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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