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This is Brent of the Brookbush
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Institute 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 therapists 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 osteopath 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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therapists 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 scalenes that's the
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anterior middle and posterior scalenes
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I'm have my friend Melissa come out she's going
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to help me demonstrate now we're going
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to use the same four step process we've
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used for all of our static manual
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release videos in this case I want to
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start with step 4 and talk about patient
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or client position notice that I had
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Melissa come out and laid down
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immediately I have seen texts and videos
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that refer to scalene release in the
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seated position it's hard for me to
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believe that it would be easy to
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palpate or release these muscles in a
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seated position where the scalenes as
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well as the other lateral stabilizers of
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the cervical spine are going to have to
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remain somewhat active to stabilize the
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cervical spine in the head against the
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force of gravity if you have somebody
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laid down all this stuff relaxes which
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means now we can get our fingers in here
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so we can actually find the scalenes and
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get a good release now trying to
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differentiate the scalenes is not easy I
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see a lot of people just kind of going
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at the side of the neck and I feel like
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they're almost just hoping that the
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scalenes are in there but there's some
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other stuff in there too that we've
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already talked about some other videos
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like the levator scapula and the
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splenius cervicus so we need to figure
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out how are we going to differentiate
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these tissues
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well first let's start with identifying
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where the posterior cervical triangle is
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because I know that my scalenes are in
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there the posterior cervical triangle
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refers to a triangle that has the SCM as
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its anterior border so more so go ahead
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you lift your head so you guys have
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somebody turn their head away and then
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lift up towards the ceiling their SCM
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pops right out that's easy to find
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all right I'm to make sure I can feel
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that border I have it identified I know
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where it is and then this mass right
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here is your upper trap that's the
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posterior border and then the bottom of
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this triangle is actually just kind of a
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top of the shoulder girdle here so
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inside there is my scalenes all right
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first step done next is going to take a
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little functional anatomy knowledge so I
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know that my scalenes anterior middle
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and posterior come off the transverse
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processes of my cervical spine the
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transverse processes are not something
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that you want to jab at but you can
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palpate by gently kind of letting your
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fingers to press into the side of the
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neck and looking for what feels like
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bony spines almost okay they're kind of
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spiny don't press real hard but you'll
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notice that they definitely feel
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different than soft tissue transverse
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processes feel like they're not going
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anywhere no matter how hard you press
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soft tissue obviously you can kind of
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kind of almost feel like you're going to
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push through once you find those
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transverse processes we now have a good
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idea of where the origin
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of these muscles are the insertion is in
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the first and second rib now if you've
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never felt the first and second rib
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these aren't your first and second ribs and
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I know that seems a little
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counterintuitive but generally speaking
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the first two ribs underneath the
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clavicle or your third and fourth rib
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your first and second rib almost exists
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behind the clavicle they're much smaller
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right they almost exist in this space
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here just above the lungs really so how
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do I figure out where those first and
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second ribs are well the easiest thing
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to do is probably
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fine c7 spinous process that's the
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biggest spinous process at the bottom of
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the base of your neck right here all
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right so if I find that on Melissa and
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then I fall off laterally now what
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you're probably going to have to do is
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flex the neck towards the side your
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palpating so that the trap will calm
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down once again you'll feel something
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that is definitely not soft tissue
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that's definitely a bone right there and
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sure enough right there I'm going to go
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ahead and move this so they can scream
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now I wouldn't have to move her strap
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for any therapeutic reason i can i can
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get at her neck without moving that but i
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want you guys to be able to see kind of
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where my hand is if i push down right
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there that's definitely bone well
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that's my first rib that's my first
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rib and then if I know where c7 is I
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could go to t1 and try to see if I can
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palpate the second rib a little harder
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palpation there guys it's almost easier
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to just kind of step off inside the AC
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joint here right into a clavicle or
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acromion shelf if I get in there and
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kind of feel the second rib that is one
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of those points where it's really
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helpful to have some live education or a
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mentor or kind of demonstrate those two
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techniques because it's not easy to find
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those in the soft tissue here guys but
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with a little bit of patience and maybe
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a colleague who is little patient with
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you I think you guys will find them at
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the very least you know that there's
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this bony floor to this area right here
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at the top of the shoulder girdle that
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your scalenes attach to from the
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transverse processes and so hopefully
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you guys can kind of summarize that i'm
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looking for something inside of this
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posterior cervical triangle that goes
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from the bony spikes on the side of the
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cervical spine to the bony floor at the
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top of my shoulder girdle now
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going back to the bony spikes if i start
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up closer to her head and I go anterior
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to posterior kind of over but not into
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those bony spikes I should start to be
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able to identify some very vertically
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aligned fascicles and my scalenes are very
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vertical muscles based on what I just
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told you they attached to being the
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first and second rib and the transverse
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processes something like my levator
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scapula which also attaches to the
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transverse processes is going to have a
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little bit more of an angle going
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towards posterior if you're still having
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a hard time identifying these fascicles
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what you could do is use your two
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fingers right to palpate in this
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posterior cervical triangle but then
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have your client like push into that
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same palm a little bit with some lateral
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flexion right that'll get a bunch of
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stuff really active including the SCM on
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what you palpated earlier but then if
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they go into just a little bit of
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flexion which is lifting their head off
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the table you definitely would inhibit
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the levator scapula so now you know that
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as long as your posterior the scalene
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our posterior the sternocleidomastoid
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you're in the posterior cervical
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triangle and you're feeling vertical
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bands that's definitely your anterior
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and middle scalene all right so now that
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we found the anterior middle scalene we
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do have to talk for a second step number
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two which is what structures are around
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these structures that I could insullt abrade
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injure with compression we have
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the carotid artery let's let's stay away
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from the carotid artery we don't need
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anybody passing out on us I think you
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will find that if you gently apply
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pressure rather than just aggressively
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going in that you would find a pulse well
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before you would ever occlude an artery
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and there's nothing
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on the feeling a pulse but it is a good
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sign that you should probably press
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somewhere else remember that the carotid
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artery isn't very thick all you have to
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do is move a few millimeters in any
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direction and I think you'll be able to
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change your finger angle to still get it
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the same fascicles without occluding
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that artery the other thing you might
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want to stay away from is there are
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little beads in here which are lymph
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nodes you don't want to like take one of
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those beads thinking it's a trigger
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point and press it up against the
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transverse process thats a very bad idea we
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don't want to try to crush lymph nodes
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is going to cause inflammation could
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cause some symptoms but we don't want to
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deal with last your brachial plexus
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actually pierces between your anterior
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middle scalene and that's its normal
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course it comes out those nerve roots
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right and they all those various nerve
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roots combine to become the brachial
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plexus and it comes out between the
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anterior middle scalene goes underneath
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the clavicle and underneath the
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pectoralis minor and then feeds all the
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nerves to the arm right we don't want to
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push on the brachial plexus because a we
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can cause some nerve symptoms we don't
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want to cause tingling we don't want to
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cause something that's going to almost
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look like a radiculopathy we don't want
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to cause numbness or that nerve pain we
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don't want to push down on the brachial
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plexus and create that searing burning
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stretch i'm sure some of you have felt
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when you stretch a nerve we want to stay
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away from all that so if your client
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complains of any of those symptoms once
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again all you got to do is move a couple
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millimeters in any direction maybe
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change the angle of your thumb and you
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should still be able to get those same
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tissues so I know this is a lot of
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information guys which is why I'm glad
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this is on video you can put it on
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repeat a couple times but let's review
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you have posterior cervical triangle we
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know it's in there if I want to
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differentiate my anterior middle
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scalenes for my levator scapula which is
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probably the only other issue we have or
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maybe the the splenius cervicus I can
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use a little bit of lateral flexion and
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then flexion off the table to make sure
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I start there
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once I found those vertical fibers to
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find the densest fascicles and to
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find these trigger points tender points
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points of acute hyperactivity I'm going
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to do my anterior to posterior strumming
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since these are vertical fibers as I
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move from inferior or superior to
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inferior and our common trigger points
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are actually much closer to the ribs so I
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think what you guys will find is nine
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times out of ten rather than there being
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trigger points up in the middle of the
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neck they're much closer to the base of
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the neck and so I can actually feel here in
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Melissa that the tightest fascicles
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are right about there I don't feel a pulse
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any nerveyness you know nerveyness no little
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lymph node type feeling beads all right
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and then I can feel that it's a little
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denser there it gives me a little nodule
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all right so I can hold that for my 30
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seconds to 2 minutes until i get a
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nice release guys an important thing
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to keep in mind here is I'm not pressing
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lateral to medial I'm actually pressing
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I have a little lateral to medial angle
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but I'm mostly pressing superior to
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inferior and so I'm pressing towards the
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rib the reason why that's important is
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pressing into the transverse processes
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is going to be painful and I think as
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soon as we stimulate pain once again it
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becomes very hard to get a release I know
00:12:1400:12:16
that this is not comfortable for Melissa
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but there's a difference between this
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and pinchy pain which just does not feel
00:12:2100:12:25
good now to find the posterior scalenes
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all you have to do is keep all that
00:12:2900:12:31
anterior to posterior strumming in mind
00:12:3100:12:35
but then think okay my posterior scalene
00:12:3500:12:39
goes from c6 c7 transverse processes
00:12:3900:12:41
down to my second rib so it's almost
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like that splenius cervicus pocket that we
00:12:4800:12:49
talked about in the splenius cervicus
00:12:4900:12:53
release video but rather than go towards
00:12:5300:12:56
the laminar trough back this way and
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towards the
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is process I'm going to go kind of out
00:13:0000:13:04
this way towards the second rib and the
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fibers are looking for are much more
00:13:0600:13:10
vertical this is good technique to pick up
00:13:1000:13:12
because posterior scalenes tend to get
00:13:1200:13:16
very overactive and I can just do the
00:13:1600:13:20
same thing again if I need it to if I
00:13:2000:13:21
needed to try to differentiate for
00:13:2100:13:24
example the posterior scalene from the
00:13:2400:13:26
anterior and middle scalene I could go
00:13:2600:13:29
lateral flexion into my palm so mostly
00:13:2900:13:31
pressing into the arm i'm using for
00:13:3100:13:33
release and then if she extends back into
00:13:3300:13:36
the table boom right all of a sudden her
00:13:3600:13:38
anterior middle scalenes calm way down
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and her posterior scalenes
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fire up just like with all your
00:13:4300:13:46
techniques guys take your time this is
00:13:4600:13:49
not a race your patient has no idea what
00:13:4900:13:51
you're doing your patient has no idea
00:13:5100:13:53
how long this is supposed to take I know
00:13:5300:13:56
you want to get a lot of work done but I
00:13:5600:13:58
used to hate when my mother said this
00:13:5800:13:59
but I'm going to tell it to you guys the
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quickest way to get anything done is to
00:14:0100:14:04
do it the right way the first time man I
00:14:0400:14:06
used to hate that but now it makes so
00:14:0600:14:10
much sense so take your time use lateral
00:14:1000:14:12
flexion use flexion and extension to
00:14:1200:14:15
help you differentiate tissues if you
00:14:1500:14:17
have to use the SCM technique of
00:14:1700:14:19
contralateral rotation an flexion to
00:14:1900:14:23
find the SCM great that's fine if you
00:14:2300:14:26
have to sit there and find c7 to find
00:14:2600:14:28
the first rib because you've never felt
00:14:2800:14:31
that before fine somebody has Anatomy
00:14:3100:14:32
that's a little different than you're
00:14:3200:14:34
used to somebody's a little maybe a
00:14:3400:14:37
bigger person or a more muscular person
00:14:3700:14:39
or much more slight than you're used to
00:14:3900:14:41
dealing with all these little cues
00:14:4100:14:42
knowing your functional anatomy and
00:14:4200:14:44
taking your time with your palpation
00:14:4400:14:47
will be your savior you can still get to
00:14:4700:14:50
all of these tissues just about anybody
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and you should be able to get to them
00:14:5200:14:55
comfortably without causing discomfort
00:14:5500:14:57
from impending a nerve or whatever just
00:14:5700:15:00
simply by keeping your functional
00:15:0000:15:01
anatomy in mind
00:15:0100:15:04
stay tuned for the close-up recap and
00:15:0400:15:06
this close-up recap of our scalene
00:15:0600:15:08
static manual release we're going to
00:15:0800:15:11
start by outlining that posterior
00:15:1100:15:14
cervical triangle most of you would lift
00:15:1400:15:15
your head real quick you guys can see
00:15:1500:15:19
there's SCM ok so this mass right here
00:15:1900:15:22
is the upper trap so we know we're going
00:15:2200:15:25
right in between the two in here this
00:15:2500:15:29
being the floor of that triangle now the
00:15:2900:15:30
first thing I'm going to look for is
00:15:3000:15:33
those transverse processes because what
00:15:3300:15:36
I don't want to end up on is end up back
00:15:3600:15:38
here where it's more likely that i'm
00:15:3800:15:40
going to release my levator scapula and
00:15:4000:15:43
splenii I want to find the origin of
00:15:4300:15:47
these muscles so that I can start doing
00:15:4700:15:52
my anterior to posterior strokes towards
00:15:5200:15:55
their insertion down on the first and
00:15:5500:15:58
second rib now if I'm having problems
00:15:5800:16:01
finding those muscles like they're not
00:16:0100:16:03
popping into my fingers I'm not feeling
00:16:0300:16:05
the strands or I think by chance I'm on
00:16:0500:16:08
either the levator scapulae or splenii I
00:16:0800:16:11
could have Melissa go ahead and kind of
00:16:1100:16:14
push into my hand here a little bit with
00:16:1400:16:16
lateral flexion and although the SCM
00:16:1600:16:19
puffs up pretty quick I know where I
00:16:1900:16:21
know thats my SCM if I have her then
00:16:2100:16:24
go into a little bit of flexion I know
00:16:2400:16:28
that the muscles behind my SCM that are
00:16:2800:16:30
puffed up from lateral flexion and
00:16:3000:16:33
flexion are my anterior and middle
00:16:3300:16:37
scalenes disflexion inhibits my
00:16:3700:16:40
levator scapula and splenii muscles
00:16:4000:16:43
so right there go ahead and relax Melissa
00:16:4300:16:47
right there I know I'm on nothing but
00:16:4700:16:49
scalene of course I can do my anterior
00:16:4900:16:52
posterior strokes here looking for the
00:16:5200:16:55
dentist fascicles once I find them I'm
00:16:5500:16:57
going to go ahead apply pressure now
00:16:5700:16:58
of course since I'm in the area of the
00:16:5800:17:01
neck I am keeping in mind do I feel a
00:17:0100:17:04
pulse am I getting any nerve symptoms
00:17:0400:17:07
does Melissa have any tingling or numbness
00:17:0700:17:11
does she have that searing stretchy pain
00:17:1100:17:13
of stretching a nerve am i on a lymph
00:17:1300:17:16
node does it feel like a like I have
00:17:1600:17:18
a little lima bean underneath my finger
00:17:1800:17:21
remember these densities inside muscle
00:17:2100:17:23
just feel like an increase in tissue
00:17:2300:17:25
density and might feel a little ball
00:17:2500:17:30
like but it's more just denser parts of
00:17:3000:17:32
the same structure that you're feeling
00:17:3200:17:35
now to find the posterior scalene is a
00:17:3500:17:38
little tricky I suggest going anterior
00:17:3800:17:41
middle scalenes first and then what you
00:17:4100:17:45
can do is ensure that you're down low
00:17:4500:17:51
enough that your lateral to c6 and c7
00:17:5100:17:53
right because that's where your
00:17:5300:17:57
posterior scalene in our originates and
00:17:5700:18:00
then you can have your patient do
00:18:0000:18:02
lateral flexion into your hand again and
00:18:0200:18:05
extend back into the table and you'll
00:18:0500:18:08
feel those fibers pop out all right so
00:18:0800:18:12
if you know you're pretty close to
00:18:1200:18:15
anterior middle scalene come back on to
00:18:1500:18:18
where you think posterior scalene may
00:18:1800:18:21
be and then you confirm by doing lateral
00:18:2100:18:24
flexion and extension you're probably in
00:18:2400:18:27
good shape go ahead and relax and then
00:18:2700:18:29
posterior scalene definitely gets
00:18:2900:18:32
tight on a lot of people the common
00:18:3200:18:34
trigger points for all of these muscles
00:18:3400:18:37
guys are very close to the first and
00:18:3700:18:39
second ribs so right about where my
00:18:3900:18:41
thumb is that right at the base of the
00:18:4100:18:43
neck there is a common trigger point for
00:18:4300:18:45
anterior scalene that's up a little
00:18:4500:18:47
higher about midway up the neck but
00:18:4700:18:50
again these are all far more common down
00:18:5000:18:54
here and as I suggested in our further
00:18:5400:18:58
away shot supine is probably the best
00:18:5800:19:01
way to get this technique done this
00:19:0100:19:04
isn't uncomfortable for me I can get my
00:19:0400:19:07
arm behind my direction of pressure
00:19:0700:19:09
which is going to be down towards the
00:19:0900:19:11
rib right not into the transverse
00:19:1200:19:15
down towards the rib and of course my my
00:19:1500:19:17
patient here is very comfortable as
00:19:1700:19:20
shes just lying with her head supported
00:19:2000:19:21
so there you have it knowing your
00:19:2100:19:23
functional Anatomy will definitely help
00:19:2300:19:25
your manual technique it'll help you
00:19:2500:19:27
differentiate structures so when you can
00:19:2700:19:28
place your hands where they need to be
00:19:2800:19:30
as well as make you aware of these
00:19:3000:19:33
sensitive structures around the tissue
00:19:3300:19:35
that you're trying to target things like
00:19:3500:19:37
nerves and lymph nodes and arteries make
00:19:3700:19:39
sure that if you're going to place your
00:19:3900:19:40
hands on a patient that you have done an
00:19:4000:19:42
assessment and have a good rationale for
00:19:4200:19:44
placing your hands on that patient and
00:19:4400:19:46
if you're going to assess make sure you
00:19:4600:19:48
reassess to ensure that your technique
00:19:4800:19:50
was effective and you have a good
00:19:5000:19:52
rationale for using that technique again
00:19:5200:19:56
now with manual therapy one-on-one live
00:19:5600:19:59
education is incredibly important please
00:19:5900:20:01
be looking for opportunities like
00:20:0100:20:04
workshops and mentorship and maybe even
00:20:0400:20:07
classes at your local university that
00:20:0700:20:10
can get you some one on one individual
00:20:1000:20:13
instruction or at least a live classroom
00:20:1300:20:16
instruction so you've had a chance to be
00:20:1600:20:20
critiqued and mentored by somebody
00:20:2000:20:22
senior to you with some experience in
00:20:2200:20:25
manual therapy techniques and before you
00:20:2500:20:28
bring the stuff back to your rehab
00:20:2800:20:31
fitness or performance setting please
00:20:3100:20:34
practice on colleagues there is no
00:20:3400:20:37
substitute for practice and it is going
00:20:3700:20:41
to take a while to get accustomed to some
00:20:4100:20:42
of the techniques that we show in these
00:20:4200:20:45
manual technique videos don't expect to
00:20:4500:20:48
learn them in two or three or even five
00:20:4800:20:50
minutes you want to have hours of
00:20:5000:20:52
experience under your belt working on
00:20:5200:20:55
various different body sizes and shapes
00:20:5500:20:57
so that when you do get that first
00:20:5700:21:00
paying client first paying customer and
00:21:0000:21:01
you're really trying to make a good
00:21:0100:21:05
positive impact really trying to promote
00:21:0500:21:08
better outcomes you feel comfortable
00:21:0800:21:10
with that technique I look forward to
00:21:1000:21:12
hearing about your outcomes and hearing
00:21:1200:21:14
your questions in the comments section
00:21:1400:21:18
of this video I'll talk with you soon