Name: Shotgun (Pubic Symphysis) Manipulation
Uploaded: 2023-04-23T07:03:30.000Z
Duration: 12 min 55 s
Description: This instructional video demonstrates Shotgun Manipulation for the pubic symphysis, a safe and effective technique designed to restore normal lumbopelvic mechanics. Learn proper patient positioning, stabilization, and thrust application to aid in the reduction of pubic symphysis dysfunction, lumbopelvic pain, and limitations in hip and core function.

English captions

https://stream.mux.com/M6G01EA1I02LO4xmb4I4lyWJh20242zGYhxhDhLvx00Hk8g.m3u8

 This instructional video demonstrates Shotgun Manipulation for the pubic symphysis, a safe and effective technique designed to restore normal lumbopelvic mechanics. Learn proper patient positioning, stabilization, and thrust application to aid in the reduction of pubic symphysis dysfunction, lumbopelvic pain, and limitations in hip and core function.

Introduction to High-Velocity Thrust Techniques

Shotgun Manipulation Technique Overview

Case Scenarios for Pubic Symphysis Dysfunction

Demonstration of the Manipulation Technique

Post-Manipulation Home Exercise Strategies

Best Practices and Considerations for Manipulations

Shotgun (Pubic Symphysis) Manipulation

This is Brent of the Brookbush Institute, in this video we're going to go over manipulations or high-velocity thrust techniques. I assume that if you're watching this video you're watching it for educational purposes and that you are a licensed professional with high velocity thrust or manipulation techniques in your scope of practice. If you are not sure check with your state board, most physical therapists, chiropractors and osteopaths you're in the clear. I believe that ATC's you can't do manipulations in the United States, although other countries again check your scope. Of course massage therapists and personal trainers these are generally not within your scope. Of course you could continue to watch these videos just for educational purposes, learn a little Anatomy learn a little biomechanics. If you're going to do these techniques please make sure that you have a good rationale for putting your hands on a patient, this should be based on assessment and if you're going to assess I'm hoping that you'll assess, use these interventions and reassess to ensure that you're getting the result that you're looking for and have good reason to continue using this technique. In this video we're going to do the shotgun manipulation, that is the pubic symphysis malalignment/ stiffness and muscle energy technique I know some of you have seen. I'm going to have my friend Yvette come out, she's going to help me demonstrate. Now this particular technique is a little hard to explain, and it's use is not perfectly explainable by biomechanics or human movement science. What I do know is that this particular technique tends to solve this little problem of when somebody has dysfunction of the pubis this works. So when might that happen, I'll give you a couple case scenarios. You have somebody with an asymmetrical weight shift on the overhead squat, you do your sacroiliac joint dysfunction tests, you notice two things you have stiffness on the side opposite of the shift, and then a lot of times you end up with, when you measure out ASIS and PSIS height you kind of see maybe something you think is an innominate torsion. What most people will go in and treat the SI joint and that's fine, but what about the other side of your pelvis. It's not ridiculous to think that your pubis would be stressed in that position and could cause it to become stiff, or maybe even a little out of alignment. So that's one potential reason. The other thing I've seen where this technique comes in real handy is I'm sure some of you have seen this like really stubborn adductor overactivity, like you can do your soft tissue techniques, you can do your release techniques but it seems like as soon as they get up and move like everything like kind of binds down a little bit. Try this technique, I mean obviously I want you to do all of the other stuff related to compensation patterns and do your overhead squat assessment and goniometry, but occasionally I'll find that the adductor overactivity is related to this pubic symphysis dysfunction, and once that's corrected with this technique all of a sudden adductor activity comes down, then you can do your soft tissue and lengthening techniques and everything finally starts to normalize. So what does this particular technique look like, well it's interesting although we call it a manipulation a lot of times we don't even have to do a thrust. So first thing I would probably start with is go ahead and lay your legs down, I would probably start with palpation of the pubic symphysis and see if I could feel anything that maybe felt like, you know one side was like this and one side was like this. Here's how to palpate somebody's pubis without getting yourself in a terrible amount of trouble. Number one ask, be like hey I think because of this pelvis thing that we're working on like we might have some stiffness here, you mind if I palpate to see if I can feel anything going on? It's okay, okay. So here's what you do, find their belly button and then drop the palm of your hand, slide it down on top of their pubis. So if you do this you're a lot less likely to miss with a nice broad surface, and it's definitely a lot less likely to get you in trouble going from top down than from bottom up. So once I find it I can then slide my thumbs right over the top of her pubis, and Yvette looks slightly like I'm not going to say that this is 100% reliable, but it looks a little bit like this side might be a little higher. Alright so we're going to see if we can correct that using this technique. Now what she's going to do is she's going to come in to hook lying position, I've seen so many variations of this technique I can't even tell you but it always comes down to resisted abduction followed by resisted adduction; and on the resisted adduction we may potentially hear a cavitation or the patient or client might feel an adjustment in their pubis, and that's supposed to be what realigns everything. So here's how I do it. I usually start with the legs all the way together and I just give them a hug, and what I say is okay like imagine you're doing, Yvette happens to follow our corrective exercise stuff so you know what a clam looks like, imagine doing a clam with both sides at the same time. So she's going to push her knees out, go ahead push push push, push, come on you got more than that, that's ridiculous come on come on, there you go, good. Now hold this for five to ten seconds and then have a relax, good and then I'm going to go out a little further, usually I'll have her push against my belly. Alright go ahead I want you to flatten my stomach for me, I need that, good and push out against my hands. So now I have nice nice a way of resisting without hurting myself, good, good good good good, and then the last one I'll do, good relax, is we'll go out as far as we can with arms long, good and there's a reason I'm doing it like this. So go out, push push push as hard as you can. Now that I have her pushing out into abduction, isometric abduction this wide, I can easily then slide my arm in between her knees like this. Go squeeze as hard as you can, squeeze squeeze squeeze squeeze squeeze good, good hold for five seconds and then relax. So I've seen this done other ways where it's like a hug and then only a fist. I find that doesn't tend to work as well. I do find that a little wider adduction does help. I find that by doing the three different distances what I'm actually doing is coaxing her into a width that allows me to slide my forearm right down between her knees, so that she can then adduct against them without losing the momentum that we build up with this abduction. Now why abduction before adduction, everybody talks about reciprocal inhibition but that doesn't make any sense, right because if we  are reciprocally inhibiting our adductors, what would be pulling the pubis apart? I have no idea, but I can tell you that if you just try to do this, generally speaking it doesn't work. So the last thing I'll show you is let's say I did those three things, so we'll mimic it right, five seconds good, five seconds good, five seconds as hard as you can, boom, down squeeze, and I got the sense that she tried as hard as she can but we didn't get it, I might do one last thing if I think she's up for it. I don't think I have any contraindications, I might do okay go ahead and abduct as hard as you can, good push push push push push. Good notice the position I'm in, right my forearms are square with the direction of force, so I'm still not using that much energy and then I would go cross hands, get my palms down there so that I'm not getting pokey on the inside of her knee, good squeeze against me, and then as she's squeezing give her a little quick high-velocity thrust. So that would be the closest thing we get to a traditional manipulation. All right so there you go. Abduction probably three times, five to ten seconds, you know I like to do a cascade of various lengths. You're then going to have them squeeze, you can squeeze fists, I like to do full forearm, make sure when you sink this forearm down it's full palm on one knee and fleshy part of your tricep on the other, because if you get bony part of your tricep into their knee or bony part of your elbow under their knee they're not going to be happy. If you wanted to give a high velocity thrust after that try, do at least one more abduction and then cross hands, and then one little move let's say two to four inches with a nice bit of vigorous force against their adduction. The great thing about this technique, is let's say it worked, let's say we think that for the next week this needs to be reinforced, we can do this at home and it's actually pretty easy. So if I have Yvette go ahead and put this around her knees like she's going to do her glute work, her glute activation work, but I'm going to have to put it up a little higher on her thighs. All right and then I'm going to have her take like a foam roll and she can hold the foam roll between her feet, and then she can make sure that this band is high enough on her thighs that the foam roll stays in place kind of held by her feet and the band. All right and you can hold on to it with your hands if you need to. So you're going to adduct against this band three times, good hold it for at least, that was like two seconds, can you hold it for five seconds. All right make sure it's a heavy band too, like a good heavy band. This isn't like an activation exercise where we need full range of motion, we need more isometric type of force. Good and don't lose that, good and then once she's done three times for ten seconds all she has to do is now squeeze against the foam roll as hard as she can. Squeeze squeeze squeeze squeeze squeeze, boom and this can be part of her home exercise program. If you're with the Brookbush Institute stuff you know that you'd be release, mobilize, lengthen then activate. This would be a mobilization technique I would put between her release techniques and whatever stretching I thought she needed to do. How's that, you think you can do that at home, cool. All right go ahead and try this at home, it's not one of those techniques that's going to work on everybody who ever try it. It's not like a cervical manipulative where once you get good at cervical manipulations or thoracic manipulations you can get a cavitation on anybody. This is one of those techniques it's very specific, but it'll make you look, I have I said this in some other videos with like these little tiny techniques that if it is the right technique it'll make you look like a hero, you'll look like a total magician. If somebody has that weird adductor tingly like the tightness that won't go away, it's kind of like hip impingement but not quite, and you get a cavitation and it all goes away good for you. If it doesn't work, if this doesn't change any of your movement assessments don't do it. Just like any other technique in our programs assess, address, reassess. This particular technique is one of those that's going to be effective maybe 20% of the time, but when it is effective it tends to be really effective, so keep it in your back pocket. You have any questions leave them in the comments box below. A couple of points to recap, knowing your anatomy and knowing your biomechanics will certainly help you choose the right technique for the right patient. If you're unsure whether manipulations are appropriate due to their higher intensity it's okay to do mobilizations. Most research points to manipulations being slightly more effective but mobilizations being very effective, and of course we have those videos for you if you want to start with those less intense techniques. Make sure that if you are doing any technique that it is based on assessment, and of course that you're reassessing ensuring that the technique is effective for the patient that you're working on, and when it comes to all manual techniques, manipulations may be more than any other, look for opportunities to get live education. Although I know videos are convenient and I'm happy to have these up for you to watch, it would be so much more helpful to use those videos as a recap of one-on-one attention with somebody who's experienced with manipulation techniques. At the very least grab a colleague and grab a friend and start practicing these before you bring them into clinic and start using them on patients and clients. I hope you enjoyed this video, if you have any questions please leave them in the comments box below.

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Joint manipulations for the lumbar spine, sacroiliac joint, and pubic symphysis. Types of manipulations, manipulations vs. mobilizations of the spine, lumbar spine, SI joint, and pubic symphysis. Optimal intervention for anterior pelvic tilt, low back pain, inadequate forward lean, asymmetrical weight shift, sacroiliac joint dysfunction, knee bow in, knee bow out, and hip symmetry. The risk of adverse events, accuracy vs sensitivity, screening, reliability, and validity of lumbar spine, SIJ, and pubic symphysis manips.

Joint Manipulation: Lumbar Spine, Sacroiliac Joint and Pubic Symphysis

The patient is supine in hook-lying (knees bent) position.

The table should be high enough for the practitioner to comfortably place their forearm between the patient's knees.

Often pubic manipulation is attempted when SIJ dysfunction has been confirmed and SIJ techniques alone do not completely resolve symptoms.

Subjective symptoms for pubic symphysis dysfunction may include 

 tendonitis or pain, and symptoms similar to femoral acetabular impingement (FAI).

Pubic symphysis caudal and cranial mobilization may also be used to "assess" stiffness via palpation, but obviously, this is a sensitive region for the patient and the technique may have limited reliability.

You may notice that this technique is quite different from the other techniques included in the manipulations courses. That is because this is actually a muscle energy technique (MET) that often results in cavitation, and although not a true manipulation is the closest approximation of a manipulation available for this joint.

The patient is asked to isometrically abduct bilaterally in hook-lying position against practitioner resistance, 3 times for 3 - 5 seconds.

There are several methods for applying resistance, but the Brookbush Institute prefers sequentially wider contraction, starting with knees together, then knees approximately 12" apart, and then knees wide enough to allow the practitioner's forearm to fit length-wise between them.

After the last isometric hold, the practitioner will slip their forearm between the patient's knees, with palm against the knee on one side and soft part of the arm above the elbow against the knee on the other side.

The practitioner then immediately cues the patient to adduct against the patient's arm.

This should occur quickly, with a goal of immediately following the isometric abduction with a near-maximal isometric contraction of the adductors. The contraction of the adductors should distract the pubic symphysis, allowing the two sides of the pubis to "realign", and an audible pop may occur. Note, as with all manipulations an audible cavitation is not necessary for the technique to be effective.

Although the technique above does not often require a high-velocity thrust, a thrust may be added.

If the same protocol above is followed, but the last step is replaced by placing both forearms between the knees with palms on medial condyles, the practitioner can add a quick thrust into abduction as the patient is maximally adducting.

The amount of motion is the same as other manipulations, relatively small and rapid (maybe 4 - 6").

Shotgun (Pubic Symphysis) Manipulation

Cuboid Manipulation

Sacroiliac Joint Chicago Technique

Thoracic Pistol Manipulation

Upper Cervical Manipulation

Radial Head Manipulation

Lumbar Spine Joint Manipulation (High Velocity Thrust)

Wrist Manipulation

Talocalcaneal Manipulation

Talonavicular and Cuneonavicular Joint Manipulations

Proximal Tibiofibular Joint Manipulation

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