap, step one we have to be
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able to palpate, differentiate this
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muscle from the other muscles in the
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area. I already have Melissa's arms up so
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we pulled the vertebral border of the
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scapula away from the other tissues we
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would be concerned about confusing
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ourselves with, being like the lower trap
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column over here, you know we have the
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mid traps that they're way up here,
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and then our serratus posterior superior
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would be somewhere in here. The vertebral
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border of the scapula is, I'm trying to
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palpate this for you guys and kind of
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show you, you see that crease I just
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created in our skin, that crease is the
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vertebral border of our scapula, and
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you'll notice that these are the common
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trigger point sites for the rhomboids
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which are all along that vertebral
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border. So well now all we have to do is
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do our strokes perpendicular to the
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fiber direction, all right so we're going
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to come through here like this, and not
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surprisingly as I do these perpendicular
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strokes, I'm finding that I have these
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dense fascicles, this increase in tissue
00:14:1000:14:13
density, this tightness occurring right
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around these X's, especially this X on
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her, maybe a little bit here too. So once
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I find that increase in tissue density
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then I'm going to search it this way
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right, make sure that I'm right on the
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tightest nodule and then I'm going to
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try to make sure I have that trigger
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point anchored, so that it's not moving
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out from under my thumb, and then once I
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have it nice and anchored I'm going to
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go ahead and put my palm over the top of
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that thumb, and I can do this with each
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of the dense fascicles, or each of the
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tight nodules in the rhomboids here, hold
00:14:5600:14:59
for 30 seconds to two minutes. The only
00:14:5900:15:00
one that's a little different is the
00:15:0000:15:01
rhomboid minor, i'm going to have
00:15:0100:15:04
Melissa move her arm down so she has
00:15:0400:15:08
her hands underneath her ASIS, and then
00:15:0800:15:09
I'm going to make sure she's abducted,
00:15:0900:15:11
her scapula is abducted as far as
00:15:1100:15:13
possible, she's protracted as far as
00:15:1300:15:13
possible,
00:15:1300:15:18
and then I'll look at the upper rhomboid
00:15:1800:15:20
fibers, and once again doing my
00:15:2000:15:22
perpendicular strokes once I find the
00:15:2200:15:23
tight fascicles,
00:15:2300:15:26
going along the length of the fiber and
00:15:2600:15:30
then anchoring that dense nodule, and
00:15:3000:15:32
putting my palm over the top of it;
00:15:3200:15:36
to apply that static pressure for 30
00:15:3600:15:39
seconds to two minutes. So there you have
00:15:3900:15:41
it, knowing your functional anatomy will
00:15:4100:15:43
definitely help your manual technique.
00:15:4300:15:45
It'll help you differentiate structure
00:15:4500:15:46
so that you can place your hands where
00:15:4600:15:48
they need to be, as well as make you
00:15:4800:15:50
aware of these sensitive structures
00:15:5000:15:52
around the tissue that you're trying to
00:15:5200:15:54
target. Things like nerves and lymph
00:15:5400:15:57
nodes, and arteries. Make sure that if
00:15:5700:15:58
you're going to place your hands on a
00:15:5800:15:59
patient that you have done an assessment
00:15:5900:16:02
and have a good rationale for placing
00:16:0200:16:03
your hands on that patient, and if you're
00:16:0300:16:05
going to assess, make sure you reassess
00:16:0500:16:07
to ensure that your technique was
00:16:0700:16:09
effective and you have a good rationale
00:16:0900:16:11
for using that technique again. Now with
00:16:1100:16:15
manual therapy, one-on-one live education
00:16:1500:16:18
is incredibly important. Please be
00:16:1800:16:21
looking for opportunities like workshops
00:16:2100:16:24
and mentorships, and maybe even classes
00:16:2400:16:26
at your local university that can get
00:16:2600:16:29
you some one-on-one individual
00:16:2900:16:31
instruction, or at least some live
00:16:3100:16:33
classroom instruction so you've had a
00:16:3300:16:38
chance to be critiqued and mentored by
00:16:3800:16:40
somebody senior to you with some
00:16:4000:16:42
experience in manual therapy techniques,
00:16:4200:16:45
and before you bring this stuff back to
00:16:4500:16:48
your rehab, fitness, or performance
00:16:4800:16:52
setting, please practice on colleagues.
00:16:5200:16:55
There is no substitute for practice and
00:16:5500:16:57
it is going to take a while to get
00:16:5700:17:00
accustomed to some of the techniques
00:17:0000:17:02
that we show in these manual technique
00:17:0200:17:04
videos. Don't expect to learn them in two
00:17:0400:17:07
or three or even five minutes. You want
00:17:0700:17:10
to have hours of experience under your
00:17:1000:17:12
belt working on various different body
00:17:1200:17:15
sizes and shapes. So that when you do get
00:17:1500:17:17
that first paying client, first paying
00:17:1700:17:19
customer, then you're really trying to
00:17:1900:17:22
make a good positive impact, really
00:17:2200:17:26
trying to promote better outcomes, you
00:17:2600:17:28
feel comfortable with that technique. I
00:17:2800:17:29
look forward to hearing about your
00:17:2900:17:32
outcomes and hearing your questions in
00:17:3200:17:34
the comments section of this video. I'll
00:17:3400:17:37
talk with you soon.