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This is Brent of the Brookbush Institute and
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in this video we're going to go over a
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joint based manual therapy technique. If you're watching this video I'm assuming
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you're watching it for educational purposes and that you are a licensed
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professional with joint based techniques within your scope. That means osteopaths,
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chiropractors, physical therapists you're probably all in the clear. Physical
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therapy assistants, athletic trainers, massage therapist you need this check
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with your governing body in your state or region to see whether this is within
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your scope of practice. Personal trainers this is definitely not within your scope
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of practice, of course all professions could use this video for purely
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educational purposes to help with learning biomechanics, anatomy and of
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course palpation. In this video we're going to go over posterior to anterior
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sacroiliac joint mobilization. I'm going to have my friend Melissa come out she's
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going to help me demonstrate. Now Melissa is going to lie prone, you'll notice that I
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have the table fairly low because I want to be able to get my chest over her
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sacrum with arms straight, so that I can use my torso and not my hands or my
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arm strength to try to manhandle this technique, that's going to wear me out very
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fast. Now before we start this mobilization we need to have good palpatory
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skills and palpatory skills basically comes down to practice and
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anatomy, like you have to know your Anatomy.
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If you haven't looked at the sacroiliac joint in a little while it's good to
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review maybe an Anatomy textbook, look at those illustrations start identifying
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various landmarks and how they relate to one another, and if you can get a hold of
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one of these plaster cast models, I know they're not perfect and the
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standard plaster cast model is of a fairly small person I would have to
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guess, maybe somebody who is like 5 foot 4, or 5 foot 3 and Melissa here's like
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almost 5 foot 8 so it's not quite perfect, but it'll do and it'll
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definitely teach us quite a bit. I'll give you a couple landmarks that you
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probably should be aware of. Every time I'm looking to do the sacroiliac joint
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posterior to anterior mobilization realizing that I'm going to be pressing
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on the sacral base, what I'm going to try to find is my PSIS. And I know that if I
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fall immediately medially and I had to practice that now, immediately
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medially off the PSIS, the posterior superior
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iliac spine, I end up roughly on the S2 S3 segment of my sacroiliac joint. Well
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okay maybe you're not great at finding the PSIS how would I do that? Well maybe
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you start with the iliac crest, and the iliac crest is fairly easy to palpate
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right that's the top of your pelvis, the top of what people call their
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hips where they wear their pants. So you could follow your iliac crest to your PSIS
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and I personally like to find the under that corner, hook underneath the
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PSIS, so I hit the same point every time and I don't end up on this. Alright so I
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want to be able to hook underneath the PSIS, maybe I have to start at the iliac
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crest. Maybe you want to take it a step further,
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what does your iliac crest line up with as far as what spinous process of the
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lumbar spine? Well it lines up with roughly L3-L4 spinous process so I
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should be able to find those spinous process, work my way down, know that L5 is
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going to feel a little hidden and then I'm going to have a divot all right like a
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little fold there and then I'm going to go on to the alligator back of the sacrum.
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And sure enough if you tried to find that I think you guys would find that it
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feels a lot like I'm describing to you right, like I can feel like this little
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divot in here right which is like this part represented right here. Another
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thing you might want to be able to identify is you know where the ischial
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tuberosity relative to the iliac crest. Where are the where's the coccyx
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relative to the rest of the sacrum relative to the iliac crest? You kind of
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want to have a good visual model in your head of where all these landmarks are,
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where your hands are, and how to get back to what you're trying to palpate, which
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in this case is the sacral base. I would definitely recommend practicing on one
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of these plaster cast models by closing your eyes, choosing a landmark, laying
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your hands down and forcing yourself to work through those landmarks until you
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end up on whatever you chose. Let's say I said sacroiliac joint here
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and then when I open my eyes am I on the sacral base, and I'm sure enough I am. You
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might want to even test yourself by choosing some of those other points.
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Can I find my coccyx right, and sure enough I found the tip of my coccyx. The
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reason being is people are not all shaped the same, you're going to be
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working through various techniques so you want to be able to go from one
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technique to the other as smoothly as possible.
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And when you lay your hands down you have no way of knowing boom there's my
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PSIS, you might get lucky, and the better you get the closer you'll
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get over time. But it is always helpful to kind of have a step by step
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process here. Let's use the simplest of these processes I'm going to
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find the iliac crest, I'm going to follow my iliac crest to my boney notches being
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my PSIS. I'm going to hook my thumb's underneath the PSIS so I find those
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corners, that corner will lead me right to the S2-S3 segment of the sacral base
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which is exactly where my thumb's need to be to do this mobilization. So
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there you have it, we have all of our palpation leading to the landmark we
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need. Now notice I kept saying S2-S3 segments of the sacral base, it's kind of
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odd and I can't totally explain why from a biomechanics standpoint. Despite the
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fact that the sacrum is fused segments of the spine right they don't move
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separate from each other, it is helpful to mobilize the segments like they
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aren't fused, if you're with me. Maybe it just has to do with the breadth of the
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joint, like our thumbs aren't wide enough to mobilize the whole thing at once.
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Maybe it has to do with the way the bumps are right, like those joints
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aren't two smooth surfaces together, they're kind of bumpy, right they fit
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together like with bumps and grooves. Maybe so maybe we're mobilizing
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different bumps and different grooves as we move through the segment, but kind of
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keep in mind that if you find the S2 to S3 segment you're probably going to have to
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move up at least one segment, and you are probably going to have to move down at
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least one segment maybe two. So you could start your mobilizations however if
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you want you can start on the S2 segment, work up one
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and then go back down two's to your S3-S4 segment and maybe go down one more. Or
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you could find S2-S3 segment and try to start at the top of the sacral base and
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work your way down. Whatever you want to do just understand that you're probably
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going to have to mobilize a few segments before you feel like you've got good
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mobility back into what was an assessed stiff SI joint if you're doing this
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mobilization. Now let's talk about hand position, this is one of those techniques
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that works best with your thumbs which is really unfortunate, because this is a
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very stiff joint which means it's going to take a lot of strength, it's going to
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take a lot of force to get a little bit of motion and that's all you're really
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looking for, is a little bit of motion. So again if I find her PSIS I fall off, my
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go-to technique is going to be just like this thumb touching thumb. I'm going to try
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to find my first resistance barrier which is right there, and then my end
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which is right there. These are very close alright the first resistance
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barrier and the end, there's not a whole lot of motion. So trying to determine the
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difference between a grade three and a grade four immobilization for example is
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going to be very hard if not impossible. Generally speaking I try to find the end
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range, I back off and then I mobilize. I think if I'm doing grade three it's a
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little less intense and more mobility, grade four I'm really kind of digging in
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and doing small oscillations at end range and I just kind of leave it at
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that. Trying to find the 50% mark or 75% mark for a joint that has very little
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motion to begin with is going to be very challenging.
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Now just to kind of go back over the same techniques we've been doing through
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all these mobilizations; first resistance barrier, end resistance, barrier back off,
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do my one to two oscillations a second kind of going from that first resistance
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barrier into roughly 50% until I get an increase in mobility, and then as I
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mentioned I'm going to have to move segments. So I actually started on the S2-S3
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segment here, I might want to move up one and then move down a couple. Try to
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get all that mobility back that I possibly can, but this is just one hand
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position. Now I'm going to show you another hand position that I've been
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working on that I have a hard time with, and I think you might have a hard time
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with it too but I'm challenging both of us to try this technique, and that's to
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use pisiform hamate on the sacral base. The reason I think this is a challenge
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is because the PSIS actually hangs over the sacral base a
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little bit, and it's actually kind of challenging to get your hand, the thicker
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part of your hand on to the sacral base. Now maybe it's just me and I've
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mentioned before I do have bigger than normal hands right, and Melissa's well
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Melissa is kind of an average-sized individual with average dimensions. Maybe
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my hands are just too big to to get in there and you guys will have an
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easier time, maybe it's a feel thing like I don't feel things as well here
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as I do the tips of my fingers. Either way it's worth trying because of how
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hard this joint is to mobilize, how delicate our thumbs are, and of course if
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we're trying to extend our careers I've mentioned several times that if you can
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find a way not to use your thumbs don't use your thumbs. There's too many
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techniques already that are totally dependent on us being able to use our
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thumbs. The other big tip for this technique or I guess the big tip for
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this technique is don't try to go on the same side, this probably won't work. If
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you go to the other side it'll work better. Now this happens to be Melissa
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stiff side, and just as a pointer more often than not, in fact almost
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always you only have one stiff SI joint they usually both don't get stiff.
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This happens to be her stiff side if I was going to keep working on her with this
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pisiform hamate grip I'd walk around the table, for you I'm just going to show
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you on her opposite side. I want to try to get underneath her PSIS
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and push down on her sacral base. So I'm going to find the PSIS, use my fingers to
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find where I want to be, put my pisiform hamate
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over my fingers and then go this way. And you can already see this would be a lot
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less pressure on me physically. I think this feels okay. I'm not sure I have got
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the same outcomes from it as I do with my thumbs, but I'm going to keep practicing.
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I want you to keep practicing because I think this could be a career
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saver long term. How's that feel Melissa, this probably feels a lot better than me
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pushing on your other side huh? Yeah so her stiff side is this side which is why
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it's a little a little bit more tender for her. So just a quick repeat of what I
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showed you. This posterior to anterior mobilization for the sacroiliac joint is
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definitely my go-to for sacroiliac joint dysfunction. Look for the stiff side, do
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my PA's, see if I can increase mobility, tends to have a pretty big effect on my
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outcomes. I did this mobilization by finding iliac crest, using my iliac crest
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to find my PSIS, hooking my fingers underneath my PSIS, dropping off
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immediately medially all right onto my sacral base, that's S2-S3 great. I can do
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this thumb technique, or I can challenge myself walk around the table and use my
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pisiform hamate because I know that'll be better for my career long term, and
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then of course I have to remember that I probably should move up and down
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segments, and treat the SI joint like it has several segments similar to how I
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would like the lumbar spine as a whole. Alright I have the plaster cast
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model set up here so you can see where we're trying to get our hands when
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we do these two different techniques, the the thumb over thumb technique for the
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same side, or we're trying to do that pisiform hamate on the opposite side. So
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here's the PSIS on the plaster cast model, we would fall right off immediately
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medially onto the sacral base and do our PAs goin segment by segment. Or we would
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try to get our pisiform hamate down into this space here on the opposite side,
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that would be the other way to do this technique. Now I've had Melissa
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roll down her belt line here just a little bit so that that we're palpating
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directly on skin. So you can see here if I follow the ilium down
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I find her PSIS right about here, so right just above her backside there and
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then if I fall off immediately medially I'm now on sacral base. So now
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I can get my hands in position and I can find the first resistance barrier, last
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resistance barrier just quite a bit of force, and then I can back off a little
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bit and do my one to two oscillations per second. Now don't forget you're not
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just going to do one segment quote-on-quote of the sacral base here, you're going to
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have to move up a little bit, make sure that you don't have stiffness higher,
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you're going have to move down a little bit and almost treat the sacroiliac
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joint like it's multi segmented like the lumbar spine.
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Now what I've challenged all of us to do is to not just use our thumbs which is
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kind of the easy way out although very hard on our thumbs, and try to teach
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ourselves to feel with this part of our hand, go to the opposite sacral base by
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falling off immediately medialy once again, onto that sacral base, and then
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trying to use that point of our pisiform portion of our hand to try to get some
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some good mobilization of the sacrum here on the ilium. Alright so you got
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your thumb over thumb technique which of course you need to learn. Of course it's
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a lot easier to palpate but once you get that down don't forget to keep working
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on this one, just to save your thumbs and add a little longevity to your career. So
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there you have it assess, address, reassess. Make sure that every time you
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choose a joint based manual therapy technique it is based on an assessment,
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and that you return to that assessment after you've finished the intervention
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to see if it was effective for the individual,
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the patient or client that you have in front of you.
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Ensure that you continue to learn your Anatomy because your Anatomy is going to
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help you with your hand placement, with understanding what a joint can do, with
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understanding what you may gain from this particular technique. And of course
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practice, you have to practice these techniques hopefully not for the first
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time on a patient or client who just walked in the door. If you can find a
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more senior instructor or a mentor to give you some really good hands-on
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instruction, use your peers for some good feedback and of course always look for
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live education to help with your manual therapy techniques. I know these videos
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make education very convenient but there is no substitute for learning manual
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therapy in a live setting, I look forward to talking to you guys again