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